Stage 2 (Forgetfulness) Very mild cognitive decline.

Subjective complaints of memory deficit, most frequently in the following area:

1. forgetting where one has placed familiar objects;
2. forgetting names on formerly knew well.

No objective evidence of memory deficit on clinical interview. No objective deficits in employment or social situations. Appropriate concern regarding symptoms.

Stage 3 (Early Confusional) Mild cognitive decline. Earliest clear-cut deficits.

Manifestations in more than one of the following areas:

1. patient may have gotten lost when traveling to an unfamiliar location;
2. co-workers become aware of patient's relatively low performance;
3. word and name finding deficit becomes evident to intimates;
4. patient may read a passage of a book and retain relatively little material;
5. patient may demonstrate decreased facility in remembering names upon introduction to new people;
6. patient may have lost or misplaced an object of value;
7. concentration deficit may be evident on clinical testing.

Objective evidence of memory deficit obtained only with an intensive interview. Denial begins to become manifest in patient. Mild to moderate anxiety accompanies symptoms.

Stage 4 (Late Confusional) Moderate cognitive decline. Clear-cut deficit on careful clinical interview.

Deficit manifest in following areas:

1. decreased knowledge of current and recent events;
2. may exhibit some deficit in memory of one's personal history;
3. concentration deficit elicited on serial subtractions;
4. decreased ability to travel, handle finances, etc.

Frequently no deficit in the following areas:

1. orientation to time and person;
2. recognition of familiar persons and faces;
3. ability to travel to familiar locations.

Inability to perform complex tasks. Denial is dominant defense mechanism. Flattening of affect and withdrawal from challenging situations occur.

Stage 5 (Early Dementia) Moderately severe cognitive decline.

Patient can no longer survive without some assistance. Patient is unable during interview to recall a major relevant aspect of their current lives, e.g., an address or telephone number of many years, the names of close family members (such as grandchildren), the name of the high school or college from which they graduated. Frequently some disorientation to time (date, day of week, season, etc.) or to place. An educated person may have difficulty counting back from 40 by 4s or from 20 by 2s. Persons at this stage retain knowledge of many major facts regarding themselves and others. They invariably know their own names and generally know their spouse's and children's names. They require no assistance with toileting and eating, but may have some difficulty choosing the proper clothing to wear.

Stage 6 (Middle Dementia) Severe cognitive decline. May occasionally forget the name of the spouse upon whom they are entirely dependent for survival. Will be largely unaware of all recent events and experiences in their lives. Retain some knowledge of their past lives but this is very sketchy. Generally unaware of their surroundings, the year, the season, etc. May have difficulty counting from 10, both backward and sometimes forward. Will require some assistance with activities of daily living, e.g., may become incontinent, will require travel assistance but occasionally will display ability to familiar locations. Diurnal rhythm frequently disturbed. Almost always recall their own name. Frequently continue to be able to distinguish familiar from unfamiliar persons in their environment.

Personality and emotional changes occur. These are quite variable and include:

1. delusional behavior, e.g., patients may accuse their spouse of being an impostor, may talk to imaginary figures in the environment, or to their own reflection in the mirror;
2. obsessive symptoms, e.g., person may continually repeat simple cleaning activities;
3. anxiety agitation, and even previously nonexistent violent behavior may occur;
4. cognitive abulla, i.e., loss of willpower because an individual cannot carry a thought long enough to determine a purposeful course of action.

Stage 7 (Late Dementia) Very severe cognitive decline. All verbal abilities are lost.