Stages of Alzheimer’s and Dementia explained by The American Association of College of Nursing

What are the 7 stages of Alzheimer’s Disease?

The more we learn about Alzheimer’s disease and other forms of dementia we release that no two people with the disease will have the same trajectory. This means that every person with the disease experiences the course of their illness differently from initial symptoms to the often long drawn-out deterioration at the end.

The purpose of this blog is to provide family carers and health professionals with a better understanding of the different stages of dementia and an outline of the course of the disease progression. There are two main models that professionals use to provide an arbitrary staging. One is a simple three-phase model (early, moderate and end), while others prefer a more detailed and structured staging criteria to loosely understand a patient’s trajectory overtime.

The most common system used is by Dr. Barry Reisberg the Clinical Director of New York University’s Ageing and Dementia Research Centre where he outlined the seven major clinical stages of Alzheimer’s disease. Dr. Reisberg developed the “Global Deterioration Scale” another tool frequently used in many diagnoses and care settings as the preferred rating scale of the trajectory of the disease.

Let us talk through the different stages based on the ideas of Dr Reisberg for you to better understand.

Stage 1 – No Cognitive Decline

During stage 1, persons are usually free from objective or subjective symptoms of cognitive or functional decline. This means any cognitive testing such as a mini mental state examination (MMSE) would be normal or no reports about memory concerns, behavioural problems or mood changes from family or friends.

This is referred to as mentally healthy persons at any age.

Worried about your memory? Is it age related forgetfulness or dementia? (Read our Dementia Care Help Sheet for more information)

Stage 2 – Normal Aged forgetfulness

A common complaint from people over the age of 65 is about their memory or changes in physical ability. At this stage the nature of these complaints are subjective, and not objective, reporting things like not being able to recall names as well as they use to, or where they have placed their keys.

The most suitable term for this stage of memory changes is normal aged forgetfulness. There is some evidence to suggest that persons with these symptoms may overtime decline faster than in comparison to other older similarly healthy persons who have not complained of forgetful symptoms.

Stage 3 – Mild Cognitive Impairment (MCI)

At this stage symptoms are often subtle and only really noticed by friends and family. The person may begin to notice cognitive problems themselves, and symptoms may manifest in a number of ways, such as repeating stories or questions. The ability to complete executive functions especially if they are still working will become more difficult and become more evident.

Physicians will be able to detect impaired cognition through memory and performance testing.

At Stage 3 persons will display the following difficulties:

  • Finding the word they want to use during conversation
  • Remembering the names of new acquaintances
  • Planning and organising
  • They may also frequently lose personal possessions, including valuables.
  • The symptoms of anxiety may begin to be more obvious during this stage also.

Stage 4 – Mild or early stages of Alzheimer’s

Once the persons is at stage 4 a diagnosis of dementia can be made with considerable accuracy. The most common symptom is decline in functional ability to manage instrumental (complex) activities of daily life. For example the person’s ability to manage finances or paying bills, to complete previously simple tasks such as preparing a meal for guests, problems with writing and or calculating figures or writing on a cheque and problems with visiting the grocers without assistance.

A person’s mood at this stage can change also to what is referred to as flattening affect or withdrawal. In simple terms the person is less emotionally responsive than previously. Which is thought to be closely related to the person’s denial of their deficit, which is also obvious at this stage.

The mean duration of this stage is 2 years.

Stage 5 – Moderate stages of Alzheimer’s

At this stage the deficits are significant enough to prevent the person from remaining safely in their own home or at least without significant support. This means at this stage persons will need assistance to ensure they are eating adequate food, attending to their own hygiene, maintenance upkeep of the house and paying day-to-day bills.

Persons at this stage will show major gaps in memory, for example may frequently find it difficult recalling major events, current location or address, certain aspects of their current life and identity.

Stage 6 – Moderately severe or mid-stage Alzheimer’s

At this stage this person with the disease needs constant supervision and frequently professional care and support, where symptoms include:

  • Ongoing memory loss, occasionally forgetting the name of a spouse or primary caregiver.
  • Inability to remember recent events or experiences in their lives or remember faces except close family and friends.
  • The ability to perform daily activities becomes further compromised, inability to choose own clothing without assistance and starting to require assistance with putting clothing on.
  • Personality and emotional changes such as anxiety, anger, confusion, sadness/depression, delusions, suspicious thoughts and agitation.
  • Repetition of simple activities.
  • Disruption to normal sleep/waking cycle more prevalent. Increasing episodes of urinary and faecal incontinence.

Stage 7 – Severe or late stages Alzheimer’s

Alzheimer’s disease is a terminal illness, person’s in stage 7 are in their final stages of life and nearing death. The ability for them to respond to their environment or communicate their needs will diminish and may only be able to utter words and phrases. Due to limited insight into their condition, they will require assistance with activities of daily living and unable to walk unassisted. Problems swallowing or impairment of sucking reflex also known as ‘infantile’ reflexes or ‘development’ reflexes are evident at this stage.

Cognitively persons are severely impaired, vocabulary is limited and communication abilities eventually disappear. The ability to walk independently or transfer from one area to another without support is no longer possible. Urinary and faecal incontinence is evident and person’s are unable to manage this task without physical assistance. Also requiring assistance with eating and drinking.

The most common cause of death at this stage is pneumonia. Due to impaired swallowing, persons are prone to aspiration, which means food is inhaled in the lungs, which then can develop into terminal pneumonia.
Other common causes of death for people with Alzheimer’s disease are stroke, heart disease and cancer. With an other percentage dying from Alzheimer’s disease itself.

Please note this is only a guide and patients can move from one stage to another quicker than others depending on co-morbidities or other medical illnesses

We hope this provides family carers, health professionals and anyone supporting people with Alzheimer’s Disease with a greater understanding on the different stages of the disease. Please share your experience of using this tool to provide some guidance to you in your role

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