Going Back to the Beginning: The Theory of Retrogenesis

Stage 1

Normal adult

Abilities consistent with expectations for a normal adult

Response is to a normal adult

Stage 2

Normal older adult

Very mild memory loss

Response is to a normal adult

Stage 3

Early dementia or mild cognitive impairment (MCI)

Early dementia—mild cognitive impairment

Memory problems apparent to coworkers and family members; individual with memory problems denies that he/she has a problem

Stage lasts approximately 7 years

Stage 4

Mild dementia

Mild dementia functional level 8–12 years of age

“great foolers”

still looks good; can engage in a conversation; careful listening may reveal the holes in this person’s memory

Asks the same question repeatedly, has difficulty managing finances—easily taken advantage of financially, driving skills deteriorating—might get lost even in familiar places—seek doctor’s advice regarding driving—obtain a driving evaluation from occupational therapist, based on OT’s findings doctor may need to send a letter to Motor Vehicle Administration based on result of OT’s driving evaluation; Experiences difficulty in shopping for groceries and in preparing meals for guests. Has difficulty writing the correct date and amount on checks. May also find it difficult to order from a menu in a restaurant and might defer to spouse to order for both. Person with AD is usually in profound denial

Stage lasts approximately 2 years

Stage 5

Moderate dementia

Functional level 5–7 years of age

Should not live alone

Needs assistance with dressing—may need help in sequencing clothing, needs oversight for appropriateness of dress for weather and/or occasion; can participate in personal care; responds to music; likes to do repetitive behaviors, i.e., clipping coupons, folding laundry, sorting coins, likes to sing and listen to music of his/her era

Can no longer live independently—someone needs to provide adequate and appropriate food, pay the rent and utilities and handle finances

Can inconsistently recall information such as name of current president, current address

Stage lasts approximately 1.5 years

Stage 6

Moderately severe dementia

Functional Level

4 years to—24/36 months

About 5 min of short-term memory; can still read—a powerful remaining ability; Needs help with all activities of daily living, loses ability to dress self independently and perform any personal hygiene tasks—lose the ability to brush teeth and handle mechanics of toileting; will become incontinent- first of urine then of stool, resists bathing—need to find bathing approaches other than

showering, still enjoys engaging in repetitive behaviors, challenging behaviors become more apparent—maybe due to untreated pain—music very powerful! Challenging behaviors become more prevalent—mean duration of this stage 2–5 years

Stage 7

Severe dementia

End stage-functional level less than 24 months—deteriorating to 4–12 weeks old

Stage 7C—eligible for hospice care under Medicare

7a.Only has six or fewer words

7b.Speech limited to the use of a single intelligible word—may be repeated over and over again

7c. Hospice eligible under Medicare—cannot walk without personal assistance

7d. Ability to sit up without assistance is lost- will fall over if there are not lateral rests (arms) on the chair

7e. Cannot smile

AD Alzheimer’s disease

Let us take a look at some general caregiving strategies for each stage of the FAST .

During stage 3, many people who are experiencing mild cognitive impairment are too frightened to have their memory evaluated. Even when family and friends comment on the individual’s failing memory, profound denial kicks in and the person can provide explanations for not remembering, i.e., “I was overly tired and that’s why I forgot.”; “I was preoccupied and didn’t hear the directions.”; “You mumbled and that is why I didn’t do what you asked me to do.” Any explanation for a faulty memory—other than the explanation of Alzheimer’s will do. This denial is so powerful that most people at this stage avoid seeking evaluation from a physician.

During stage 4, the person still retains good social skills and can convince anyone who does not look too closely that he/she is okay. She or he might be called “a great Fooler”! The story of Mildred illustrates her ability to “fool” even the physician.

Mildred went to see her primary care doctor for a routine checkup and to have her insulin level evaluated. Mildred was accompanied by her daughter who had taken her mother to the lab to get her lab work completed. The results of a recent HbA1c test were not encouraging to the doctor. He said, “Mildred, what is going on? Your blood work is not what it should be. Are you eating more sugar or sweets than you should be eating?” He said this with a smile but was quite alarmed with the lab results. The doctor expressed concern that Mildred’s test results showed a high level of blood sugar indicating that Mildred’s diabetes was not being adequately controlled. He asked Mildred to tell him what she had eaten for breakfast. Without hesitation, Mildred spouted off a perfect diabetic meal. She told him that she had four ounces of orange juice, a half of a cup of Special K© cereal, about a half a cup of skimmed milk and a piece of toast with just a little butter. The doctor was perplexed and said he would like to send a home healthcare nurse into see Mildred and provide him with more information. The home care nurse called Mildred the evening before the scheduled visit and told Mildred that the nurse would come to her home at 7AM and not to eat or take her insulin until the nurse arrived. The nurse told Mildred that she wanted to check Mildred’s glucometer and to get a good reading of her blood sugar. When the nurse arrived the next morning, Mildred couldn’t produce her glucometer and told the nurse that she had already tested her blood sugar and it was fine but she was unable to elaborate on what “fine” meant. The nurse than said let’s take a look at your refrigerator and your pantry to see if there are foods that you are eating that are raising your blood sugar levels. The nurse found no Special K, no orange juice or skim milk—instead she found a bag of chocolate candies and sugared drinks in Mildred’s refrigerator and a gallon of ice cream in the freezer with a spoon stuck in the ice cream! Was Mildred lying to her doctor? No she was telling him what she used to eat when she actively managed her diabetes—she doesn’t remember what she ate for breakfast. Mildred is a “great Fooler”! She looks good; she can engage in conversation; but what she reports might be very different from reality!

During stage 4, the ability to manage financial matters is impaired and individuals at this stage of the disease are easy targets for unsavory people who are willing and able to take advantage of the trusting nature of an elderly person whose cognitive ability is that of a child between 8 and 12 years old. Scams include asking for money for needy children but going beyond just a request for money—telling the old person that if they want to make a continuing contribution to whatever cause is being extolled, all the older person needs to do is to provide her/his bank account and routing number and automatic deductions can be made from the account. The unsavory person now has access to this trusting person’s checking account. The following are signs that the person with Alzheimer’s has been a victim of a financial scam: