Problems swallowing pills

Also called Pill dysphagia, Difficulty taking tablets

Very common, rarely asked about, and a major hidden cause of medicines simply not being taken. Crushing tablets can be dangerous.

What it is

Difficulty swallowing tablets and capsules, either from a physical swallowing problem or from anxiety and gagging with no physical abnormality.

It is common: a substantial minority of adults report difficulty, and many manage it silently by skipping doses, which is a large and invisible cause of untreated illness.

It matters most in the groups least likely to raise it: older people, people with dysphagia after stroke or in Parkinson's disease or dementia, people with a learning disability, and children.

**Crushing tablets or opening capsules is not a neutral solution.** Modified-release preparations release their whole dose at once when crushed, which can be dangerous. Enteric coatings protect the stomach or protect the drug from acid. Some drugs are hazardous to the person crushing them, including cytotoxics and hormones. Crushing is frequently done in care settings without checking, and often outside the product licence, which requires a specific decision and documentation.

The right sequence is: ask whether there is a difficulty; check whether a liquid, dispersible, patch, injection or different formulation exists; ask a pharmacist before crushing anything; and consider whether the medicine is still needed at all. See polypharmacy.

Swallowing technique also helps: the lean-forward method for tablets and the pop-bottle method for capsules both work and are almost never taught.

Signs you might notice

Coughing, gagging or choking on tablets.

Tablets sticking in the throat, or a feeling that they have.

Taking a very long time over medicines, or needing large volumes of drink.

Avoiding or skipping doses, hiding tablets, or spitting them out.

Tablets found in bedding, pockets or the mouth.

Distress or anxiety at medicine times.

Assess further: coughing on food and drink as well as tablets, a wet voice after swallowing, weight loss, or recurrent chest infections, which indicate dysphagia and need speech and language therapy assessment.

Urgent: a tablet felt to be stuck causing chest pain, drooling or inability to swallow saliva, which may be an impacted tablet or an oesophageal problem.

Also: burning chest pain after tablets, which can be tablet-induced oesophagitis, particularly with doxycycline, alendronate and potassium.

How it can affect day-to-day life

Asking the question is the intervention. Most people never volunteer it, because it feels trivial or embarrassing, and clinicians assume that a prescribed medicine is a taken medicine.

Position matters: sitting upright, and staying upright for at least 30 minutes after certain tablets such as alendronate and doxycycline, which cause oesophageal ulceration if they lodge.

Plenty of water, a full glass rather than a sip, helps tablets pass.

The lean-forward technique for tablets, tilting the chin down while swallowing, and the pop-bottle method for capsules, sucking water from a flexible bottle, both improve success substantially and take a minute to teach.

Alternatives are often available: liquids, dispersible or orodispersible tablets, patches, injections, and sometimes a different drug in the same class.

Never add a crushed tablet to a whole meal or drink that may not be finished; the dose becomes unknown.

Covert administration, giving medicines hidden in food without the person's knowledge, is lawful only in specific circumstances for a person who lacks capacity, with a best interests decision, pharmacist advice and clear documentation. It is not a workaround for refusal by somebody with capacity. See mental capacity.

Supporting someone well

Ask the question. Most people will not raise it.

Ask a pharmacist before crushing anything or opening a capsule. Some are dangerous crushed.

Ask whether a liquid, dispersible, patch or injectable form exists.

Sit upright, use a full glass of water, and stay upright for 30 minutes after alendronate, doxycycline and similar.

Teach the lean-forward technique for tablets and the pop-bottle method for capsules.

Review whether every medicine is still needed; fewer tablets is often the best answer.

Get a swallow assessment if food and drink are also difficult.

Never hide medicines in food without a proper best interests decision and documentation.

Record what actually gets taken, not what is prescribed.

Where to get help

A pharmacist, who is the right person for formulation advice and can advise on crushing.

A GP practice for a medication review and alternative formulations.

Speech and language therapy for a swallow assessment where food and drink are also affected.

Urgent care for a tablet stuck with chest pain or drooling.