David Smithard

University of Greenwich · School of Health & Social Care

Eating and drinking are fundamental to life. However, older patients are often restricted with oral intake due to feared risk of aspiration. Eating and Drinking with Acknowledged Risks (EDAR) is an alternative process which enables comfort, dignity, and autonomy for these patients. While national guidance has been developed for EDAR in the UK, othe...

Introduction: Acquired swallowing impairment is a major public health issue that often leads to increased morbidity and slower recovery. Speech and language therapists (SLTs) have taken the lead in the assessment and treatment of dysphagia, which is reflected in guidelines where early intervention is recommended. This is in addition to the central...

Purpose Older patients with pneumonia are commonly restricted from oral intake due to concerns towards aspiration. Eating and drinking with acknowledged risks (EDAR) is a shared decision-making process emphasising patient comfort. As part of our project to find the barriers and facilitators of EDAR, we aimed for this initial study to see how freque...

Background Understanding the impact of pharmacological therapy on pneumonia severity is crucial for effective clinical management. The impact of angiotensin-converting enzyme inhibitors (ACEis) and beta-blockers (BBs) on pneumonia severity remains unknown, warranting further investigation. Methodology This retrospective study examined the hospital...

Purpose Little is known about the long-term and functional prognoses of older adults with pneumonia, which complicates their management. There is a common belief that aspiration is a poor prognostic factor; however, the diagnosis of aspiration pneumonia (AP) lacks consensus criteria and is mainly based on clinical characteristics typical of the fra...

Introduction Older adults are susceptible to anticholinergic effects. Dysphagia and pneumonia are associated with anticholinergic usage, though a definitive causative relationship has not been established. There is no effective way to predict the prognosis of older adults with pneumonia; therefore, this study investigates the predictive value of an...

Introduction Dysphagia is associated with long-term conditions including strokes, dementia, Parkinson’s disease and frailty. Dysphagia affects 30–40% of the population aged over 65 years-old. Adults with dysphagia often experience long-term conditions requiring multiple medications (often > 5) to manage these. The thickening of liquids is a common...

Background The Minimal Eating Observation Form – Version II (MEOF-II) is a brief and easy to use screening tool for eating difficulties, that is psychometrically robust. The aim of this study was to explore convergent (measuring similar constructs) and discriminant (measuring somewhat different constructs) validity of the MEOF-II to other validated...

As the medical world continues to search for ways of improving the swallowing of many millions of Dysphagia sufferers around the world, this paper is devoted to presenting the case for carbonated water to be considered as a potential solution for many. The effectiveness of carbonated water (CW) in the rehabilitation of Dysphagia has been studied pe...

Introduction Dysphagia is associated with long-term conditions including strokes, dementia, Parkinson’s disease and frailty. Dysphagia affects 30-40% of the population aged over 65-years-old. Adults with dysphagia are likely to experience long-term conditions requiring multiple medications (often >5) to manage this. The thickening of liquids is a c...

This paper presents a deep learning framework for medical video segmentation. Convolution neural network (CNN) and transformer-based methods have achieved great milestones in medical image segmentation tasks due to their incredible semantic feature encoding and global information comprehension abilities. However, most existing approaches ignore a s...

Introduction Oral frailty (OF), gradual loss of oral function combined associated with presbyphagia often in conjunction with cognitive and physical decline, has been recommended to be considered as a geriatric giant. DENTAL has been suggested as a possible screening tool for OF. We have looked at the prevalence of OF and its association with dysph...

Background: Dysphagia poses a huge health issue in our ageing population, impacting patients psychologically and through risk of aspiration, malnutrition and airway obstruction. The use of carbonated liquids to provide sensory enhancement as a tool to stimulate neuromuscular activity in dysphagia rehabilitation remains an area with limited researc...

Pneumonia is a common reason for admission afflicting frail older adults. Those who are the frailest are more likely to be provided with a diagnosis of aspiration pneumonia. This diagnosis has no clear definition and no clinical consensus. It is therefore time to stop attempting to differentiate between pneumonia type and use the term frailty-assoc...

Introduction. Patient self-evaluation is an important aspect in the assessment of dyspha-gia and comprises both Functional Health Status (FHS) and Health-Related Quality of Life (HR-QoL). As many measures combine both FHS and HR-QoL, disease-related functioning cannot be distinguished from disease-related quality of life as experienced by the patie...

In older adults, community-acquired pneumonia (CAP) is often aspiration-related. However, as aspiration pneumonia (AP) lacks clear diagnostic criteria, the reported prevalence and clinical management vary greatly. We investigated what clinical factors appeared to influence the diagnosis of AP and non-AP in a clinical setting and reconsidered a more...

Purpose Community-acquired pneumonia (CAP) is highly common across the world. It is reported that over 90% of CAP in older adults may be due to aspiration. However, the diagnostic criteria for aspiration pneumonia (AP) have not been widely agreed. Is there a consensus on how to diagnose AP? What are the clinical features of patients being diagnosed...

Background: Swallowing difficulties (dysphagia) and community-acquired pneumonia are common in frail older people and maybe addressed through targeted training of the anterior neck musculature that affects the swallow. We have developed a swallowing exercise rehabilitation intervention (CTAR-SwiFt) by adapting a previously established swallowing ex...

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 le...

Introduction Dysphagia poses a huge health issue in our ageing population, impacting patients psychologically and through risk of aspiration, malnutrition and airway obstruction. The use of carbonated liquids to provide sensory enhancement as a tool to stimulate neuromuscular activity in dysphagia rehabilitation remains an area with limited researc...

Dysphagia is increasingly being recognised as a geriatric syndrome (giant). There is limited research on the prevalence of dysphagia using electronic health records. To investigate associations between dysphagia, as recorded in electronic health records and age, frailty using the electronic frailty index, gender and deprivation (Welsh index of mult...

Restraint has been used within health care settings for many centuries. Initially physical restraint (PR) was the method of choice, in present times. Within critical care units PR and chemical restraint are used, frequently in tandem. Restraint is not a benign intervention and PR specifically is associated with physical and psychological trauma tow...

Older people with swallowing problems are more likely to encounter medication errors than those without dysphagia. Although recommendations on diet and fluids are considered after a swallowing assessment, medication formulation is often overlooked. A multidisciplinary approach is needed to ensure safety in medicines administration, particularly in...

Purpose Dysphagia prevalence in younger community dwelling adults and across nations is sparse. We investigated the prevalence of swallowing problems in an unselected cohort of people aged 18–65 years. Methods The EAT-10 Assessment Tool was converted into an anonymized online survey. Invitations were e-mailed to author contacts and onwards dispers...

Patient Reported Outcome Measures (PROMs) assess clinical outcomes from the perspective of the patient. The stroke community recommended fifteen questions for use in stroke survivors, based on the established PROMIS10 with five additional stroke-specific questions. This study aimed to determine its association with the National Institute of Health...

Oropharyngeal dysphagia is common in nursing home residents. The objective of this scoping review was to summarize and disseminate the findings from the literature on interventions for dysphagia in nursing home residents. Searches were conducted in four databases. The criteria for including the studies were nursing home residents, dysphagia, interv...

The current coronavirus pandemic presents the greatest healthcare crisis in living memory. Hospitals across the world have faced unprecedented pressure. In the face of this tidal wave of demand for limited healthcare resources, how are clinicians to identify patients most likely to benefit? Should age or frailty be discriminators? This paper seeks...

The ethics of physical restraint in the Emergency Department (and elsewhere) has always been an emotive and controversial issue. Recently a vanguard of advocacy groups and regulatory agencies have been aiming to reduce and optimize its use, resulting in new guidance around physical restraint. This article considers prevailing opinions surrounding p...

Discussion regarding cardiopulmonary resuscitation and admission to an intensive care unit is frequently fraught in the context of older age. It is complicated by the fact that the presence of multiple comorbidities and frailty adversely impact on prognosis. Cardiopulmonary resuscitation and mechanical ventilation are not appropriate for all. Who d...

Background sarcopenia registries are a potential method to meet the challenge of recruitment to sarcopenia trials. We tested the feasibility of setting up a UK sarcopenia registry, the feasibility of recruitment methods and sought to characterise the pilot registry population. Methods six diverse UK sites took part, with potential participants age...

Introduction Around 920,000 people in the UK have been Diagnosed with Heart Failure with a median age of diagnosis been 77 years. The most commonly used test used to diagnose and measure prognosis in HF is BNP levels. B—Type Natriuretic Peptide is a hormone which is released in response to pressure changes in the ventricles. It causes Natriuresis w...

Introduction: With increasing age the prevalence of frailty, sarcopenia, undernutrition and dysphagia increases. These are all independent markers of outcome. This study explores the prevalence of these four and explores relationships between them. Methods: A convenience sample of 122 patients admitted to acute medical and frailty wards were recrui...

The term frailty is being increasingly used by clinicians, however there is no strict consensus on the best screening method. The expectation in England is that all older patients should have the Clinical Frailty Scale (CFS) completed on admission. This will frequently rely on junior medical staff and nurses, raising the question as to whether ther...

As people and the population age, the prevalence of swallowing problems (dysphagia) increases. The screening for dysphagia is considered good practice in stroke care, yet is not routinely undertaken in the management of frail older adults. A short swallow screen, the 4QT, was developed following a review of the literature. The screen has four quest...

Objectives: Delirium is associated with increased mortality in older adults. National guidance recommends that all people with dementia who are admitted to hospital are screened for delirium. However, the impact of screening for delirium among inpatients with dementia has not been examined. This study aims to examine this relationship. Methods: Sec...

Dysphagia is common—not only associated with stroke, dementia, Parkinson’s but also in many non-neurological medical problems—and is increasingly prevalent in ageing patients, where malnutrition is common and pneumonia is frequently the main cause of death. To improve the care of people with dysphagia (PWD) and minimise risk of aspiration and choki...

Objective: To investigate perceptions and acceptability of, and attitudes towards, acupuncture for post-acute stroke and rehabilitation care by exploring the views of different stakeholders. Methods: Three electronic surveys were conducted to gauge the breadth of knowledge and acceptance of acupuncture in post-acute stroke and rehabilitation care a...

The international approach to the assessment and management of dysphagia in the acute phase post stroke is little studied. A questionnaire was sent to clinicians in stroke services that explored the current practice in dysphagia screening, assessment, and management within the acute phase post stroke. The findings from four (the UK, the US, Canada,...

Restraint in modern non-psychiatric-based healthcare is often regarded as a rare occurrence. It is deemed to be used as a last resort to prevent patients from directly harming themselves. However, techniques are used in modern day practice which are considered direct and indirect restraints with the justification of maintaining patient safety, but...

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

Despite the remarkable burden of dysphagia, appropriate multidisciplinary management is lacking in Iran and patients are often deprived of effective treatments. Obtaining a full understanding of knowledge, attitude and practice (KAP) of healthcare providers is necessary to determine the gaps in improvement of the quality of care for dysphagic patie...

Society revolves around food, both as a physical necessity and a social nicety; thus, eating and drinking (and, hence, swallowing safely) have become a cornerstone of social life. [...]

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 practic...

Purpose of Review This paper is a brief overview of the relationship between frailty, swallowing and dysphagia. Its goal is to explore the interplay between age and sarcopenia in the development of dysphagia, which is known to be linked to aspiration pneumonia. It is postulated that there is growing justification for routine screening for dysphagia...

Introduction The proportion of elderly people around the world is increasing. One of the key factors of this longer life is healthy aging. Iran is one among many countries with a changing demographic profile, due to the rapid increase in the aging population. One of the health threatening problems of elderly people is dysphagia. Dysphagia can affec...

Post-stroke dysphagia is common, associated with poor outcome and often requires non-oral feeding/fluids. The relationship between route of feeding and outcome, as well as treatment with glyceryl trinitrate (GTN), was studied prospectively. The Efficacy of Nitric Oxide in Stroke (ENOS) trial assessed transdermal GTN (5 mg versus none for 7 days) in...

Swallowing problems are common in very frail older people and their identification, assessment and management can be difficult. David G Smithard emphasises the importance of a thorough assessment by the multidisciplinary team

Introduction: Progress in understanding and management of vascular cognitive impairment (VCI) has been hampered by lack of consensus on diagnosis, reflecting the use of multiple different assessment protocols. A large multinational group of clinicians and researchers participated in a two-phase Vascular Impairment of Cognition Classification Conse...

Traduction française des recommandations de l'ESSD et de la Société Européenne de Gériatrie concernant la dysphagie oro-pharyngée comme syndrome gériatrique

People with many different medical problems will develop swallowing problems or dysphagia. The management of dysphagia cannot be done in isolation, particularly as the end of life approaches. Interventions to assist in the provision of nutrition are in most countries a medical treatment. Decisions will need to be made that will be influenced as muc...

The population is ageing, with the greatest proportional increase in those >80 years of age. Many of these people will be frail and at risk of stroke. Research has shown that the very old have much to benefit from hyperacute stroke intervention, but at the same time they suffer increased mortality. Their outcome following stroke and intervention is...

Dysphagia is one of the many complications of stroke. It is common and is an independent marker of outcome. Dysphagia management is important. Although the speech and language pathologist is the key worker in dysphagia management, they are supported by all members of the multi-disciplinary team. Stroke patients should be screened on admission for t...

This position document has been developed by the Dysphagia Working Group, a committee of members from the European Society for Swallowing Disorders and the European Union Geriatric Medicine Society, and invited experts. It consists of 12 sections that cover all aspects of clinical management of oropharyngeal dysphagia (OD) related to geriatric medi...

Objective: To investigate whether nasogastric tubes (NGTs) increase poststroke pneumonia (PSP), mortality, or poor outcomes in nil-by-mouth acute stroke patients. Methods: This study analyzed prespecified outcomes of PSP at 14 days and mortality and function measured by the modified Rankin Scale at 90 days in 1,217 nil-by-mouth stroke patients a...

Objective: Diagnosing stroke-associated pneumonia (SAP) is challenging and may result in inappropriate antibiotic use or confound research outcomes. This study evaluates the diagnostic accuracy of algorithm-defined versus physician-diagnosed SAP in 1088 patients who had dysphagic acute stroke from 37 UK stroke units between 21 April 2008 and 17 Ma...

The replacement of fluids (usually water), may be undertaken in one of three ways: • orally: People may drink it or it may be administered via an enteral tube; • intravenously where fluid is provided via a cannula into a vein; or • subcutaneously, where fluids are administered between the subcutaneous layer of the skin and fat. This is called hy...

There are 835,000 people in the UK who have dementia at an annual cost to the UK economy of £26 billion. Most people with dementia live in the community with one in three living alone at home with much of the care being met by unpaid carers. Seventy percent of care home residents have dementia. Dementia is an umbrella term that covers a multitude o...

Background Risks and prevalence of malnutrition and dehydration are high in older people but even higher in older people with dementia. In the EDWINA (Eating and Drinking Well IN dementiA) systematic review we aimed to assess effectiveness of interventions aiming to improve, maintain or facilitate food/drink intake indirectly, through food service...

Post-stroke dysphagia (a difficulty in swallowing after a stroke) is a common and expensive complication of acute stroke and is associated with increased mortality, morbidity, and institutionalization due in part to aspiration, pneumonia, and malnutrition. Although most patients recover swallowing spontaneously, a significant minority still have dy...

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...

Background: Eating and drinking difficulties are recognised sources of ill health in people with dementia. In the EDWINA (Eating and Drinking Well IN dementiA) systematic review we aimed to assess effectiveness of interventions to directly improve, maintain or facilitate oral food and drink intake, nutrition and hydration status, in people with co...

p> Background : Stroke remains one of the largest causes of impairment and disability globally. Stroke involves high costs to the health economy. Objective : To explore the extent of recovery of voluntary movements and function in dense acute strokes treated with the optokinetic chart stimulation based OKCSIB protocol. Methods : The experimental...

Swallowing problems are common and may occur in non neurological conditions. Swallowing problems are often insidious and ignored in older people; dysphagia should be recognized as a geriatric syndrome. It is important to identify this to ensure appropriate intervention and management is put into place. A Community Nurse is ideally placed to do this...

Background: Post-stroke pneumonia is associated with increased mortality and poor functional outcomes. This study assessed the effectiveness of antibiotic prophylaxis for reducing pneumonia in patients with dysphagia after acute stroke. Methods: We did a prospective, multicentre, cluster-randomised, open-label controlled trial with masked endpoi...

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-reporte...

Enteral feeding is the nutritional support of choice for acutely ill patients with functional gastrointestinal tracts who are unable to swallow. Several benefits including reduced mortality and length of hospital stay have been associated with early initiation of enteral feeding. However, misplacement of conventional nasoenteric tubes is relatively...

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 malnutr...

David G Smithard1,2 1Royal Victoria Hospital, Kent Community Health NHS Trust, Folkestone, UK; 2Department of Electronics and Digital Arts, University of Kent, Canterbury, UK Abstract: As the global population increases in age and the pressures on hospital resources increase, with a defined budget, the management of people in their own home environ...