Many people who have dementia reach a point in their disease when they feel the need to ask questions or even perform an activity over and over again. Many professionals feel this behavior is harmless and will pass in a short period of time. The advice to families is often to ignore this behavior or distract the person in some way. However, this type of behavior is often triggered by anxiety, boredom, fear or the environment. Sometimes I also believe, especially when it is repetitive activities, it can be triggered by memories.
Considering the possible causes, has always led me to encourage caregivers to try to find the reason to reduce the behaviors. This is because I think the person experiencing these behaviors is in distress. Often the cause is something simple and a few changes in the way care is given solves the problem. Sometimes nothing seems to help, and caregivers must simply wait it out.
Exploring the reasons for perseveration, which is what these behaviors are called, requires assessing the person’s level of stress, expressions of concern or fear, level of appropriate activities and stimulation, and the immediate environment when the behaviors are present.
For instance, “Rose” was taking care of Barbara, her mother who had dementia. Rose moved in to her mother’s home after Barbara was diagnosed with moderate Alzheimer’s disease and it was obvious she needed help and supervision. After a few months, Barbara’s memory had gotten worse and she began to ask questions about almost everything. Often the same question was repeated over and over again. “Is it four o’clock yet? When will it be four? Are you going to tell me when it is four o’clock?”
Using the four o’clock issue, and considering triggers include anxiety and fear, think about any meaning four o’clock may have for the individual today or any time in the past. Try asking what will happen at four o’clock. If you get an answer such as “my mother is coming for me at four.” Do not argue about it. Take a step into the person’s reality and encourage them to talk about why she is coming. What will happen when she comes? Continue talking to allow the person to reminisce about their mother, and then after a few minutes gently spin the conversation away toward another topic or divert their attention with a treat such as tea and cookies. Many times, the experience of reminiscing about something the person’s memory gets “stuck” on helps to move them past that point.
Using time again as an example, perseveration may be triggered by boredom. For instance, the caregiver may have told the person with dementia that they have a four o’clock appointment at the doctor’s office. Sometimes this triggers questions starting as soon as they are told. “When is my appointment? Is my appointment at four o’clock?” etc. over and over again.
It may well be that there is nothing interesting for the person to do and their mind is stuck on the four o’clock appointment either because there is some anxiety over possibly forgetting, or they simply can’t focus on anything else. So perseveration occurs. Reassurance and distraction with an interesting activity usually helps.
Sometimes the question is about the time because the person is afraid of forgetting. Again, reassurance that you will help them remember can help. Another trick is to sing the time to the person with dementia. Often, in the earlier stages of dementia, this can help them to remember it.
Lastly, repetitive movements are also called a form of perseveration. The one incident I think of the most was “Leo” a patient I had who spent the whole day trying to screw his cane into every nook and cranny he could find. He would not stop even to eat. We could not dissuade him from doing so until a friend visited in the afternoon and mentioned that he and Leo had worked in an automobile plant and what Leo was doing looked a lot like their work. They used long handled wrenches to secure bolts deep inside the car engines. Since Leo was no longer very verbal, we encouraged the friend to sit with him and reminisce a bit about their time at work. Happily, when the friend left, Leo was no longer obsessed with his repetitive movements.
As I mentioned above, while it is often possible to stop perseveration by trying to find the cause, sometimes it will continue no matter what. Caregiver coping skills come in handy at this point.
Stephanie Zeman MSN RN
Kisses for Elizabeth