Stages of Dementia

Different people and different organizations have….of course…………different ways of defining the stages of dementia.  I am going to use the following 6 stage classification of dementia because it is easiest for me to understand, so I’m hoping it will be the same for you.  I actually learned this in a class taught by Susan Coulter, LCSW. 

1. Early Forgetfulness

Forgets names and events.  Is occasionally lost.  Decisions are hard to make. May realize that they are forgetful.  Accuses others of actions. May be angry, irritable, demanding and/or stubborn.

The purpose of these actions are to defend against fears and to compensate for mistakes that are made.

Their need is to feel competent and as able to function as well as they were before.

Strategies for dealing with this stage are to use “non-critical verbal reminders”, lists, reassurances.

At this point, you may consider having an assessment done and although it would be impossible to diagnose Alzheimer’s at this point, other causes for the symptoms might be found.

2. Early Confusion-Mild Dementia

Has concrete thinking; leaves out of substitutes words. Has increased short-term memory loss. May get lost. May withdraw socially. Denies forgetting. Is more self-centered and defensive.

The purpose of these actions are to avoid embarassment and cope with helplessnes.

Their needs are to have their fears dealt with, to have their defensive reactions understand and to address any depression that may be present.

Strategies for dealing with this stage are to allow the person to talk about their fears; validate their feelings, use simple directions, and avoid confrontations. There are also some memory enhancement techniques that may be used if the person is will to try them.

3.  Moderate Dementia

Uses phrases instead of sentences; Is easily disoriented; Has difficulty with instructions, poor concentration; Has decreased visual field; Tends to hide ( or hoard ) things; Asks repetetative questions or repeats same statement numerous times; Clings; angers easily.

The purpose of these actions are an attempt to orient himself/herself, to organize their thoughts and to maintain a sense of self (or person).

Their needs are to have less responsibility, to avoid situations they can’t handle  and to be able to depend upon a safe, reliable person.

Strategies for dealing with this stage are to use short, simple phrases and instructions; demonstarte what you would like him or her to do; use pictures; speak slowly; structure activities; and offer “jobs” according to his or her ability to perform them (these are mostly jobs to help them feel productive and useful).

4.  Advanced Moderate Dementia

Cannot complete thoughts; cannot understand or interpret what is happening; has no ability to use logic; may wander; wants to “go home”; moves objects; is unpredictable.

The purpose for these actions is that he or she is searching for the familiar or acting out a previous role that they once held; they may also be reacting to misunderstood information.

Their needs are to feel safe and to have predictable events and routines.  A supportive, non-threatening environment is essential.  They will also need help with personal care.

Strategies for dealing with this stage are to have a friendly, non-sudden approach; respect distance; keeps meals, bedtimes and other activities of daily living at the same time each day and to have familiar items around the loved one.

5. Severe Dementia

There is almost no comprehension; they are often anxious ; they may recognize familiar faces but not names; often incontinent; only smiles and babbles – uses “word salad” (a mismatched jumble of words); pacing is often seen; reactions are impulsive; is easily combative; may hallucinate , yell or exhibit sexual behavior.

The purpose of these actions are mostly a reaction to feeling confused, anxious, or suffering from hallucinations and/or delusions.

The needs in this stage are more for personal protection from themsleves such as wandering or trying to do chores that they were previously able to do (such as cooking).  They need help to comprehend and to be kept in a safe environment.

Strategies to use in this stage include the careful use of touch, smiling, soothing music, offering foods that they enjoy and can eat. Medications sometimes become necessary to help to decrease the anxiety or distress since it is difficult for them to process information.

6-7.  Very Severe Dementia

There is little or no speech; they are bedridden and incontinent; often have difficulty swallowing; they may gaze but there is little reaction to any stimuli; usually passive at this point.

The actions in this stage are mostly instinctual.

Their needs now are for total care – feeding, bathing, dressing, movement (such as range-of-motion exercises to prevent contractures), repositioning if bed-ridden.

Strategies in this stage are to be attentive to primary care details such as repositioning in bed in order to prevent bed sores, massaging boney prominences such as elbows, heels, knees, hips, buttocks etc, also in order to prevent bed sores. Touch is good and it is important to talk reassuringly even though we are not sure if there is any understanding.

I have learned that in dementia, there is one prominent rule and that is that THERE ARE NO RULES.  A person with dementia may be in one stage on a certain day and by the next day (or hour), they may be in a different stage.  They may have only some or all of the characteristics listed here. They may also bypass a certain stage completely.

I found that in understanding the stages of dementia and having methods in place for future use that I was less frightened when I recognized new or different behaviors in my father.  My father hasn’t gone through all the stages but in knowing them I was also able to determine at what point I would need or want to consider alternate living arrangements.

I hope that this information will bring some comfort to you and your decisions as you care for your aging loved one.