What is the hand-under-hand approach for dementia patients?

Dementia affects an estimated 55 million people worldwide, profoundly impacting communication and daily life. Understanding and implementing supportive strategies is crucial for dignified care. Here, we'll explore what is the hand-under-hand approach for dementia patients, a technique that fosters connection and independence.

Quick Summary

The hand-under-hand approach is a compassionate caregiving technique where the caregiver places their hand underneath the patient's, providing gentle guidance and support rather than control. This method, often associated with Teepa Snow's Positive Approach to Care, preserves dignity, reduces agitation, and fosters participation in activities by utilizing retained muscle memory.

Key Points

• Foundation in Positive Approach: The technique was developed by Teepa Snow as part of her broader philosophy of compassionate, person-centered dementia care.

• Gentle Guidance, Not Control: The caregiver places their hand underneath the person's, offering support and guidance while allowing the individual to feel they have control.

• Preserves Dignity: By promoting participation and utilizing preserved motor skills, the method helps the person with dementia maintain a sense of purpose and self-worth.

• Reduces Agitation: The non-threatening, supportive nature of hand-under-hand minimizes resistance and frustration for both the patient and the caregiver.

• Improves Communication: It serves as a powerful form of non-verbal communication, conveying intent clearly and reducing misunderstandings.

• Versatile for Daily Tasks: This technique can be applied to many activities, including eating, dressing, walking, and grooming, to encourage participation and independence.

Origins and Philosophy of Hand-Under-Hand

Developed by occupational therapist Teepa Snow, the hand-under-hand technique is a key component of her Positive Approach to Care (PAC) philosophy. This method is rooted in the understanding that as dementia progresses, a person's brain experiences changes that alter their perception and processing of the world. Traditional approaches, such as gripping a person's hand from the top or forcing them to do a task, can feel invasive and threatening, triggering a defensive or agitated response.

The fundamental principle of hand-under-hand is to 'do with,' not 'do to' or 'do for' someone. By placing your hand underneath theirs, you provide a non-threatening, supportive foundation. This position allows the person with dementia to use their gross motor skills and remaining muscle memory, giving them a sense of control and participation in their own care. It acts as a tactile, non-verbal communication tool, offering reassurance and guidance without an overwhelming show of dominance.

Step-by-Step Guide to Implementing Hand-Under-Hand

Using the hand-under-hand technique effectively requires a calm and patient approach, often preceded by a positive physical approach (PPA).

Approaching with Purpose

1. Get into their visual field: Approach from the front, in the person’s line of sight, to avoid startling them. This gives them time to process your presence.
2. Smile and make eye contact: A calm, friendly facial expression and eye contact build trust and indicate that you are a safe person.
3. Offer an open hand: Extend your hand in a calm, open gesture. This allows them to respond at their own pace.
4. Offer a handshake: If the person reciprocates, this signals permission to enter their personal space. You can then transition from the handshake to the hand-under-hand position.

Transitioning to Hand-Under-Hand

1. Place your hand underneath theirs: Gently slide your hand under their palm, so their hand rests on top of yours. Your fingers and thumb remain free.
2. Position yourself to the side: This position is less confrontational and allows you to move with them, rather than against them.
3. Guide, don't control: Use gentle pressure and movement to guide their actions. If you are helping them eat, for example, your hand becomes a supportive base as their hand still holds the utensil and performs the motion of bringing food to their mouth.

Practical Applications in Daily Care

The hand-under-hand approach can be adapted for a wide variety of activities of daily living (ADLs), helping to preserve independence and reduce resistance.

• Eating and drinking: Guide a utensil to their mouth, allowing them to feel the motion and continue the process themselves. This capitalizes on long-retained muscle memory.
• Getting dressed: To help put on a jacket, place your hand through the sleeve, offer a hand-under-hand shake, and gently guide their arm through.
• Walking: Provide steady support while walking by moving your hand with theirs, guiding rather than pulling or forcing.
• Grooming: Assist with brushing hair or teeth by placing your hand under theirs as they hold the brush. This promotes continued engagement and sensory input.
• Transitioning: Gently guide them to a chair or help them stand up by tipping their forearm upward, providing a physical cue.

Hand-Under-Hand vs. Hand-Over-Hand

The contrast between the two techniques highlights why the hand-under-hand method is generally preferred in dementia care.

Feature	Hand-Under-Hand	Hand-Over-Hand
Hand Position	Caregiver's hand is underneath, supporting the person's hand.	Caregiver's hand is over the person's hand, gripping from above.
Control	Provides a sense of control and independence to the person with dementia.	Can feel restrictive and controlling to the person, potentially triggering distress.
Sensory Input	Offers comforting, gentle tactile input from below.	Top-down pressure can be perceived as forceful or threatening.
Brain Function	Utilizes gross motor skills and long-term muscle memory.	Demands fine motor skills that may be lost, increasing frustration.
Emotional Impact	Fosters trust, partnership, and dignity.	Can lead to resistance, anxiety, and a feeling of being done to.
Relationship	Reinforces a trusting and compassionate relationship.	Can damage rapport and create a sense of helplessness.

Benefits for Caregivers and Patients

Beyond reducing agitation, the hand-under-hand approach provides significant benefits for both the person with dementia and their caregiver.

• Reduces stress and frustration: Caregivers often report less resistance and struggle during tasks, leading to reduced stress for both parties.
• Improves communication: This technique serves as a powerful non-verbal communication method, conveying intent clearly and respectfully.
• Enhances quality of life: By promoting continued participation in daily activities, it boosts the person's sense of purpose and self-worth.
• Strengthens relationships: The method fosters a closer, more trusting bond between the caregiver and the individual, emphasizing partnership over dominance.
• Increases safety: Gentle guidance minimizes the risk of falls or injury that can occur during a struggle.

Conclusion: A Gentle Path to Connection

The hand-under-hand approach represents a profound shift in thinking about dementia care. It moves away from task-oriented assistance toward person-centered support, recognizing the individual's remaining abilities rather than focusing on their deficits. By offering a calm, supportive hand from below, caregivers can guide with respect, maintain a connection, and empower those living with dementia to participate in their own lives with dignity. Mastering this simple yet powerful technique can transform daily interactions, leading to a more peaceful and trusting environment for everyone involved. For additional resources and training on this topic, consult the Positive Approach to Care website. https://teepasnow.com/dementia-education-for-organizations-overview/

Frequently Asked Questions

Why is the hand-under-hand approach for dementia patients more effective than hand-over-hand?

The hand-under-hand technique is more effective because it's less threatening and more supportive. Placing your hand underneath the person's hand utilizes their retained gross motor skills and provides a sense of control, whereas placing your hand over theirs can feel forceful and cause resistance.

Can I use the hand-under-hand technique for eating?

Yes, it is highly effective for assisting with eating and drinking. By placing your hand under the person's as they hold their utensil, you can gently guide their movements, allowing them to participate in the process rather than being fed.

Is the hand-under-hand approach only for advanced dementia?

No, this technique can be used at various stages of dementia. It's particularly useful in mid-to-later stages when fine motor skills decline, but it can also be a gentle, non-threatening way to offer support and connect with someone in earlier stages as well.

What is the key to a successful hand-under-hand interaction?

The key is to approach with respect and patience. Ensure you are in the person's line of sight, make calm eye contact, and transition into the hand-under-hand position gently. Always observe their reaction and be ready to back off if they show signs of distress.

How does hand-under-hand help with dressing?

For dressing, you can use the technique to guide an arm into a sleeve. Instead of pulling or forcing, you place your hand through the sleeve and offer a hand-under-hand connection, guiding their arm easily into place. This is less stressful for both of you and prevents injury or ripped clothing.

How can hand-under-hand help someone with balance issues?

For mobility and balance, the technique allows you to provide a steady, supportive guide. By walking alongside the person with your hand under theirs, you can anticipate shifts in their balance and provide reassurance, making them feel safer and more secure.

Is the hand-under-hand method a form of manipulation?

No, it is the opposite. The intent is not to control the person but to partner with them respectfully. The method uses non-verbal cues and provides a tactile, sensory input that helps the person feel secure and participate in their care, maintaining their dignity.