The Stages of Alzheimer's Disease

The Stages of Dementia – What to Expect.

When a person we love starts to have memory problems or difficulty figuring out simple problems, it’s time to arrange for an evaluation to find out if dementia is a problem. Most people are not diagnosed however, until their symptoms become obvious to the physician.

This can be a problem since many people with Alzheimer’s Disease are good at covering up their deficits.  For instance, if a physician asks: “Can you tell me what you had for breakfast?” -- the reply may be “juice, eggs and coffee” even though the person forgot that pancakes were on the breakfast menu.

In other words, people who don’t remember, often make it up and sound so convincing that the physician finds nothing wrong. This is called confabulation, and is a defense mechanism to avoid embarrassment.  Unless a family understands this and sits in on the physician’s evaluation, the cover-up will go unnoticed. It helps to understand the stages of Alzheimer’s Disease to understand this.

Stage 1

There is no noticeable impairment.

Stage 2

At this point families notice that something is wrong, but physicians usually do not, despite the fact that the person being examined is having memory lapses and is usually aware of this.  More than half of people over 65 experience some problems with cognitive or even functional difficulties.  Frequent complaints of misplacing things, word finding and concentration problems are common and may be thought to be the result of aging.  Often the physician will opt to “wait and see” if the symptoms get worse or remain stable since they do not seem to be a major problem.

Stage 3

In addition to changes associated with normal aging, the person with Alzheimer’s or other dementias may begin to repeat questions and experience difficulties with complex tasks. Those who are still employed will have noticeable difficulties with job performance. Concentration ability will decline and the person with dementia often develops anxiety at this point.  Some people will never progress beyond this point. The rest, however, will experience a significant decline. Stage 3 can last as long as seven years.

Stage 4

Moderate cognitive decline - Mild or early-stage Alzheimer's disease.

At this point, a careful medical interview should be able to detect clear-cut symptoms in several areas:

• Forgetfulness of recent events
• Impaired ability to perform challenging mental arithmetic — for example, counting backward from 100 by 7s
• Greater difficulty performing complex tasks, such as planning dinner for guests, paying bills or managing finances
• Forgetfulness about one's own personal history
• Becoming moody or withdrawn, especially in socially or mentally challenging situations

Stage 5

Moderately severe cognitive decline - Moderate or mid-stage Alzheimer's disease.

Gaps in memory and thinking are noticeable, and individuals begin to need help with day-to-day activities. At this stage, those with Alzheimer's may:   

• Be unable to recall their own address or telephone number or the high school or college from which they graduated
• Become confused about where they are or what day it is
• Have trouble with less challenging mental arithmetic; such as counting backward from 40 by subtracting 4s or from 20 by 2s
• Need help choosing proper clothing for the season or the occasion
• Still remember significant details about themselves and their family
• Still require no assistance with eating or using the toilet

Stage 6

Severe cognitive decline - Moderately severe or mid-stage Alzheimer's disease.

Memory continues to worsen, personality changes may take place and individuals need extensive help with daily activities. At this stage, individuals may:

• Lose awareness of recent experiences as well as of their surroundings
• Remember their own name but have difficulty with their personal history
• Distinguish familiar and unfamiliar faces but have trouble remembering the name of a spouse or caregiver
• Need help dressing properly and may, without supervision, make mistakes such as putting pajamas over daytime clothes or shoes on the wrong feet
• Experience major changes in sleep patterns — sleeping during the day and becoming restless at night
• Need help handling details of toileting (for example, flushing the toilet, wiping or disposing of tissue properly)
• Have increasingly frequent trouble controlling their bladder or bowels
• Experience major personality and behavioral changes, including suspiciousness and delusions (such as believing that their caregiver is an impostor)or compulsive, repetitive behavior like hand-wringing or tissue shredding
• Tend to wander or become lost

Stage 7

Very severe cognitive decline - Severe or late-stage Alzheimer's disease.

In the final stage of this disease, individuals lose the ability to respond to their environment, to carry on a conversation and, eventually, to control movement. They may still say words or phrases.

At this point, individuals need help with much of their daily personal care, including eating or using the toilet. They may also lose the ability to smile, to sit without support and to hold their heads up. Reflexes become abnormal. Muscles grow rigid. Swallowing is impaired. Eventually the body starts to shut down and the individual is no longer able to absorb, metabolize or excrete nutrients. Barring concurrent illness, refusal of food and water is an indication that the disease has progressed to the end stage.

Throughout the course of this devastating disease, caregivers, both family and professional, try hard to provide good care and improve the quality of life of the person with dementia.

Stephanie Zeman RN MSN
Kisses for Elizabeth