perseverate |pərˈsevəˌrāt|
verb [ intrans. ] Psychology
repeat or prolong an action, thought, or utterance after the stimulus that prompted it has ceased.

I would add to this definition: confusing to those subjected to it.

Perseveration is something we expect of young children. We’ve all seen a child hold on to an idea or thought long after the thing that triggered it is past. The idea is often often predicated by “I want…”. They can hold on tenaciously and be difficult to redirect. When this behavior occurs in public and the only right answer is “no”, it can lead to further escalation – sometimes hysterics — especially if one’s child is tired. We’ve all been there. It’s a challenge with our children. Small wonder when we stumble into aged parents exhibiting this same behavior, we don’t know what to do!

With perseveration, the repetitive phrase almost becomes a mantra, and perhaps this is where the brain becomes wired to separate “want” from “have”; power over our desires to relinquishing them. It is where we learn “wait”, “not now”, or “you are safe”. Rarely can a young child be reasoned with logically, distraction tends to be a parent’s best friend in this situation. With children, it may take us by surprise, but it isn’t frightening (frustrating maybe!), or dangerous (usually). As their ability to understand time, patience, limitations increases with maturation, perseverating happens less frequently.

It feels very different when Elders, perhaps due to subclinical dementia, demonstrate perseveration. I heard a story recently about an elderly father who showed up to a Memorial with an agenda. He wanted something. He had apparently wanted this item for some time, and felt entitled to it. He spoke about it to family for several days before the memorial, where he would see the people he needed to talk to about it. His immediate family didn’t know what to do about his pit bull like tenacity, and when he did engage with the family who owned the object – loudly, publicly and at the gathering after the memorial – they were mortified. He wanted what he wanted, and that was all. Perseveration. “I wish I could have been this big” (demonstrated his daughter, closing her index finger and thumb together). “I wish I could have become invisible. We didn’t know what to do.”

In the end, this daughter left her father at the gathering. He could still drive. He lived independently and could engage in intelligent conversation but his behavior around his object of desire baffled and deeply embarrassed his family. Listening to the story and empathizing with the adult child, I thought again about how a lack of understanding regarding behavioral changes left everyone powerless to help him. Arguments ensued (with the inheritor of the belonging denying anyone else had any rights to it), upsets happened. No one had insight to de-escalate or re-direct his behavior, in part, out of respect for his position as a family Elder. No one wanted to appear patronizing.

Bad behavior is bad behavior and it doesn’t matter what the age. With our children, we know it is lack of understanding, patience, experience. But when our parents exhibit that same behavior, we expect more. They have demonstrated (and taught us!) appropriate boundaries, social skills, understanding and higher functioning emotions like empathy.

Perseveration is different from bad behavior, though. It suggests that a pathway in the brain is not working correctly, a thought becomes a compulsion. In the extreme, it can be a symptom of serious mental illness or an abrupt cognitive decline, but can also just be a more benign indication of changed cognition in that one instance. The individual likely won’t recognize they are doing this; and they aren’t engaging that way on purpose. Some automated thought loop in their head has been triggered. The challenge is for family or caregivers to find a way through it.

As a mother, I used to say “distraction and bribery” were my two best friends. This can be just as true with Elders who are stuck in a thought loop like this. I offer the following as tools for coping:
1. Validate their experience, whether it be something they want, they lost, they fear losing. Validate it, let them know they are heard. NOTE: if an Elder seems to be perseverating on a bad caregiver, living situation or expresses the same story of exploitation, abuse or neglect, this MUST be investigated thoroughly. Just because they repeat the story doesn’t mean it isn’t real. In the case of abusive care, the abuser is counting on the fact that people discount the Elder’s story because they have dementia or a history of perseverating.
2. Examine how you can relieve the anxiety. What can be changed to make the Elder more comfortable? How can they feel more powerful in this situation?
3. How can you redirect the thought process? One option would be to tell Dad “I hear that this is very important to you. You know that everyone is going to be sad and upset at the Memorial. Let’s talk to Bill and ask him not to do anything with what you want until after you and he have had a chance to talk about it, and we’ll make a time to do that together.” This probably would have had to be restated in many ways, several times, right up to the point of seeing Bill. (“Remember Dad, we’re going to make a special time to talk to Bill about this later. Please be patient.”)
4. Follow through. Trust-building and integrity is as important with Elders as it is with children. When they perceive a lack of trust and integrity, anxiety escalates. Elders have little to depend on. Make sure that you can be counted on to watch their back.
5. Don’t quit. If your child was screaming an “I want” statement in the grocery, you wouldn’t stop trying to find a way to redirect or de-escalate the situation. Treat the Elders in your life the same — with calm, patience and understanding. Your anxiety will magnify theirs. Perseveration means that something is beyond their self-control, and Elder or no, they need a kind intervention to break the thought cycle loose and see beyond it’s immediacy.

We don’t want to “Parent our parents”, but we can use our parenting skills to be better children, better advocates and better friends to them as their ability to “roll with the tide” becomes less flexible. They need us, as we needed them when we were young. Breathe deeply. You can do this!

Getting to “yes”

There is a cycle to the life process. We start our lives dependent on others for care, nurturing, and safety, and we often conclude our lives in the same fashion. In the middle years though, we are full of ourselves, our independence, our power to make choices and effect change.

As those qualities and activities that we take for granted begin to diminish — our vision, our hearing, the stamina to shop or clean house, the reflexes to allow for safe driving — we run out of ways to show our power. Often, all that’s left is the power of “no”. This can manifest in refusing care, non-compliance with medical and medication regimens, and increased anger, depression, isolation or anxiety.

If you are encountering a frustrating situation with an Elder where the answer always seems to be “No”, if you are wanting to just “step in and and decide”, let me offer some alternatives.

1.  Examine the idea that this person’s behavior represents the only way they know right now to exert power in their lives at this moment.  For someone who has lost the ability to easily say “yes” — or who has had so many others tell them “no” … you can’t drive anymore, you can’t afford that, you can’t live by yourself, you can’t stay in your home, you can’t have ice cream, etc., being able to refuse is the last bastion of their independence. Can you look at “no” from their point of view?

2.  Help clarify values — both yours and theirs. There is nothing like fighting with someone to keep them safe and medically compliant if their first concern is how will they afford to feed the cat if they incur a budget busting medical expense or “what will the neighbors think?”  One example of this from my life involved my own mother’s refusal to use a Life Alert system.  My 87 year old mother lived alone in her home, about 2 miles from me.  Yes, we could (and did) check on her by phone and in person daily.  As a nurse, though, I understood the reality of both her night time bathroom trips, health issues that caused her to bleed rapidly when injured, as well as the life-changing impact even witnessed fall could bring.  But I couldn’t convince her to get a Life Alert button.  It turned out to be a vanity issue (as the cost was about $35.00 a month).  She didn’t want to wear “the button”, because it made her feel old.  It finally took another professional’s intervention to point out that she was torturing her children by not wearing it.  That she could understand — the power of saying “no” to this communication device was causing us emotional pain, and she didn’t want that either.  It gave her power, in that instance, to say “yes” because she was doing something proactive to nurture her children.  (She would sacrifice vanity to reduce our stress, but not for her own safety.  Hey. Whatever it takes.)

3.  Seek concensus. On what points can you agree? Build your strategies from there.  “I know you feel like you take too many medicines.  Let’s look at them together and remember what they are for.”  Review with your Elder the root condition being treated, and why that’s important.  For example, “The blue pill keeps your blood pressure down.  If your blood pressure goes up, it increases your risk for a stroke.  Taking the medication is the most sure way right now to keep your blood pressure controlled and reduce your risk of stroke.  Can we make an appointment together to talk to your doctor about what other things you can do to reduce your blood pressure, and what physical markers would make them feel safe in reducing your dosage or discontinuing the medication?” (Look for more on polypharmacy and seniors in a later post).

Together, make a plan that empowers the Elder to say “yes”.

Physical changes in taste, sight, hearing, smell can also lead to refusals, especially around institutionalized food.  If you have an Elder that is suffering from Failure to Thrive because of lost appetite or missed meals, look for environmental changes that can be made (sometimes using a bright colored plate to make the food more visible makes it more appealing).  Is the food tasteless?  Try adding fresh herbs (avoiding excessive salt), like basil, lemon or garlic to give it some zest and wake up the taste buds.  Do their teeth hurt or are dentures ill-fitting making chewing difficult? Often there is a physical cause underlying refusals that we (or caregivers) don’t take the time to tease out, and make refusals a power struggle instead of a cue about discomfort.

When we are pressed for time, it is easy to discount someone exerting their power and authority through the use of “No” as just being obstinate or difficult.  Seek to find that underlying cause, without judgement or patronizing.  This aged individual has probably forgotten more than you currently know and has seen life through many transitions.  A gentle, understanding and cooperative spirit often gives such an entrenched person a sense of significance and value, and helps bring them around to more positive decision making.  It’s certainly easier on the heart than frustration and annoyance, and lifts the Love vibe to a shining level.

Remember always that this person has seen more, dreamed more, lost more and had to be stronger than you may ever face. Don’t demand. Don’t demean. Offer dignity, respect and the time to really hear what’s on their heart. This gives us all the power to get to “Yes!”.

Blessings to you and your family this day!


Welcome to Holding Hands, a map for the Journey of the Aging Family

My name is Katherine Davis.  I am a nurse, mom, retired midwife and passionate advocate for families.  In my younger years, this meant supporting attachment parenting and assisting families with preparing for the birth of their children.  In my current life, I have taken that philosophy of attachment in the family and applied it to the most fragile members, our Elders, as they transition from independence to interdependence in their aging.  Daily, I hear about the challenges the middle generation (my generation) faces trying to balance parenting their children and being advocates for their parents’ changing needs.
I know this struggle, this dance on a tightrope of needs, having raised my teenagers through the last 6 years of my mother’s life, much of that punctuated with medical visits, hospitalizations, unexpected behaviors, and generally a lack of planning and a lot of “crisis” reactivity.  In retrospect, I can see how I could have set us all up (3 generations) for success, but didn’t have the tools to anticipate the needs of my loved ones.  Now I take that knowledge and wish to share it with you, fellow travelers.


Thank you for taking the time to read my thoughts.  It is my fondest desire that you find support, hope and maybe a pearl or two of wisdom that is of use to you in your own journey with your aging family.
Many blessings,

Katherine Davis, RN, BSN, CCM