OBJECTIVES:To examine how practice constraints contribute to barriers in the health care of persons with dementia and their families, particularly with respect to behavioral aspects of care. DESIGN:Cross-sectional qualitative interview study of primary care physicians. SETTING: Physicians' offices.PARTICIPANTS: Forty primary care physicians in Northern California. MEASUREMENTS:Open-ended interviews lasted 30-60 minutes and were structured by an interview guide covering clinician background and practice setting, clinical care of a particular patient, and general approach to managing patients with AD or dementia. Interviews were transcribed and themes reflecting constraints of practice were identified through a systematic coding process. RESULTS:Recurring themes (i.e., those present in ≥25% of physician interviews) included insufficient time, difficulty in accessing and communicating with specialists, low reimbursement, poor connections with community social service agencies, and lack of interdisciplinary teams. Physician narratives suggest that these constraints may lead to delayed detection of behavior problems, "reactive" as opposed to proactive management of dementia, and increased reliance on pharmacological rather than psychosocial approaches. CONCLUSION:Physicians often feel challenged in caring for dementia patients, particularly those who are more behaviorally complex, because of time and reimbursement constraints as well as other perceived barriers. Our results suggest that more effective educational interventions (for families and physicians) and broader structural changes are needed to better meet the needs of the elderly with dementia and their families now and in the future. Without these changes, dementia care is likely to continue to fall short.KEY WORDS: dementia; quality of care; barriers; qualitative.

A prospective follow-up study of 60 randomly selected cases of closed adult civilian head injuries was conducted for three months from the time of head injury to assess the frequency, patterns, and factors related to post-traumatic psychiatric disturbances. Eighty per cent of the cases had a neuropsychiatric disturbance as assessed at 1 1/2 months. The commonest was post-concussional syndrome (43 per cent). The extent of social dysfunction was directly related to the severity of head injury. However, the total number of symptoms (largely subjective) correlated highly with pre-traumatic neuroticism. The inter-relatedness of organic and personality factors in the post-traumatic syndrome, and their predictive value, are discussed.

Forty three patients of subarachnoid haemorrhage of unknown aetiology have been studied for their clinical presentation, rebleed rate, morbidity and mortality. The results have been compared with other similar studies. The present study and those of others indicate a very good prognosis in acute stage. The rebleed rate ranged between 0 and 7% over a period of two to three years. The mortality rate ranged between 0 and 5% during the same period of follow-up. Majority of the patients returned to their full working capacity. The benign nature of this subgroup as compared to the poor outcome of subarachnoid haemorrhage as a whole prompted us to call it "Benign subarachnoid haemorrhage".

The clinical and radiological profiles of 63 patients with contre-coup haematomas were studied. The overall mortality was 53%. The mortality in patients with contre-coup haematomas alone was only half of that found in patients with associated coup injury (80%).

Brainstem auditory evoked responses (BAER) were studied in 20 children with clinically diagnosed and CT-confirmed congenital hydrocephalus before and after shunt surgery. Ninety-five percent of the children showed abnormal responses preoperatively. Prolonged wave V latency was the most common abnormality, followed by increased interwave latencies. Total absence of evoked responses was more common in children with communicating hydrocephalus. Following shunt surgery 50% of cases returned to normal and 20% showed a significant improvement. Abnormalities persisted in 10% of cases. BAER abnormalities referrable to caudal brainstem dysfunction recovered first, following CSF diversion. Study of BAER is useful for identifying physiological brainstem abnormalities in hydrocephalic children and promises to be a sensitive non-invasive diagnostic tool for the detection of "non-infective complications" of shunt surgery, if performed serially during follow up.