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The clarification of dementia stages isn't an exact measure, as like most other things in life, the progression lies on a continuum. Most of the general public classify dementia stages by using the general classifications of mild, moderate and severe. Although these stages can provide a general idea of where on the continuum a dementia person falls, medical professionals use a more specific scale in order to classify stages and levels. Using these more detailed levels allows professionals to determine and provide the most accurate level of care.
While there are several scales and tests used to measure the progression of dementia, the most commonly used scale is the Global Deteriorations Scale (GDS), also known as the Reisberg Scale. The Global Deterioration Scale is a scale that is used to stage individuals with cognitive impairments consistent with dementia (including Alzheimer’s disease) according to a 7 point scale. Staging using the GDS helps families and caregivers understand the cognitive deficits and set realistic goals for living situations and therapy, as well as to maintain independence and improve quality of life for individuals with dementia.
As the disease progresses, different signs and symptoms will become increasingly obvious. According to the GDS, there are seven different stages of Alzheimer’s disease correlating with four distinct categories: no Alzheimer’s when symptoms are not noticeable, mild Alzheimer’s (or early-stage) when symptoms start to become evident, moderate Alzheimer’s (or middle-stage) when symptoms are blatant and assistance is required, and severe Alzheimer’s (late-stage) where deficits are significant and complete care is typically required. Let's explore each stage in more depth.
STAGES 1 – 3: No Dementia
STAGE 1 - No Cognitive Decline
In Stage 1 of dementia, there are no signs of dementia, the person functions normally and is mentally healthy. People with no dementia diagnosis are considered stage 1. There are no signs or symptoms, no memory loss or behavioral problems, or anything else associated with the onset of dementia. When a health professional examines them, there are no cognitive issues evident. This is the essentially the "normal" person who lives independently in the community.
STAGE 2 - Very Mild Cognitive Decline or Mild Cognitive Impairment (MCI)
As the disease progresses into stage 2, classified as very mild cognitive decline, there is forgetfulness that is often attributed to normal signs of aging. In this stage, sometimes called SCI (Subjective Cognitive Impairment), persons may exhibit subjective memory and/or other cognitive complaints. Personal observations, sometimes accompanied by complaints of being forgetful, such as difficulties with recall of names, and/or with misplacing objects, often develop in this stage. In this early stage, their functioning at work and in social situations haven't been affected.
In addition, caregivers may start to notice some level of forgetfulness, but symptoms of dementia are still not apparent to medical professionals or loved ones. Caregiving at this stage is about finding a balance between independence and assistance. When in doubt, assume your loved one can accomplish a given task on his or her own, unless there is an immediate risk to safety. At this stage, most people continue to live independently in the community without the need for regular care.
STAGE 3 - Mild Cognitive Decline or Mild Cognitive Impairment (MCI)
In this last of the early dementia stages, the earliest clear-cut deficits become apparent. Objective evidence of memory deficits are obtained with an intensive interview and there is decreased performance in demanding professional and social settings. In this stage, your loved one starts having trouble with two or more of the following symptoms: getting lost in unfamiliar places, finding the right word, retaining little information after reading, difficulty remembering names they've just learned, or losing something valuable. Coworkers may start to notice that they are having memory problems, difficulty with concentration and trouble with complex problem solving. Driving difficulties and verbal repetition also become detectable.
This stage is also known as mild cognitive impairment (MCI) and it is crucial that caregivers recognize the signs of this stage for early diagnosis and intervention. Loved ones may begin to notice signs of cognitive decline as they experience increased forgetfulness, decreased performance at work, speech difficulty, and trouble focusing on everyday tasks. Persons in this stage continue to reside in independent community living, but may require a friend or family member to "check in" or "help out" on occasion.
STAGE 4: EARLY-STAGE DEMENTIA
Stage 4 - Moderate Cognitive Decline or Mild Dementia
Early-stage dementia has only one stage – stage 4, moderate cognitive decline, which is easier for health care providers to recognize during interviewing. People in this stage still look "normal", but will have difficulty concentrating, will forget recent or current events, and will have difficulty managing finances, completing meal preparation and traveling alone to new locations. Additionally, they may experience difficulty socializing and begin withdrawing from friends and family. Persons in this stage also have problems finding the right words in a conversation, losing track of the day or time, increasing feelings of anxiety and irritability, trouble planning or organizing events and developing an unwillingness to try new things. However, even in stage 4 dementia, they typically don't have trouble traveling to familiar places, knowing where they are or what year or season it is, or recognizing people they know well.
In this stage, caregivers should make a concerted effort to actively engage the person with dementia and set simple goals using visual cues and demonstration to help with task completion. Caregivers will play a more significant role in this stage and subsequent stages. Caregivers should create a scheduled day routine and make adjustments to schedules as needed to provide the necessary level of care while also seeking support from other caregivers. Persons in this stage benefit from advanced planning of events to reduce frustration and anxiety and should be encouraged to seek and ask for help when encountering difficulty with problems. Use of external memory cues such as calendars and medication pill boxes can be beneficial to assist with maintaining their maximum independence. This stage may require the consideration of an adult day care or other supervision in order to maintain their safety.
STAGES 5 – 6: MID-STAGE DEMENTIA
STAGE 5 - Moderately Severe Cognitive Decline or Moderate Demetia
In stage 5, signs and symptoms of dementia will be very easy to identify. Short-term memory will be mostly lost ,and confusion and forgetfulness will be more pronounced throughout activities of daily living. These persons have difficulty remembering even familiar information such as addresses, names of family members and are often disoriented to the date, time and year. They typically still know their children and their partner's name and are able to feed and toilet themselves, but struggle with choosing appropriate clothing and/or completing grooming tasks. This can result in persons in this stage looking "unfinished or disheveled" with prompts required to encourage loved ones to change clothes and take showers. Withdrawal from activities continue and they tend to cling to familiar persons and resist change. They become increasingly sensitive to noise with reduced visual perception, frequently experiencing "tunnel vision", and develop reduced communication abilities. Cognitive abilities are significantly impaired and similar to those of an 8 year old, although they perceive themselves to be approximately 20-40 years old.
In this stage, persons can no longer survive independently in the community without some assistance, and require cueing for activities for daily living. Assistance up to 24 hours may be required and environmental adaptations must be modified in order to reduce risk of injury. Caregivers should allow additional time for task completion and be mindful that their loved one may experience delusions, so using clear line of sight and simple communication is essential during interactions. Reasoning in this stage is no longer possible, so avoid correcting then and focus on reassuring them if they become agitated. An Assisted Living Facility (ALF) or Skilled Nursing Facility (SNF) may be required if extensive home care is not available.
STAGE 6 - Severe Cognitive Decline
In stage 6 of dementia, we are entering the last stages of dementia and communication is severely disabled. Delusions, compulsions and anxiety may occur and with increased frequency. Memory problems are so severe that they may even forget their spouse's name at times. They are largely unaware of their surroundings and won't know what week or year it is. Stage 6 also brings increased agitation, wandering and changes with sleep patterns, often confusing day and night. Further behavior changes may occur such as obsessiveness, anxiousness and possibly uncharacteristic violence. They are largely unable to complete activities of daily living (ADLs) without extensive assistance and they often become incontinent.
As these final stages of dementia progress, persons become more and more helpless. Few abilities are left in this stage and caregivers are required to anticipate needs and assist with completion of almost all ADLs. They may still recognize whether someone is familiar or not and recall some details of their lives, but the memories are vague and unreliable. Falls become more frequent with shuffling gait and decreased posture, resulting in increased need for assistance with transferring and walking. Cognitive abilities are similar to those of a 2-5 year old and they may begin to eat with their fingers, disrobe and demonstrate poor attention. Communication is basic with significantly impaired cognitive abilities, and persons in this stage using primarily yes/no and gestures. Caregivers will need to monitor intake to ensure proper nutrition and be mindful of potential swallowing problems as general functions become impaired and weakened. Full time assistance is typically needed at this stage and an ALF or SNF may be necessary.
STAGE 7: LATE-STAGE DEMENTIA
Stage 7 - Very Severe Cognitive Decline or Severe Dementia
This final category of dementia includes only one stage. A person in this stage usually has no ability to speak or communicate and requires assistance with most all activities, including walking. Problems with eating and swallowing become more prevalent and considerable changes in weight often occur (either loss or gain). They experience a gradual loss of speech, although they may experience angry outbursts due to confusion. Communication is typically reduced to a couple of words, and basic functions such as the ability to smile, move or hold their head up are gradually lost. In this latter stage, they also become more vulnerable to infections, particularly pneumonia.
During this stage, caregivers will focus mostly on providing comfort and quality of life. Care options may exceed what you feel you can provide at home since around-the-clock care will be needed. Caregivers will complete all ADLs, and will need to break down tasks using simple communication and an abundant amount of visual cueing and modeling in order to enhance their loved one's comprehension and reduce the risk of resistance. Focusing on safety issues, fall prevention and positioning needs are critical as basic abilities become obsolete. The need for a skilled nursing facility (SNF) or Hospice is typically required as this stage is the precursor to death.
While the exact symptoms displayed in each stage can differ from person to person, this can be used as a guideline, helping families know what to expect and when to expect it. Has your loved one followed a similar path? Share your experiences with us in the comments below or in our forum. If you are seeking assistance with your dementia loved one, we can help. Contact us today!
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