Stage 6a
At this stage, the ability to perform basic activities of daily life becomes compromised. Functionally, five successive substages are identifiable. Persons initially in stage 6a, in addition to having lost the ability to choose their clothing without assistance, begin to require assistance in putting on their clothing properly. Unless supervised, the person with Alzheimer’s disease may put their clothing on backward, they may have difficulty putting their arm in the correct sleeve, or they may dress in the wrong sequence.
The total duration of the stage of moderately severe Alzheimer’s disease (stage 6a through 6e) is approximately 2.5 years in otherwise healthy persons.
Stage 6b
At approximately the same point in the evolution of AD, but generally just a little later in the temporal sequence, AD persons lose the ability to bathe without assistance (stage 6b). Characteristically, the earliest and most common deficit in bathing is difficulty adjusting the temperature of the bath water. Once the caregiver adjusts the temperature of the bath water, the AD person can still potentially otherwise bathe independently. As this stage evolves, additional deficits occur in bathing and dressing independently. In this 6b substage, AD persons generally develop deficits in other modalities of daily hygiene such as properly brushing their teeth.
Stages 6c, 6d, 6e
With the further evolution of AD, persons lose the ability to manage independently the mechanics of toileting (stage 6c). Unless supervised, the person with AD may place the toilet tissue in the wrong place. The AD person may also forget to flush the toilet properly. As the disease evolves in this stage, AD person subsequently become incontinent. Generally, urinary incontinence occurs first (stage 6d), then fecal incontinence occurs (stage 6e). The incontinence can be treated, or even initially prevented entirely in many cases, by frequent toileting. Subsequently, strategies for managing incontinence, including appropriate bedding, absorbent undergarments, etc., become necessary.
In this sixth stage cognitive deficits are generally so severe that persons will display little or no knowledge when queried regarding such major aspects of their current life circ*mstances as their current address or the weather conditions of the day.
In this stage, the AD person’s cognitive deficits are generally of such magnitude that the person with AD may, at times, confuse their wife with their mother or otherwise misidentify or be uncertain of the identity of close family members. At the end of this sixth stage, the ability to speak begins to break down.
Recall of current events in this 6th moderately severe stage of AD is generally deficient to the extent that the AD person frequently cannot name the current national head of state or other, similarly prominent newsworthy figures. Persons at this sixth stage will most often not be able to recall the names of any of the schools which they attended. They may or may not recall such basic life events as the names of their parents, their former occupation or the country in which they were born. They still have some knowledge of their own names; however, persons in this stage may mistake the identity of persons, even close family members. Calculation ability is frequently so severely compromised at this stage that even well-educated persons with AD have difficulty counting backward consecutively from 10 by 1s.
Emotional changes generally become most overt and disturbing in this sixth stage of AD. Although these emotional changes may, in part, have a neurochemical basis, they are also clearly related to the AD person’s psychological reaction to their circ*mstances. For example, because of their cognitive deficits, persons at this stage can no longer channel their energies into productive activities. Consequently, persons may begin to fidget, to pace, to move objects around, or to manifest other forms of purposeless or inappropriate activities. Because of their fear, frustration and shame regarding their circ*mstances, these persons frequently develop verbal outbursts and also threatening, even violent behavior. Because these AD persons can no longer survive independently, they commonly develop a fear of being left alone. Treatment of these and other behavioral and psychological symptoms involves counseling regarding appropriate activities and the psychological impact of the illness on the person with AD frequently in combination with pharmacological interventions.
The mean duration of this sixth stage of AD is approximately 2.5 years. As this stage comes to an end, the AD person, who is doubly incontinent and needs assistance with dressing and bathing, begins to manifest overt breakdown in the ability to articulate sentences and words. Stuttering (verbigeration), neologisms, making up nonexistent words, and/or an increased paucity of speech, become manifest.
