The staging and assessment of moderate to severe Alzheimer disease

Alzheimer disease (AD) and its stages are clinically defined by the patterns of gradual and progressive decline in cognition and in functional ability with accompanying neuropsychiatric symptoms. The moderate to severe AD (MSAD) stages are particularly important both for their prevalence and for the transitions that occur at these stages. In MSAD, cognitive losses accelerate, neuropsychiatric symptoms increase, and functional autonomy is lost. There is increasing burden on caregivers, who report poorer self-rated health, increased depressive symptoms, and more use of psychoactive medications. The neurologic care of MSAD demands both skilled assessment and management. Beyond the cognitive and neurobehavioral symptom complex in MSAD, a range of other issues also emerge, including gait and movement disorders, nutritional problems, and incontinence. This review addresses the symptoms and staging of AD and emphasizes the key management issues.