Table 1 is a modified version of the FAST test https://www.mccare.com/pdf/fast.pdf that was first issued in 1988 by B. Reisburg, This modified version covers the Dementia stages (6 & 7) of Alzheimer’s Disease (AD). My modification leaves out stages 1 through 5 and changes stage 6 from Moderately Severe Dementia to Moderate Dementia. My view is that dementia issues start with the patient inability to self-sustain Activities of Daily Living (ADL) with an MMSE score below 10. Ethel’s AD did not impact our lifestyle from 2001 until early 2016. However, ADL issues were evident throughout 2015. Moving to Las Ventanas in 2012 was the right decision. As described in my book, Ethel’s MMSE Score relative to the FAST STAGES 6 & 7 began near the end of 2014. The following article describes Ethel’s decline relative to this modified FAST table. Italics indicate an excerpt from my book. Whether the table takes into consideration age-linked immune system decline as well as physical adverse events is unknown.
TABLE 1 – MODIFIED FUNCTIONAL ASSESSMENT STAGING TEST (FAST)
|STAGE||STAGE NAME||CHARACTERISTIC||UNTREATED AD DURATION (months) Cum||MENTL AGE (years)||MMSE (score)|
|6a||Moderately Dementia||Needs help putting on clothes||4.8||4.8 mo.||5||9|
|6b||Moderately Dementia||Needs help bathing||4.8||9.4 mo.||4||8|
|6c||Moderately Dementia||Needs help toileting||4.8||1 yr. 2 mo.||4||5|
|6d||Moderately Dementia||Urinary incontinence||3.6||1yr. – 6 mo.||3-4||3|
|6e||Moderately Dementia||Fecal incontinence||9.6||2 yrs. 3 mo.||2-3||1|
|7a||Severe Dementia||Speaks 5-6 words||12||3 yrs. 3 mos.||1.25||0|
|7b||Severe Dementia||Speaks only 1 clear word||18||4 yrs. 9 mos.||1||0|
|7c||Severe Dementia||Can no longer walk||12||5 yrs. 9mos||1||0|
|7d||Severe Dementia||Can no longer sit up||12||6 yrs. 9 mos.||0.5-0.8||0|
|7e||Severe Dementia||Can no longer smile||18||8 yrs. 3 mos.||0.2-0,4||0|
|7f||Severe Dementia||Can no longer hold head up||12+||9 yrs. 3 mos.||0 -0.2||0|
Home Care – Moderate Dementia (61,6b, & 6c)
Ethel’s decline became noticeable with evidence of agitation, anxiety, confusion, frustration, depression, worry, personality change, and wandering. Everything became “at the moment”. Bruce’s challenge was to figure out how to keep “at the moment” events and activities interesting. Bruce’s helped with the jigsaw puzzles (large pieces) that maintained Ethel’s interest. His approach was to help until the last few pieces, as Ethel was very proud of completing the puzzle with no recall of any help. Her memory was only the final few pieces, so she believed she had done the whole puzzle. In 2015 puzzles went from 250 pieces to 200 to 100. At the beginning of 2016, Ethel’s disease progressed to the point where she became frustrated, agitated, and anxious whenever she was not busy with something to do. Bruce judged these signs as time for Memory Care.
Memory Care – Moderate Dementia (6d & 6f)
Ethel entered Memory Care on February 28, 2016. She was amble without aides, She participated in activities. We went to the dining room as she fed herself and indicated when she needed to use the bathroom. She still had a small vocabulary and understood some communication or instructions. Adjustment to memory care took a couple of months. Depends helped with urine control. Though she declined to MMSE zero by October 2016, she still maintained fecal control. At this point the FAST Table became a valuable comparison tool.
Memory Care – Severe Dementia (7a)
Decline evidence began to show in dining room behavior, balance. and non-verbal communication. Bruce stopped taking Ethel to the dining room near the end of 2016. Anticipating a need, Bruce purchased a walker and began training for its use, though not needed yet. Then, in August 2017, a major significant physical event began with confusion, walking, and balance problem. Ethel went to the hospital emergency room where they diagnosed a urinary tract infection (UTI0, prescribed an antibody and sent her home. A week after completing the antibody with no improvement, her primary care doctor order a different antibody along with a home health care nurse to monitor Ethel.
On September 14, 2017, three days after completing her second antibody and not having had a bowel movement for 5 days, Ethel was given Mira LAX in accordance with an “as needed” memory care order. The home health care nurse came the next day, September 15, 2017 and recommended Ethel should go to the hospital because of an impacted colon. At a different hospital ER, the doctors determined through a CAT Scan that Ethel had an abscess on her appendix that ruptured. A team of doctors assessed her condition (11:00 pm), admitted her and removed Ethel’s appendix with an incision, due to the breeched abscess that needed to be cleaned. A week after discharge, Ethel was back in the hospital due to a blood clot in her leg. She was treated to prevent a pulmonary embolism along with concerns of a blood infection. They inserted a stent up through her groin to prevent any future clot concerns. This was our first major impact with non-verbal communication as Ethel was unable to communicate her pain. We learned later, the infection in the urinary tract was probably due to an abscess, that was beginning on her appendix. These adverse events indicated the lack of hospital staff skills involving non-verbal communication. They willingly accepted Bruce’s help with Ethel (the CAT Scan, feeding, vitals, and many other duties).
How physical problems impact AD Dementia is difficult to assess. However, Ethel needed to use a walker from this point. Whether these events were physical decline, the disease, or both is unknown. Bruce’s believes the physical problems accelerate the FAST Table’s time periods and age levels. Also, during this stage, Ethel began the need to be fed, as she lost the ability to use utensils. Without help, she would just sit and stare at the food (a marker for this stage).
Memory Care – Severe Dementia (7b)
Ethel’s second major non-verbal significant event began near the end of 2017. Her earlier refusal to open her mouth to have her teeth clean, or X-ray taken, or extractions resulted in problems. This led us to an oral dentist who used anesthesia and extracted seven molar teeth on her first visit. Eighteen months later another four were removed. Then, three months later a front tooth broke at the gum line and had to be removed. Recovering from the front tooth removal, she developed a UTI which complicated determining pain cause and treatment.
Memory Care – Severe Dementia (7c)
During this period, Ethel balance became an issue which resulted in using a wheelchair instead of her walker. As indicated by the FAST Table, this stage indicates an age level of a 1 year old. Ethel displays evidence of this in early 2019 by trying to eat with her fingers. Nearing the end of 2019, Ethel is now having problems locating her mouth when she uses her fingers. At this point it is hard to perceive how another 3 ½ years shown on the FAST Table is realistic.