Blackburn J.A., Dulmus C.N. (Editors). Handbook of gerontology: evidence-based approaches to theory, practice, and policy

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AD at age 65, approximately half of the population over 85 years old has it. On the

other hand, the relationship between age and prevalence is complex for subjects

younger than 65 or older than 85. The prevalence in those age groups is also influ-

enced by other factors, in addition to age.

Family History Another strong risk factor is family history, especially for early-

onset cases (Chandra, Philipose, Bell, Lazaroff, & Schoenberg, 1987; Heston, Mas-

tri, Anderson, & White, 1981). Case-control studies of AD were reanalyzed to

examine the association of AD with family history (van Duijn et al., 1991). The

relative risk of AD for those with at least one first-degree relative with dementia

was 3.5. When focusing on the age at onset of AD, the relative risk decreased with

increasing onset age. However, even among patients with onset of disease after 80

years, there were still significantly more subjects with one or more first-degree

relatives with dementia compared to the controls. The relative risk of AD was sig-

nificantly lower in patients who had one first-degree relative with dementia com-

pared to those who had two or more affected relatives.

Down Syndrome Neuropathological changes that are observed in the brain of pa-

tients with Down syndrome are similar to those in AD. More than half of Down

syndrome patients develop AD. A family history of Down syndrome is also a risk

factor for AD (Amaducci et al., 1986; Hofman et al., 1991). The presence and num-

ber of first-degree relatives with Down syndrome are strongly related to the de-

velopment of AD.

Head Trauma The relationship between head trauma and AD has been studied,

because AD-like neuropathological changes in the brain were observed in the

brains of punch-drunk syndrome patients. Exposure to head trauma with loss of

consciousness may be associated with the development of AD. Stronger associa-

tions were observed in cases without a positive family history of dementia and in

men (Mortimer et al., 1991).

Depressive State One of the psychological risk factors considered in a collabora-

tive analysis of case-control studies was depression as medical history, especially

for presenile and senile persons (Jorm et al., 1991). While depressive symptoms

may be part of the symptoms of the preclinical stages of AD, depressive episodes

that occurred even more than 10 years before the onset of AD were associated

with the development of AD (Kokmen, Chandra, & Schoenberg, 1988).

Sex Women are more likely to get AD than men, but the reason is not known.

There is an argument that women are at higher risk of AD because they live

longer than men. However, this tendency was observed in each age stage (Lopez

Pousa, Llinas Regla, Vilalta Franch, & Lozano Fernandez de Pinedo, 1995). More-

over, women get AD more easily even when the factor of life expectancy is ex-

cluded statistically (Cummings, Vinters, Cole, & Khachaturian, 1998).

Education Level Several surveys reported that a lower education level was asso-

ciated with the development of AD. Because the results of cognitive test batter-

Alzheimer’s Disease 337

ies are influenced by education level, different cut-off points were used for dif-

ferent education levels and confirmed this association (Zhang et al., 1990). This

association can be understood as follows. When one receives a longer educa-

tion and achieves higher cognitive functions, dementia symptoms do not ap-

pear until the pathologic changes in the brain become more severe. It can be

assumed that a longer education has a preventive effect against the clinical ap-

pearance of AD.

Lifestyles Previous studies suggested that lifestyles that include mental and

physical activity and an active social network have a protective effect against

dementia (Fratiglioni, Paillard-Borg, & Winblad, 2004), even though the evi-

dence is not strong enough to support preventive and therapeutic strategies.

To investigate the association between physical activity at midlife and the

subsequent development of dementia and AD, approximately 21-year follow-

up data were presented. Leisure-time physical activity at midlife at least

twiceaweekwasassociatedwithareducedriskofdementiaandAD(Rovio

et al., 2005). Moreover, a 6.2-year follow-up study of 1,740 persons older than

65 without cognitive impairment were completed to determine whether regu-

lar exercise is associated with a reduced risk for dementia and AD. The study

found that the incidence rate of dementia for participants who exercised 3 or

more times per week was significantly lower than that of participants who ex-

ercised fewer than 3 times a week (Larson et al., 2006). The effect of social net-

works on the risk of cognitive impairment was estimated in a longitudinal,

epidemiological, clinicopathological study. Eighty-nine elderly people with-

out dementia underwent annual clinical evaluations. Social network data

were obtained by structured interview, and brain autopsy was done at the

time of death. Although cognitive function was inversely related to disease

pathology in the brain, social network size modified the association between

pathology and cognitive function. Even at more severe levels of disease pathol-

ogy, cognitive function remained higher for participants with larger network

sizes (Bennett, Schneider, Tang, Arnold, & Wilson, 2006). The hypothesis that

an active and socially integrated lifestyle protects against dementia and AD

indicates the possibilities of the development of interventions for prevention

and treatment of AD.

Miscellaneous Other possible positive and negative risk factors for AD are a med-

ical history of hypothyroidism, mother’s age at birth, and smoking. These factors

need to be further studied and discussed.

ROGNOSIS AND

ORTALITY

Prognosis There are possible prognostic models using the rate of progression

in cognitive decline, dependence in activities of daily living (ADL), institu-

tionalization, and survival as parameters. A 4.5-year prospective study was

performed using “total dependence in activities of daily living,” “inconti-

nence,” and “institutionalization at follow-up” as end points. The results

suggested that the initial degree of severity rather than the variation in the

rate of progression correlates most closely with the prognosis in the early to

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intermediate stages of AD (Drachman, O’Donnell, Lew, & Swearer, 1990). The

relationship between disease severity and prognosis should be taken into ac-

count before discussing the differences in the rates of disease progression.

When using “survival” as the prognostic parameter for the population 75

years and older, older age, male sex, low education, comorbidity, and func-

tional disability were associated with shorter survival (Aguero-Torres,

Fratiglioni, Guo, Viitanen, & Winblad, 1998).

A population-based prospective study of persons 55 years and older was con-

ducted, and high age and low cognitive performance were the strongest predic-

tors of institutionalization and death (Ruitenberg et al., 2001). The relationship

between the presence of psychotic symptoms and dependence in both basic and

instrumental ADL were investigated in patients with AD who were referred to a

memory clinic. Dependence in ADL was associated with psychotic symptoms as

well as cognitive decline and depression, but the possible causal relationship be-

tween psychotic symptoms and dependence in ADL needs to be further investi-

gated (Tran, Bedard, Molloy, Dubois, & Lever, 2003). On the other hand, the

annual rates of change in the cognitive and functional scales have been calcu-

lated in AD patients and investigated in relation to the clinical predictors

(Swanwick, Coen, Coakley, & Lawlor, 1998). Although age and duration of symp-

toms at entry were not predictive of the rate of decline partly because of the large

variability in the progression rate, male sex was associated with a faster decline

in cognition.

Risk Factors of Mortality The number of remaining years of life and the risk fac-

tors for mortality of demented patients are the most important factors in terms of

social and economic issues. Larger numbers of older adults will require more so-

cial services and care, with an attendant increase in medical costs.

Estimates of the median survival from the clinical onset of dementia vary

from 5 to 9.3 years. However, previous studies may have underestimated the

deleterious effects of dementia because patients with rapidly progressing de-

mentia died before commencement of the studies (length bias). Recently, the

median survival from the onset of dementia symptoms, with adjustment for

length bias, was estimated in the Canadian Study of Health and Aging (Wolfson

et al., 2001). From a random sample of 10,263 subjects 65 years and older, 821

subjects with dementia, including 648 patients with AD, were followed up for 5

years. The estimated median survival was 3.3 years after the adjustment for the

length bias, even though the mean age at sampling was 83.8 years (Kawas &

Brookmeyer, 2001). In the Personnes Agees Quid prospective population-based

cohort study in France, 2,923 elderly were followed up for 8 years, and 281 per-

sons were diagnosed as having incident dementia. The median survival time of

the demented patients was 4.5 years (Helmer, Joly, Letenneur, Commenges,

& Dartigues, 2001). These studies thus showed shorter survival than in the

earlier studies.

A number of surveys were recently conducted to study the survival and risk

factors associated with dementia. An 8-year follow-up study showed that deaths

from cerebrovascular diseases and respiratory disease were more frequent in pa-

tients with dementia than in persons without dementia (Helmer et al., 2001).

With regard to late-stage AD, a 5-year follow-up study in a long-term care facility

showed that better physical health and the presence of delusions were associated

Alzheimer’s Disease 339

Table 13.1

Criteria of Mild Cognitive Impairment (MCI)

Memory complaint, preferably corroborated by an informant

Objective memory impairment

Normal general cognitive function

Intact activities of daily living

Not demented

Source:

“Mild Cognitive Impairment: Clinical Characterization and

Outcome,” by R. C. Petersen et al., 1999,

Archives of Neurology, 56,

pp. 303–308. Reprinted with permission.

with longer survival (Carlson et al., 2001). For early-onset AD, a 5-year follow-up

study of 46- to 64-year-old persons showed that male sex, earlier onset, concur-

rent physical illness at the time of diagnosis, and a low score on the Mini-Mental

State Examination increased the likelihood of death (Ueki, Shinjo, Shimode,

Nakajima, & Morita, 2001).

There is a sex difference in mortality of patients with dementia. Men with AD

have an increased risk of mortality relative to women. A 2-year follow-up study

of AD patients age 65 found that the most important predictors of the age at death

in men were the severity of dementia and occurrence of delirium (Lapane et al.,

2001). In women, the age at death was associated with dependence in physical

functioning, pressure ulcers, aphasia, depression, and malnutrition. The presence

of comorbid conditions, including cerebrovascular diseases, Parkinson’s disease,

and pulmonary disease, were associated with accelerated age at death, and the

association was more evident in women than men.

ILD

OGNITIVE

MPAIRMENT

There are people who are not demented but show mild memory loss or mild de-

cline of other cognitive functions exceeding what would be expected for their

age and educational level. Studies have suggested that people with cognitive de-

cline consisting mainly of memory loss are at higher risk of dementia. There is a

transitional condition between normal aging and dementia. That condition has

been discussed as age-associated memory impairment, age-associated cognitive

decline, mild cognitive disorder, age-related cognitive decline, mild neurocogni-

tive disorder, and cognitive impairment with no dementia. More recently, atten-

tion has been paid to what is thought to be a transitional state to dementia,

referred to as mild cognitive impairment (MCI; Petersen et al., 1999). This is the

clinical state of individuals who are memory impaired but are otherwise func-

tioning well and do not meet the clinical criteria for dementia. The clinical cri-

teria for MCI are shown in Table 13.1. Recent recommendations for MCI criteria

include the following points: (a) The person is neither normal nor demented; (b)

there is evidence of cognitive deterioration shown by either objectively mea-

sured decline over time or subjective report of decline by self or informant in

conjunction with objective cognitive deficits; and (c) activities of daily living are

preserved and complex instrumental functions are either intact or minimally

impaired (Winblad et al., 2004).

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Not all people with MCI develop dementia, but many do. Epidemiological

studies addressed the conversion rate of MCI to dementia. Longitudinal studies

published between 1991 and 2001 were reviewed and summarized, and the an-

nual conversion rate from MCI to dementia in the studies was found to vary from

2% to 31% (Bruscoli & Lovestone, 2004). A meta-analysis of all 1,616 subjects gave

a calculated mean annual conversion rate of 10.24% (95% CI: 6.9% to 11.9%). The

variation in the conversion rate may be explained by the following factors. The

mean age of the cohort ranged from 61.2 to 80.9, although the incidence of AD

and dementia in the elderly increases with age regardless of the presence or ab-

sence of MCI. The follow-up period could have influenced the conversion rate; it

ranged from a minimum of 1.5 years to a maximum of 10 years. Some studies

were conducted in clinical settings, and others in community settings. The mean

annual conversion rate was higher in clinic attenders and lower in community-

dwelling volunteers. Moreover, the most critical issue underlying the variation

among the studies was the criteria used to diagnose MCI. Further discussion of

the standard criteria for MCI is needed.

AN EVIDENCE-BASED ASSESSMENT

OF ALZHEIMER’S DISEASE

IAGNOSTIC

RITERIA

The concept of dementia was described in the 10th revision of the International

Statistical Classification of Diseases and Related Health Problems (ICD-10; World

Health Organization, 2003) and the Diagnostic and Statistical Manual of Mental

Disorders, third edition, revised (DSM-III-R; American Psychiatric Association,

1987), which were recommended by the Quality Standards Subcommittee of the

American Academy of Neurology (Knopman et al., 2001). Both these diagnostic

criteria stipulate that dementia should be caused by a brain disease, should be

chronic and progressive, and necessarily affects higher cognitive functions.

Also, differentiation from other conditions such as delirium and depression is

necessary.

Several sets of diagnostic criteria and scores have been developed for differ-

entiation of the dementia subtypes, including AD. The NINCDS-ADRDA crite-

ria were introduced in 1984 (McKhann et al., 1984) and confirmed the

availability of valid operationalized criteria for AD. These criteria have been

used more widely than others in research as well as in clinical settings and are

recommended by the Quality Standards Subcommittee of the American Acad-

emy of Neurology (Knopman et al., 2001). In the criteria, three degrees of cer-

tainty are described: probable AD, possible AD, and definite AD. The clinical

diagnosis of AD is based on a profile of symptoms, characteristic history, and

the absence of other causes of dementia. The following elements should be con-

firmed after the establishment of the presence of dementia. It is specified that

deficits are required not only in memory but also in other cognitive functions,

such as language ability, constructional ability, thinking, or executive function.

Such deficits should show gradual onset, with progressive decline over a period

of years. To secure the certainty of the diagnosis, an upper age limit of 90 is set

in the criteria because it is sometimes difficult to determine the significance of

cognitive impairment in such very old people, even if for practical reasons the

Alzheimer’s Disease 341

diagnosis of AD is the mode for patients 90 and older in the clinical setting. Dif-

ferential diagnosis should be done by confirmation of the absence of other

causes on the basis of the medical history, examination, and investigation.

When another significant brain disease is present besides AD, such as cere-

brovascular disease, diagnostic difficulties arise. It is important to note that the

presence of concurrent disorders, which may contribute to the dementia, does

not necessarily preclude a diagnosis of AD. An advantage of these criteria is that

they require clinical evaluation, cognitive assessment, and routine blood screen-

ing, but not novel or extensive techniques. The NINCDS-ADRDA criteria have

been repeatedly evaluated in a number of studies and have shown high inter-

rater reliability (Farrer et al., 1994; Kukull et al., 1990; see Table 13.2).

Table 13.2

Criteria for Clinical Diagnosis of Alzheimer’s Disease

I. The criteria for the clinical diagnosis of PROBABLE Alzheimer’s disease include:

• Dementia established by clinical examination and documented by the Mini-Mental

Test; Blessed Dementia Scale, or some similar examination, and confirmed by

neuropsychological tests;

• Deficits in two or more areas of cognition;

• Progressive worsening of memory and other cognitive functions;

• No disturbance of consciousness;

• Onset between ages 40 and 90, most often after age 65; and

• Absence of systemic disorders or other brain diseases that in and of themselves

could account for the progressive deficits in memory and cognition.

II.

Other clinical features consistent with the diagnosis of PROBABLE Alzheimer’s dis-

ease, after exclusion of causes of dementia other than Alzheimer ’s disease, include:

• Progressive deterioration of specific cognitive functions such as language (apha-

sia), motor skills (apraxia), and perception (agnosia);

• Impaired activities of daily living and altered patterns of behavior;

• Family history of similar disorders, particularly if confirmed neuropathologically;

• Laboratory results of:

Normal lumbar puncture as evaluated by standard techniques;

Normal pattern or non-specific changes in EEG, such as increased slow-wave

activity;

Evidence of cerebral atrophy on CT with progression documented by serial

observation.

III.

Other clinical features consistent with the diagnosis of PROBABLE Alzheimer’s dis-

ease, after exclusion of causes of dementia other than Alzheimer ’s disease, include:

• Plateaus in the course of progression of the illness;

• Associated symptoms of depression, insomnia, incontinence, delusions, illusions,

hallucinations, catastrophic verbal, emotional, or physical outbursts, sexual disor-

ders, and weight loss;

• Other neurological abnormalities in some patients, especially with more advanced

disease and including motor signs such as increased muscle tone, myoclonus, or

gait disorder;

• Seizures in advanced disease;

• CT normal for age.

(continued)

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Table 13.2

Continued

IV. Features that make the diagnosis of PROBABLE Alzheimer’s disease uncertain or

unlikely include:

• Sudden, apoplectic onset;

•

Focal neurological findings such as hemiparesis, sensory loss, visual field deficits,

and incoordination early in the course of the illness;

•

Seizures or gait disturbances at the onset or very early in the course of the illness.

V. Clinical diagnosis of possible Alzheimer ’s disease:

•

May be made on the basis of the dementia syndrome, in the absence of other neu-

rological, psychiatric, or systemic disorders sufficient to cause dementia, and in

the presence of variations in the onset, in the presentation, or in the clinical

course;

• May be made in the presence of a second systemic or brain disorder sufficient to

produce dementia, which is not considered to be the cause of dementia;

• Should be used in research studies when single gradually progressive severe

cognitive deficit is identified in the absence of other identifiable cause.

VI. Criteria for diagnosis of definite Alzheimer ’s disease are:

•

The clinical criteria for probable Alzheimer’s disease and histopathological evidence

obtained from a biopsy or autopsy.

VII. Classification of Alzheimer’s disease for research purposes should specify features

that may differentiate subtypes of the disorder, such as:

• Familial occurrence;

• Onset before age of 65;

• Presence of trisomy-21.

Source:

“Clinical Diagnosis of Alzheimer’s Disease: Report of the NINCDS-ADRDA Work Group

under the Auspices of Department of Health and Human Services Task Force on Alzheimer ’s Dis-

ease,” by G. McKhann et al., 1984,

Neurology, 34,

pp. 939–944. Reprinted with permission.

INTERVIEW SCHEDULE

SYCHOGERIATRIC

SSESSMENT

CALES

The Psychogeriatric Assessment Scales (PAS; Jorm et al., 1995) provides an assess-

ment of the clinical changes seen in both dementia and depression. It is a set of

scales covering the clinical domains of dementia and depression as defined by the

ICD-10 (World Health Organization, 2003) and DSM-III-R (American Psychiatric

Association, 1994). It should be applied by a trained lay interviewer or clinician after

familiarization with the manual, and usually takes 10 minutes for each subject. The

scales are based on the items in the Canberra Interview of the Elderly (Mackinnon

et al., 1993), which is a standardized diagnostic interview administered by lay inter-

viewers that involves both examination of the subject and interview of an informant.

The purpose of the PAS is to describe a brief yet comprehensive profile of a subject’s

mental state using a straightforward interview which can be quickly administered

by lay interviewers after training. It is intended for use in clinical settings as well as

for research purposes. When the PAS was developed, various factors were analyzed

using three samples—two clinical samples and one population sample—to derive a

set of independent dimensions underlying the clinical domains of dementia and de-

pression, and then latent trait analysis was applied to select a subset of items having

the most appropriate psychometric properties relative to each other. Five factors

emerged from the principal component analysis of each item in the scales: cognitive

Alzheimer’s Disease 343

Table 13.3

Factors Derived from the Geriatric Mental

State Schedule (GMSS)

1. Depression

2. Anxiety

3. Impaired memory

4. Retarded speech

5. Hypomania

6. Somatic concerns

7. Observed belligerence

8. Reported belligerence

9. Obsessions

10. Drug alcohol dependence

11. Cortical dysfunction

12. Disorientation

13. Lack of insight

14. Depersonalization-derealization

15. Paranoid delusion

16. Subjective experience of disordered thought

17. Visual hallucination

18. Auditory hallucination

19. Abnormal motor movements

20. Nonsocial speech

21. Incomprehensibility

Source:

“A Semi-Structured Clinical Interview for the Assessment of Di-

agnosis and Mental State in the Elderly—The Geriatric Mental State

Schedule: Pt. I. Development and Reliability,” by J. R. Copeland et al.,

1976,

Psychological Medicine, 6,

pp. 439–449. Reprinted with permission.

decline, cognitive impairment, behavior change, stroke, and depression. The internal

consistency of the PAS ranged from .58 to .86, and the test-retest correlation was be-

tween .47 and .66; its validity was proven against other mood and cognitive scales.

ERIATRIC

ENTAL

TATE

CHEDULE

The Geriatric Mental State Schedule (GMSS; Copeland et al., 1976; Gurland et al.,

1976) is a standardized, semistructured interview schedule for measuring a wide

range of psychopathology in elderly people in both institutionalized and commu-

nal settings. It is based on the Present State Examination (PSE; Luria & McHugh,

1977; Wing, Nixon, von Cranach, & Strauss, 1977) and the Psychiatric Status

Schedule (PSS; Spitzer, Endicott, Fleiss, & Cohen, 1970). Many of the items of the

GMSS were adopted from the eighth edition of the PSE, with additional items

taken from the PSS. The GMSS consists of a number of detailed questions con-

cerning the patient’s psychopathology and behavior in the prior month; it allows

classification of the patient by symptom profile and can depict changes in that

profile over time. There is extensive literature on the GMSS. Many different fac-

tors have been derived from the results (see Table 13.3). There is also a computer-

ized algorithm of proven reliability and validity, the Automated Geriatric

Examination for Computer Assisted Taxonomy (AGECAT; Copeland, Dewey, &

Griffiths-Jones, 1986; Copeland, Dewey, Wood, et al., 1986).

Table 13.4

Functional Assessment Staging (FAST)

Stage 1: No cognitive decline.

No subjective complaints of memory deficit. No memory deficit evident on clinical

interviews.

Stage 2 (Forgetfulness):

Very mild cognitive decline.

Subjective complaints of memory deficit, most frequently in the following area:

Forgetting where one has placed familiar objects;

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 regarding symptoms.

Stage 3 (Early Confusional):

Mild cognitive decline. Earliest clear-cut deficits.

Manifestations in more than one of the following areas:

Patient may have gotten lost when traveling to an unfamiliar location;

Co-workers become aware of patient’s relatively low performance;

Word and name finding deficit becomes evident to intimates;

Patient may read a passage of a book and retain relatively little material;

Patient may demonstrate decreased facility in remembering names on introduction

to new people;

Patient may have lost or misplaced an object of value;

Concentration deficit may be evident on clinical testing.

Objective evidence of memory deficit obtained only with an intensive interview. Denial

begins to become manifest in patients. Mild to moderate anxiety accompanies symptoms.

Stage 4 (Late Confusional):

Moderate cognitive decline. Clear-cut deficit on careful clinical

interview.

Deficit manifest in following areas:

Decreased knowledge of current and recent events;

May exhibit some deficit in memory of one’s personal history;

Concentration deficit elicited on serial subtractions;

Decreased ability to travel, handle finances, etc.

GLOBAL ASSESSMENT

UNCTIONAL

SSESSMENT

TAGING

Evaluation of the functional performance and activities of daily living skills is an

essential aspect of the assessment of dementia patients. Functional Assessment

Staging (FAST; Reisberg, 1988; Sclan & Reisberg, 1992) was developed on the basis

of empirical and systematic examination of the functional decline occurring in

patients with AD. By classifying the progress of AD in terms of functional stages,

the FAST helps health professionals and caregivers meet the needs of AD pa-

tients. It permits specific evaluation of the changes in function throughout the

entire course of AD. The FAST is shown in Table 13.4.

The FAST divides the disease process of AD into seven major stages of func-

tional abilities and losses, with a total of 16 successive stages and substages: Stage

1: no cognitive decline; Stage 2 (Forgetfulness): very mild cognitive decline; Stage 3

(Early Confusional): mild cognitive decline, earliest clear-cut deficits; Stage 4 (Late

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Table 13.4

Continued

Frequently no deficit in the following areas:

Orientation to time and person;

Recognition of familiar persons and faces;

Ability to travel to familiar locations.

Inability to perform complex tasks. Denial is dominant defense mechanism. Flattening

of affect and withdrawal from challenging situations occur.

Stage 5 (Early Dementia):

Moderately severe cognitive decline. Patient can no longer

survive without some assistance. Patients are 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 diffi-

culty counting back from 40 by 4s or from 20 by 2s. Persons at this stage retain knowl-

edge of many major facts regarding themselves and others. They invariably know their

own names and generally know their spouse’s and children’s names. They require no

assistance with toileting and eating, but may have some difficulty choosing the proper

clothing to wear.

Stage 6 (Middle Dementia):

Severe cognitive decline. May occasionally forget the

name of the spouse on whom they are entirely dependent for survival. Will be largely

unaware of all recent events and experiences in their lives. They retain some knowl-

edge of their past lives but this is very sketchy. Generally unaware of their surround-

ings, 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 dis-

play ability to recall familiar locations. Diurnal rhythm frequently disturbed. Almost

always recall their own names. 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:

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;

Obsessive symptoms, e.g., person may continually repeat simple cleaning activities;

Anxiety agitation, and even previously nonexistent violent behavior may occur;

Cognitive abulla, i.e., loss of willpower because an individual cannot carry a thought

long enough to determine a purposeful course of action.

Stage 7 (Late Dementia):

Very severe cognitive decline. All verbal abilities are lost. Fre-

quently there is no speech at all—only grunting. Incontinent of urine, requires assistance

toileting and feeding. Loss of basic psychomotor skills, e.g., ability to walk, sit and head

control. The brain appears to no longer be able to tell the body what to do. Generalized

and cortical neurologic signs and symptoms are frequently present.

Source:

“Functional Assessment Staging (FAST),” by B. Reisberg, 1988,

Psychopharmacology

Bulletin, 24,

pp. 653–659. Reprinted with permission.