The Global Deterioration Scale (GDS)

The Global Deterioration Scale (GDS) is a reliable tool that tracks the progression of Alzheimer’s disease across seven stages of cognitive decline. It helps healthcare providers tailor their treatments and support your loved one’s healthcare needs every step along the way.

Watch: Understanding the Different Lobes of the Brain. Speaker: Dr Tam Cummings.

Stage 1: No Impairment (Preclinical Alzheimer's Disease)

What to Expect in This Stage 

• No noticeable symptoms.  
• Brain changes begin, but no memory deficits are detected. 
• Daily life remains unaffected. 

Implications for Loved Ones and Caregivers

For Loved Ones

No noticeable cognitive or functional issues. The following lifestyle changes may help delay symptom onset: 

• Take daily walks. 
• Spend time with friends.
• Eat heart-healthy, plant-based meals. 
• Get 7-8 hours of quality sleep each night. 
• Address hearing loss, if necessary. 

For Caregivers 

At this stage, your loved one is independent and not showing noticeable cognitive decline. No direct care is needed at this time

However, it may be helpful to begin learning about Alzheimer’s and available resources, so you’re prepared if and when needs change.

Assessments for Stage 1

Medical History and Physical Examination 

If your loved one has a family history of Alzheimer’s or dementia, it’s a good idea to talk with their healthcare provider. Reviewing their medical and family history can help identify potential risks and guide early screenings and preventative measures to support their long-term health.

This proactive approach helps you stay prepared as a caregiver. 

Stage 2: Very Mild Cognitive Decline

What to Expect in This Stage 

• No clinical evidence of memory deficits.  
• No significant impact on work or social activities. 
• Subtle memory lapses (e.g., forgetting familiar names, words, or the location of everyday objects).

Implications for Loved Ones and Caregivers

For Loved Ones

Cognitive decline is minimal, but your loved one may become frustrated or anxious about their minor memory lapses.

For Caregivers 

You may notice subtle but manageable memory lapses. Emotional support and reassurance are key to helping your loved one feel more at ease during this stage

Does your loved one use sticky notes to help them remember routine information? Take this quiz to find out if it’s dementia. 

Assessments for Stage 2

If your loved one is diagnosed with stage 2 Alzheimer’s, your loved one should undergo one or more of the following cognitive and neuropsychological tests to identify subtle memory changes and establish a baseline for future care. These allow you to understand the progression of Alzheimer’s and plan for your loved one’s care needs: 

• Dementia Behavioral Assessment Tool (DBAT)

  This assessment helps caregivers and family members recognize the current level of decline and the next steps required for care. 
• Mini-Mental State Examination (MMSE) 

  This 30-point questionnaire is commonly used to screen for Alzheimer’s, providing healthcare providers with an overall measure of cognitive impairment. 
• Montreal Cognitive Assessment (MoCA) 

  This simple, 10-minute screening tool is used to identify mild cognitive impairment and early dementia.

Does your loved one use sticky notes to help them remember routine information? Take this quiz to find out if it’s dementia.

Stage 3: Mild Cognitive Decline

What to Expect in This Stage 

• Some clinical evidence of a concentration deficit. 
• More significant memory issues (e.g., difficulty finding the right words, misplacing personal items, etc.). 
• Noticeable cognitive challenges that impact daily life, relationships, work, and social activities. 
• Increased withdrawal from socializing due to growing frustration and anxiety.

Implications for Loved Ones and Caregivers

For Loved Ones

You may notice increased frustration with memory lapses and a tendency to withdraw from social activities and relationships.

For Caregivers 

You may offer more support with daily tasks while also managing the emotional challenges that may arise. Start thinking about a home healthcare team to support you and your loved one.

Quiz: Is it Still Safe to Drive? 

Assessments for Stage 3

Cognitive Testing

In stage 3 Alzheimer’s, the following tests can help assess cognitive function: 

• Dementia Behavioral Assessment Tool (DBAT) 

  This assessment helps caregivers and family members recognize the current level of decline and the next steps required for care. 
• Mini-Cog 

  A quick, 3-minute screening for short-term memory and visuospatial skills. 
• Montreal Cognitive Assessment (MoCA) 

  A simple, 10-minute test to identify mild cognitive impairment and early dementia. 

Functional Assessments

The following assessments can evaluate and identify functional decline:

• Activities of Daily Living (ADLs) 

  Evaluates a person’s ability to perform everyday tasks (e.g., bathing, dressing, toileting, transferring, continence, and feeding) to determine whether assistance is needed. 
•  Instrumental Activities of Daily Living (IADL) 

  Measures a person’s ability to perform complex tasks (e.g., managing finances) and track changes over time.

Is It Still Safe to Drive?

Stage 4: Moderate Cognitive Decline (Mild Alzheimer's)

What to Expect in This Stage 

• Difficulty recalling current or recent events. 
• Confusion about time or place. 
• Noticeable memory deficits and difficulty with personal history. 
• Struggles with complex tasks (e.g., cooking or managing medication) without help.

Does your loved one have trouble finding the right words? Take this quiz to see if it’s time for memory care. 

Implications for Loved Ones and Caregivers

For Loved Ones

Completing daily tasks independently becomes harder, leading to anxiety and frustration. Maintaining personal hygiene and routine may require more help.

For Caregivers 

You will take on more responsibility at this stage, assisting with ADLs and other tasks. Emotional support is crucial as confusion and disorientation increase. Consider hiring a home healthcare team to support you and your loved one.

Note: Many caregivers experience stress and fatigue in this stage. Practicing self-care and exploring support options is highly recommended to avoid burnout. 

Assessments for Stage 4

Monitoring brain function and behavioral changes is essential for understanding your loved one’s needs. 

Behavioral and Psychological Assessments

Common Stage 4 assessments include:

• Dementia Behavioral Assessment Tool (DBAT) 

  This assessment helps caregivers and family members recognize the current level of decline and the next steps required for care. 
• Cohen-Mansfield Agitation Inventory (CMAI)  

  A 29-item questionnaire to assess agitation and mood changes.

Functional Assessments

The following assessments can evaluate and identify functional decline:

• Activities of Daily Living (ADLs) 

  Evaluates a person’s ability to perform everyday tasks (e.g., bathing, dressing, toileting, transferring, continence, and feeding) to determine whether assistance is needed. 
•  Instrumental Activities of Daily Living (IADL) 
  Measures a person’s ability to perform complex tasks (e.g., managing finances) and track changes over time.
• Neurological Evaluation 

  A comprehensive 3-part physical exam that may include:
  • Physical exam to assess motor skills, balance, coordination, reflexes, and sensory function. 
  • Cognitive assessment of your loved one’s memory, language, reasoning, and problem-solving abilities
  • Magnetic Resonance Imaging (MRI) or Positron Emission Tomography (PET) to identify possible structural abnormalities in the brain.

Does your loved one have trouble finding the right words? Take this quiz to see if it’s time for memory care.

Stage 5: Moderately Severe Cognitive Decline 

What to Expect in This Stage 

• Severe memory loss (e.g., forgetting personal history, the names or faces of close family members, or an address or telephone number of many years). 
• Significant confusion and marked decline in independence. 
• Needing regular assistance with daily living tasks like dressing, preparing meals, and bathing. 
• Noticeable emotional changes (e.g., paranoia or delusions). 

Implications for Loved Ones and Caregivers

For Loved Ones

As memory loss progresses, your loved one may struggle to recognize family members or remember personal history, leading to confusion, frustration, and anxiety.

For Caregivers 

You will need to offer ongoing assistance with daily tasks, but your loved one may resist, requiring frequent Alzheimer’s care plan adjustments. This can be emotionally taxing, so remember to prioritize self-care and seek additional support when needed.

Assessments for Stage 5

At this stage, you and your loved one will likely have an Alzheimer’s care team in place. They may recommend one or more of the following: 

• Dementia Behavioral Assessment Tool (DBAT) 

  This assessment helps caregivers and family members recognize the current level of decline and the next steps required for care.
• Neurological and Imaging Studies 

  This may include CT/MRI and PET scans to evaluate structural brain changes.
• Laboratory Tests 

  Blood work to check for underlying medical conditions (e.g., thyroid disorders or vitamin deficiencies).
• Psychiatric Evaluation  

  This evaluation helps you and your loved one’s care team manage mood or behavioral disturbances over time.

Watch: Communication Tips in Dementia Care Presented by Dr. Tam Cummings.

Stage 6: Severe Cognitive Decline (Moderate Alzheimer's) 

What to Expect and Impact on Life

Cognitive Impairment 

• Severe memory loss, especially of recent events and personal information. 
• Loss of awareness of surroundings (e.g., time, place, and identity). 
• Decreased ability to communicate. 

Functional Impairment 

• Struggles with daily activities (e.g., bathing, dressing, eating).
• Requiring help with toileting and incontinence.
• Inability to travel independently (e.g., walking, taking the bus, etc.).

Behavioral Changes 

• Increased agitation, restlessness, and wandering. 
• Delusions, paranoia, and hallucinations. 
• Marked personality changes (e.g., apathy, withdrawal, or aggression). 

Implications for Loved Ones and Caregivers

For Loved Ones

Your loved one may no longer recognize family members and struggle with basic motor skills like walking or eating.

For Caregivers 

Providing 24/7 care is crucial at this stage. The emotional and physical demands can be overwhelming as you manage severe symptoms, which may include aggression or agitation. Your loved one may now need specialized Alzheimer’s care from an experienced team of certified dementia providers within a compassionate, assisted living memory care community.

Comprehensive Assessments at Stage 6

At this stage, several assessments are commonly used to understand your loved one’s needs and to guide care planning: 

• Dementia Behavioral Assessment Tool (DBAT) 

  This assessment helps caregivers and family members recognize the current level of decline and the next steps required for care. 
• Functional Assessments 

  These evaluate your loved one’s ability to perform daily activities and their increasing dependence on caregivers.
• Informant-Based Questionnaires 

  Caregiver tools like The Eight-Item Informant Interview to Differentiate Aging and Dementia (AD8®) are used to assess memory, orientation, judgment, and functional changes (from your perspective), identifying shifts in behavior or ability.
• Psychiatric Evaluation  

  A psychiatric evaluation help manage depression and other emotional challenges that may arise, ensuring your loved one’s emotional well-being is addressed. 

Watch: Free Dementia Webinar: What Does That Behavior Mean? Presented by Dr. Tam Cummings.

Stage 7: Very Severe Cognitive Decline (End-Stage Alzheimer's) 

What to Expect and End-Stage Symptoms 

Physical Symptoms

• Inability to control body movements. 
• Inability to walk, sit, or hold up head without assistance. 
• Rigid muscles, abnormal reflexes, and an inability to swallow. 
• Inability to control bladder or bowel movements. 
• Limited ability to respond to the environment or recognize loved ones. 

Care Needs 

• Require daily assistance with personal care tasks. 
• Require 24/7 care for help with walking, sitting, and swallowing. 
• Vulnerable to infections, like pneumonia. 
• Pressure sores may develop when sitting or lying in one position for prolonged periods. 

Implications for Loved Ones and Caregivers 

For Loved Ones

At this stage, your loved one will require 24/7 supervision, either in-home or at a residential memory care community. They may be unable to communicate or recognize others, and all daily activities will need assistance.

For Caregivers 

As a family caregiver, you will face deeply emotional challenges, including making end-of-life decisions about advanced medical interventions. The emotional strain can be overwhelming, which is why finding the right support team for you and your loved one is essential.

Watch: Supporting End-of-Life Care

Final Stages of Assessment 

• Dementia Behavioral Assessment Tool (DBAT) 

  This assessment helps caregivers and family members recognize the current level of decline and the next steps required for care. 
• Actively Dying Assessment Tool (ADAT) 

  This assessment allows caregivers and family to track and recognize the signs and stages of the final part of life.  
• Continued Functional Assessments  

  Ongoing evaluations will help you and your care team plan for your loved one’s changing needs, ensuring that Alzheimer’s care is provided with compassion and dignity. 
• Behavioral and Psychological Assessments
  These care assessments will help address late-stage behavioral challenges and ensure appropriate emotional and psychological support is available. 
• Preparing for End-of-Life Care and Advanced Medical Evaluations 

  This stage will prioritize your loved one’s comfort and well-being, help guide decisions, and ensure your loved one receives the most appropriate care in their final stages.