Repetitive Questioning II (2024)

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Gerontol Geriatr Med
v.4; Jan-Dec 2018
PMC5813854

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Gerontol Geriatr Med. 2018 Jan-Dec; 4: 2333721417740190.

Published online 2018 Feb 13. doi:10.1177/2333721417740190

PMCID: PMC5813854

PMID: 29468186

R. C. Hamdy, MD,¹ A. Kinser, PhD,¹ A. Depelteau, PhD,¹ J. V. Lewis, MD,¹ R. Copeland, MD,¹ T. Kendall-Wilson, RN,² and K. Whalen, BA¹

Author information Article notes Copyright and License information PMC Disclaimer

Abstract

Repetitive questioning is a major problem for caregivers, particularly taxing if they are unable to recognize and understand the reasons why their loved one keeps asking the same question over and over again. Caregivers may be tempted to believe that the patient does not even try to remember the answer given or is just getting obnoxious. This is incorrect. Repetitive questioning is due to the underlying disease: The patient’s short term memory is impaired and he is unable to register, encode, retain and retrieve the answer. If he is concerned about a particular topic, he will keep asking the same question over and over again. To the patient each time she asks the question, it is as if she asked it for the first time. Just answering repetitive questioning by providing repeatedly the same answer is not sufficient. Caregivers should try to identify the underlying cause for this repetitive questioning. In an earlier case study, the patient was concerned about her and her family’s safety and kept asking whether the doors are locked. In this present case study, the patient does not know how to handle the awkward situation he finds himself in. He just does not know what to do. He is not able to adjust to the new unexpected situation. So he repeatedly wants to reassure himself that he is not intruding by asking the same question over and over again. We discuss how the patient’s son-in-law could have avoided this situation and averted the catastrophic ending.

Keywords: Alzheimer’s/dementia, anxiety, confusional states, caregiving and management

Objectives

At the end of this case presentation, readers will appreciate the following:

Repetitive questioning can be due to the patient feeling awkward, being thrust in an unexpected situation, and not knowing how to cope with the new arising situation.
Coping strategies include the following:
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1. Getting the patient to relax, feel secure, and feel at ease;
2. Distracting the patient by asking his advice or assistance and/or discussing a topic he is knowledgeable about;
3. Redirecting the patient’s mental activity by asking him to get involved in some task he is familiar with;
4. Deflecting the patient’s anxiety by asking him to help with some specific activity, and
5. Making the patient feel valued.
Repetitive questioning is quite taxing to the caregivers. Remaining calm under duress can be very difficult, but is crucial.

Case Presentation

Characters

Bill has been diagnosed with Alzheimer’s disease about a year ago. He is in the early stage. His wife died about 9 months ago. He lives on his own, is independent with his daily activities, and regularly drives his car to go to Church, the senior citizens center, shopping, and visiting friends.
Peter is Bill’s son-in-law.

Scenario

Bill has been diagnosed with early stage Alzheimer’s disease about a year ago. His wife died about 9 months ago; he now lives on his own, is independent with his daily activities, and regularly drives his car to church, the senior citizens center, shopping, and visit friends.

One morning, Bill decided to visit his daughter Emily and her husband Peter who live approximately 20 miles from his home. He had not seen them for quite some time and thought it would be a good idea to visit. On his way there, Bill stopped to buy a bouquet of flowers for his daughter and some chocolate for Peter.

Upon Bill’s arrival at their home, he rings the doorbell with some trepidation. Peter opens the door and is obviously annoyed. He had planned to catch up with his paperwork and realizes that he will have to forgo this because of Bill’s surprise visit. Although Peter tries to hide his annoyance, he finds it difficult to do so given his history with Bill: Peter has always felt that Bill disapproved of him as a husband for Emily and even now senses Bill critiquing his every move. Nonetheless, he welcomes Bill, invites him in, and informs him that Emily is away and will not be back until very late at night.

Bill is taken aback because he had not anticipated that his daughter would be away. He feels awkward that he cannot shake hands with Peter as he has the bouquet of flowers in one hand and the chocolate in the other. Peter directs him to the front room and invites him to sit down without mentioning anything about the gifts of flowers and chocolate.

Several times, Peter attempts to start a conversation with Bill but without success. Most of Bill’s responses are monosyllabic. Also, at frequent intervals, Bill asks Peter whether the chair he is sitting in is Peter’s chair. Peter assures him each time that it is not, only to be asked the very same question a minute or so later. Peter stops trying to engage Bill in a conversation. There is another long period of silence, with both men looking around the room—at the ceiling, the furniture, the floor, the decorations on the wall, and back at the ceiling. They do not talk to each other except for Bill asking if he is sitting in Peter’s chair. Peter notices that he is tapping his fingers on the arm of the chair and stops doing it so. Once again, Peter interrupts the silence by trying to engage Bill in a conversation: “Have you been following the local events on TV?” Bill responds, “Not really.” Another long period of silence: both men feel increasingly uncomfortable and awkward. Peter makes several other attempts to engage Bill in some discussion about weather, politics, and local events but to no avail. Bill repeats the same question over and over again: “Am I sitting in your chair?”

In desperation, Peter offers to make some coffee and get some cake. Peter leaves Bill alone while he goes to the kitchen. When he returns, Bill again and relentlessly engages in his repetitive questioning: “Am I sitting in your chair?” Peter gets irritable, excuses himself by saying that he needs “some fresh air” and leaves Bill alone. He returns a few minutes later, but it is back to the repetitive questioning.

Peter is finding it more and more difficult to hide his exasperation. Eventually, he blows up and reprimands Bill for not listening and for repeatedly asking the same question about favorite chairs over and over again. Bill is now upset and leaves the house to return to his own home.

Case Analysis

Turning points/triggers that led to this aberrant behavior of repetitive questioning include the following:

Peter did not address Bill’s underlying anxiety and apprehension, resulting from the unexpected stressful situation of not finding his daughter at home. Bill had not anticipated this situation.

Peter did not greet Bill warmly. His initial greeting when he saw Bill was lukewarm as he was upset about being pulled from his other commitments. Peter also did not extend a hand for, or comment on, the flowers and chocolate Bill was holding. Bill must have felt awkward, apprehensive, and unwelcome.

Could it have been avoided?

Bill would have felt much more welcome and comfortable if Peter had greeted him warmly, acknowledged the gifts he was bearing, and thanked him. After explaining that Emily was not home, he could have offered to phone her or text her to let her know that her Dad was visiting. Bill would have felt much more comfortable and less apprehensive.

This also could have been an opportunity for Peter to explain that he has an assignment to complete that day and may not be able to sit with Bill for any period of time. “I’m so glad you came, I needed a short break from the work I was doing!” or “How about we grab a cup of coffee and a few cookies before I get back to my work?” In all probability, Bill would have gone back home content and the whole situation would have been avoided.

2. Peter did not recognize that the underlying cause of Bill’s repetitive questioning was his inability to cope being alone with him.

In this scenario, the main reason for the repetitive questioning is that the patient is feeling awkward and uncomfortable being in a situation he had not anticipated: alone with his son-in-law. This was not what Bill had planned; he had expected to visit his daughter whom he had not seen for some time. It never crossed his mind that she may not be at home. Bill’s sudden decision to visit his daughter who then was not there created a situation that he was unable to adjust to. He does not know how to handle it and instead of facing the issue, diverts his energy and concerns to the possibility that he may be sitting in his Peter’s favorite chair. The questioning also functions as a way to fill the periods of silence between him and his son-in-law.

In the previous scenario on repetitive questioning (Case 2), the questioning was grounded in the patient’s concern about her own and her family’s security because she had just watched a TV program on violence. In that case, the patient’s repetitive questioning is due to this concern and to her inability to retain long enough in her memory the fact that the doors are locked and the family is secure. Specific strategies to cope with this type of repetitive questioning have been discussed in that case study.

Could it have been avoided?

Several strategies can be used to avoid or avert these situations before a catastrophic outcome is reached:

Distract, deflect, and/or re-direct the patient’s focus of attention. Strategies to this end include the following:
1. Getting the patient involved in a conversation on a topic he is familiar with.
  Rather than making attempts at starting a conversation on conventional topics such as weather, politics, health, road conditions, and local events, a topic should be chosen that is very familiar to the patient and that he should feel confident about. A good strategy is to rely on old memories. Memory impairment in patients with Alzheimer’s disease is usually limited to recent events; most patients retain remote memories. The patient might, for instance, be asked about how he met his wife, how he was as a young lad, what sorts of jobs he had, whether he ever contemplated any other career, and what it was like growing up in that part of the country and during that time period. Going down “Memory Lane” usually works and could be helped by finding some old photographs or mementos to talk about. “I just found this old picture of you and Emily when you went to Italy. It must have been a tremendous experience. Please tell me more.” Peter is now engaging Bill, getting him to talk about his daughter and is redirecting his energy and attention to friendlier territory.
  It is nevertheless important to ensure, while attempting to start a conversation with patients who have dementia, that the patient does not feel he or she is being questioned or interrogated. Many patients with dementia, especially Alzheimer’s disease and Dementia with Lewy Bodies, have paranoid delusions. They therefore may feel they are being questioned for some nefarious purpose and may therefore become suspicious, anxious, irritable, or even violent and aggressive. Similarly, caution must be exercised to avoid talking about sensitive topics that may trigger an aberrant response. For example, if the patient is asked to talk about his experience serving overseas during the war and has been diagnosed with posttraumatic stress disorder, then discussing his war-time experience may trigger an aberrant reaction.
  Finally, if there is no way of sparking a conversation, it is probably best to stop trying, as persistence may eventually backfire and make the patient suspicious of the reasons why so much effort is made to initiate a conversation. Paranoid patients may think that the conversation is, for instance, being recorded at the behest of some “authority” and that this forebodes bad news for the patient.
2. Asking the patient for advice.
  Asking the patient for advice is another strategy to get the patient focused on some issue other than whether or not he is sitting in his son-in-law’s chair, provided he can genuinely formulate some useful opinion on the issue addressed. Otherwise, these attempts are likely to make the patient feel even more inadequate. Obviously, the selected topic depends on the patient’s background and individual past experiences. Asking the patient’s advice or help also satisfies the patient’s need to feel needed and wanted. The patient, for instance, may be asked about decorating a room or a recently purchased item.
3. Inviting the patient to help with a task he can do:
  Asking the patient to help with some task he can easily manage serves two purposes. First, the patient’s mental energy is focused on the task and diverted from the repetitive questioning. Second, as with the strategy of asking for advice, it fulfills the patient’s need to be needed. Now the patient is no longer intruding; he is actually helping Peter and is needed and wanted. He serves a purpose; he is not superfluous. It is important nevertheless to ensure that the patient is able to easily complete the task. Any task would do, depending on the patient’s background and past experience. Helping in the kitchen to slice the cake or open a bag of cookies while Peter makes coffee would have been a good opportunity to make Bill feel wanted and needed.
4. Inviting the patient to join in some recreational activity he enjoys:
  Watching an old movie or an episode of a TV series the patient may have seen and enjoyed several times in the past is a useful ploy to divert the patient’s attention. The same applies to sing-along songs the patient may have enjoyed many years ago. Having a set of these movies and songs recorded is quite useful.
  The patient, however, should not be told to watch a movie. Rather, he should be invited to watch the movie: “You know, I just bought this movie and did not have a chance to watch it. Would you like to watch it with me now?” To complete the ambience, some popcorn, nuts, or other snacks could be made available. Given the patient’s impaired memory for recent events, there is little fear that the patient would remember it if he had seen that movie or TV episode before.
  Similarly, when listening to old songs, rather than asking the patient to join in the singing, the caregivers could set the example by singing with the recording. The activity should appear to be spontaneous, allowing the patient to join in by choice.
Making the patient feel needed, wanted, loved, and secure.
Bill was left alone when Peter decided to make the coffee and get some cake, and again when he went out for “some fresh air.” This probably reinforced Bill’s insecurity and his suspicion that he is not welcome. Bill would have felt more secure and less apprehensive had Peter invited him to join him in the kitchen and outside the house.
No matter what strategy is used, it is important to make sure the patient feels needed, wanted, loved, and secure. In Bill’s case, he suddenly and unexpectedly finds himself on his own with his son-in-law. He feels insecure, not needed, and vulnerable. He does not know how his son-in-law feels about him. It therefore behooves the son-in-law to reassure the patient that all is well even though Emily is not home; to help Bill feel needed, appreciated, and welcome; and to show him care and affection.

3. Peter became irritable and left Bill on his own while he went to prepare the coffee and later in search of fresh air.

Caregivers should remember that getting upset usually aggravates the situation. In the case of repetitive questioning, caregivers must bear in mind that patients are just unable to remember the answer they were given; they genuinely forget it only a few seconds later. They are not being obnoxious; they hear the answer and understand it, but then forget it. As they are preoccupied by the issue, they keep asking the same question over and over again.

Could it have been avoided?

It is easy to counsel caregivers to avoid getting irritable and to remain calm and in control of the situation while caring for patients with dementia, especially if the patient has aberrant behaviors such as repetitive questioning. Remaining calm and not getting upset is nevertheless a sine qua non for avoiding catastrophic situations from developing and escalating. But the caregivers’ patience can be taxed to the limit especially if they do not understand the reasons patients with dementia have aberrant behaviors and particularly if caregivers have no support. Even knowing that the patient is not purposefully being obnoxious, and knowing that remaining calm is a critical component of caregiving for these patients, caregivers often have an exceptionally difficult, sometimes overwhelming, responsibility managing patients with dementia. This difficulty is further complicated in situations like Peter’s, where the relationship between the caregiver and the patient is strained. The fact that his wife was not home when her father came to visit was unsettling for Peter as well, and he struggled to manage his own feelings, the situation, and his father-in-law.

The physical, mental, emotional, and spiritual well-being of caregivers must be ensured to avoid them becoming the “second victims” of dementia. It should be remembered that caregivers often become exhausted and frustrated, and feel lonely, imprisoned, misunderstood, and abandoned. Unfortunately, many caregivers have no support and, on their own, provide care to their loved ones 24 hr a day, 7 days a week. Provisions must be made to ensure the caregivers’ health if catastrophic outcomes with dementia patients are to be avoided.

Case Discussion

As mentioned in this case and in Case 2, repetitive questioning can be extremely taxing to caregivers. It can emerge from a number of motivations, and it behooves the caregivers to find out why the patient is repeatedly asking the same question. The common denominator for all types of repetitive questioning is a short attention span and an impaired memory for recent events which result in the patient not being able to register and retain the answer. Every time the patient asks the question, it is as if that question was asked for the first time. The patient therefore may wonder why the caregiver is getting irritable.

Various causes of repetitive questioning need different strategies to cope with them. In Case 2, the main reason for the repetitive questioning was concern about security. In contrast, in the present case, repetitive questioning is due to the patient feeling awkward, having unmet expectations, and being unable to adjust to an unexpected new situation he had not considered: the discovery that his daughter was away.

Identifying the root source of the repetitive questioning other than inability to retain the answer given is useful in guiding caregiver response strategies. It may reduce the questioning and reduce the likelihood of the caregiver responding aggressively. Still, having to answer a question repeatedly could aggravate even the most patient caregiver. Peter’s leaving to get some fresh air or make the coffee may well have been the best choice for him to make if it would help him remain calm. In this case it did not, but perhaps in combination with communicating care and appreciation, and identifying the source of the questioning and responding accordingly, Peter and Bill could have passed the time together in a way that did not further complicate their relationship.

Summary

Strategies to cope with repetitive questioning due to an unexpected unfamiliar situation include the following:

Deflect the patient’s focus of attention by
1. Getting involved in a conversation on a topic familiar to her or him.
2. Asking for the patient’s advice.
3. Inviting the patient to accomplish or help with a task.
4. Inviting the patient to engage in a recreational activity he or she enjoys.
5. Remembering happy past events: “going down memory lane” with the help of photographs or mementos.
Helping the patient feel needed, wanted, loved, and secure.
Providing support for caregivers so they are better equipped to handle the frustration and exhaustion that caregiving for dementia patients can create.

Footnotes

Authors’ Note: This case report has not been previously published.

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

References and Recommended Reading

www.alz.org › Caregiver Center › Stages & Behaviors
www.alzheimer-europe.org/Living-with-dementia/Caring-for-someone-with-dementia/Changes-in-behaviour/Repetitive-questioning#fragment-1

Articles from Gerontology and Geriatric Medicine are provided here courtesy of SAGE Publications

As an expert in the field of gerontology and caregiving for individuals with Alzheimer's disease and dementia, I've extensively studied and analyzed various research articles and case studies related to the topic. One such article that aligns with my expertise is "Repetitive Questioning in Alzheimer’s Disease: A Case Study" by R. C. Hamdy, MD, et al., published in Gerontol Geriatr Med in 2018 (PMID: 29468186, PMCID: PMC5813854, DOI: 10.1177/2333721417740190).

The article addresses the challenging issue of repetitive questioning in individuals with Alzheimer's disease, shedding light on the underlying causes and offering practical strategies for caregivers to manage and prevent such behavior. The study features a case presentation involving a patient named Bill, diagnosed with early-stage Alzheimer's disease, and his son-in-law, Peter, who experiences difficulties in handling Bill's repetitive questioning during an unexpected visit.

Key Concepts and Insights from the Article:

Repetitive Questioning and Underlying Causes:
- Repetitive questioning is identified as a significant challenge for caregivers, often stemming from the patient's short-term memory impairment and the inability to register, encode, retain, and retrieve information.
- The article emphasizes that the behavior is not intentional but results from the underlying disease, with patients genuinely forgetting the answers shortly after receiving them.
Case Presentation - Bill and Peter:
- Bill's unexpected visit to his daughter's home creates a situation where he feels awkward and unable to cope, leading to repetitive questioning.
- Peter, the son-in-law, struggles to handle the situation, and the article analyzes the turning points and triggers that contribute to the escalation of repetitive questioning.
Coping Strategies for Caregivers:
- The article provides valuable coping strategies for caregivers facing repetitive questioning, including:
  - Getting the patient to relax, feel secure, and at ease.
  - Distracting the patient with familiar topics or tasks.
  - Redirecting the patient's mental activity to involve them in a task they are familiar with.
  - Deflecting anxiety by engaging the patient in specific activities.
  - Making the patient feel valued and needed.
Recognition of Underlying Anxiety:
- The case study highlights the importance of recognizing and addressing the underlying anxiety and apprehension in patients, such as Bill's discomfort with an unexpected situation.
Avoidance of Aggravating Factors:
- The article emphasizes that caregivers should avoid aggravating factors, such as becoming irritable, as patients with dementia are genuinely unable to remember the answers they receive.
Caregiver Support:
- Caregivers are reminded of the crucial role they play and the need for support to ensure their well-being, as managing patients with dementia can be exceptionally challenging.

In summary, this article provides a comprehensive understanding of the complexities associated with repetitive questioning in Alzheimer's patients and equips caregivers with practical strategies to navigate and mitigate such challenging behaviors.