One of the most valuable tools physicians and care professionals use when working with people living with dementia is the FAST Scale, short for Functional Assessment Staging.
Rather than focusing solely on memory loss, the FAST Scale looks at functional changes—the everyday, observable abilities that tend to shift as Alzheimer’s disease or other dementias progress. This makes it especially useful for tracking decline over time and understanding what kind of support may be needed at each stage.
What many people don’t realize is that the FAST Scale isn’t just for clinicians. Family members and loved ones can also use it to better understand changes they’re seeing and to prepare for what comes next.
Below is a stage-by-stage overview of the FAST Scale, including practical guidance for each phase.
Stage 1: No Cognitive Decline
At this stage, there are no noticeable changes in thinking, memory, or daily function. Most people reading this are likely in Stage 1.
What to do
This is the ideal time to plan ahead. Put care preferences in writing, organize legal and medical documents, and focus on healthy habits like good nutrition, regular movement, and mentally stimulating activities. Just as important, work on reducing fear or negative beliefs about aging and dementia. Planning early can significantly ease stress later.
Stage 2: Mild Forgetfulness
Stage 2 includes occasional lapses such as misplacing items, forgetting appointments, or losing track of tasks. These changes are usually subtle and not noticeable to others.
Everyone experiences forgetfulness. All people with dementia become more forgetful—but not everyone who is forgetful has dementia.
What to do
Don’t panic. Anxiety can make memory issues feel worse. Use simple tools like reminder apps, calendars, sticky notes, or smart devices. If forgetfulness becomes consistent rather than occasional, begin tracking patterns and stay curious—not fearful.
Stage 3: Noticeable Changes to Others
In this stage, cognitive changes become more apparent to coworkers or loved ones. Tasks that require concentration or planning may feel harder. People may forget recurring meetings, struggle with complex work, or feel disoriented in unfamiliar places.
These symptoms can also be caused by stress, sleep issues, or medical conditions—not just dementia.
What to do
Take a step back and assess the bigger picture. Is life too demanding right now? Are stress, mental health, or physical health factors at play? Once these are considered, start a thoughtful conversation with a healthcare provider about next steps.
Early Dementia
Stage 4: Difficulty With Planning and Complex Tasks
Multi-step activities become more challenging. Someone may need to repeatedly check a recipe they once knew by heart or return from the store with duplicates or unnecessary items—even with a list. A diagnosis of Mild Cognitive Impairment (MCI) is often made at this stage.
What to do
Meet with a physician to rule out other causes. Begin using organizational tools and routines early, while they’re still easy to learn. Review care preferences and start open conversations with loved ones to ensure wishes are understood and respected.
Mid-Stage Dementia
Stage 5: Functional Changes Are More Obvious
Loved ones may notice changes in clothing choices, grooming, or hygiene. The person may feel everything is fine, even when it isn’t. Cognitive decline is now measurable, and the diagnosis may shift to moderate cognitive impairment.
What to do
Lean into support. Alzheimer’s cafés and support groups can be invaluable. View reminders about hygiene or clothing as acts of care—not criticism. For caregivers, use kindness and creativity. When possible, keep things light and fun rather than corrective.
Stage 6: Increasing Need for Daily Support
Stage 6 includes five substages and reflects growing difficulty with activities of daily living. At this point, a physician may diagnose major neurocognitive disorder, the clinical term for dementia.
Stage 6a: Help With Dressing
What to do
Choose easy-to-wear clothing and simplify choices. Matching color schemes and eliminating complicated fasteners can help preserve independence.
Stage 6b: Help With Bathing
What to do
Make the bathroom safer and easier to navigate. Labels, numbered steps, and multi-use products reduce confusion. Home modifications can greatly improve comfort and dignity.
Stage 6c: Help Using the Toilet
What to do
Use visual cues like photos or diagrams to guide each step. Bidet attachments can also make hygiene easier and more comfortable.
Stage 6d: Difficulty Getting to the Bathroom in Time
What to do
First, rule out infections such as UTIs. If medical causes are excluded, try scheduled bathroom visits and absorbent underwear, which can reduce stress and stigma.
Stage 6e: Forgetting to Use the Bathroom
What to do
Anticipate needs based on routine—after meals, upon waking, or after coffee. When incontinence care is necessary, move slowly, gently, and with reassurance.
Late-Stage Dementia
Stage 7 reflects severe changes in language and mobility. The focus shifts from intervention to comfort, dignity, and presence.
Stage 7a: Limited Speech
Language may shrink to just a few words per day.
What to do
Adjust communication to match what your loved one can understand. Even if speech is limited, comprehension may still be strong.
Stage 7b: Single-Word Communication
What to do
Rely on body language, facial expressions, and tone. Meaning is often conveyed without words.
Stage 7c: Difficulty Walking
What to do
Encourage movement with appropriate support for as long as it’s safe. Mobility aids may help early on; later, a wheelchair may be necessary.
Stage 7d: Trouble Sitting Upright
What to do
Use supportive seating and assistive devices.
Important: Supports should never be used as restraints.
Stage 7e: Loss of Smiling
What to do
This is a physical change, not an emotional one. Look for other signs of comfort or contentment.
Stage 7f: Loss of Head Control
What to do
This is often the time to involve hospice if you haven’t already. Focus on comfort, connection, and being present.
Final Thoughts
The FAST Scale highlights losses—but dementia is not only about what disappears. Many people living with dementia experience deeper emotional connections, heightened sensitivity, and meaningful moments of presence.
Acknowledging loss is important, but focusing only on decline increases suffering. By paying attention to what remains, we can improve quality of life—for those living with dementia and for those who love them.