Understanding Positive Approach to Care (PAC): A Person-Centered Philosophy for Dementia Care
Positive Approach to Care (PAC), developed by Teepa Snow, is a person-centered philosophy that transforms how we connect with individuals living with dementia. It recognizes that challenging behaviors are expressions of unmet needs or brain changes, not personal attacks. This approach offers concrete techniques like hand-under-hand to build trust and reduce distress. You are not alone in feeling overwhelmed; these practical skills can bring calm and connection to your caregiving journey.
Key points
- PAC is about connection, not control. Focus on understanding the person's experience, not correcting their behavior.
- Hand-under-hand is a gentle, respectful way to offer help that reduces startle and builds trust.
- Approach from the front, use a warm tone, and validate emotions before redirecting.
- Create a calm environment and use simple, positive language to reduce confusion.
- PAC techniques work for all relationships, not just dementia care—they improve communication with anyone who feels vulnerable.
- Caregiver self-awareness is key: take a timeout, step back, and try a different approach when something isn't working.
What Is PAC and Why Does It Matter?
PAC is a relationship-centered care philosophy that shifts the focus from managing behaviors to understanding the person behind the dementia. Unlike traditional approaches that try to control or redirect, PAC emphasizes connection, respect, and adapting to the individual's changing abilities. The core belief is that every person, regardless of cognitive decline, retains personhood—their unique history, preferences, and emotions. This aligns with Kitwood's concept of personhood, which highlights relationship, uniqueness, and embodiment. By valuing the person's experience, caregivers can reduce distress and improve quality of life for both the care receiver and themselves.
The Signature Technique: Hand-Under-Hand
Hand-under-hand is a gentle, non-threatening way to offer assistance or comfort. Instead of grabbing or guiding from above (which can startle or feel controlling), you slide your hand under the person's hand, palm up, and gently support or guide their movements. This technique respects the person's autonomy and reduces the fight-or-flight response common in dementia. It is especially useful during tasks like eating, grooming, or when the person is anxious. Many caregivers find it works not only with dementia but also with children or anyone who feels vulnerable. As Teepa Snow notes, these skills are applicable to all relationships.
The PAC Coaching Difference
PAC coaching is not about giving a list of rules; it is about teaching caregivers to observe, adapt, and connect. Coaches help you see the world from the person's perspective, understand their brain changes, and adjust your approach in real time. This is different from traditional training that might focus on behavior management or task completion. PAC coaching emphasizes self-awareness—taking a timeout, stepping back, and trying something different when a situation isn't working. The goal is to create a positive experience for everyone, not just to complete a task.
General caregiving information, not medical advice. Check medications and major care changes with your clinician.
Step-by-step
Approach from the front, make eye contact, smile, and say their name before touching them to avoid a startle response.
Use hand-under-hand for assistance: slide your palm under theirs, palm up, and gently guide their hand to the task.
Speak slowly with short, positive sentences and offer simple choices (e.g., 'red shirt or blue?') instead of yes-no questions.
Validate their feelings before redirecting: name the emotion ('I see you're frustrated'), then offer a gentle option.
Watch body language and treat every behavior as communication—pause and ask what need they might be expressing.
Shape the environment for calm: lower noise, reduce clutter, soften harsh light, and play familiar music from their young adult years.
When agitation rises, step back, lower your voice, and give space for a few minutes without arguing or reasoning.
Invite them into meaningful activities tied to their past (e.g., sorting seeds if they loved gardening) to preserve purpose.
What not to do
Don't approach from behind, hover over them, or grab their hand from above—this can trigger a startle reflex.
Don't argue, correct, or try to reason when they are confused or upset; the brain cannot process logic then.
Don't force a task when they resist—step back and try later at a calmer moment.
Don't do everything for them; let them do what they still can and offer small choices to preserve dignity.
Don't use baby talk, elderspeak, or talk about them as if they aren't in the room.
Practical tools
Hand-Under-Hand Script
Say 'May I help you with this?' as you slide your palm under theirs. If they accept, gently guide; if they pull away, say 'We can try later.'
Positive Phrase Cheat Sheet
Keep a card with phrases like 'Let's try this together,' 'I see you're upset—I'm here,' and 'Would you like to sit or stand?'
Music Playlist
Build a playlist of songs from their young adult years (ages 18–25) on a simple device; play during meals or anxiety to calm and unlock memories.
Environment Checklist
Before each interaction, scan for low noise, uncluttered surfaces, and soft lighting without glare to reduce confusion.
Daily Routine Visual Schedule
Use a whiteboard with simple pictures (e.g., toothbrush for brushing). Point and say 'Next, we will…' to lower anxiety through predictability.
Behavior Detective Log
Note when challenging moments happen, what preceded them, and what helped, to reveal patterns like hunger or overstimulation.
Discuss with your clinician
Ask your doctor: 'Could my loved one's agitation be related to an untreated infection or pain? Should we review their medications for side effects?'
Discuss with a dementia specialist: 'Are there any non-drug approaches like PAC that could reduce the need for antipsychotic medications?'
Ask a social worker: 'Are there local PAC training programs or support groups for caregivers that I can access?'
Consult an occupational therapist: 'Can you teach me hand-under-hand and other PAC techniques for daily care tasks?'
Related guides
- Person-Centered Care Basics: A Practical Guide for Compassionate Dementia Care
- hand-under-hand for mouth and oral care
- Using Validation Therapy to Reduce Conflict with Your Loved One
- Sensory communication strategies for dementia
- caregiver leadership and self-advocacy
- adapting dental care as dementia progresses
- Using familiar songs to engage a person with dementia
- Assisting with Activities of Daily Living (ADLs) in Dementia Care
- Touch cues for sitting assistance in Lewy body dementia
- Single-sensory care techniques for late-stage dementia