Abstract
Repetitive questioning is due to an impaired episodic memory and is a frequent, often presenting, problem in patients with Alzheimer’s disease (amnestic type). It is due to the patients’ difficulties learning new information, retaining it, and recalling it, and is often aggravated by a poor attention span and easy distractibility. A number of factors may trigger and maintain repetitive questioning. Caregivers should try to identify and address these triggers. In the case discussion presented, it is due to the patient’s concerns about her and her family’s safety triggered by watching a particularly violent movie aired on TV. What went wrong in the patient/caregiver interaction and how it could have been avoided or averted are explored. Also reviewed are the impact of repetitive questioning, the challenges it raises for caregivers, and some effective intervention strategies that may be useful to diffuse the angst that caregivers experience with repetitive questioning.
Keywords: Alzheimer’s/dementia, aberrant behavior, repetitive questions, abuse
Objectives
At the end of this case presentation, readers will
Recognize that repetitive questioning is a frequent problem in patients with Alzheimer’s disease, especially the amnestic type.
Understand the pathophysiology of repetitive questioning.
Appreciate that repetitive questioning is often a manifestation of the patient’s concern about a particular issue.
Identify a number of coping strategies. These include answering the question by more than one modality (auditory, visual, and tactile), placing prominent posters in the patient’s visual field, establishing a rigid routine, avoiding triggers, and finally distracting the patient.
Appreciate that repetitive questioning can be very frustrating and taxing to caregivers and cohabitants.
Case Presentation
Characters
Marjorie is a 74-year-old woman with Alzheimer’s disease, amnestic type, diagnosed about 6 months ago. She lives with her daughter, her son-in-law and granddaughter.
Alexie, Marjorie’s daughter.
Paul, Marjorie’s son-in-law.
Jackie, 8 years old, Marjorie’s granddaughter.
Scenario
Having just finished dinner, all are sitting in the living room. The TV is switched on. A particularly violent movie is aired. Paul is working on his laptop. Alexie is reading a book. Jackie is playing with her iPad. Only Marjorie is watching TV and is thoroughly absorbed by the movie.
Marjorie suddenly asks, “Are the doors locked?” She is assured they are, but a short time later, she asks the same question. Again, the family reassures her. Only a few minutes later she asks again, “Are the doors locked?” With some irritation, Paul tells her that the doors are indeed bolted and the security system is on. He also tells her that the movie she is watching is based on fiction and not true facts. He emphasizes that whatever she is watching does not and cannot occur in true life, especially in their neighborhood: a secure gated community where only residents and their guests are allowed. He also suggests that she watch another less violent TV program. But Marjorie refuses. She says she is not afraid, she is just concerned about everyone’s safety.
Over the next hour, Marjorie asks a number of times if the doors are locked. Each time, but with increasing irritation, she is told the doors are indeed locked. Tension is building. Eventually Paul leaves the room, stating that he needs to concentrate on the work he is doing on his laptop. Marjorie’s repetitive questioning is too much of a distractor. Jackie quietly follows him excusing herself and stating that she is going to her room.
When Marjorie asks again whether the doors are locked, Alexie puts down the book she has been trying to read and takes her mother to the door to show her that it is indeed locked. This satisfies Marjorie for a short time, but then only a few minutes later, she again asks, “Are the doors locked?”
A climax is now reached: Alexie is outraged. She throws her book across the room, jumps out of her chair, and violently pulls her mother out of her chair and pushes her hard against the wall beside the door and says, “This is ridiculous! There, check it yourself” Marjorie looks frightened. Alexie then drags her to the window, but Marjorie falls to the ground. Alexie picks her up and pushes her against the door and says, “There, check it again!” Marjorie falls again. Now she cannot get up. Afraid, she remains lying on the floor. She starts to cry.
Paul and Jackie come running from their rooms. They pick up Marjorie. Gradually with hugs and kisses, peace is restored. The members of the family retire for the night. Marjorie continues to watch TV. Sometime later, Marjorie goes to Paul and Alexie’s bedroom door, knocks on the door, and asks, “Are the doors locked?”
Case Analysis
Turning Points/Triggers That Led to This Aberrant Behavior
The violent movie aired on television triggered this entire episode
For patients with dementia, certain events can trigger anxiety that then initiates and sustains a repetitive questioning behavior. While watching the movie, Marjorie became scared and, probably due to her impaired judgment, was not able to differentiate between the fictitious events unfolding in the violent movie she was watching and real life, thinking the events occurring in the movie were real-life events occurring in her own neighborhood. She became genuinely concerned about the possible threat to her and her family’s safety. The family at first did not see the connection, but then when they did, they were not able to alleviate Marjorie’s concern.
Could it have been avoided?
Marjorie is genuinely concerned about violence and her family’s safety. Exposure to violent and scary movies as well as documentaries or even sometimes the news may be distressing to patients with dementia. Not watching the violent movie or promptly changing channels would have avoided the entire episode.
Alternatively, watching a relaxing, sedating TV program or reruns of old favorite episodes or just listening to music is more conducive to a good restful evening and night’s sleep, especially as no one was watching the violent movie except Marjorie. So it would not have mattered if they were watching a repeat of an old movie or a rerun of a series that Marjorie enjoyed watching in the past: given her impaired memory, she would not have remembered watching that movie or rerun again and probably would have enjoyed it. The other family members would have continued with their own activities.
The family’s attempts to stop Marjorie’s repetitive questioning were ineffectual
In this particular case, the concern is about crime, violence, and intruders breaking in, hence, the questioning about the doors being locked. Marjorie, however, like other patients with Alzheimer’s disease genuinely forgets the answer to her question. In fact, she has probably forgotten that she even asked the question. She was not being obnoxious; she heard the answer and probably understood it, but then forgot it. As she is preoccupied by the issue of intruders, crime, and violence, she asks the same question over and over again. Often patients with dementia can become almost obsessive-compulsive about a particular issue, even when they have not had true problems with this issue in the past.
Could it have been avoided?
Strategies to reduce repetitive questioning include the following:
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Employ more than one sensory modality to answer the question:
Just answering the question verbally involves only one sensory system: hearing. If, on the contrary, the patient is shown that the doors are locked, in addition to being told, she now has visual input as well: she sees the doors are locked. This reinforces the auditory response. If, in addition, she can touch and manipulate the locks, physically ensuring the doors are locked, she now has tactile information. In this manner, the information is conveyed through three different sensory channels: auditory, visual, and tactile systems as opposed to only one. This may help reinforce the information received.
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Make a poster with the answer clearly written on it, easily legible from a distance.
If the patient asks the same question over and over again, it may be helpful to write the answer on a board and display it prominently where the person has to notice it. In Marjorie’s case, the poster could read the following: DOORS ARE LOCKED. A sign could also be placed on the doors and windows stating that they are locked and the security system is switched on.
If the repetitive questioning is limited to a few issues, such as whether the doors are locked, what day it is, whether the dog has been fed, and whether the heating is on, it is sometimes useful to have a board with these issues clearly displayed and ticked whenever they have been accomplished. The board could then be prominently displayed within the patient’s visual field.
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Establish a routine.
It can be helpful to establish a routine if the person’s repetitive questioning is confined to one single or just a few issues. If the same concern about the doors being locked is expressed most nights, then it may be useful to introduce checking the locks as part of a routine prior to sitting down to watch TV after the evening meal. If the same routine is carried out every night, it may become ingrained in the person that the TV does not get switched on without first ensuring the doors are locked: if the TV is on, the doors must have been locked.
It must nevertheless be understood that this strategy will not work in many, probably in most instances, because it depends on the person being able to develop an association between different activities. Because the transmission of information from nerve cell to other nerve cells is impaired in patients with Alzheimer’s disease and several other dementias and because nerve cells are destroyed by the disease, the few remaining nerve connections may not allow such associations to develop. This is a reason why patients with Alzheimer’s disease are not able to learn new skills. On the contrary, if routines are followed and repetitively reinforced, the associations may be made. It is worth trying.
Distraction and redirection
Getting the person involved in an enjoyable nonthreatening activity such as watching an old favorite movie or TV show is a useful strategy to distract the patient from her concerns. There is no fear of the person getting bored as the patient’s impaired memory ensures that each time the show is viewed, it is a novel experience for the patient.
Alternatively, the patient may be asked to complete a task such as folding clothes that have just been washed, sorting out the contents of a drawer, or some other activity that would distract from the main concern of whether the doors are locked and keep the patient occupied for a period of time. It is always useful to have at hand a series of these tasks. It is nevertheless important to realize that if a true fear exists, distraction and redirection may not resolve the issue unless the initial trigger is removed and fear is allayed. Removing the person to another room to get her involved in some other activity may be helpful.
Jackie, Marjorie’s granddaughter, could have played a role distracting her grandmother: for instance, she could have shown her photographs on her iPad or invited her grandmother to play games on the iPad. Given the wide variety of games available, it should not be too difficult to find a game Marjorie can play even with her degree of cognitive and memory impairment.
Remain calm, reassure the patient
Of paramount importance, caregivers should remain calm under all circumstances: a very difficult, almost impossible task, but essential if catastrophic reactions are to be avoided. Caregivers should avoid telling the patient that her question has already been answered: if the patient could grasp this, she would not be asking the same question over and over again. The patient heard the answer, and probably understood it but was unable to retain the information for any period of time, hence the repeated questioning.
Trying to convince the patient that she just asked this question and that it was answered is futile, ends up irritating the caregivers, and often leads to a catastrophic ending. When caregivers feel they are about to lose their temper or become aggressive, they should just leave the room, try to calm down, and return later. Caregivers must understand that it is safe and justifiable to step away for a moment to recompose after ensuring the patient is safe to be left alone.
Reassure the patient that she is loved and cared for
Caregivers also should reassure the patient that she is loved and cared for. Patients with dementia, especially Alzheimer’s disease, tend to have paranoid ideation. Caregivers therefore must remember that the patient feels lonely, anxious, threatened, and often rejected. A gentle touch, hug, and kiss are reassuring. Jackie, Alexie, or even Paul could have moved closer to her grandmother, sat beside her, took her hand, and tried to comfort and reassure her. They must realize that she is genuinely concerned, apprehensive, and afraid and needs to be reassured. As often a special affinity exists between grandchildren and grandparents, Jackie could have played an important role allaying Marjorie’s anxiety by moving closer to her, holding her hand, and, as mentioned above, sharing some photographs on her iPad.
Avoid verbal and physical abuse
Caregivers should be careful when patients with Alzheimer’s disease or other dementias exhibit repetitive questioning as this may lead to verbal and even physical abuse. This indeed happened in this case when Marjorie’s daughter pulled her out of her chair and dragged her to show her that the doors are indeed locked. This is also bound to have a nefarious effect on Marjorie’s granddaughter.
If the caregivers feel they are about to verbally or physically abuse the patient, it is best they withdraw from the room, try to pause, and not return until ready to face the repetitive questioning. Verbal and physical abuse tend to develop very insidiously: the caregiver does not mean to be abusive but finds herself sucked in and trapped in a vicious cycle culminating in abusing the patient. Abuse can have serious consequences and significant repercussions on the patient and caregivers.
Case Discussion
Repetitive questioning is a prominent feature of Alzheimer’s disease, especially in the early stages when there may be no other features suggestive of Alzheimer’s dementia. It is irritating and frustrating to caregivers who do not really understand what is going on and may therefore be tempted to think the patient is just being obnoxious. Even caregivers who understand the illness well can find the constant questioning very frustrating because it interferes with their own personal activities such as reading a book, watching a movie or TV, or just engaging in a discussion with other people.
The main reason for repetitive questioning is the patient’s short attention span and inability to store in her memory the information she has just received. Repetitive questioning is usually triggered by the patient seeing or hearing something that elicits concerns and is often aggravated by anxiety or apprehension about a particular issue. A vicious cycle is therefore easily generated: the more the patient is concerned, the more she is anxious and the more frequently she repeats the question.
Caregivers and loved ones should be aware and accept repetitive questioning as an integral part of the underlying dementia. The patients are not repeating the question just for the sake of repeating it; they are not purposely being difficult or awkward and are not trying to be the center of attention. They are genuinely concerned about a particular issue—in this case, violence, crime, and their own personal safety—and want to make sure they are safe—in this case, that the doors are locked. They just do not remember the answer they have just been given. They truly forget the answer. So they keep asking the same question over and over again. To the patients every time they ask the question, it is as if they asked it for the very first time.
Repetitive questioning is one of the most common and frustrating “aberrant behaviors” of patients with Alzheimer’s disease. It is worsened by stress and preoccupation with an issue. Repetitive questioning exasperates relatives, caregivers, and even visitors. Getting upset does not help the situation, and usually aggravates it.
Caregivers will need support and the help of other family members or friends to help answer the questions calmly. It might also be helpful if caregivers could arrange to spend some time away from the patient to help reduce their own stress and agitation. Caregiver education and support are key elements to ensure various coping mechanisms are built in and utilized when the situation arises. These will be discussed in other case studies.
Caregivers need to know that repetitive questioning is a symptom of Alzheimer’s disease. Remaining calm, reassuring the patient, ensuring she knows she is loved, and using some of the strategies listed above should be helpful.
Summary
Repetitive questioning is a frequent problem in patients with Alzheimer’s disease and is often a very early manifestation of the disease before other symptoms of cognitive impairment are obvious. This behavior is often due to genuine concerns the patient has. A number of coping strategies are available, including the following:
Using more than one sensory modality to answer the concern: hearing, vision, and touch in combination to answer the questioning.
Using posters or sign boards addressing the question and displaying them prominently in front of the patient.
Establishing a daily routine.
Avoiding triggers known to bring on anxiety that leads to repetitive questioning.
Using distracting activities that occupy the person’s mind, blocking out what might otherwise lead to repetitive questioning.
Reassuring the patient that she is loved and making her feel secure and needed.
Finding ways to give the caregiver a break from the responsibility of repetitive answering by, for instance, instructing family members and friends on how to handle repetitive questioning and enlisting their help in sharing the burden of answering repeatedly. The burden of caregiving can also be reduced by seeking out opportunities for the caregiver to have a break from caregiver responsibilities and repetitive answering for a while.
Footnotes
Authors’ Note: This case report has not been previously published.
Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
References and Recommended Reading
- Albert M. S., DeKosky S. T., Dickson D., Dubois B., Feldman H. H., Fox N. C., Phelps C. H. (2011). The diagnosis of mild cognitive impairment due to Alzheimer’s disease: Recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, 7, 270-279. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Anand K. S., Dhikav V., Sachdeva A., Mishra P. (2016). Perceived caregiver stress in Alzheimer’s disease and mild cognitive impairment: A case control study. Annals of Indian Academy of Neurology, 19(1), 58-62. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Boltz M., Galvin J. E. (Eds.). (2016). Dementia care: An evidence-based approach. Sitzerland: Springer International Publishing. [Google Scholar]
- Budson A. E., Solomon P. R. (2016). Memory loss, Alzheimer’s disease, and dementia: A practical guide for clinicians (2nd ed.). Philadelphia, PA: Elsevier. [Google Scholar]
- Carlsson C. M., Gleason C. E., Puglielli L., Asthana S. (2009). Dementia including Alzheimer’s disease. In Halter J. B., Ouslander J. G., Tinetti M. E., Studenski S., High K. P., Asthana S. (Eds.), Hazzard’s geriatric medicine and gerontology (6th ed., pp. 797-812). New York, NY: McGraw-Hill. [Google Scholar]
- Haley W. E. (1997). The family caregiver’s role in Alzheimer’s disease. Neurology, 48(5, Suppl. 6), S25-S29. [DOI] [PubMed] [Google Scholar]
- Hamdy R. (1998). Clinical presentation. In Hamdy R., Turnbull J., Edwards J., Lancaster M. (Eds.), Alzheimer’s disease: A handbook for caregivers (3rd ed., pp. 74-86). St. Louis, MO: Mosby Year Book. [Google Scholar]
- Hu C., Kung S., Rummans T. A., Clark M. M., Lapid M. I. (2015). Reducing caregiver stress with internet-based interventions: A systematic review of open-label and randomized controlled trials. Journal of the American Medical Informatics Association, 22, e194-209. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Jahn H. (2013). Memory loss in Alzheimer’s disease. Dialogues in Clinical Neuroscience, 15, 445-454. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Knopman D. S., DeKosky S. T., Cummings J. L., Chui H., Corey-Bloom J., Relkin N., . . . Stevens J. C., et al. (2001). Practice parameter: Diagnosis of dementia (an evidence-based review). Neurology, 56, 1143-1153. [DOI] [PubMed] [Google Scholar]
- Lancaster M., Abusamara L., Clark W. (1998). Management of difficult behaviors. In Hamdy R., Turnbull J., Edwards J., Lancaster M. (Eds.), Alzheimer’s disease: A handbook for caregivers (3rd ed., pp. 150-170). St. Louis, MO: Mosby Year Book. [Google Scholar]
- McKhann G. M., Knopman D. S., Chertkow H., Hyman B. T., Jack C. R., Jr., Kawas C. H., . . . Phelps C. H. (2011). The diagnosis of dementia due to Alzheimer’s disease: Recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, 7, 263-269. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Rabins P. V., Lyketsos C. G., Steele C. D. (2016). Practical dementia care (3rd ed.). Oxford University Press. [Google Scholar]
- Sadowsky C. H., Galvin J. E. (2012). Guidelines for the management of cognitive and behavioral problems in dementia. The Journal of the American Board of Family Medicine, 25, 350-366. [DOI] [PubMed] [Google Scholar]
- Samia L. W., Hepburn K., Nichols N. (2012). Flying by the seat of our pants: What dementia family caregivers want in an advanced caregiver training program. Research in Nursing & Health, 6, 598-609. [DOI] [PubMed] [Google Scholar]
- Seeley W. W., Miller B. L. (2015). Alzheimer’s disease and other dementias. In Kasper D., Fauci A., Hauser S., Longo D., Jameson J., Loscalzo J. (Eds.), Harrison’s principles of internal medicine (pp. 19e). New York, NY: McGraw-Hill. [Google Scholar]
- Sperling R. A., Aisen P. S., Beckett L. A., Bennett D. A., Craft S., Fagan A. M. (2011). Toward defining the preclinical stages of Alzheimer’s disease: Recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, 7, 280-292. [DOI] [PMC free article] [PubMed] [Google Scholar]