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Lavrencic LM, Delbaere K, Broe GA, Daylight G, Draper B, Cumming RG, Garvey G, Allan W, Hill TY, Lasschuit D, Schofield PR, Radford K. Dementia Incidence, APOE Genotype, and Risk Factors for Cognitive Decline in Aboriginal Australians: A Longitudinal Cohort Study. Neurology 2022; 98:e1124-e1136. [PMID: 35140131 DOI: 10.1212/wnl.0000000000013295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 12/17/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Aboriginal Australians are disproportionately affected by dementia, with incidence in remote populations approximately double non-Indigenous populations. This study aimed to identify dementia incidence and risk factors in Aboriginal Australians residing in urban areas, which are currently unknown. METHODS A population-based cohort of Aboriginal Australians aged 60+ was assessed at baseline and 6-year follow-up. Life-course risk factors (baseline) were examined for incident dementia or mild cognitive impairment (MCI) using logistic regression analyses; adjustments were made for age. APOE genotyping was available for 86 people. RESULTS Data were included from 155 participants aged 60-86 years (mean=65.70, SD=5.65; 59 male). There were 16 incident dementia cases (age-standardised rate 35.97/1,000 person-years, 95% CI 18.34-53.60); and 36 combined incident MCI and dementia cases. Older age (OR 2.29, 1.42-3.70), male sex (OR 4.14, 1.60-10.77), unskilled work history (OR 5.09, 1.95-13.26), polypharmacy (OR 3.11, 1.17-8.28), and past smoking (OR 0.24, 0.08-0.75) were associated with incident MCI/dementia in the final model. APOE ε4 allele frequency was 24%; heterozygous or homozygous ε4 was associated with incident MCI/dementia (bivariate OR 3.96, 1.25-12.50). DISCUSSION These findings provide the first evidence for higher dementia incidence in Aboriginal Australians from urban areas, where the majority of Aboriginal people reside. This study also sheds light on sociodemographic, health and genetic factors associated with incident MCI/dementia at older ages in this population, which is critical for targeted prevention strategies.
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Lee W, Chang S, DiGiacomo M, Draper B, Agar MR, Currow DC. Caring for depression in the dying is complex and challenging - survey of palliative physicians. BMC Palliat Care 2022; 21:11. [PMID: 35034640 PMCID: PMC8761382 DOI: 10.1186/s12904-022-00901-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Depression is prevalent in people with very poor prognoses (days to weeks). Clinical practices and perceptions of palliative physicians towards depression care have not been characterised in this setting. The objective of this study was to characterise current palliative clinicians' reported practices and perceptions in depression screening, assessment and management in the very poor prognosis setting. METHODS In this cross-sectional cohort study, 72 palliative physicians and 32 psychiatrists were recruited from Australian and New Zealand Society of Palliative Medicine and Royal Australian and New Zealand College of Psychiatrists between February and July 2020 using a 23-item anonymous online survey. RESULTS Only palliative physicians results were reported due to poor psychiatry representation. Palliative physicians perceived depression care in this setting to be complex and challenging. 40.0% reported screening for depression. All experienced uncertainty when assessing depression aetiology. Approaches to somatic symptom assessment varied. Physicians were generally less likely to intervene for depression than in the better prognosis setting. Most reported barriers to care included the perceived lack of rapidly effective therapeutic options (77.3%), concerns of patient burden and intolerance (71.2%), and the complexity in diagnostic differentiation (53.0%). 66.7% desired better collaboration between palliative care and psychiatry. CONCLUSIONS Palliative physicians perceived depression care in patients with very poor prognoses to be complex and challenging. The lack of screening, variations in assessment approaches, and the reduced likelihood of intervening in comparison to the better prognosis setting necessitate better collaboration between palliative care and psychiatry in service delivery, training and research.
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Couzner L, Day S, Draper B, Withall A, Laver KE, Eccleston C, Elliott KE, McInerney F, Cations M. What do health professionals need to know about young onset dementia? An international Delphi consensus study. BMC Health Serv Res 2022; 22:14. [PMID: 34974838 PMCID: PMC8722147 DOI: 10.1186/s12913-021-07411-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/13/2021] [Indexed: 12/12/2022] Open
Abstract
Background People with young onset dementia (YOD) have unique needs and experiences, requiring care and support that is timely, appropriate and accessible. This relies on health professionals possessing sufficient knowledge about YOD. This study aims to establish a consensus among YOD experts about the information that is essential for health professionals to know about YOD. Methods An international Delphi study was conducted using an online survey platform with a panel of experts (n = 19) on YOD. In round 1 the panel individually responded to open-ended questions about key facts that are essential for health professionals to understand about YOD. In rounds 2 and 3, the panel individually rated the collated responses in terms of their importance in addition to selected items from the Dementia Knowledge Assessment Scale. The consensus level reached for each statement was calculated using the median, interquartile range and percentage of panel members who rated the statement at the highest level of importance. Results The panel of experts were mostly current or retired clinicians (57%, n = 16). Their roles included neurologist, psychiatrist and neuropsychiatrist, psychologist, neuropsychologist and geropsychologist, physician, social worker and nurse practitioner. The remaining respondents had backgrounds in academia, advocacy, or other areas such as law, administration, homecare or were unemployed. The panel reached a high to very high consensus on 42 (72%) statements that they considered to be important for health professionals to know when providing care and services to people with YOD and their support persons. Importantly the panel agreed that health professionals should be aware that people with YOD require age-appropriate care programs and accommodation options that take a whole-family approach. In terms of identifying YOD, the panel agreed that it was important for health professionals to know that YOD is aetiologically diverse, distinct from a mental illness, and has a combination of genetic and non-genetic contributing factors. The panel highlighted the importance of health professionals understanding the need for specialised, multidisciplinary services both in terms of diagnosing YOD and in providing ongoing support. The panel also agreed that health professionals be aware of the importance of psychosocial support and non-pharmacological interventions to manage neuropsychiatric symptoms. Conclusions The expert panel identified information that they deem essential for health professionals to know about YOD. There was agreement across all thematic categories, indicating the importance of broad professional knowledge related to YOD identification, diagnosis, treatment, and ongoing care. The findings of this study are not only applicable to the delivery of support and care services for people with YOD and their support persons, but also to inform the design of educational resources for health professionals who are not experts in YOD.
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Strutt PA, Barnier AJ, Savage G, Picard G, Kochan NA, Sachdev P, Draper B, Brodaty H. Hearing loss, cognition, and risk of neurocognitive disorder: evidence from a longitudinal cohort study of older adult Australians. NEUROPSYCHOLOGY, DEVELOPMENT, AND COGNITION. SECTION B, AGING, NEUROPSYCHOLOGY AND COGNITION 2022; 29:121-138. [PMID: 33371769 DOI: 10.1080/13825585.2020.1857328] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Addressing midlife hearing loss could prevent up to 9% of new cases of dementia, the highest of any potentially modifiable risk factor identified in the 2017 commissioned report in The Lancet. In Australia, hearing loss is the second-most common chronic health condition in older people, affecting 74% of people aged over 70. Estimates indicate that people with severe hearing loss are up to 5-times more likely to develop dementia, but these estimates vary between studies due to methodological limitations. Using data from the Sydney Memory and Aging Study, in which 1,037 Australian men and women aged between 70 and 90 years were enrolled and completed biennial assessments from 2005-2017, investigations between hearing loss and baseline cognitive performance as well as longitudinal risk of neurocognitive disorder were undertaken. Individuals who reported moderate-to-severe hearing difficulties had poorer cognitive performances in the domains of Attention/Processing Speed and Visuospatial Ability, and on an overall index of Global Cognition, and had a 1.5-times greater risk for the neurocognitive disorder during 6-years' follow-up. Hearing loss independently predicted risk for MCI but not dementia. The presence of hearing loss is an important consideration for neuropsychological case formulation in older adults with cognitive impairment. Hearing loss may increase cognitive load, resulting in observable cognitive impairment on neuropsychological testing. Individuals with hearing loss who demonstrate impairment in non-amnestic domains may experience benefits from the provision of hearing devices; This study provides support for a randomized control trial of hearing devices for improvement of cognitive function in this group.
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Day S, Roberts S, Launder NH, Goh AMY, Draper B, Bahar-Fuchs A, Loi SM, Laver K, Withall A, Cations M. Age of Symptom Onset and Longitudinal Course of Sporadic Alzheimer's Disease, Frontotemporal Dementia, and Vascular Dementia: A Systematic Review and Meta-Analysis. J Alzheimers Dis 2021; 85:1819-1833. [PMID: 34958038 DOI: 10.3233/jad-215360] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Understanding how the age of dementia symptom onset affects the longitudinal course of dementia can assist with prognosis and care planning. OBJECTIVE To synthesize evidence regarding the relationship of age of symptom onset with the longitudinal course of sporadic Alzheimer's disease (AD), vascular dementia (VaD), and frontotemporal dementia (FTD). METHODS We searched Medline, CINAHL, Embase, PsycINFO, PubMed, and Scopus for longitudinal studies that examined the impact of sporadic AD, VaD, or FTD symptom onset age on measures of cognition, function, or behavioral symptoms. Studies that examined age at diagnosis only were excluded. Quantitative meta-analysis was conducted where studies reported sufficient data for pooling. RESULTS Thirty studies met all inclusion criteria (people with AD (n = 26), FTD (n = 4)) though no studies examined VaD. Earlier onset of AD was associated with more rapid annual cognitive decline (estimate = -0.07; 95% CI -0.14 to 0.00; p = 0.045). Most studies that stratified their sample reported that younger AD onset (usually < 65 years) was associated with more rapid cognitive decline. Other evidence was inconclusive. CONCLUSION Younger people with AD appear to have a poorer prognosis in terms of faster cognitive decline than older people with AD. More research is required to determine the impact of symptom onset age in VaD and FTD, and on functional decline in all dementias.
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Veinovic M, Hill TY, Lavrencic L, Lasschuit D, Broe GA, Delbaere K, Draper B, Garvey G, Radford K. Telephone cognitive screening with older aboriginal Australians: A preliminary study. Alzheimers Dement 2021. [DOI: 10.1002/alz.055849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Draper B. Older people in hospitals for the insane in New South Wales, Australia, 1849-1905. HISTORY OF PSYCHIATRY 2021; 32:436-448. [PMID: 34269082 DOI: 10.1177/0957154x211029479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Older people had high admission rates to hospitals for the insane in New South Wales, Australia, in the second half of the nineteenth century. The medical casebooks of 226 patients aged 60 years and over admitted to two hospitals for the insane between 1849 and 1905 were examined. Aggressive behaviour (35.4%), suicidal behaviour (23.9%), fears of harm to self (19.9%) and alcohol issues (13.7%) were identified. Physical health factors (35.8%), functional impairment (18.6%) and poor nourishment (8.8%) were noted. Common diagnoses were mania (36.7%), dementia (31.9%) and melancholia (17.7%). Twenty-first-century diagnoses were assigned in nearly 94 per cent of cases with concordance that varied by diagnosis. The majority of admissions had serious mental disorders, with only 29.6 per cent being discharged.
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Lavrencic L, Broe GA, Daylight G, Delbaere K, Draper B, Duma S, Fulham M, Hill TY, Lasschuit D, Piguet O, Poulos L, Rae C, Timbery A, Radford K. Developing a protocol for neuroimaging to investigate brain ageing and dementia in collaboration with aboriginal Australian communities. Alzheimers Dement 2021. [DOI: 10.1002/alz.051947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Lavrencic L, Yong Z, Daylight G, Broe GA, Draper B, Radford K. Behavioural and psychological symptoms of dementia in aboriginal australians. Alzheimers Dement 2021. [DOI: 10.1002/alz.055105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Wijeratne C, Johnco C, Draper B, Earl J. Doctors' reporting of mental health stigma and barriers to help-seeking. Occup Med (Lond) 2021; 71:366-374. [PMID: 34534344 DOI: 10.1093/occmed/kqab119] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Medical practitioners experience high levels of mental disorders but may be reluctant to seek care. AIMS To determine medical practitioner attitudes towards other doctors with anxiety/depression, barriers to seeking mental healthcare, treatments received for depression and the effects of age. METHODS Data from the National Mental Health Survey of Doctors and Medical Students, conducted in Australia, were analysed (N = 10 038 medical practitioners). Attitudes to anxiety/depression were assessed with 12 statements (total stigma score, range 12-60). Barriers to seeking professional help, and coping strategies used, for anxiety/depression were measured. Practitioners with a history of depression were asked what personal supports and treatments were received. Practitioners were compared by age-younger (40 years and younger), middle-aged (41-60) and older (61+). RESULTS Attitudes and help-seeking behaviours varied with age. Older doctors had a more positive outlook and less total stigma, with the exception that they believed a doctor with anxiety/depression was less reliable. Younger practitioners were most likely to report barriers, such as confidentiality, impact on career progression and registration, to seeking help. For practitioners with depression, counselling and counselling plus medication were most likely to be received by the younger and middle-aged groups, whereas medication alone was most likely to be received by the middle-aged and older groups. CONCLUSIONS Stigmatizing attitudes towards mental disorder and barriers to help-seeking remain prevalent within the medical profession. Our results suggest doctors' health programs should address mental health stigma in younger practitioners and facilitate education about psychological treatments in older practitioners.
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Haber PS, Riordan BC, Winter DT, Barrett L, Saunders J, Hides L, Gullo M, Manning V, Day CA, Bonomo Y, Burns L, Assan R, Curry K, Mooney-Somers J, Demirkol A, Monds L, McDonough M, Baillie AJ, Clark P, Ritter A, Quinn C, Cunningham J, Lintzeris N, Rombouts S, Savic M, Norman A, Reid S, Hutchinson D, Zheng C, Iese Y, Black N, Draper B, Ridley N, Gowing L, Stapinski L, Taye B, Lancaster K, Stjepanović D, Kay-Lambkin F, Jamshidi N, Lubman D, Pastor A, White N, Wilson S, Jaworski AL, Memedovic S, Logge W, Mills K, Seear K, Freeburn B, Lea T, Withall A, Marel C, Boffa J, Roxburgh A, Purcell-Khodr G, Doyle M, Conigrave K, Teesson M, Butler K, Connor J, Morley KC. New Australian guidelines for the treatment of alcohol problems: an overview of recommendations. Med J Aust 2021; 215 Suppl 7:S3-S32. [PMID: 34601742 DOI: 10.5694/mja2.51254] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/21/2021] [Accepted: 06/29/2021] [Indexed: 11/17/2022]
Abstract
OF RECOMMENDATIONS AND LEVELS OF EVIDENCE Chapter 2: Screening and assessment for unhealthy alcohol use Screening Screening for unhealthy alcohol use and appropriate interventions should be implemented in general practice (Level A), hospitals (Level B), emergency departments and community health and welfare settings (Level C). Quantity-frequency measures can detect consumption that exceeds levels in the current Australian guidelines (Level B). The Alcohol Use Disorders Identification Test (AUDIT) is the most effective screening tool and is recommended for use in primary care and hospital settings. For screening in the general community, the AUDIT-C is a suitable alternative (Level A). Indirect biological markers should be used as an adjunct to screening (Level A), and direct measures of alcohol in breath and/or blood can be useful markers of recent use (Level B). Assessment Assessment should include evaluation of alcohol use and its effects, physical examination, clinical investigations and collateral history taking (Level C). Assessment for alcohol-related physical problems, mental health problems and social support should be undertaken routinely (GPP). Where there are concerns regarding the safety of the patient or others, specialist consultation is recommended (Level C). Assessment should lead to a clear, mutually acceptable treatment plan which specifies interventions to meet the patient's needs (Level D). Sustained abstinence is the optimal outcome for most patients with alcohol dependence (Level C). Chapter 3: Caring for and managing patients with alcohol problems: interventions, treatments, relapse prevention, aftercare, and long term follow-up Brief interventions Brief motivational interviewing interventions are more effective than no treatment for people who consume alcohol at risky levels (Level A). Their effectiveness compared with standard care or alternative psychosocial interventions varies by treatment setting. They are most effective in primary care settings (Level A). Psychosocial interventions Cognitive behaviour therapy should be a first-line psychosocial intervention for alcohol dependence. Its clinical benefit is enhanced when it is combined with pharmacotherapy for alcohol dependence or an additional psychosocial intervention (eg, motivational interviewing) (Level A). Motivational interviewing is effective in the short term and in patients with less severe alcohol dependence (Level A). Residential rehabilitation may be of benefit to patients who have moderate-to-severe alcohol dependence and require a structured residential treatment setting (Level D). Alcohol withdrawal management Most cases of withdrawal can be managed in an ambulatory setting with appropriate support (Level B). Tapering diazepam regimens (Level A) with daily staged supply from a pharmacy or clinic are recommended (GPP). Pharmacotherapies for alcohol dependence Acamprosate is recommended to help maintain abstinence from alcohol (Level A). Naltrexone is recommended for prevention of relapse to heavy drinking (Level A). Disulfiram is only recommended in close supervision settings where patients are motivated for abstinence (Level A). Some evidence for off-label therapies baclofen and topiramate exists, but their side effect profiles are complex and neither should be a first-line medication (Level B). Peer support programs Peer-led support programs such as Alcoholics Anonymous and SMART Recovery are effective at maintaining abstinence or reductions in drinking (Level A). Relapse prevention, aftercare and long-term follow-up Return to problematic drinking is common and aftercare should focus on addressing factors that contribute to relapse (GPP). A harm-minimisation approach should be considered for patients who are unable to reduce their drinking (GPP). Chapter 4: Providing appropriate treatment and care to people with alcohol problems: a summary for key specific populations Gender-specific issues Screen women and men for domestic abuse (Level C). Consider child protection assessments for caregivers with alcohol use disorder (GPP). Explore contraceptive options with women of reproductive age who regularly consume alcohol (Level B). Pregnant and breastfeeding women Advise pregnant and breastfeeding women that there is no safe level of alcohol consumption (Level B). Pregnant women who are alcohol dependent should be admitted to hospital for treatment in an appropriate maternity unit that has an addiction specialist (GPP). Young people Perform a comprehensive HEEADSSS assessment for young people with alcohol problems (Level B). Treatment should focus on tangible benefits of reducing drinking through psychotherapy and engagement of family and peer networks (Level B). Aboriginal and Torres Strait Islander peoples Collaborate with Aboriginal or Torres Strait Islander health workers, organisations and communities, and seek guidance on patient engagement approaches (GPP). Use validated screening tools and consider integrated mainstream and Aboriginal or Torres Strait Islander-specific approaches to care (Level B). Culturally and linguistically diverse groups Use an appropriate method, such as the "teach-back" technique, to assess the need for language and health literacy support (Level C). Engage with culture-specific agencies as this can improve treatment access and success (Level C). Sexually diverse and gender diverse populations Be mindful that sexually diverse and gender diverse populations experience lower levels of satisfaction, connection and treatment completion (Level C). Seek to incorporate LGBTQ-specific treatment and agencies (Level C). Older people All new patients aged over 50 years should be screened for harmful alcohol use (Level D). Consider alcohol as a possible cause for older patients presenting with unexplained physical or psychological symptoms (Level D). Consider shorter acting benzodiazepines for withdrawal management (Level D). Cognitive impairment Cognitive impairment may impair engagement with treatment (Level A). Perform cognitive screening for patients who have alcohol problems and refer them for neuropsychological assessment if significant impairment is suspected (Level A). SUMMARY OF KEY RECOMMENDATIONS AND LEVELS OF EVIDENCE Chapter 5: Understanding and managing comorbidities for people with alcohol problems: polydrug use and dependence, co-occurring mental disorders, and physical comorbidities Polydrug use and dependence Active alcohol use disorder, including dependence, significantly increases the risk of overdose associated with the administration of opioid drugs. Specialist advice is recommended before treatment of people dependent on both alcohol and opioid drugs (GPP). Older patients requiring management of alcohol withdrawal should have their use of pharmaceutical medications reviewed, given the prevalence of polypharmacy in this age group (GPP). Smoking cessation can be undertaken in patients with alcohol dependence and/or polydrug use problems; some evidence suggests varenicline may help support reduction of both tobacco and alcohol consumption (Level C). Co-occurring mental disorders More intensive interventions are needed for people with comorbid conditions, as this population tends to have more severe problems and carries a worse prognosis than those with single pathology (GPP). The Kessler Psychological Distress Scale (K10 or K6) is recommended for screening for comorbid mental disorders in people presenting for alcohol use disorders (Level A). People with alcohol use disorder and comorbid mental disorders should be offered treatment for both disorders; care should be taken to coordinate intervention (Level C). Physical comorbidities Patients should be advised that alcohol use has no beneficial health effects. There is no clear risk-free threshold for alcohol intake. The safe dose for alcohol intake is dependent on many factors such as underlying liver disease, comorbidities, age and sex (Level A). In patients with alcohol use disorder, early recognition of the risk for liver cirrhosis is critical. Patients with cirrhosis should abstain from alcohol and should be offered referral to a hepatologist for liver disease management and to an addiction physician for management of alcohol use disorder (Level A). Alcohol abstinence reduces the risk of cancer and improves outcomes after a diagnosis of cancer (Level A).
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Cations M, Loi SM, Draper B, Swaffer K, Velakoulis D, Goh AM. A call to action for the improved identification, diagnosis, treatment and care of people with young onset dementia. Aust N Z J Psychiatry 2021; 55:837-840. [PMID: 34382425 DOI: 10.1177/00048674211037542] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Hosie A, Agar M, Caplan GA, Draper B, Hedger S, Rowett D, Tuffin P, Cheah SL, Phillips JL, Brown L, Sidhu M, Currow DC. Clinicians' delirium treatment practice, practice change, and influences: A national online survey. Palliat Med 2021; 35:1553-1563. [PMID: 34096396 DOI: 10.1177/02692163211022183] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Recent studies cast doubt on the net effect of antipsychotics for delirium. AIM To investigate the influence of these studies and other factors on clinicians' delirium treatment practice and practice change in palliative care and other specialties using the Theoretical Domains Framework. DESIGN Australia-wide online survey of relevant clinicians. SETTING/PARTICIPANTS Registered nurses (72%), doctors (16%), nurse practitioners (6%) and pharmacists (5%) who cared for patients with delirium in diverse settings, recruited through health professionals' organisations. RESULTS Most of the sample (n = 475): worked in geriatrics/aged (31%) or palliative care (30%); in hospitals (64%); and saw a new patient with delirium at least weekly (61%). More (59%) reported delirium practice change since 2016, mostly by increased non-pharmacological interventions (53%). Fifty-five percent reported current antipsychotic use for delirium, primarily for patient distress (79%) and unsafe behaviour (67%). Common Theoretical Domains Framework categories of influences on respondents' delirium practice were: emotion (54%); knowledge (53%) and physical (43%) and social (21%) opportunities. Palliative care respondents more often reported: awareness of any named key study of antipsychotics for delirium (73% vs 39%, p < 0.001); changed delirium treatment (73% vs 53%, p = 0.017); decreased pharmacological interventions (60% vs 15%, p < 0.001); off-label medication use (86% vs 51%, p < 0.001: antipsychotics 79% vs 44%, p < 0.001; benzodiazepines 61% vs 26%, p < 0.001) and emotion as an influence (82% vs 39%, p < 0.001). CONCLUSION Clinicians' use of antipsychotic during delirium remains common and is primarily motivated by distress and safety concerns for the patient and others nearby. Supporting clinicians to achieve evidence-based delirium practice requires further work.
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Do VQ, Draper B, Harvey L, Driscoll T, Braithwaite J, Brodaty H, Mitchell R. Examining trajectories of hospital readmission in older adults hospitalised with hip fracture from residential aged care and the community. Arch Osteoporos 2021; 16:120. [PMID: 34405278 DOI: 10.1007/s11657-021-00966-x] [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: 12/08/2020] [Accepted: 05/06/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED Hip fracture trajectories have not been examined for older adults in aged care or living in the community. Trajectories of health care use were defined by distinct predictive factors. These results can inform the development of targeted strategies to reduce health service use following hip fracture. OBJECTIVE To examine hospital service use trajectories of older adults who were hospitalised for hip fracture and living in a residential aged care facility (RACF) or the community, and to identify factors predictive of trajectory group membership. These findings may inform future programmes aimed at reducing unexpected hospitalisations and subsequently reduce health care costs. METHODS A group-based trajectory analysis of hospitalisations was conducted for adults aged ≥ 65 years hospitalised for hip fracture during 2008-2009 in New South Wales, Australia. Linked hospitalisation and RACF data were examined for a 5-year period. Group-based trajectory models were derived for RACF and community-dwelling older adults based on the number of subsequent hospital admissions following the index hip fracture. Multinomial logistic regression examined predictors of trajectory group membership for subsequent hospital admissions. RESULTS There were 5752 hip fracture hospitalisations, with two-thirds of hip fractures occurring in community-dwellers. Key predictors of trajectory group membership for both RACF residents and community-dwellers were age group, sex, hospital length of stay and cognitive impairment. Assistance with activities of daily living and complex health care needs were also predictive of group membership in RACF residents. Location of residence and time to move to a RACF were additional predictors of group membership for community-dwellers. CONCLUSION Health service use trajectories differed for RACF residents and community-dwellers; however, there were similar patient characteristics that defined trajectory group membership. Low users of hospital services living in RACFs or the community included older adults with generally unfavourable health conditions, potentially indicating that palliative care or advanced care directives and community-care initiatives, respectively, have played a part in the lowered frequency of rehospitalisation.
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Lee W, Sheehan C, Chye R, Chang S, Loo C, Draper B, Agar M, Currow DC. Study protocol for SKIPMDD: subcutaneous ketamine infusion in palliative care patients with advanced life limiting illnesses for major depressive disorder (phase II pilot feasibility study). BMJ Open 2021; 11:e052312. [PMID: 34183351 PMCID: PMC8240583 DOI: 10.1136/bmjopen-2021-052312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/10/2021] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Major depressive disorder (MDD) in people with advanced life-limiting illnesses can have significant impact on the quality-of-life of those affected. The management of MDD in the palliative care setting can be challenging as typical antidepressants may not work in time nor be tolerated due to coexisting organ dysfunctions, symptom burden and frailty. Parenteral ketamine was found to exhibit effective and rapid-onset antidepressant effect even against treatment-resistant depression in the psychiatric population. However, there is currently neither feasibility study nor available prospective study available to inform of the safety, tolerability and efficacy of such for MDD in the palliative setting. METHODS AND ANALYSIS This is an open-labelled, single arm, phase II pilot feasibility study involving adult patients with advanced life-limiting illnesses and MDD across four palliative care services in Australia. It has an individual dose-titration design (0.1-0.4 mg/kg) with weekly treatments of subcutaneous ketamine infusion over 2 hours. The primary outcome is feasibility. The secondary outcomes are related to the safety, tolerability and antidepressant efficacy of ketamine, participants' satisfaction in relation to the trial process and the reasons for not completing the study at various stages. The feasibility data will be reported using descriptive statistics. Meanwhile, side effects, tolerability and efficacy data will be analysed using change of assessment scores from baseline. ETHICS AND DISSEMINATION Ethics approval was acquired (South Western Sydney Local Health District: HREC/18/LPOOL/466). The results of this study will be submitted for publication in peer-reviewed journals and presented at relevant conferences. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trial Registry Number: ACTRN12618001586202; Pre-results.
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Wand APF, Pourmand D, Draper B. Using interpreters with culturally and linguistically diverse older adults: What do we need to know? Australas J Ageing 2021; 39:175-177. [PMID: 33051998 DOI: 10.1111/ajag.12751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 11/26/2022]
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Wijeratne C, Johnco C, Draper B, Earl JK. Older Physicians' Reporting of Psychological Distress, Alcohol Use, Burnout and Workplace Stressors. Am J Geriatr Psychiatry 2021; 29:478-487. [PMID: 33023799 DOI: 10.1016/j.jagp.2020.09.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/11/2020] [Accepted: 09/11/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Most of the published data on the psychological health of physicians has focused on the youngest members of the profession. The aims of this analysis were to determine how psychological morbidity changes across the career cycle. METHODS We report data from the cross-sectional National Mental Health Survey of Doctors and Medical Students, conducted in Australia. Age differences in psychological distress, suicidal ideation, alcohol use, burnout, workplace, and personal stressors were examined for younger (40 years and younger), middle aged (41-60), and older (61+) physicians. RESULTS A total of 10,038 physicians responded. Older physicians reported significantly less psychological distress, burnout and suicidal ideation than younger and middle aged colleagues, findings that were maintained after adjusting for sex and excluding trainees. There were no group differences in overall alcohol use and high risk drinking. On multivariate analysis, the largest contributor to psychological distress in older physicians was a past history of mental disorder. There was a decline across age groups in the endorsement as "very stressful" of work-life conflict and work-anxiety stressors such as fear of making mistakes. Older physicians were least likely to feel very stressed by all workplace stressors. CONCLUSION The better psychological health of older physicians highlights the need to consider physician health according to age and career stage. Apart from the decline in work stressors, in particular work-life conflict, there may be a survivor effect such that physicians who practice into older age have developed greater resilience and professional maturation.
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Lennon MJ, Lam BCP, Crawford J, Brodaty H, Kochan NA, Trollor JN, Numbers K, Draper B, Thalamuthu A, Sachdev PS. Does Antihypertensive Use Moderate the Effect of Blood Pressure on Cognitive Decline in Older People? J Gerontol A Biol Sci Med Sci 2021; 76:859-866. [PMID: 33225353 DOI: 10.1093/gerona/glaa232] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND While midlife hypertension is deleterious, late-life hypertension has been associated with better cognitive outcomes in several studies. Many questions remain, including the relative benefit or harm of a blood pressure (BP) target and antihypertensive therapy of <120 in very old individuals. METHODS The Sydney Memory and Aging Study (n = 1015) comprises a cohort of 70- to 90-year-olds, who were followed biennially for 8 years. Global cognition was assessed with a battery of 10 neuropsychological tests. Blood pressure was measured at Waves 1 and 2 and classified into 3 systolic groupings: group 1 (≤120 mmHg), group 2 (121-140 mmHg), and group 3 (>140 mmHg). Multiple regression, linear mixed modeling, and Cox regression examined the effect of BP and antihypertensives. RESULTS There were no overall significant differences in global cognition or dementia between the disparate BP groups. However, in those not taking antihypertensives, the systolic BP (SBP) > 140 mmHg group had a significantly worse global cognitive trajectory compared to SBP ≤ 120 mmHg (b = -0.067, 95% CI [-0.129, -0.006], p = .030). Within the SBP ≤ 120 mmHg group those taking antihypertensives had significantly worse global cognition trajectories compared to those not taking antihypertensives even when controlling for past history of hypertension (b = -0.077, 95% CI [-0.147, -0.007], p = .030). CONCLUSIONS Untreated hypertension in old age is related to worse global cognitive decline. However, ongoing treatment at new recommendations of lower SBP targets may be related to poorer cognitive decline and should be considered carefully in older populations.
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Samaras K, Crawford JD, Draper B, Trollor JN, Brodaty H, Sachdev PS. Response to Comment on Samara et al. Metformin Use Is Associated With Slowed Cognitive Decline and Reduced Incident Dementia in Older Adults With Type 2 Diabetes: The Sydney Memory and Ageing Study. Diabetes Care 2020;43:2691-2701. Diabetes Care 2021; 44:e74. [PMID: 33741702 DOI: 10.2337/dci20-0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Castelli Dransart DA, Lapierre S, Erlangsen A, Canetto SS, Heisel M, Draper B, Lindner R, Richard-Devantoy S, Cheung G, Scocco P, Gusmão R, De Leo D, Inoue K, De Techterman V, Fiske A, Hong JP, Landry M, Lepage AA, Marcoux I, Na PJ, Neufeld E, Ummel D, Winslov JH, Wong C, Wu J, Wyart M. A systematic review of older adults' request for or attitude toward euthanasia or assisted-suicide. Aging Ment Health 2021; 25:420-430. [PMID: 31818122 DOI: 10.1080/13607863.2019.1697201] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Prevalence rates of death by euthanasia (EUT) and physician-assisted suicide (PAS) have increased among older adults, and public debates on these practices are still taking place. In this context, it seemed important to conduct a systematic review of the predictors (demographic, physical health, psychological, social, quality of life, religious, or existential) associated with attitudes toward, wishes and requests for, as well as death by EUT/PAS among individuals aged 60 years and over. METHOD The search for quantitative studies in PsycINFO and MEDLINE databases was conducted three times from February 2016 until April 2018. Articles of probable relevance (n = 327) were assessed for eligibility. Studies that only presented descriptive data (n = 306) were excluded. RESULTS This review identified 21 studies with predictive analyses, but in only 4 did older adults face actual end-of-life decisions. Most studies (17) investigated attitudes toward EUT/PAS (9 through hypothetical scenarios). Younger age, lower religiosity, higher education, and higher socio-economic status were the most consistent predictors of endorsement of EUT/PAS. Findings were heterogeneous with regard to physical health, psychological, and social factors. Findings were difficult to compare across studies because of the variety of sample characteristics and outcomes measures. CONCLUSION Future studies should adopt common and explicit definitions of EUT/PAS, as well as research designs (e.g. mixed longitudinal) that allow for better consideration of personal, social, and cultural factors, and their interplay, on EUT/PAS decisions.
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Paradise M, Crawford JD, Lam BCP, Wen W, Kochan NA, Makkar S, Dawes L, Trollor J, Draper B, Brodaty H, Sachdev PS. Association of Dilated Perivascular Spaces With Cognitive Decline and Incident Dementia. Neurology 2021; 96:e1501-e1511. [PMID: 33504642 DOI: 10.1212/wnl.0000000000011537] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 12/08/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To determine whether severe perivascular space (PVS) dilation is associated with longitudinal cognitive decline and incident dementia over 4 and 8 years, respectively, we analyzed data from a prospective cohort study. METHODS A total of 414 community-dwelling older adults aged 72-92 years were assessed at baseline and biennially for up to 8 years, with cognitive assessments, consensus dementia diagnoses, and 3T MRI. The numbers of PVS in 2 representative slices in the basal ganglia (BG) and centrum semiovale (CSO) were counted and severe PVS pathology defined as the top quartile. The effects of severe PVS pathology in either region or both regions and those with severe BG PVS and severe CSO PVS were examined. White matter hyperintensity volume, cerebral microbleed number, and lacune number were calculated. RESULTS Participants with severe PVS pathology in both regions or in the CSO alone had greater decline in global cognition over 4 years, even after adjustment for the presence of other small vessel disease neuroimaging markers. The presence of severe PVS pathology in both regions was an independent predictor of dementia across 8 years (odds ratio 2.91, 95% confidence interval 1.43-5.95, p = 0.003). The presence of severe PVS pathology in all groups examined was associated with greater dementia risk at either year 4 or 6. CONCLUSIONS Severe PVS pathology is a marker for increased risk of cognitive decline and dementia, independent of other small vessel disease markers. The differential cognitive associations for BG and CSO PVS may represent differences in their underlying pathology.
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Wand APF, Draper B, Brodaty H, Hunt GE, Peisah C. Evaluation of an Educational Intervention for Clinicians on Self-Harm in Older Adults. Arch Suicide Res 2021; 25:156-176. [PMID: 31941427 DOI: 10.1080/13811118.2019.1706678] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Clinicians may lack knowledge and confidence regarding self-harm in older adults and hold attitudes that interfere with delivering effective care. A 1-hour educational intervention for hospital-based clinicians and general practitioners (GPs) was developed, delivered, and evaluated. Of 119 multidisciplinary clinicians working in aged care and mental health at two hospitals, 100 completed pre/post-evaluation questions. There were significant improvements in knowledge, confidence in managing, and attitudes regarding self-harm in late life, and the education was rated as likely to change clinical practice. No GP education sessions could be conducted. A brief educational intervention had immediate positive impacts for hospital-based clinicians albeit with high baseline knowledge. The sustainability of these effects and effectiveness of the intervention for GPs warrant examination.
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Lee W, Pulbrook M, Sheehan C, Kochovska S, Chang S, Hosie A, Lobb E, Parker D, Draper B, Agar MR, Currow DC. Clinically Significant Depressive Symptoms Are Prevalent in People With Extremely Short Prognoses-A Systematic Review. J Pain Symptom Manage 2021; 61:143-166.e2. [PMID: 32688012 DOI: 10.1016/j.jpainsymman.2020.07.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 12/13/2022]
Abstract
CONTEXT Currently, systematic evidence of the prevalence of clinically significant depressive symptoms in people with extremely short prognoses is not available to inform its global burden, assessment, and management. OBJECTIVES To determine the prevalence of clinically significant depressive symptoms in people with advanced life-limiting illnesses and extremely short prognoses (range of days to weeks). METHODS A systematic review and meta-analysis (random-effects model) were performed (PROSPERO: CRD42019125119). MEDLINE, Embase, PsycINFO, CINAHL, and CareSearch were searched for studies (1994-2019). Data were screened for the prevalence of clinically significant depressive symptoms (assessed using validated depression-specific screening tools or diagnostic criteria) of adults with advanced life-limiting illnesses and extremely short prognoses (defined by survival or functional status). Quality assessment was performed using the Joanna Briggs Institute Systematic Reviews Checklist for Prevalence Studies for individual studies and Grading of Recommendations Assessment, Development and Evaluation (GRADE) across studies. RESULTS Thirteen studies were included. The overall pooled prevalence of clinically significant depressive symptoms in adults with extremely short prognoses (n = 10 studies; extremely short prognoses: N = 905) using depression-specific screening tools was 50% (95% CI: 29%-70%; I2 = 97.6%). Prevalence of major and minor depression was 10% (95% CI: 4%-16%) and 5% (95% CI: 2%-8%), respectively. Major limitations included high heterogeneity, selection bias, and small sample sizes in individual studies. CONCLUSIONS Clinically, significant depressive symptoms were prevalent in people with advanced life-limiting illnesses and extremely short prognoses. Clinicians need to be proactive in the recognition and assessment of these symptoms to allow for timely intervention.
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Rossie M, Croot K, Allison KC, Brodaty H, Crawford JD, Lee T, Henry JD, Draper B, Close J, Ong MY, Lam BCP, Sachdev PS, Kochan NA. Predictors of acceptability and emotional response to computerized neuropsychological assessments in older adults: The CogSCAN Study. Alzheimers Dement 2020. [DOI: 10.1002/alz.044730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Mitchell R, Draper B, Close J, Harvey L, Brodaty H, Do V, Driscoll T, Braithwaite J. Trajectories of Hospital Readmission After A Fall Injury for Older Adults Living in Aged Care or The Community. Int J Popul Data Sci 2020. [DOI: 10.23889/ijpds.v5i5.1476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
IntroductionFall injuries are one of the leading causes of hospitalisation for adults aged ≥65 years. Distinguishing key characteristics of older adults who are either living in aged care or in the community who have multiple hospital readmissions after a fall injury may inform targeted approaches to the prevention of hospital readmissions.
Objectives and ApproachTo examine trajectories of hospital readmission of older adults living in aged care or the community after a fall injury hospitalisation and to identify factors predictive of trajectory group membership. A group-based trajectory analysis of hospital readmissions of adults aged ≥65 years who had a fall injury hospitalisation during 2008-09 in New South Wales, Australia was conducted. Linked hospitalisation and aged care data were examined for a 5 year period to 2013. Group-based trajectory models were derived based on number of subsequent readmissions following the index admission. Multinominal logistic regression examined predictors of trajectory group membership.
ResultsThere were 24,729 fall injury hospitalisations; 78.8% of fallers were living in the community and 21.2% in aged care. Five distinct trajectory groups were identified for community-living (i.e. Moderate-declining, Chronic, Low-constant, Low-declining, and High users) and four trajectory groups for aged care residents (i.e. Low, Moderate-declining, Moderate-chronic, and High users). Key predictors of trajectory group membership for both community-living and aged care residents were age group, number of comorbidities, and dementia status. For aged care residents, depression, assistance with activities of daily living, and number of subsequent fall injury admissions were also predictors of group membership, with time to move to an aged care facility a predictor of group membership for community-living.
Conclusion / ImplicationsIdentifying trajectories of ongoing hospital use informs targeting of strategies to reduce hospital admissions and design of services to allow community-living individuals to remain as long as possible within their own residence.
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