Difficulty swallowing: what is dysphagia and what can you do?

What is dysphagia?

Dysphagia is a medical term that describes difficulty when swallowing. This is surprisingly common, especially when it comes to taking tablets or capsules. In fact, many people who have no problem swallowing food struggle when it comes to taking medication.

In the limited range of surveys of the general adult population without dysphagia, the proportion reporting some degree of difficulty swallowing solid oral dosage forms, such as tablets and capsules, is typically around 15–20%, with numbers ranging from 6% through to 50%.¹

A survey within pharmacies in England and Northern Ireland found that:²

• Almost 60% of people experience difficulties swallowing their treatments
• 68% needed to open a capsule or crush a tablet to swallow it
• 69% admitted not taking a tablet or capsule because it proved hard to swallow
• 72% of patients and carers reported that their doctor or nurse never asked if they had difficulty taking tablets or capsules before writing their prescriptions

Surprisingly, although conditions that can cause dysphagia become more common with increasing age, more people between 18 and 64 reported having these problems (44%) than those age 65 and older (26%).

Most of those having problems swallowing pills described the sensation as having a pill stuck in their throat (80%), having a bad aftertaste in their mouth (48%), or gagging (32%). Worryingly, 8% of those with difficulty swallowing tablets admitted that they had skipped medication doses, and 4% had discontinued using their medication altogether.

Tablets or capsules: which is easier to swallow?

To help understand whether different sizes, shapes, surfaces or even colours of medication caused problems, a study asked people to swallow tablets and capsules with different appearances.³ The results showed that:

• Gelatine capsules were easier to swallow than tablets
• Coated tablets were easier to swallow than uncoated tablets
• People preferred tablets and capsules that were white in colour
• They disliked purple tablets and brown capsules the most

Overall, there was a strong preference for tablets that were small and white, circular and coated. If the level of ingredients required a bigger tablet, the preferred format was an oblong or oval tablet with a coating. In general, however, capsules were preferred to tablets.

The same preferences are likely to be true of food supplements, which some people also find difficult to swallow.

Tablet and capsule alternatives

New drug formulations mean that many medical treatments are now available as patches, dissolvable (effervescent) tablets, sprays and products that dissolve on the tongue without water – as well as syrups – to help overcome swallowing problems.

Similar advances in food supplements mean that many vitamins, minerals and herbal remedies are available as gummies, sprays, liquids, drops, tinctures and dissolvable effervescent tablets, all of which many people may find easier to take than tablets or capsules.

Capsules can be harder to swallow than tablets

Although surveys suggest that capsules are more popular than tablets, they can prove difficult to swallow, too. This is because capsules are lighter than water and float, due to air trapped inside the gelatine shell. In comparison, tablets are heavier than water and do not float. This makes a difference due to how the body's swallowing mechanism works.

Stages of swallowing

In order to swallow food, the tongue rolls chewed food into a ball (bolus) which, when pushed to the back of the mouth, triggers the swallowing reflex. When it comes to taking a medicine or supplement, the usual method is to place the tablet or capsule on the tongue, fill the mouth with water, tilt the head back and swallow.

This works well for tablets because they do not float, and because gravity assists swallowing when the head is tilted back.If this technique is used with a capsule, however, it can float on the water in the front of the mouth, placing it in the wrong part of the mouth for ease of swallowing.⁴

Causes of dysphagia

If you have difficulty swallowing pills but no problems swallowing food or liquid, the underlying cause is likely to be the physical sensation of the small, hard pill in your mouth, which may make you gag, along with the thought of having to get it down.

For those who also have trouble swallowing food or liquid, however, poor coordination of muscles and reflexes in the mouth and oesophagus may be a cause. This can happen with gastro-oesophageal reflux disease or age-related weaking of the swallowing muscles.

Dysphagia can also result from dry mouth conditions (such as those associated with Sjogren's disease and rheumatoid arthritis) or neurological conditions such as multiple sclerosis, stroke, Parkinson's disease or dementia.

Is dysphagia curable?

If you have persistent difficulty swallowing, it's important to tell your doctor (especially if it's a new symptom) so the underlying cause can be identified. In a few cases, for example, this may be one of the first signs of a throat cancer.

If a medical cause is identified, treatment will depend on the condition, but may include dietary advice, exercises and techniques used in speech and language therapy, or dilation of any obstruction. Most swallowing problems can be improved in this way, although a cure is not always possible.

Did you know? Botox is sometimes used to treat swallowing difficulties caused by stiffening of muscles in the oesophagus (achalasia), which stops food and drink reaching the stomach.

How to overcome dysphagia

If no underlying cause is found and dysphagia is not due to a physical constriction or neurological or muscular problem, and if it only affects medicine or supplements, you may be able to overcome it with practice. If you take tablets or capsules every day, for example, you may find a way of taking them that works for you. You could also swap some of your tablets or capsules for sprays or gummies, if available – see 'Tablet and capsule alternatives' below.

Swallowing techniques

A study published in the Annals of Family Medicine tested two techniques designed to help people swallow 16 differently shaped tablets or capsules.⁵

Technique 1

The pop-bottle method for swallowing large tablets involves filling a plastic pop/water bottle with water, putting the tablet on your tongue, closing your lips tightly around the opening of the bottle and taking a drink using a sucking motion. Swallow the water right away and the pill should go down with it. Don't let air into the bottle; it should squeeze in as you suck and swallow.

Technique 2

The lean-forward method for swallowing capsules involves putting the capsule on your tongue, taking a sip of water, then bending the head forward before you swallow.

The study found that the pop-bottle method substantially improved swallowing of tablets in 60% of people, and the lean-forward technique for capsules in 89%.

For more information see the full study.