The Global Deterioration Scale

the global deterioration scale

GDS, developed by Dr. Barry Reisberg, provides caregivers an overview of the stages of cognitive function for those suffering from a primary degenerative dementia such as Alzheimer’s disease

beginning in stage 5

an individual can no longer survive without assistance

pre-dementia stages

stages 1-3

dementia stages

stages 4-7

GDS level 1

no cognitive decline, no subjective reports, no objective evidence

GDS level 2

very mild cognitive decline, age associated memory impairment

GDS level 2 subjective reports 

forgetting placement of familiar objects, forgetting names one formerly knew well

GDS level 2 objective evidence

no memory deficits in clinical interview, no deficits in employment or social situation

express appropriate concern

GDS levels 1 and 2

GDS level 3

mild cognitive decline (mild cognitive impairment), earliest “clear cut” deficits

GDS level 3 subjective reports

getting lost going to unfamiliar areas, word and name-finding deficits, little to no retention after reading, decreased facility in remembering names upon introduction to new people, obvious poor performance in the workplace, misplacement of objects of value 

GDS level 3 objective evidence

only with an intensive interview, possible concentration deficits in clinical testing

denial

begins to become manifest in patients in GDS level 3

mild to moderate anxiety

accompanies symptoms in GDS level 3

GDS level 3 continued

mental status is oriented, good motor function, memory function with subjective decline a significant risk factor, starting to show short-term or episodic memory deficits modestly, independent with ADLs, iADLs may be difficult

the nun study

linguistic analysis of autobiographies written by over 200 nuns, lower idea density and grammatical complexity in autobiographies written early in life means nuns were more likely to develop AD later in life

language changes in GDS level 3

decreased verbal fluency in semantic and letter fluency, impaired discourse processing with gist level story retell, decreased lexical diversity, less thematic info, more irrelevant comments, more verbose, fewer words and core elements

GDS level 4

moderate cognitive decline, mild dementia; clear cut deficit on careful clinical interview

GDS level 4 noticeable deficits

deficits with knowledge of current and recent events, memory of one’s personal history, concentration, ability to travel, handle finances, ability to perform complex tasks

denial

dominant defense mechanism in GDS level 4

GDS level 4 continued

may be disoriented to time, good motor function, episodic memory deficits clear (recent events and some personal history), difficulty with iADLs

language GDS level 4

speech fluent, frequent pauses, slower rate, expressive language with mild anomia, spoken language better than written, more general and empty words, oral discourse has more sentence fragments 

AD middle stage

GDS level 5

GDS level 5

moderately-severe cognitive decline, moderate dementia

GDS level 5 noticeable deficits

unable to recall major relevant aspect of current life, names of close family members, name of high school or college they graduate from, frequently disoriented to time or to place

GDS level 5 continued

dramatic changes in mental status, disorientation and confusion about place and time, good motor function but increased restlessness and wandering, decreased episodic memory and memory span, encoding and retrieval deficits, perform worse on all tests

language in GDS level 5

speech fluent but slow, halting, silent pauses, content affected with loss of vocab, degradation of conceptual knowledge, impaired category generation, confrontation naming

AD late stages 

GDS levels 6 and 7

GDS level 6

severe cognitive decline, moderately severe dementia

GDS level 6 deficits

largely unaware of all recent events, generally unaware of surroundings, may have difficulty counting backward from 10, will require assistance

GDS level 6 personality and emotional changes

delusional behavior, obsessive symptoms, anxiety symptoms, agitation, violent behavior, cognitive abulia with loss of will or initative

GDS level 7

very severe cognitive decline, severe dementia

GDS level 7 continued

all verbal abilities lost, the brain appears to be no longer able to tell the body what to do, disoriented to time and place, poor motor skills, end up non-ambulatory, global failure of memory, completely dependent on others to survive

language in stages 6-7

speech fluent, slow, halting, meaningful output greatly reduced, variability from silence to being unable to contribute to conversation, severity can be mapped to other things, unable to write, auditory and reading comprehension impaired