Why medicines are given this way

Giving medicines (usually crushed tablets or opened capsules) with food may be necessary for people:

• unable to swallow tablets or capsules, especially if they cannot swallow thin fluids
• whose medicines are given covertly

For advice on medicines in swallowing difficulties, see Choosing medicines formulations in swallowing difficulties.

In all cases, only crush tablets or open capsules if it is safe and appropriate to do so. Checking if tablets can be crushed or capsules opened and Checking if medicines can be given with food provide advice.

Unable to swallow tablets or capsules

People who are unable or unwilling to swallow medicines whole may prefer to take crushed tablets or opened capsules with food.

Unable to swallow thin liquids

Many people with swallowing difficulties cannot swallow thin liquids safely.

Thin liquids, such as water, travel quickly and may be aspirated (go the wrong way), which can lead to pneumonia.

Thicker fluids travel more slowly, allowing the person more time to co-ordinate the swallow response. Food and fluid that is the correct thickness for the patient can be swallowed safely.

Finding the correct fluid thickness level for the patient

People unable to safely swallow food and drink need a SALT (speech and language therapist) assessment. The SALT will determine the appropriate level of fluid thickness and food texture for the patient and document in the swallow assessment report.

Establishing the consistency of fluid and food and person can swallow safely is important . Fluids that are too thin put the patient at risk of aspiration; too thick and the liquid can leave a residue that can be aspirated.

Defining fluid thickness and food texture

Fluid consistency and food texture are graded according to the International Dysphagia Diet Standardisation Initiative (IDDSI) framework. This provides a common terminology and consists of a continuum of eight levels ranging from 0 to 7. Drinks can be Levels 0 to 4; foods can be Levels 3 to 7:

• IDDSI Level 0: ‘thin’ (consistency of water)
• IDDSI Level 1: ‘slightly thick’
• IDDSI Level 2: ‘mildly thick’
• IDDSI Level 3: ‘moderately thick’ (same consistency as liquidised food)
• IDDSI Level 4: ‘extremely thick’ (same consistency as pureed food)

Thickening agents can be used to modify the consistency of thin liquids to IDDSI Levels 1, 2, 3 or 4.

‘Thickened fluids’ refers both to naturally thick fluids and those that are artificially thickened. Thickeners and thickened fluids provides information on artificial thickeners.

The patient’s SALT swallow assessment report will state the IDDSI levels of food and fluid suitable for the patient. If the patient is unable to swallow Level 0 fluids, they cannot safely swallow thin liquids; thin liquid medicines should be avoided.

How to give medicines this way

Before giving medicines with food or thickened fluid, check:

• not all tablets can be crushed or capsules opened and it is important this has been checked and documented
• instructions to crush tablets or open capsules, and administer with soft food or thickened fluid should be included in the patient’s MAR chart or care plan, and ideally on the medicine’s dispensing label
• carers and care home staff may only administer prescription medicines on the instruction of the prescriber and must be trained and competent to do so

Consider the following practical tips:

• medicines should be mixed with food immediately before administration
• if you are giving multiple medicines, ideally give them one at a time so it is clear which the patient has taken
• use a small amount of food or fluid to ensure the full dose of medicine is taken
• if you are giving medicines at mealtime, give it at the start of the meal to make sure the patient takes the dose

Choice of food

Not all medicines can be given with food. The dispensing label will say if food or milk has to be avoided before or after taking the medicine. If in doubt, check with a pharmacist. Checking if medicines can be given with food provides advice.

Practical tips for giving medicines with food or fluid:

• use foods and fluids the person likes
• ensure the food or fluid is the correct thickness for the patient (as above)
• the food or fluid should be cold or warm, not piping hot
• mixing liquid medicines with food or thickened fluid may alter the consistency and is not recommended

Medicines that interact with milk

Some medicines should not be given with milk. Their dispensing label will say if this is the case. Avoid mixing these medicines with dairy products (or calcium-fortified non-dairy products) such as yoghurt or custard. Apple puree is a suitable alternative if safe for the patient to swallow.

Disguising bitter medicines

Crushed tablets or capsule contents may taste very bitter. It can be helpful to mask the taste by using food or fluid with a strong flavour. Bitter tastes may be best masked by foods also with a bitter or sour flavour. Sweet-tasting foods can be used, but the flavour may need to be stronger to overcome the bitterness. Blackcurrant cordial (thickened to the appropriate consistency) and chocolate custard are commonly recommended.

Very cold foods may also disguise poor-tasting medicines, but ice and ice-cream are not suitable for people unable to swallow thin fluids.

Covert administration

Hiding medicines in food (‘covert administration’) is approved only in certain circumstances. has further information.

Additional considerations for covert administration

Taste and appearance are particularly important if medicines are to be given covertly. Consider:

• disguising the taste of bitter medicines (see above)
• the appearance of brightly-coloured medicines may need to be disguised
• liquid medicines may alter the consistency of foods. Give liquid medicines with a small amount of drink, or switch to a different dosage form.

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