Recognizing Alzheimer's Disease

As healthcare professionals we are often asked to define Alzheimer's disease, dementia, and memory loss. In order to do so we must begin by defining dementia. Dementia is a loss of mental ability severe enough to interfere with normal "activities of daily living" (ADL's). Dementia occurs as a result of gradual death of brain cells resulting in loss of cognitive abilities. Dementia leads to impairments in memory, planning, and behavior. Dementia usually is caused by degeneration in the cerebral cortex, the part of the brain responsible for thoughts, memories, actions, and personality. The most common cause of dementia is Alzheimer's disease accounting for one-half to three-fourths of all cases. Therefore, Alzheimer's disease and memory impairment are dementia. In that Alzheimer's disease accounts for the majority of dementia the following seven stages of deterioration and clinical characteristics are defined:

Stage 1: No cognitive decline (Normal). No subjective complaints of memory deficit.

Stage 2: Very mild cognitive decline (Forgetfulness) Subjective complaints of memory deficit, most frequently in the following areas: (a) forgetting where one has placed familiar objects; (b) forgetting names one formerly knew well.

Stage 3: Mild cognitive decline (Early Confusional) Early 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) word and name deficit recognized by others.

Stage 4: Moderate cognitive decline (Late Confusional) Clear cut deficit. Deficit manifest in following areas: (a) decreased knowledge of current and recent events; (b) may exhibit some deficit in memory of one's personal history; (c) decreased ability to travel, handle finances, etc.

Stage 5: Moderately severe cognitive decline (Early Dementia) Patient can no longer survive without some assistance. Patient is unable during interview to recall a major relevant aspect of their current life, e.g., their address or phone number of many years, the names of close members of the family, the name of the high school or college from which he or she graduated, frequently some disorientation to time (date, day of the week, season, etc. or to place.

Stage 6: Severe cognitive decline (Middle Dementia) May occasionally forget the name of the spouse whom he or she is entirely dependent for survival. Patient will be largely unaware of all recent events and experiences. Patients are generally unaware of their surroundings. May have difficulty counting from 10 both backward and sometimes forward. Will require assistance with "activities of daily living" (ADL'S), e.g., may become incontinent. Personality and emotional changes occur. They are quite variable and include: (a) delusional behavior, e.g., patients may accuse their spouse of being an imposter, 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 individual cannot carry a thought long enough to determine a purposeful course of action.

Stage 7: Very severe cognitive decline (Late Dementia) All verbal abilities are lost. Frequently 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. The brain appears to no longer be able to tell the body what to do.