Functional impairment

Although the cognitive decline in AD is the core symptom, it is the functional deterioration that has the most impact on the person themselves and it is the functional loss that necessitates most of the care needs of patients with AD, including nursing-home residency.(4) Increasingly, abilities to function in ordinary life (activities of daily living (ADLs)) are lost, starting with the most subtle and easily avoided and progressing to the most basic and essential. In general, functional abilities decline alongside cognitive abilities. However, the precise correlation between these functions is not perfect, suggesting that factors other than disease severity account for part of the variance between patients.(5) Functional abilities are related to gender; for example, cooking abilities are rehearsed more frequently in women, and home-improvement skills in men. However, the overall pattern shows some similarities between groups of patients with similar disease severity. This is exploited in the Functional Assessment Staging (FAST) scale/6) in the original form, this is a seven-point scale of functional impairment, with stage 1 as no impairment and stage 7 as severe AD. A sequential decline is mapped by descriptions of the abilities that are lost: stage 2, difficulties with language and finding objects; stage 4, difficulties with finances; stage 6, incontinence and inability to dress or wash oneself.

ADLs are divided into those that relate to self-care and those that concern instrumental activities. Instrumental ADLs, those related to the use of objects or the outside world, are lost first and can be subtle.(7) A change in the ability to use the telephone properly or to handle finances accurately may not be apparent. Self-care ADLs include dressing and personal hygiene and are also lost gradually; for example, untidiness in clothing progresses to difficulties in dressing. Personal hygiene becomes poor as dentures are not cleaned and baths taken less often, before finally assistance is required with all self-care tasks.

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