Crushing Pills in Nursing Homes: One in Three Manipulations May Be Unsafe

Every day, in nursing homes across Italy, nurses quietly perform one of medicine’s most routine yet least examined tasks: they crush tablets, open capsules, and stir powdered medication into applesauce or yogurt. A new national study suggests that this everyday act of practical caregiving carries a hidden burden of risk. In the largest investigation of its kind in Italy, researchers found that nearly one in four solid oral dosage forms given to residents of long-term care facilities had been altered before administration, and that more than a third of those alterations were potentially inappropriate, meaning they could compromise the safety or effectiveness of the drugs involved.

The study, published in European Geriatric Medicine, was conducted as part of the Prescription-Day LTCFs 2024 project, a national multicenter point-prevalence survey involving 82 Italian long-term care facilities. Point-prevalence designs capture a snapshot of practice on a single day, which makes them particularly useful for revealing what actually happens at the bedside rather than what guidelines say should happen. After exclusions, the analysis included 3,174 residents with a mean age of 84.8 years, nearly three-quarters of whom were women. The population reflected the classic profile of institutional geriatric care: heavy multimorbidity, dementia in 47.9 percent of residents, polypharmacy with a mean of 7.3 medications per person, and documented dysphagia, or difficulty swallowing, in 14.7 percent.

The technical definition of manipulation in the study was deliberately broad. It covered tablet crushing or splitting, capsule opening, and mixing medications with food or liquids. These practices exist for understandable reasons. Older adults with dementia may refuse whole pills, residents with dysphagia may be physically unable to swallow them, and enteral feeding tubes simply cannot accommodate intact tablets. But the pharmaceutical logic of a dosage form is rarely arbitrary. Extended-release coatings, enteric coatings designed to protect the stomach or the drug, and sublingual or buccal formulations all depend on the integrity of the tablet or capsule. Destroying that integrity can convert a controlled 24-hour release into an immediate dose dump, inactivate acid-labile compounds, expose caregivers to hazardous powder, or produce inaccurate partial doses when tablets are split unevenly.

To judge whether each manipulation was appropriate, the researchers used a hierarchical framework that integrated several authoritative sources: the SIFO Handbook from the Italian Society of Hospital Pharmacy, the Friuli Venezia Giulia regional Do Not Crush list, the 2025 update of the Therapeutic Research Center’s crush guidance, the manufacturer’s Summary of Product Characteristics for each drug, and, where sources conflicted or were silent, expert review. This layered approach matters because international guidance is not always consistent, and a single reference list can leave gaps. By triangulating multiple sources, the team aimed to reduce the risk of both over- and under-labeling manipulations as unsafe.

The numbers were striking. Among 20,290 oral prescriptions recorded on the survey day, including 15,214 tablets and 802 capsules, 4,655 solid oral dosage forms, or 23.0 percent, were modified. Of those modifications, 27.9 percent were classified as outright inappropriate and a further 10.8 percent as likely inappropriate. Translated to the resident level, 1,006 people, or 31.7 percent of the study population, received at least one potentially inappropriate manipulation, and 11.9 percent received three or more. In other words, on any given day in an Italian nursing home, roughly one resident in three is exposed to a medication practice that guidance documents say should not occur.

The type of dosage form mattered. Capsules fared far worse than tablets: 68.8 percent of capsule manipulations were judged inappropriate, compared with 37.7 percent of tablet manipulations. This difference has a plausible pharmacological basis. Many capsules contain enteric-coated or modified-release granules or pellets that must remain intact to function; emptying the capsule destroys the release mechanism. Among the medications most frequently involved were pantoprazole, a proton-pump inhibitor often formulated as gastro-resistant granules; trazodone, an antidepressant widely prescribed for sleep in older adults; and amlodipine, a common antihypertensive. Each of these drugs is ubiquitous in geriatric prescribing, which helps explain how inappropriate manipulations accumulate so quickly in this population.

Perhaps the most telling finding is a simple arithmetic mismatch. Only 14.7 percent of residents had documented dysphagia, yet 23 percent of all oral dosage forms were manipulated. Manipulation, in other words, is happening far more often than the clinical problem it is nominally meant to solve. The authors interpret this gap as evidence of organizational and behavioral drivers rather than purely clinical necessity. Routine, habit, staffing pressures, the absence of pharmacist review at the point of administration, and the sheer logistical difficulty of coordinating seven or more medications per resident across multiple administration times all push staff toward the fastest available solution, which is often to crush first and ask questions later, if at all.

The residents most likely to experience inappropriate manipulation were also the most vulnerable: those classified as frail, and those living with dementia or dysphagia. This creates a sobering paradox. The patients whose physiology and cognition make them least able to tolerate medication errors, whether a sudden release of a drug intended for slow absorption or an underdose from an unevenly split tablet, are precisely the ones most exposed to those errors. For extended-release formulations of cardiovascular or psychotropic medications, an unintended immediate release can mean hypotension, sedation, or cardiac effects that are difficult to anticipate in a frail older body. For drugs with narrow therapeutic windows, inaccurate splitting can push residents into subtherapeutic or toxic territory without anyone noticing until symptoms appear.

The study is not without the usual limits of observational survey research. It captures a single day in each facility, so it cannot track the consequences of inappropriate manipulation over time, and the appropriateness classification, however rigorous, ultimately depends on reference lists that themselves evolve. The population was also limited to residents in stable condition, excluding acute illnesses that might change medication handling. Still, the scale and national scope of the survey, together with its explicit, multi-source appropriateness framework, make it one of the clearest quantitative portraits to date of a practice that has long flown under the radar of medication safety research, which has historically focused more on prescribing errors and drug-drug interactions than on what happens to the pill between the blister pack and the mouth.

The authors’ conclusion is a call for structural change rather than individual blame. They argue for standardized, nationally harmonized guidance on dosage form manipulation, greater involvement of prescribers and pharmacists in deciding how each medication should be given, and multidisciplinary collaboration between physicians, nurses, and pharmacists. Practical remedies already exist in the pharmaceutical arsenal: liquid formulations, dispersible tablets, transdermal patches, and drugs that are genuinely safe to crush can often replace problematic products when prescribers review regimens with manipulation in mind. The deeper message of the study is that medication safety in long-term care does not end at the prescription. The humble act of altering a pill, repeated thousands of times a day across thousands of facilities, deserves the same systematic attention, training, and oversight that prescribing itself receives, because for a third of nursing home residents, the difference between a safe dose and a hazardous one may come down to whether someone reached for the pill crusher.

Subject of Research: Prevalence and safety of crushing or altering solid oral medications in long-term care facilities

Article Title: Prevalence and appropriateness of solid oral dosage form manipulation in long-term care facilities

Article References: Malara, A., Zucchelli, A., Trevisan, C., Borselli, G., Antonelli Incalzi, R., Onder, G., Cherubini, A., Cignarella, A., Marengoni, A., Morandi, A., Castaldo, A., Testa, G. D., Leosco, D., Ungar, A., & Prescription Day LTCFs Workgroup (2026). Prevalence and appropriateness of solid oral dosage form manipulation in long-term care facilities. European Geriatric Medicine. https://doi.org/10.1007/s41999-026-01618-4

Image Credits: AI Generated

DOI: 10.1007/s41999-026-01618-4

Keywords: long-term care facilities, solid oral dosage form manipulation, medication safety, dysphagia, polypharmacy, dementia, geriatrics, tablet crushing, nursing homes, pharmacology, drug administration, inappropriate medication use