Crushed No More? Whole Tablets Safe in Stroke Dysphagia
For decades, stroke patients with swallowing difficulties have routinely received crushed tablets to reduce the risk of aspiration. New clinical data now challenge this practice. A study using endoscopic swallowing diagnostics in patients with poststroke dysphagia has shown that whole tablets, when administered with a soft bolus such as applesauce, are often swallowed safely — without signs of penetration or aspiration. In contrast, crushed forms left significantly more residue in the pharynx, potentially impairing drug absorption and increasing the risk of complications. The research, coordinated by the Karl Landsteiner University of Health Sciences (KL Krems), calls into question the default use of crushed tablets and points to the need for updated clinical guidelines. A more differentiated approach could reduce medication errors and improve the safety of pharmaceutical treatment in stroke care.
Poststroke dysphagia is one of the most frequent and serious complications following a stroke, affecting up to 75% of patients. It increases the likelihood of pneumonia, malnutrition, and delays in recovery. While international guidelines recommend standardized screening to detect swallowing impairments, they offer little guidance on how to handle oral medications—especially solid tablets and capsules. In everyday practice, tablets are often crushed or altered without first assessing the patient’s ability to swallow. To address this lack of evidence, the Division of Neurology at University Hospital Tulln (a teaching and research centre of KL Krems) coordinated a systematic investigation using fiberoptic endoscopy to evaluate the actual safety of tablet intake.
Old Habits, New Evidence
“Our aim was to understand what really happens when patients with poststroke dysphagia swallow whole versus crushed tablets,” says Michaela Trapl-Grundschober, speech therapist and scientist at the Division of Neurology. “It’s widely assumed that crushing tablets is the safer option — but our results show that this isn’t necessarily the case.” The study involved 60 stroke patients who underwent Fiberoptic Endoscopic Evaluation of Swallowing (FEES) with placebo tablets of different sizes and shapes, both in whole and crushed form. All whole tablets that were actually swallowed passed into the stomach without any sign of penetration or aspiration. In contrast, crushed tablets left behind more pharyngeal residue, especially in the vallecular space — an area where residues can easily accumulate and remain unnoticed for a longer time.
These results stand in clear contrast to current practice on stroke units. A previous study by the same research team, published in 2024, had already shown that many nurses routinely modify tablets for patients with suspected dysphagia — even before any specialist assessment. The survey revealed considerable uncertainty among nursing staff about which medications can be safely altered, and how. Most respondents reported using texture-modified foods such as applesauce or yoghurt to administer crushed tablets, despite known risks of altered pharmacokinetics and reduced drug efficacy. The new study now provides clinical evidence that this practice is especially unnecessary in cases of mild to moderate stroke.
Reassessing the Applesauce Method
In the recent study, three common types of placebo tablets were tested alongside their crushed versions in a randomized within-subject design. Each was administered with a small amount of applesauce, reflecting routine clinical practice. Particularly noteworthy: Even the smallest tested tablet (8 mm) performed better in terms of swallowing safety and efficiency than its crushed counterpart — suggesting that crushing such tablets may be unnecessary. The largest tablet was more likely to remain at the base of the tongue, but patients generally noticed it and were able to swallow it successfully with an additional spoonful of applesauce. These findings suggest that, in moderately dysphagic patients, swallowing whole tablets with a soft bolus may be both safe and more effective, provided individual swallowing function is carefully assessed using instrumental methods.
The implications for stroke care are significant. Safe and reliable medication delivery is a cornerstone of early stroke treatment. Yet the modification of tablets is often based more on habit than on evidence. With endoscopic data now supporting the use of intact tablets in selected patients, the KL Krems highlights the need for a more differentiated approach. Rather than crushing medication by default, clinicians should consider individual swallowing function and base their decisions on clear diagnostic findings. This could help reduce avoidable complications, ensure more accurate dosing, and ultimately improve patient outcomes. The study also reflects KL Krems’ focus on interdisciplinary, health policy-relevant research.
Original Publications
Medication Administration in Poststroke Dysphagia: Evaluating Swallowing Safety of Solid Dosage Forms, M. Trapl-Grundschober: W. Struhal: Y. Teuschl: S. Schulz: S. Sollereder: J. Osterbrink, Stroke 2025;56:2494-2502, DOI: 10.1161/STROKEAHA.125.051237. https://kris.kl.ac.at/en/publications/medication-administration-in-poststroke-dysphagia-evaluating-swal
Oral intake of solid medications in patients with post-stroke dysphagia. A challenge for nurses?, M. Trapl-Grundschober: S. Schulz: S. Sollereder: L. Schneider: Y. Teuschl: J. Osterbrink, J Clin Nurs 2025;34:872-882, DOI: 10.1111/jocn.17081
More on KL Krems research: https://www.kl.ac.at/en/research/research-blog
