Stages of Dementia: Stages 4 and 5

Stage 4

Stage four is mild dementia. It's a moderate cognitive decline, but it is considered mild dementia. One of the most defining factors of stage four is that there's going to be this breakdown in complex activities of daily living or instrumental activities of daily living, also known as IADLs.  

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So, when you think of complex, I want you to think of:

• Managing finances
• Managing the household
• Caring for pets
• Managing medications
• Grocery shopping
• Meal preparation
• Traveling
• Driving

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...those sorts of more complex activities that are very reliant on memory, reasoning, logic, problem solving. They have a lot of moving components, you're going to start seeing a breakdown in it. Okay?

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So, consider a couple of things. So maybe you notice with finances, that mom is paying bills twice, maybe missing bill payments all together. Maybe she's falling victim to different scams. That's a sign, okay? Another thing might be with driving, maybe they're taking a lot longer to run errands. Maybe they're getting lost on their way to somewhere or back home. Maybe they're responding a lot more slowly to traffic signs and signals, things like that. When it comes to medications, maybe they're having a hard time remembering, did I take this pill that I not take this pill? How many times a day am I supposed to take this pill. Remembering that they even have medications to take those sorts of breakdowns? When it comes to like grocery shopping and meal prep, there may be some challenges as far as following new recipes, building a proper grocery list. So, being able to look and see what they already have, and know, "Okay, I have this, but I still need these things." Then, getting to the grocery store, remembering exactly what they need, where to find it, navigating those aisles. Maybe you also notice that they're leaving the stove on more frequently or the oven on more frequently. Maybe they're putting things on the stovetop or in the oven or in the microwave that shouldn't belong there. Maybe they're burning more food because they're not keeping track of the time correctly, things like that. And you have to remember that this may look different for every person because dementia affects everyone differently. So, the breakdown and these complex activities may be different. But those are some of the things that you want to keep in mind.

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Now, the good thing is in this stage, people are still usually oriented as far as like time and place, but they might need reminders. So, they have a general understanding of what year it is, what season it is, what month it is, the 'round about day, and they know where they are, usually. They are also usually aware of like familiar faces and familiar names, especially of people who interact with them on a pretty regular basis.  

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Now, what I will say is the four areas that family members or friends really start noticing is that residual breakdown in job performance from stage three, which gets worse. They notice the financial issues, the issues with meal prep, and the issues with driving. That's when the alarms start going off, like "hmm, there might be a problem going on." Now, this is where families start kind of taking over. And, I want to tell you that this is where you should be very mindful and careful about how you proceed because you don't want to just take something away from someone because there's that saying, "everything that you do for someone is something you're taking away from them." And, that's how it can feel. At stage four the person is usually very aware that they're having a hard time and that things just aren't making sense for them like it used to. So, they're there wanting to do these things, but they're just struggling to do it. So for somebody to come along, pointed out and then want to take it away from them, that can cause a lot of anger, resentment, push-back, as far as like, "no, you're not taking that away from me. You're not doing that I'm not letting you."

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You want to be careful. You want to make sure you approach it as far as a partnership, and you try to work with them, have them involved along the process, give them choices. You really want it to be a partnership. If you notice on my platform, I use care partner a lot. And that's because I feel like the best way to have a positive healthy relationship along this dementia care journey is to build a partnership. So, if you can keep your partner as in control of their life as possible, you'll get a lot less kickback. Okay? The waters are still going to be rough. I mean relationships in general can be rough and then you throw dementia in there, and it can get rough. But, if you try to be mindful that it's not a good feeling when people start taking things away from you, I think it will help you approach it in a more skillful, tactful, and mindful manner.  

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Stage 5

Stage five is considered moderate dementia or a moderately severe cognitive decline. In stage five, the defining factor is that you're going to start to see a breakdown in basic activities of daily living, meaning personal self-care. Now, this is not so much in a physical sense at this stage. This is more in a "memory, mental capacity" type of way. So, what I mean by that is, they can physically put their clothes on, they can brush their teeth, they can feed themselves, but they just have to remember to do it. What you might notice is that dad is wearing the same clothes for two or three days and won't change them if you don't tell him to or that dad hasn't bathed in two or three days and won't unless you tell him to, or mom goes all day without eating, or dad eats, and then 20 minutes later complains about being hungry and that he hasn't eaten. That's what I mean. They can physically do things, but they're having a hard time remembering if they need to do something or if they've already done something. That's where the breakdown really starts happening in those basic self-care tasks.

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So, what becomes important at this stage is definitely having a routine, giving reminders, cues, prompts for them to engage in some activity, okay, whether that be getting dressed, taking a bath, eating — those types of things.  

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Another thing that you might notice at stage five is that they have a hard time choosing appropriate clothing for the weather or for an event or an occasion. So, they might need some reminders or cues to kind of help them pick out the proper outfit coordinate items, things like that.  

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Something else that's really important for you to know about stage five is that there's going to be increased confusion and disorientation especially when it comes to the place and the time. And also, they're not going to know their phone number usually, and they're not going to know their address, but they do usually know who they are, what their name is—they may even know the name of their spouse or their children. But as far as like grandchildren or other distant relatives, or maybe friends that don't really keep in touch, they might forget their names and might not even recognize their face.

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So, one of the important things that I want to tell you about stage five is that if you haven't seen resistance already at stage four, stage five is usually where you really start to see a little bit of resistance. When it comes to caring for ourselves, that's usually even more sensitive than how we handle our other affairs. So, if we're not remembering to change our clothes and somebody tells us that we've been wearing something for two days,and we need to change and take a shower. And then, they try to help us do those things it may be like, "I can shower myself; I know how to take care of myself; I've already changed; I've already done that." They can get really defensive, okay?  

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You definitely want to be mindful of how you approach your partner and how you bring up they haven't changed clothes, that they haven't bathed, that they need to eat. You want to ease into those things. You definitely don't want to over help. If all they need is just a reminder or a cue and there's a routine that you can put in place, you definitely want to go that method first and then as they need more assistance, slowly start to add more assistance.  

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