Safe to crush? A pilot study into solid dosage form modification in aged care

Medication administration in aged care facilities: A mixed-methods systematic review

AIM(S)

To synthesize aged care provider, resident and residents' family members' perspectives and experiences of medication administration in aged care facilities; to determine the incidence of medication administration errors, and the impact of medication administration on quality of care and resident-centredness in aged care facilities.

DESIGN

A mixed-methods systematic review.

PROSPERO ID

CRD42023426990.

DATA SOURCES

The AMED, CINAHL, MEDLINE, EMBASE, EMCARE, PsycINFO, Scopus and Web of Science core collection databases were searched in June 2023.

REVIEW METHODS

Included studies were independently screened, selected and appraised by two researchers. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist was followed, with the Mixed Methods Appraisal Tool was used for critical appraisal. Convergent synthesis of data, thematic synthesis and meta-analysis were performed.

RESULTS

One hundred and twenty-eight studies were included (33 qualitative, 85 quantitative and 10 mixed-methods). Five themes were formulated, including 1) Staffing concerns, 2) The uncertain role of residents, 3) Medication-related decision-making, 4) Use of electronic medication administration records and 5) Medication administration errors. Educational interventions for aged care workers significantly reduced medication administration errors, examined across five studies (OR = 0.37, 95%CI 0.28-0.50, p < .001).

CONCLUSIONS

Medication administration in aged care facilities is challenging and complex on clinical and interpersonal levels. Clinical processes, medication errors and safety remain focal points for practice. However, more active consideration of residents' autonomy and input by aged care workers and providers is needed to address medication administration's interpersonal and psychosocial aspects. New directions for future research should examine the decision-making behind dose form modification, aged care workers' definitions of medication omission and practical methods to support residents' and their family members' engagement during medication administration.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

It is important that medication administration in aged care facilities be more clearly acknowledged as both a clinical and interpersonal task. More attention is warranted regarding aged care workers clinical decision-making, particularly concerning dose form modification, covert administration and medication omissions. Resident-centred care approaches that support resident and family engagement around medication administration may improve adherence, satisfaction and quality of care.

IMPACT

What Problem Did the Study Address? Medication administration in aged care facilities is a complex clinical and interpersonal activity. Still, to date, no attempts have been made to synthesize qualitative and quantitative evidence around this practice. There is a need to establish what evidence exists around the perspectives and experiences of aged care workers, residents and resident's family members to understand the challenges, interpersonal opportunities and risks during medication administration. What Were the Main Findings? There is a lack of empirical evidence around resident-centred care approaches to medication administration, and how residents and their families could be enabled to have more input. Dose form modification occurred overtly and covertly as part of medication administration, not just as a method for older adults with swallowing difficulties, but to enforce adherence with prescribed medications. Medication administration errors typically included medication omission as a category of error, despite some omissions stemming from a clear rationale for medication omission and resident input. WHERE AND ON WHOM WILL THE RESEARCH HAVE AN IMPACT?: The findings of this systematic review contribute to aged care policy and practice regarding medication administration and engagement with older adults. This review presents findings that provide a starting point for aged care workers in regards to professional development and reflection on practice, particularly around clinical decision-making on dose form modification, medication administration errors and the tension on enabling resident input into medication administration. For researchers, this review highlights the need to develop resident-centred care approaches and interventions, and to assess whether these can positively impact medication administration, resident engagement, adherence with prescribed medications and quality of care.

REPORTING METHOD

This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Page et al., 2021).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution to this systematic review.

Point Prevalence Survey of Acute Hospital Patients with Difficulty Swallowing Solid Oral Dose Forms

The safe administration of solid oral dose forms in hospital inpatients with swallowing difficulties is challenging. The aim of this study was to establish the prevalence of difficulties in swallowing solid oral dose forms in acute hospital inpatients. A point prevalence study was completed at three time points. The following data were collected: the prevalence of swallowing difficulties, methods used to modify solid oral dose forms to facilitate administration, the appropriateness of the modification, and patient co-morbidities. The prevalence of acute hospital inpatients with swallowing difficulties was an average of 15.4% with a 95% CI [13.4, 17.6] across the three studies. On average, 9.6% of patients with swallowing difficulties had no enteral feeding tube in situ, with 6.0% of these patients receiving at least one modified medicine. The most common method of solid oral dose form modification was crushing, with an administration error rate of approximately 14.4%. The most common co-morbid condition in these patients was hypertension, with dysphagia appearing on the problem list of two (5.5%) acute hospital inpatients with swallowing difficulties. Inappropriate modifications to solid oral dose forms to facilitate administration can result in patient harm. A proactive approach, such as the use of a screening tool to identify acute hospital inpatients with swallowing difficulties, is required, to mitigate the risk of inappropriate modifications to medicines to overcome swallowing difficulties.

Development of Losartan Orally Disintegrating Tablets by Direct Compression: a Cost-Effective Approach to Improve Paediatric Patient's Compliance

The development of suitable dosage forms is essential for an effective pharmacological treatment in children. Orally disintegrating tablets (ODTs) are attractive dosage forms that avoid swallowing problems, ensure dosage accuracy and are easy to administer as they disintegrate in the oral cavity. This study aimed to develop ODTs containing losartan potassium (LP) for the treatment of arterial hypertension in children. The ODTs, produced by the cost-effective manufacturing process of direct compression, consisted of a mixture of diluent, superdisintegrant, glidant and lubricant. Five superdisintegrants (croscarmellose sodium, two grades of crospovidone, sodium starch glycolate and pregelatinized starch) were tested (at two concentrations), and combined with three diluents (mannitol, lactose and sorbitol). Thus, thirty formulations were evaluated based on disintegration time, hardness and friability. Two formulations, exhibiting the best results concerning disintegration time (< 30 s), hardness and friability (≤ 1.0%), were selected as the most promising ones for further evaluation. These ODTs presented favourable drug-excipient compatibility, tabletability and flow properties. The in vitro dissolution studies demonstrated 'very rapid' drug release. Preliminary stability studies highlighted the requirement of a protective packaging. All quality properties retained appropriate results after 12 months of storage in airtight containers. In conclusion, the ODTs were successfully developed and characterised, suggesting a potential means to accomplish a final prototype that enables an improvement in childhood arterial hypertension treatment.

Optimization of solid oral dosage form administration to patients with swallowing difficulties: An integrative review

AIM

To appraise and synthesize research investigating optimizing the administration of solid oral dosage forms (SODFs) to adults with swallowing difficulties.

DESIGN

An integrative review.

METHODS

An electronic search was conducted on Medical Literature Analysis and Retrieval System Online (Public Medline interface), Elsevier SciVerse Scopus and Scientific Electronic Library Online (updated February 2023). Restriction regarding the publication date was not considered for the inclusion of records. Studies addressing risks, general aspects, recommendations about patient postural adjustments, swallowing techniques, swallowing aids and aspects of concealment of SODFs were included.

RESULTS

Fifty-three records published between 2002 and 2021 were included. The main administration risks were aspiration, asphyxia and solid oral dosage form-induced oral/oesophageal mucosal lesions. The most frequent general aspect reported was administering one oral dosage form at a time. The sitting position was the most patient postural adjustment mentioned. The most frequently reported solid oral dosage form swallowing technique was the lean-forward method for capsules. Solid oral dosage form swallowing aids cited: tongue and throat lubricant and solid oral dosage form coating device, swallowing cup and swallowing straw.

CONCLUSION

The literature data on administering SODFs for adults with swallowing difficulties were appraised and synthesized. Some aspects, for example, not administering SODFs simultaneously, can make swallowing safer. Postural adjustments and solid oral dosage form swallowing aids are important to avoid administration risks. Swallowing SODFs can be easier if learned by techniques. Liquid and food are helpful as vehicles, and several of these have been listed.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

By optimizing the contributing factors of administering oral pharmacotherapy, the nurse can use appropriate practices to improve patient safety. Additionally, knowing and establishing the administration aspects are reasonable steps for standardizing care for patients with swallowing oral dosage form difficulties.

IMPACT

This study addressed administering SODFs to adult patients with swallowing difficulties. The administration of SODFs to adult patients with swallowing difficulties can be optimized if only one oral dosage form at a time is administrated and if patient postural adjustments, swallowing techniques and swallowing aids are used. This investigation will impact the care of patients with swallowing difficulties.

REPORTING METHOD

The authors declare they adhered to the relevant EQUATOR guidelines and report following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 Statement.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

VIDEOFLUOROSCOPIC EVALUATION OF THE IMPACT OF CAPSULE SIZE AND SUBJECT'S AGE AND GENDER ON CAPSULE SWALLOWING

BACKGROUND

People recurrently have difficulties swallowing solid medications, which can be associated with the size of the medication and the age and gender of individuals.

OBJECTIVE

To evaluate the impact of capsule size and adults' age and gender on oral and pharyngeal capsule transit during capsule swallows.

METHODS

Videofluoroscopy was used to measure capsule oral and pharyngeal transit during swallows in 49 healthy individuals (17 men and 32 women), with a mean age of 46 years (ranging from 23 to 88 years). Smaller capsules were filled with 0.50 mL of barium sulfate, and larger capsules were filled with 0.95 mL of barium sulfate; the volume of liquid ingested with the capsules was also quantified in each ingestion. The measurements included the oral preparation time, oral transit time, swallowing reaction time, time to laryngeal vestibule closure, laryngeal vestibule closure duration, pharyngeal transit time, and upper esophageal sphincter opening duration.

RESULTS

The capsule size did not influence either the oral or pharyngeal transit time. Increased liquid volume was ingested with larger capsules and by people older than 40 years. The oral transit time was shorter in older adults (60-88 years), and the time to laryngeal vestibule closure was longer in women.

CONCLUSION

The size of large capsules did not make a difference in oral or pharyngeal transit when compared with smaller capsules. The capsule size and the participant's age influenced the volume of liquid ingested - larger capsules and older individuals required a larger volume. The capsule oral transit was faster in individuals older than 60 years.

BACKGROUND

•Swallowing is influenced by the characteristics of what is being swallowed.

BACKGROUND

•There was no difference in swallowing capsules containing 0.50 mL or 0.95 mL.

BACKGROUND

•Larger capsules need more liquid ingestion to make swallowing easier.

BACKGROUND

•Individuals older than 40 years need a greater volume of liquid to swallow capsules than younger adults.

Medication delivery errors in outpatients with percutaneous endoscopic gastrostomy: effect on tube feeding replacement

Patients with enteral access usually receive oral drugs via feeding tubes and correct drug administration remains a challenge. The aim of this study was to identify common medication delivery errors (MDEs) in outpatients with percutaneous endoscopic gastrostomy (PEG) and evaluate their association with the need for tube replacement due to deterioration or clogging. A 2-year retrospective study that comprised adult outpatients with a placed/replaced PEG tube and whose electronic medical record included home medication was carried out. Treatment with medication that should not be crushed and administered through an enteral feeding tube was considered an MDE. We included 269 patients and 213 MDEs (20% of oral prescriptions) were detected in 159. Ninety-two percent of the medications associated with MDEs could be substituted by appropriate formulations. Tube replacement due to obstruction was needed in 85 patients. MDEs were associated with increased risk for tube replacement (OR 2.17; 95% CI 1.10-4.27). Omeprazole enteric-coated capsules were associated with the greatest risk (OR 2.24; 95% CI 1.01-4.93). PEG outpatients are highly exposed to MDEs, leading to a significant increase in the odds of tube replacement, mainly when treated with omeprazole. The use of appropriate alternative therapies would prevent unnecessary adverse events.

Adult Patients with Difficulty Swallowing Oral Dosage Forms: A Systematic Review of the Quantitative Literature

The aim of this systematic review was to identify and critically appraise the available evidence regarding solid oral dosage forms (SODFs), e.g., tablets, and challenges regarding the oral administration of medicine to inpatients in a variety of healthcare settings such as (1) hospitals, (2) nursing homes and (3) long-term stay units (LTSUs). A literature search was undertaken in September 2021 and repeated in June 2023 in the following databases: PubMed, EMBASE, CINAHL, Scopus, Web of Science, The Cochrane Library, PsycINFO and ProQuest. A Microsoft Excel® spreadsheet was devised to collate the following data from each eligible study: study author and year, country, number of participants, title, duration (follow-up period), study design, inclusion and exclusion criteria, method and data collection, relevant outcomes, and key findings. A total of 3023 records were identified, with 12 articles being included in the final systematic review. Seven of the twelve studies reported on the prevalence of difficulties swallowing SODFs, which varied from 10-34.2%. Nine of the twelve studies reported the methods used to manipulate SODFs, with the most reported method being tablet crushing. Given the prevalence of swallowing difficulties and the subsequent crushing of medicines in response to this, it is evident that concerns should be raised regarding the potential for a medication administration error to occur.

The prevalence and perceived effectiveness of using a medication-swallowing lubricant in aged care facilities across Australia

Objective

To explore the extent of use and perceived effectiveness of using a medication lubricant that is specifically designed to help people who struggle to swallow their solid medications whole.

Method

Health care workers of varying professional levels in aged care facilities (ACFs) across Australia who are involved in medication administration were invited to participate in a structured online survey.

Results

Of the 355 health care workers who completed the survey, 48% had used the medication lubricant to aid administration of whole and/or crushed solid oral dosage forms, and of these 89% agreed with the statement that "it is effective method to facilitate medication swallowing in residents." The main benefits of using the medication lubricant were considered to be easier medication administration to residents (49%), reduction in need for crushing of medications (34%), and better adherence with medications (33%).

Conclusions

This study showed that using a medication lubricant for aged care residents may facilitate the process of medication administration for health care workers, which they perceive to improve residents' adherence with medications. Serious complications associated with solid dosage form modification may also be decreased by using a medication lubricant, as the need for modifying medications is reduced. Therapeutic Goods Administration (TGA)-approved medication lubricants could therefore be a valuable tool to aid the medication administration for patients who have difficulties swallowing medications. Future research may consider the clinical efficacy and acceptability of medication lubricants specifically for people with swallowing difficulties.

Nurses' knowledge and practice regarding mixing medications with food: a multicenter cross-sectional study from a developing country

BACKGROUND

Different pharmaceutical characteristics of the dosage form (DF) have a direct effect on how easily oral solid medicine is swallowed. The practice of crushing tablets or opening the capsule occurs daily in the hospital, and most nurses are unknowledgeable regarding these issues. Coadministration of medications with food can cause changes in drug absorption and lead to an alteration in gastrointestinal motility, which can cause an unexpected effect on the dissolution and absorption of the drug. Therefore, this study aimed to investigate nurses' knowledge and practices regarding the mixing of medications with food or drink in Palestine.

METHODS

From June 2019 to April 2020, a cross-sectional study was conducted, encompassing nurses working in government hospitals across various districts of Palestine. The data were collected through face-to-face interviews, using questionnaires that assessed nurses' understanding and implementation of mixing medications with food. The sampling method employed was convenience sampling. To analyze the gathered information, the Statistical Package for the Social Sciences version 21 (IBM-SPSS) was utilized.

RESULTS

A total of 200 nurses participated in the study. The data show a significant difference between the median knowledge scores according to the department of work (p < 0.001). The highest median [interquartile] knowledge score of 15 [12-15] was found for nurses working in the neonatal intensive care unit. In addition, nurses in the pediatric ward and the men's medical ward had high scores of 13 [11.5-15] and 13 [11-14], respectively. In general, the results show that 88% of nurses modified oral DF prior to administration to patients. Regarding the type of food used, mixing medicine into juice was the most common procedure performed by nurses (approximately 84%); 35% of nurses used orange juice to mix with medicine. The most common reason for crushing was to administer medications to patients with a nasogastric tube (41.5%). In regard to medications, aspirin was the most frequently used drug that was crushed by the nurses (44%); however, 35.5% of nurses did not feel sufficiently trained to carry out this practice. Concerning the sources of information, 58% of nurses usually asked pharmacists for information about medications.

CONCLUSIONS

The results of this study show that crushing and mixing medications with food is common among nurses, and most nurses are unaware of the dangerous effect of this practice on patient health. Pharmacists, as medication experts, should participate in sharing knowledge about unnecessary crushing situations or when crushing should be avoided and try to find an alternative, when available, to aid administration.

A Pilot Study on Pharmacists' Knowledge, Attitudes and Practices towards Medication Dysphagia via Asynchronous Online Focus Group Discussion

Medication dysphagia (MD) refers to difficulty swallowing oral medications. To cope, patients may inappropriately modify or skip medications, leading to poorer outcomes. Little is known about healthcare professionals' (HCPs') perspectives in managing MD. This study investigated pharmacists' knowledge, attitudes, and practices (KAP) in caring for patients with MD. An asynchronous online focus group was pilot tested in seven pharmacists, with up to two questions posted daily on an online platform over 15 days. Thematic analysis of the transcripts revealed five interrelated themes: (1) knowledge about MD; (2) management of MD; (3) expectations of patient proactivity; (4) desire for objectivity; (5) professional roles. The findings provided insight into pharmacists' KAP and may be incorporated into a full-scale study involving various HCPs.

Perceived Usability of Tablet Crushers: Comparison of Devices by People with and without Limited Hand Functions

Tablet crushing is a common practice used by patients and their carers, mainly to facilitate swallowing. Various tablet-crushing devices with different designs are currently available on the market. This study aimed to compare the usability of different tablet-crushing devices in people with and without limited hand functions. The hand function of 100 adults recruited from the general community (40 of whom self-reported a limited hand function) was assessed using the hand and finger function subscale of the Arthritis Impact Measurement Scale version 2. The hand strength was measured using a dynamometer. Participants crushed tablets using 11 crushing devices and completed a Rapid Assessment of Product Usability and Universal Design questionnaire for each device. Hand-held twist-action crushers with an ergonomic grip received the highest usability scores among both groups, irrespective of the cost (p < 0.05). Crushers with bags were scored lower by those with limited hand functions, although the score improved if the device was automatic. Preferences regarding electronic crushers significantly changed once the cost was revealed. Economical twist-action crushers with ergonomic grips and without bags or cups were the most favoured crushers.

Determine the impact of a structured pharmacist-led medication review - a controlled intervention study to optimise medication safety for residents in long-term care facilities

Background

Medication reviews contribute to protecting long-term care (LTC) residents from drug related problems (DRPs). However, few controlled studies have examined the impact on patient-relevant outcomes so far.

Objective

We examined the impact of a one-time, pharmacist-led medication review on medication changes (primary endpoint) including discontinued medication, the number of chronic medications, hospital admissions, falls, and deaths (secondary endpoints).

Methods

A prospective, controlled intervention study was performed in three LTC facilities. In the intervention group (IG), after performing a medication review, a pharmacist gave recommendations for resolving DRPs to physicians, nurses and community pharmacists. The control group (CG) received usual care without a medication review. (i) We assessed the number of medication changes and the secondary endpoints in both groups before (t0) and after (t1, t2) the intervention. (ii) Additionally, the medication review was evaluated in the IG with regard to identified DRPs, the healthcare professional’s feedback on the forwarded pharmacist recommendations and whether DRPs were finally resolved.

Results

107 (IG) and 104 (CG) residents were enrolled. (i) More medication changes were identified in the IG than in the CG at t1 (p = 0.001). However, no significant difference was identified at t2 (p = 0.680). Mainly, medication was discontinued in those medication changes. Chronic medications increased in the CG (p = 0.005) at t2 while hospital admissions, falls, and deaths showed no differences. (ii) Overall, 1252 DRPs (median: 10; minimum-maximum: 2–39) were identified. Recommendations for 82% of relevant DRPs were forwarded to healthcare professionals, of which 61% were accepted or clarified. 22% were not accepted, 12% required further review and 6% remained without feedback. 51% of forwarded DRPs were finally resolved.

Conclusions

We found more medication changes in the IG compared to controls. Mostly, medication was discontinued. This suggests that our intervention was successful in discontinuing unnecessary medication. Other clinical outcomes such as falls, hospitalisations, and deaths were not improved due to the one-time intervention. The medication review further identified a high prevalence of DRPs in the IG, half of which were finally resolved.

Trial registration

German Clinical Trials Register, DRKS00026120 (www.drks.de, retrospectively registered 07/09/2021).

Solid Oral Dosage Forms Use in Adults with Neurological Disorders and Swallowing Difficulties: A Scoping Review

Swallowing difficulties affects the deglutition of solid oral dosage forms (SODFs) and it is a common problem among neurological disorders. Interventions may improve the use of SODFs in healthcare settings. The aim of this study was to map the available research about the interventions aiming the effective and safe use of SODFs in adults with neurological disorders and swallowing difficulties and to identify potential literature gaps in this scientific field. A scoping review was carried out based on Joanna Briggs Institute guidelines and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, in PubMed, Scopus, and SciELO databases (March 2021). Peer-reviewed observational studies assessed the effectiveness and safety of SODFs in adults with neurological disorders and swallowing difficulties in the healthcare organizations setting were included. 11 studies were included (three case reports, two mixed-methods intervention studies, and six analytic studies). The frequency of women ranged from 49 to 67%, and the age from 57 to 91 years. Most studies (n = 7) included elderly patients, Parkinson (n = 6) and dementia (n = 3). Medication review was the most frequently reported intervention, 35% (9/26). In most studies, interventions were targeted to patients during hospitalization (n = 7) and performed by physicians (n = 8). At least 20 different outcomes were evaluated in the studies. Implementing specific protocols for using SODFs aimed at the swallowing difficulties of this population is not a common practice. Additional studies on interventions aimed at optimizing SODFs are needed to support the safety and efficacy of oral therapy in this patient group.

To crush, or not to crush? Unauthorised covert administration of medication in nursing homes

BACKGROUND AND OBJECTIVES

This study aimed to explore the experiences and perceptions of nursing home staff and residents of unauthorised covert administration of medication. Prior studies identify that covert medication administration (crushing medication to administer in food or drink) is common in nursing home settings. Still, few recognise that this practice may occur without consultation or clinical authorisation.

DESIGN

An exploratory qualitative study was conducted with nursing home staff and residents as part of a more extensive mixed-methods study on medication omissions and clinical decision-making.

METHODS

We conducted a qualitative study using focus groups and semi-structured interviews across four geographical areas in New Zealand to better understand nursing home staff and residents' experiences and perspectives on covert administration. Semi-structured interviews took place with 11 Clinical managers/leads and one senior Registered Nurse; role specific focus groups were held with Registered Nurses (n = 6), Health Care Assistants (n = 14), and Residents (n = 12). Data were analysed using thematic analysis.

FINDINGS

Participants described covert administration as a practical option if a nursing home resident refused medication but recognised it was a deception that carried ethical and clinical risks, particularly when unauthorised. Participants felt that unauthorised covert administration stemmed from doubts about residents' competence and the competing demands staff face during medication administration. Staff, who typically relied on advice from their pharmacies around which medications were safe to crush, expressed a need for more education.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

This study provides evidence that unauthorised covert administration of medications is an ongoing practice, using New Zealand nursing homes as an example. The results emphasise that nursing home staff and residents are aware that this practice carries ethical and clinical risks and requires a certified process to legitimise its authorised form.

Medicine self-administration errors in the older adult population: A systematic review

BACKGROUND

Medicine self-administration errors (MSEs) are a longstanding issue in patient safety. Although many studies have examined MSEs in the general adult population, the MSEs that occur specifically in the older adult population and their contributing factors are not well understood.

OBJECTIVE

To identify the types of MSEs and their contributing factors among community-dwelling older adults.

METHODS

PubMed, Medline, Embase, CINAHL and Scopus were searched for primary studies published between January 1, 2014 and June 12, 2020. Studies which reported MSEs among community-dwelling older adults (≥50 years of age) and written in English were included in the review.

RESULTS

Eleven studies met the inclusion criteria. The most commonly reported MSE was a dosing error, followed by missed dose, wrong medicine, incorrect administration methods, wrong administration time and wrong frequency. Seven of the included studies also described factors which contributed to the occurrence of MSEs. The most commonly reported factor contributing to MSEs was complex treatment regimens due to use of multiple medicines. Other factors identified included cognitive decline, decline in physical abilities, lack of social support, lack of knowledge about treatment regimens and negative attitudes and beliefs towards medicines. In most cases, MSEs occurred when multiple contributing factors were present.

CONCLUSION

The literature highlights a number of types of MSEs and their contributing factors which occur in the older adult population. Given that many MSEs are preventable, future research is needed into how pharmacists can support the identification and mitigation of factors contributing to MSEs in the older adult population.

Establishing an Electronic Referral System from Speech and Language Therapy to Pharmacy to Improve Medication Administration in Patients with Dysphagia in an Acute Hospital Setting

Dysphagia affects swallowing not only of food and drink, but also of orally administered medications. Altering solid or liquid dose formulations renders administration unlicensed and may have adverse effects. Medication administration in patients with dysphagia necessitates a multidisciplinary approach with no one profession holding all necessary expertise. This project aimed to improve the process of medication administration for patients with dysphagia in an acute hospital. Following a baseline audit of practice, an electronic referral system from Speech & Language Therapy (SLT) to Pharmacy was established. Repeat post-implementation audits documenting medication administration to patients with dysphagia and SLT compliance in completing electronic referral were conducted. Of the 43 patients included in the post-implementation audits, 14 (32.6%) were referred from SLT to Pharmacy using the electronic referral system. Those patients referred electronically were reviewed by Pharmacy quicker than those patients who were not referred and had a higher percentage of optimally administered medications. All SLTs eligible (n = 10) were surveyed to explore use of the system and barriers to its use; reasons given for not completing an electronic referral included not prioritizing the referral if under time pressure and lack of IT access to make the referral. Overall compliance with use of the electronic referral system was lower than expected; further work is needed to establish consistency of practice in using the electronic referral system in the interest of optimizing medication administration to patients.

Drug modification by nurses in Norwegian nursing homes: A cross-sectional study

Crushing and dividing pills among older patients in nursing homes appears to be a common yet not harmless practice. Because few updates exist regarding the role of nurses and their dispensing of drugs in nursing homes, this study sought to describe the occurrence, methods, and causes of nurses' drug modification and to examine possible factors associated with drug modification in this context. A cross-sectional study of 273 dispensing episodes of solid oral drugs made by nurses, were observed during day and evening shifts. Modifications were made in 20.5% of the dispensing episodes, including 80.4% where alterations were made by crushing and 19.6% where alterations were made dividing. The most commonly reported reasons for modification were 'swallowing difficulties' (53.6%) and 'lack of understanding by the patient' (19.6%). The logistic regression analysis showed a significant association between the occurrence of drug modification and both cognitive impairment and administration method.

Medication administration in Australian residential aged care: A time-and-motion study

RATIONALE/AIM

Medication administration is a complex and time-consuming task in residential aged care facilities (RACFs). Understanding the time associated with each administration step may help identify opportunities to optimize medication management in RACFs. This study aimed to investigate the time taken to administer medications to residents, including those with complex care needs such as cognitive impairment and swallowing difficulties.

METHOD

A time-and-motion study was conducted in three South Australian RACFs. A representative sample of 57 scheduled medication administration rounds in 14 units were observed by a single investigator. The rounds were sampled to include different times of day, memory support units for residents living with dementia and standard units, and medication administration by registered and enrolled nurses. Medications were administered from pre-prepared medication strip packaging. The validated Work Observation Method By Activity Timing (WOMBAT) software was used to record observations.

RESULTS

Thirty nurses were observed. The average time spent on scheduled medication administration rounds was 5.2 h/unit of average 22 residents/day. The breakfast medication round had the longest duration (1.92 h/unit). Resident preparation, medication preparation and provision, documentation, transit, communication, and cleaning took an average of 5 minutes per resident per round. Medication preparation and provision comprised 60% of overall medication round time and took significantly longer in memory support than in standard units (66 vs 49 seconds per resident per round for preparation, 79 vs 58 for provision; P < .001 for both). Almost half (42%) of tablets/capsules were crushed in memory support units. The time taken for medication administration was not significantly different among registered and enrolled nurses.

CONCLUSIONS

Nurses took an average of 5 minutes to administer medications per resident per medication round. Medication administration in memory support units took an additional minute per resident per round, with almost half of tablets and capsules needing to be crushed.

Factors that affect health-care workers' practices of medication administration to aged care residents with swallowing difficulties: An Australia-wide survey study

OBJECTIVES

To understand the barriers and facilitators of medication administration to aged care residents with swallowing difficulties.

METHODS

Health-care workers in aged care facilities across Australia involved in medication administration to residents completed an online survey.

RESULTS

Of 355 respondents, 90.9% reported 'everyday' encounters with residents with swallowing difficulties and 94.1% modified medications to facilitate administration. Time constraints (63.4%) and workload (69.0%) were common barriers. Only 39.0% believed swallowing abilities are considered at the prescribing stage. Pill size (95.8%), polypharmacy (75.2%) and lack of alternative formulations (74.9%) contributed to these challenges. Support from other health-care professionals (91.5%) and training (85.9%) were the most favoured facilitators.

CONCLUSION

Health-care workers are faced with various challenges when caring for residents with swallowing difficulties. Promoting multidisciplinary collaborations, provision of training and medication review services, and improving skill mix and staffing composition in aged care facilities are needed to address these challenges.

Patient-Centric Medicine Design: Key Characteristics of Oral Solid Dosage Forms that Improve Adherence and Acceptance in Older People

Older people represent a very heterogeneous patient population and are the major user group of medication. Age-related changes mean that this population can encounter barriers towards taking medicines orally. The aim of this study was to investigate the characteristics of oral solid dosage forms that contribute to an age appropriate dosage design, with an aim to improve overall medication adherence and acceptance in older people. Fifty-two semistructured interviews were conducted with older people, informal (family) carers, and health and social care professionals. Formulation characteristics impacted three stages of the medication taking process: (1) medication identification and memorability, (2) medication handling and (3) swallowability. Small round tablets (≤7 mm) are least accepted amongst older people and their carers and had a negative impact on all stages. The use of bright, two-coloured preparations and interesting shapes improves identification and further aids memorability of indications and the timing of tablets. Palatability, while useful to enhance swallowability, also has an impact on the visual appeal and memorability of medication. Environmental, patient, medication and disease characteristics also determine preferences for formulation. Developing an age appropriate dosage design for older people, therefore, requires a holistic, patient-centric approach to improve adherence and acceptance.

Factors affecting Australian aged care facility workers in administering oral medication to residents with swallowing difficulties

Swallowing difficulties are common in older people and can complicate the administration of oral medications. The aim of this study was to explore factors affecting healthcare workers in their practices of oral medication administration to aged care residents with swallowing difficulties. A purposeful sample of 17 healthcare workers composed of clinical/care managers, registered nurses (RNs), enrolled nurses (ENs), and assistants in nursing (AINs) from three aged care facilities in Queensland, Australia participated in semi-structured interviews. Leximancer was used for quantitative content analysis. The responses centered on three main factors. Participants discussed workprocess-related factors including time, workload, and stress and frustrations resulting from work processes. Medication-related factors included strategies to facilitate medication administration, uncertainties around modifying medications, availability/cost of alternatives, multidisciplinary medication management, prescribing considerations, and polypharmacy. Resident-related factors were discussed around individualized needs of residents especially those with dementia-associated swallowing difficulties. Ideas differed among the four groups of participants. Managers discussed workprocess-related factors pertaining to staff and facility. RNs focused on how clinical aspects of the medication practices were affected by work processes. ENs were task-oriented and their responses focused on work processes. AIN responses centered on reliance on RNs in performing medication tasks. The findings suggest that healthcare workers' practices of medication administration to residents with swallowing difficulties are affected by various factors associated with work processes, medications, and resident characteristics. Although these factors affect all levels of healthcare workers, the needs of each group vary depending on their level of training and responsibilities.

The influence of crushing amorphous solid dispersion dosage forms on the in-vitro dissolution kinetics

Solid dosage forms of amorphous solid dispersions (ASDs) have rarely been assessed for their crushability, although it might possibly be a more frequent practice than thought to facilitate oral administration in several clinical conditions (e.g. dysphagia) when no oral liquids of the same drug are available. Nevertheless, there are concerns that contraindicate these formulations' modification by grinding. For example, amorphous-amorphous phase separation, induction of crystallization, decreasing particle sizes, etc. might occur during grinding without knowing the implications on bioavailability. Hence, in this study, Sporanox® (itraconazole), Intelence® (etravirine), Noxafil® (posaconazole) and Norvir® (ritonavir), were selected as "model" enabling formulations (based on ASD) to evaluate if this concern was justified. Their assessment in simple and biorelevant media by two-stage in-vitro drug-release testing was performed which resulted in strong suspicion that pulverization is contradicted for some of these formulations. Despite differences were observed, uncertainty remains on the clinical relevance of these data as by golden standard it should still be confirmed by bioequivalence trials.

Nurse experiences of medication administration to people with swallowing difficulties living in aged care facilities: a systematic review of qualitative evidence

OBJECTIVE

To identify nurses' experiences of administering oral medications to residents of aged care facilities (ACFs) with swallowing difficulties.

INTRODUCTION

Administering medicines to older people with swallowing difficulties is a challenging task. Nurses frequently modify oral medications e.g. by crushing/splitting tablets or opening capsules, to facilitate the administration process. These practices are associated with an increased risk of medication administration errors. However, the reasons for these practices from the nurse's perspective are not well understood.

INCLUSION CRITERIA

The review investigated studies on the experiences of nurses of any level with the responsibility of medication administration in ACFs in terms of problems and challenges they encountered when administering oral medicines to aged care residents with swallowing difficulties. Aged care facilities providing all levels of care were considered for inclusion. Qualitative studies including, but not limited to, phenomenology, grounded theory, ethnography and action research designs as well as mixed methods studies and text and opinion papers were considered.

METHODS

A comprehensive database search of PubMed, CINAHL, Embase and Scopus was conducted between October and December 2016. MedNar and ProQuest Dissertations and Theses were used to search for gray literature. No date limitation was applied. The Joanna Briggs Institute Qualitative Assessment and Review Instrument critical appraisal tool (JBI-QARI) was used to assess the quality of the papers. The JBI-QARI data extraction instrument was used to extract qualitative findings. Data synthesis was not applicable in the final analysis due to the inclusion of only one article.

RESULTS

The initial search resulted in 1681 unique titles for screening. A total of 202 abstracts were screened, after which a full-text review conducted for 19 articles. After the full-text review, only one article was eligible to be included in the final report. The included study scored highly in terms of methodological quality. The findings highlighted issues around time constraints, complexity of medication administration process to residents of ACFs with swallowing difficulties, cost and resources for alternative strategies, inefficient information flow and communication among healthcare professionals, and nurses' knowledge and training needs.

CONCLUSION

The limited findings of this systematic review indicate that further research is necessary to provide evidence of nurses' experiences with regards to administering oral medications to older people with swallowing difficulties living in ACFs. A comprehensive understanding of these experiences may lead to organizational system changes to support nurses and older people with swallowing difficulties in ACFs.

Quality and Safety in Aged Care Virtual Issue: What Australian research published in the Australasian Journal on Ageing tells us

OBJECTIVE

To review studies published in the Australasian Journal on Ageing (AJA) about the aged care workforce, and to identify influences on quality of care and potential policy directions.

METHODS

Articles in the AJA on the aged care workforce published from 2009 to 2018 were identified, grouped into themes and rated for quality.

RESULTS

Twenty-eight articles were identified. Articles fell into four themes: (i) staff knowledge, skills and attitudes; (ii) staff well-being and workforce stability; (iii) environmental factors that influence staff capacity; and (iv) interventions to improve staff capacity. Studies reinforced the importance of staff-consumer, staff-relatives and staff-staff relationships and a supportive workplace culture for staff work ability and capacity to provide high quality care.

CONCLUSIONS

It is possible to improve practice in community and residential aged care, given: (i) enough staff; (ii) better training in person-centred practice; and (iii) a supportive staff culture that encourages staff to put their training into practice.

Using behavioural science to explore patient perceptions

Purpose

This paper aims to develop a behavioural science informed communication strategy aimed at health professionals and patients promoting best practice recommendations regarding the use of specialist liquid medicines for elderly people with swallowing difficulties.

Design/methodology/approach

The medicine prescribing, formulation and administration related challenges and experiences of health professionals and elderly patients with swallowing difficulties were identified through a pragmatic literature search. Key findings across the papers were synthesised into themes, before being linked to domains from a behavioural science framework. Published recommendations for behaviour change techniques that can be used to target the domains were then mapped to the domains. Guidance on how to develop a communication strategy, drawing on the insight gained from the literature review and the behavioural science recommendations, and designed to stimulate change in health-care professionals’ and patients’ behaviours, was then developed.

Findings

In total, 13 themes emerged across 15 papers, including “patient and health professional roles and remits”. These themes were linked to nine domains from the framework, highlighting the range of individual, social and environmental factors influencing patients’ and health professionals’ perceptions and experiences. A summary table, mapping the domains and underpinning themes to recommended behaviour change techniques, was used to develop the subsequent communication strategy recommendations. Recommendations include using techniques such as providing social processes of encourage, pressure and support to change patients’ and health professionals’ perceptions of their roles/responsibilities in medicines prescribing and administration, delivered via, for example, an educational leaflet and/or online training.

Practical implications

The summary table and guidance can inform development of an evidence-based strategy for communicating best practice recommendations regarding the use of liquid medicines for elderly patients with swallowing difficulties, tailored to the perceptions and challenges identified.

Originality/value

The behavioural science approach is less established within the pharmaceutical industry for promotion of best practice recommendations and related products, yet it offers a framework for an evidence-based and systematic approach that goes beyond a literature review or focus group.

Challenges and innovations of drug delivery in older age

Both drug delivery performance and various age-related physical, mental and physiological changes can affect drug effectiveness and safety in elderly patients. The many drug delivery systems developed over the years include recent novel transdermal, nasal, pulmonary and orally disintegrating tablets that provide consistent, precise, timely and more targeted drug delivery. Certain drug delivery systems may be associated with suboptimal outcomes in the elderly because of the nature of drug present, a lack of appreciation of the impact of age-related changes in drug absorption, distribution and clearance, the limited availability of pharmacokinetic, safety and clinical data. Polypharmacy, patient morbidity and poor adherence can also contribute to sub-optimal drug delivery systems outcomes in the elderly. The development of drug delivery systems for the elderly is a poorly realised opportunity, with each system having specific advantages and limitations. A key challenge is to provide the innovation that best meets the specific physiological, psychological and multiple drug requirements of individual elderly patients.

Challenges and innovations of delivering medicines to older adults

Older adults with multimorbidity, polypharmacy, and complex health needs are the major consumer of health care. Ensuring that medicines are used safely, effectively, and delivered efficiently in this population is challenging. In this context, the approach to medicines delivery should seek to overcome some of the difficulties of delivering medicines to older people, and ensure each medication is delivered by the optimal and most convenient route for the patient in question. However, this poses significant obstacles, as the development of medicines suitable for use in older populations does not often account for complex health needs, potential challenges in relation to drug disposition, safety of excipients and limitations with practical usability of dosage forms. The objective of this review is to summarise and discuss current challenges and novel approaches to delivering medications to older adults.

Dosage form modification and oral drug delivery in older people

Many people cannot swallow whole tablets and capsules. The cause ranges from difficulties overriding the natural instinct to chew solids/foodstuff before swallowing, to a complex disorder of swallowing function affecting the ability to manage all food and fluid intake. Older people can experience swallowing difficulties because of co-morbidities, age-related physiological changes, and polypharmacy. To make medicines easier to swallow, many people will modify the medication dosage form e.g. split or crush tablets, and open capsules. Some of the challenges associated with administering medicines to older people, and issues with dosage form modification will be reviewed. Novel dosage forms in development are promising and may help overcome some of the issues. However, until these are more readily available, effective interdisciplinary teams, and improving patient health literacy will help reduce the risk of medication misadventures in older people.

Knowledge and practice of healthcare professionals relating to oral medicine use in swallowing-impaired patients: a scoping review

Objectives

Swallowing impairment is a growing problem that affects 16% of the overall population and can significantly affect medicine-taking. However, little is known about the knowledge and practice of healthcare professionals (HCPs) relating to swallowing-impaired (SI) patients. The aim of this scoping review was to investigate the knowledge and practice of HCPs in supporting SI patients with their medicine-taking, to identify their reference sources, and to describe their training and information needs.

Method

Databases searched included Scopus, Web of Science, Medline and Google Scholar from inception to August 2017. Qualitative and quantitative studies describing knowledge and practice of HCPs relating to medicine use in SI patients were included.

Key findings

The nine included studies, from an initial 142, involved nurses (nine studies), pharmacists (one study) and doctors (two studies) in hospitals or aged-care facilities. A knowledge deficit linked to lack of training was revealed, particularly with identification of modified-release dosage forms, medication that can/cannot be crushed, vehicle for safe dispersion, consequences of inappropriate modification, drug stability and legal aspects. Written information sources were named, but not used in practice. Pharmacists were the primary experts for consultation, and were involved in nurse education, and were members of multidisciplinary teams.

Conclusions

Knowledge in nurses was inadequate, with practice indicating potentially serious medication-related errors. Additional training, either undergraduate or as continuing professional development, is recommended. Information to guide safe medicine modification practice should be accessible to all practitioners. Pharmacists could take the lead role in offering training to nurses.

Drug loss while crushing tablets: Comparison of 24 tablet crushing devices

This study investigated 24 tablet crushing devices for drug loss using different methods to recover the crushed tablet. 24 devices were compared: 3 with disposable cups, 6 with disposable bags, 12 without separate vessels and 3 types of mortar and pestle. One paracetamol tablet was crushed and recovered by tapping the powder out. Where appropriate, depending on crusher size and manufacturer instructions, the powder was also recovered by mixing with water or food. Paracetamol recovery (quantity that can be delivered to a patient) and leftover (quantity remaining in the device) were measured using a validated UV method and the entire experiment was replicated 3 times. Drug recovery ranged from 86.7-98.1% when the crushed tablet was tapped out of the crushers (average loss 5.8%). Significant losses were measured for 18 crushers, particularly manually operated hand-twist crushers with a serrated crushing surface, and some devices with disposable bags or cups. Rinsing the crushed powder with water once resulted in an average of 24.2% drug loss, and this was reduced to 4.2% after a second rinse. If crushing is unavoidable, maximizing medication delivery to the patient is essential. Rinsing twice resulted in similar paracetamol recovery to tapping the powder out; however only water rinses have the potential for direct consumption by the patient, minimizing drug loss across the entire crushing and transfer process.

A spoonful of sugar helps the medicine go down? A review of strategies for making pills easier to swallow

Solid oral dosage forms such as tablets and capsules are generally the preferred method of drug delivery due to their convenience, cost, and acceptability. However, for many people, it can be a challenge to swallow solid oral medications, even those with healthy swallowing function. This review describes current strategies available to facilitate medication administration to otherwise healthy people with pill-swallowing difficulties. In general, restoring and maintaining the ability to swallow pills whole should ideally be the first choice in managing people with pill-swallowing difficulties. A number of strategies can potentially make it easier to swallow pills whole. These include postural adjustments, using pill-swallowing aids, and teaching pill-swallowing techniques. Where these are not successful or appropriate, then other approaches have to be considered using alternative formulations/routes of administration or deprescribing. If there is no other option, and it is not directly contraindicated for each specific medication dosage form, pills may be modified and mixed in foods and drinks to aid swallowing. In conclusion, people with pill-swallowing difficulties can benefit from a number of strategies designed to facilitate swallowing medications. However, these strategies should be further evaluated with regard to the evidence relating to both their efficacy and safety.

Oral medicine modification for older adults: a qualitative study of nurses

OBJECTIVE

Oral medicines are frequently modified (eg, tablets crushed) for older adults. However, these modifications can have clinical, legal and/or ethical implications. Nurses bear responsibility for medicine administration and hence, perform these modifications. The aim of this study was to investigate the knowledge, attitudes and beliefs of nurses about oral medicine modification for older adults.

DESIGN

A qualitative study was conducted using semi-structured, face-to-face interviews with nurses providing care to older adults in acute and long-term care settings. Interviews were audio-recorded, transcribed verbatim and analysed thematically.

SETTINGS

Sixteen purposively selected care settings; 4 acute-care and 12 long-term care settings were included. Nurses were recruited by convenience sampling at these sites.

PARTICIPANTS

Eighteen nurses participated (83% female, 67% long-term care, 33% acute-care, median age (IQR) 38 years (32.5-52.0)).

RESULTS

Three major themes: modifying-a necessary evil, nurses' role as patient advocate and modifying-we are working very much as a team and two minor themes: fractional dosing, and covert administration emerged from the data. Nurses viewed oral medicine modifications as being a routine and necessary occurrence in geriatric patient care due to limitations of available formulations and the presence of age-related challenges in drug administration. Nurses' knowledge of residents' requirements ensured that they advocate for those with individualised formulation needs, however, nurses rely on pharmacists for information about modifications. Nurses expressed a desire for supports including increased education and ward-specific, pharmacist-developed recommendations on common modifications.

CONCLUSIONS

This study has provided useful insights into the views of nurses regarding oral medicine modification for older adults. The unique and varied formulation requirements of older adults must be acknowledged. Increased engagement by healthcare professionals, the pharmaceutical industry, regulatory agencies and policy-makers is required to facilitate the development of age-appropriate formulations. In the interim, practical interventions, informed by the findings of this study, are required.

Assessment of Clinical Practices for Crushing Medication in Geriatric Units

OBJECTIVES

To assess the modification of the form of medication and evaluate staff observance of good clinical practices.

DESIGN

One-day assessment of clinical practices.

SETTING

17 geriatrics units in the 3 Teaching Hospitals of Paris-Sud (APHP), France.

PARTICIPANTS

Elderly in-patients with difficulties swallowing capsules and tablets.

MEASUREMENTS

Assessment of target-patient prescriptions and direct observation of nurses' medical rounds.

RESULTS

155/526 in-patients (29.5%) were unable to swallow tablets or capsules: 98 (40.3%) in long-term care, 46 patients (23.8%) in the rehabilitation unit and 11 (12.2%) in the acute care unit (p = .005). In thirty-nine (27.3%) of the 143 prescriptions studied all tablets were safe to crush and all capsules were safe to open. In 104 cases, at least one medication could not be safely modified, including 26 cases (18.2%) in which none of the prescribed drugs were safe to crush or open. In 48.2% of the 110 medications that were crushed, crushing was forbidden, and presented a potential threat in 12.7% of cases or a reduced efficacy in 8.2% of cases. Crushing methods were rarely appropriate: no specific protective equipment was used (81.8%), crushing equipment was shared between patients without cleaning (95.1%), medications were spilled or lost (69.9%). The method of administration was appropriate (water, jellified water) in 25% of the cases, questionable (soup, coffee, compote, juice, cream) in 55% of the cases and unacceptable (laxative) in 21% of the cases.

CONCLUSION

Management of drug prescriptions in patients with swallowing difficulties is not optimal, and may even have iatrogenic effects. In this study, 12.7% of the modifications of the drug form could have been harmful. Doctors, pharmacists and nurses need to reevaluate their practices.

The knowledge, attitudes and beliefs of patients and their healthcare professionals around oral dosage form modification: A systematic review of the qualitative literature

OBJECTIVES

The objective of this systematic review was to synthesize the available qualitative evidence on the knowledge, attitudes and beliefs of adult patients, healthcare professionals and carers about oral dosage form modification.

DESIGN

A systematic review and synthesis of qualitative studies was undertaken, utilising the thematic synthesis approach.

DATA SOURCES

The following databases were searched from inception to September 2015: PubMed, Medline (EBSCO), EMBASE, CINAHL, PsycINFO, Web of Science, ProQuest Databases, Scopus, Turning Research Into Practice (TRIP), Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews (CDSR). Citation tracking and searching the references lists of included studies was also undertaken. Grey literature was searched using the OpenGrey database, internet searching and personal knowledge. An updated search was undertaken in June 2016.

REVIEW METHODS

Studies meeting the following criteria were eligible for inclusion; (i) used qualitative data collection and analysis methods; (ii) full-text was available in English; (iii) included adult patients who require oral dosage forms to be modified to meet their needs or; (iv) carers or healthcare professionals of patients who require oral dosage forms to be modified. Two reviewers independently appraised the quality of the included studies using the Critical Appraisal Skills Programme Checklist. A thematic synthesis was conducted and analytical themes were generated.

RESULTS

Of 5455 records screened, seven studies were eligible for inclusion; three involved healthcare professionals and the remaining four studies involved patients. Four analytical themes emerged from the thematic synthesis: (i) patient-centred individuality and variability; (ii) communication; (iii) knowledge and uncertainty and; (iv) complexity. The variability of individual patient's requirements, poor communication practices and lack of knowledge about oral dosage form modification, when combined with the complex and multi-faceted healthcare environment complicate decision making regarding oral dosage form modification and administration.

CONCLUSIONS

This systematic review has highlighted the key factors influencing the knowledge, attitudes and beliefs of patients and healthcare professionals about oral dosage form modifications. The findings suggest that in order to optimise oral medicine modification practices the needs of individual patients should be routinely and systematically assessed and decision-making should be supported by evidence based recommendations with multidisciplinary input. Further research is needed to optimise oral dosage form modification practices and the factors identified in this review should be considered in the development of future interventions.