Unveiling the Influence of Psychological Dysphagia on Patient Compliance

During the past 20 years, numerous advancements have been made in drug formulations and routes of administration. Enhanced understanding of drug transport across tissues has bettered the patient adherence to the treatment regimen and pharmacologic response. Various routes of drug administration have been developed that deliver the benefit of being comparatively painless. In addition, the existence of the potential for greater flexibility in diversified clinical situations helps to focus on pros and cons of alternative routes of drug administration.

Oral Route of Drug Administration:

The oral route of drug administration has been most common due to several reasons including cost-effectiveness, ease of accessibility, public familiarity, ease of administration, solidity and uncomplicated manufacturing procedure. Pills including tablets and capsules are extensively used for the administration of prescription drugs as well as for the intake of supplements such as vitamins. In addition, drugs formulated as solid dosage form are more stable than liquid dosage form. 

Tablets and capsules are the exclusive choice for healthcare and pharmaceutical industry because they are most accepted among all accessible oral dosage forms. However, swallowing is a compound process and research studies have highlighted the swallowing difficulties experienced by patients while consuming tablets and capsules which can adversely affect the patient compliance. Although alternative routes have accelerated the development of drug delivery technology over the past two decades but they have proved to be expensive as compared to oral medications, where extensive range of inexpensive generic substitutes are also accessible.

A Hard Pill to Swallow:

The expression “a hard pill to swallow” isn’t just a metaphor because swallowing pills can be a difficult and absolutely unpleasant experience for the patients. It can be caused by several conditions, for instance cancer, stroke, multiple sclerosis, Parkinson's disease and spinal cord injury. One in every three people strives to swallow pills due to a disorder called dysphagia in which a person feels difficulty in moving food from the mouth to the throat. A majority of such people don’t face any difficulty while ingesting food and fluids which clearly indicates that this problem is specifically associated with tablets and capsules.

The dosage form is typically moistened by the functioning of the tongue against the palate, during the oral phase of swallowing medicament. It works in combination with water, which is generally taken to aid swallowing. Then it is forced by the tongue towards the oropharynx. It is smoothed by the closure of the nasopharynx caused by upward movement of the soft palate. Scintigraphy details affirm that it just takes 1.5s to swallow a bolus of water, whereas tablets usually take a little longer i.e. 4-7s. Any tablet is labelled as adherent if more than 20s are needed to move it from the esophagus. Typically, uncoated tablets have a prolonged residence time as compared to coated ones. Most of tablets and capsules can’t be chewed due to the bitter or unpleasant taste of the API. In addition, the process of chewing or breaking up these dosage forms can adversely affect their effectiveness.

Psychological Dysphagia Related to Tablets and Capsules:

Difficulty to swallow capsules and tablets could be psychological in nature in the light of fact that the chalky texture of the pills signalizes the brain to treat it in the way as it's not food. It can be associated with the fear or anxiety of chocking or gagging while engulfing the solid dosage forms as a mental barrier might be created if someone recalls a time when a tablet slid back on the tongue without going down the esophagus. Frustration also might make it difficult to swallow tablet supplements or pills as one is fighting against the natural desire of body to chew something before engulfing it. 

As tablets and capsules are difficult to swallow than foodstuffs, therefore, intake of water is typically needed. Many people with psychological dysphagia take large quantities of water or other fluids to move the tablets and capsules down the throat. Some patient may solve the problem by breaking the tablet into pieces and then taking it or crushing it followed by dissolution in water. Some patient may chew the tablet or capsule prior to its ingestion. These actions can affect the drug release characteristics, bioavailability and efficacy of the medicament.

Patient Non-compliance: 

The most worrisome situation is the withdrawal of treatment by the patient, in case of swallowing difficulty leading to patient non-compliance. Patients who face trouble while swallowing pills either delay the intake of the dose of their medication or skip the dose entirely. As a result, they do not comply with the regimens prescribed to them and the desired therapeutic response in not achieved. Most of patients who are known to be non-compliant to the treatment belong to pediatric and geriatric populations.

Recommendations:

Recognizing and addressing psychological dysphagia is essential for promoting better health outcomes and improving the overall well-being of individuals. Here, I would recommend these strategies:

• New processes should be constructed and implemented to address the inconsistent flow of information regarding the occurrence of swallowing difficulties faced by the patients between the nurse, pharmacist and physician.
• Patients should be permitted to express their clear preferences with respect to medication related characteristics.
• Health-care providers should prescribe, dispense and administer suitable oral dosage forms or modified dosage forms to dysphagic patients that are easy to swallow.
• Patient should be alerted at the beginning of the treatment about the significance to the adherence to the treatment in order to achieve desired clinical outcomes.
• Training and education should be provided to the nurses to prevent the undesirable modification of medications as per the patient preference in hospitals.
• Awareness programs should be arranged to address the problematic administration of oral solid dosage forms among the patients and doctors as well as within the pharmaceutical industry.
• Swallowability should be made an obligatory principle for the designing and licensing of oral medications by the industry and regulatory bodies to advance the patient adherence with prescribed treatments.
• In order to satisfy unmet needs of the patients to enhance patient compliance, patient-centered drug products should be designed on the basis of target patient group, their biological and physiological environment, disease or disorder, active pharmaceutical agents, route of administration and drug delivery technologies.
• In order to make the process of taking pills easier, different head posture techniques and use of devices should be taught to patients.
• Techniques to swallow pills should be taught to the children at an earlier age as they require comparatively less training than old age.
• Physical characteristics of tablets and capsules which can affect the ease of swallowing should be considered while their formulation such as shape, size, weight, surface area, tablet coating, disintegration time etc.
• Regulatory environment should develop a new set of guidelines for the introduction of new innovative dosage forms as the present guidelines must be structured in conformance with conventional dosage forms.
• Pharmaceutical companies should offer call center programs to answer the specific queries of the patients and their care takers regarding the medications prescribed to them.
• Pharmaceutical companies should offer one-to-one coaching to the patients and their care takers with certified educators so that patients can receive educational and therapeutic guidance from a clinician as per their specific needs.

Conclusion:

Psychological dysphagia poses a unique set of challenges, particularly in the realm of oral solid dosage forms. By fostering understanding, employing patient-centered strategies, and embracing alternative solutions, we can pave the way for a more inclusive and supportive approach to medication management. Through these efforts, we aim to transform the pill-taking experience from a source of anxiety to a pathway for improved health and well-being.