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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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To evaluate whether 2 techniques (the pop-bottle method for tablets and the lean-forward technique for capsules) ease swallowing of tablets and capsules, we conducted a cross-sectional study including 151 adults of the general German population. Participants swallowed 16 differently shaped placebos, rated their ease of swallowing on an 8-point Likert scale, and swallowed the 2 dosage forms that they had rated most difficult again using the appropriate technique. The pop-bottle method substantially improved swallowing of tablets in 59.7% (169/283) and the lean-forward technique for capsules in 88.6% (31/35). Both techniques were remarkably effective in participants with and without reported difficulties swallowing pills and should be recommended regularly. INTRODUCTIONA mong ambulatory patients who report difficulty in swallowing pills, 1 in 3 experience vomiting, gagging, choking, or having tablets blocked in the throat.1,2 Therefore, the modification of dosage forms (58.8%) and nonadherence (9.4%) are frequent 1,2 and can worsen medical conditions and increase health care costs.3 Given that tablets and capsules differ markedly in physical properties such as size, shape, and density, optimal swallowing techniques likely differ, too. 4 This study aimed to evaluate the influence of 2 techniques on the swallowing of tablets (the pop-bottle method) and capsules (the lean-forward technique). METHODSAfter obtaining ethical approval and written informed consent, we enrolled 151 participants of the general population (52.3% women, mean age 45.8 years (range 18 to 85 years), 55.6% reporting difficulties swallowing solid dosage forms) in a single-blind experiment (German Clinical Trials Register Number: DRKS00004174). We manufactured 16 differently shaped placebos (capsules; round, oval, and oblong tablets) in 4 size groups.In the pop-bottle method, the tablet is placed on the tongue, the lips are tightly closed around the opening of a flexible PET (polyethylene terephthalate) bottle, and the tablet is swallowed in a swift suction movement to overcome the volitional phase of swallowing. 5 In the lean-forward technique, capsules are swallowed in upright position with the head bent forward (Figure 1 and Supplemental Patient Handout). 6The participants randomly swallowed all dosage forms with their eyes closed, using 20 ml of non-carbonated water, and rated the ease of swallowing on an 8-point Likert scale (0 = very easy, 7 = very difficult to swallow). Structured questionnaires were used to assess participants' ability to swallow placebos (eg, sensation in throat during swallowing). To evaluate the impact of the 2 swallowing strategies, within each of the 2 largest dosage-size groups (large mean ± SD: 474 ± 5.5 mm 3 , very large 834 ± 9.2 mm 3 ), the dosage form that caused the greatest difficulty was picked as intervention placebo and then swallowed using the pop-bottle technique (for tablets) 5 or the lean-forward technique (for capsules) 6 and rated again. Julia T. Schiele, PhD 551The Wilcoxon signed-rank test ...

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