FAST Isn’t a Memory Test: It’s a Map of Decline

Picture of a map with text overlay, "Fast isn't a memory test: It's a map of decline."

Introduction

FAST is a staircase you only go down. Each step lost, never regained. It marks the body’s slow surrender to Alzheimer’s disease (Reisberg, 1988)

Every team member knows FAST. But few master documenting it well enough to protect patients and recertifications. This guide explains dementia staging, documenting decline, and using FAST to identify hospice eligibility, while addressing its limitations for equitable care. Identify eligibility before it’s too late.

The Forgotten Scale That Built the Frame

The FAST Scale—Functional Assessment Staging Tool—was developed in 1984 by Dr. Barry Reisberg to stage Alzheimer’s disease progression for research, not hospice.

Decades later, it’s a cornerstone of hospice eligibility, defining the threshold of irreversible functional decline, often at stage 7c. However, while FAST is critical, research highlights limitations in its prognostic accuracy and applicability, prompting ongoing debates in palliative care. Clinicians should use it as part of a broader assessment to ensure equitable and accurate decisions.

What FAST Is—and Isn’t

FAST stages Alzheimer’s disease—not all dementias. Apply it cautiously to related disorders (e.g., vascular, Lewy body, or frontotemporal dementias). In vascular dementia, decline may be stepwise with plateaus; in Parkinson’s, early motor and speech losses can mimic 7c or 7d without matching Alzheimer’s trajectory. Critics note that FAST’s assumption of sequential, irreversible decline can exclude up to 41% of patients whose progression is nonlinear—such as those with comorbidities like strokes—making staging challenging. For these cases, supplement FAST with tools like the Palliative Performance Scale (PPS) or Advanced Dementia Prognostic Tool (ADEPT) for better prognostication.

For non-Alzheimer’s dementias, use FAST language (e.g., loss of ambulation, speech, self-care) to describe decline without forcing a score. FAST tracks function—mobility, toileting, speech—not memory or cognition. Even at 7f, a patient may flinch at a name or glance toward music. Their body may be silent, but they’re not gone. FAST’s focus on function is valuable, but its limitations in predicting short-term survival mean it should not stand alone.

Think of FAST as a staircase you only descend. Each step is lost in order, from stage 1 (normal function) to 7f (bedbound, mute, incontinent). Regression is rare and must be documented. The clinical tipping point is FAST 7c—loss of independent ambulation—requiring all prior stages (6, 7a, 7b).

Critics note that FAST’s assumption of sequential, irreversible decline can exclude up to 41% of patients whose progression is nonlinear…” Kiely et al. 2009

FAST 7c: The Line in the Sand

FAST is one of the foundational hospice metrics. 7c is more than a score. It’s the pivot point that can unlock hospice support, or delay it until crisis. CMS criteria begin at 7a—full dependence for dressing. But in practice, auditors and hospices often hold the line at 7c, loss of ambulation. That gap leaves families stranded in months of decline that qualify by regulation but not by culture.

FAST 7c isn’t occasional standby help—it’s total loss of independent walking or transferring. No walker with assist. No shuffle to the commode. If a patient needs full hands-on help to move, they’re 7c. We’ve seen patients denied hospice because teams didn’t document this shift. FAST makes decline visible, preventing falls, wounds, or crises.

FAST 7c Observation Examples:

  • No longer walks to meals, even with a walker
  • Needs hands-on assist for toilet transfers
  • Cannot bear weight during pivot
  • No longer propels wheelchair independently

“We noticed it during morning care. She stopped pivoting and started sliding. Transfers became two-person. That’s when we named 7c.”

Documenting FAST with the Story

Without a dated narrative linking stage to function, it’s a guess—not evidence. 

How to Write a FAST 7c Narrative (3 Things):

  • Use a specific date
  • Name a functional loss (e.g., ambulation, transfer)
  • Describe irreversibility or progression

Example CTI Phrasing: “As of 3/12/25, patient meets FAST 7c—requires hands-on assist for all mobility and no longer transfers without 2-person support. Functional decline is permanent and progressive.”

Social workers can note when families describe loss of shared meals. Chaplains may hear when prayer groups stop visiting because the patient no longer leaves bed. These details support the FAST narrative and protect eligibility.

FAST 7c typically aligns with PPS 40–50 and near-total ADL dependency. Anchor FAST 7c to PPS and ADL trends so the IDG and auditors see the same picture you do.

 Score FAST based on sustained observations or caregiver reports—isolated moments don’t define eligibility.

Teachable Moment Prompt: If a nurse says, “He’s walking less lately,” reply: “Let’s assess for FAST 7c today and document if he’s crossed that threshold.”

Common Misunderstandings

Families and clinicians often misinterpret FAST:

  • “She smiles at me. How can she be 7f?” Smiles don’t mean someone can stand. FAST measures sustained functional loss, not cognition or emotion.
  • “He says a few words. Isn’t that stage 6?” Speech at 7b is one word daily; occasional words don’t change staging.
  • “She’s in memory care. Doesn’t that mean FAST 7?” Facility placement doesn’t define FAST stage—function does.

FAST is a map of functional decline, not memory or personality. Clear documentation prevents these errors from delaying care.

Controversies and Limitations of FAST

While FAST is a cornerstone in dementia staging, it’s not without debate. Research highlights limitations that clinicians should navigate for accurate, equitable care.

  1. Poor Prognostic Value for 6-Month Mortality: FAST 7c, a common hospice threshold, has low accuracy in predicting 6-month survival (c-statistic ~0.51, near chance), risking delays or denials. Only ~22% of nursing home residents with advanced dementia who die within 6 months meet 7c criteria.
  2. Assumption of Linear Progression: FAST assumes sequential decline, but up to 41% of patients cannot be staged due to nonlinear progression from comorbidities (e.g., strokes, infections).
  3. Limited Validation for Non-Alzheimer’s Dementias: Designed for Alzheimer’s, FAST lacks validation for types like vascular or Lewy body dementia, risking misapplication.
  4. Lack of Empirical Basis and Equity Issues: Dementia prognostic tools, including FAST, underperform across racial and ethnic groups [Harrison et al., 2019, CAPC, 2023] risking later referrals for those already underserved. This underscores the need for holistic documentation to promote equity.

Practical Advice: Combine FAST with PPS (broader applicability) and/or ADEPT (better mortality prediction). Document comorbidities and discuss in IDG meetings to advocate for patients. This fosters trust and equity.

ToolStrengthsLimitations in Dementia
FASTTracks functional declinePoor prognosis accuracy, linear assumption
PPSBroad applicabilityLess specific to dementia
ADEPTBetter 6-month predictionMore complex to score

What FAST Tells Us Before the Family Can

Families track emotion, not erosion. Hospice must name when decline becomes permanent—the shift from moment to pattern. FAST provides structure to document this, turning subtle changes into evidence. When FAST is missing or misapplied—due to its limitations in nonlinear cases—it’s often the most vulnerable who suffer: those without documentation, advocacy, or English as a first language. Getting FAST right isn’t just compliance—it’s equity.

Who Notices What:

No metric stands alone. FAST confirms what trajectory, BMI, PPS, and narrative support. Documenting FAST well protects eligibility and trust across families and audits.

Documenting FAST correctly isn’t just eligibility. It’s stewardship. It shows the family—and the system—that we saw the slope, not just the silence.

3 Key Insights

Two Common Mistakes

One Takeaway

FAST marks the line before the silence—not just after.

Glossary

The clinical point at which physical dependency justifies hospice services based on regulatory standards.

Bibliography

Educational Image Prompt

Note: This visual is for training use only. It should not be used as a standalone eligibility guide.

Create a stepped slope graphic showing FAST stages 6–7f.
Label each stage with 2–4 word descriptors.
Highlight 7c–7f as the “Hospice Eligibility Range.”
Include icons: fading speech bubble, walker, transfer assist, bed, mute symbol.
Use neutral, educational tones—no dramatization.

Sparks

To Do

Plan follow-up blog: When FAST and PPS Don’t Match: How to Document Both

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