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Swallowing Tablets and Capsules Increases the Risk of Penetration and Aspiration in Patients with Stroke-Induced Dysphagia

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Abstract

We evaluated the prevalence of difficulties swallowing solid dosage forms in patients with stroke-induced dysphagia and whether swallowing tablets/capsules increases their risk of penetration and aspiration. Concurrently, we explored whether routinely performed assessment tests help identify patients at risk. Using video endoscopy, we evaluated how 52 patients swallowed four different placebos (round, oval, and oblong tablets and a capsule) with texture-modified water (TMW, pudding consistency) and milk and rated their swallowing performance according to the Penetration Aspiration Scale (PAS). Additionally, Daniels Test, Bogenhausener Dysphagiescore, Scandinavian Stroke Scale, Barthel Index, and Tinetti’s Mobility Test were conducted. A substantial proportion of the patients experienced severe difficulties swallowing solid oral dosage forms (TMW: 40.4 %, milk: 43.5 %). Compared to the administration of TMW/milk alone, the placebos increased the PAS values in the majority of the patients (TMW: median PAS from 1.5 to 2.0; milk: median PAS from 1.5 to 2.5, each p value <0.0001) and residue values were significantly higher (p < 0.05). Whereas video-endoscopic examination reliably identified patients with difficulties swallowing medication, neither patients’ self-evaluation nor one of the routinely performed bedside tests did. Therefore, before video-endoscopic evaluation, many drugs were modified unnecessarily and 20.8 % of these were crushed inadequately, although switching to another dosage form or drug would have been possible. Hence, safety and effectiveness of swallowing tablets and capsules should be evaluated routinely in video-endoscopic examinations, tablets/capsules should rather be provided with TMW than with milk, and the appropriateness of “non per os except medication” orders for dysphagic stroke patients should be questioned.

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Acknowledgments

We are grateful to all participating speech and language therapists and physicians who supported us to perform this survey. The manufacturing of punches for the production of placebos was supported in part by Fette Compacting GmbH, Schwarzenbek, Germany. Additionally, we thank FMC BioPolymer (Brussels, Belgium), BASF SE (Lampertheim, Germany), Dr. Paul Lohmann GmbH KG (Emmerthal, Germany), Colocorn GmbH (Idstein, Germany), and Capsugel Belgium NV (Bornem, Belgium) for kindly providing excipients for the placebos. The work of JTS was funded by the Graduiertenkolleg 793 (German Research Foundation, DFG). RQ’s and WEH’s contribution was partly supported by the BMBF (Federal Ministry of Education and Research, Grant No. 01ET1004B). The sponsors and funding organizations had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

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Authors and Affiliations

  1. Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany

    Julia T. Schiele, Renate Quinzler & Walter E. Haefeli

  2. Centre of Geriatric Medicine, Agaplesion Bethanien Hospital, Rohrbacherstraße 149, 69126, Heidelberg, Germany

    Heike Penner, Nikolai Wezler, William Micol & Peter Oster

  3. Department of Pharmaceutical Technology and Biopharmaceutics, University of Heidelberg, Im Neuenheimer Feld 366, 69120, Heidelberg, Germany

    Hendrik Schneider & Gabriele Reich

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  1. Julia T. Schiele
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Correspondence to Walter E. Haefeli.

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Schiele, J.T., Penner, H., Schneider, H. et al. Swallowing Tablets and Capsules Increases the Risk of Penetration and Aspiration in Patients with Stroke-Induced Dysphagia. Dysphagia 30, 571–582 (2015). https://doi.org/10.1007/s00455-015-9639-9

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  • DOI: https://doi.org/10.1007/s00455-015-9639-9

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