To Crush or Not to Crush: That is the Medication Administration Question

Dysphagia is a relatively common geriatric syndrome, manifesting as difficulty or discomfort while swallowing. As pharmacists, we will encounter individuals experiencing dysphagia regardless of practice site. Approximately 11% to 14% of community-dwelling adults ≥65 years old and >30% of residents in skilled nursing or long-term care experience dysphagia.^1-3 Adults with dysphagia or their caregivers may resort to splitting or crushing tablets, often inappropriately, to aid in administration.

The relatively high prevalence of dysphagia and resultant alterations in medication administration emphasize the need to identify patients with dysphagia and to better educate and counsel patients on medication crushing. Pharmacists are uniquely suited for this role, and a recently published review article details the current literature around medication crushing and how inappropriate crushing may alter the effectiveness and safety of medications.⁴

When identifying patients who may have dysphagia, I often rely on what I call my “pharmacist Spidey-sense.” It’s that gut feeling we all have when we realize we need to investigate something a little further. It occurs during a team meeting when a fellow health care professional mentions a patient is having trouble swallowing or recently had surgery or radiation. It can also happen when you overhear a patient or caregiver speaking to a team member regarding new mouth pain or a new diagnosis of a disease state highly associated with swallowing difficulties such as Parkinson disease or stroke. In many of these instances, I find myself starting to inquire more about the patient’s swallowing difficulty and if it’s impacting how they are taking or being administered their medications.

Recognizing your pharmacist Spidey-sense in identifying patients with dysphagia requires more than an understanding of how it manifests and the workarounds patients may employ. It is equally important to understand the prescription and OTC medications that may induce dysphagia (see Table¹⁵) and to proactively inquire about their use. Electronic patient records often do not fully capture OTC drug use, but gathering this information may be critical in understanding if or why a patient has dysphagia beyond physiologic or pathologic changes.

Table. Examples of Medications Associated With Dysphagia¹⁵

It is crucial for pharmacists to probe for dysphagia because many community-dwelling adults and their caregivers do not recognize they have dysphagia despite having swallowing difficulties. Even more troublesome is that these same patients and caregivers will routinely modify medications to make them easier to swallow without consulting a clinician. For example, studies have demonstrated that nearly 1 in 5 community-dwelling patients will modify their medications to aid swallowing,⁵ and rates of modification increase among those with swallowing difficulties.⁶ In a survey of nurses on inpatient units, approximately 2 in 3 nurses reported crushing tablets or opening capsules for their patients with swallowing difficulties.⁷ These are frequencies that should put all pharmacists on alert to better identify patients who may have dysphagia and educate patients, caregivers, and clinical staff about proper medication administration.

Pharmacy students may inquire why pharmacists focus so intently on crushing medications because it appears to be a simple process; however, this act is ultimately a medication error when the tablet is not indicated for crushing. Even when a medication can be crushed, it doesn’t necessarily mean it should be crushed. Pharmacists understand that crushing medications may alter the pharmacokinetic properties of the drug, which may then change its effectiveness and safety.⁸ This may be especially true if the crushed medication is placed into a vehicle (eg, liquid, soft food) that may further alter the properties of the medication.^9,10 And truthfully, although pharmacists care and think about pharmacokinetics, it's not really something all other health care professionals think about. Drug loss due to crushing may also be a concern. Despite properly using commercial crushing devices and subsequently rinsing thoroughly, there may be a drug loss of between 0.5% and 10.4% depending on the device used.¹¹ It is these alterations, however small they may appear, that can have a dramatic effect on the clinical outcomes for our patients.

Until recently, an important resource clinicians used for determining whether a medication was safe to crush was the List of Oral Dosage Forms That Should Not Be Crushed (commonly referred to as the “Do Not Crush” list).¹² This list also provided information for drugs that required a specific protocol when being crushed. As the “Do Not Crush” list is no longer being updated or published by the Institute for Safe Medication Practices, it can be more challenging or time-consuming to identify which medications can be crushed and the best method to do so.

Although not as robust or freely available, there are alternatives. The FDA biopharmaceutics classification system categorizes drugs according to their solubility and intestinal permeability,¹³ and may inform delivery vehicle selection when specific mixing guidance is unavailable. Clinical references such as Lexicomp also provide valuable medication crushing information but require a paid subscription, limiting easy access depending on your organization’s clinical resources.

Previous research has shown that poor medication crushing practices may be commonplace.^5-7,14 Thus, a focus on the implementation of straightforward processes may help ensure that medication administration protocols are properly reviewed and executed by the care team and may result in higher quality of care. It may also be advisable to institute observed medication passes where instant feedback can be provided to clinical staff who are distributing medications.

The crushing of medications by patients with dysphagia or their caregivers may appear to be a simple act, but it risks reducing effectiveness and increasing adverse outcomes if done inappropriately. Pharmacists should actively work to identify patients who may have dysphagia, regardless of formal diagnosis, and then subsequently work with the care team to devise a medication administration plan that maintains the safety and effectiveness of the crushed product. At the end of the day, trust that pharmacist Spidey-sense.

Acknowledgments

Medical writing and editorial support were provided by Jory Fleischauer, PharmD, of The Curry Rockefeller Group, LLC (Tarrytown, NY), and were funded by Sumitomo Pharma America, Inc. (Marlborough, MA).

References

1. Roy N, Stemple J, Merrill RM, Thomas L. Dysphagia in the elderly: preliminary evidence of prevalence, risk factors, and socioemotional effects. Ann Otol Rhinol Laryngol. 2007;116(11):858-865. doi:10.1177/000348940711601112

2. Holland G, Jayasekeran V, Pendleton N, Horan M, Jones M, Hamdy S. Prevalence and symptom profiling of oropharyngeal dysphagia in a community dwelling of an elderly population: a self-reporting questionnaire survey. Dis Esophagus. 2011;24(7):476-480. doi:10.1111/j.1442-2050.2011.01182.x

3. Wolf U, Eckert S, Walter G, et al. Prevalence of oropharyngeal dysphagia in geriatric patients and real-life associations with diseases and drugs. Sci Rep. 2021;11(1):21955. doi:10.1038/s41598-021-99858-w

4. Blaszczyk A, Brandt N, Ashley J, Tuders N, Doles H, Stefanacci RG. Crushed tablet administration for patients with dysphagia and enteral feeding: challenges and considerations. Drugs Aging. 2023;40(10):895-907. doi:10.1007/s40266-023-01056-y

5. Godaert L, Cofais C, Proye E, Allard Saint Albin L, Drame M. Medication modification in a population of community-dwelling individuals aged 65 years or older. Age Ageing. 2022;51(2) doi:10.1093/ageing/afab240

6. Schiele JT, Quinzler R, Klimm HD, Pruszydlo MG, Haefeli WE. Difficulties swallowing solid oral dosage forms in a general practice population: prevalence, causes, and relationship to dosage forms. Eur J Clin Pharmacol. 2013;69(4):937-948. doi:10.1007/s00228-012-1417-0

7. Clauson H, Rull F, Thibault M, Ordekyan A, Tavernier J. Crushing oral solid drugs: assessment of nursing practices in health-care facilities in Auvergne, France. Int J Nurs Pract. 2016;22(4):384-390. doi:10.1111/ijn.12446

8. Cornish P. "Avoid the crush": hazards of medication administration in patients with dysphagia or a feeding tube. Can Med Assoc J. 2005;172(7):871-872. doi:10.1503/cmaj.050176

9. Manrique YJ, Lee DJ, Islam F, et al. Crushed tablets: does the administration of food vehicles and thickened fluids to aid medication swallowing alter drug release? J Pharm Pharm Sci. 2014;17(2):207-219. doi:10.18433/j39w3v

10. Carrier MN, Garinot O, Vitzling C. Stability and compatibility of tegaserod from crushed tablets mixed in beverages and foods. Am J Health Syst Pharm. 2004;61(11):1135-1142. doi:10.1093/ajhp/61.11.1135

11. Thong MY, Manrique YJ, Steadman KJ. Drug loss while crushing tablets: comparison of 24 tablet crushing devices. PLoS One. 2018;13(3):e0193683. doi:10.1371/journal.pone.0193683

12. Institute for Safe Medication Practices. Oral dosage forms that should not be crushed. 2022. Accessed September 15, 2022, 2022. https://www.ismp.org/recommendations/do-not-crush

13. Benet LZ. The role of BCS (biopharmaceutics classification system) and BDDCS (biopharmaceutics drug disposition classification system) in drug development. J Pharm Sci. 2013;102(1):34-42. doi:10.1002/jps.23359

14. Fodil M, Nghiem D, Colas M, et al. Assessment of clinical practices for crushing medication in geriatric units. J Nutr Health Aging. 2017;21(8):904-908. doi:10.1007/s12603-017-0886-3

15. Balzer K. Drug-induced dysphagia. Int J MS Care. 2000;2(1):40-50.