Research in care homes has demonstrated that medication management practices in patients with dysphagia and those receiving medicines covertly may be inappropriate, illegal, and potentially cause harm. This paper presents the results of a... more
Research in care homes has demonstrated that medication management practices in patients with dysphagia and those receiving medicines covertly may be inappropriate, illegal, and potentially cause harm. This paper presents the results of a feasibility study piloting a resident and healthcare professional best practice charter to improve such practices in care home residents with dysphagia. A charter was developed through a multi-professional expert panel, implemented in one care home, and then piloted in 22 homes in England, Wales, and Northern Ireland. A website was setup and developed iteratively to support the process. Care home staff and residents provided initial feedback on the implementation process and on perceived outcomes six months post implementation. A total of 16 (88.9%) out of 18 respondents from nine homes for six months reported a positive response to the charter. More than 80% of responses regarding the implementation process, impact on staff confidence, and perceiv...
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Research Interests: Gerontology, Health Informatics, Dementia, Environmental Health, Public Health, and 11 moreHealth Administration, Medicine, Nursing Research, Malnutrition, Library and Information Studies, Psychological Intervention, Systematic review, LICENSE, Public health systems and services research, Waiver, and Licensee
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Background The Sarcopenia Quality of Life (SarQoL) questionnaire is a disease-specific sarcopenia quality of life tool. We aimed to independently assess SarQoL with a particular focus on its suitability as a clinical trial outcome... more
Background The Sarcopenia Quality of Life (SarQoL) questionnaire is a disease-specific sarcopenia quality of life tool. We aimed to independently assess SarQoL with a particular focus on its suitability as a clinical trial outcome measure. Methods We analysed data from the UK Sarcopenia Network and Registry. Measures of physical performance and lean mass were collected at baseline. SarQoL and the Strength, Assistance, Rise, Climb - Falls (SARC-F) questionnaire (to assess functional ability) were collected at both baseline and six-month follow-up. Global changes in fitness and quality of life at 6 months were elicited on seven-point Likert scales. Internal consistency was assessed using Cronbach’s alpha. Responsiveness (Cohen’s d and Guyatt coefficients) and minimum clinically important differences were calculated for participants reporting slight improvement or worsening in their global scores. Concurrent validity was assessed by correlating baseline SarQoL scores with measures of p...
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Background: Post-stroke dysphagia is common, associated with poor outcome, and patients often require non-oral feeding/fluids. The relationship of feeding status on outcome, and treatment with transdermal glyceryl trinitrate (GTN) was... more
Background: Post-stroke dysphagia is common, associated with poor outcome, and patients often require non-oral feeding/fluids. The relationship of feeding status on outcome, and treatment with transdermal glyceryl trinitrate (GTN) was studied in the ENOS trial. Methods: ENOS assessed GTN (5 mg vs none for 7 days) in 4,011 patients with acute stroke and high blood pressure. Feeding status (oral = normal diet, soft diet; non-oral = nasogastric tube, percutaneous endoscopic gastrostomy tube, parenteral fluids, none) was assessed at baseline and day 7. The primary outcome was the modified Rankin Scale (mRS) measured at day 90. Analyses of outcomes were adjusted for baseline covariates. †2p<0.001. Results: In comparison with oral feeding, non-oral patients (N=1331, 33.2%) were older (73.9 vs 68.5 years†), more likely to be female (47.3 v 40.4%†) and had more severe stroke (Scandinavian Stroke Scale 24.6 v 38.3†). By day 7, 56.8% patients had improved from non-oral to oral feeding, and...
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Research Interests: Geriatrics, Psychiatry, Gerontology, Dementia, Risk, and 15 moreMortality, Medicine, Logistic Regression, Screening, Delirium, Audit, Outcomes, Science Technology, Odds ratio, Inpatients, Geriatrics and Gerontology, Confidence Interval, confounding, Psychology and Cognitive Sciences, and Medical and Health Sciences
As people get older and approach the end of their lives, their medical situation can become more complex and they will often need various treatments. David Smithard explains the ethical principles behind medical decisions about older... more
As people get older and approach the end of their lives, their medical situation can become more complex and they will often need various treatments. David Smithard explains the ethical principles behind medical decisions about older persons
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To assess the association between the use of medications with anticholinergic activity and the subsequent risk of injurious falls in older adults. Prospective, population-based study using data from The Irish Longitudinal Study on Ageing.... more
To assess the association between the use of medications with anticholinergic activity and the subsequent risk of injurious falls in older adults. Prospective, population-based study using data from The Irish Longitudinal Study on Ageing. Irish population. Community-dwelling men and women without dementia aged 65 and older (N = 2,696). Self-reported injurious falls reported once approximately 2 years after baseline interview. Self-reported regular medication use at baseline interview. Pharmacy dispensing records from the Irish Health Service Executive Primary Care Reimbursement Service in a subset (n = 1,553). Nine percent of men and 17% of women reported injurious falls. In men, the use of medications with definite anticholinergic activity was associated with greater risk of subsequent injurious falls (adjusted relative risk (aRR) = 2.55, 95% confidence interval (CI) = 1.33-4.88), but the risk of having any fall and the number of falls reported were not significantly greater. Great...
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Research Interests: Treatment Outcome, Dysphagia, Medicine, Stroke, Prospective studies, and 15 morePopulation, Humans, Female, Pneumonia, Male, Antibiotic Prophylaxis, Two Stroke Engine, Aged, Anti-Bacterial Agents, Aspiration Pneumonia, Severity of Illness Index, Acute Disease, The Lancet, Deglutition disorders, and Medical and Health Sciences
Malnutrition and dysphagia are common after stroke and frequently occur together. Failure to recognise their presence and manage them effectively will result in increased morbidity and mortality. Infection risk may be raised, recovery and... more
Malnutrition and dysphagia are common after stroke and frequently occur together. Failure to recognise their presence and manage them effectively will result in increased morbidity and mortality. Infection risk may be raised, recovery and rehabilitation will be slowed, and people will be more likely to end up in long-term care. Treatment of malnutrition and swallowing difficulties requires early recognition, e.g. through routine screening procedures, and their management requires input from the multi-disciplinary team.
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Symptoms of fatigue are often reported by patients in both the acute and chronic stages of recovery following a stroke. It is commonly associated with low mood and sleep disturbances, but can arise in their absence. However, it has also... more
Symptoms of fatigue are often reported by patients in both the acute and chronic stages of recovery following a stroke. It is commonly associated with low mood and sleep disturbances, but can arise in their absence. However, it has also been associated with poorer long-term outcome and, as such, its aetiology warrants a greater understanding. There is convincing evidence that inflammatory cascades and cytokine signalling precipitated by the infarct promote fatigue, and these pathways may harbour therapeutic targets in its management.
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OBJECTIVES: To determine whether the use of medications with possible and definite anticholinergic activity increases the risk of cognitive impairment and mortality in older people and whether risk is cumulative.DESIGN: A 2‐year... more
OBJECTIVES: To determine whether the use of medications with possible and definite anticholinergic activity increases the risk of cognitive impairment and mortality in older people and whether risk is cumulative.DESIGN: A 2‐year longitudinal study of participants enrolled in the Medical Research Council Cognitive Function and Ageing Study between 1991 and 1993.SETTING: Community‐dwelling and institutionalized participants.PARTICIPANTS: Thirteen thousand four participants aged 65 and older.MEASUREMENTS: Baseline use of possible or definite anticholinergics determined according to the Anticholinergic Cognitive Burden Scale and cognition determined using the Mini‐Mental State Examination (MMSE). The main outcome measure was decline in the MMSE score at 2 years.RESULTS: At baseline, 47% of the population used a medication with possible anticholinergic properties, and 4% used a drug with definite anticholinergic properties. After adjusting for age, sex, educational level, social class, n...
Research Interests: Pharmacoepidemiology, Cognition, Medicine, Comorbidity, England, and 15 moreProspective studies, Population, Humans, Female, Male, Aged, Longitudinal Studies, Odds ratio, Health surveys, Geriatric Assessment, Anticholinergic, Confidence Interval, Cognition disorders, Cholinergic antagonists, and Medical and Health Sciences
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Although clinically evident aspiration is common in subjects with dysphagia, a significant proportion may aspirate silently, i.e., without any outward signs of swallowing difficulty. This article reviews the literature on the prevalence,... more
Although clinically evident aspiration is common in subjects with dysphagia, a significant proportion may aspirate silently, i.e., without any outward signs of swallowing difficulty. This article reviews the literature on the prevalence, etiology, and prognostic significance of silent aspiration. An electronic database search was performed using silent aspiration, aspiration, dysphagia, and stroke as search terms, together with hand-searching of articles. Silent aspiration has been described in many conditions and subgroups of patients (including normal individuals), using a number of detection methods, making comparisons a challenge. The best data are for acute stroke, in which 2%-25% of patients may aspirate silently. Mechanisms associated with silent aspiration may include central or local weakness/incoordination of the pharyngeal musculature, reduced laryngopharyngeal sensation, impaired ability to produce a reflexive cough, and low substance P or dopamine levels. In terms of prognosis, silent aspiration has been associated with increased morbidity and mortality in many but not all studies. However, some degree of silent aspiration at night may be normal in healthy individuals. The phenomenon of silent aspiration is poorly understood and further research is needed to improve methods of detection and thereby better define its prevalence and prognostic significance.
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As many as 40% of older people are prescribed medications with anticholinergic activity. Studies have suggested the significant effect of anticholinergic medication on cognition but there is controversy. Objective: Analysis of 15908... more
As many as 40% of older people are prescribed medications with anticholinergic activity. Studies have suggested the significant effect of anticholinergic medication on cognition but there is controversy. Objective: Analysis of 15908 patients impact of anticholinergic drugs on cognition. Methods: The anticholinergic burden scale (ABS) coded drugs 0 (none), 1 (mild), 2 (moderate), or 3 (severe). Scores were summed for each participant to give a total Anticholinergic Cognitive Burden (ACB) score. Study 1 MRC CFAS with 11,994 participants and cross sectional coding part of a 19 year longitudinal; Study 2 LASER-AD - Dementia Specific 18 month longitudinal with 224 participants. Study 3 SAP REDS USA 1 year follow up with 3690 participants. Study 1 MRC-CFAS - A statistically significant dose-response relation was observed between increasing ACB score and decreasing MMSE, e.g. those with an ACB score of 5 or greater were associated with making 21% (95%CI 8%-35%) more errors on the MMSE. The relationship with cognitive impairment was only seen for ACB conferred by Central Nervous System medications, in particular antipsychotics. Study 2 LASER AD - Anti-cholinergic burden had no significant effect on cognitive decline at 18 months as assessed by the ADAS-cog. The ADAS-cog decreased by a mean of 4.63 in the cohort of patients with an ACB of 0, compared with a mean decrease of 7.4 in patients with an ACB of>0 (mean difference=2.83; t=1.107; df=100; p=0.271; CI-2.24-7.9). Study 3 SAP REDS - Anticholinergic burden for 60 days was associated with a significant effect on cognitive decline as measured by the Community Screening Interview for Dementia odds ratio 1.55p<0.05 (CI-1.05-2.29) with a possible burden dose response effect. Conclusion: An inverse relation existed between the anticholinergic burden of current medication use and cognition in study 1 and study 3; in study 1 the association was driven by the ACB of CNS medications. However, in study 2 no association was detected. Thus the abandonment of use of medication with anticholinergic effects may not be warranted. Further research is required to determine the clinical relevance.
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Rationale The majority of stroke patients are discharged home dependent on informal caregivers, usually family members, to provide assistance with activities of daily living, including bathing, dressing, and toileting. Many caregivers... more
Rationale The majority of stroke patients are discharged home dependent on informal caregivers, usually family members, to provide assistance with activities of daily living, including bathing, dressing, and toileting. Many caregivers feel unprepared for this role, and this may have a detrimental effect on both the patient and caregiver. Aims To evaluate whether a structured, competency-based training programme for caregivers improves physical and psychological outcomes for patients and their caregivers after disabling stroke, and to determine if such a training programme is cost-effective. Design A cluster randomized controlled trial. The trial aims to recruit 25 patient and caregiver dyads from each of the 36 participating stroke rehabilitation units. Stroke units have been randomized to either the intervention or control group with randomization stratified by geographical region and quality of care. The intervention is the London Stroke Carer Training Course developed and evaluat...