AGS BEERS CRITERIA

FOR POTENTIALLY INAPPROPRIATE MEDICATION USE IN OLDER ADULTS FROM THE AMERICAN GERIATRICS SOCIETY This clinical tool, based on The AGS 2012 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (AGS 2012 Beers Criteria), has been developed to assist healthcare providers in improving medication safety in older adults. Our purpose is to inform clinical decision-making concerning the prescribing of medications for older adults in order to improve safety and quality of care. Originally conceived of in 1991 by the late Mark Beers, MD, a geriatrician, the Beers Criteria catalogues medications that cause adverse drug events in older adults due to their pharmacologic properties and the physiologic changes of aging. In 2011, the AGS undertook an update of the criteria, assembling a team of experts and funding the development of the AGS 2012 Beers Criteria using an enhanced, evidence-based methodology. Each criterion is rated (quality of evidence and strength of evidence) using the American College of Physicians’ Guideline Grading System, which is based on the GRADE scheme developed by Guyatt et al. The full document together with accompanying resources can be viewed online at www.americangeriatrics.org. INTENDED USE The goal of this clinical tool is to improve care of older adults by reducing their exposure to Potentially Inappropriate Medications (PIMs). n This should be viewed as a guide for identifying medications for which the risks of use in older adults outweigh the benefits. n These criteria are not meant to be applied in a punitive manner. n This list is not meant to supersede clinical judgment or an individual patient’s values and needs. Prescribing and managing disease conditions should be individualized and involve shared decision-making. n These criteria also underscore the importance of using a team approach to prescribing and the use of nonpharmacological approaches and of having economic and organizational incentives for this type of model. n Implicit criteria such as the STOPP/START criteria and Medication Appropriateness Index should be used in a complementary manner with the 2012 AGS Beers Criteria to guide clinicians in making decisions about safe medication use in older adults. The criteria are not applicable in all circumstances (eg, patient’s receiving palliative and hospice care). If a clinician is not able to find an alternative and chooses to continue to use a drug on this list in an individual patient, designation of the medication as potentially inappropriate can serve as a reminder for close monitoring so that the potential for an adverse drug effect can be incorporated into the medical record and prevented or detected early. TABLE 1: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Organ System/ Recommendation, Rationale, Therapeutic Category/Drug(s) Quality of Evidence (QE) & Strength of Recommendation (SR) Anticholinergics (excludes TCAs) Avoid. First-generation antihistamines (as single agent or as part of combination products) n Brompheniramine Highly anticholinergic; clearance reduced with advanced age, and n Carbinoxamine tolerance develops when used as hypnotic; increased risk of confun Chlorpheniramine sion, dry mouth, constipation, and other anticholinergic effects/ n Clemastine toxicity. n Cyproheptadine n Dexbrompheniramine Use of diphenhydramine in special situations such as acute treatn Dexchlorpheniramine ment of severe allergic reaction may be appropriate. n Diphenhydramine (oral) n Doxylamine QE = High (Hydroxyzine and Promethazine), Moderate (All others); SR n Hydroxyzine = Strong n Promethazine n Triprolidine Antiparkinson agents n Benztropine (oral) n Trihexyphenidyl

Table 1 (continued from page 1) TABLE 1: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Organ System/ Recommendation, Rationale, Therapeutic Category/Drug(s) Quality of Evidence (QE) & Strength of Recommendation (SR) Avoid except in short-term palliative care to decrease Antispasmodics n Belladonna alkaloids oral secretions. n Clidinium-chlordiazepoxide n Dicyclomine Highly anticholinergic, uncertain effectiveness. n Hyoscyamine n Propantheline QE = Moderate; SR = Strong n Scopolamine Antithrombotics Dipyridamole, oral short-acting* (does not apply to the extended-release combination with aspirin) Ticlopidine* Anti-infective Nitrofurantoin

Cardiovascular Alpha1 blockers n Doxazosin n Prazosin n Terazosin Alpha agonists n Clonidine n Guanabenz* n Guanfacine* n Methyldopa* n Reserpine (>0.1 mg/day)* Antiarrhythmic drugs (Class Ia, Ic, III) n Amiodarone n Dofetilide n Dronedarone n Flecainide n Ibutilide n Procainamide n Propafenone n Quinidine n Sotalol Disopyramide*

Dronedarone

Avoid. Not recommended for prevention of extrapyramidal symptoms with antipsychotics; more effective agents available for treatment of Parkinson disease.

Digoxin >0.125 mg/day

QE = Moderate; SR = Strong PAGE 1

Table 1 (continued on page 2)

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Avoid. May cause orthostatic hypotension; more effective alternatives available; IV form acceptable for use in cardiac stress testing. QE = Moderate; SR = Strong Avoid. Safer, effective alternatives available. QE = Moderate; SR = Strong Avoid for long-term suppression; avoid in patients with CrCl 6 mg/day n Imipramine n Perphenazine-amitriptyline n Trimipramine Antipsychotics, first- (conventional) and second- (atypical) generation (see online for full list)

Avoid. Highly anticholinergic, sedating, and cause orthostatic hypotension; the safety profile of low-dose doxepin (≤6 mg/day) is comparable to that of placebo. QE = High; SR = Strong Avoid use for behavioral problems of dementia unless non-pharmacologic options have failed and patient is threat to self or others. Increased risk of cerebrovascular accident (stroke) and mortality in persons with dementia. QE = Moderate; SR = Strong

Thioridazine Mesoridazine

Avoid.

Barbiturates n Amobarbital* n Butabarbital* n Butalbital n Mephobarbital* n Pentobarbital* n Phenobarbital n Secobarbital* Benzodiazepines Short- and intermediate-acting: n Alprazolam n Estazolam n Lorazepam n Oxazepam n Temazepam n Triazolam Long-acting: n Chlorazepate n Chlordiazepoxide n Chlordiazepoxide-amitriptyline n Clidinium-chlordiazepoxide n Clonazepam n Diazepam n Flurazepam n Quazepam Chloral hydrate*

Avoid.

Meprobamate

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Highly anticholinergic and greater risk of QT-interval prolongation. QE = Moderate; SR = Strong

High rate of physical dependence; tolerance to sleep benefits; greater risk of overdose at low dosages.

Table 1 (continued from page 3) TABLE 1: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Organ System/ Recommendation, Rationale, Therapeutic Category/Drug(s) Quality of Evidence (QE) & Strength of Recommendation (SR) Avoid chronic use (>90 days) Nonbenzodiazepine Benzodiazepine-receptor agonists that have adverse events similar hypnotics n Eszopiclone to those of benzodiazepines in older adults (e.g., delirium, falls, n Zolpidem fractures); minimal improvement in sleep latency and duration. n Zaleplon QE = Moderate; SR = Strong Ergot mesylates* Avoid. Isoxsuprine* Lack of efficacy. QE = High; SR = Strong Endocrine Androgens Avoid unless indicated for moderate to severe n Methyltestosterone* hypogonadism. n Testosterone Potential for cardiac problems and contraindicated in men with prostate cancer. QE = Moderate; SR = Weak Desiccated thyroid Avoid. Concerns about cardiac effects; safer alternatives available. QE = Low; SR = Strong Estrogens with or without progestins Avoid oral and topical patch.Topical vaginal cream: Acceptable to use low-dose intravaginal estrogen for the management of dyspareunia, lower urinary tract infections, and other vaginal symptoms. Evidence of carcinogenic potential (breast and endometrium); lack of cardioprotective effect and cognitive protection in older women. Evidence that vaginal estrogens for treatment of vaginal dryness is safe and effective in women with breast cancer, especially at dosages of estradiol 325 mg/day Diclofenac Diflunisal Etodolac Fenoprofen Ibuprofen Ketoprofen Meclofenamate Mefenamic acid Meloxicam Nabumetone Naproxen Oxaprozin Piroxicam Sulindac Tolmetin

Avoid chronic use unless other alternatives are not effective and patient can take gastroprotective agent (protonpump inhibitor or misoprostol).

Indomethacin Ketorolac, includes parenteral

Avoid. Increases risk of GI bleeding/peptic ulcer disease in high-risk groups (See Non-COX selective NSAIDs) Of all the NSAIDs, indomethacin has most adverse effects. QE = Moderate (Indomethacin), High (Ketorolac); SR = Strong Avoid. Opioid analgesic that causes CNS adverse effects, including confusion and hallucinations, more commonly than other narcotic drugs; is also a mixed agonist and antagonist; safer alternatives available. QE = Low; SR = Strong Avoid. Most muscle relaxants poorly tolerated by older adults, because of anticholinergic adverse effects, sedation, increased risk of fractures; effectiveness at dosages tolerated by older adults is questionable. QE = Moderate; SR = Strong

n n n n n n n n n n n n n n n n

Pentazocine*

Skeletal muscle relaxants n Carisoprodol n Chlorzoxazone n Cyclobenzaprine n Metaxalone n Methocarbamol n Orphenadrine

Increases risk of GI bleeding/peptic ulcer disease in high-risk groups, including those ≥75 years old or taking oral or parenteral corticosteroids, anticoagulants, or antiplatelet agents. Use of proton pump inhibitor or misoprostol reduces but does not eliminate risk. Upper GI ulcers, gross bleeding, or perforation caused by NSAIDs occur in approximately 1% of patients treated for 3–6 months, and in about 2%–4% of patients treated for 1 year. These trends continue with longer duration of use. QE = Moderate; SR = Strong

Table 2 (continued from page 5) TABLE 2: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to DrugDisease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome Disease or Drug(s) Recommendation, Rationale, Quality of Evidence Syndrome (QE) & Strength of Recommendation (SR) Avoid. Syncope Acetylcholinesterase inhibitors (AChEIs) Peripheral alpha blockers n Doxazosin Increases risk of orthostatic hypotension or bradyn Prazosin cardia. n Terazosin QE = High (Alpha blockers), Moderate (AChEIs,TCAs and Tertiary TCAs antipsychotics); SR = Strong (AChEIs and TCAs),Weak (Alpha blockers and antipsychotics) Chlorpromazine, thioridazine, and olanzapine Central Nervous System Chronic Bupropion Avoid. seizures or Chlorpromazine epilepsy Clozapine Lowers seizure threshold; may be acceptable in Maprotiline patients with well-controlled seizures in whom alterOlanzapine native agents have not been effective. Thioridazine Thiothixene QE = Moderate; SR = Strong Tramadol Avoid. Delirium All TCAs Anticholinergics (see online for full list) Avoid in older adults with or at high risk of delirium Benzodiazepines because of inducing or worsening delirium in older Chlorpromazine adults; if discontinuing drugs used chronically, taper to Corticosteroids avoid withdrawal symptoms. H2-receptor antagonist Meperidine Sedative hypnotics QE = Moderate; SR = Strong Thioridazine Dementia Anticholinergics (see online for full list) Avoid. & cognitive Benzodiazepines Avoid due to adverse CNS effects. impairment H2-receptor antagonists Avoid antipsychotics for behavioral problems of Zolpidem dementia unless non-pharmacologic options have Antipsychotics, chronic and as-needed use failed and patient is a threat to themselves or others. Antipsychotics are associated with an increased risk of cerebrovascular accident (stroke) and mortality in persons with dementia. QE = High; SR = Strong History of falls or fractures

*Infrequently used drugs. Table 1 Abbreviations: ACEI, angiotensin converting-enzyme inhibitors; ARB, angiotensin receptor blockers; CNS, central nervous system; COX, cyclooxygenase; CrCl, creatinine clearance; GI, gastrointestinal; NSAIDs, nonsteroidal anti-inflammatory drugs; SIADH, syndrome of inappropriate antidiuretic hormone secretion; SR, Strength of Recommendation; TCAs, tricyclic antidepressants; QE, Quality of Evidence TABLE 2: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to DrugDisease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome Disease or Drug(s) Recommendation, Rationale, Quality of Evidence Syndrome (QE) & Strength of Recommendation (SR) Cardiovascular Avoid. Heart failure NSAIDs and COX-2 inhibitors Nondihydropyridine CCBs (avoid only for systolic heart failure) Diltiazem Verapamil

n n

Pioglitazone, rosiglitazone

Potential to promote fluid retention and/or exacerbate heart failure. QE = Moderate (NSAIDs, CCBs, Dronedarone), High (Thiazolidinediones (glitazones)), Low (Cilostazol); SR = Strong

Anticonvulsants Antipsychotics Benzodiazepines Nonbenzodiazepine hypnotics n Eszopiclone n Zaleplon n Zolpidem TCAs/SSRIs

Insomnia

Parkinson’s disease

Ability to produce ataxia, impaired psychomotor function, syncope, and additional falls; shorter-acting benzodiazepines are not safer than long-acting ones. QE = High; SR = Strong

Oral decongestants Pseudoephedrine Phenylephrine Stimulants Amphetamine Methylphenidate Pemoline Theobromines Theophylline Caffeine All antipsychotics (see online publication for full list, except for quetiapine and clozapine)

Avoid.

Antiemetics Metoclopramide Prochlorperazine Promethazine

Quetiapine and clozapine appear to be less likely to precipitate worsening of Parkinson disease.

n n n n n n n

n n n

Cilostazol Dronedarone

Avoid unless safer alternatives are not available; avoid anticonvulsants except for seizure.

CNS stimulant effects. QE = Moderate; SR = Strong

Avoid. Dopamine receptor antagonists with potential to worsen parkinsonian symptoms.

QE = Moderate; SR = Strong 3

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Table 2 (continued on page 6)

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Table 2 (continued on page 7)

Table 2 (continued from page 6) TABLE 2: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to DrugDisease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome Disease or Drug(s) Recommendation, Rationale, Quality of Evidence Syndrome (QE) & Strength of Recommendation (SR) Gastrointestinal Avoid unless no other alternatives. Chronic Oral antimuscarinics for urinary inconticonstipation nence n Darifenacin Can worsen constipation; agents for urinary inconn Fesoterodine tinence: antimuscarinics overall differ in incidence of n Oxybutynin (oral) constipation; response variable; consider alternative n Solifenacin agent if constipation develops. n Tolterodine n Trospium QE = High (For Urinary Incontinence), Moderate/Low (All Others); SR = Strong Nondihydropyridine CCB n Diltiazem n Verapamil First-generation antihistamines as single agent or part of combination products n Brompheniramine (various) n Carbinoxamine n Chlorpheniramine n Clemastine (various) n Cyproheptadine n Dexbrompheniramine n Dexchlorpheniramine (various) n Diphenhydramine n Doxylamine n Hydroxyzine n Promethazine n Triprolidine

History of gastric or duodenal ulcers

Urinary Estrogen oral and transdermal (excludes incontinence intravaginal estrogen) (all types) in women

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Stress or mixed urinary incontinence

Avoid in women.

Alpha-blockers Doxazosin Prazosin Terazosin

n n n

Aggravation of incontinence. QE = Moderate; SR = Strong

Table 2 Abbreviations: CCBs, calcium channel blockers; AChEIs, acetylcholinesterase inhibitors; CNS, central nervous system; COX, cyclooxygenase; NSAIDs, nonsteroidal anti-inflammatory drugs; SR, Strength of Recommendation; SSRIs, selective serotonin reuptake inhibitors; TCAs, tricyclic antidepressants; QE, Quality of Evidence TABLE 3: 2012 AGS Beers Criteria for Potentially Inappropriate Medications to Be Used with Caution in Older Adults Drug(s) Recommendation, Rationale, Quality of Evidence (QE) & Strength of Recommendation (SR) Aspirin for primary preven- Use with caution in adults ≥80 years old. tion of cardiac events Lack of evidence of benefit versus risk in individuals ≥80 years old. QE = Low; SR = Weak

Anticholinergics/antispasmodics (see online for full list of drugs with strong anticholinergic properties) n Antipsychotics n Belladonna alkaloids n Clidinium-chlordiazepoxide n Dicyclomine n Hyoscyamine n Propantheline n Scopolamine n Tertiary TCAs (amitriptyline, clomipramine, doxepin, imipramine, and trimipramine) Aspirin (>325 mg/day) Avoid unless other alternatives are not efNon–COX-2 selective NSAIDs fective and patient can take gastroprotective agent (proton-pump inhibitor or misoprostol).

Kidney/Urinary Tract Chronic kid- NSAIDs ney disease stages IV and V Triamterene (alone or in combination)

Table 2 (continued from page 7) TABLE 2: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to DrugDisease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome Disease or Drug(s) Recommendation, Rationale, Quality of Evidence Syndrome (QE) & Strength of Recommendation (SR) Lower Inhaled anticholinergic agents Avoid in men. urinary tract symptoms, Strongly anticholinergic drugs, except May decrease urinary flow and cause urinary retenbenign antimuscarinics for urinary incontinence tion. prostatic (see Table 9 for complete list). hyperplasia QE = Moderate; SR = Strong (Inhaled agents),Weak (All others)

May exacerbate existing ulcers or cause new/additional ulcers. QE = Moderate; SR = Strong Avoid. May increase risk of kidney injury.

Dabigatran

Use with caution in adults ≥75 years old or if CrCl 20

M ajor Depression, severe

Anti depressant and psychotherapy (especially if not improved on monotherapy)

* If symptoms present ;;:: two years, then probable chronic depression which warrants antidepressants or psychotherapy (ask "In the past 2 years have you felt depressed or sad most days, even if you felt okay sometimes?")

++ If symptoms present ;;:: one month or severe functional impairment, consider active treatment 6

STABLE RESOURCE TOOLKIT

The Patient Health Questionnaire (PHQ-9) Patient Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date of Visit _ _ _ __ __ Over the past 2 weeks, how often have you been bothered by any of the following problems?

Not At all

Several More Nearly Days Than Half Every the Days Day

1. Little interest or pleasure in doing things

0

2

3

2. Feeling down, depressed or hopeless

0

2

3

3. Trouble fall ing asleep, staying asleep, or sleeping too much

0

2

3

4. Feeling tired or having little energy

0

2

3

5. Poor appetite or overeating

0

2

3

6. Feeling bad about yourself- or that you're a failure or have let yourself or your family down

0

2

3

7. Trouble concentrating on things, such as reading the newspaper or watching television

0

2

3

8. Moving or speaking so slowly that other people could have noticed . Or, the oppositebeing so fidgety or restless that you have been moving around a lot more than usual

0

2

3

9. Thoughts that you would be better off dead or of hurting yourself in some way

0

2

3

Column Totals

+

+

Add Totals Together

10. If you checked off any problems, how diffi cult have those problems made it for you to Do your work, take care of things at home, or get along with other people?

0

Not difficult at all

0

Somewhat difficult

0

Very difficult

0

Extremely difficult

© 1999 PFizer Inc. All rights reserved. Used with permission 7

Caregiver Strain Questionnaire I am going to read a list of things which other people have found to be difficult in helping out after somebody comes home from the hospital Would you tell me whether any of these apply to you? (GIVE EXAMPLES) Yes = 1

No = 0

Sleep is disturbed (e.g., because . . . is in and out of bed or wanders around at night) It is inconvenient (e.g., because helping takes so much time or it's a long drive over to help) It is a physical strain (e.g., because of lifting in and out of a chair; effort or concentration is required) It is confining (e.g., helping restricts free time or cannot go visiting) There have been family adjustments ( e.g., because helping has disrupted routine; there has been no privacy) There have been changes in personal plans (e.g., had to turn down a job; could not go on vacation) There have been emotional adjustments (e.g., because of severe arguments) Some behavior is upsetting (e.g., because of incontinence; . . . has trouble remembering things; or . . . accuses people of taking things) It is upsetting to find . . . has changed so much from his/her former self (e.g., he/she is a different person than he/she used to be) There have been work adjustments (e.g., because of having to take time off) It is a financial strain Feeling completely overwhelmed (e.g., because of worry about …; concerns about how you will manage) Total Score (count yes responses)

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The Stages of Alzheimer's Disease At the New York University Medical Center's Aging and Dementia Research Center, Barry Reisberg, MD and colleagues have developed the Functional Assessment Staging (FAST) scale, which allows professionals and caregivers to chart the decline of people with Alzheimer's disease. The FAST scale has 16 stages and sub-stages: FAST Scale Stage

Characteristics

1... normal adult

No functional decline.

2... normal older adult

Personal awareness of some functional decline.

3... early Alzheimer's disease

Noticeable deficits in demanding job situations.

4... mild Alzheimer's

Requires assistance in complicated tasks such as handling finances, planning parties, etc.

5... moderate Alzheimer's

Requires assistance in choosing proper attire.

6... moderately severe Alzheimer's

Requires assistance dressing, bathing, and toileting. Experiences urinary and fecal incontinence.

7... severe Alzheimer's

Speech ability declines to about a half-dozen intelligible words. Progressive loss of abilities to walk, sit up, smile, and hold head up.

Detailed Description of Each of the 7 Stages Stage 1 No cognitive decline. No subjective complaints of memory deficit. No memory deficit evident on clinical interviews. Stage 2 (Forgetfulness) Very mild cognitive decline. Subjective complaints of memory deficit, most frequently in the following area: a. b.

forgetting where one has placed familiar objects; forgetting names on formerly knew well.

No objective evidence of memory deficit on clinical interview. No objective deficits in employment or social situations. Appropriate concern regarding symptoms. Stage 3 (Early Confusional) Mild cognitive decline. Earliest clear-cut deficits. Manifestations in more than one of the following areas: a. b. c. d. e. f. g.

patient may have gotten lost when traveling to an unfamiliar location; co-workers become aware of patient's relatively low performance; word and name finding deficit becomes evident to intimates; patient may read a passage of a book and retain relatively little material; patient may demonstrate decreased facility in remembering names upon introduction to new people; patient may have lost or misplaced an object of value; concentration deficit may be evident on clinical testing.

Objective evidence of memory deficit obtained only with an intensive interview. Denial begins to become manifest in patient. Mild to moderate anxiety accompanies symptoms. Stage 4 (Late Confusional) Moderate cognitive decline. Clear-cut deficit on careful clinical interview. Deficit manifest in following areas: a. b. c.

decreased knowledge of current and recent events; may exhibit some deficit in memory of one's personal history; concentration deficit elicited on serial subtractions; 10

d.

decreased ability to travel, handle finances, etc.

Frequently no deficit in the following areas: a. b. c.

orientation to time and person; recognition of familiar persons and faces; ability to travel to familiar locations.

Inability to perform complex tasks. Denial is dominant defense mechanism. Flattening of affect and withdrawal from challenging situations occur. Stage 5 (Early Dementia) Moderately severe cognitive decline. Patient can no longer survive without some assistance. Patient is unable during interview to recall a major relevant aspect of their current lives, e.g., an address or telephone number of many years, the names of close family members (such as grandchildren), the name of the high school or college from which they graduated. Frequently some disorientation to time (date, day of week, season, etc.) or to place. An educated person may have difficulty counting back from 40 by 4s or from 20 by 2s. Persons at this stage retain knowledge of many major facts regarding themselves and others. They invariably know their own names and generally know their spouse's and children's names. They require no assistance with toileting and eating, but may have some difficulty choosing the proper clothing to wear. Stage 6 (Middle Dementia) Severe cognitive decline. May occasionally forget the name of the spouse upon whom they are entirely dependent for survival. Will be largely unaware of all recent events and experiences in their lives. Retain some knowledge of their past lives but this is very sketchy. Generally unaware of their surroundings, the year, the season, etc. May have difficulty counting from 10, both backward and sometimes forward. Will require some assistance with activities of daily living, e.g., may become incontinent, will require travel assistance but occasionally will display ability to familiar locations. Diurnal rhythm frequently disturbed. Almost always recall their own name. Frequently continue to be able to distinguish familiar from unfamiliar persons in their environment. Personality and emotional changes occur. These are quite variable and include: a. b. c. d.

delusional behavior, e.g., patients may accuse their spouse of being an impostor, may talk to imaginary figures in the environment, or to their own reflection in the mirror; obsessive symptoms, e.g., person may continually repeat simple cleaning activities; anxiety agitation, and even previously nonexistent violent behavior may occur; cognitive abulla, i.e., loss of willpower because an individual cannot carry a thought long enough to determine a purposeful course of action.

Stage 7 (Late Dementia) Very severe cognitive decline. All verbal abilities are lost. Frequently there is no speech at all - only grunting. Incontinent of urine, requires assistance toileting and feeding. Lose basic psychomotor skills, e.g., ability to walk, sitting and head control. The brain appears to no longer be able to tell the body what to do. Generalized and cortical neurologic signs and symptoms are frequently present. Alzheimer's Disease and Skill Abilities Dr Reisberg has also shown that the decline typical of Alzheimer's disease is the flip side of normal skill acquisition by infants, children, and young adults:

Ability

Age of acquisition during normal Alzheimer's stage at which development ability is lost

Hold a job. Function independently in the world.

12 years and older

3... early Alzheimer's disease

Handle simple finances.

8-12 years

4... mild Alzheimer's

Select proper clothing.

5-7 years

5... moderate Alzheimer's

Available from ElderCare Online TM

www.ec-online.net

© Barry Reisberg, MD 1984 11

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