Why do we need a new diagnostic category of “subjective cognitive decline?”  We already have a system in place to stage the level of memory loss and concerns.  The challenge of a slowly progressive disease like Alzheimer’s is that it unfolds over several decades, it has subtle beginnings (difficult to tell from senior moments early on), and it does not always lead to dementia (i.e., disability).  This means that many, but not all, will be aware that they are changing well before it can be recognized from the outside.

The Global Deterioration Scale is designed to stage level of memory loss and has been available for years.  It comes in several forms but in essence the scale marks seven stages from no decline to total disability.  It serves as a guide to determine what actions need to be taken and what level of caregiving is required.  The stages are as follows:

Stage 1: Normal.  No obvious memory deficits on either interview or objective assessment beyond normal aging.  May be marked by subjective complaints that should be monitored by serial memory assessments.

Stage 2: Forgetfulness.  Often manifested by subjective complaints about forgetting or not as “sharp” as in the past but no obvious memory deficits on either interview or objective assessment.  If prior thorough memory testings, score has declined compared to baseline. Memory screenings at this level are not helpful as they are too easy

Stage 3: Early Confusional State. Marks earliest clear-cut deficits on interview and objective testing.  Slowness in doing complex tasks and often less able to organize things.   Memory Screenings may show mild changes.

Stage 4: Late Confusional State.  Very clear-cut deficits on both thorough objective testing and clinical interview.   Instrumental activities of daily living (IADLs) such as handling finances, doing the checkbook, cooking is impaired.  Memory Screenings show mild changes.  Needs assistance with complex tasks.

Stage 5: Early Dementia.  Person so impaired that they would no longer survive without some assistance.  Cannot live alone.  Needs caregiving for meals, managing medications, shopping.  Forgetful of major facts about personal life.  Personal care still intact.  Memory Screenings show moderate changes.

Stage 6:  Middle Dementia.  Severe impairment on both interview and objective assessment.  Unaware of surroundings.  Needs assistance with activities of daily living (ADLs) such as toileting, bathing, may be incontinent, cannot travel alone.  Very passive as a rule and disengaged.  Difficulty with communication.   Needs 24/7 supervision.  May do very well in secured, structured memory are units.

Stage 7: End Stage or Terminal Dementia.  Very severe cognitive decline.  Cannot talk, cannot dress, incontinent, bedbound, needs to be fed.  Consider hospice as part of the care plan.

Strategic planning starting in stage one is essential for effective treatment of progressive memory loss.  Your best protection comes from monitoring stages and proactively planning ahead for how to manage changes before they occur.  The best plans get on top of things before the person forgets that they forget.