Challenges and Prevention of Pressure Ulcer in Hospital Settings for Dementia Patients

This literature review addresses the challenges and prevention of pressure ulcers in hospital settings for dementia patients. It discusses the impact of dementia on patient care and the strategies to prevent pressure ulcers.

Quality and Safety
in Healthcare
Practice

INTRODUCTION...........................................................................................................................1
PROBLEM.......................................................................................................................................1
BACKGROUND.............................................................................................................................1
STRATEGY.....................................................................................................................................2
LITERATURE REVIEW................................................................................................................2
1. Problems of dementia in UK..............................................................................................2
2. Pressure Ulcer.....................................................................................................................3
3. Hospital practices for controlling the problem...................................................................4
4. Responsibility of care providers in UK..............................................................................5
5. Challenges of nurses...........................................................................................................6
6. Pressure Ulcers in Ireland and steps to overcome..............................................................7
DISCUSSION..................................................................................................................................9
CONCLUSION..............................................................................................................................10
REFERENCES..............................................................................................................................11

INTRODUCTION
Quality in healthcare is a term which shows the level of care offered by hospitals to their
patients at the need of need in an affordable price. Their main objective is to provide best
services with qualitative products for controlling the worst conditions of patients. There are
number of practices which are design by governing bodies for directing health care sector about
the actions that they need to take at hospitals (Woo and et. Al., 2017). Thus, this project is going
to conduct a literature review for accumulating the information related to the “challenges and
prevention of pressure Ulcer in hospital settings especially for dementia patient”. Therefore,
main objective of this review is to address the issue of dementia patients at hospital settings who
developed pressure ulcer and due to their dementia status nurses ignore changing their position
as it might disturb their sleep.
PROBLEM
Health care quality is an effective level of value that is provided by various healthcare
professionals. In fact, with appropriate quality in other areas, it is an assessment of whether a
thing is sufficient enough for the meeting the patient needs. However, certain key problems are
also associated with the organizations that are affecting the health of people, staffs and other
members working within the centre (Dye, Reeder and Terry, 2013).
 Problem related to dementia is state where there is damage in cognitive function of an
individual means that he/she is not having an ability to think for performing day-to-day
activities.
 Pressure ulcer is also named as a bedsore which means the damage of skin or underlying
tissue that mainly incurred over a bony eminence because of long term pressure.
BACKGROUND
In the recent time, it has been seen that dementia and pressure ulcer problems are creating
a lot of negative implication to the patient health condition. These problems are resultant into
several diseases and injuries which initially or secondly affect the brain like Alzheimer’s disease
or stroke. Simply, it’s a major cause of disability and dependency among aged human beings
across the worldwide. It means that risk of this health issue is very high in older people because
few aged people are having difficulty in moving. Along with this, if there is an additional
problem of dementia then the possibilities of pressure ulcers increased too much (Mah'd
Alloubani, Almatari and Almukhtar, 2014). Generally, elders whose are restricted to bed also
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face complications related to bedsores due to the minimized mobility of limbs such as; infection
in chest, pressure sores and contracture in muscles. All these problems emerge due to the
improper positioning. Therefore, it’s essential for care providers to enhance their nursing skills in
order to guide elders people towards position changing continuously for controlling the
possibilities of pressure ulcers which really dangerous for their existing life. However, it is
important to have an effective quality and services should be delivering to the affected patient so
that chances of health problems could be overcome in the future.
STRATEGY
Health care practices can go for foot cradle which is a kind of tool in a tent shape that
will protect the sheets as well as blankets from resting directly on the patient feet whosoever is
lying on bed. Health care organization must provide protective foam to the patient for placing it
under a foot while resting instead of just lying down on mattress. It’s a responsibility of nurses
whose are taking care of dementia patient to guide them about continuous turning or shifting of
positions in order to make sure that blood can supply in every area of body parts instead of
blocking at one place. There are number of people whose are suffering from dementia issue has
developed incontinence and use qualitative incontinence pads as well as pull-ups which will
wick the moisture away from skin and change it consistently (Kondrotaitė, 2012). Moreover, it’s
important for patient to gently wash the bodily skin by using clean washcloth in place of just
rubbing it. Additionally, nurses can also use or suggest patient for using creams like; Baza as it
prevent the skin of patient from incontinence (Boyko, Longaker and Yang, 2018). However,
there are some treatment that involves management of local as well as distant infection, removal
of necrotic tissue and possibly surgery to cure the patient. In case of dementia patient, the
nursing practitioner needs to make use of cognitive decline strategy, meditation and psychosocial
stress management techniques to cure the patient.
LITERATURE REVIEW
1. Problems of dementia in UK
According to the facts of World Health Organization, 2019, dementia can be influences
the memory level of an individual, orientation, calculation, destroy the learning potentiality,
language and lost the decision making process. However, person who are facing a dementia
problem influence every individual in distinct ways as it fully depends upon the impact of
sickness as well as person’s character before becoming ill. As per medical science, this problem
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has been caused due to the damaging of nerve cells and this cell is connected with brain which
resultant into deterioration of individual cognitive functions. Along with this, number of
problems and issues has been faced by the person such as; emergence of pressure ulcer that
created due to longer pressure on a specific body part (Ticinesi and et. Al., 2016).
This problem is a very dangerous for a person health because in some cases it starts
becoming more black or swollen which is an indication of tissue death. Simply, this problem
mainly incurred over bony regions that are very close to the skin as this ulcer forms when there is
a reduction in supplying of blood to specific skin area due to which that area becomes starved of
oxygen and nutrients. For example; sitting or lying in similar pose for a longer period of time is a
most common cause which create pressure ulcers for many dementia patients. This problem is
mainly encountered by old age people as their skin are very thin, dry or weak due because of
ageing or numerous disease pressure. Some of the major reason due to which pressure ulcers
increased in dementia patient are; problem in moving, walking, improper diet or dehydration,
incontinence, improper supply of blood, agitation, restlessness, facing a problem in sharing their
pain with other member and so on. All these issues are encountered by the patient of dementia
which resultant into pressure ulcers (Chamanga and Ward, 2015). According to the given
scenario, dementia patients are encountering a major health issues that is; pressure ulcer due to
the continuous pressure on a skin because of their current cognitive problem. Nurses are also
avoiding to change them because they get scared that disturbances affect their sleep due to which
patients are facing a pressure ulcer. Instead of this, dementia patients are also encountering many
more challenges from which some are very straightforward and easy to manage but few are
undefeatable that really hard to address. Although, every individual whose are suffering from
dementia problem are having unique journey but some face similar experiences such as;
forgetting routes, anxiety, fear and so on. Pressure ulcer is a somehow common problem that is
faced by Dementia patients because they don’t know how to take care of themselves but it’s a
responsibilities of family members to take care of person whose are having a mental problem
(Schoeps, Tallberg and Gunningberg, 2017).
2. Pressure Ulcer
Mainly, pressure sore is considered as ulcerated part of skin over bony areas and this
situation incurred when the part of body is continuously pressurized due to lying down in a same
position. As a result, supply blood stopped in that particular area and it develop pressure sore.
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However, these situations mainly happen with those patients whose are chronically ill,
overweight, underweight, not able to move from one position to other, gone through any bodily
operation, mentally ill etc. Some of the common sites due to which this problem occurred are
shown below (Ellis, 2017).
According to the Rezaei and et.al., 2016, it has been understood that these positions plays
a very significant role in creating sores but somehow these are necessary also due to which
nurses doesn’t disturbed their patients as it might disturb their sleep. Although, it’s hard to
control these kind of issues for nurses but still it’s important to take some prevention for
reducing the localized pressure. Initially, nurse need to enforce patients to adopt suitable
positioning for controlling the pressure over bony areas. Secondly, need to alter the positions and
turn in every 2 hours for maintaining a proper blood supply over the entire body parts. Care
providers need to ignore friction between body and bed while lifting or transferring of elder
people. It’s imperative for hospitals to arrange appropriate kind of chair and instruct the elder
person who is sitting on chair that kindly change their posture in every 30 minds by taking
support from upper limbs. Moreover, requisite to acquire suggestion from health professionals in
context with the use of pressure-reliving devices which are shown in below image (McGraw,
2019).
3. Hospital practices for controlling the problem
Olin and et.al., 2014, it’s important for hospitals to make available these above products
for supporting those patients whose are suffering from pressure ulcers as this will maintain a
proper supply of blood in every body parts of a patient. Additionally, nurses need to take some
other measures also for resolving the issues related to pressure ulcer such as; significant to
maintain clothing and bed linen fully clean or dry, control the placing of heavy objects over the
body part like; hot-water bottle, make sure that dressings of wound or bandages must not so tight
and nurses need to keep their nails shorts while treating elder patients or remove their jewelleries
as it may cause injury to patient (Barnes and et.al., 2012). Apart from this, some of the hygiene
related to the person will also help in reducing the probabilities of pressure ulcers such as; need
to clean the skin or dry, change the napkins frequently for minimizing the possibilities of
infection related to skin in elders whose are suffering from incontinence, be attentive towards the
condition of skin, identify the signs of pressure sores and acquire medical suggestion at the time
of need. Furthermore, dementia patients whose are having a high probability of pressure ulcers
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need to focus on their diet and make sure that he/she must have nutritious food with full of
protein like; egg, milk and beans for maintaining the skin healthier (Carlsson and Gunningberg,
2017).
On contrary to this, Elderly Health Service, 2016 states that contracture in muscles also
an outcome of prolonged immobility and improper positioning which leads to stiffness in joint as
well as minimize the range of movements especially in those patients whose are suffering from
stroke, Parkinson’s disease or those whose are involved in a state of bedridden. Hence,
prevention for resolving muscle contracture is that nurses have to make sure that the dementia
patient who is facing this issue must adopt suitable positioning and try to alter their positions in
every next 2 hours. Some of the measures that might take by nurses in their clinical practices
such as; provide a support in affected side with the help of pillows during sleep, elbow and
fingers need to be straight with palm fronting upwards (Abelha and et.al., 2015). Secondly, nurse
can also reduce the probabilities by placing a pillow under the knee of patient specially on
affected side and keep the knee bent slightly. Additionally, nurse can instruct the patient to
follow lateral position while lying on bed like; use a pillow for supporting those side which is
influenced by a problem with elbow straight and using of pillow for maintaining a direct contact
of knees with each other for protecting deformity. Along with this, sitting straight is also a best
position by acquiring a support from back side and pillow can use by a patient for supporting
upper limbs by placing the feet on floor.
4. Responsibility of care providers in UK
According to Armijo‐Olivo and et.al., 2012, care providers of UK hospitals are
responsible to make sure that all the above instruction must aware by patient whose are not in
their senses either by teaching in a polite way or showing picture is also a best option for nurses.
An elder people can understand the things through images and nurses can use these images for
motivating them to adopt these postures while sleep for resolving the problems related to
pressure ulcers. Interestingly, nurses are also having an opportunity to conduct motivational
programmes for encouraging the patients towards healthy life (Dinesh and et.al., 2013). For
example; promoting elders or dementia patient for performing regular exercise like; stretching of
body for maintaining a proper circulation of blood, joint flexibility and protecting their muscles
from contracture. In fact, healthcare organization can also use some useful measures such as;
utilizing firm pillow which is having an appropriate thickness of almost 5cm to 10cm,
5

comfortable mattress for giving adequate support and selecting of wheelchair for resting the back
or neck. Hence, all the above mentioned strategies and prevention is really useful for health care
associations in controlling the probabilities pressure ulcers of dementia patient in corrective
manner (Nakanishi and et. al., 2017). In most part of the UK, it has been estimated that 676000
people have been suffering from Dementia. According to the UK report, the number of dementia
patient in the UK is being estimated to increase over 1 million by 2021. It happens to be more
worse case situation, under an assumption that there are less number of public health intervention
along with the changes that are been driven by an aging population. However, the total
population prevalence of dementia between 65s is 7.1% which equals one in every 79 (1.3%) of
the entire UK population. For the purpose of providing cure to these people, NHS picks up £4.3
billion of total cost for the treatment of dementia people.
5. Challenges of nurses
According to the viewpoint of Daniel Press, MD, Michael Alexander, 2020 number of
challenges are encountered by nurses while handling the patient of dementia because they are not
in their senses due to which care providers need to be very attentive towards them as single
mistake might resultant into heavy loss (Middleton and et.al., 2013). Mainly, patients whose are
suffering from dementia issue are having a very low potentiality to make corrective decisions
due to which major issue that is face by nurse is a safety problem. Thus, concerns related to
safety are emerging at higher extent and predictable way due to the growth in dementia.
Therefore, resolving the problems related to safety can help healthcare organization in
controlling several major serious accidents.
Esther Heerema, Shaheen Lakhan, MD,Phd, 2020 mention in their article that care
providers whose are dealing with dementia patient requisite to be attentive for protecting them
from pressure ulcer. Some of the measures that need to take nurses and health practices for
overcoming the challenges of dementia patient include several things. Initially, it’s important to
conduct regular skin assessment test for visually inspecting the skin of a dementia patient
especially on those body points where pressures are very high such as; heels, coccyx and
buttocks (Kim, 2013). Most suitable time period for performing this assessment activity is when
nurse is instructing the patient during bathing. For remembering this step, it’s vital for nurse to
schedule both activities one is bathing and assessment of skin on calendar as it aids in
memorizing the procedure. Secondly, nurse can also go for the option of floating heels on a
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pillow by placing a pillow under the calves for making sure that heel of a person maintained in a
floating position in air rather than resting directly on bed. Hospitals are having an opportunity to
conduct physical as well as occupational therapy services by paying at home or hospitals in order
to evaluate or to identify the most suitable position and seating interventions for comfort or skin
prevention (Howard-Anderson and et.al., 2012).
Nurses have to organize a suitable place in hospital for assessing the contractures in order
to identify that where the contact of skin of a dementia patient is constant as it will maximize the
risk of pressure sores. For instance; if arms of an individual have tightened up and involuntarily
bends at the elbow due to the stroke then that part of body is at higher risk because of moisture
and heat has been imprisoned there. Consequently, it has been understood that numerous of
options are available that needs to follow by health care organization and requisite to change
their hospital settings accordingly in order to protecting dementia patients from pressure ulcers
(Pomey and et.al., 2015).
6. Pressure Ulcers in Ireland and steps to overcome
In other words, DANIEL BLUESTEIN, MD, ASHKAN JAVAHERI, MD, 2015,
mentioned that pressure ulcers are also known as decubitus which is identified from reddening of
skin at severe, deep craters with uncovered muscle or bone and this problem mainly threaten the
growth of patients whose are having limited mobility. This article states that almost 70% of
ulcers are identified in older people whose are age of 65 years as compared to younger one.
Therefore, it’s really significant for every health care practices to set the risk assessment program
at their hospital services in order to preventing individuals or dementia patients from the
probabilities of pressure ulcers. Mainly, this tool helps an organization of health care by
identifying the risky elements and inspecting the skin of patients such as; assessment of body
internally as well as externally (World Health Organization, 2017). Moreover, firm needs to
make sure that appointed nurses are educated and registered under the national council bodies so
that she can treat the patient in a corrective way by understanding her duty towards sufferer.
Risk factors for pressure ulcers
Internal
Limited mobility
 Injury of spinal cord
 Accident of cerebrovascular
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 Fractures
 Pain
Improper nutrition
 Lack of dentition
 Dietary restriction
 Poverty
 Dehydration
Comorbidities
 Depression
 Diabetes
 Minimization in pain sensation
Ageing skin
 Loosing elasticity
 Alteration in dermal Ph
 Minimization of dermal-epidermal flow of blood.
External
 Pressure due to hard surface such as; stretcher
 Inability of patient for moving properly in bed
 Cut off from muscle movements
These above factors are the signs which will show the possibilities of pressure ulcers in a
body part of a person through risk assessment process. After knowing this, nurses need to take
instant steps for controlling its spreading or infection which might resultant into very dangerous
effects. Therefore, hospital practices need to act accordingly on these above identified factors for
making suitable interventions. Interestingly, there are number of foreign countries such as;
Australia, Canada, France, Norway, Sweden and the Netherlands which are compared with
Ireland care practices. During Autumn 2013, Service information and development center has
conducted a survey of almost 602 Irish Nursing Homes for identifying the facilities which are
provided by specialist care units. As a result, it has been observed that maximum number of
dementia patient is located in rural and town regions instead of cities.
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DISCUSSION
According to the suggestion from Agency for health Care policy and research, patients
whose are suffering from bedsores must be repositioned in every two hours. Furthermore, for
controlling the shear, its indispensable for nurses to make sure that head of the patient bed will
not be elevated more than 30 degrees and must be maintained at a minimum degree of elevation
in order to protect the person from other medical complications like; aspiration or worsening of
congestive failure of heart. On the other hand, Susan L Mitchell, 2019 states that advance care
planning is a most vital in managing the patients which are on advance stage of dementia.
However, care providers whose are giving services at primary stage are having a great
opportunity to design patients with early disease and their families about what needs to expect in
future stages of dementia (Algaet and et.al., 2014). Lastly, it has been understood that health care
associations have to change their settings in a systematic way for controlling the probabilities of
risky situations at prior stage. For example; implementing safety measures in hospitals by
providing safeguard environment to the dementia patients for controlling the chances of
accidents, brief the nurses about individual’s current situation in a corrective manner, requisite to
be attentive while handling the complicated situations of dementia patient with pressure ulcers
and so on (Boyko, Longaker and Yang, 2018).
DATA EXTRACTION
Data sources Connectors ETL process Processed data
Journal/ PDF URL Link Analysis- Evaluation-
Interpretation
SQL server
Challenges of nurses
Articles/ paper URL Link Analysis- Evaluation-
Interpretation
Prevention or hospital
practices
Blogs/ Official
Websites
URL Link Analysis- Evaluation-
Interpretation
Information about
pressure Ulcer
Google scholar URL Link Analysis- Evaluation-
Interpretation
Problem encountered
by dementia patient
such as; pressure
ulcer.
Journal URL Link Analysis- Evaluation- Pressure Ulcers:
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Interpretation Prevention,
Evaluation, and
Management.
Article URL Link Analysis- Evaluation-
Interpretation
Care of patients with
advanced dementia
CONCLUSION
From the above project report, it has been concluded that quality is an utmost important
aspect in health care organization. It is vital to have an effective tools and techniques to deal with
the critical problems such as dementia and pressure ulcer. However, these problems are having
negative impact on the mental as well as behavior of the affected person. Therefore, it is
important to have proper cure planning to overcome these problems by providing valuable
services according to their requirements.
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REFERENCES
Books and Journals:
1. Woo, K.Y and et. Al., 2017. Exploration of pressure ulcer and related skin problems
across the spectrum of health care settings in Ontario using administrative
data. International wound journal, 14(1), pp.24-30.
2. Ticinesi, A and et. Al., 2016. Survival in older adults with dementia and eating problems:
To PEG or not to PEG?. Clinical nutrition, 35(6), pp.1512-1516.
3. Chamanga, E. and Ward, R., 2015. Documentation and record-keeping in pressure ulcer
management. Nursing Standard (2014+), 29(36), p.56.
4. Schoeps, L.N., Tallberg, A.B. and Gunningberg, L., 2017. Patients' knowledge of and
participation in preventing pressure ulcers–an intervention study. International wound
journal, 14(2), pp.344-348.
5. Ellis, M., 2017. Pressure ulcer prevention in care home settings. Nursing older
people, 29(3).
6. McGraw, C.A., 2019. Nurses’ perceptions of the root causes of community‐acquired
pressure ulcers: Application of the Model for Examining Safety and Quality Concerns in
Home Healthcare. Journal of clinical nursing, 28(3-4), pp.575-588.
7. Carlsson, M.E. and Gunningberg, L., 2017. Predictors for development of pressure ulcer
in end-of-life care: a national quality register study. Journal of palliative medicine, 20(1),
pp.53-58.
8. Nakanishi, M and et. Al., 2017. Quality of care for people with dementia and professional
caregivers' perspectives regarding palliative care in Japanese community care
settings. International journal of geriatric psychiatry, 32(12), pp.1342-1351.
9. Boyko, T.V., Longaker, M.T. and Yang, G.P., 2018. Review of the current management
of pressure ulcers. Advances in wound care, 7(2), pp.57-67.
10. World Health Organization, 2019. Dementia. [Online]. Available through<
https://www.who.int/news-room/fact-sheets/detail/dementia>.
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11. Elderly Health Service, 2016. Proper Positioning for the Prevention of Pressure Sores and
Muscle Contracture. [Online]. Available
through<https://www.elderly.gov.hk/english/carers_corner/positioning/
prevention_of_pressure_sores.html >.
12. Susan L Mitchell, 2019. Care of patients with advanced dementia. [Online]. Available
through<https://www.uptodate.com/contents/care-of-patients-with-advanced-dementia?
topicRef=5080&source=see_link >.
13. DANIEL BLUESTEIN, MD, ASHKAN JAVAHERI, MD, 2015. Pressure Ulcers:
Prevention, Evaluation, and Management. [Online]. Available
through<https://www.aafp.org/afp/2008/1115/p1186.html >.
14. Esther Heerema, Shaheen Lakhan, MD,Phd, 2020. Prevention Tips for Pressure Sores in
Dementia. [Online]. Available through<https://www.verywellhealth.com/prevent-
pressure-sores-in-dementia-3573624 >.
15. Daniel Press, MD, Michael Alexander, 2020. Safety and societal issues related to
dementia. [Online]. Available through<https://www.uptodate.com/contents/safety-and-
societal-issues-related-to-dementia >.
16. Dye, C., Reeder, J.C. and Terry, R.F., 2013. Research for universal health coverage.
17. Mah'd Alloubani, A., Almatari, M. and Almukhtar, M.M., 2014. Effects of leadership
styles on quality of services in healthcare. European Scientific Journal. 10(18).
18. Kondrotaitė, G., 2012. Evaluation of the quality of public services in Lithuanian
municipalities. Intelektinė ekonomika. 6(3). pp.393-411.
19. Rezaei, S., and et.al., 2016. Measurement of quality of educational hospital services by
the SERVQUAL model: the Iranian patients’ perspective. Electronic physician. 8(3).
p.2101.
20. Olin, S.S., and et.al., 2014. Quality indicators for family support services and their
relationship to organizational social context. Administration and policy in mental health
and mental health services research. 41(1). pp.43-54.
21. Armijo‐Olivo, S., and et.al., 2012. Assessment of study quality for systematic reviews: a
comparison of the Cochrane Collaboration Risk of Bias Tool and the Effective Public
Health Practice Project Quality Assessment Tool: methodological research. Journal of
evaluation in clinical practice. 18(1). pp.12-18.
12

22. Algaet, M.A., and et.al., 2014. Provisioning quality of service of wireless telemedicine
for e-health services: A review. Wireless Personal Communications. 78(1). pp.375-406.
23. World Health Organization, 2017. Patient safety: making health care safer (No.
WHO/HIS/SDS/2017.11). World Health Organization.
24. Pomey, M.P., and et.al., 2015. Patient partnership in quality improvement of healthcare
services: Patients’ inputs and challenges faced. Patient Experience Journal. 2(1). pp.29-
42.
25. Howard-Anderson, J., and et.al., 2012. Quality of life, fertility concerns, and behavioral
health outcomes in younger breast cancer survivors: a systematic review. Journal of the
National Cancer Institute. 104(5). pp.386-405.
26. Kim, J.I., 2013. Levels of health-related quality of life (EQ-5D) and its related factors
among vulnerable elders receiving home visiting health care services in some rural
areas. Journal of Korean Academy of Community Health Nursing. 24(1). pp.99-109.
27. Middleton, B., and et.al., 2013. Enhancing patient safety and quality of care by improving
the usability of electronic health record systems: recommendations from AMIA. Journal
of the American Medical Informatics Association. 20(e1). pp.e2-e8.
28. Dinesh, T.A., and et.al., 2013. Reducing waiting time in outpatient services of large
university teaching hospital-A six sigma approach. Management in health. 17(1).
29. Abelha, A., and et.al., 2015. Improving quality of services in maternity care triage
system. International Journal of E-Health and Medical Communications
(IJEHMC). 6(2). pp.10-26.
30. Barnes, T.R., and et.al., 2012. Antipsychotics in dementia: prevalence and quality of
antipsychotic drug prescribing in UK mental health services. The British Journal of
Psychiatry. 201(3). pp.221-226.
31. Complied by Suzanne Cahill and Dearbhla O’ Caheny, The Dementia Services
Information and Development Centre (DSIDC), St James’s Hospital, Dublin. Specialist
Care Units for People with Dementia in Ireland.
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