Clinical Stages

At present, Alzheimer's disease is an irreversible, gradually progressive condition associated with relentless deterioration. In the earliest stage the patient may exhibit only minimal memory impairment and cognitive deficits. In the last stage the patient is commonly bed-ridden in the fetal position, doubly incontinent, and mute. Several classifications have been developed for categorizing patients according to stage. Although these classifications are useful for determining the level of care a patient needs and for comparing groups of patients with one another, they are not truly useful as prognostic indicators because of the great variability in the rate of deterioration exhibited by different patients. However, usually the younger the patient is when the disease manifests itself, the faster will be its rate of progression. Similarly, when there is a strong family history of Alzheimer's disease, the rate of progress tends to be more rapid than if no such history exists.

The two classifications most widely used involve three stages and seven stages. It is important to realize that both classifications are arbitrary and that there is a great deal of overlap among the various stages. Furthermore, not all patients go through all these stages. It also must be emphasized that a rapid rate of deterioration is often caused by other diseases or factors.

Alzheimer's disease has a very insidious onset and a slow, relentless progress. One of the best indicators of these two aspects of the disease is the inability of the patient's relatives to agree on a specific date when the symptoms started to manifest themselves. For instance, the patient's daughter may think it was last Christmas, whereas his wife may believe that the patient's condition started to deteriorate much earlier. In contrast to strokes of multi-infarct dementia, no one can pinpoint an exact date or time when the disease manifested itself or the patient's condition suddenly deteriorated.

For practical purposes, the three - stage classification is preferred because the characteristic features of each stage are easier to recognize and the need of the patient in each stage are so different.

Stage 1

Stage 1, which lasts between 1 and 3 years, is characterized by the following signs:

* Poor recent judgment

* Impaired acquisition of new information

* Mild anomia (difficulty finding the correct name for an object)

* Minimal visuospatial impairment (skills that enable individuals to decipher direction i.e. ability to find their way to a certain location)

* Personality changes

The patient may appear "normal" to people who do not know him. However, the patient's immediate contacts know that there has been a change in his behavior, personality, and intellectual functioning. This stage is a difficult period because the patient still has some insight into to his condition and cannot understand or cope with the complexity of his situation. At times the patient may rebel and refuse to accept that he is fighting a losing battle and become depressed and irritable or withdraw into apathy.

This stage can be particularly taxing for the patient's family. On one hand, they understand and appreciate the patient's actions; on the other, they question the validity of his judgment and yet do not want to appear to question or doubt his integrity, intentions, and ability to look after his family. Such a situation may require professional intervention to safeguard the family's financial assets.

A particularly difficult problem concerns the patient's ability to drive a motor vehicle. Driving is a symbol of independence and may be the person's only means of transportation. However, while driving, the patient may make serious mistakes that could endanger himself or others. In addition to having poor judgment, many patients with Alzheimer's disease have a slow reaction time and may be easily distracted, both of which make driving hazardous.

Toward the end of stage 1, memory impairment and impaired ability to make rational decisions often cause the patient to become lost even in familiar surroundings. This development is another traumatic and stressful experience for the patient's relatives. For example, a man goes to a store one block away to buy something, and 2 hours later he has not returned. Five hours later the police call his wife to tell her they have found him several miles away.

It is understood that a patient's relatives may be reluctant to take away his sense of initiative and independence by confining him indoors. Yet, whenever he leaves home, they worry that he may become lost, be mugged, or be involved in an accident. Often the relative resorts to writing their address and phone number on a card and leaving it in one of the patient's pockets.

Patients with Alzheimer's disease can become lost because they may not recognize familiar signs. Since they do not know where they are, they start to panic. When they panic, their judgment becomes even more impaired and they may not be able to retrace their steps. Although stress may sharpen a normal person's mental abilities, in a patient with dementia, it can lead to severe confusion.

In the first stage of Alzheimer's disease, the clinical examination is essentially within normal limits, although some patients have a reduced sense of smell.

Stage 2

Stage 2 lasts between 2 and 10 years and is characterized by the following signs:

* Profound memory loss, both remote and recent

* Significant impairment of other cognitive parameters, as evidenced by two or more of these symptoms:

A. anomia ( difficulty finding the correct word for an object)

B. agnosia ( inability to recognize various objects)

C. apraxia ( inability to carry out purposeful movements and actions)

D. aphasia ( impairment in the speech process)

In stage 2 the anomia becomes much more pronounced and interfere with the patient's daily activities. These signs can be recognized by people who are meeting the patient for the first time. Later in this stage the patient may develop significant apraxia, which leaves him unable to perform simple tasks such as feeding or washing himself, even though he has no muscle weakness or coordination difficulties.

At this stage patients with Alzheimer's disease tend to become very restless. They often are seen pacing the room or walking outside as if constantly searching for something. They do not like to stay in one place and want to keep moving.

The patient's personality, which in the first stage was variable, now is mostly apathetic. The individual has no insight into his condition and does not seem bothered by his relatives' distress over it. This lack of insight is exemplified by the patient's denial of problems with his memory despite evidence of profound memory loss. If confronted with the fact that his memory is poor, the patient usually makes some excuse, such as that he has other things to remember and cannot be bothered with such details.

The patient may make "near misses." For instance, when asked which day of the week it is, he may say that the day is Monday (rather than Tuesday). When corrected, he may question the relevance of today being Tuesday rather than Monday. If an examiner asks him to remember three or four objects, he may question the importance of being able to do so. In contrast, patients suffering from depression readily acknowledge problems with their memory; rather than making near misses, they refuse to cooperate with the examiner.

Stage 3

Stage 3, which last between 8 and 12 years, is notable for the following features:

* Severe impairment of all cognitive functions

* Physical impairment involving unsteadiness, repeated falls, reduced mobility

* Total loss of ability to care for oneself.

Intellectual impairment is obvious at this stage. For example, a patient may not recognize his wife and children and may confuse them with his parents.

Complete disorientation to time, place, and other individuals is evident, and the patient cannot cope with his basic needs. As the condition progresses, complete mutism may occur and motor deficits may become apparent. The patient may develop generalized muscular rigidity, and his mobility may be grossly reduced.

In contrast to stage 2, in which the patient wandered constantly, he now spends most of the time sitting in a chair or lying in bed. An attitude of generalized flexion gradually is adopted, with the patient lying curled up in bed. Eventually the patient assumes the fetal position. At this stage urinary (and sometimes fecal) incontinence may develop.

Ronald C. Hamdy (c) copyright 1992

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