Alzheimer's Disease:

Signs and symptoms of Alzheimer’s

When Alzheimer's disease begins to destroy brain cells, no outward symptoms are evident.  After a while, small memory lapses appear and grow more serious.  The afflicted individual may forget the names of familiar people or places, the words to express what they want to say, or the location of everyday objects.

As the memory lapses of early Alzheimer’s become more serious, other cognitive deficits and behavior problems develop:

While these are the major symptoms of Alzheimer’s, not all patients have all these symptoms. However, it is good to be aware of the most typical warning signs, as it is important to recognize problems early, and get help for them. 

Are people with Alzheimer's aware of their signs and symptoms?

People with Alzheimer's show a range of responses to their own behavior and condition:

• Denial (in the early stages)
• Blame others for making them “look ridiculous”
• Complete self-awareness (“I’m sorry, I have Alzheimer's”)
• Frustration, agitation, rage
• Vacant despair, with no apparent recognition that they were once a different person

By the middle stage of Alzheimer's, most victims no longer are aware that they don’t remember things or aren’t communicating coherently. This is fortunate for them.  In a safe environment with good care and social contact, most Alzheimer’s patients seem relatively free of suffering.  For their friends and relatives it’s a different story: the long steady decline of their loved one is painful to watch.  The demands of Alzheimer’s care also take a toll, over the many years before inevitable death. Depression is more common among the caregivers of Alzheimer's patients than it is among the patients themselves.

The stages of Alzheimer’s disease

If you or a loved one has received a diagnosis of Alzheimer’s disease, you may be wondering what to expect with the disease as it takes its course.  From the time of diagnosis, a person usually lives from three to twenty years, with an average of eight years.  The three main stages Alzheimer’s have the following defining characteristics.

The Main Stages of Alzheimer's Disease
Early-stage Alzheimer's (Mild)	Mid-stage Alzheimer's (Moderate)	Late-stage Alzheimer’s (Severe)
Memory loss or other cognitive deficits are noticeable, yet the person can compensate for them and continue to function independently.	Mental abilities decline, the personality changes, and physical problems develop so that the person becomes more and more dependent on caregivers.	Complete deterioration of the personality and loss of control over bodily functions requires total dependence on others for even the most basic activities of daily living.

People vary in the length of time spent in each stage, and in which stage the signs and symptoms appear. Because the stages overlap, it is difficult to definitively place a person in a particular stage. However, the progression is always toward a worsening of symptoms.  The stages identify groups of symptoms that reflect more and more brain decay and increasing dependence on caregivers. The end result of Alzheimer's is death, whether caused by the inability of the brain to keep the body going, or by another disease or injury along the way.

No matter what stage the individual is in at the time of diagnosis, apathy is a major problem from the beginning to the very end. More than forty per cent of people in early-stage Alzheimer's show a lack of interest, initiative, and emotional involvement. In the last stage of Alzheimer's, more than ninety per cent of people are apathetic.

Early-stage Alzheimer’s signs & symptoms

The focus of early-stage Alzheimer's is cognitive decline. The Alzheimer's sufferer, as well as family, friends, co-workers, and medical practitioners start to notice the changes. Memory and concentration problems are evident and measurable by cognitive tests. Communication issues surface. Changes in personality and a few idiosyncratic behaviors begin to appear. As a result, the person’s performance suffers both at home and at work. The apathy and lack of engagement that is characteristic of all three stages begins here.

Early signs and symptoms could include any of the following.

Cognitive and memory problems begin to appear…

• Confusion
• Forgets names and words; might make up words, or quit talking to avoid mistakes
• Repeats questions, phrases or stories, in the same conversation
• Forgets their own history, recent personal events, and current events
• Less able to plan, organize, or think logically
• Increasing difficulty with routine tasks such as planning dinner, grocery shopping, paying bills 
• Increasingly unable to make decisions; defers to others’ choices
• Poor judgment; decline in problem-solving skills
• Money and math problems
• Disoriented in time and place; may become lost in familiar places.
• Trouble concentrating and learning new things; avoids change
• Withdraws from social and mental challenges
• Misplaces valuable possessions; hides things or puts things away in strange places and then forgets where they are

Communication problems are observed…

• May converse “normally” until a memory lapse occurs
• Begins to have difficulty expressing themselves
• Even if unable to speak well, can respond to what you tell them--to your emotional reactions, and to humor
• Increasing difficulty comprehending reading material

Personality changes are evident…

• Apathetic, withdrawn, avoids people
• Anxious, irritable, agitated
• Insensitive to others’ feelings
• Easily angered when frustrated, tired, rushed, or surprised

Idiosyncratic behaviors start to develop…

• Hoards, checks, or searches for objects of little value
• Forgets to eat, or eats constantly, or eats only one kind of food

When Alzheimer’s has been diagnosed early, the loss of abilities is often mild, and with a little help, the individual can continue living independently much as they did before.  In this early stage, some people experience minor physical compensations, such as falling asleep easily, or immunity to colds, but these positive aspects of Alzheimer's are short-lived.  In fact, by the time this condition is diagnosed, some of the problems described above may have already progressed to the point where the individual is already in the middle stage of the disease, needing considerable caregiver support.

Mid-stage Alzheimer’s signs & symptoms

The focus of mid-stage Alzheimer's is a decline in functioning of many body systems at once and steadily increasing dependence on caregivers.  In mid-stage Alzheimer's disease, the cognitive problems of early Alzheimer’s get worse and new ones develop. Memory and cognition problems become severe; communication becomes warped; and the personality is transformed.

The person has a marked change in appearance and hygiene as they become less and less able to take care of themselves. Physical problems increase, including problems with voluntary control of the body, and health declines. Wandering, aggressiveness, hallucinations, and paranoia appear.

This stage is the longest. Those sufferers who are able to recognize their own decline are especially at risk for becoming suicidal during this stage.

The range of problems that may occur include the following.

Significant cognitive decline and memory problems continue…

• Forgets recent events, forgets their own history. When they can’t remember something, they may make up something instead.
• Increasing difficulty in sorting out names and faces of family and friends, but can still distinguish familiar from unfamiliar faces
• Still knows their own name, but no longer remembers their own address or phone
• Loses track of their own possessions. May take others’ belongings.
• Can no longer think logically or clearly. Can’t organize their own speaking or follow others’ logic. Can no longer follow written or oral instructions or a sequence of steps. Arithmetic and money problems escalate.
• Disoriented about the season, the day of the week, the time of day
• Disconnected from reality. Does not recognize self in the mirror. May think that a television story is real.

Impaired communication skills worsen…

• Problems with speaking, understanding, reading, and writing
• Repeats stories, words, and gestures; repetitive questions
• May still be able to read, but cannot respond correctly
• Problems finishing sentences
• May revert to their first speaking language (and need a multilingual caregiver)

Personality changes become more significant …

• Apathetic, withdrawn
• Anxious, agitated
• Unmannerly, aggressive or threatening
• Suspicious, paranoid; may accuse spouse of having an affair, or accuse family members of stealing
• Delusional, has hallucinations. May hear, see, smell, or taste things that aren’t present
• May have an exaggeration of their normal personality characteristics

Idiosyncratic behaviors evolve…

• Inappropriate sexual behavior: may mistake another person for their spouse, may disrobe or masturbate in public
• Rummages through things, hides things
• Restlessness, pacing, repetitive movements: fingers certain objects over and over; tries doorknobs; hand-wringing; tissue-shredding
• Wandering, including chatting to oneself while wandering. May wander away from the caregiver and familiar, safe surroundings. (One-quarter to one-half of all people with Alzheimer's wander.)
• Disruption of the normal sleep-wake cycle: “sundowning” (naps during the day, active from late afternoon through the night)

Dependence and need for help with the activities of daily living increases…

• May eat without help, but needs help remembering to drink enough liquids and to eat enough
• Needs help dressing appropriately for the weather or occasion. May need help putting clothing onto the correct body part.
• Needs help with grooming: bathing, brushing teeth, combing hair
• Needs help using the toilet
• May no longer be safe when left alone: could fall, burn self, poison self, neglect self. Although able to care for self in some ways, needs full-time supervision for safety.

Voluntary control of the body begins to decline…

• Urinary and fecal incontinence increase over time
• Has trouble getting comfortable in a chair or on the toilet
• Muscle twitches

Late-stage Alzheimer’s signs & symptoms

The focus of late-stage Alzheimer's is the complete deterioration of the personality.  Cognitive symptoms worsen, and physical symptoms become profound. The loss of brain cells in all parts of the brain leads to lack of functioning in all systems of the body. The wild behaviors of earlier stages disappear, replaced by a dulling of the mind and body.

Cognitive and memory problems decline further, and complete dependence on others is necessary …

• Doesn’t recognize familiar people, including their spouse and family members (a lack of visual ability may contribute to this)
• Needs complete help with all activities of daily living
• Requires full-time care

Communication skills are nearly gone…

• Appears uncomfortable, but cries out when touched or moved
• Can no longer smile
• Either doesn’t speak, or speaks incoherently, with just words or phrases
• May call or cry out repetitively, or groan or mumble loudly
• Can’t write or comprehend reading material

Voluntary control of the body increasingly disappears…

• Can’t control their movements. Muscles are rigid.
• Complete urinary and bowel incontinence
• Cannot walk, stand, sit up, or hold up their head without assistance. Falls frequently if not assisted or propped well.
• Bedridden.
• Can’t swallow easily, may choke on food
• No more wandering; can’t move voluntarily

Health declines considerably…

• Frequent infections
• Seizures
• Loses weight
• Skin becomes thin and tears easily
• Reflexes are abnormal

The body shuts down…

• May refuse to eat or drink
• Can’t respond to the environment
• May quit urinating
• Little response to touch
• Sensory organs shut down: the organs may function correctly, but the brain can’t interpret the input.
• May only feel cold and discomfort
• Exhausted, sleeps more

Personality changes and idiosyncratic behavior become extreme…

• Apathetic, withdrawn (continues from early-stage Alzheimer's)
• Dulling of the personality
• May pat or touch things repeatedly 

As the end of life approaches, the Alzheimer’s patient may require around-the-clock care.  It will be necessary for loved ones to decide whether that care can occur at home or in a facility. The guidance of a physician or a hospice team will be needed.

Related links for Alzheimer’s Disease

General information about the signs, symptoms, and stages of Alzheimer's Disease

Ten Warning Signs of Alzheimer's Disease – This list is especially useful because it spells out differences between mild cognitive changes that are often seen as a normal part of aging versus the more severe deficits that are characteristic of Alzheimer's Disease. (Alzheimer's Association)

What are the symptoms of Alzheimer's Disease? – Experts disagree as to whether cognitive decline is a normal part of aging, but this link and the one above help distinguish mild impairments from the more serious ones associated with dementia. (University of Maryland Medical Center)

Stages of Alzheimer's Disease – Staging systems are considered to be helpful for understanding how the disease progresses and for care planning.  Seven stages are described here, starting with “no impairment” then moving through various degrees of impairment from “very mild” to “very severe.” (Alzheimer's Association)

Functional Assessment Staging of Alzheimer’s Disease. (FAST)© – Developed by Dr. Barry Reisberg at the NYU Medical Center Aging and Dementia Research Center, the Functional Assessment Staging Scale shows the progression of Alzheimer’s in 16 stages/sub-stages. (Alzheimer's...for caregivers)

Doug Russell, L.C.S.W., Jeanne Segal, Ph.D., and Monika White, Ph.D., contributed to this article. Last modified on: 12/14/07.