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Adlbrecht L, Karrer M, Helfenberger N, Ziegler E, Zeller A. Facilitators and barriers to implementing a specialized care unit for persons with cognitive impairment in an acute geriatric hospital: a process evaluation. BMC Geriatr 2024; 24:29. [PMID: 38184542 PMCID: PMC10771665 DOI: 10.1186/s12877-023-04612-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 12/17/2023] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND Implementing dementia care interventions in an acute hospital poses multiple challenges. To understand factors influencing the implementation, in-depth knowledge about specific facilitators and barriers is necessary. The aim of this study was to identify facilitators and barriers to implementing an interprofessional, multicomponent intervention of a specialized unit for persons with cognitive impairment in an acute geriatric hospital. METHODS We conducted a process evaluation as part of a participatory action research study. For data collection, semi-structured individual interviews with fifteen professionals involved in the implementation of the specialized unit. We further conducted two focus groups with twelve professionals working on other units of the geriatric hospital. We performed a qualitative content analysis following Kuckartz's content-structuring analysis scheme. RESULTS We identified the following barriers to implementing the specialized unit: uncontrollable contextual changes (e.g., COVID-19 pandemic), staff turnover in key functions, high fluctuation in the nursing team, traditional work culture, entrenched structures, inflexible and efficiency-oriented processes, monoprofessional attitude, neglect of project-related communication, and fragmentation of interprofessional cooperation. An established culture of interprofessionalism, an interprofessionally composed project group, cooperation with a research partner, as well as the project groups' motivation and competence of managing change facilitated the implementation. CONCLUSIONS The implementation faced numerous barriers that can be described using the key constructs of the i-PARIHS framework: context, recipients, innovation, and facilitation. Overcoming these barriers requires an organizational development approach, extended project duration and increased process orientation. Furthermore, strategically planned, precise and ongoing communication towards all persons involved seems crucial. Differences between the work cultures of the professions involved deserve particular attention with regard to project-related roles and processes.
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Affiliation(s)
- Laura Adlbrecht
- Competence Center Dementia Care, Department of Health, Institute of Applied Nursing Sciences, Eastern Switzerland University of Applied Sciences, Rosenbergstrasse 59, 9000, St.Gallen, Switzerland.
| | - Melanie Karrer
- University of Applied Sciences for Health Professions Upper Austria, Semmelweisstraße 34/D, Linz, 4020, Austria
| | - Nicole Helfenberger
- Geriatrische Klinik St. Gallen AG, Rorschacher Strasse 94, St. Gallen, 9000, Switzerland
| | - Eva Ziegler
- Geriatrische Klinik St. Gallen AG, Rorschacher Strasse 94, St. Gallen, 9000, Switzerland
| | - Adelheid Zeller
- Competence Center Dementia Care, Department of Health, Institute of Applied Nursing Sciences, Eastern Switzerland University of Applied Sciences, Rosenbergstrasse 59, 9000, St.Gallen, Switzerland
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Morita K, Fukahori H, Ogawara H, Iwagami M, Matsui H, Okura T, Itoh S, Fushimi K, Yasunaga H. Outcomes of a financial incentive scheme for dementia care by dementia specialist teams in acute-care hospitals: A difference-in-differences analysis of a nationwide retrospective cohort study in Japan. Int J Geriatr Psychiatry 2021; 36:1386-1397. [PMID: 33733528 DOI: 10.1002/gps.5537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/12/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The quality of care for dementia in acute-care settings has been criticised. In 2016, the Japanese universal health insurance system introduced a financial incentive scheme for dementia care by dementia specialist teams in acute-care hospitals. This study aimed to investigate the effectiveness of this financial incentive scheme on short-term outcomes (in-hospital mortality and 30-day readmission). DESIGN AND METHODS Using a Japanese nationwide inpatient database, we identified older adult patients with moderate-to-severe dementia admitted for pneumonia, heart failure, cerebral infarction, urinary tract infection, intracranial injury or hip fracture from April 2014 to March 2018. We selected 180 propensity score-matched pairs of hospitals that adopted (n = 180 of 185) and that did not adopt (n = 180 of 744) the financial incentive scheme. We then conducted a patient-level difference-in-differences analysis. In a sensitivity analysis, we restricted the postintervention group to patients who actually received dementia care. RESULTS There was no association between a hospital's adoption of the incentive scheme and in-hospital mortality (adjusted odds ratio [aOR]: 0.97; 95% confidence interval [CI]: 0.88-1.06; p = 0.48) or 30-day readmission (aOR: 1.04; 95% CI: 0.95-1.14; p = 0.37). Only 29% of patients in hospitals adopting the scheme actually received dementia care. The sensitivity analysis showed that receiving dementia care was associated with decreased in-hospital mortality. CONCLUSIONS The financial incentive scheme to enhance dementia care by dementia specialist teams in Japan may not be working effectively, but the results do suggest that individual dementia care was associated with decreased in-hospital mortality.
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Affiliation(s)
- Kojiro Morita
- Department of Health Services Research, University of Tsukuba, Tsukuba, Ibaraki, Japan.,Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Hiroki Fukahori
- Division of Gerontological Nursing, Faculty of Nursing and Medical Care, Keio University, Fujisawa-shi, Kanagawa, Japan
| | - Hirofumi Ogawara
- Major in Nursing, Graduate School of Health Management, Keio University, Fujisawa-shi, Kanagawa, Japan
| | - Masao Iwagami
- Department of Health Services Research, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Toru Okura
- Yamato Homecare Clinic Osaki, Osaki-shi, Miyagi, Japan
| | - Sakiko Itoh
- Department of Gerontological Nursing and Care System Development, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
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McCausland BMS, Patel HP, Amin J, Baldwin DS, Loughran K, Osman-Hicks VC. A systematic review of specialist inpatient dementia care services versus standard inpatient dementia care in acute hospitals. Aging Clin Exp Res 2019; 31:595-610. [PMID: 30259497 PMCID: PMC6491402 DOI: 10.1007/s40520-018-1021-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 08/04/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Specialist inpatient dementia units (SIDU) have been developed to address adverse outcomes often experienced by people living with dementia admitted to acute hospitals. However, the evidence base of their effectiveness remains limited. AIM To review the current literature to establish the comparative effectiveness of acute hospital SIDU vs. standard ward care (SWC). METHODS We did an online search of 12 biomedical databases from inception to 31st October 2017. Studies of inpatients with any form of dementia in acute hospitals, published in English language peer-reviewed journals, using experimental, observational or qualitative study designs, comparing SIDU with SWC and which measured any qualitative or quantitative outcome of the patient or carer experience were included in the search criteria. We used a standardised data extraction and appraisal form. RESULTS Three of 46 full-text studies evaluated were suitable for analysis. Due to study heterogeneity, pooled odds ratios were only possible for mortality [OR 1.06 (CI 1.0-1.4)]. Otherwise, a narrative synthesis was performed. Although quantitative measures of length of stay, mortality and behavioural and psychiatric symptoms of dementia are not significantly lower, SIDU are associated with greater patient and carer satisfaction, reduced readmission rates, more accurate and comprehensive assessment processes, documentation of resuscitation decisions, and increased rates of discharge to the patient's own home. CONCLUSIONS Although SIDU may be associated with improved care outcomes, the current evidence of their effectiveness is markedly limited. Further research and service evaluation of SIDU as a method for providing high-quality dementia care in acute NHS Trusts is needed. PROSPERO CRD42017078364.
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Affiliation(s)
- B M S McCausland
- University of Southampton Faculty of Medicine (Clinical and Experimental Sciences), University Hospital Southampton NHS Foundation Trust, Southampton, UK.
- Department of Psychological Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
| | - H P Patel
- Academic Geriatric Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Medicine for Older People, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Medical Research Council Lifecourse Epidemiology Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- National Institute for Health Research Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - J Amin
- University of Southampton Faculty of Medicine (Clinical and Experimental Sciences), University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Psychological Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - D S Baldwin
- University of Southampton Faculty of Medicine (Clinical and Experimental Sciences), University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - K Loughran
- University of Southampton Faculty of Medicine (Clinical and Experimental Sciences), University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - V C Osman-Hicks
- University of Southampton Faculty of Medicine (Clinical and Experimental Sciences), University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Psychological Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Alabaf Sabbaghi S, De Souza D, Sarikonda P, Keevil VL, Wallis SJ, Romero‐Ortuno R. Allocating patients to geriatric medicine wards in a tertiary university hospital in England: A service evaluation of the Specialist Advice for the Frail Elderly (SAFE) team. Aging Med (Milton) 2018; 1:120-124. [PMID: 31942488 PMCID: PMC6880728 DOI: 10.1002/agm2.12029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 06/19/2018] [Indexed: 11/12/2022] Open
Abstract
The number of older patients admitted to acute hospitals has increased; however, their needs are heterogeneous and there is no gold-standard method of triaging them towards practicing comprehensive geriatric assessment (CGA). In our hospital, the SAFE (Specialist Advice for the Frail Elderly) team provide an initial geriatric assessment of all emergency admissions of patients aged ≥75 years (with some assessments also occurring in those aged 65 to 74 years) and recommend as to whether CGA in a dedicated Department of Medicine for the Elderly (DME) ward may be required. SAFE assessments include routine screening for geriatric syndromes using validated tools. Our aim was to compare the characteristics (age, gender, acute illness severity on admission as per modified early warning score (MEWS), Charlson Comorbidity Index, Clinical Frailty Scale (CFS), presence of dementia and delirium) and outcomes (length of stay, delayed discharge, inpatient mortality, discharge to usual place of residence, and new institutionalization) of patients listed to a DME ward, to those not listed. We analyzed all SAFE team assessments of patients admitted nonelectively between February 2015 and November 2016. Of 6192 admissions, 16% were listed for a DME ward. Those were older, had higher MEWS and CFS score, were more often affected by cognitive impairment, had longer hospital stay, higher inpatient mortality, and more often required new institutionalization. Higher CFS and presence of dementia and delirium were the strongest predictors of DME ward recommendation. Routine measurement of markers of geriatric complexity may help maximize access to finite inpatient CGA resources.
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Affiliation(s)
- Setareh Alabaf Sabbaghi
- Department of Medicine for the ElderlyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Darryl De Souza
- Specialist Advice for the Frail Elderly (SAFE) TeamAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Premchand Sarikonda
- Specialist Advice for the Frail Elderly (SAFE) TeamAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Victoria L. Keevil
- Department of Medicine for the ElderlyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
- Clinical Gerontology UnitDepartment of Public Health and Primary CareUniversity of CambridgeCambridgeUK
| | - Stephen J. Wallis
- Department of Medicine for the ElderlyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Roman Romero‐Ortuno
- Department of Medicine for the ElderlyAddenbrooke's HospitalCambridge University Hospitals NHS Foundation TrustCambridgeUK
- Clinical Gerontology UnitDepartment of Public Health and Primary CareUniversity of CambridgeCambridgeUK
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Hammond SP, Cross JL, Shepstone L, Backhouse T, Henderson C, Poland F, Sims E, MacLullich A, Penhale B, Howard R, Lambert N, Varley A, Smith TO, Sahota O, Donell S, Patel M, Ballard C, Young J, Knapp M, Jackson S, Waring J, Leavey N, Howard G, Fox C. PERFECTED enhanced recovery (PERFECT-ER) care versus standard acute care for patients admitted to acute settings with hip fracture identified as experiencing confusion: study protocol for a feasibility cluster randomized controlled trial. Trials 2017; 18:583. [PMID: 29202786 PMCID: PMC5715500 DOI: 10.1186/s13063-017-2303-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 10/31/2017] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Health and social care provision for an ageing population is a global priority. Provision for those with dementia and hip fracture has specific and growing importance. Older people who break their hip are recognised as exceptionally vulnerable to experiencing confusion (including but not exclusively, dementia and/or delirium and/or cognitive impairment(s)) before, during or after acute admissions. Older people experiencing hip fracture and confusion risk serious complications, linked to delayed recovery and higher mortality post-operatively. Specific care pathways acknowledging the differences in patient presentation and care needs are proposed to improve clinical and process outcomes. METHODS This protocol describes a multi-centre, feasibility, cluster-randomised, controlled trial (CRCT) to be undertaken across ten National Health Service hospital trusts in the UK. The trial will explore the feasibility of undertaking a CRCT comparing the multicomponent PERFECTED enhanced recovery intervention (PERFECT-ER), which acknowledges the differences in care needs of confused older patients experiencing hip fracture, with standard care. The trial will also have an integrated process evaluation to explore how PERFECT-ER is implemented and interacts with the local context. The study will recruit 400 hip fracture patients identified as experiencing confusion and will also recruit "suitable informants" (individuals in regular contact with participants who will complete proxy measures). We will also recruit NHS professionals for the process evaluation. This mixed methods design will produce data to inform a definitive evaluation of the intervention via a large-scale pragmatic randomised controlled trial (RCT). DISCUSSION The trial will provide a preliminary estimate of potential efficacy of PERFECT-ER versus standard care; assess service delivery variation, inform primary and secondary outcome selection, generate estimates of recruitment and retention rates, data collection difficulties, and completeness of outcome data and provide an indication of potential economic benefits. The process evaluation will enhance knowledge of implementation delivery and receipt. TRIAL REGISTRATION ISRCTN, 99336264 . Registered on 5 September 2016.
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Affiliation(s)
- Simon P Hammond
- Department of Psychological Sciences, Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | - Jane L Cross
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | - Lee Shepstone
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | - Tamara Backhouse
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | - Catherine Henderson
- Department of Social Policy, London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK
| | - Fiona Poland
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | - Erika Sims
- Norwich Clinical Trial Unit, Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | | | - Bridget Penhale
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | - Robert Howard
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, W1T 7NF, UK
| | - Nigel Lambert
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | - Anna Varley
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | - Toby O Smith
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | - Opinder Sahota
- Nottingham University Hospitals NHS Trust, Queens Medical Centre Campus, Derby Road, Nottingham, NG7 2UH, UK
| | - Simon Donell
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, NR4 7UY, UK
| | - Martyn Patel
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, NR4 7UY, UK
| | - Clive Ballard
- Exeter Medical School, University of Exeter, Penryn Campus, Penryn, Cornwall, TR10 9FE, UK
| | - John Young
- Faculty of Medicine and Health, University of Leeds, Leeds, LS2 9JT, UK
| | - Martin Knapp
- Department of Social Policy, London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK
| | - Stephen Jackson
- Department of Clinical Gerontology, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - Justin Waring
- Nottingham University Business School, Jubilee Campus, Nottingham, NG8 1BB, UK
| | - Nick Leavey
- Norwich Clinical Trial Unit, Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | - Gregory Howard
- Norwich Clinical Trial Unit, Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | - Chris Fox
- Department of Psychological Sciences, Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK.
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Briggs R, Dyer A, Nabeel S, Collins R, Doherty J, Coughlan T, O'Neill D, Kennelly SP. Dementia in the acute hospital: the prevalence and clinical outcomes of acutely unwell patients with dementia. QJM 2017; 110:33-37. [PMID: 27486262 DOI: 10.1093/qjmed/hcw114] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 06/21/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Studies have demonstrated that a significant minority of older persons presenting to acute hospital services are cognitively impaired; however, the impact of dementia on long-term outcomes is less clear. AIM To evaluate the prevalence of dementia, both formally diagnosed and hitherto unrecognised in a cohort of acutely unwell older adults, as well as its impact on both immediate outcomes (length of stay and in-hospital mortality) and 12-month outcomes including readmission, institutionalisation and death. DESIGN Prospective observational study. METHODS 190 patients aged 70 years and over, presenting to acute hospital services underwent a detailed health assessment including cognitive assessment (standardised Mini Mental State Examination, AD8 and Confusion Assessment Method for the Intensive Care Unit). Patients or informants were contacted directly 12 months later to compile 1-year outcome data. Dementia was defined as a score of 2 or more on the AD8 screening test. RESULTS Dementia was present in over one-third of patients (73/190). Of these patients, 36% (26/73) had a prior documented diagnosis of dementia with the remaining undiagnosed before presentation. The composite outcome of death or readmission to hospital within the following 12 months was more likely to occur in patients with dementia (73% (53/73) vs. 58% (68/117), P = 0.043). This finding persisted after controlling for age, gender, frailty status and medical comorbidities, including stroke and heart disease. CONCLUSION A diagnosis of dementia confers an increased risk of either death or further admission within the following 12 months, highlighting the need for better cognitive screening in the acute setting, as well as targeted intervention such as comprehensive geriatric assessment.
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Affiliation(s)
- R Briggs
- From the Department of Age-Related Health Care, Tallaght, Hospital, Dublin, Ireland
| | - A Dyer
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - S Nabeel
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - R Collins
- From the Department of Age-Related Health Care, Tallaght, Hospital, Dublin, Ireland
- Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
| | - J Doherty
- From the Department of Age-Related Health Care, Tallaght, Hospital, Dublin, Ireland
| | - T Coughlan
- From the Department of Age-Related Health Care, Tallaght, Hospital, Dublin, Ireland
- Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
| | - D O'Neill
- From the Department of Age-Related Health Care, Tallaght, Hospital, Dublin, Ireland
- Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
| | - S P Kennelly
- From the Department of Age-Related Health Care, Tallaght, Hospital, Dublin, Ireland
- Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
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