2. Head, Hands, Heart Tutorial for Therapists HomeCare Rehab and Nursing LLC

3. What is Head, Hands, Heart? A simplified approach to working with patients with dementia: Early (Head) Middle (Hands) Late/End (Heart)

4. How is the level determined? Many dementia assessments can be used including: Allen Cognitive Level Screen Global Deterioration Scale Brief Cognitive Rating Scale Routine Task Inventory The score is then valued as either early, middle, or late/end stage dementia.

5. Why do I need to know the level of dementia? The treatment plan, goals, and outcomes will be influenced by what specific skills the patient still has. It is immeasurably valuable to have a level established for care of the patient for comparison as the dementia progresses- interventions and approaches will need periodic revision.

6. What is the Head? “HEAD” = thinking Early Stage Dementia Goal-directed in function and may have some limited ability for new learning

7. HEAD –Loss of inhibitions (frontal lobe). –Unable to self-monitor. –No insight into deficits (nothing is wrong with them)…problem is with the world. –Loss of independence and dignity, loss of role in life. –Words are the best fighting tool they have. –Memory issues frustrate caregivers.

8. HEAD Cognitive skills/Communication: Understands beginning, middle, and end of an activity. Can seek help but may not remember emergency procedures. Rigid, likes routine. Self-centered communication, confabulates, high verbal output. Recognizes highly visible striking cues in the environment. Limited reading comprehension. New learning possible with maximum repetition if highly valued. Believe that nothing is wrong with them. Well, maybe you say it’s wrong but that’s just the way I like it. My way is the best way.

9. HEAD Precautions: Unable to understand precautions, complications, hazards. Written language is not reliable. Signs are not really effective.

10. HEAD If you tell me to go brush my teeth I will stay on task. I just may forget to use toothpaste or rinse out my mouth. Feeding: May eat too fast or too slow. Annoyed with others eating near them. Complains about food. Grooming: May neglect unseen surfaces (back of head). Sequencing errors.

11. HEAD Dressing/Bathing: Performs familiar self care with decreased attention to unseen surfaces. Follows routine. Remembers what they are doing throughout task. Clothing selection may be based on striking features (brightest shirt in the closet). Quality may not be good. I am really drawn to bold, striking visual input. Did you ever notice that I choose bright clothing and wear too much make- up?

12. HEAD Toileting: May neglect parts of the task. May require verbal reminders to initiate task. Completes the task although quality may not be good. This is a huge loss of dignity for me- and a very overwhelming task at times.

13. HEAD Functional Mobility: Able to navigate using familiar landmarks. Transfer skills depend on familiarity of environment. Carries walker if distracted, but will correct with cues. Notices barriers above and below knee. Trunk becoming more rigid. I can remember new things with tons of patience and practice!

14. HANDS “HANDS”= reaching, grabbing, holding objects Level 3 of the Allen Cognitive Scale Middle Stage Dementia Medicare “Mod Assist” Not goal directed, cannot be expected to complete a task without assistance Copyright © 2002

15. HANDS Behaviors: Pacing, repetitive actions Agitated, worried, trembling hands Unpredictable with social interactions Confused, acts randomly Have you seen my mother? Has anyone seen my mother ? Copyright © 2002

16. HANDS Cognitive skills/ communication: Able to name objects Decreased sense of task completion Needs verbal cues to sequence steps of an activity Responds best to demonstrated instructions Word finding problems Loses the thread of a story Jargons, incoherent sentences I have to get out of here. I’m late for work and the train is on that other thing over the @#%*! out that window day @#%*! right here in Chantilly. Copyright © 2002

17. HANDS Precautions: At risk for falls Unable to understand precautions, complications, or hazards Does not recognize need for help At risk for accidents- poison, sharp objects, elopement I love to use my hands...and touch everything! I tend to get into things I shouldn’t and carry them around with me. Copyright © 2002

18. HANDS Self-care skills: May initiate action with familiar object- but not sustain to completion Resistant to care Layers clothes until all items used up, unable to orient clothing or sequence task Needs supervision or assistance with toileting I am sometimes very resistant to care. Don’t you sneak up on me or just might get slugged! Copyright © 2002

19. HANDS Feeding: May reach for food from other place settings or centerpiece Unable to complete meal without redirection and set-up Plays with food and utensils You may notice that I play with my food or grab other’s food from their plates. I’m easily distracted and overstimulated. Copyright © 2002

20. HEART “HEART” = feeling, living Level 1 and 2 of the Allen Cognitive Scale. Late and End Stage Dementia Medicare “Max Assist/ Dependent” Respond to internal and external stimuli through any of the five senses Copyright © 2002

21. HEART End Stage: Mostly bedbound Can move limbs and head Total assistance for self care and mobility. Late Stage: Can overcome gravity Can sit, stand and/or walk (mobility) Have a sense of balance, although not good Copyright © 2002

22. HEART Precautions: Contractures Skin Breakdown Falls Aspiration Because I can’t move or communicate well, I’m really at risk for contractures, falls, and skin breakdown. YOU can prevent this from happening to me! Copyright © 2002

23. HEART Cognitive Skills/ Communication: Speech mostly unintelligible, mumbles incoherently Unable to follow most verbal commands Poor attention span, distracted by moving objects A funny trick I know: I may only be able to say one or two words, but I can sing a whole song without any errors. Copyright © 2002

24. HEART Feeding: May be able to feed self with limited or extensive assistance More successful with finger foods Can sip from a cup held to lips until very end stages- don’t introduce a straw too early! I can only see things less than 12 inches from my face. Bring the world to me! Copyright © 2002

25. HEART Dressing/Bathing/ Grooming: Has no idea what to do with objects Assists caregivers by holding positions, moving limbs, and standing I have a major fear of falling. I may resist, hit, or kick but it’s only to protect myself from injury. I’m not just being difficult. Copyright © 2002

26. HEART Toileting: Needs assistance with managing clothing, perineal hygiene, and positioning on toilet Frequently incontinent Inappropriate toileting locations- sometimes the same place over and over. Can assist caregiver by holding onto grab bar. You may know me by my “death grip”. I have a hard time releasing things from my hands. Copyright © 2002

27. HEART Functional Mobility: Higher level “hearts” walk aimlessly, pace, rock, and march. Lower level “hearts” can only respond with a grimace or glance. Seek stability and comfort Enjoy gross motor activities- without a sense of purpose. I can turn my head to track a moving object even at the last stages of my disease. Give me moving stuff to look at! Copyright © 2002