Stages of Dementia: Stages 6 and 7

Stage 6

Stage six is moderately severe dementia or severe cognitive impairment or cognitive decline. This is where you're really, really going to notice a breakdown in those basic activities of living. So dressing, bathing or going to the bathroom, feeding themselves, those sorts of things. This is now beyond just needing a reminder or cue to do it. This is having a really hard time physically doing it and it can be for a number of reasons, okay. It could be due to decreased contrast sensitivity, decrease depth perception, it can be decreased ability to sequence things. They have a harder time initiating tasks... motor planning, meaning I know what I want to do, but I can't figure out how to sequence my movements to be able to do that thing. So, they are going to need a lot more help and a lot more support. So you're going to notice that maybe they can't dress themselves properly — maybe they put their shirt on backwards. Maybe when they're trying to put their pants on, they put their legs through the wrong hole. If you put a light colored shirt on light colored bedding, they may have a hard time figuring out where their clothing items are.  

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Sometimes, as the dementia progresses in stage six, they even have a hard time trying to figure out what something is used for.  For example, with a fork we know that it's a utensil that we use to eat certain foods with. But to them, they might see the fork and not understand what to do with it. So, that's where these issues start to become really evident. This also extends over into remembering to flush the toilet, and also remembering how to flush the toilet. This also extends to washing their hands, understanding how to sequence that like, "Okay, I have to turn the water on. I have to get soap. I have to wash my hands. The way that I wash my hands is like this. I got to get all parts of my hand. Okay, I need to turn it off. I need to dry my hands."...those sorts of things. And if you think about it, we all kind of sequence it differently. Some people put soap in their hands first, then turn on the faucet, and wash. Some people dry their hands before turning off the water. So, this can look a little bit different for every person. The point is, there's a breakdown in sequencing and being able to put all those things together. Sometimes what you may also notice is maybe they can brush their teeth if you set it up for them. But, they might just stay in one place and not move on. They'll just stay there. And then you have to say, "Oh, don't forget to get the other side of your mouth" and then they'll go. Then, you might have to cue them until they complete their whole mouth. But then after that, they might not remember what to do with the toothpaste in their mouth. So some will swallow and others you have to to cue, "Okay, make sure you spit it out."

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This is also where you start noticing more incontinent episodes of the urine and the bowels. Usually when somebody becomes incontinent, it's going to be urine incontinence first and then eventually bowel incontinence. You'll also start noticing more episodes of them urinating or defecating in odd places. For example, maybe they'll urinate in a trash can or in a plant or you might notice that they're having a hard time just making it to the bathroom in general. You may also start noticing changes in things like their sleep patterns, or in their personality and behaviors. So maybe you notice they're becoming increasingly more agitated or aggressive or maybe this is where they start having more delusions or hallucinations, or maybe they start wandering more, which can become problematic as well.

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Another thing we have to think about is time. In stage six, what you start to notice thing is that it's almost as if they're on a whole separate timeline. And then, there still is this diminished concept of time within the timeline. For example, say your name is Amy, you're the daughter, okay? You are 52 years old. Sometimes what happens is it's not necessarily that they don't remember that they have a daughter and that their daughter's name is Amy. But the Amy that they remember is on a separate timeline. So maybe the Amy that they remember is 8 year old Amy, not 52 year old Amy. So if they ask you, where's Amy? Have you seen Amy? and you're thinking I'm right here. What do you mean I'm right here. Usually it's because the Amy that they're remembering is on a separate timeline. So it's not necessarily that they don't remember you. It's just that the 52 year old you and the eight year old you is not you do That makes sense. So, in stage six, you really start noticing that they're kind of on this separate timeline in a sense. And this timeline can change.  

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Another thing that kind of throws people off is that there can be these fluctuating moments of confusion and lucidity, where some days they're just like, really, really confused and they're really somewhere else. And then, there's other days where it seems like they kind of have a better feel for what's going on and who you are and things like that. So, that kind of throws people off because they don't understand why that's happening— it's just the brain. The brain is a very amazing thing. It's very complex, and we know very little about it. That is the easiest way to explain it.

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Another thing you'll start noticing is increased difficulty with speech, as well as decreased inability to like be able to count backwards from 10 and being able to say "10 9 8 7 6 5 4 3 2 1." They might also occasionally forget the names of their spouse or their children. It kind of just depends where they're at in their timeline, but usually they can recognize familiar faces in the sense like, "Oh, you look familiar. I recognize you. You don't." I've had quite a few patients where they can't remember my name, but they can remember that they've seen me before. They don't remember what I was there for or when, but they just remember, "that's a recognizable face."

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Stage six can be increasingly difficult for care partners because not only is your partner now needing more assist, but now you're getting these increased episodes of incontinence, which makes things difficult. Plus, you may notice changes in their sleep patterns, right? You may notice changes in their personality or behavior. And so, all this together can create some especially unique challenges that you are faced with. What I want to tell you is that stage five, it was super important to have routine stage six, it's going to be even more important to have a routine. People with dementia and usually just people in general, for the most part, tend to fare better with some kind of routine. And by routine, I don't mean at this time you have to do a certain thing. This time you have to do a certain thing. At this time you have to do a certain thing.

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That's more of like a schedule which does work for some people. But it's better If you have something that's more time fluid, which is a routine, meaning that you do things in the same order, that helps because it doesn't matter what time the person wakes up. You kind of have this routine that you have, first we do this, once we do that we do this, we do this, we do this — that tends to work a lot better than if you don't have a routine. You also want to try not to over help. When a person is having all these difficulties, it becomes very easy to want to just step in and do it for the person. But I want to encourage you to try to let them do as much as they can for themselves, whether that means setting up environmental support, so making the environment more friendly. Whether that means just cueing them, maybe giving them a visual demonstration, or physically cueing them or walking through the task with them step by step. You really want to encourage them to be active participants in their care. And honestly, the longer you can get them to actively participate in a task, the longer they'll be able to do it. It's one of those things "if you don't do it, you lose it." So, it's important that you try to keep them involved and refrain from just doing everything before them, especially at stage six, where it becomes so easy to just do it for them because it's quicker, it's more convenient, and there's just less fuss, right?

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Stage 7

Stage 7 is severe dementia, or very severe cognitive decline or impairment. This is where the body is slowly starting to shut down, and they're slowly beginning to lose their function. So their speech will become limited. And for some, speech may become nonexistent altogether, you may start noticing impairments in their swallowing, so you might have to change the food consistency. And even then, they may still have issues, which puts them at an increased risk for aspiration. So, you have to really watch that. It could eventually advance to the point where they're refusing food and water altogether. Another thing that starts happening is they begin to lose the ability to walk and the ability to control their movements. They might also exhibit abnormal reflexes or rigidity as they kind of progress through stage seven. So that's important to know because eventually they will become bedridden or wheelchair bound, but even in a wheelchair, you may notice that they have a hard time keeping themselves upright. So they still usually end up becoming bed bound. Because they become bed bound or chair bound, it puts them at increased risk for bed sores. You really have to make sure that you're changing their positions frequently, even every two hours if you can. I know for some caregivers, it's really hard to do that. I say, four hours max, two hours ideally, you want to change their position. Even if it's just shifting them around in bed. Just think, for example, when you sleep, there's very few of us who stay in that same static position all night. Most of us shift at least a little bit in our sleep, okay? So it's really important that you move them out of that position so that they do not get bed sores, okay? Because bed sores once you get them, they're super hard to heal. So if you can avoid them altogether, that's best.  

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Another thing you have to watch out for is repeated infections. This can be pneumonia from aspiration or this could be something like a UTI (urinary tract infection). So, you just want to be mindful that these things can occur more frequently in stage 7.  

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One thing that can really throw caregivers off again in stage 7 is that fluctuation between complete confusion and lucidity, where it's kind of like for a brief moment they have some idea of what's going on and who you are. It's really intriguing for both caregivers and myself. It's very hard to understand, but it's something that happens and that I want you to be aware because it's a completely normal occurrence in stage 7.  

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So when we think about stage 7 — what is most important? Honestly, the answer to that question is comfort and quality of life. You want to keep them as comfortable as possible. That extends to the mattress, mattress pad, chair cushion, pillows, the temperature of the room, not too bright of light, not too loud of noise. Some people like to have their hands stroked, or their hair, head, or cheek stroked. You can sing to them. You can put lotion on their body and make sure that their skin isn't dry and flaky, especially the feet because I feel like the feet are oftentimes neglected. You want to keep the feet clean dry, but moisturized. Another thing you can do is play soft music in the background. Sometimes instrumental type music is better than words, but it just depends on the person. You can open the windows let some fresh air in. You can open the blinds and let some daylight in. Another thing you can do is things to stimulate the vision. So, for some people, they'll start sleeping a lot in Stage 7. This is more so because the body is shutting down. So for visual stimuli, if they are keeping your eyes open, if they have a window you can put a bird feeder outside the window so they can see birds and squirrels or a small fish tanks, so they can watch the fishies. Some even like looking at a little mobile like you would put over like a baby's crib, but they have different ones available for your partner to look at.  You could put up a nice pleasant picture of something. So, there are still some things that you can do to keep the person comfortable, but also ensure that they still have a good quality of life as their dementia is slowly progressing.  

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Stages 6 and 7 are especially important stages because I think it really brings to light that dementia is terminal and it is progressive. The unfortunate thing about dementia is that if the person does not pass away from something else like a heart attack or stroke, complications due to diabetes, pneumonia or some type of infection, they ultimately will pass away due to their dementia because the brain is dying and the body is shutting down. And again, like I always say, I don't say this to scare you, I simply say this to inform you. This is why when a person gets the diagnosis of dementia it's important that you start planning and preparing. As the dementia progresses, which the timeline looks a little bit different for everybody as far as how they progress through these stages— though that differs, the end result is fairly the same. For most people, no matter what type of dementia they may have, stages 6 and 7 look very similar. So, I just want you to keep that in mind.  

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Image Credit: freepik

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