By Ashley Fredde
Teepa Snow had been properly warned that “Ms. Jackson is on a tear” by the on-duty nurse when she strode into the room.
She recalls huffing in exasperation and thinking in response “That’s because yall don’t know how to do this.” By her own admission, as a young nursing assistant she was cocky — but not without merit.
Snow, now 71, had worked with people with developmental disabilities as a teen and throughout her earlier adulthood, starting her career in the basement of a church. But on that day nearly 45 years ago, she was the first graduate out of the University of North Carolina at Chapel Hill’s occupational therapy program. Her interest in geriatrics, stroke, head injury and developmental disability led her to the long-term care facility in Henderson where she had met Ms. Jackson.
Jackson was a Southern Baptist, like Snow’s grandmother. Snow could recite the hymns by heart, finish the prayers, slip into the rhythm of a Bible’s chapters and verse. The shared understanding often worked in her favor among her charges.
When Snow arrived at the room, Jackson was standing in the doorway with her bedsheet wrapped around her. Her pajamas were peeking out beneath, and her sleep cap was perched atop her head. In her arms she carried her belongings — a Bible in one hand, a teddy bear tucked against her side, and a water pitcher — as if preparing to travel.
She caught sight of Snow.
“Hey, you. Girl,” she called. “Come here. Come here. I need you to carry me to see Mr. Dukes.”
Snow said her response then was much different than it would be now. She redirected Jackson toward the bathroom, toward the morning routine, toward what “needed to be done.” Jackson’s insistence turned into frustration that included some expletives thrown at Snow, embellished with the swift smack of the Bible she carried.
Staff quickly administered the powerful anti-psychotic drug haloperidol to subdue her.
The next day, Snow arrived to find Jackson’s room empty — she had been admitted to the hospital for shingles. Realization dawned that Jackson had been asking Snow to take her to Duke Hospital, where Duke ran a clinic for indigent populations.
“That was a big moment of appreciation — that she was trying to communicate with me super clearly, and I was so sure I knew the right answer,” Snow recalled. “Ever since, early on, I have believed challenging situations happen because we people are trying to communicate and we’re not good at picking up on the communication.”
Seeing the person, not the disease
Decades later, Snow, now an international expert trainer on the care of people with dementia, sees things differently.
Snow’s approach, which she would later formalize through her Hillsborough-based Snow Approach Foundation, centers on a simple shift: See the person before the diagnosis.
“People have dementia. It doesn’t diminish their humanness. It diminishes capacity in some areas, but in other areas, they’re actually quicker at picking up on things that you wish they didn’t,” Snow said. “That’s where the work comes from is that belief that whatever you have left, it’s not fair for me to take things away from you that you still have capacity for. And it turns out people like that.”
That approach is seen in one of Snow’s most widely taught methods, the “hand-under-hand” technique — which she slips into demonstrating easily. She takes time to notice the person’s dominant hand, and other preferences, before approaching from the side and positioning herself at eye level. Then she offers a hand beneath the other person’s hand rather than grabbing from above. The technique allows the person living with dementia to control the movement and preserve autonomy.
The hand-under-hand technique is a part of Snow’s training program, Positive Approach to Care, which is built around concrete, repeatable skills that are easily learned by people who are providing care for people living with dementia — whether in an institution or at home with a loved one. The emphasis is practical: not only understanding why behavior happens, but learning how to respond differently.
To help people understand differences in approach, Snow films how-to videos and examples using kitchen, bedroom and bathroom sets arranged in different formats to mimic someone’s situation.
“When a community is moving into this space of being truly person-centered, when it cares about both employees and residents and families as people first … we see the relationships start to be present,” Snow said. “It’s this ability to be curious about another human being’s preferences, needs.”
The program puts the focus on the abilities someone with dementia still has instead of centering what has been lost. Care partners are encouraged to work with the person, instead of acting on them and doing for them — shifting whole interactions into collaboration. The goal of the approach is to reduce friction and build a relationship that makes daily care feel less like a struggle.
Part of that is recognizing brain changes in the person living with dementia without reducing the person to the behaviors they’re displaying, the core of Snow’s GEM State Model. Instead of ranking loss, the model describes different cognitive states — Sapphire, Diamond, Emerald, Amber, Ruby and Pearl — each representing different abilities and needs.
“Once we get healthy in relationships again with people living with dementia, it makes all the difference in the world,” she said. “We stop seeing them as resistive to care. We stop seeing them as noncompliant, we stop seeing people as unable — and we start looking for what is possible.”
A system not built for dementia
Each year, more families enter a system of care that Snow believes is “broken” when it comes to dementia. An estimated 7.2 million older Americans are living with Alzheimer’s disease, including more than 210,000 in North Carolina — 11.6 percent of the state’s population of people 65 and older, according to the Alzheimer’s Association 2025 report.
Another 200,000 Americans under 65 are living with younger-onset Alzheimer’s. Deaths attributed to the disease continue to rise, with North Carolina Alzheimer’s deaths rising 147 percent between 2000 and 2022, according to the report, when the population of people over 65 in the state nearly doubled to just under 2 million.
“No matter how well you do your job, you lose your patient. No matter how well you do this, their abilities are going to change on you, no matter how much you work with a family, at some point that family is going to lose them,” Snow said. “This is the only condition that I know about that for sure: They will die, and there’s no way out right now.”
Despite the prevalence of the diagnosis, Snow argues that the system around it is fragmented.
“I go in and I find out I have the condition,” she said. “I’m leaving without anything other than ‘Get your affairs in order.’”
Too often, she said, families leave medical appointments without a road map — no phased plan, no structured education, no network.
“We wouldn’t do that with a cancer patient,” she said. “How are we going to live? Are we in a palliative mode? Are we still in a preventive mode? What’s our game plan?”
With no plan in place, the burden often shifts almost entirely to families. The total lifetime cost of care for someone with dementia approaches $400,000, with roughly 70 percent of the cost borne by family care partners through unpaid labor and out-of-pocket expenses, according to the Alzheimer’s Association.
The national median cost for in-home dementia care is $33 per hour, according to the Genworth Cost of Care Survey 2024. Monthly rates range from $2,145 for 15 hours per week to $6,292 for 40 hours per week. Location, care needs, and the level of the direct care person’s training all can affect the price.
In North Carolina alone, Medicaid costs tied to dementia care are estimated at $1.8 billion, and Medicare spending averages were $28,484 per person with dementia in 2023, the report stated. Much of that cost is for placing a dementia patient in a facility once their care becomes too much for families.
“We have this expectation that families will do care until they can’t,” Snow said.
Families who are already reaching their breaking point often show up in the form of a hospital admission or emergency room visit, she said. That breaking point isn’t because the family doesn’t care, Snow said, but it does often illustrate that they weren’t adequately prepared.
The new dynamic often reshapes relationships between the person living with dementia and the people Snow refers to as care partners, whether they are children or partners who may also be aging. Snow believes dementia care must account for two changing brains.
“There should be duality in our work,” she said. “We should be asking, ‘How are you doing here?’”
One of Snow’s first directives to care partners can be revealing: “‘Tell me what you still like about the person you’re living with now.’ When the answer is insistence that they love the person but no real answer beyond that,” she said, “we’re at a crisis point.”
While families are struggling, the professional workforce is experiencing a shortage that makes it ill-equipped to meet the growing need. In North Carolina, a 61 percent increase in geriatricians will be needed by 2050 to meet the demand, according to the Alzheimer’s Association.
“Policy makers want there to be a cheap fix, and right now, we don’t have a plan for caring for people living with dementia. We truly don’t,” Snow said. “It’s going to crash the system soon because we’re going to end up putting them in acute care situations and long term care situations that we can’t afford — and break families.”
What Snow is asking for is not a miracle cure, she said, but honesty — and preparation.
“Please quit promising people what you can’t deliver,” she said. “Let’s start talking about how we’re going to help people live through this disease.”
The post NC’s Teepa Snow is teaching how to approach dementia differently appeared first on North Carolina Health News.
