When AD progresses into the moderate stage of illness, usually about 3 to 5 years after onset of the earliest symptoms, the patient has significantly impaired memory ability and cannot recall much of what has recently occurred. He or she fails to recognize familiar environments or people. Visuospatial confusion is demonstrated by the patient’s substantial misjudging of directionality and distances; driving is no longer safe.
Language disability is marked by increasing difficulty in finding words and in ability to express ideas; inappropriate words (paraphasic errors) are substituted for those that would better convey meaning. In addition, the patient’s ability to comprehend conversation and to read and write is increasingly impaired.
The patient has great difficulty in organizing tasks, and evidence of apraxia and agnosia emerges. As a result, it becomes more difficult for patients to independently attend to grooming, hygiene, and toileting, and to recognize and use eating and writing utensils and household appliances effectively. In moderate AD, the patient becomes substantially dependent on caregivers. This stage of illness also tends to progress more rapidly than the mild stage.
It is generally in the moderate stage of illness that patients with AD exhibit more severe and frequent neuropsychiatric symptoms. Apathy may persist and worsen, and increasing restlessness, as well as verbal and physical agitation, may emerge. Patients may express delusional beliefs of a persecutory nature (eg, theft, abandonment, infidelity) and harbor concerns that their home is not where they live.
It is not unusual for a patient with AD to insist that he leave his home in order to “go home.” This home often refers to where the patient was raised, the patient having forgotten that his or her parents are long since deceased.
Patients may be verbally and physically abusive to those around them. There may be yelling, screaming, and physical aggression directed toward caregivers who attempt to assist, redirect, or comfort the patient. Many patients display purposeless and repetitive motor behaviors, including fidgeting, rearranging household and personal items, and restless searching and pacing.
Severe stageWhen patients enter the more severe stages of illness, usually about 7 to 9 years after symptom onset, communication with those afflicted becomes very difficult for caregivers. Aphasia reaches a level so severe that the patient can no longer express ideas clearly and has great impairment in understanding the conversation or directives of other people. The patient’s language output is restricted to barely intelligible repetitive utterances. Ultimately, mutism results and meaningful verbal interaction with the patient is extremely difficult.
The patient wholly depends on others for self-care and all other activities to tests. For donepezil(Drug information on donepezil) and rivastigmine(Drug information on rivastigmine), larger doses were associated with larger symptomatic cognitive effects as assessed by the Alzheimer’s Disease Assessment Scale Cognitive Subscale, a commonly used outcome measure. Clinical global improvement was shown to be superior for each drug over placebo.
Terminal stages