Five Stages of Alzheimer's Disease

Content provided by the Faculty of the Harvard Medical School
Excerpted from a Harvard Special Health Report

One way of describing Alzheimer's disease is to divide it into five stages.

Stage 1. Memory problems occur. Initially, they may seem like slight absentmindedness and may go unnoticed by others. Some people with Alzheimer's are quite successful at hiding these symptoms, but this becomes increasingly difficult. They may lose or misplace valuable objects. They may not fully absorb what they read or hear, and their performance on the job or in social situations begins to suffer. They may become confused in new surroundings or lost in an unfamiliar part of town. Word-finding problems or aphasia — the inability to comprehend language — may begin at this stage.

The first personality change is usually a loss of spontaneity. People who have Alzheimer's disease may avoid situations that challenge their abilities and may become withdrawn, apathetic, moody, depressed, irritable, or anxious. They typically deny their problems are serious, even to themselves, and may blame others for their failures. The family may assume that the person is under stress or suffering from an emotional problem.

Stage 2. The person's memory problems are now more obvious to others. Because it's difficult for people with Alzheimer's to retain new information, they may lose the thread of conversations. They sometimes have difficulty recalling current events, such as who the president is, and even bits of information from their own personal history, such as where they attended school. Their ability to perform mathematical calculations suffers, and they may no longer be able to manage their own finances. Depression often becomes prominent at this stage, further hampering the ability to function.

Impaired reasoning and judgment make traveling more difficult. Although people at this stage may be able to find their way around familiar areas, their ability to handle unexpected events is impaired, which makes driving risky. In addition, dishonest people can now more easily victimize them. People with Stage 2 Alzheimer's can have a striking lack of insight into their problems. They may refuse any assistance with finances, but forget to pay bills; insist on driving, but have a series of fender-benders; continue to cook, but repeatedly scorch empty pots on the stove.

Stage 3. Memory can fluctuate daily or even hourly. People sometimes forget major events in their lives, and yet continue to deny having memory problems. As they try to fill memory gaps, their conversation may become disjointed and contain irrelevant content. Often they are unaware of the date or the time of year.

The continuing deterioration of memory makes people feel insecure, which they may express with paranoia or anger. They may accuse others of hiding things, stealing, or plotting against them. Their emotions are unstable, and their relations with others may be marred by rapid mood swings that have no apparent cause. Individuals may have episodes of crying, angry outbursts, and agitation.

At this stage, people with Alzheimer's are no longer able to survive without some assistance. Although able to manage many basic activities of daily living, such as using the toilet and eating, they only partially complete some tasks because they cannot remember all the steps involved. Their grooming and choice of clothes may be the most obvious sign of this difficulty. A simple decision such as which sweater to wear can be overwhelming.

The decreased ability to think forces the person to withdraw from social activities that require active participation. Undemanding activities such as attending a concert may still be enjoyable, but going to a dinner party would be bewildering. The inability to handle potentially stressful situations causes anxiety, which can trigger catastrophic reactions such as shouting, cursing, or hitting others.

Stage 4. Dramatic changes occur. The person may begin to look ill. His or her language skills are considerably reduced, and memory impairment becomes so profound that everything can seem unfamiliar and threatening. Some knowledge of the past is usually retained, but it is fragmentary.

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More than 5.3 million people in the United States are living with Alzheimer's disease, with a new person developing the disease every 70 seconds. Americans ages 65 and older with Alzheimer's and dementia pay three times as much in health care costs.