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The Five Stages and Different Behaviors of Alzheimer’s Disease

Fellow North Carolinian Teepa Snow along with colleagues Melanie Bunn and Claudia Allen have developed a hierarchy for the different stages of Alzheimer’s Disease.   By understanding the behaviors of your loved one with Alzheimer’s and the stage of the disease, you can provide him or her with care more successfully and with less frustration.

  • Stage 5 – Early Loss (of Cognitive Ability)
  • Stage 4 – Moderate Loss
  • Stage 3 – Middle Loss
  • Stage 2 – Severe Loss
  • Stage 1 – Profound Loss

Follow the guidelines here to so you and your loved one can get along with less friction and frustration.  Always keep in mind three things:

  1. With Alzheimer’s Disease and all dementias, your loved one has brain damage and is unable to do things he or she used to.  You need to make the adjustment, not them.
  2. As the disease progresses, your loved one will understand less and less the meaning of words.  They will be less able to express themselves.  However they still feel.  Try to maintain an upbeat attitude and cheery voice.  Yes, sometimes it’s hard to do.
  3. If it’s not dangerous, let it be.  Who cares if dad’s shirt does not match his slacks?  If he was able to get dressed by himself, compliment him on his “new look” and enjoy your time with him.  You’ll both be happier.

Alzheimer’s Stage 5

Loved ones with Stage 5 Alzheimer’s show cognitive decline, but in many ways can get by with minimal supervision.  While they look to authority figures for help and direction, they are successful at following prompted schedules and are good at sticking with familiar routines.  In fact, deviation from  established routines may cause them tremendous disquiet.  People with Stage 5 Alzheimer’s can become frustrated when things don’t go well and when others do not behave “correctly”.  A typical Stage 5 behavior is to become upset if someone sits in “my seat” in the dining room.

Caring for the Stage 5 Alzheimer’s individual requires a firm, yet gentle approach.  They want to feel in charge, but still need prompting.  As a caregiver, you should be clear, concrete, but never bossy.  Make the decision process simpler.  Rather than asking open ended questions like, “What would you like to do today?”, offer two choices.  For example, “Would you like to go to the park, or go see a movie?”  “Do you want to have noodle soup or tomato soup?”   By limiting choices, you make the decision process simpler while leaving your loved one in control.

With all activities, remember that a key behavior change is for them to process information at a slower pace.  Break complex tasks into parts.  Rather than saying, “Go get dressed”, break it into individual tasks.  “Let’s put on our pants.  Do you want the brown ones or the black ones?”  “Let’s put on our blouse.  The white one or the pink one?”

Alzheimer’s Stage 4

A mother or father with Stage 4 Alzheimer’s will ask questions again and again.  They rely on visual cues much more than verbal ones.  You need to use clear gestures to communicate with them, as they do much better with demonstration than verbal instructions.  At this stage of Alzheimer’s disease, your loved one will exhibit problems with activities of daily living, like hygiene and grooming.  Normally simple activities will seem complex, so the Stage 4 patient needs things broken down into steps.

As with all stages of the disease, a caregiver should avoid pointing out mistakes.  Simply work around them.  Take pleasure in their accomplishments, however small. Use simple, clear instructions, ONE STEP AT A TIME.  Make good use of demonstration, gestures and visual cues.  For example, if you are helping your dad get dressed,

  1. Make eye contact,
  2. Hand him his T-shirt,
  3. With a big smile say, “Let’s put on your T-shirt”,
  4. Pretend you are putting a T-shirt on yourself, and
  5. Repeat with each item of clothing.

Alzheimer’s Stage 3

If your loved one is at Stage 3, you will find he or she will need step-by-step guidance.  At Stage 3, it’s all about sensory input.  Alzheimer’s sufferers like to handle and touch things.  They may often grab things belonging to others and, if in an assisted living facility, will hoard them in their room.  Stage 3 patients are often attracted to things that smell, look and taste good.  They are uncomfortable in busy, crowded environments.

When your mom or dad is at Stage 3 of Alzheimer’s the observation that caring for an elder loved one is like caring for a toddler becomes very apparent. You must accept that the distinction between “yours” and “not yours” ceases to exist — everything is theirs.  The strategy is not to get into fights, but simply to make trades and use distraction as much as possible.  At Stage 3, it’s best, as much as possible, to put inappropriate objects out of the way.  Let your loved one have access to things that are “OK to get into”.   Limit noise in the environment and try to keep them away from over-stimulation.

It’s a curious thing that someone at Stage 3 does not mix well with someone at Stage 5.  Stage 3 sufferers have lost all sense of order, while Stage 5 patients need to have everything predictable and orderly.

Alzheimer’s Stage 2

At Stage 2 of Alzheimer’s disease, your loved one’s ability to communicate is greatly reduced.  Stage 2 patients tend either to nap or appear to be asleep, or are active, walking or moving around in their wheelchair.  They will use their hands poorly and movements will not be consistent.  At this stage, suggested movements by caregivers need to be “big” or over-emphasized.  The Stage 2 Alzheimer’s patient will have limited awareness of others and may often invade their personal space.

Care for a person at Stage 2 needs to emphasize gross motor movements and focus on simple, one step activities.  Projects need to be broken down into individual steps.  Caregivers must remind themselves to slow down and keep the environment quiet.  “hand under hand” assistance is particularly valuable at Stage 2.

Alzheimer’s Stage 1

At Stage 1, the Alzheimer’s patient will typically be bed bound or chair bound.  Your loved one will spend more time asleep or in a state of unawareness.  You will notice many “primitive” reflexes, as they will startle easily.  The Stage 1 patient may cry out or mumble regularly.

Care for Stage 1 Alzheimer’s patients must be kept elementary.  Use large, firm yet gentle movements.  Caregivers should speak in gentle, soothing tones of voice.  Yourt loved one may understand little, but they will be sensitive to the tone of voice you use.