Medicines in frailty and swallowing difficulty

The first step in pharmacy guidance for swallowing difficulty is to assess necessity. Unnecessary medicines can be stopped, once-daily options considered, and non-oral routes such as patches or suppositories explored. Fewer, simpler doses are easier for someone who struggles with swallowing and reduce the risk of choking or refusal.

In frailty the same logic applies more widely. Scottish polypharmacy guidance covers goals of care, time to benefit, falls, deprescribing, swallowing and monitoring as a package, because a medicine that prevents a problem years ahead may matter less to a person whose priorities are comfort and independence today.

The NHS says dysphagia is usually caused by another health condition such as stroke, dementia, multiple sclerosis or cerebral palsy, and that some medicines, antipsychotics for example, can themselves cause swallowing problems. Referral to a speech and language therapist or dietitian is common, and treatment can include softer foods, thickeners and swallowing techniques.

Where swallowing is unsafe, a speech and language therapist decides the fluid consistency level using IDDSI guidelines. Pharmacy guidance adds that liquid medicines should not be thickened routinely because the final consistency cannot be reliably checked, and that starch-based thickeners should not be mixed with macrogol laxatives.

Crushing is often assumed to be harmless and is not. The Specialist Pharmacy Service identifies several groups where it should be avoided.

• Modified-release preparations, which may have MR, SR, XL or LA in the name, are usually unsuitable, because crushing releases the whole dose at once with a risk of toxicity or loss of effect.

• Enteric-coated tablets have a protective coating that crushing destroys.

• Hazardous medicines: cytotoxic or teratogenic medicines should not be crushed unless there is no alternative, and antibiotics, immunosuppressants and hormones can pose inhalation risks to carers.

• Some tablets with simple film or sugar coatings can be crushed safely, but instructions vary between brands of the same medicine, so the product information should be checked first.

Where a licensed liquid or dispersible form exists, it is often the simplest choice. The Specialist Pharmacy Service lists classes where alternatives are commonly sought, including anticoagulants, proton pump inhibitors, antidepressants, statins, ACE inhibitors and ARBs, diabetes medicines, antiplatelets and Parkinson's medicines, with special monitoring for clozapine.

The guidance sets a preferred order: licensed medicines used as licensed, then licensed medicines used off-label, then unlicensed specials. It advises caution when switching a modified-release product to a liquid, since the release profile and absorption can change.

Pharmacy guidance notes that many medicines can be given safely with a spoonful of soft food, though exceptions exist and should be checked individually. Mixing a medicine into a whole meal risks incomplete dosing if the meal is not finished, so small portions are usually advised.

Medicines given covertly, without the person knowing, raise legal and ethical issues and should only follow a formal best-interests process with pharmacist and prescriber input, not an informal decision at the bedside.

Decisions should involve the person, carers and local guidance, with regular review as conditions and abilities change. Practical factors include who gives the medicine, their manual dexterity, how well they can follow instructions and whether dust from crushing is a risk. A community pharmacist or medicines optimisation team can check a product against its summary of product characteristics.

For tube feeding, the Specialist Pharmacy Service publishes separate advice on giving medicines through enteral tubes. Never improvise by dissolving products that were not designed for it.