Alzheimer’s symptoms vary. The stages below provide a general idea of how abilities change during the course of the disease.
Stage 1: No impairment
Stage 2: Very mild decline
Stage 3: Mild decline
Stage 4: Moderate decline
Stage 5: Moderately severe decline
Stage 6: Severe decline
Stage 7: Very severe decline
Not everyone will experience the same symptoms or progress at the same rate. This seven-stage framework is based on a system developed by Barry Reisberg, M.D., clinical director of the New York University School of Medicine’s Silberstein Aging and Dementia Research Center.
|Stage 1:||No impairment (normal function)
The person does not experience any memory problems. An interview with a medical professional does not show any evidence of symptoms of dementia.
|Learn more: Risk Factors Identifying Mild Cognitive Impairment
(approx 21 min.)
Mild cognitive decline (early-stage Alzheimer’s can be diagnosed in some, but not all, individuals with these symptoms)
Friends, family or co-workers begin to notice difficulties. During a detailed medical interview, doctors may be able to detect problems in memory or concentration. Common stage 3 difficulties include:
- Noticeable problems coming up with the right word or name
- 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
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- Becoming moody or withdrawn, especially in socially or mentally challenging situations
Help is available
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|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
It is difficult to place a person with Alzheimer’s in a specific stage as stages may overlap.
- 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
Learn more: Late-Stage Care
|Vascular dementia is a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving brain cells of vital oxygen and nutrients.|
About vascular dementia
Inadequate blood flow can damage and eventually kill cells anywhere in the body. The brain has one of the body’s richest networks of blood vessels and is especially vulnerable.
In vascular dementia, changes in thinking skills sometimes occur suddenly following strokes that block major brain blood vessels. Thinking problems also may begin as mild changes that worsen gradually as a result of multiple minor strokes or other conditions that affect smaller blood vessels, leading to cumulative damage. A growing number of experts prefer the term “vascular cognitive impairment (VCI)” to “vascular dementia” because they feel it better expresses the concept that vascular thinking changes can range from mild to severe.
Vascular brain changes often coexist with changes linked to other types of dementia, including Alzheimer’s disease and dementia with Lewy bodies. Several studies have found that vascular changes and other brain abnormalities may interact in ways that increase the likelihood of dementia diagnosis. Sign up for our enews to receive updates about Alzheimer’s and dementia care and research.
Vascular dementia is widely considered the second most common cause of dementia after Alzheimer’s disease, accounting for 20 to 30 percent of cases. Many experts believe that vascular dementia remains underdiagnosed — like Alzheimer’s disease — even though it’s recognized as common.
Symptoms can vary widely, depending on the severity of the blood vessel damage and the part of the brain affected. Memory loss may or may not be a significant symptom depending on the specific brain areas where blood flow is reduced.
Vascular dementia symptoms may be most obvious when they happen soon after a major stroke. Sudden post-stroke changes in thinking and perception may include:
These changes may happen at the same time as more familiar physical stroke symptoms, such as a sudden headache, difficulty walking, or numbness or paralysis on one side of the face or the body.
Multiple small strokes or other conditions that affect blood vessels and nerve fibers deep inside the brain may cause more gradual thinking changes as damage accumulates. Common early signs of widespread small vessel disease include impaired planning and judgment; uncontrolled laughing and crying; declining ability to pay attention; impaired function in social situations; and difficulty finding the right words.
Because vascular cognitive impairment may often go unrecognized, many experts recommend professional screening with brief tests to assess memory, thinking and reasoning for everyone considered to be at high risk for this disorder. Individuals at highest risk include those who have had a stroke or a transient ischemic attack (TIA, also known as a “ministroke”). Additional high-risk groups include those with high blood pressure, high cholesterol, or other risk factors for heart or blood vessel disease.
Professional screening for depression is also recommended for high-risk groups. Depression commonly coexists with brain vascular disease and can contribute to cognitive symptoms.
If brief screening tests suggest changes in thinking or reasoning, a more detailed assessment is needed. Core elements of a workup for vascular dementia typically include:
According to a 2011 scientific statement issued by the American Heart Association (AHA) and the American Stroke Association (ASA), and endorsed by the Alzheimer’s Association and the American Academy of Neurology (AAN), the following three criteria suggest the greatest likelihood that mild cognitive impairment (MCI) or dementia is caused by vascular changes:
The guidelines also discuss cases where the diagnosis may be less clear-cut, such as the common situation where vascular changes coexist with brain changes associated with other types of dementia.
As with Alzheimer’s disease, advancing age is a major risk factor for vascular cognitive impairment or dementia.
Additional risk factors are the same ones that raise risk for heart problems, stroke and other diseases that affect blood vessels. Many of these vascular factors also raise risk for Alzheimer’s. The following strategies may reduce your risk of diseases that affect your heart and blood vessels — and also may help protect your brain:
Learn more: Be Heart Smart
The U.S. Food and Drug Administration (FDA) has not approved any drugs specifically to treat symptoms of vascular dementia, but there is some clinical trial evidence that certain drugs approved to treat Alzheimer’s may also offer a modest benefit in people diagnosed with vascular dementia.
Controlling risk factors that may increase the likelihood of further damage to the brain’s blood vessels is an important treatment strategy. There’s substantial evidence that treatment of risk factors may improve outcomes and help postpone or prevent further decline.
Individuals should work with their physicians to develop the best treatment plan for their symptoms and circumstances.
Like other types of dementia, vascular dementia shortens lifespan. Some data suggest that those who develop dementia following a stroke survive three years, on average. As with other stroke symptoms, cognitive changes may sometimes improve during recovery and rehabilitation from the acute phase of a stroke as the brain generates new blood vessels and brain cells outside the damaged region take on new roles.
Learn more: Clinical Studies for Dementia
By John Gever, Senior Editor, MedPage Today
University of Pennsylvania School of Medicine and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner
The final months of advanced dementia are marked by “distressing symptoms and burdensome interventions,” investigators concluded in the first systematic, prospective investigation of the disease’s late-stage clinical course.
Among 323 patients with advanced dementia in nearly two dozen nursing homes who were followed for 18 months, more than 40% developed pneumonia, while half had at least one febrile episode, and 85% suffered eating problems, according to Susan L. Mitchell, MD, MPH, of the Hebrew Senior Life Institute for Aging Research in Boston, and colleagues.
Some 55% of the sample died during follow-up, the researchers reported in the Oct. 14New England Journal of Medicine. Most suffered from Alzheimer’s.
During their final three months of life, 41% of dying patients underwent at least one intensive intervention, such as hospitalization, transport to an emergency room, tube feeding, or parenteral treatment.
“Patients, families, and health care providers must understand and be prepared to confront the end stage of this disease, which is estimated to afflict more than 5 million Americans currently and is expected to afflict more than 13 million by 2050,” Mitchell and colleagues wrote.
They also found that when patients’ surrogates and guardians understood the expected clinical course, burdensome interventions were much less likely during the final three months of life (adjusted odds ratio 0.12, 95% CI 0.04 to 0.37), relative to proxies with poor understanding.
In an accompanying editorial, Greg A. Sachs, MD, of Indiana University School of Medicine in Indianapolis, said the study “moves the field forward in major ways with respect to both prognosis and the terminal nature of advanced dementia.”
Not only should clinicians, nursing home staff, and patients’ families be aware of the study results, Sachs suggested, but so should Congress and the government’s major health agencies.
“Much more research is needed on the use of palliative care for these patients, including studies on prognosis, patients in less advanced stages of dementia, alternative care settings, intervention trials, and, eventually, the effects of implementing programs designed to improve current systems of care,” he wrote.
The study focused on nursing home patients in the Boston area who could no longer recognize family members or walk independently.
About 72% had scores of zero on the Test for Severe Impairment, and the mean scores on the Bedford Alzheimer’s Nursing Severity subscale was 21.0 (SD 2.3). The mean age of the group was 85, and patients had been in nursing home care for a median of three years.
Dementia was related to vascular insufficiency in 17% of the patients and to Alzheimer’s disease in 72%. Symptoms in the remainder had other causes.
Patients underwent exams every three months. Caregivers and guardians or other surrogate decision-makers were also interviewed regularly.
In particular, each guardian or surrogate was asked whether he or she thought the patient would survive another six months. Also, at study baseline they were asked whether they understood the general clinical complications that might be expected in advanced dementia and whether they had discussed these issues with a nursing home physician.
Median patient survival was 478 days, Mitchell and colleagues reported. They calculated the following probabilities of complications:
- Pneumonia: 41.1%
- Febrile episode: 52.6%
- Eating problems: 85.8%
Patients developing these problems had relatively high mortality rates in the following six months: 46.7% after a bout of pneumonia, 44.5% after a fever, and 38.6% after eating problems began.
On the other hand, patients who could eat normally were very unlikely to die. Only about 10% of these patients died during the entire follow-up period, compared with about 70% of those who developed eating problems at some point.
Other sentinel events included 14 cases of seizure, 11 gastrointestinal bleeds, and seven hip or other bone fractures. But only seven of the 42 sentinel events occurred during the last three months of life for those who died during follow-up.
Symptoms causing acute distress were also common in the study. From 40% to 45% of patients suffered one or more of the following: dyspnea or pain for at least five days per month, pressure ulcers at stage II or higher, and aspiration. Nearly 54% experienced periods of agitation, the researchers found.
Among the entire study sample, about one-third received parenteral therapy, while 17% were admitted to a hospital, 10% had an emergency room visit, and 8% were tube-fed.
Pneumonia accounted for more than two-thirds of the hospitalizations, Mitchell and colleagues said.
Only 30% of those who died during follow-up had been referred to hospice care, and 22% of the overall sample.
The interviews with surrogates and guardians showed that 96% believed that comfort was the primary goal of therapy. Less than 20% said a nursing home physician had discussed prognosis with them.
About 80% indicated that they understood the medical complications likely to occur, but only 33% said they had discussed them with a physician.
Mitchell and colleagues noted that most of these findings had been observed in previous studies, but those were either retrospective or cross-sectional analyses or had focused on hospitalized patients. “The clinical course of advanced dementia has not been described in a rigorous, prospective manner,” they said, prompting their study.
They said their results “can be used to inform families and care providers that infections and eating problems should be expected and that their occurrence often indicates that the end of life is near.”
They added, “Families and providers should also understand that although these complications may be harbingers or even precipitants of death, as they are in other terminal diseases (e.g., the acquired immunodeficiency syndrome, cancer, and emphysema), it is the major illness, in this case dementia, that is the underlying cause of death.”
In his editorial, Sachs said it was important that clinicians and patients’ families approach advanced dementia “as a terminal illness requiring palliative care.” He argued that these patients should qualify for hospice care whether or not they have other serious illnesses.
He also criticized moves by the government to restrict hospice care in nursing homes. “Although no one can argue against the need to root out fraud and unseemly conflicts of interest, it would be a shame to take hospice away from patients with dementia, who could truly benefit from it,” Sachs wrote.
Mitchell and colleagues noted that their study was limited by its narrow geographic focus and its reliance on charts and nursing reports for some data. They also emphasized that their reported survival times do not represent survival from onset of advanced dementia.
They also noted, “We can report only the associations between the health care proxies’ perceptions of prognosis and of the complications expected and the use or nonuse of aggressive interventions — we cannot draw conclusions about cause and effect.”