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

Purpose: Medication administration in long-term care facilities (LTCFs) is complicated by multimorbidity, frailty, cognitive impairment, polypharmacy, and dysphagia. Solid oral dosage form (SODF) manipulation is common but may compromise medication safety. We aimed to determine the prevalence of SODF manipulation and evaluate its appropriateness in Italian LTCFs. Methods: We conducted a national multicenter point-prevalence study (Prescription-Day LTCFs 2024) in 82 Italian LTCFs. Of the 3400 enrolled residents, 3174 were included after excluding residents with acute conditions and facilities enrolling fewer than five residents. The study population had a mean age of 84.8 years, of which 74.1% were women, with high multimorbidity, dementia (47.9%), polypharmacy (mean 7.3 medications), and dysphagia (14.7%). SODF manipulation included tablet crushing or splitting, capsule opening, and mixing medications with food or liquids. Appropriateness was evaluated using a hierarchical framework integrating the SIFO Handbook, the Friuli Venezia Giulia "Do Not Crush" list, the TRC 2025 update, the Summary of Product Characteristics, and expert review. Results: Among 20,290 oral prescriptions (15,214 tablets and 802 capsules), 4655 SODFs (23.0%) were modified. Of these, 27.9% were inappropriate and 10.8% likely inappropriate. Overall, 1006 residents (31.7%) received at least one inappropriate or likely inappropriate modification, and 11.9% received three or more. Inappropriate manipulation was more frequent for capsules than tablets (68.8% vs 37.7%). Frequently involved medications included pantoprazole, trazodone, and amlodipine. Residents exposed to inappropriate manipulation were more likely to be frail and to have dementia or dysphagia. Conclusions: SODF manipulation is highly prevalent in Italian LTCFs, with more than one-third of modifications being potentially inappropriate. The frequency of manipulation exceeded the prevalence of dysphagia, suggesting organizational and behavioral drivers. Standardized guidance and greater prescriber and pharmacist involvement are needed to improve medication safety.