1.

Different methods for swallowing pills

One of the suggested tips from the provided website was to crush the pills into a powder.
When looking at this technique physiologically, crushing the pill may assist in forming a more
cohesive bolus. The texture of liquid and the texture of the pill vary significantly. When the pill
is taken with a thin liquid, the liquid may travel faster than the tablet or capsule (Corbin-Lewis,
2005). By crushing the pills, it is making the consistencies more analogous to each other and
therefore allows them to travel at more similar rates. By doing this, a more cohesive bolus may
be formed and it may be easier for the patient to swallow. Although this technique may help with
the physiology of the swallow, it is not recommended in all situations. While the editors note
provides a brief disclosure about avoiding crushing slow release tablets, this tip is still largely
inept, as there are still many other factors that fail to be addressed.
There are three different types of medication release; immediate release, enteric coated,
and controlled release. Each of these act in different ways. Immediate release medications are
designed to release shortly after entering the system. They act quicker than other medications
and therefore need to be taken more frequently throughout the day. Extended release
medications, or time released medications, are designed to release over a longer period of time.
This allows the medication to remain in the system on a more consistent basis over periods of
time and designed to be taken less frequently. The final type of medication is enteric coated pills.
These are designed to be released after the pill passes the stomach. The outside is coated with a
layer that protects it from the acid in the stomach so that when it reaches the stomach it is not
released before it is intended (Kelly, 2011). By crushing either and extended release medication
or an enteric coated one, the integrity of the design of the medication is altered. Jennifer Kelly
states, medicines with enteric coats, e.g. lansoprazole, and small therapeutic windows, e.g.
digoxin, were identified as being crushed prior to administration. Digoxin tablets have a
bioavailability of 0.7 (Lisalo 1977) and crushing may increase this to 1, i.e. an almost 50%
increase in dosage absorbed, and consequently crushing without appropriate monitoring could
adversely affect patient safety (Kelly, 2011, p. 2622). This can be very dangerous for the
consumer because the dosage entering the system differs from the intended dose that was
prescribed. The same applies for the extended release tablets. If the pill is crushed, the
medication is released much quicker and in a higher dose than which was intended, which can be
very dangerous for the patient. When crushing medication, it is warranted to consult the
pharmacist before doing so.
Another tip that is recommended on the website is to take the pill with food. By taking
the medication with food, it will likely create a more cohesive bolus. As previously stated, the
liquid travels at a higher velocity than the pill. This may result in the liquid being swallowed and
the medication remaining in the oral or pharyngeal cavity. Corbin-Lewis and Liss state that the
length of time and amount of movement of the hyolaryngeal complex increases with thicker
foods. As well, the bolus holds together and does not split around the epiglottis as does a liquid
swallow (Corbin-Lewis, 2005, p. 269). By combining the pill with food, it will form a more
cohesive bolus and will likely be easier to swallow. By thickening the consistency with which
the capsule or tablet is taken with, it will increase hyolaryngeal complex movement to increase
the likelihood of a successful swallow (Chi-Fishman, 2002). This is due to the fact that adequate

hyolaryngeal complex movement is necessary to initiate a swallow and open the upper
esophageal sphincter, which allows the bolus to pass into the stomach via peristalsis. By
increasing the movement of the hyolaryngeal complex, the rest of the swallow is more likely to
be successful.

2. Straw drinking versus cup drinking

Many studies have examined the difference in physiology between sequential straw drinking
and cup drinking. The literature indicates that the physiology between these methods differ.
When drinking through a straw, the patient is more inclined to engage in sequential swallows.
When the patient swallows continuously, the hyolaryngeal complex remains partially elevated.
Daniels et. al reports, that older adults maintain partial HLC elevation as the literature on motor
control physiology suggests that it is more efficient to allow muscles to remain activated and
subtly contracted rather than to completely deactivate and reactivate repeatedly (Daniels, 2004,
p. 42) Therefore, if individuals are having difficulty initiating a swallow due to hyolaryngeal
complex elevation, engaging in consecutive swallows where the complex remains slightly
elevated may be beneficial. This study also found that penetration may be considered normal for
sequential swallows in straws (Daniels, 2004). For an individual that exhibits difficulty closing
off the airway, sequential swallows from straw drinking may increase the risk of aspiration.
Drinking from a cup requires a muscular control to engage in a tight seal so that the bolus
is contained to the oral cavity. A person with poor motor control of the lips and muscles required
for this task may benefit from the use of a straw when drinking. When utilizing a straw, the bolus
initiates in a more posterior position, which may allow for better control. Harry Lawless found
that when drinking sequentially through a straw, the upper esophageal sphincter remains open for
a longer period of time (Lawless, 2003). This may be beneficial to a patient with dysphagia
because the longer the upper esophageal sphincter remains open, the greater likelihood that the
bolus will enter and pass to the stomach.
Daniels et. al found that the average volume per swallow when drinking from a cup was
greater than the average volume per swallow when compared to sequential straw drinking
(Daniels, 2000). As the volume of the bolus increases, so does the velocity and forward
movement trajectory of the swallowing mechanism (Chi-Fishman, 2002). If a person with
dysphagia has difficulty closing off the airway in time, drinking greater volumes through cup
drinking may not be warranted. This is due to the fact that it will speed up the transit of the bolus
and increase the risk of aspiration if the patient cannot close off the airway in time. However, if
the patient is having difficulty elevating the hyolaryngeal complex to initiate a swallow,
increasing the size of the bolus by drinking through a cup may assist in hyolaryngeal elevation
and the initiation of a swallow. Therefore, we cannot assume that one form is always safer than
another. The safety of the swallow and modifications that need to be made rely on the
individuals underlying physiological deficits and should be treated as thus.

References
Chi-Fishman, G., & Sonies, B. (2002). Effects of Systematic Bolus Viscosity and Volume
Changes on Hyoid Movement Kinematics. Dysphagia, 17(4), 278-287.
doi:10.1007/s00455-002-0070-3

Corbin-Lewis, K., & Liss, J. (2005). Physiological Bases of Compensatory Treatment Strategies.
In Clinical anatomy & physiology of the swallow mechanism (2nd ed., pp. 257-281).
Cengage Learning.
Daniels, S., & Foundas, A. (2000). Swallowing Physiology of Sequential Straw Drinking.
Dysphagia, 16, 176-182. doi:10.1007/s00455-001-0061-0
Daniels, S., Corey, D., Hadskey, L., Legendre, C., Priestly, D., Rosenbek, J., & Foundas, A.
(2004). Mechanism Of Sequential Swallowing During Straw Drinking In Healthy Young
And Older Adults. Journal of Speech, Language, and Hearing Research, 47, 33-45.
doi:10.1044/1092-4388(2004/004)
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), 26152627. doi: 10.1111/j.1365-2648.2011.05700.x
Lawless, H., Bender, S., Oman, C., & Pelletier, C. (2003). Gender, Age, Vessel Size, Cup vs.
Straw Sipping, and Sequence Effects on Sip Volume. Dysphagia, 18, 196-202.
doi:10.1007/s00455-002-0105-0