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Alzheimer’s Disease

 

 

 

 

 

 

Although the terms Alzheimer’s and Dementia are often used interchangeably, Alzheimer’s disease and dementia are two different terms.

Dementia is an umbrella term. There are many different forms of dementia e.g. Alzheimer’s disease, vascular dementia, dementia with Lewy bodies, and frontotemporal dementia. 

ALZHEIMER’S DISEASE IS THE MOST COMMON FORM OF DEMENTIA. 

 

Alzheimer’s disease (AD) is a progressive disorder that causes brain cells to degenerate and die. Alzheimer’s disease is the most common cause of dementia and is characterized by a continuous decline in thinking, behavioral and social skills that disrupts a person’s ability to function independently. The early signs of the disease may be forgetting recent events or conversations. As the disease progresses, a person with Alzheimer’s disease will develop severe memory impairment and lose the ability to carry out everyday tasks.

While a number of scales exist, one of the most widely used instruments to stage the course of Alzheimer’s disease is The Global Deterioration Scale for Primary Degenerative Dementia which was developed by Dr Barry Reisberg.
Dr  Reisberg, was the first person to describe many of the most important symptoms of AD and the characteristic clinical course of AD. His staging tools are presently governmentally mandated measures throughout the U.S., and widely used worldwide.

** The Global Deterioration Scale for Primary Degenerative Dementia is also referred to as the GDS and the Reisberg Scale.*


THE REISBERG SCALE

The Reisberg Scale is a 7 stage rating scale in which:
Stage 1 reflects no cognitive decline
Stage 2 reflects very mild cognitive decline 
Stages 3-7 are defined, respectively, as mild, moderate, moderately severe, severe, and very severe cognitive decline.


The chart below is an overview of the 7 stages of the Reisberg Scale 

Stage 1

 

 NO MEMORY DECLINE
No problems with memory
Stage 2 MILD
Memory problems (forgetting keys, wallet etc.)
No impact on social life
Stage 3 MILD
Others begin to notice memory problems
Increased forgetfulness
Denies having a problem
Stage 4 CLEAR-CUT DEFICITS
Orientated to time and place
Difficulty with sequencing/planning
Denial
At home
IADL deficits
Stage 5 MOD-SEVERE DECLINE
Cannot live alone
Requires cues and assistance
Forgets address and phone numbers
Disorientated to time and space
Inability to drive
Stage 6 SEVERE
Irritable
Obsessive/delusional
Incontinent
Incomplete sentences
Stage 7 VERY SEVERE
Cannot sit, stand walk or talk
At risk for falls, infections and diseases




 


The chart below reviews the 7 stages of The Reisberg Scale in detail.

Stage Symptoms Treatment Examples Video
Stage 1

No impairment (normal function)

 The person does not experience any memory problems. Does not show any evidence of symptoms of dementia. No treatment required Normal function
Stage 2

Very mild cognitive decline

May be normal age-related changes or earliest signs of Alzheimer’s disease.

 The person may feel as if he or she is having memory lapses.
-forgets familiar words
-forgets the location of everyday objects.
No symptoms of dementia can be detected during a medical examination or by friends, family or co-workers.		 Cognitive evaluation to determine level of functional impairment.

Recommendations for adaptations to compensate for higher level problem solving and organizational skills.
-use of a planner
-digital calendar with electronic signals for reminders
-online banking with automatic payments and deposits
-large digital clock with date
-GPS in primary vehicle if patient drives.

Evaluation and treatment of physical conditions that may be affecting cognitive status.

 A doctor explains the symptoms of mild to moderate Alzheimer’s disease.
Stage 3

Mild cognitive decline

Early-stage Alzheimer’s can be diagnosed in some, but not all, individuals with these symptoms.

 -Noticeable word finding problems
-Trouble remembering names when introduced to new people
-Having noticeably greater difficulty performing tasks in social or work settings
-Forgetting material that one has just read
-Losing or misplacing a valuable object
-Increasing trouble with planning or organizing
-Family, friends, or co-workers begin to notice problems
-Doctors may detect problems in memory or concentration during a detailed interview		 Adaptations to compensate for memory loss
-may be electronic if patient used electronic devices prior to onset of cognitive decline
-use manual methods if patient did not use electronics
-electronic planner or wall calendar
-labels on cupboard, drawers and closets
-pill organizers
-wall hooks or basket organizers for commonly used items
.
Evaluation of home for safety
-assess walkways and stairs
-remove obstacles
-remove or tape down throw rugs and runners
-insure that smoke detectors are present and operational
-observe patient’s mobility within the home and provide adaptations to compensate for any observed safety concerns
.
Family and caregiver education in functional cognitive decline, what to expect, and how to approach the patient.
 A woman with early stage Alzheimer’s looks at pictures of her old house during a therapy session.
Stage 4

Moderate cognitive decline

Mild or Early-stage Alzheimer’s disease.

 -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-A careful medical interview should clearly detect problems		 Adaptations for cognitive decline-microwavable meals or Meals on Wheels to reduce need for cooking
-colored labels on appliance controls
-simplify wardrobe and organize by color
-written wall charts for steps of common tasks (i.e. hygiene routine, fixing breakfast, etc.)
-pre-programmed phone numbers for family, doctor, etc.
.
Family and caregiver education.
.
Recommendations:
-assistance with finances, appointments, shopping, community mobility.
-structured leisure opportunities to prevent the patient from becoming isolated.
-senior or community center programs
-familiar hobbies		 A social worker discusses the middle stages of Alzheimer’s disease.
Stage 5

Moderately severe cognitive decline

Moderate or Mid-stage Alzheimer’s disease.

 -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		 Adaptations for cognitive decline
-Simple wall calendar and digital clock with date.
-Medical alert bracelet or note in wallet/purse with identification information.
-Group clothing into outfits or assist patient in selecting the next day’s outfit.
-Organize hygiene and grooming items in the bathroom within sight on the counter.
.
Family and caregiver education
.
Recommendations:
-daily supervision and assistance with IADL tasks (cooking, shopping, house cleaning, yard work, community mobility).
-supervise daily administration of medications		 A son records his father who has mid-stage Alzheimer’s during daily household tasks.
Stage 6

Severe cognitive decline

Moderately severe or Mid-stage Alzheimer’s disease.

 -Memory continues to worsen, personality changes may take place-Individuals need extensive help with daily activities.

Individuals with severe cognitive decline 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 a caregiver is an impostor) or compulsive, repetitive behavior like hand-wringing or tissue shredding
-Tend to wander or become lost

 Family and caregiver education regarding cognitive decline.

Recommendations:
-24-hour supervision
-set-up and supervision during basic ADL tasks
-supervision during meals to insure adequate nutritional intake.
-participation in structured leisure activities that focus on long term memory.
-viewing photo albums
-driving to familiar places.
-community programs that focus on dementia care
-adult daycare
-a personal alarm for safety to prevent wandering or falls.

 A son interviews his father, who has stage 6 Alzheimer’s disease, about his personal history.
Stage 7

Very severe cognitive decline

Severe or Late-stage Alzheimer’s disease.

 -Individuals lose the ability to respond to their environment, to carry on a conversation and, eventually, to control movement.
-May still say words or phrases
-Individuals need help with much of their daily personal care, including eating or using the toilet -May also lose the ability to smile
-May lose the ability to sit without support and to hold head up.
-Reflexes become abnormal and muscles grow rigid.
-Swallowing may become impaired.		 Family and caregiver education
-Facilitate active participation of patient in simple tasks as able, such as self-feeding or grooming tasks
.
Recommendations:
-24-hour total care
-may recommend long term care placement if family or caregiver has difficulty caring for patient
-Assessment of positioning in bed and chair
-provide adaptations for postural support and preservation of skin integrity.-Passive range of motion or splinting to reduce or prevent contractures. 		A daughter talks with her mother who has late stage Alzheimer’s disease.

 

THE LINK BETWEEN THE REISBERG SCALE AND THE BASIC 3 STAGE MODEL

 

Overview of the 3 STAGE MODEL (applies to all types of dementia)

Stage 1 – Early/Mild dementia
Often this phase is only apparent in hindsight. At the time it may be missed, or put down to old age or overwork. The onset of dementia is usually very gradual and it is often impossible to identify the exact time it began.

Stage 2 – Middle/Moderate dementia
At this stage the problems are more apparent and disabling.

Stage 3 –  Late/Advanced/Severe/End-stage dementia
At this third and final stage, the person is severely disabled and needs total care.

 

Below is a chart illustrating how the 3 Stage Model and the 7 Stage Model correlate.

REISBERG SCALE

This scale is more comprehensive in description and has 7 stages
3 STAGE MODEL

This scale is very basic and has 3 general stages
Stage 1:
No Impairment		 No Dementia
Stage 2:
Very Mild Decline		 No Dementia
Stage 3:
Mild Decline		 No Dementia
Stage 4:
Moderate Decline		 Early-Stage Dementia
Stage 5:
Moderately Severe Decline		 Middle-Stage Dementia
Stage 6:
Severe Decline		 Middle-Stage Dementia
Stage 7:
Very Severe Decline		 Late-Stage Dementia

In the first three stages of the seven-stage model, an individual is not considered to have dementia, as the symptoms are commonly associated with typical aging and are not typically noticeable by healthcare providers or family members.

At stage four a person is considered to have early-stage dementia.

Stage five marks the beginning of middle-stage dementia, which continues through stage six.

Stage seven is the end-stage of dementia (and life).

 

Dr Natali Edmonds, a board certified geropsychologist who specializes in dementia, explains the 3 stage and 7 stage models of dementia.

 

Resources:
https://www.alzinfo.org/understand-alzheimers/clinical-stages-of-alzheimers/
https://link.springer.com/referenceworkentry/10.1007%2F978-94-007-0753-5_1173
https://www.alzinfo.org/about/bios/dr-barry-reisberg/

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