Mohammed T. Abou-Saleh

310 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYTable 2 Functional assessment stages (FAST) and time course offunctional loss in normal aging and AD*FASTstage Clinical characteristics Clinical diagnosis1 No decrement Normal adult2 Subjective deficit in wordfinding or recallinglocation of objectsAge-associatedmemoryimpairment(normal agedforgetfulness)3 Deficits noted in demanding Mild cognitiveemployment settings4 Requires assistance in complextasks, e.g. handling finances,planning dinner partyvascular dementia. Only in a small minority of dementia cases, anestimated 4% of the total, do Lewy bodies appear independently ofAD and/or cerebrovascular disease. In these cases, a distinctiveclinical picture has been described, marked by fluctuating cognition,recurrent well-formed visual hallucinations, and parkinsonianfeatures 12 . There is a relatively rapid progression of the dementingdisorder in Lewy body dementia, in comparison with AD.Other forms of dementia that occur earlier, as well as in laterlife, including frontotemporal dementia and Creutzfeldt–Jakobdisease, also differ in presentation and course from the classicalAD course outlined in Tables 1 and 2. This AD course, whichapplies to the great majority of dementia patients, is described inTables 1 and 2 and very briefly outlined below.Mild ADimpairmentMild AD5 Requires assistance in choosingproper attireModerate AD6a Requires assistance dressing Moderatelysevere AD6b Requires assistance in bathingproperly6c Requires assistance withmechanics of toileting (suchas flushing, wiping)6d Urinary incontinence6e Fecal incontinence7a Speech ability limited to abouta half-dozen words7b Intelligible vocabulary limitedto a single word7c Ambulatory ability lost7d Ability to sit up lost7e Ability to smile lost7f Ability to hold head up lostSevere ADEstimatedduration ofFAST stageor substagein AD {7 years**2 years18 months5 months5 months5 months4 months10 months12 months18 months12 months12 months18 months12 monthsor longer*Adapted from Reisberg 27 . Copyright & 1984 by Barry Reisberg, M.D.{ In subjects without other complicating illnesses who survive and progress to thesubsequent deterioration stage.**Although the potentially observed duration is 7 years, patients are generally pastthe midpoint of this stage when brought for evaluation.Stage 4 on the GDS and FAST scales, this stage has a meanduration of 2 years. Although overt deficits are present onassessment, patients are still capable of independent communitysurvival, although the ability to manage financial and similarlycomplex affairs becomes compromised. Patients at this stagegenerally endeavor to conceal their deficits, just as humans ingeneral endeavor to appear intelligent and try to presentthemselves well. This concealment may also take the form ofdenial, whereby the patient tries to hide his/her problems fromhim/herself. Another defense mechanism is a flattening of affect,in which the patient is less participatory in social situations andappears to become more quiet and withdrawn. Medicationsfrequently prescribed for AD patients, such as the SSRIantidepressants, may mask these otherwise common symptomsof affective flattening, making these patients appear even moreovertly normal, despite their cognitive deficits.Moderate ADStage 5 on the GDS and FAST scales, this stage has a meanduration of 1.5 years. Patients at this stage have deficits that aresufficient to interfere with independent community survival.Patients who are left alone in the community at this stage areeither assisted by neighbors, relatives or others, or they are preyedupon by less scrupulous persons in our society. Functionally,persons at this stage develop incipient deficits with basic activitiesof daily life. More specifically, patients begin to require assistancein choosing the proper clothing to wear for the season and/or theoccasion. Without assistance, patients will, for example, wear thesame clothes day after day. A variety of emotional responsesdevelop in an attempt to cope with the deficits in this stage. Thesecommonly include suspiciousness, anger and false beliefs 13 . Themagnitude of these emotional responses is probably dependent inpart on the social supports provided to the patient. Patients whoperceive themselves as secure may present themselves in sociallyappropriate ways at this stage and may successfully conceal theirdeficits in social situations.Moderately Severe ADStage 6 on the GDS and FAST scales, this stage has a meanduration of 2.5 years. Patients at this stage develop deficits inbasic activities of daily life. First, difficulties with dressing andbathing occur. Patients will put on clothing in the improper orderor backwards unless assisted. At about the same time, patientsdevelop difficulties with independently adjusting the shower- orbath-water temperature. With the progression of this stage,problems with independent toileting and independent continenceoccur. Collectively, these problems are such that not only can thepatient not survive independently but, additionally, spouses orother caregivers begin to require additional help to manage thepatient in a community setting. Emotional problems in the patientpeak in this stage and generally include aggressivity and activitydisturbances 13 . The newer atypical neuroleptics can be very usefulin managing the overt emotional reactions in the patient, as canpsychological non-pharmacological, management approaches 14,15 .Severe ADStage 7 on the GDS and FAST scales, this is the final stage of AD.Patients succumb throughout the course of this stage; however,the mean time to demise is about 2–3 years. Patients who progressto the final substage of severe AD, may survive for 7 or moreyears in this stage. Speech ability breaks down prior to the adventof this stage in the course of AD, and patients emerge in the finalseventh stage with very limited remaining speech; generally a halfdozen or fewer intelligible words are discernible in the course ofan intensive interview in which numerous queries are presented tothe patient. With the progression of this stage, speech becomeseven more circumscribed. Ambulatory ability may be lostprematurely; however, after speech is lost, the ability of thepatient to walk is inevitably lost. Subsequently, the ability to sit