Head, Hands, Heart Tutorial for Therapists

HomeCare Rehab

and Nursing LLC

What is Head, Hands, Heart?

• A simplified approach to working with patients with dementia:

Early (Head)

Middle (Hands)

Late/End (Heart)

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.

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.

What is the Head?

• “HEAD” = thinking• Early Stage Dementia• Goal-directed in

function and may have some limited ability for new learning

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.

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.

HEADPrecautions:• Unable to understand

precautions, complications, hazards.

• Written language is not reliable.

• Signs are not really effective.

HEADIf 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.

HEADDressing/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?

HEADToileting:• 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.

HEADFunctional 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!

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

HANDS• Behaviors:• Pacing, repetitive actions• Agitated, worried,

trembling hands• Unpredictable with social

interactions• Confused, acts randomly

Have you seen my mother?

Has anyone

seenmy

mother?

Copyright © 2002

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

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

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

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

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

HEARTEnd 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

HEARTPrecautions:• 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

HEARTCognitive 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

HEARTFeeding:• 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

HEARTDressing/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

HEARTToileting:• 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

HEARTFunctional 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