1. Deglutition and Alternative Options to Receive Pharmacological Medications
Swallowing difficulties have become an increasing concern for healthcare providers due
to increasing numbers of a geriatric population, from longer lifetime expectancy, directly
affecting hospitals and long-term care facilities. As we age our bodies naturally do not function
as efficiently and effectively, especially with the presence of pathological factors. Disordered
swallowing is also known as dysphagia, which is the difficulty transporting a solid or liquid
bolus from the oral cavity to stomach. Dysphagia can be caused by motor, sensory, or
behavioral problems, which often occurs secondary to another disorder. One major issue that
affects particularly the ageing population whom suffer from dysphagia is the ability to receive
their medications that are prescribed to be taken orally. It has been reported that about one third
of patients in long term care facilities experience serious difficulties with swallowing solid oral
dosage forms (SODF) of medication (Stegemann, Gosch, & Breitkreutz, 2012). This paper will
investigate alternative options to receive mediations non-orally in order to improve the quality of
care for people with dysphagia.
As previously mentioned, dysphagia can be caused by motor, sensory, or behavioral
problems, often occurring secondary to another disorder. Normal swallowing alone is a complex
process and can be broken up into 4 phases: the oral preparatory phase, the oral transit phase, the
pharyngeal phase, and the esophageal phase. The oral prep phase consists of manipulating and
preparing solid and liquid textures to create a bolus within the oral cavity, mechanically reducing
the consistency and volume. The oral transit is initiated when the bolus is posteriorly moved to
the back of the mouth by way of anterior-posterior lingual movement. In a healthy adult, this
phase should only take about .9-1.5 seconds. The pharyngeal phase begins when the bolus head
passes, triggering a pharyngeal swallow and should take about .6-1 second to complete. The

2. final phase, the esophageal phase consists of the bolus being carried through the upper
esophageal sphincter (UES), which uses force and pressure through the larynx to bring the bolus
to the lower esophageal sphincter (LES). In a healthy adult, this phase should take about 8-20
seconds. Dysphasia stemming from a pathophysiology can occur at any and multiple phases of
swallowing simultaneously. Dysphagia due to ageing emerges from physiological, anatomical,
motoric and sensory changes (Stegemann, Gosch, & Breitkreutz, 2012). Specifically, a decrease
in muscle strength and sensory function are correlated with tongue and lingual pressure, which
creates a slower bolus velocity, leading to delays in laryngeal vestibule closure and UES transit
time, ultimately leading to a delayed swallowing reflex (Stegemann, Gosch, & Breitkreutz,
2012). Having a delayed swallowing reflex will put the person at risk for aspiration because
there is a prolonged time of airway exposure.
The most typical and suggested route to receive medications is to take them orally. This
is because the gastrointestinal tract has the best features for drug absorption (Cora, Romeiro,
Stelzer, Americo, Oliveira, Baffa, & Miranda, 2005). In a study done in 2005, a biomagnetic
technique called alternated current biosusceptometry (ACB) was used to investigate the
interactions between solid dosage forms and the human gastro intestinal tract (Cora, et al., 2005).
The biomagnetic process consists of ingesting a magnetic material that can be either in a
magnetic marker (MM) or a magnetic tracer (MT) (Cora, et al., 2005). The MM provides a
punctual magnetic source while the MT is a system that disperses magnetic material in a test
meal (Cora, et al., 2005). An MT was used to tract the process between drug administration and
the onset of pharmacological action. The process includes disintegration of the solid form,
dissolution of the released particles, and drug absorption (Cora, et al., 2005). It was found that
the disintegration phase depends on the type of pharmaceutical form and the quantity and

3. properties of the in active properties in a medication (the excipients) used, meaning that
everything within a dose of medication affects the disintegration phase (Cora, et al., 2005). The
release of particles and absorption phases depends on the type of dosage form, for example a
single unit is a tablet or capsule and a multiple unit is a large quantity that requires to be
measured out into smaller amounts for individual units, like an aliquot of Thick-it (Cora, et al.,
2005). Another important factor to consider is drug solubility on the absorption process. The
solubility can be determined by the drug’s physicochemical properties and the pH within the
gastrointestinal tract, affecting the drug’s duration within the gastrointestinal tract mucosa (Cora,
et al., 2005). Inversely, a drug’s physicochemical properties also affect the pH within the
gastrointestinal tract. From this, the complexity of a typical SODF process through the
gastrointestinal tract is. Thus, there are vital factors that are involved in altering SODF which
are essential to know before drug manipulation.
Ageing as a process impacts many functions within the body, which becomes a concern
for health providers because of how ageing affections the way that medications absorb and
function in the body. For example, cellular, molecular and physiological functionality of tissues
and organs can also influence how drugs enter, distribute and are eliminated from the body
(Perrie, Singh Badhan, Kirby, Lowry, Mohammed, & Ouvang, 2012). Specifically, changes in
the lungs, like reduced lunch capacity which causes slower absorption (Perrie, et al., 2012).
Therefore, there is a need for alternative drug administration as side from SODF. Other forms of
receiving medications are liquid, fast-melt dosage systems, drug delivery to the eye,
intramuscular, intravenous, orally disintegrating, transdermal patch, sublingual, and rectal forms
(Perrie, et al., 2012; Muramatsu, Litzinger, Fisher, & Takeshita, 2010). Since there are so many
alternative options, it is important to consider the complexity of combining the effects of ageing

4. and alternative drug administration; because different delivery methods change the way
medications function. For example, drug delivery to the eye depends on the tear film acts as a
barrier for the medication, which changes as a person ages and can impact the absorption and
function of the particular medication being delivered (Perrie, et al., 2012). Yet, in transdermal
drug delivery, there is no significant difference in absorption within age groups, but dose
administration is still considered depending on the age of a patient (Perrie, et al., 2012).
One study that was done in 2010 focuses on alternative formulations, delivery methods,
and administration options for psychotropic medications in elderly patients with behavioral and
psychological symptoms of dementia (BPSD) (Muramatsu, et al., 2010). The medications
included in the review were antidepressants, anxiolytics, antipsychotics, mood stabilizers,
cognitive enhancers (Muramatsu, et al., 2010). The participants within the studies were
specifically within the geriatric population with BPSD who would refuse medication due to their
swallowing difficulties (Muramatsu, et al., 2010). The alternative delivery methods of
medication were short- and long-acting intramuscular, intravenous, liquid, orally disintegrating,
transdermal patch, sublingual, and rectal forms (Muramatsu, et al., 2010). The study also looked
into further altering the medications like crushing tablets, opening capsules, mixing within food
or liquids, or delivering through a tube (Muramatsu, et al., 2010). It was found that there is no
evidence within the literature to compare the efficacy of SODF with alternative delivery forms.
However, the alternative delivery forms are often the only choice of delivery method for patients
with dysphagia (Muramatsu, et al., 2010). With this information, can be seen how imperative it
is for healthcare providers to know all of the different types of delivery forms that are available
to patients with dysphagia and to understand that altering the SODF can change the affects of the
medications, like the absorption and performance (Muramatsu, et al., 2010).

5. It is crucial for healthcare providers to understand the pharmacology behind alternative
drug delivery because only some medications can safely be chewed, crushed, or cut however;
this does not apply to all SODFs (Paparella, 2010). Specific drug classes are unsafe to alter
when changing SODFs for patients who have difficulties swallowing. On the other hand, some
medications should not be manipulated by being opened, cut, or crushed can also be unsafe for
whoever is administering the medication (Paparella, 2010). Some of the drug classes that can be
manipulated are analgesics, cardiovascular medications, nonsteroidal anti-inflammatory agents,
antiepileptics, and antibiotics (Paparella, 2010). The drug classes that cannot be manipulated
are phenytoin, isosorbide, nifedipine, verapamil, Losec, MS Contin, oxycodone, and
erythromycin (Paparella, 2010). One main reason why certain SODFs cannot be chewed
crushed, or cut is because they are sustained- release formulations and are formulated to
distribute the medication more slowly; as long as 12 to 24 hours (Paparella, 2010). The specific
medications that have this extended release function often have suffixes attached to their name in
order to identify them as long acted (Paparella, 2010). Such suffixes are SR, SA, CR, CD, TD,
ER, TR, XL, XR, and LA (Paparella , 2010). Another type of medication that cannot be
manipulated are enteric- coated drugs (Paparella, 2010). Chewing, crushing, or cutting enteric-
coated drugs can result in a rapid absorption, leading to a toxic amount of medication within a
patient’s system, or may become inactive in the stomach (Paparella, 2010). Crushing a
sublingual tablet could also cause the medication to become ineffective (Paparella, 2010).
Whoever is administering a medication and with carcinogenic/teratogenic potential could be at
risk if the powder becomes aerosolized or has contact with the skin (Paparella, 2010). Some
other consequences with crushing or cutting a SODF are that it may result in a bitter tastes,

6. unusual texture, or local anesthetic effect and stains the patient’s teeth and irritate the mouth,
esophageal mucosa, or stomach lining (Paparella, 2010).
As previously mentioned, changing SODFs will affect the absorption and performance of
medications, which can result in error without the proper education. Error rates have been
commonly found within long term care facilities due to the amount of residents who are in need
of alternate dosage forms due to having dysphagia and nurses who are unaware of the effects of
the changes made to SODFs, despite best intentions (Stegemann, Gosch, & Breitkreutz, 2012).
It has observed that nurses are regularly altering prescribed SODFs in order to help patients who
have swallowing by crushing tablets and opening capsules and mixing them into foods or
beverages (Stegemann, Gosch, & Breitkreutz, 2012). This alternation in SODF is very risky and
could result in drug instability and changes in drug performance (Stegemann, Gosch, &
Breitkreutz, 2012). Another major concern is that patients who live at home without any
assistive care are also making these changes in their prescribed SODFs with little to no education
in pharmacology, not realizing the risk in altering SODFs (Stegemann, Gosch, & Breitkreutz,
2012). In both of these scenarios certain precautions need to be taken, like being properly
information about altering SODFs and alternative delivery methods, and then asking a series of
questions before administering the drug (Gilbar & Hosp, 1999). Some questions that need to be
asked are: 1. Is the drug in an appropriate dosage form for administration? 2. Can a different
dosage form or medication be used or altered? 3. Is the medication compatible with enteral
feed? 4. Are there any factors that may affect drug absorption and performance? (Gilbar &
Hosp, 1999). These question lead to better understanding of the dosage form and avoid any
harmful errors.

7. A study done in 2011, further investigates the alternative delivery methods or oral
medications to patients with and without dysphagia in order to measure the appropriateness of
the alternative methods and administration error rate (Kelly, Wright, & Wood, 2011). The
participants included patients with and without dysphagia, including those with enteral feeding
tubes (Kelly, Wright, & Wood, 2011). The method consisted of observing 2,129 oral
medications being prepared and administered to patients in the stroke and care-of-the-elderly
wards at four acute general hospitals in East of England (Kelly, Wright, & Wood, 2011). The
results revealed 817 errors which consisted of 313 patients with dysphagia (Kelly, Wright, &
Wood, 2011). It was seen that there is a higher risk for patients with dysphagia, and an even
higher risk for patients who have feeding tubes (Kelly, Wright, & Wood, 2011).
When specifically using a feeding tube, some factors to consider are if altering or mixing
the medication is necessary, if altered or mixed will the drug or feeding tube be degraded and/or
inactive, or if a medication needs to interact with food, can it interact appropriately with the
enteral formulas (Gilbar & Hosp, 1999). Another factor to consider is the placements of the
feeding tube, which can affect the absorption of medications (Gilbar & Hosp, 1999). Proper
placement requires the distal end of the tube to be situated past the absorption site, however if the
tube is placed too far in the gastrointestinal tract, the primary location where the medication’s
action could be bypassed (Gilbar & Hosp, 1999). Patients with feeding tubes often have
irritation of the gastrointestinal tract, resulting in diarrhea which can result in stripping of the
intestinal mucosa and create a malabsorption cycle (Gilbar & Hosp, 1999). Thus, diarrhea
causes a decrease in the absorption and function of medications that travel through the
gastrointestinal tract (Gilbar & Hosp, 1999).

8. Another study that was done in 2013, investigates the challenges of SDOF administration
by a feeding tube. The study focuses on the comparison of different combinations of open or
confined crushing of the SODF suspension and the amount of aerosol contamination during
crushing and suspending (Salmon, Pony, Chevallard, Diouf, Tall, Pivot, & Pirot, 2013). When a
patient is put on a feeding tube, the ideal situation is to delivery their medications through
alternate pathways, like intravenously or intramuscularly, but this cannot always be the case
since not all medications can be transformed in to a liquid dosage form (Salmon, et al., 2013).
Some of the main concerns when administering SODFs by way of feeding tubes are the
pharmaceutical relevance of crushing, the loss and concomitant aero-contamination of drug
substance, the drug–nutriment interactions and as mentioned before, feeding tube clogging
(Salmon, et al., 2013). The SODFs crushing and suspending protocols consisted of one open
crushing/open suspending protocol, a confined crushing/open suspending protocol, and a
confined crushing/confined suspending protocol (Salmon, et al., 2013). The first protocol used a
mortar and pestle to crush and suspend the SOFD in mineral water (Salmon, et al., 2013). The
second protocol used a pill crusher and the transferred the powder to a mortar and suspended in
mineral water (Salmon, et al., 2013). The third protocol used a device that combined crushing
and suspending the SODF consisting of a regular pill crusher and a tube that was adapted to a 60-
mL feeding syringe in order to transfer the SODF suspension in the syringe without spilling
(Salmon, et al., 2013). The results showed that all three protocols used were efficient for
crushing and suspending properties, but there was a significantly higher aerosolisation of SODF
particles in both open crushing and suspending protocol (Salmon, et al., 2013). In all three
protocols, it was found that efficiency of crushing was similar and that the preparation resulted in
equally stable suspensions (Salmon, et al., 2013). As a result, both confined crushing and

9. suspending protocol are efficient, time saving, and safe alternatives to receive SODF medications
prescribed orally to patients with feeding tubes (Salmon, et al., 2013).
A study that focuses on oral drug administration by a feeding tube was done in 2012,
which investigated the frequency of administration the number of tablets given per day, and the
percentage of adults receiving enteral nutrition who also received intravenous medications
(Soares Barbosa, A.P., Lacerda de Paula,Soares Barbosa, D., & Ferreira da Cunha, 2012). This
retrospective study examined 170 cases of patients who received any of the 100 different
medications that were prescribed to be administered through the feeding tube (Soares Barbosa, et
al., 2012). The patients received their medications between 1-17 times a day and in the SODF
which were administered up to 76 drugs per day, some of which were administered two to three
times a day (Soares Barbosa, et al., 2012). The results showed that most of the cases were
administered four or more of their medications simultaneously through their feeding tube (Soares
Barbosa, et al., 2012). Further research is suggested to investigate the amount of nutrients
actually infused due to the amount of residue remained in the feeding tubes after administration
(Soares Barbosa, et al., 2012). It was also noted that the amount of water used to flush the tubes
after each dose administration per day could have a negative effect, causing fluid overload or
electrolyte abnormalities (Soares Barbosa, et al., 2012).
A current study that was done in 2014 focuses specifically on subcutaneous drug
administration as an alternative to SODF (Bartz, Klein, Seifert, Herget, Ostegathe, & Stiel,
2014). The study investigated the efficacy and local reactions of subcutaneous medications
(Bartz, et al., 2014). The data included dosage and volume of injection, type of needles, and
injection site; along with subjective data which consisted of perceptions of patients of their
tolerability and acceptability of the subcutaneous route of drug administration (Bartz, et al.,

10. 2014). The participants included 120 patients from an inpatient palliative care unit who were
administered medication via needles in the thighs and upper arms (Bartz, et al., 2014). The study
mentioned possible complications of subcutaneous route of drug administration which could be
infection, bruising, irritation, and skin changes at the site of injection, and slow absorption if a
patient has poor circulation, however, none were seen as a result of the study (Bartz, et al.,
2014). The results provide that using subcutaneous route of drug administration is a practical
and safe alternative method (Bartz, et al., 2014). It is important to note that this form of drug
administration requires proper nursing care and can have risks and complications (Bartz, et al.,
2014).
In conclusion, drug dosage and administration has become an increasing concern for the
ageing population due to nature changes from the ageing process and pathological factors such as
dysphagia. When the traditional SODF cannot be used to receive medications, there are various
types of alternative drug administration forms that can be used. These alternate forms of drug
administration include liquid, fast-melt dosage systems, drug delivery to the eye, intramuscular,
intravenous, orally disintegrating, transdermal patch, sublingual, and rectal forms (Perrie, et al.,
2012; Muramatsu, et al., 2010). Other alternative drug administration forms are through a
feeding tube, which is a common used for patients with severe dysphagia and the subcutaneous
route. Both forms of administration are safe and practical; however there are risks involved such
as diarrhea which affects absorption and function of medications that travel through the
gastrointestinal tract, and infection, bruising, irritation, and skin changes at the site of injection
(Gilbar & Hosp, 1999; Bartz, et al., 2014). Some of the main concerns when administering
manipulations of SODFs through a feeding tube are the pharmaceutical relevance of crushing,
the loss and concomitant aero-contamination of drug substance, the drug–nutriment interactions

11. and as mentioned before, feeding tube clogging (Salmon, et al., 2013). Further research still
needs to look into the efficacy of alternative drug delivery forms and the efficacy of altering
SODFs for the safety and quality of care for patients with dysphagia.

12. References
Bartz, L., Klein, C., Seifert, A., Herget, I., Ostegathe, C., & Stiel, S. (2014). Subcutaneous
Administration of Drugs in Palliative Care: Results of a Systematic Observational Study.
Journal of Pain and Symptom Management, 48 (4), 540-547.
Cora, L.A., Romeiro, F.G., Stelzer, M., Americo, M.F., Oliveira, R.B., Baffa, O., Miranda, J.R.A.
(2005). AC biosusceptometry in the study of drug delivery. Advanced Drug Delivery
Reviews, 57 (8), 1223–1241.
Gilbar, P.J. & Hosp, D. (1999). A guide to enteral drug administration in palliative care. Journal
of Pain and Symptom Managemen, 17 (3), 197-207.
Kelly, J., Wright, D., & Wood, J. (2011). Medicine administration errors in patients with
dysphagia in secondary care: a multi-centre observational study. Journal of advanced
nursing, 67(12), 2615–2627.
Muramatsu, R.S., Litzinger, M.H.J., Fisher, E., & Takeshita, J. (2010). Alternative formulations,
delivery methods, and administration options for psychotropic medications in elderly
patients with behavioral and psychological symptoms of dementia. The American
Journal of Geriatric Pharmacotherapy, 8 (2), 98–114.
Paparella ,S. (2010). Identified safety risks with splitting and crushing oral medications. Journal
of Emergency Nursing, 36 (2), 156-158.

13. Perrie, Y., Singh Badhan, R.K., Kirby, D.J., Lowry, D., Mohammed, A.R., & Ouvang, D.
(2012).The impact of ageing on the barriers to drug delivery. Journal of Controlled
Release, 161 (2), 389–398.
Salmon, D., Pony, E., Chevallard, H., Diouf, E., Tall, M., Pivot, C., & Pirot, F. (2013).
Pharmaceutical and safety considerations of tablet crushing in patients undergoing enteral
intubation. International Journal of Pharmaceutics, 443, 146– 153.
Soares Barbosa, A.P., Lacerda de Paula, S., Soares Barbosa, D., & Ferreira da Cunha, D. (2012).
Oral drug administration by enteral tube in adults at a tertiary teaching hospital. e-SPEN
Journal , 7, 241- 244.
Stegemann, S, Gosch, M.,& Breitkreutz, J. (2012). Swallowing dysfunction and dysphagia is an
unrecognized challenge for oral drug therapy. International Journal of Pharmaceutics,
430, 197– 206.