Dementia Support Group

The 7 Stages of Dementia

Global Deterioration Scale

The Global Deterioration Scale (GDS), developed by Dr. Barry
Reisberg, provides caregivers an overview of the stages of cognitive
function for those suffering from a primary degenerative dementia
such as Alzheimer's disease. It is broken down into 7 different
stages. Stages 1-3 are the pre-dementia stages. Stages 4-7 are the
dementia stages. Beginning in stage 5, an individual can no longer
survive without assistance. Within the GDS, each stage is numbered (1-
7), given a short title (i.e., Forgetfulness, Early Confusional, etc
followed by a brief listing of the characteristics for that stage.
Caregivers can get a rough idea of where an individual is at in the
disease process by observing that individual's behavioral
characteristics and comparing them to the GDS. (From geriatric-
resources)
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The Global Deterioration Scale for Assessment of Primary Degenerative
Dementia

Level 1 – NO COGNATIVE DECLINE: No subjective complaints of memory
deficit. No memory deficit evident on clinical interview.

Level 2 – VERY MILD COGNATIVE DECLINE (Age Associated Memory
Impairment):
Subjective complaints of memory deficit, most frequently in following
areas: (a) forgetting where one has placed familiar objects; (b)
forgetting names one formerly knew well. No objective evidence of
memory deficit on clinical interview. No objective deficits in
employment or social situations. Appropriate concern with respect to
symptomatology.

Level 3 – MILD COGNATIVE DECLINE (Mild Cognitive Impairment):
Earliest clear-cut deficits. Manifestations in more than one of the
following areas: (a) patient may have gotten lost when traveling to
an unfamiliar location; (b) co-workers become aware of patient's
relatively poor performance; (c) word and name finding deficit
becomes evident to intimates; (d) patient may read a passage or a
book and retain relatively little material; (e) patient may
demonstrate decreased facility in remembering names upon introduction
to new people; (f) patient may have lost or misplaced an object of
value; (g) concentration deficit may be evident on clinical testing.
Objective evidence of memory deficit obtained only with an intensive
interview. Decreased performance in demanding employment and social
settings. Denial begins to become manifest in patient. Mild to
moderate anxiety accompanies symptoms.

Level 4 – MODERATE COGNITIVE DECLINE (Mild Dementia):
Clear-cut deficit on careful clinical interview. Deficit manifest in
following areas: (a) decreased knowledge of current and recent
events; (b) may exhibit some deficit in memory of ones personal
history; (c) concentration deficit elicited on serial subtractions;
(d) decreased ability to travel, handle finances, etc. Frequently no
deficit in following areas: (a) orientation to time and place; (b)
recognition of familiar persons and faces; (c) ability to travel to
familiar locations. Inability to perform complex tasks. Denial is
dominant defense mechanism. Flattening of affect and withdrawal from
challenging situations frequently occur.

Level 5 – MODERATELY SEVERE COGNITIVE DECLINE (Moderate Dementia):
Patient can no longer survive without some assistance. Patient is
unable during interview to recall a major relevant aspect of their
current lives, e.g., an address or telephone number of many years,
the names of close family members (such as grandchildren), the name
of the high school or college from which they graduated. Frequently
some disorientation to time (date, day of week, season, etc.) or to
place. An educated person may have difficulty counting back from 40
by 4s or from 20 by 2s. Persons at this stage retain knowledge of
many major facts regarding themselves and others. They invariably
know their own names and generally know their spouses' and children's
names. They require no assistance with toileting and eating, but may
have some difficulty choosing the proper clothing to wear.

Level 6 - SEVERE COGNITIVE DECLINE (Moderately Severe Dementia):
May occasionally forget the name of the spouse upon whom they are
entirely dependent for survival. Will be largely unaware of all
recent events and experiences in their lives. Retain some knowledge
of their past lives but this is very sketchy. Generally unaware of
their surroundings, the year, the season, etc. May have difficulty
counting from 10, both backward and, sometimes, forward. Will require
some assistance with activities of daily living, e.g., may become
incontinent, will require travel assistance but occasionally will be
able to travel to familiar locations. Diurnal rhythm frequently
disturbed. Almost always recall their own name. Frequently continue
to be able to distinguish familiar from unfamiliar persons in their
environment. Personality and emotional changes occur. These are quite
variable and include: (a) delusional behavior, e.g., patients may
accuse their spouse of being an impostor, may talk to imaginary
figures in the environment, or to their own reflection in the mirror;
(b) obsessive symptoms, e.g., person may continually repeat simple
cleaning activities; (c) anxiety symptoms, agitation, and even
previously nonexistent violent behavior may occur; (d) cognitive
abulla, i.e., loss of willpower because an individual cannot carry a
thought long enough to determine a purposeful course of action.

Level 7 - VERY SEVERE COGNITIVE DECLINE (Severe Dementia):
All verbal abilities are lost over the course of this stage.
Frequently there is no speech at all -only unintelligible utterances
and rare emergence of seemingly forgotten words and phrases.
Incontinent of urine, requires assistance toileting and feeding.
Basic psychomotor skills, e.g., ability to walk, are lost with the
progression of this stage. The brain appears to no longer be able to
tell the body what to do. Generalized rigidity and developmental
neurologic reflexes are frequently present.
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The alzheimers association now has a plain English version of the
seven stages, available at http://www.alz.org/AboutAD/Stages.asp

From Act mental health consultants--
A simplified version of 7 stages. Seems to describe the problems and
care requirements seen in the nursing home. Very understandable. Also
gives range of time duration for each stage.
http://www.actmentalhealth.com/New...
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By the way, most doctors do not bother trying to determine the stage
the person is in - except that they might indicate mild, moderate or
severe. The doctors are more interested in treating the individual
patient and the problems he/she is having at the time of the visit.
They find no value in staging the dementia patient.
Caregivers tend to want the staging system to get an idea of where
their LO is in the process and what lies ahead.
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A simplified checklist version of the seven stages is the Functional
Assessment Staging Test (FAST). Note that stages 6 and 7 are broken
down into smaller steps.

1 No difficulties, either subjectively or objectively
2 Complains of forgetting location of objects; subjective word
finding difficulties only.
3 Decreased job functioning evident to coworkers; difficulty in
traveling to new locations.
4 Decreased ability to perform complex tasks (e.g., planning dinner
for guests; handling finances; marketing).
5 Requires assistance in choosing proper clothing for the season or
occasion.

6a Difficulty putting clothing on properly without assistance.
6b Unable to bathe properly; may develop fear of bathing. Will
usually require assistance
adjusting bath water temperature.
6c Inability to handle mechanics of toileting (i.e., forgets to
flush; doesn't wipe properly).
6d Urinary incontinence, occasional or more frequent.
6e Fecal incontinence, occasional or more frequent.

7a Ability to speak limited to about half a dozen words in an average
day.
7b Intelligible vocabulary limited to a single word in an average
day.
7c Nonambulatory (unable to walk without assistance).
7d Unable to sit up independently.
7e Unable to smile.
7f Unable to hold head up.

Comment on the FAST by dementia expert Geri Hall

"You look for the stage which is the highest number where your person
has symptoms because the losses are cumulative. If a patient is in
stage 3, I expect them to have some issues with money, working,
driving, shopping, short-term memory, time sense, etc -- In stage 4 I
see issues with driving, shopping, cooking, cleaning, doing chores,
participating in higher level activities and social affairs. But the
person brings the deficits from stage 3 with them into stage 4. The
deficits don't resolve.

And, there are those of us who work with these patients day to day
who strongly disagree with several points on the FAST Scale. The one
major issue is bathing. Problems with bathing are the hallmark of the
beginnings of stage 5.

G Hall recaps the seven stages ---
Problems with driving, managing money, and shopping = stage 3. If you
notice she can't cook, clean, or do the laundry = stage 4. If she
requires help (or strong encouragement to bathe, clean her teeth, or
select different clothing each day = stage 5. If she has trouble with
falling or bowel and bladder control and/or falling, she is in stage
6. If she can no longer walk, stage 7. The losses are cumulative and
not every patient has exactly the same losses.
Posted on 03/27/08, 11:03 pm