In a 2011 study that investigated the link between neurocognitive measures and instrumental activities of daily living (IADLs) in women and men with mild Alzheimer’s disease (AD), the results of the study demonstrated that memory and executive functioning were related to IADL scores. Executive functioning was linked to total activities of daily living (ADL) abilities. Comparisons stratified on gender found that attention span predicted total ADL score in both men and women. Attention predicted bathing and eating ability in women only. Language ability predicted specific IADL functions in men (food preparation) and women (driving). The researchers concluded that even in patients with mild Alzheimer’s, the ability to perform IADLs requires complex cognitive processes (Hall et al. 2011). These skills are lost in a relatively orderly and predictable sequence.

When an individual has deteriorated to stage 4 on the functional assessment staging tool (FAST) scale with a cognitive level of somewhere between 8 and 12 years of age, but before there has been a diagnosis of Alzheimer’s, family and friends are noticing changes that are worrisome. Once a diagnosis is made, these same family members and friends recall the early signs that should have alerted them to a problem, but as the changes multiply with increasingly more serious consequences, denial no longer works and Alzheimer’s becomes a reality. Looking back, family members can usually recall the individual losses that gave them cause for worry but somehow they ignored. Perhaps it was the inability to pay bills and manage the checking account that first gave them reason to pause. Or, perhaps their anxiety stemmed from their Mother’s inability to cook anything more than a cup of soup and a grilled cheese sandwich, when they had always known her to be a “world class” cook. Or, perhaps the worry arose when they saw a laboratory report that indicated Mom’s blood sugar was very high, when for years she had done a wonderful job of managing her diabetes. However, as these losses begin to multiply along with the resultant problems from the inability to manage the checkbook; the inability to shop and cook meals that are “diabetic appropriate”; the getting lost in a neighborhood where the parent not only grew up but also raised a large family—denial fails! Loving family members will insist that their loved one see a physician. In fact, some family members will either insist on accompanying that person to the physician’s office or will contact the physician prior to their loved one’s appointment to fill the physician in on the problems that the family is seeing. What the family is observing is the slow degradation of many of the activities and skills that accompany “being an adult.” Alzheimer’s is responsible for these losses and more.

First, the IADLs , including food preparation, housekeeping and laundry, managing financial matters, shopping , using the telephone, taking medication, and handling transportation—all of these skills deteriorate then disappear. Before most individuals have even received a diagnosis of Alzheimer’s, family members and close friends have noted changes. A daughter is puzzled when she calls her mother to get her mother’s cheese cake recipe, only to be given vague directions. A son stops by just to say hello to his father and becomes concerned about the large pile of unopened and presumably unpaid bills piled on the kitchen table. Almost imperceptibly, the skills of being an independent adult disappear.

The IADLs include the following skills: managing finances, handling transportation—either driving or navigating public transportation, shopping, preparing meals, using the telephone and other communication devices, managing medications, and performing housework and basic home maintenance. The ADLs include bathing , dressing , and toileting . Let us examine what happens to each of these skills in stages 4, 5, and 6 on the FAST scale.