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Clinical Stages of Alzheimer's Disease
Stage 5: Moderate Alzheimer's disease
At this stage, deficits are of sufficient magnitude as to prevent independent, catastrophe-free, community survival. Patients can no longer manage on their own in the community. If they are ostensibly alone in the community then there is generally someone who is assisting in providing adequate and proper food, as well as assuring that the rent and utilities are paid and the patient's finances are taken care of. For those who are not properly watched and/orsupervised, predatory strangers may become a problem. Very common reactions for persons at this stage who are not given adequate support are behavioral problems such as anger and suspiciousness.
Cognitively, persons at this stage frequently cannot recall such major events and aspects of their current lives as the name of the current president, the weather conditions of the day, or their correct current address. Characteristically, some of these important aspects of current life are recalled, but not others. Also, the information is loosely held, so, for example, the patient may recall their correct address on certain occasions, but not others.
Remote memory also suffers to the extent that persons may not recall the names of some of the schools which they attended for many years, and from which they graduated. Orientation may be compromised to the extent that the correct year may not be recalled. Calculation deficits are of such magnitude that an educated person has difficulty counting backward from 20 by 2s.
Functionally, persons at this stage have incipient difficulties with basic activities of daily life. The characteristic deficit of this type is decreased ability to independently choose proper clothing (Figure 5). This stage lasts an average of approximately 1.5 years.
Figure 5 Stage 5: Moderate Alzheimer's disease.
In this stage, deficits are of sufficient magnitude as to prevent catastrophe-free, independent community survival. The characteristic functional change in this stage is incipient deficits in basic activities of daily life. This is manifest in a decrement in the ability to choose proper clothing to wear for the weather conditions and/or for the daily circumstances (occasions). Some patients begin to wear the same clothing day after day unless reminded to change. The spouse or other caregiver begins to counsel regarding the choice of clothing. The mean duration of this stage is 1.5 years.
Stage 6: Moderately severe Alzheimer's disease
At this stage, the ability to perform basic activities of daily life becomes compromised. Functionally, five successive substages are identifiable. Initially, in stage 6a, patients, in addition to having lost the ability to choose their clothing without assistance, begin to require assistance in putting on their clothing properly. Unless supervised, patients may put their clothing on backward, they may have difficulty putting their arm in the correct sleeve, or they may dress themselves in the wrong sequence.
Figure 6 Stage 6a: Moderately severe Alzheimer's disease.
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In the stage of moderately severe Alzheimer's disease, the cognitive deficits are of sufficient magnitude as to interfere with the ability to carry out basic activities of daily life. Generally, the earliest such deficit noted in this stage is decreased ability to put on clothing correctly without assistance. The total duration of the stage of moderately severe AD (stage 6a through 6e) is approximately 2.5 years.
For example, patients may put their street clothes on over their night clothes (Figure 6). At approximately the same point in the evolution of AD, but generally just a little later in the temporal sequence, patients lose the ability to bathe independently without assistance (stage 6b). Characteristically, the earliest and most common deficit in bathing is difficulty adjusting the temperature of the bath water (Figure 7). Initially, once the spouse adjusts the temperature of the bath water, the patient can still potentially otherwise bathe independently. Subsequently, as this stage evolves, additional deficits in bathing independently as well as in dressing independently
Figure 7 Stage 6b: Moderately severe Alzheimer's disease.
Requires assistance adjusting the temperature of the bath water. At approximately the same time as Alzheimer's patients begin to lose the ability to put on their clothing properly without assistance, but generally just a little bit later in the disease course, patients begin to require assistance in handling the mechanics of bathing. Difficulty adjusting the temperature of the bath water is the classical earliest deficit in bathing capacity in Alzheimer's disease.
occur. In this 6b substage, patients generally develop deficits in other modalities of daily hygiene such as properly brushing their teeth independently. With the further evolution of AD, patients lose the ability to manage independently the mechanics of toileting correctly (stage 6c). Unless supervised, patients may place the toilet tissue in the wrong place (Figure 8). Many patients will forget to flush the toilet properly. As the disease evolves in this stage, patients subsequently become incontinent. Generally, urinary incontinence occurs first (stage 6d), then fecal incontinence occurs (stage 6e). The incontinence can be treated, or even initially prevented entirely in many cases, by frequent toileting (Figure 9). Subsequently, strategies for managing incontinence, including appropriate bedding, absorbent undergarments, etc., become necessary.
In this sixth stage cognitive deficits are generally so severe that persons will display little or no knowledge when queried regarding such major aspects of their current life circumstances as their current address or the weather conditions of the day.
Figure 8 Stage 6c: Moderately severe Alzheimer's disease.
Requires assistance with cleanliness in toileting. After Alzheimer's patients lose the ability to dress and bathe without assistance, they lose the ability to independently maintain cleanliness in toileting.
Figure 9-Stage 6d and 6e: Moderately severe Alzheimer's disease.
Requires assistance to maintain continence. After Alzheimer's patients lose the ability to dress, bathe and toilet without assistance, they develop incontinence. Generally, urinary incontinence precedes fecal incontinence. Strategies to prevent episodes of incontinence include taking the patient to the restroom and supervision of toileting.
Recall of current events is generally deficient to the extent that the patient cannot name the current national head of state or other, similarly prominent newsworthy figures. Persons at this sixth stage will most often not be able to recall the names of any of the schools which they attended. They may, or may
Figure 10 Stage 6: Moderately severe Alzheimer's disease.
In this stage the patient's cognitive deficits are generally of such magnitude that the patient may at times confuse their wife with their mother or otherwise misidentify or be uncertain of the identity of close family members. At the end of this stage, speech ability overtly breaks down.
not, recall such basic life events as the names of their parents, their former occupation and the country in which they were born. They still have some knowledge of their own names; however, patients in this stage begin to confuse their spouse with their deceased parent and otherwise mistake the identity of persons, even close family members, in their own environment (Figure 10). Calculation ability is frequently so severely compromised at this stage that even well-educated patients had difficulty counting backward consecutively from 10 by 1s.
Emotional changes generally become most overt and disturbing in this sixth stage of AD. Although these emotional changes may, in part, have a neurochemical basis, they are also clearly related to the patient's psychological reaction to their circumstances. For example, because of their cognitive deficits, patients can no longer channel their energies into productive activities. Consequently, unless appropriate direction is provided, patients begin to fidget, to pace, to move objects around and place items where they may not belong, or to manifest other forms of purposeless or inappropriate activities. Because of the patient's fear, frustration and shame regarding their circumstances, as well as other factors, patients frequently develop verbal outbursts, and threatening, or even violent, behavior may occur. Because patients can no longer survive independently, they commonly develop a fear of being left alone. Treatment of these and other behavioral and psychological symptoms which occur at this stage, as well as at other stages of AD, involves counseling regarding appropriate activities and the psychological impact of the illness upon the patient, as well as pharmacological interventions.
The mean duration of this sixth stage of AD is approximately 2.3 years. As this stage comes to an end, the patient, who is doubly incontinent and needs assistance with dressing and bathing, begins to manifest overt breakdown in the ability to articulate speech. Stuttering (verbigeration), neologisms, and/or an increased paucity of speech, become manifest.
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