Global Deterioration Scale

The Global Deterioration Scale (GDS), developed by Dr. Barry Reisberg, provides caregivers an overview of the stages of cognitive function for those suffering from a primary degenerative dementia such as Alzheimer's disease. It is broken down into 7 different stages. Stages 1-3 are the pre-dementia stages. Stages 4-7 are the dementia stages. Beginning in stage 5, an individual can no longer survive without assistance. Within the GDS, each stage is numbered (1-7), given a short title (i.e., Forgetfulness, Early Confusional, etc followed by a brief listing of the characteristics for that stage. Caregivers can get a rough idea of where an individual is at in the disease process by observing that individual's behavioral characteristics and comparing them to the GDS. (From geriatric-resources) _____________________________

The Global Deterioration Scale for Assessment of Primary Degenerative Dementia

Level 1 – NO COGNATIVE DECLINE: No subjective complaints of memory deficit. No memory deficit evident on clinical interview.

Level 2 – VERY MILD COGNATIVE DECLINE (Age Associated Memory Impairment): Subjective complaints of memory deficit, most frequently in following areas: (a) forgetting where one has placed familiar objects; (b) forgetting names one formerly knew well. No objective evidence of memory deficit on clinical interview. No objective deficits in employment or social situations. Appropriate concern with respect to symptomatology.

Level 3 – MILD COGNATIVE DECLINE (Mild Cognitive Impairment): Earliest clear-cut deficits. Manifestations in more than one of the following areas: (a) patient may have gotten lost when traveling to an unfamiliar location; (b) co-workers become aware of patient's relatively poor performance; (c) word and name finding deficit becomes evident to intimates; (d) patient may read a passage or a book and retain relatively little material; (e) patient may demonstrate decreased facility in remembering names upon introduction to new people; (f) patient may have lost or misplaced an object of value; (g) concentration deficit may be evident on clinical testing. Objective evidence of memory deficit obtained only with an intensive interview. Decreased performance in demanding employment and social settings. Denial begins to become manifest in patient. Mild to moderate anxiety accompanies symptoms.

Level 4 – MODERATE COGNITIVE DECLINE (Mild Dementia): Clear-cut deficit on careful clinical interview. Deficit manifest in following areas: (a) decreased knowledge of current and recent events; (b) may exhibit some deficit in memory of ones personal history; (c) concentration deficit elicited on serial subtractions; (d) decreased ability to travel, handle finances, etc. Frequently no deficit in following areas: (a) orientation to time and place; (b) recognition of familiar persons and faces; (c) ability to travel to familiar locations. Inability to perform complex tasks. Denial is dominant defense mechanism. Flattening of affect and withdrawal from challenging situations frequently occur.

Level 5 – MODERATELY SEVERE COGNITIVE DECLINE (Moderate Dementia): Patient can no longer survive without some assistance. Patient is unable during interview to recall a major relevant aspect of their current lives, e.g., an address or telephone number of many years, the names of close family members (such as grandchildren), the name of the high school or college from which they graduated. Frequently some disorientation to time (date, day of week, season, etc.) or to place. An educated person may have difficulty counting back from 40 by 4s or from 20 by 2s. Persons at this stage retain knowledge of many major facts regarding themselves and others. They invariably know their own names and generally know their spouses' and children's names. They require no assistance with toileting and eating, but may have some difficulty choosing the proper clothing to wear.

Level 6 - SEVERE COGNITIVE DECLINE (Moderately Severe Dementia): May occasionally forget the name of the spouse upon whom they are entirely dependent for survival. Will be largely unaware of all recent events and experiences in their lives. Retain some knowledge of their past lives but this is very sketchy. Generally unaware of their surroundings, the year, the season, etc. May have difficulty counting from 10, both backward and, sometimes, forward. Will require some assistance with activities of daily living, e.g., may become incontinent, will require travel assistance but occasionally will be able to travel to familiar locations. Diurnal rhythm frequently disturbed. Almost always recall their own name. Frequently continue to be able to distinguish familiar from unfamiliar persons in their environment. Personality and emotional changes occur. These are quite variable and include: (a) delusional behavior, e.g., patients may accuse their spouse of being an impostor, may talk to imaginary figures in the environment, or to their own reflection in the mirror; (b) obsessive symptoms, e.g., person may continually repeat simple cleaning activities; (c) anxiety symptoms, agitation, and even previously nonexistent violent behavior may occur; (d) cognitive abulla, i.e., loss of willpower because an individual cannot carry a thought long enough to determine a purposeful course of action.

Level 7 - VERY SEVERE COGNITIVE DECLINE (Severe Dementia): All verbal abilities are lost over the course of this stage. Frequently there is no speech at all -only unintelligible utterances and rare emergence of seemingly forgotten words and phrases. Incontinent of urine, requires assistance toileting and feeding. Basic psychomotor skills, e.g., ability to walk, are lost with the progression of this stage. The brain appears to no longer be able to tell the body what to do. Generalized rigidity and developmental neurologic reflexes are frequently present. __________________

The alzheimers association now has a plain English version of the seven stages, available at http://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp ---------------

From Act mental health consultants-- A simplified version of 7 stages. Seems to describe the problems and care requirements seen in the nursing home. Very understandable. Also gives range of time duration for each stage. (Ay attempt to state a duration for stages is only an approximation.) http://www.actmentalhealth.com/News%202000,%2011-12.htm __________________

By the way, most doctors do not bother trying to determine the stage the person is in - except that they might indicate mild, moderate or severe. The doctors are more interested in treating the individual patient and the problems he/she is having at the time of the visit. They find no value in staging the dementia patient. Caregivers tend to want the staging system to get an idea of where their LO is in the process and what lies ahead. -----------------------------------------

A simplified checklist version of the seven stages is the Functional Assessment Staging Test (FAST). Note that stages 6 and 7 are broken down into smaller steps.

1 No difficulties, either subjectively or objectively 2 Complains of forgetting location of objects; subjective word finding difficulties only. 3 Decreased job functioning evident to coworkers; difficulty in traveling to new locations. 4 Decreased ability to perform complex tasks (e.g., planning dinner for guests; handling finances; marketing). 5 Requires assistance in choosing proper clothing for the season or occasion.

6a Difficulty putting clothing on properly without assistance. 6b Unable to bathe properly; may develop fear of bathing. Will usually require assistance adjusting bath water temperature. 6c Inability to handle mechanics of toileting (i.e., forgets to flush; doesn't wipe properly). 6d Urinary incontinence, occasional or more frequent. 6e Fecal incontinence, occasional or more frequent.

7a Ability to speak limited to about half a dozen words in an average day. 7b Intelligible vocabulary limited to a single word in an average day. 7c Nonambulatory (unable to walk without assistance). 7d Unable to sit up independently. 7e Unable to smile. 7f Unable to hold head up.

Comment on the FAST by dementia expert Geri Hall

"You look for the stage which is the highest number where your person has symptoms because the losses are cumulative. If a patient is in stage 3, I expect them to have some issues with money, working, driving, shopping, short-term memory, time sense, etc -- In stage 4 I see issues with driving, shopping, cooking, cleaning, doing chores, participating in higher level activities and social affairs. But the person brings the deficits from stage 3 with them into stage 4. The deficits don't resolve. And, there are those of us who work with these patients day to day who strongly disagree with several points on the FAST Scale. The one major issue is bathing. Problems with bathing are the hallmark of the beginnings of stage 5. G Hall recaps the seven stages --- Problems with driving, managing money, and shopping = stage 3. If you notice she can't cook, clean, or do the laundry = stage 4. If she requires help (or strong encouragement to bathe, clean her teeth, or select different clothing each day = stage 5. If she has trouble with falling or bowel and bladder control and/or falling, she is in stage 6. If she can no longer walk, stage 7. The losses are cumulative and not every patient has exactly the same losses. ----------

A detailed expansion of the seven stages was developed by dementia expert Geri Hall. It describes the stages using lost capabilities that will be observed by the family caregiver. It can be found at http://www.biostat.wustl.edu/archives/html/alzheimer/2008-06/msg00110.html

citation for this version is as follows: Hall, G. (2007). MAPS Module 2: Stages of Alzheimer's disease. Phoenix: Banner Alzheimer's Institute




[This Message was Edited on 06/28/2008]

I think my Husband is at stage 5. He lives in Florida with his unmarried sister who's taking care of him for now. I'll check with her about the "bathing" status. My question is this: When I speak with my husband on the phone, he's very pleasant, more so than ever (married since 1968 but we lived separately for 10 years before he was diagnosed in 2003 and moved to Florida to live with his sister), tells me he loves me, and is extremely polite. He doesn't offer any subjects to talk about. I do that. I tell him of our daughter's whereabouts, what she's up to, how she's doing in Graduate School, her dog, her work, etc.. He listens very carefully without making any comments. He choses very brief words to answer questions if I ask -- about the weather or his family. What stage is this? He says he'd love to get together, etc. Should I go and visit him or will he remember the bad memories from the past that made us decide to live separate more than 10 years ago? Should I urge him to visit me (in upstate New York)? Of course, he wouldn't travel alone. I understand he reads a lot. Is he retaining anything or just looking at words? I asked him once -- in response to his extreme politeness- if he knew who I was. He did with no difficulty - by name and said that I was his wife. I'm so unused to his extreme politeness as if I'm his boss's wife. Thus my question. If I visit him, can it be beneficial to him any way -- give him a few moments of joy, for instance? Thanks for any advice you can give me. Challa

This is a difficult subject to make a decision on. I definitely would say if it does happen, you are the one that needs to do the traveling...it would be much too difficult for him to travel and then stay in a place that will be strange to him. The politeness is very common. Although he knows who you are, his emotions and memories of what that should mean to him are probably long gone. The fact that he does best on the phone when you are talking, is also part of it. Asking questions of someone at his stage can cause stress and confusion because they are unable to formulate an answer...my dad is in an earlier stage and different kind of dementia but I still avoid asking "remember" type questions. So, before you make plans to go, think long and hard about why you would go and what you and your husband would get out of it, if anything. With love, Patricia

Dear Patricia:

thanks so much for your answer and input. the second i had said: "you know who I am, right?" I had regretted it, but it was too late. I couldn't believe he was being so "polite" to me . Obiously, he remembers my name and identity, with no memories attached to "me." He was always a polite person to strangers.

As to visiting him, I thought I would go if it were to be of any help to him, not to me. Perhaps, back in my mind I also thought we could recapture something that was gone so long ago. I was a bit surprised when my daughter, after visiting her father last week, showed little interest in seeing him again. I told her that I would "dog-sit" her dog this coming X-mas if she wanted to go and visit her father again. Her response was: "But what's the point?" Perhaps she's more intuitive than I am. It certainly doesn't give her any pleasure, and it means nothing to him. Do you agree? Thanks again for your advice. Love and Patience to you. Challa.

Oh, if only we could capture the past, sigh. My father has dementia, but can still carry on a conversation and knows his own kids--though he did not recognize his 23 year old grandaughter last time she visited and I think it was because he hadn't seen her for a while. But even after he was told who she was, he never really connected with her. I see my father at least twice a week for lunch at his place, which is only 10 minutes from my house. When the day comes he doesn't know me, I will still come because I will still know him and can bring him special foods and other treats. But I know others who wouldn't visit in that circumstance and I never know if it is because it upsets them too much or because it's a great excuse not to visit. But if you have not seen one another in a long time, the trip would be difficult for you and nothing to him. Maybe instead you could take that money and send it for a vacation for his sister or to pay for some respite or inhome care--that could well be the best way to honor your husband, by honoring the woman who cares for him. With love, Patricia

Dear Norbert, I have not been on much as of late as My sweet husband went HOME in March and I have been diagnoised with lung cancer and have been going for treatment and such. I have been looking for a list I used to have about the do's and don'ts dealing with dementia. I can't seem to find it and am sure you could help. I wanted to give it to my sister as her husband has some form of dementia. Thank you for your help. You have been there for many times for all of us. Carole

for all newbies

Thanks Norbert!

Thankyou Norbert for the 7 levels of Dementia. I think my husband is at stages 5 and 6. It made me feel sad that he has gotten this far. I feel so helpless that their wasn't anything I could do to save him from this unforgiving disease. Joan42

Being new here and just now starting to get an education, this was very helpful.

Anything else I should know for the beginging?

thanks again, KIm

Thank you for posting this info. After reading this, I think my mom is a 6. She lives 1000 miles away with my dad who also has ALZ, but a mild version (if he has it at all). I am leaving tomorrow to go and have my mom committed to some health care facility. She will probably fight me and hate me in the end. But it is not fair to let my dad to handle it alone. This is the hardest thing I have ever done in my life.

I would say my uncle is in stage 6. Does anyone have any kind of a timetable for the start of stage 7. My uncle has gone from stage 3 to stage 6 in less than a year. At this point my uncle has several things going on. First he is incontinent, but still able to clean himself up (thank god for depends briefs, which he thinks are regular underwear). A few months ago he would wash up between showers, now doesn't wash himself well and he fights me about taking a shower every few days. He says its to tiring to bother. Despite numerous reminders, he calls my son Clinton, my son's name is Clayton. He asks when we got the cats, they have been here longer than he has. Most recently he has started substituting nonsense words for what he wants to say and has trouble pronouncing any word more than 2 syllables. He told my husband last night that he needed to get more exercise and that my husband should do some calbronics (I'm assuming he combined calastenics(sp?) and aerobics). He also tried to get out the words umbrella and superb and couldn't do it. These instances are becoming more frequent. He lets me know when he is confused because he giggles when he doesn't understand where he is or what is going on. He is very much like a 2 year old, tantrums and all. He avoids leaving the house whenever possible and stays in his room except for meals. He is sleeping a lot more, but is still very enthusiastic about food. Everything is his favorite. Despite a high caloric intake, he is losing weight. He has lost 10 lbs in the last 8 months. I'm thinking that it will be less than a year before I have to place him in a nursing home. Before he came to live with me a little over a year ago, I really didn't even know the man (he's my husband's uncle) and I am not a nurse. I can't picture myself bathing him and changing his diapers. I give him his insulin shot every night and cut up his meat when he forgets what his knife is for, but the really personal care issues are too much for me to deal with. Thanks again, Mariellen

for Becky

Wow...I really like the info this board has. Thanks Norbert for explaining the various stages, plus all the other info. Have a good day!

I just reread my post from September and it is hard to believe how much worse my husband's uncle has become in a few short months.

for Steach

Norbert-

This has been so helpful. Thank you very, very much for taking the time to give us so much information.

This is somewhat comforting to me- I know this must sound very strange; however, at least now, I know that I have been able to care for her throughout the majority of these stages. I now feel that I will be able to let go of some of the guilt that I have been feeling for taking Gram to a nursing-care facility. From reading your information, I know that Gram is at a stage 6.

SVDV and Others- The guilt for taking my Gram to a care facility has hurt my heart, sole, and mind. I have been beating myself-up since I took her to the facility- 3 weeks ago. Now, after reading Norbert's information, I feel as though I can forgive myself and move on. I know that I did the very best that I could to care for her for as long as I did. I now know that I am not capable of caring for her at home; this is difficult to admit to myself and to all of you- but it is the reality.

Norbert, I wish that I had more intense words other than "thank you" to express my gratitude. I am so grateful for your post. By reading your post, and others', I really can set the guilt free now. You have helped me more than you could ever imagine.

From the bottom of my heart, I will be forever grateful.

Love, Steach

What would be gained by his visiting you. Evidentally you didn't have a good marriage before and why do you think a visit would "fix" things. My suggestion is for you to go on with your life and let him be where he is, with his sister and evidentally a world of his own. I hope I don't sound cruel, just realistic. A 10 year separation is sorta final, I think.

Hi All! I'm new to the group and I've just read that one of the first signs of Alzheimer's can be a decline in "physical activity". My father died 2 years ago of Alzheimer's and he read, did crosswords, played bridge, golf, tennis, did exercises every morning of his life until he couldn't. He took vitimans, took supplements, rarely drank, never smoked in his life. He did just about everything they say to "avoid" getting Alzheimer's and he got it anyway. So when I hear someone say, "I'm doing this or that to avoid getting Alzheimers (usually with a small laugh afterword out of nervousness)", I think best of luck-but it may not stop it. I'm not angry, just sad. It seems he did everything correctly and I miss him terribly...

BUMP --hope this helps Gladness

Bump for Margaret
[This Message was Edited on 10/16/2006]

Bump for new members. Gladness

Norbert> Some time ago you offered some rules caregivers should follow in order to get better responses from AD patients. Could you please publish that again...

One of them was Do not Confront.

Thank you very much for your kindness.

Alfredo

THANKS FOR THIS INFO FOR PEOPLE LIKE ME. MARRIED 62 YEARS AND LOOKING FORWARD TO THE BEST THING IN MY LIFE STAYING AROUND FOR AS LONG AS I DO. WE ARE INTO THIS AD THING FOR FIVE YEARS NOW AND ALTHOUGH I DID NOT KNOW WHAT IT WAS IN THE BEGINNING I DO NOW. WE STILL LAUGH TOGETHER AT MOST OF THE THINGS THAT HAPPEN AND ENJOY OUR OUTINGS TOGETHER,EVEN THOUGH WHEN WE GET THERE WE ONLY STAY A FEW MINUTES AND LEAVE.ONCE AGAIN THANK YOU FOR SHARING YOUR KNOWLEDGE.

Norbert has postings on almost everything related to AD. He is a resident gem. Hope this helps y'all who are new to this and seeking answers. Do use the search engine in the upper left had top of this page. It is invaluable. Treetp

I never bumped.....hope I did it right :O/

Mern

Well, as hard as it is to admit, according to the list of stages, we're nearing the end here. I can't believe how the disease speeds up at the end. Just last week, mother was smiling at me and patting my face. Yesterday, she lagged eating and today she refuses food. She is no longer able to sit up and just falls over.

I've wondered for some time now if one of her medications could be contributing to her decline. The two I suspect are Namenda and Sertraline, generic for Zoloft. According to pharmacology, the Namenda could be hurting more than helping at this point. I read that it causes confusion and sleepiness. Seems like she just wants to sleep all the time, especially the last two weeks. She only takes 10 mg/day.

She was unable to tolerate the Aricept because it caused her to lose consciousness. We'd leave the room and come back to find her laying in the floor. Of course, it only happened once, which was enough for us. She perked right back up when we took her off it.

I really fearing that this is just the end. But I will hold on to hope till she takes her last breath, doing anything I can to prolong her life. Does anyone have any advice on Namenda and could it be contributing to her sleepiness?

Thanks for the group and the ones who take time to share.

...hopeful