Health professionals often discuss dementia in “stages”. This is referencing the progression of a person’s dementia or Alzheimer’s disease. Having guidelines that define the stages helps physicians determine the best treatments by aiding the communication between doctors and caregivers. Dementia is usually considered as having three stages: mild (or “early”), moderate (or “middle”), and severe (or “late”). A more specific stage of dementia is commonly assigned based on symptoms.
It can also be helpful to know how symptoms change over stages. Alzheimer’s and similar diseases can cause dramatic swings in mood and behavior, and the activities a person is physically able to do. They will change as dementia progresses causing stress for friends and relatives. Knowing what’s coming can help prepare for your loved one’s social, medical, and personal needs.
This article discusses the stages based on various established scales, including symptoms particular to each stage. There is also advice on caring for someone based on their stage of dementia, including technology that can help and which types of assisted living homes are most appropriate.
–Which Stage? If you aren’t sure which stage of dementia you or your loved one are in right now, take an online Alzheimer’s test. This can help pinpoint an individual’s symptoms and stage.
Rather than simply using “early-stage,” “middle-stage,” and “late-stage” dementia as descriptors, there are scales that provide a more comprehensive description. These scales help better understand the different stages of Alzheimer’s disease based on how well a person thinks (their cognitive decline) and functions (their physical abilities). These are the Global Deterioration Scale for Assessment of Primary Degenerative Dementia, the Functional Assessment Staging Test, and the Clinical Dementia Rating.
The most commonly used scale is often referred to simply as GDS, or by its more formal name, the Reisberg Scale (or by the lengthy name “Global Deterioration Scale for Assessment of Primary Degenerative Dementia”). The GDS divides into seven stages based on the amount of cognitive decline. This test is most relevant for people who have Alzheimer’s disease because some other types of dementia (like Frontotemporal dementia) do not always include memory loss.
Someone in stages 1-3 do not typically exhibit enough symptoms for a dementia diagnosis. By the time a diagnosis has been made, a dementia patient is typically in stage 4 or beyond. Stage 4 is considered “early dementia,” stages 5 and 6 are considered “middle dementia,” and stage 7 is considered “late dementia.”
|Global Deterioration Scale (CGS) / Reisberg Scale
|Signs and Symptoms
|Expected Duration of Stage
No Cognitive Decline
|– Normal function
– No memory loss
– People with NO dementia are considered in Stage 1
Very Mild Cognitive Decline
|– Forgets names
– Misplaces familiar objects
– Symptoms not evident to loved ones or doctors
Mild Cognitive Decline
|– Increased forgetfulness
– Slight difficulty concentrating
– Decreased work performance
– Gets lost more frequently
– Difficulty finding right words
– Loved ones begin to notice
|The average duration of this stage is between 2 years and 7 years.
Moderate Cognitive Decline
|– Difficulty concentrating
– Forgets recent events
– Cannot manage finances
– Cannot travel alone to new places
– Difficulty completing tasks
– In denial about symptoms
– Socialization problems: Withdraw from friends or family
– Physician can detect cognitive problems
|The average duration of this stage is 2 years.
Moderately Severe Cognitive Decline
|– Major memory deficiencies
– Need assistance with ADLs (dressing, bathing, etc.)
– Forgets details like address or phone number
– Doesn’t know time or date
– Doesn’t know where they are
|The average duration of this stage is 1.5 years.
Severe Cognitive Decline (Middle Dementia)
|– Cannot carry out ADLs without help
– Forgets names of family members
– Forgets recent events
– Forgets major events in past
– Difficulty counting down from 10
– Incontinence (loss of bladder control)
– Difficulty speaking
– Personality and emotional changes
|The average duration of this stage is 2.5 years.
Very Severe Cognitive Decline (Late Dementia)
|– Cannot speak or communicate
– Require help with most activities
– Loss of motor skills
– Cannot walk
|The average duration of this stage is 1.5 to 2.5 years.
The Functional Assessment Staging Test (FAST) is another scale that describes the stages of dementia. Like the GDS Scale, FAST is a seven-stage system based more on one’s level of functioning and ability to perform activities of daily living (ADLs) than cognitive decline. A person may be at a different stage cognitively (GDS stage) than functionally (FAST stage).
|Functional Assessment Staging Test (FAST)
|Level of Functional Decline
|Expected Duration of Stage
|No functional decline.
|Normal older adult
|Personal awareness of some functional decline.
|Early Alzheimer’s disease
|Noticeable deficits in demanding job situations.
|The average duration of this stage is 7 years.
|Requires assistance in complicated tasks such as handling finances, traveling, planning parties, etc.
|The average duration of this stage is 2 years.
|Requires assistance in choosing proper clothing.
|The average duration of this stage is 1.5 years.
|Moderately severe Alzheimer’s
|Requires assistance with dressing, bathing, and toileting. Experiences urinary and fecal incontinence.
|The average duration of this stage is 3.5 months to 9.5 months.
|Speech ability declines to about a half-dozen intelligible words. Progressive loss of ability to walk, to sit up, to smile, and to hold head up.
|The average duration of this stage is 1 year to 1.5 years.
The Clinical Dementia Rating (CDR) scale uses a five-point system based on cognitive (thinking) abilities and how well a person functions. This scale is widely used in dementia research, not as a tool for communication between medical professionals, patients, and their families.
Someone with suspected dementia is evaluated in six areas: Memory, orientation, judgment and problem-solving, community affairs, home and hobbies, and personal care. Based on interviews with the subject and others, including family members, one of five possible stages is assigned.
|Clinical Dementia Rating (CDR) Scale
|Expected Duration of Stage
|Very Mild Dementia – Memory problems are slight, but consistent.
– Some difficulty with time and problem-solving
– Daily life is slightly impaired
– Individuals can perform personal care activities
|The average duration is anywhere from a few years up to 7 years.
|Mild Dementia – Memory loss is moderate, especially for recent events, and interferes with daily activities.
– Moderate difficulty with solving problems
– Cannot function independently at community affairs outside the home
– Difficulty with daily activities and hobbies, especially complex ones
|The average duration is 2 years.
|Moderate Dementia – More profound memory loss, generally retaining highly learned material.
– Disorientation with respect to time and place
– Impaired judgment, especially having difficulty handling problems
– Little to no independent function at home
– Can only do simple chores
– Fewer interests
|The average duration is between 2 and 4 years.
|Severe Dementia – Severe memory loss.
– Disorientation with respect to time or place
– No judgment or problem solving abilities
– Cannot participate in community affairs outside the home
– Requires help with all tasks of daily living
– Requires help with most personal care
– Frequent incontinence
|The average duration is 1 to 2.5 years.
No two people with dementia experience the disease exactly the same way. That means the rate of decline varies by the individual and the type of dementia. In addition, it is not uncommon for individuals to have mixed dementia, meaning they have more than one type. That said, there is a natural course of the disease, and over time the capabilities of all persons with dementia will worsen. Eventually, the ability to function goes away. Keep in mind that changes in the brain from dementia begin years before diagnosis when there are no outward symptoms. This makes it difficult to know how much time a person has left, though there are ways (like an Alzheimer’s Life Expectancy Calculator that is under development) to come close to knowing life expectancy.
|Life Expectancy by Dementia Type
|10 years following diagnosis
|5 years following diagnosis
|Dementia with Lewy Bodies
|2 to 8 years following pronounced symptoms
In this early stage of dementia, an individual can function rather independently, and often is still able to drive and maintain a social life. Symptoms may be attributed to the normal process of aging. They might be:
– Slight lapses in memory, such as misplacing eyeglasses or having difficulty finding the right word.
– Planning, organizing, concentrating on tasks, or accomplishing tasks at work.
The early stage of dementia normally lasts between 2 and 4 years.
In the middle stage of dementia, often the longest stage of the disease, brain damage causes a person to have difficulty expressing thoughts and performing daily tasks. Memory issues are more severe than in the earlier stage. Someone in this stage might forget their address, be unable to recall personal history, and become easily confused about where they are. Communication becomes harder. The individual may lose track of thoughts, may be unable to follow conversations, and may have trouble understanding what others are saying. Mood and behavior change and the following symptoms can appear:
– Repeating actions or words
This moderate stage of dementia, on average, lasts between 2 and 10 years.
In late-stage dementia, also known as advanced dementia, individuals have significant issues with communication. Patients may:
– Not verbally communicate
– Have their memory worsen. Your loved one might forget family members’ names or go back to a different time period altogether and revert to their childhood days.
– Have difficulty walking
At the end of this stage, the individual will most likely be bedridden. This severe stage of dementia lasts approximately 1 to 3 years.
An individual may not require care assistance after the initial diagnosis of dementia, but that will change as the disease progresses and symptoms worsen. There are about 16 million unpaid caregivers of people with dementia in the United States. While many caregivers are providing daily help for family members, they also hire someone to help. There are many options for care assistance, such as in-home care, adult day care, and nursing home care. Financial assistance is available.
Early Stage Dementia
In the early stage of dementia a person can function rather independently and requires little care assistance. Simple reminders of appointments and names of people may be needed. Caregivers can also assist with coping strategies to help loved ones remain as independent as possible. That can be doing things like writing out a daily to-do list and a schedule for taking medications. Safety should always be considered. If any tasks cannot be performed safely alone, supervision and assistance should be provided. During this period of dementia, it’s a good idea for caregivers and loved ones to discuss the future. For example, a long-term care plan should be made and financial and legal matters put in place.
Middle Stage Dementia
In the middle stage of dementia, patients start losing their independence. Assistance with activities of daily living, such as bathing, grooming, and dressing is normally required. Initially, an individual may only need prompts or cues to perform these tasks, such as reminders to shower or having clothes laid out on the bed. However, at some point more hands-on assistance will be required. Establishing a routine becomes important, and caregivers need to exercise patience. Since individuals in this stage of dementia have greater difficulty communicating, caregivers need to talk slowly, clearly and use non-verbal communication. Individuals will no longer be able to drive, so transportation will be required. It is also in this stage of dementia when supervision is necessary because it becomes unsafe to leave your loved one alone.
Late Stage Dementia
A person in this last stage of dementia requires a significant amount of care. Assistance and supervision are required 24 hours per day. Dementia patients may require assistance getting in and out of bed, moving from the bed to a chair, or are bedridden and require help changing positions to avoid bedsores. Swallowing becomes an issue in late-stage dementia, and caregivers have to make sure food is cut into small pieces, is soft (like yogurt and applesauce), or is pureed. At some point, the individual will be 100% dependent on their caregiver and will no longer be able to complete any daily living activities alone. Not all families are equipped to offer this level of care. There are other options for care, such as hiring a part-time caregiver or moving your loved one to a nursing home.
Eventually, caregiving for someone with dementia gets to a point where the amount of support one can give will not be appropriate anymore. The needs of a person with progressive dementia (like Alzheimer’s disease) become overwhelming, and moving into a full-time residence with trained staff becomes necessary. You should plan for this well before it becomes necessary. That is done by visiting communities and asking lots of questions.
Depending on your loved one’s stage of illness, different living options are available:
Assisted Living in Early Stages
Assisted living residences are a combination of room and board with medical and personal care. These are often great options for someone in the early stages of Alzheimer’s disease or related dementia. Full-time supervision means residents are safe. Housing is provided through living units like private studios or apartments so someone with mild dementia can still feel a sense of independence.
Services offered in assisted living include meals, help with activities of daily living (ADLs), social activities, and transportation to and from doctor’s appointments. Before moving in, the residence will assess your loved one to make sure it’s a good fit.
Memory Care in Middle to Late Stages
Some assisted living residences offer memory care, also called “Special Care Units” or “Alzheimer’s Care Units.” Memory care is better for someone in the middle stages of dementia when independence has become more difficult and nearly impossible. Memory care can be a wing or special section of assisted living, or there are stand-alone memory care homes. These are more appropriate for people past the earliest stages because the staff is trained specifically to communicate with and care for people with dementia. Speaking with someone who has dementia requires careful technique. Similarly, activities for people with dementia are more considerate of the participants’ ability (or inability) to function and understand.
Memory care residences have physical designs that are appropriate for people with dementia. Someone with Alzheimer’s may become upset when encountering a wall, so memory care buildings have circular hallways. Because people with dementia are prone to wandering, memory care residences have increased security and supervision with special locks on doors.
Nursing homes are appropriate for someone with dementia if there are other medical needs. They are best able to support patients who need full-time nursing care, medical devices like tubes to breathe or eat, or cannot walk. The ability to evacuate without assistance in an emergency is a required regulations in several states.
Nursing homes are not ideal for someone with advanced dementia unless there are other medical considerations. These residences are staffed with trained nurses whose expertise is administering healthcare. In comparison, training for staff in assisted living with memory care is specifically tailored to deal with issues related to dementia. They focus on how to communicate when a resident is feeling depressed or withdrawn, and how to encourage socialization. For this reason, memory care is usually the best option.
Numerous tools and technological aids can make living with dementia easier for people at any stage.
Tech for Early-Stage Dementia
– Pillboxes to manage medications don’t have to be complex in the early stages but is a good idea to know that your loved one is taking the right medicine at the right time.
– Automatic stove/oven turn-offs will help when your loved one leaves the stove on. This seems like an absent-minded mistake at first, but it will be more common that a task is started and not finished. With turn-offs, your loved one is safer making simple mistakes.
– Use appliance monitors to let concerned friends or family track whether a person with dementia has turned off the oven, coffee maker, or any other electronic device. Monitors are cheap (around $30 typically) and easy to use, plugging the device into an outlet and then sending a signal to your smartphone if it’s on for too long. You can even turn off appliances remotely.
– Object locators or key finders help with the inevitable forgetfulness that many people in early stages experience. A small beeper attaches to the frequently lost item, like the TV remote or eyeglasses, and chirps a signal whenever you press a button on the locator. These often cost around $20.
Tech for Middle-Stage Dementia
– Medication dispensers become more complex the deeper into dementia you get. For someone who is out of the middle stages, it’s a good idea to invest in a high-tech dispenser that sounds an alarm and provides the correct dosage when it’s time to take certain medicines. These can cost from $60 to hundreds of dollars.
– Stove knob covers prevent someone from using the stove. A person with slightly more advanced dementia may be in danger of causing an accident like a fire if they’re allowed to cook. You can also remove the knobs.
– Clocks for people with dementia have special features that specifically address issues like disorientation, where a person becomes confused about the time of day. Dementia clocks have large, bright numbers and say “Morning” or “Afternoon.” Staying aware of the time of day can help someone maintain bodily (circadian) rhythms and sleep better. These cost about $40 and up.
– Medical alerts, also known as Personal Emergency Response Systems (PERS), are worn clipped to clothing or on a lanyard and have a button that easily calls for medical help. These are useful for someone at risk of falling, or who might wander and become lost. Alerts often have GPS tracking. Costs vary, and some medical alerts include subscriptions to security services.
– Talking photo albums can help someone who is losing track of people and names in their family. Pictures in the albums are set next to buttons that play pre-recorded messages explaining who or what is in the image.