Global Deterioration Scale – 7 Levels of Dementia

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The Global Deterioration Scale (GDS) is one of several different types of tests that professional use to assess an individual for dementia and the severity of it.

If you have a parent or grandparent who is experiencing some cognitive declines, it’s not uncommon for it to worsen over time. People, perhaps even the individual him or herself, begin to wonder if it’s a form of dementia.

The GDS was first proposed in 1982 by Dr. Barry Reisberg, a Research Professor in the NYU Department of Psychiatry who has directed Alzheimer’s research for 30 years.

At that time, there was no generally recognized global rating instrument that could accurately rate the level of dementia. We now have different types of memory tests that professionals can use, including:

• Mini-Mental State Exam (MMSE)
• Test Your Memory (a self-performed test)
• Self-Administered Gerocognitive Exam (SAGE)
• SLUMS Alzheimer’s Exam

The Global Deterioration Scale still has a place, however. It provides a level of dementia severity that professionals can use to track how quickly the dementia is progressing. It also providers healthcare workers with context, so they can better understand where the individual is at as they begin working with them.

How the GDS Can Help Families

The onset of dementia and its progression can be frightening for everyone involved. Once you, as a family member, understand where your loved one is at in dementia severity, it can help provide the context for caregiving and planning.

Consider the following questions and scenarios where the Global Deterioration Scale could be helpful. We’ll revisit them in a moment.

1. When does forgetting names mean there’s a true problem?
2. I noticed that Grandpa seemed kind of lost in our house last time we brought him here for his birthday. Is this to be expected if he has dementia starting?
3. Dad’s boss told Mom that he should consider retirement. He said his memory on important projects hasn’t been too good.
4. When does someone with dementia get to the point where family should step in and take care of their finances?
5. When Grandma forgot Grandpa’s name, it seemed like she was already suffering from severe cognitive decline. It seemed like she was fine before that. Were there signs I missed along the way?
6. It seems like Grandpa is having personality changes and doing things that are not appropriate. We don’t know what to do about it.
7. I heard that incontinence is part of severe dementia. I know I won’t be able to handle that at home. What do I do?

The Global Deterioration Scale sets up cognitive decline into seven different levels. These levels are progressive. By recognizing where your loved one is on the Global Deterioration Scale, you can make wise decisions for the care of your loved one. For example, if you understand that assistance with toileting and eating occur in Level 7, you’ll know that this may be a time when you will have to utilize caregivers in the home or transport your loved one to a memory care facility.

The 7 Global Deterioration Scale Levels

The GDS has 7 levels where 1 is no cognitive decline and 7 is the most severe. See the chart below that breaks out each level and the cognitive, behavioral, and physical changes that can be observed at each level.

Level	Cognitive Changes	Behavioral Changes	Physical Changes
1 – No cognitive  decline	No changes	No changes. The person is their normal self.	No changes.
2 – Very mild cognitive decline	Age Associated Memory Impairment. Subjective complaints of memory loss such as forgetting names of people known for years or where familiar objects are. No memory deficits found on tests.	No changes in what one remembers on the job or in social situations.	No changes.
3 – Mild cognitive decline	Mild Cognitive Impairment. Deficits in remembering names and words. Reading retention is poor. Name recall for newly introduced people is poor. Patient loses or misplaces important objects of value. Clinical memory testing shows deficits.	Coworkers start commenting on poor performance of patient. Decreased performance in demanding employment and social settings.	Anxiety appears.
4 – Moderate cognitive decline	Mild Dementia. With clinical interviews, clear-cut deficits are seen in any of the following areas: Current/recent eventsLoss of memory of personal historyMath calculations are difficultDecreased ability to travel, handle $$ Deficits not seen  in orientation to time and place, face identification of familiar people in life, ability to travel and navigate.	Inability to perform complex tasks. Denial is common. Withdraws from social situations. Flattening of affect.	No further changes.
5 – Moderately severe cognitive decline	Moderate Dementia. Unable to recall major relevant details about life such as address, telephone number, names of family members. Some disorientation to time (date, day of week, season, etc.) or place.  Counting backwards could cause problems.	May have difficulty choosing the proper clothing to wear.	No additional changes. No assistance needed for toileting and eating.
6 – Severe cognitive decline	Moderately Severe Dementia Occasionally forgets spouse name. Largely unaware of all recent events and life experiences. Knowledge about their life is sketchy. Generally unaware of surroundings, what year it is, the season of the year. May have difficulty counting backwards from the number 10. Some difficulty counting forward. Can recall own name. Can tell the difference between people they know and don’t know.	Requires travel assistance most of the time although may be able to travel on own occasionally to familiar places. Personality and emotional changes occur: 1) delusions, often about people, 2)obsessive behaviors, 3) agitation, 4) loss of will power.	May become incontinent Anxiety symptoms Requires some assistance with daily living activities Daily rhythms frequently disturbed.
7 – Very severe cognitive decline	Severe Dementia. All verbal abilities lost. May not have ability to speak – only makes guttural noises and rare emergence of seemingly forgotten words and phrases.	Same as previous stage.	Incontinent of urine. Requires assistance toileting and feeding. Ability to walk lost. Brain can’t tell body what to do. Generalized rigidity. Developed neurological reflexes are frequently present.

Reconsidering Those Questions and Scenarios

Now that you understand about the different levels, let’s look at the the seven previously mentioned questions and concerns.

1. When does forgetting names mean there’s a true problem?

Memory starts to become a real problem at Level 4.

2. I noticed that Grandpa seemed kind of lost in our house last time we brought him here for his birthday. Is this to be expected if he has dementia starting?

Getting lost may start to become a problem at Level 5 and then worsens with further levels.

3. Dad’s boss told Mom that he should consider retirement. He said his memory on important projects hasn’t been too good.

This occurs at Level 3. Retirement may be needed, depending on the potential effects on others from the memory loss. For example, if forgetfulness puts someone in danger, it may be better to retire to prevent future problems.

4. When does someone with dementia get to the point where family should step in and take care of their finances?

At Level 4.

5. When Grandma forgot Grandpa’s name, it seemed like she was already suffering from severe cognitive decline. It seemed like she was fine before that. Were there signs I missed along the way?

Yes, signs start at Level 2.

6. It seems like Grandpa is having personality changes and doing things that are not appropriate. We don’t know what to do about it.

Always contact your primary care physician and your memory care physician. Seek outside consultants who have worked in changing the progress of those with dementia.

7. I heard that incontinence is part of severe dementia. I know I won’t be able to handle that at home. What do I do?

Start preparing for incontinence if you will not be seeking alternative treatments for dementia that have proven to be successful. You may want to start looking for memory care facilities when your loved one reaches Level 4 or 5.