The Double Challenge: Dementia, Dysphagia, and Medications

Dementia and dysphagia frequently coexist. In Hong Kong, studies estimate that up to 84% of people with advanced dementia develop dysphagia. These patients often also have complex medication regimens — for blood pressure, heart conditions, diabetes, psychiatric symptoms, and pain management.

Managing oral medications in this population is uniquely difficult: the patient may resist taking medication, may not understand swallowing instructions, may pocket tablets in the cheek rather than swallow, or may forget they have taken medication and demand it again. Combined with dysphagia, each administration carries aspiration risk.

This page offers evidence-informed strategies for caregivers and care home nurses in Hong Kong.

Why Medication Timing at Mealtimes Matters

Mealtimes provide a structured, routine opportunity to administer medications. The presence of food can help:

• Stimulate swallowing reflexes that may be diminished at other times
• Provide a vehicle for crushed tablets (mixed into food)
• Create a calm, familiar context that reduces resistance

However, care is needed: some medications should not be taken with food (see below), and dementia patients may hide tablets in food and then not finish the meal.

Strategies for Patients Who Resist Medication

Non-Pharmacological Approaches First

• Choose the right moment: administer medications during a calm period, not when the patient is agitated or distressed
• One medication at a time: reduce overwhelm by giving one item at a time with small sips of thickened fluid between each
• Use familiar language and gentle reassurance: brief, simple sentences in Cantonese or the patient’s native language tend to work better than lengthy explanations
• Involve family members: some patients accept medications more readily from familiar faces

When the Patient Pockets or Spits Out Tablets

Check the patient’s mouth after each administration — pocketed tablets that are later aspirated when the patient lies down are a significant aspiration risk. If pocketing is consistent:

• Request a pharmacist review to switch to liquid formulations
• Consider whether the tablet can be crushed and mixed more thoroughly into food so it is undetectable
• Document the pattern and discuss with the prescribing physician — some medications may be deprescribed if swallowing cannot be ensured

Covert Medication Administration

Mixing crushed medications into food without a patient’s knowledge is practised in many care settings and is ethically and legally complex. In Hong Kong:

• The Mental Capacity Ordinance (Chapter 636) requires that decisions made for incapacitated individuals are in their best interests
• Covert medication should be a last resort, documented in the care plan, and agreed upon by the multidisciplinary team (physician, nurse, pharmacist, and if possible a family member with lasting power of attorney)
• Some medications should never be given covertly without informed decision-making processes (e.g., psychiatric medications, medications with significant side effects)

In practice, mixing crushed medication into a small spoonful of food (not the full meal) is widely used — if the patient does not eat the specific spoonful, this is noted and the dose is treated as missed.

Liquid Formulations for Dementia Patients

Liquid medications are often the safest option for patients with dementia and dysphagia. They can be:

• Administered by syringe to the side of the mouth (buccal administration), bypassing the need for active swallowing cooperation
• Mixed into thickened fluid at the correct IDDSI level
• Dosed accurately without crushing-related losses

Request liquid formulations from the HA pharmacy at the next prescription renewal. Inform the doctor of the specific swallowing and compliance challenges so the clinical indication is documented.

Common Liquid Forms Available in Hong Kong

• Paracetamol oral solution / syrup — widely available
• Metronidazole suspension — HA pharmacy
• Haloperidol oral solution — available for psychiatric indications
• Risperidone oral solution — available; can be mixed into orange juice or water
• Lactulose solution — already liquid
• Most antihypertensives and cardiac medications do not have commercial liquid forms in HK — extemporaneous compounding is available through HA pharmacy on prescription

Specific Drug Classes: Dementia Medications

Donepezil (Aricept) and Other Cholinesterase Inhibitors

Donepezil is available as an oral disintegrating tablet (ODT) that dissolves on the tongue without swallowing — this is an excellent option for patients who struggle with standard tablets. Confirm with your pharmacist whether the ODT form is available in Hong Kong under the HA formulary or via private pharmacy.

Rivastigmine is also available as a transdermal patch (Exelon Patch) — avoids oral administration entirely. Suitable for patients with severe dysphagia or persistent refusal. Discuss with the prescribing geriatrician.

Antipsychotics (for BPSD)

Patients with dementia-associated behavioural and psychological symptoms (BPSD) may be prescribed haloperidol, risperidone, or quetiapine. These:

• Come in liquid forms (haloperidol, risperidone) — request from prescriber
• Quetiapine can be crushed if standard immediate-release tablets are prescribed — do NOT crush quetiapine XR
• Clonazepam drops (sublingual) can be an option for acute agitation — discuss with physician

Aspiration Risk During Medication Administration

Patients with dementia and dysphagia are at high aspiration risk during medication. Signs of aspiration during drug administration:

• Coughing or choking immediately after swallowing
• Wet, gurgling voice quality after medication
• Watery eyes, facial flushing
• Refusal to continue

If aspiration is suspected: stop, position upright, encourage gentle coughing, monitor for fever or respiratory deterioration in the following 24–48 hours. Report to the physician if chest infection signs develop.

Deprescribing Consideration

For patients with advanced dementia and severe dysphagia, a medication review to deprescribe non-essential drugs is often appropriate. The palliative care principle of “comfort-focused care” may mean that preventive medications (statins, aspirin for primary prevention, osteoporosis drugs) are discontinued in favour of comfort and dignity. This conversation should involve the physician, family, and where appropriate, a palliative care specialist.

In Hong Kong, the HA’s palliative care teams at hospitals including Queen Mary, Tuen Mun, Princess Margaret, and Pamela Youde Nethersole Eastern can provide guidance on appropriate deprescribing at end of life.