The Seven Stages of Dementia: Symptom Changes Over Time

Dementia usually refers to a set of symptoms that primarily affect older adults. These symptoms can include problems with memory, cognition, and management of daily life. According to the Centers for Disease Control and Prevention (CDC), Alzheimer's disease tends to be the most common type of dementia. Multiple other diseases can also cause dementia, and some people develop dementia for unknown reasons.

In 1982, a medical researcher named Dr. Barry Reisberg and his associates outlined seven stages of dementia. They called these stages the Global Deterioration Scale. Sometimes, these stages are also called the seven stages of Alzheimer's. These dementia stages can provide a general outline for the phases people experience throughout the progression of dementia. Those living with dementia often benefit from working with a therapist to cope with the changes they may experience.

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Stage 1: No dementia symptoms

Generally, in the first stage of dementia, a person isn't yet showing noticeable signs of memory loss, cognitive impairment, or difficulty with daily life. However, if a person is developing Alzheimer's disease, changes in the brain may occur that will later be recognized as the cause of dementia symptoms.

Johns Hopkins researchers have found that among people with Alzheimer's disease, brain changes often begin between three and 10 years before outward symptoms develop. In some people, brain changes may begin as early as 30 years before symptoms become apparent. This research is still in its early stages, so at this point, doctors do not yet screen for brain changes in asymptomatic patients.

Stage 2: Subjective memory loss

In the second stage of dementia, a person usually begins to experience mild forms of memory loss. These may include forgetting people's names or misplacing items more easily. This memory loss is considered subjective because it's typically noticed by the person experiencing it, but it doesn’t affect them enough for other people to notice and consider it abnormal. Sometimes, this stage is also referred to as subjective cognitive decline.

When a person experiences subjective memory loss, their symptoms are generally "indistinguishable" from regular forgetfulness. That means a person at this stage usually does not yet know that they are developing dementia. Like stage one, stages two and three are normally considered pre-dementia stages. In these stages, a person cannot yet be diagnosed with dementia, but they are in the process of developing it.

Stage 3: Mild cognitive impairment

Mild cognitive impairment (MCI) is a diagnosis normally given to people who are experiencing some signs of dementia but are not yet impacted enough to qualify for a dementia diagnosis. Sometimes, others, like friends, family members, and coworkers, notice MCI symptoms in a person. Other times, the symptoms are more subtle and might not be noticed for years. On average, a person is in the MCI stage for seven years, and cognitive decline symptoms may become more severe as time goes on.

If they are still employed, a person with MCI may notice that their work seems more difficult, and tasks they used to handle easily sometimes fall through the cracks. Focusing may become difficult and remembering things might seem like a struggle. These symptoms may cause stress and anxiety, and as they become more severe, choosing to retire could relieve stress.

In general, a person in the MCI stage should seek an evaluation by a medical professional. A wide variety of conditions can cause MCI or similar symptoms, so it can be important to determine what is happening as early as possible in order to begin the right type of treatment or management plan.

Stage 4: Moderate cognitive decline

When a person experiences moderate cognitive decline, their ability to manage daily life may diminish. Many people continue to live independently during this stage, but they may need help with certain tasks, like preparing meals or paying bills. 

A person's memory and mood typically change during this stage. They may often forget what day or time it is or forget about something they did recently. Their mood may become emotionally flat, and they may socially withdraw. Many people in this stage may be in denial about their cognitive decline, and they might try to hide their symptoms or deny having them.

Stage 5: Moderately severe cognitive decline

The moderately severe cognitive decline stage is usually considered moderate dementia. At the moderately severe decline stage, living independently may become difficult or impossible. People may need daily help, such as reminders to get dressed and help with making meals. Often, a person in this stage needs someone else to pay their bills and either help with or take over their finances. Some people in this stage can stay in their own homes as long as they have the right daily help, while others may move into assisted living or another facility.

Often, people at this stage quickly forget major events in which they recently participated. They may struggle to remember the president's name, their current address, or the day's weather, even if they've recently been outside. In addition to problems with recent memories, a person at this stage may lose memories from long ago, such as the names of schools they attended or years they graduated. Their symptoms may vary from day to day, so they may seem to have a good memory on some days and major memory deficits on other days. 

Receiving support tends to be essential at this stage. Without adequate support, it can be possible for others to take advantage of individuals with dementia. In addition, a person who does not have enough support may display anger, behavioral problems, and suspiciousness.

Stage 6: Severe cognitive decline

Severe cognitive decline can also be called moderately severe dementia. With severe decline, most people can no longer live independently, even with someone coming over daily to help them. Instead, a person in this stage usually requires 24-hour supervision. 

The severe cognitive impairment a person in stage six experiences can cause them to majorly struggle with remembering events or being aware of what is occurring. They rarely know what day it is, their address, or the day's weather. They may even confuse people they have known for years with others and, for example, call their wife by their daughter's name. They may not recognize friends and family members, and as a result, they may show signs of suspiciousness when they believe a stranger is pretending to know them.

Many times, stage six can lead to major changes in mood and personality. A person may become restless and frequently pace around the room. They may become aggressive or even violent toward others and, at the same time, deeply fear being left alone. These types of symptoms can make living with others difficult, and they typically require proper care and management.

On average, people remain in stage six for about two and a half years. Stage six can be broken into multiple substages based on the person's ability to complete various tasks.

Stage 6a

In stage 6a, a person may not only forget to change their clothes each day without a reminder, but they typically become physically unable to properly put clothes on by themselves. For example, without assistance, they may put their arm through the neck hole of a shirt or put pants on backward.

Stage 6b

Stage 6b is normally marked by the inability to bathe oneself. Often, the first sign of bathing difficulty is trouble adjusting water to the correct temperature. In the beginning of stage 6b, a person may be able to shower or bathe on their own if someone else turns the water on and adjusts the temperature for them, so it's not too hot or cold. With time, a person in stage 6b usually requires more assistance with bathing themselves. They may also need help with other aspects of hygiene, like brushing their teeth.

Stages 6c, 6d, 6e

In stages 6c, 6d, and 6e, a person generally loses the ability to use the toilet properly. Initially, in stage 6c, they may forget to flush the toilet after using it. As 6c progresses, they may not wipe properly or fail to put toilet paper into the toilet after using it.

In stage 6d, a person may experience urinary incontinence. In stage 6e, they may experience fecal incontinence. Going to the bathroom frequently throughout the day may prevent episodes of accidents during this stage. With time, wearing special undergarments and sleeping on special bedding is usually required.

Stage 7: Very severe cognitive decline

Very severe cognitive decline is the final stage, and it can also be called severe dementia. This stage is normally characterized by a very severe decline and can be broken into six substages.

Stage 7a

In stage 7a, the vocabulary of a person with severe dementia may deteriorate. They may only be able to remember a few words, which can greatly limit their ability to communicate with others and be understood.

Stage 7b

In stage 7b, a person can either lose their ability to speak or only have one word they can say. Once a person cannot speak, they usually lose their ability to walk and move around. Receiving excellent care at the start of stage 7b may prolong the period of time a person can continue walking or moving around, however. Stage 7b lasts about one and a half years on average.

Stage 7c

In stage 7c, a person may no longer speak or walk. This stage often lasts for about one year.

Stage 7d

In stage 7d, a person may no longer sit up without help. If placed in a chair, they will usually fall over unless there are armrests or other devices to help them sit upright. Stage 7d generally lasts for about one year.

Stage 7e

In stage 7e, a person may no longer be able to smile. Instead, they may make facial expressions described as grimaces. This stage tends to last for about a year and a half.

Stage 7f

In stage 7f, a person may no longer hold up their head without assistance. People can remain in stage 7f for an indefinite amount of time. That said, many people pass away due to pneumonia or other infections after entering this stage.

Those who stay in stage 7f for a long period of time may develop rigid muscles and joints. With time, their exams may show that they can no longer move their joints, such as their elbows, with the same range of motion they previously had. People may also develop joint deformities during this stage or other substages of stage seven.

Remote therapy for dementia

Therapy may not directly treat dementia, but it may help people process thoughts and emotions related to a dementia diagnosis and become more accepting of the changes they are experiencing. Remote therapy may be particularly helpful because it doesn't require a person to travel to a therapist’s office. Instead, remote therapy generally allows a person to receive treatment from the comfort of their own home. BetterHelp is a remote therapy platform that can connect individuals with qualified therapists who suit their needs and preferences.

Researchers haven't specifically studied the efficacy of remote therapy for dementia. That said, the Alzheimer's Society recommends talk therapy for people in the early and middle stages of dementia. They note that research shows therapy can help people experiencing dementia talk openly about their experiences, maintain healthy relationships, and reduce symptoms of anxiety and depression.

In addition, existing research reports that online therapy typically produces the same client outcomes as in-person therapy, which suggests that online therapy could be just as helpful as in-person therapy for those with dementia.