An older patient tells the health care team that swallowing medications is difficult. Pills get stuck in the throat. Some trigger gagging. Others are skipped altogether because taking them has become an ordeal. The concern is documented, the difficulty is acknowledged, and in some cases, a swallowing assessment is even performed. Yet the prescription remains unchanged.

Weeks later, the patient has missed doses or stopped the medication altogether. The medical record notes “noncompliance” or “failure to follow medical advice.” What happened?

Too often, health care assumes that identifying a barrier is the same as addressing it. It is not. A documented obstacle that remains unaddressed is still an obstacle.

Difficulty swallowing pills is a common, and often overlooked, barrier to medication adherence among older adults. Up to 40 percent of American adults report problems swallowing pills, including gagging, choking, vomiting, or the sensation that a pill is lodged in the throat. Yet pill swallowability remains an afterthought in many prescribing decisions. For many older adults, the issue is not motivation. It is mechanics. And when a mechanical problem is treated as a behavioral problem, both patients and providers can lose sight of the real cause.

A common but overlooked barrier

Difficulty swallowing medications becomes increasingly common with age. Changes in swallowing function, reduced saliva production, frailty, and neurologic conditions such as stroke, Parkinson’s disease, and dementia can all make solid oral medications harder to take. Even when dysphagia is not formally diagnosed, the practical barrier may still be present: The medication may be too large, too dry, too difficult to swallow safely, or anxiety-provoking enough that the patient avoids it.

The problem is compounded by polypharmacy. Nearly nine in ten adults age 65 and older take at least one prescription medication, and more than four in ten take five or more. As pill burden increases, so does the likelihood that at least one medication will become difficult to swallow.

Research shows that tablet and capsule size can strongly affect swallowing difficulty. Larger solid medications are associated with substantially higher odds of swallowing problems, reinforcing a simple point: pill design matters. For many patients, a large tablet is not a minor inconvenience. It can trigger gagging, choking, coughing, anxiety, embarrassment, or fear of aspiration. Over time, these experiences can lead patients to avoid medications entirely.

Identifying a barrier is not the same as removing it

The most troubling aspect of this issue is not that swallowing difficulties exist. It is that health care systems often identify the problem but fail to address it. Patients report difficulty swallowing. Family members raise concerns. Pharmacists identify barriers. Speech-language pathologists perform evaluations. Questionnaires such as the PILL-5 can document pill-swallowing difficulty. The problem is recognized, the assessment is completed, and the barrier is documented. Yet nothing changes. The same medication is prescribed, the same formulation is dispensed, and the same obstacle remains.

Health care frequently operates under the assumption that recognizing a problem is equivalent to solving it. A swallowing assessment does not make a pill easier to swallow. Documentation alone does not improve adherence. Identifying a barrier without addressing it simply leaves the patient facing the same obstacle that existed before the assessment occurred.

When patients continue to struggle, the burden remains entirely on them. Swallowing difficulty is one example of a broader pattern in health care: Barriers are identified, documented, and then left for patients to overcome on their own. When the patient cannot overcome them, the failure is recorded as noncompliance.

When noncompliance becomes the wrong diagnosis

Language matters. When patients skip doses, alter medications, or discontinue treatment because they cannot comfortably swallow a pill, the resulting behavior is often described as noncompliance. But is noncompliance truly the problem?

Patients frequently resort to crushing tablets, opening capsules, splitting medications, or skipping doses altogether. Some of these modifications can alter absorption, interfere with medications designed for delayed or extended release, or create additional safety risks. The resulting treatment failure may then be attributed to the patient rather than to the barrier that made adherence difficult in the first place.

Once the label “noncompliant” enters the medical record, it can take on a life of its own. Future providers may see the label without seeing the barrier that preceded it. What began as an unaddressed swallowing difficulty can gradually become a narrative about patient behavior. It may influence future clinical encounters, quality reviews, utilization decisions, and even legal proceedings. Yet the medical record may contain little discussion of an equally important question: Were reasonable efforts made to remove the obstacle?

Were alternative formulations considered? Could a liquid formulation have been prescribed? Was an orally disintegrating tablet available? Could a smaller tablet, oral film, sprinkle formulation, or compounded preparation have achieved the same therapeutic goal? Was the overall medication regimen simplified to reduce pill burden? Too often, these questions are never asked. The focus remains on whether the patient followed the treatment plan rather than whether the treatment plan was realistically achievable. Documentation should not stop at noting that a patient did not take a medication. It should also reflect whether practical barriers were identified and what steps were taken to address them.

Designing treatment plans patients can actually follow

Fortunately, solutions already exist and are often straightforward. Many medications are available in more swallowable forms, and when commercial options are not appropriate or available, compounding pharmacies may be able to prepare customized alternatives. Other interventions may be even simpler, including evidence-supported swallowing techniques such as the pop-bottle method for tablets or the lean-forward technique for capsules, safe administration with soft foods, or changes in timing, spacing, or overall pill burden.

These adjustments should be made with clinical guidance because not all medications can be crushed, opened, mixed with food, or altered safely. Medications designed for delayed or extended release, in particular, may lose their intended safety or absorption profile if modified incorrectly.

Health care systems should consider incorporating routine screening for pill-swallowing difficulty into medication reconciliation, particularly for older adults and patients taking multiple medications. Pharmacists and speech-language pathologists should be engaged earlier when barriers are identified, not after treatment failure occurs.

The pharmaceutical industry also has a role to play. Drug development has historically prioritized efficacy, stability, manufacturing efficiency, and dosing precision. These priorities remain essential. However, swallowability should be recognized as a critical component of effectiveness in actual patient care. A medication cannot work if patients cannot take it. The goal is not simply to tell patients to try harder, but to redesign the regimen so the patient has a realistic path to adherence.

Moving from blame to problem solving

Medication adherence should not be viewed solely as a measure of patient behavior. It should also be viewed as a measure of how well health care professionals design treatment plans that patients can realistically follow. As the population ages, health care systems will increasingly care for patients with swallowing difficulties, complex medication regimens, and multiple chronic conditions. Simply documenting barriers is not enough. Identifying a problem is only the first step; the responsibility is to act on it.

Before labeling an older patient noncompliant, health care professionals should ask a more complete question: Did we remove the barriers we already knew existed? If the answer is no, the failure should not be placed entirely on the patient.

Sometimes the problem is not that a patient refused treatment. Sometimes the problem is that the health care system recognized the barrier, documented the barrier, assessed the barrier, and then left the barrier exactly where it was.

Laurel A. Coons is a scientist with a background in genomics and biomedical research. She completed her doctoral training in pharmacology and cancer biology at Duke University and conducted research at the National Institute of Environmental Health Sciences. Her work has focused on genomic regulation, endocrine signaling, and translating complex scientific data into insights relevant to medicine and patient care.

She shares professional updates on X at laurelcoons.