Medication Administration in Poststroke Dysphagia: Evaluating Swallowing Safety of Solid Dosage Forms

BACKGROUND: International guidelines recommend standardized dysphagia screening in acute stroke, as up to 75% of patients develop poststroke dysphagia. While medication swallowing is also advised for assessment, no validated screening tools or instrumental evidence exist on solid dosage form (SDF) management. Whole tablets are often crushed to reduce aspiration risk, yet the actual risk of aspiration for both forms remains unknown. Despite its widespread clinical use, crushed medication swallowing has never been evaluated using fiberoptic endoscopic evaluation of swallowing. Closing this evidence gap is essential for guiding safe medication administration in patients with dysphagic stroke. METHODS: A prospective, single-center, cross-sectional study with an experimental design was conducted on 60 patients with acute stroke (<7 days). The swallowing safety and efficiency of 1 crushed placebo tablet and 3 different types of whole placebo tablets, each administered with an accompanying applesauce bolus, were compared using fiberoptic endoscopic evaluation of swallowing. The primary outcome was the incidence of unsafe swallowing, as determined by the Penetration-Aspiration Scale. Secondary outcomes included the presence and location of pharyngeal residue associated with each SDF condition. RESULTS: Of 60 patients with stroke (mean age, 73.4±10.7 years; 55% male) with a median Gugging Swallowing Screen score of 14 indicating moderate dysphagia, 58 patients completed the crushed SDFs trial. Whole SDFs were not swallowed (chewed, spit out, and stopped) in 20 of the 174 trials. All fully swallowed tablets (n=154) were safe, with no penetration or aspiration observed. In contrast, 22 of 154 accompanying boli (14.3%) and 7 of 58 crushed SDFs (12.1%) were rated unsafe, without a significant difference. Crushed SDFs caused significantly more vallecular residues (P<0.001). CONCLUSIONS: These findings highlight the need to reconsider the routine practice of crushing SDFs for patients with dysphagic stroke. A paradigm shift towards using whole SDFs, guided by fiberoptic endoscopic evaluation of swallowing, could enable more frequent administration, reduce errors, and enhance medication efficacy. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT05173051.