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Introduction

Alzheimer's disease is a progressive, degenerative disease that destroys vital brain cells. As each area of the brain is affected, certain functions or abilities can be lost. The losses affect the individual's ability to think, to remember, to understand and to make decisions. In addition to affecting a person's mental abilities, Alzheimer's disease affects moods and emotions. Along with loss of abilities, changes in behaviour occur. Gradually, independence disappears.

Approach to care

It is important to remember that the approach to care can enhance the individual's quality of life. The Alzheimer Society developed the Guidelines for Care to ensure that people with Alzheimer's disease receive the special type of care that reflects the unique nature of the disease.

A person-centred approach to care recognizes that each individual deserves to be treated with dignity and respect. By understanding the person's personality, life experiences, support systems and ways of coping, the individual's physical, social, emotional and spiritual needs can be met.

Although the person loses many abilities as the disease progresses, it is helpful to focus on the abilities that do remain, such as the senses of touch and hearing, and the ability to respond to emotion.

Duration of the disease

The progression of Alzheimer's disease varies from person to person and can span three to 20 years (the average length of the disease is between eight and 12 years^[1]). The progression can be described as a series of stages, providing a guide to the pattern of the disease, which can help when making care decisions.

One staging system explains the disease in three stages: early, middle and late. Another staging system, often used by medical professionals, is the Global Deterioration Scale (also called the Reisberg Scale^[2]). This scale divides the disease into seven stages.

Whichever staging system is used, or if none is used, it's important to remember that the disease affects each person differently. The order in which the symptoms appear and the length of each stage will vary from person to person. There is no clear line when one stage ends and another begins. In many cases, stages will overlap. Some people experience many of the symptoms in each stage, while others experience only a few. There may be fluctuations from day to day with a person appearing more confused one day, for example, and less so another.

Three Stages of Alzheimer Disease

Early Stage

A person in this stage will usually be aware of the diagnosis and will be able to participate in decisions affecting future care. Symptoms can include mild forgetfulness and communication difficulties, such as finding the right word and following a conversation. Some people stay involved in activities while others become passive or withdrawn. The individual may become depressed or anxious. It is important to monitor the emotional well-being of the person.

Abilities Affected	Typical Symptoms
Mental abilities	mild forgetfulness; difficulty learning new things and following conversations; difficulty concentrating or limited attention span; problems with orientation, such as getting lost or not following directions; communication difficulties such as finding the right words
Moods and emotions	mood shifts; depression
Behaviours	passiveness; withdrawal from usual activities; restlessness
Physical abilities	mild co-ordination problems

Middle Stage

This stage brings a further decline in the person’s mental and physical abilities. Memory will continue to deteriorate as the person forgets personal history and no longer recognizes family and friends. Increased confusion and disorientation to time and place will result in requiring assistance in many daily tasks, such as dressing, bathing, using the toilet.
In this stage, some become restless and pace or wander. Registering the person with the Safely Home (former Alzheimer Wandering Registry) will provide peace of mind should he/she become lost. In response to the loss of abilities, a person may react in a number of ways. For example, he or she may become less involved in activities or repeat the same action or word over and over again. It can be helpful to understand more about the disease and develop strategies to deal with these situations.

Abilities affected	Typical Symptoms
Mental abilities	continued memory problems; forgetfulness about personal history; inability to recognize friends and family; disorientation about time and place
Mood and emotions	personality change; confusion; anxiety; suspiciousness; mood shifts; anger; sadness/depression; hostility; apprehension
Behaviours	declining ability to concentrate; restlessness (pacing, wandering); repetition; delusions; aggression; uninhibited behaviour; passiveness
Physical abilities	assistance required for daily tasks (e.g., dressing, bathing, using the toilet); disrupted sleep patterns; appetite fluctuations, language difficulties; visual spatial problems

Late Stage

In this last stage, the person becomes unable to remember, communicate or look after him/herself. Care is required 24 hours a day. Eventually, the person will become bed-ridden, have difficulty eating or swallowing, and lose control of bodily functions. This stage eventually ends with the person’s death, often from secondary complications such as pneumonia.

Abilities affected	Typical Symptoms
Mental abilities	loss of ability to remember, communicate or function; inability to process information; severe speaking difficulties; severe disorientation about time, place and people
Mood and emotions	possible withdrawal
Behaviours	non-verbal methods of communication
Physical abilities	sleeps longer and more often; becomes immobile (bed-ridden); loses ability to speak; loses control of bladder and bowels; has difficulty eating and/or swallowing; unable to dress or bathe; may lose weight

The Global Deterioration Scale (GDS)

Some health care professionals use the Global Deterioration Scale (GDS), also called the Reisberg Scale, to measure progression of Alzheimer’s disease. This scale divides Alzheimer’s disease into seven stages of decreasing ability.

Stage	Typical Symptoms
Stage 1: No cognitive decline	Experiences no problems in daily living
Stage 2: Very mild cognitive decline	Forgets names and locations of objects. May have trouble finding words.
Stage 3: Mild cognitive decline	Has difficulty traveling to new locations. Has difficulty handling problems at work.
Stage 4: Moderate cognitive decline	Has difficulty with complex tasks (finances, shopping, planning dinner for guests)
Stage 5: Moderate severe cognitive decline	Needs help to choose clothing. Needs prompting to bathe.
Stage 6: Severe cognitive decline	Needs help putting on clothing. Requires assistance bathing, may have a fear of bathing. Has decreased ability to use the toilet, or is incontinent.
Stage 7: Very severe cognitive decline	Vocabulary becomes limited, eventually declining to single words. Loses ability to walk and sit. Becomes unable to smile.

Modified from Global Deterioration Scale, Reisberg, 1982

Resources:
1. Guidelines for Care, Alzheimer Society of Canada
(If you'd like a copy of this booklet, contact us at 416 322 6560)
2. Safely Home (former Alzheimer Wandering Registry)

Footnotes:

1. The Canadian Journal of Neurological Sciences Supplement; Canadian Consensus Conference on Dementia, Volume 28 (Supplement 1), February 2001, p. S22.
2. Reisberg, B., Ferris, S.H., de Leon, M.J., and Crook, T., American Journal of Psychiatry, 139:1136-1139, 1982.