Sunday, December 13, 2009

7 Stages of Dementia

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) _____________________________

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.


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. __________________

The alzheimers association now has a plain English version of the seven stages, available at

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.,%2011-12.htm __________________

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. -----------------------------------------

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.


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