The Functional Assessment Staging Test (FAST) is a standardized, validated tool used to track the progressive decline of functional abilities in patients with Alzheimer’s disease and related dementias. Developed by Dr. Barry Reisberg, this scale provides a structured framework for clinicians and caregivers to understand the severity and trajectory of the illness. The test organizes the disease into seven primary stages, representing a continuum of cognitive and physical deterioration. Stage 7 represents the most severe and advanced stage of the disease, indicating profound functional impairment and total dependence for all daily needs.
Understanding the Functional Assessment Staging Test (FAST)
The FAST scale is a detailed roadmap for charting the downward progression of dementia, moving sequentially from Stage 1 to Stage 7. The early stages, Stage 1 and Stage 2, describe a person who is functioning normally or experiencing only very mild, age-associated memory loss. These initial stages do not typically affect a person’s ability to live independently or perform complex tasks.
Progression into Stage 3 signifies the onset of mild cognitive impairment, where difficulties begin to interfere with complex tasks like managing personal finances, organizing bills, or traveling to new locations. By Stage 4, the cognitive deficits become more noticeable, often leading to a formal diagnosis of dementia, and complex task performance is significantly impaired. The patient may struggle with preparing a meal or handling medications.
Stage 5 marks moderately severe cognitive decline, where the individual can no longer live alone safely and requires assistance with choosing appropriate clothing. The decline accelerates in Stage 6, which is classified as severe cognitive decline, requiring constant supervision and help with basic activities of daily living (ADLs). This stage is further broken down into sub-stages (6a through 6e) that detail the progressive loss of independence in dressing, bathing, and using the toilet.
The Specific FAST Stage 7 Markers
Stage 7 is the terminal phase of the disease, characterized by the complete loss of verbal and psychomotor skills, and it is the primary indicator for considering hospice care. This stage is broken down into six sub-stages, 7a through 7f, each representing a non-reversible loss of a fundamental human function. A patient must exhibit the functional deficit of the preceding sub-stage before being classified into the next. These sub-stages document a comprehensive functional collapse, indicating total physical dependence:
- Stage 7a: Vocabulary is severely limited, typically to only five or six words a day.
- Stage 7b: Patient is only able to speak one intelligible word.
- Stage 7c: Inability to walk without assistance due to neurological decline.
- Stage 7d: Loss of the ability to sit up independently.
- Stage 7e: Loss of facial motor control, specifically the inability to smile.
- Stage 7f: Inability to hold the head up independently.
Secondary Indicators for Hospice Eligibility
While reaching FAST Stage 7 is a necessary condition for hospice consideration in advanced dementia, it is often not the sole requirement for admission. The FAST score is a measure of functional decline, but a physician must also certify that the patient’s prognosis is six months or less, which requires additional clinical evidence of rapid physiological deterioration. This assessment relies heavily on the presence of specific secondary indicators.
Recurrent Infections
One of the most significant secondary indicators is the presence of recurrent infections within the last year, which suggests a failing immune system. This includes multiple episodes of pyelonephritis, urinary tract infections, sepsis, or aspiration pneumonia, which often occurs due to difficulty swallowing (dysphagia). These infections, which are difficult to manage in an end-stage patient, strongly support a limited life expectancy.
Nutritional Decline
Nutritional decline is another major factor, typically evidenced by significant, involuntary weight loss. A loss of 10% or more of body weight over the previous six months, or a low serum albumin level (below 2.5 gm/dl), serves as a prognostic marker. The inability to maintain sufficient fluid and calorie intake is a critical sign of advanced disease progression.
Pressure Ulcers
The presence of multiple, progressive pressure ulcers that are Stage 3 or Stage 4, despite receiving optimal medical care, is a serious secondary indicator. These non-healing wounds, along with recurrent fevers after antibiotic treatment, reflect the body’s diminishing capacity to recover from physical stress. The combination of a high FAST score and these physiological complications provides the clinical justification for a terminal diagnosis and hospice eligibility.