Practice constraints, behavioral problems, and dementia care: Primary care physicians' perspectives

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. PARTIVAIPANTS: 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.