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Death Grip

Did you ever notice that someone in the later stages of dementia has a difficult time letting go of things?

Maybe he can’t put his fork down, or let go of the walker or grab bar?

And telling him over and over to “let go” just doesn’t seem to work… so you pull the item out of his hand, or pry his fingers off of the bar.

There are a number of issues at play here:

  1.  Palmar reflex- the tendency of the hand to close tightly around something when the palm is stimulated.  Many new parents show off their baby’s “strength” by how tightly the baby can hold onto their parents’ fingers.  The reflex is a developmental motor pattern that we needed long ago to hold onto our mamas while they swung from tree to tree.  We don’t need the reflex for that purpose any longer, but it is present in babies as a survival function (for feeding from breast or bottle) and as a stepping stone for future advanced movements.  The newer movement patterns dampen the old reflexive ones.  Newer movement patterns are just like newer memories- they are the first to go.  As higher, more evolved movement patterns become damaged by Alzheimer’s disease, the reflex is no longer inhibited.  The palm becomes very sensitive to closing around objects.
  2. Apraxia- the inability to carry out a purposeful movement.  Release of objects is a learned motor skill, one that is susceptible to damage from Alzheimer’s disease.  People with Alzheimer’s require more time to carry out a motor command.  Apraxia is a challenging problem.
  3. Impaired language skills- the language centers become so damaged in Alzheimer’s disease that virtually all verbal communication becomes pointless (not conversational inflection, body language, and facial expression- but that’s for another post).  Repeating the commands to “let go” accomplishes nothing, just as raising your voice only adds to the confusion and can cause an even tighter grip.  Pulling on the person’s arm or prying the fingers off of a bar can also cause adverse reactions based on fear- if I don’t understand why you want me to let go, I’m only going to hold on tighter.  I don’t want to fall.
  4. Prying the fingers or pulling the fork out of the hand only promotes a clenched fist.  What this means is that opportunities to practice purposeful release are taken away, and the hands will posture more and more often in a clenched position.  This will ultimately lead to hand contractures and non-functional hands.

 

So what is the correct approach to managing this common symptom?

1.  Demonstrate the action of opening your hand, and do it within 14 inches of his face so that he can visually attend to your action.

2.  State a one word command like “Open”, or “Release”.

3.  Allow at least 10 seconds for the hand to completely open.

The best way to prevent hand contractures and preserve functional release is to provide opportunities to grasp and release objects.  Most people at this stage enjoy rummaging and manipulating objects, so be sure to encourage this activity instead of preventing it.

 

Keep Those Hands Open

 

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5 comments

  1. Olivia Morrissette

    I’ve noticed that some folks with dementia will walk along holding onto their shirt tail, or other hem of their clothing. I think it’s around the period when their verbal and/or conversation abilities are dimming. I even observed my mother doing it. Not sure if it’s the same as the death grip, or palmar reflex, though; possibly it has some kind of orienting or steadying function.

    • Great observation Olivia! Actually Claudia Allen (renown occupational therapist and founder of the Allen Cognitive Disability Theory) had noticed this too at a certain level of cognitive impairment. She noticed that people had a tendency to follow the perimeter of things- like the hem of a shirt, or the edge of a plate. You might notice that your mother eats the food around the edge of her plate more than the middle. So, in using this tendency toward your advantage, you could intentionally place things that you wanted her to attend to at the perimeter of an area. She might be more likely to explore something with her hands or engage in an activity if the medium was along the edge of a surface, box, or room.
      “ACL 3.6 Placing objects at the edge requires attention to the perimeter or shape of the object”
      Such an interesting topic!

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