F.A.S.T. Can Be About Slow…

In order to qualify for hospice care, a dementia patient must have a FAST score of 7. FAST is an acronym for the Reisberg Functional Assessment STaging Scale. A scale nicknamed FAST to determine dementia’s severity is blatantly ironic. As various dementias (Alzheimer’s, Lewy Bodies, etc.) worsen, the person typically becomes, well, slower.

Currently the Reisberg scale lists 16 distinctive categories, including these two:

  • Stage 3: Decreased job functioning evident to coworkers; difficulty in traveling to new locations
  • Stage 4: Decreased ability to perform complex tasks (e.g., planning dinner for guests, handling finances)

Those who have cared for someone with dementia usually sense the “slowing down” of a loved one only after he or she has worsened. Who among us hasn’t experienced Stage #3’s “difficulty in traveling to new locations?” Recently I drove to San Francisco for the first time in years and got lost. I studied my Google Map directions and my worn-out AAA street map and couldn’t figure out where I was! Had I “slowed down and entered Stage #3? I wrote the first draft of this essay near April 15…tax day! Who hasn’t complained—young, old, fast or slow—about the complexity of taxes? If my frustration about handling finances dramatically increased, should I blame Stage #4 or a calendar date? It’s easy to rationalize or joke about slow or sluggish days.

Stage 7, with its six different sub-stages, is—quite literally—no laughing matter:

  • Sub-stage 7a: Ability to speak limited (1 to 5 words a day)
  • Sub-stage 7b: All intelligible vocabulary lost
  • Sub-stage 7c: Non-ambulatory
  • Sub-stage 7d: Unable to sit up independently
  • Sub-stage 7e: Unable to smile
  • Sub-stage 7f: Unable to hold head up
Dad, in the 1940s with a favorite car. He could talk "forever" and very intelligently about his cars!

Dad, in the 1940s with a favorite car. He could talk “forever” and very intelligently about his cars!

When a dementia patient has any sub-stage in the 7s, they may be deemed “hospice appropriate.” But as with all the ways we evaluate, label and statistically analyze diseases and disease progression, we are only making guesses. My father had dementia. The first hospice that visited him at his memory care facility determined he wasn’t eligible because he spoke with 5 or more words. Thus, he wasn’t at 7a. And many of his words, though limited, seemed intelligible. Thus, he wasn’t at 7b. Except the nurse examining him hadn’t lived with him . . . and had no way to determine how much of his “speech” was rooted less in reality and more in his delusions.

For one hospice, his FAST wasn’t “slow” enough! A second hospice evaluated my father—who no longer smiled (7e), but could hold up his head (7f)—and guessed he had six months or less to live. Dad died three months after the first hospice said he hadn’t yet reached Stage 7.

We kid ourselves into thinking medicine and science will solve everything or predict anything. Even with more advances, perhaps even with a more precise Reisberg scale, we’ll still be a long way from solutions. However accurate FAST becomes, I think it’s more important to slow down and make sure you spend time with those you love.

(Hospice vigorously protects a patient’s privacy. I’ll take care with how I share my experiences. Any names used are fictitious. Events are combined and/or summarized.)

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