Walking Through the Six-A to Six-E Substages

What do the FAST stage 6 substages mean?

On the fast scale, stage 6 is where personal care starts needing another pair of hands, and the lettered substages record which piece has gone. They run in a fixed order and mark five separate losses that can sit many months apart 1Ref 1Reisberg B (1988).Functional Assessment Staging (FAST).The FAST scale's seven major stages of functional decline in Alzheimer's dementia and its lettered substages within stage 6, the ordered content of those substages from dressing through bowel incontinence, and that the markers used in dementia hospice eligibility sit at stage 7 rather than stage 6.. That spacing is the point: a family can live inside fast stage 6 for a long stretch, and the letter tells them where in that stretch they are.

The letters are a sequence, not a score. Nobody adds them up, and there is no total. A clinician records the furthest point reached: someone at 6c has already passed 6a and 6b, and before those, everything fast stage 4 and fast stage 5 described.

One caution: secondary reproductions letter these items slightly differently, and some run to a sixth. A letter copied off a website is not the same object as one assigned by a clinician who examined the person.

6a and 6b: dressing and bathing

These two go first because they are the most complicated things an adult does before breakfast. Dressing is a sequencing problem — layers in order, front from back, the right garment for the right limb. Bathing is a sequencing problem with water temperature, balance, and a slippery floor added. 6a means dressing no longer happens correctly without help; 6b means the same for washing 1Ref 1Reisberg B (1988).Functional Assessment Staging (FAST).The FAST scale's seven major stages of functional decline in Alzheimer's dementia and its lettered substages within stage 6, the ordered content of those substages from dressing through bowel incontinence, and that the markers used in dementia hospice eligibility sit at stage 7 rather than stage 6..

At 6a the clothes usually still go on. They go on wrong. Two shirts, a cardigan buttoned to the wrong hole, yesterday's trousers over today's. Handing over one garment at a time, in order, is the adjustment most households arrive at, and it often buys back months of the person dressing themselves.

6b is different in kind, because being washed by another person is the most exposing thing an adult can be asked to accept. Resistance here is rarely about hygiene. It is about cold, about noise, about being undressed in front of a son or a daughter. Agitation is common through this middle stretch 3Ref 3National Institute on Aging (NIH) (2024).What Are the Signs of Alzheimer's Disease?.That agitation is common in the moderate stage of Alzheimer's and that supervision and help needs rise steadily through it., and the bathroom is where it surfaces first.

6c: the toilet, and why it is not yet incontinence

6c is the most misread letter on the whole scale. It describes the mechanics of using the toilet coming apart — managing clothing, wiping, flushing, dealing with the tissue — in a person who still knows they need to go and still gets there 1Ref 1Reisberg B (1988).Functional Assessment Staging (FAST).The FAST scale's seven major stages of functional decline in Alzheimer's dementia and its lettered substages within stage 6, the ordered content of those substages from dressing through bowel incontinence, and that the markers used in dementia hospice eligibility sit at stage 7 rather than stage 6.. The bladder and bowel are working. The procedure around them is not.

That distinction changes the care plan completely. A person at 6c needs prompting, company, and a bathroom that is easy to find at night: a light left on, a clear path, a door that is obviously a bathroom door. A person at 6d needs something different. Reaching for pads at 6c solves a problem that has not happened yet and takes away a function the person still has.

Getting the letter right here usually means less loss, not more. Many families discover that what looked like incontinence was a person who could not find the bathroom in an unlit hallway.

6d and 6e: incontinence, and why it comes last

6d is urinary incontinence and 6e is bowel incontinence, and on this scale they sit at the end of the stage rather than the start 1Ref 1Reisberg B (1988).Functional Assessment Staging (FAST).The FAST scale's seven major stages of functional decline in Alzheimer's dementia and its lettered substages within stage 6, the ordered content of those substages from dressing through bowel incontinence, and that the markers used in dementia hospice eligibility sit at stage 7 rather than stage 6.. Continence is held longer than dressing, bathing, or the mechanics of the toilet, which is why its arrival is treated as a genuine step down rather than as an accident.

The practical consequences are mostly about skin and about nights. Skin that stays damp breaks down, so a look at the lower back, the hips, and the heels becomes part of ordinary care. Nights get broken. Laundry becomes a fixed daily job rather than a weekly one.

The safety point matters more than any of that. Incontinence that appears suddenly, or arrives out of order — before dressing or bathing have gone — is not the scale advancing. That pattern points at a urinary tract infection, constipation, uncontrolled pain, or a new medication, and it is worth a same-day call to the person's clinician rather than a resigned adjustment to the care plan. Function that drops in days rather than seasons usually has a cause worth finding.

Why the substages fall in this particular order

The order is not arbitrary. It follows the same list of basic self-care activities that geriatric medicine has used since 1963, when the Katz Index named six of them — bathing, dressing, going to toilet, transferring, continence, and feeding — and rated each one simply as independent or dependent 2Ref 2Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. (1963).Studies of Illness in the Aged: The Index of ADL: A Standardized Measure of Biological and Psychosocial Function.The six activities of daily living named by the original Katz Index — bathing, dressing, going to toilet, transferring, continence, and feeding — each rated independent or dependent, and the Index's hierarchical A-through-G grading from independent in all six to dependent in all six, with a separate category for patterns that do not fit the hierarchy.. Nearly every functional scale since has inherited that list, including this one.

What Katz added was direction. The original index graded people from A, independent in all six functions, through to G, dependent in all six, with a separate category for the people whose pattern did not fit the hierarchy 2Ref 2Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. (1963).Studies of Illness in the Aged: The Index of ADL: A Standardized Measure of Biological and Psychosocial Function.The six activities of daily living named by the original Katz Index — bathing, dressing, going to toilet, transferring, continence, and feeding — each rated independent or dependent, and the Index's hierarchical A-through-G grading from independent in all six to dependent in all six, with a separate category for patterns that do not fit the hierarchy.. In other words, these losses tend to arrive in a predictable sequence — and the exceptions were common enough to need their own label.

The stage 6 letters are that hierarchy, applied to dementia. Which is also why a person who loses them out of sequence is worth a second look rather than a new letter.

What each letter changes about the day

The honest summary is that stage 6 converts supervision into hands-on work. At 6a the caregiver is present at the start of the day. By 6e the caregiver is present for most of it, including at night. This is the stretch in which the broader middle stage of the illness is usually described as needing steadily more help and closer watching 3Ref 3National Institute on Aging (NIH) (2024).What Are the Signs of Alzheimer's Disease?.That agitation is common in the moderate stage of Alzheimer's and that supervision and help needs rise steadily through it..

• 6a — an extra twenty minutes in the morning, clothing chosen the night before.
• 6b — a second person, a shower chair, or a switch from bath to shower. Often the first task a family pays someone else to do.
• 6c — prompting on a schedule instead of waiting to be asked, and a bathroom route that works in the dark.
• 6d — supplies, laundry, and a daily look at the skin.
• 6e — round-the-clock coverage in practice, whoever provides it.

Somewhere in this range most families first read memory care criteria seriously, because 24-hour coverage is the thing being bought. The letters are useful in that conversation precisely because they are specific: naming 6c and 6d says more than saying somebody has gotten worse.

How a clinician actually assigns a letter

By history, from someone who sees the person daily. There is no blood test and no scan for a FAST letter. A clinician asks what the person can do without help on an ordinary day — not their best day and not their worst — and records the furthest loss. Family observation is the raw material, which is why writing things down between visits changes the answer.

Other instruments get used alongside it and can sound contradictory. The Clinical Dementia Rating Sum of Boxes adds six rated domains, including personal care, into a total from 0 to 18, with higher meaning more impairment; scores of 16.0 to 18.0 correspond to its most severe global stage 5Ref 5O'Bryant SE, Waring SC, Cullum CM, et al. (2008).Staging dementia using Clinical Dementia Rating Scale Sum of Boxes scores: a Texas Alzheimer's research consortium study.That the CDR Sum of Boxes totals six rated domains including personal care into a score from 0 to 18, that higher scores mean greater impairment, and that scores of 16.0 to 18.0 correspond to the most severe global CDR stage.. A CDR-SB total runs 0 to 18 across six domains 5Ref 5O'Bryant SE, Waring SC, Cullum CM, et al. (2008).Staging dementia using Clinical Dementia Rating Scale Sum of Boxes scores: a Texas Alzheimer's research consortium study.That the CDR Sum of Boxes totals six rated domains including personal care into a score from 0 to 18, that higher scores mean greater impairment, and that scores of 16.0 to 18.0 correspond to the most severe global CDR stage.. The Global Deterioration Scale — Reisberg staging, from the same group in 1982 — takes the same illness and stages it by cognition rather than function 6Ref 6Reisberg B, Ferris SH, de Leon MJ, Crook T (1982).The Global Deterioration Scale for assessment of primary degenerative dementia.The existence and clinical origin of the seven-stage Global Deterioration Scale, published in 1982 by the same research group, as a staging framework for primary degenerative dementia..

So a person can carry a FAST letter and a CDR number that seem to disagree. They are measuring different things, and the disagreement is information rather than error.

What the stage 6 letters cannot tell you

They cannot tell you how long. The scale describes what has been lost, never how fast the next loss arrives, and two people at 6c today may be nowhere near each other in a year. Any number offered as a timeline for a specific person is being invented somewhere between the source and the reader.

They also do not settle eligibility. Families sometimes arrive at these letters looking for the hospice LCD dementia threshold; it is written around fast stage 7 markers, not stage 6 ones 1Ref 1Reisberg B (1988).Functional Assessment Staging (FAST).The FAST scale's seven major stages of functional decline in Alzheimer's dementia and its lettered substages within stage 6, the ordered content of those substages from dressing through bowel incontinence, and that the markers used in dementia hospice eligibility sit at stage 7 rather than stage 6.. The fast substages 7 letters are where that conversation actually lives. Reaching 6e is not a hospice criterion by itself.

And a letter earned during a hospital stay, an infection, a move, or a bad week is not a stage. The broad three-part description of the illness — early, middle, late — exists partly because single observations are unreliable 4Ref 4Alzheimer's Association (2024).Stages of Alzheimer's.That Alzheimer's is commonly described in three broad stages — early, middle, and late — with increasing help needed through the middle stage.. What the letters are good for is naming a specific loss precisely enough that a clinician can act on it.