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Apraxia

Apraxia is the inability to perform purposeful movements in the absence of significant weakness, sensory loss, poor coordination, or lack of comprehension or motivation. Apraxia usually indicates a lesion in the cerebral hemisphere. Its onset, severity, and duration vary.

Apraxia is classified as ideational, ideomotor, or kinetic, depending on the stage at which voluntary movement is impaired. It can also be classified by type of motor or skill impairment. For example, facial and gait apraxia involve specific motor groups and are easily perceived. Constructional apraxia refers to the inability to copy simple drawings or patterns. Dressing apraxia refers to the inability to correctly dress oneself. Callosal apraxia refers to normal motor function on one side of the body accompanied by the inability to reproduce movements on the other side. (See How apraxia interferes with purposeful movement.)

Assessment

History

Obtain the patient’s history. Ask whether he has a previous history of neurologic disease. Does he have a history of headaches or dizziness? 

Ask about previous cerebrovascular disease, atherosclerosis, neoplastic disease, infection, or hepatic disease.

Physical examination

First, obtain the patient’s vital signs and assess his level of consciousness. Perform a neurologic assessment, staying alert for evidence of aphasia or dysarthria. Assess motor function, observing for weakness and tremors. Assist with testing sensory function, deep tendon reflexes, and visual field deficits.

Stay alert for signs and symptoms of increased intracranial pressure (ICP), such as headache and vomiting. If present, elevate the head of the bed 30 degrees and monitor the patient closely for altered pupil size and reactivity, bradycardia, widened pulse pressure, and irregular respirations. Have emergency resuscitation equipment nearby, and be prepared to give mannitol I.V. to decrease cerebral edema after inserting a urinary catheter to avoid bladder rupture.

If the patient is experiencing seizures, stay with him and have another nurse notify the physician immediately. Avoid restraining the patient. Assist him into a supine position, loosen tight clothing, and place a pillow or other soft object beneath his head. Don’t place anything into his mouth. Turn the patient’s head to the side to provide an open airway.

Pediatric pointers

Detecting apraxia in children can be difficult. However, a sudden inability to perform a previously accomplished movement warrants prompt neurologic evaluation because a brain tumor — the most common cause of apraxia in children — can be treated effectively if detected early.

Brain damage in a young child may cause developmental apraxia, which interferes with the ability to learn activities that require sequential movement, such as hopping, jumping, hitting or kicking a ball, or dancing. When caring for a child with apraxia, be aware of his limitations and provide an environment conducive to rehabilitation. Provide emotional support because playmates will usually tease a child who can’t perform normal physical activities.

Geriatric pointers

Pre-existing diseases, such as dementia (Alzheimer’s type, vascular, or others), previous stroke, or dehydration, may interfere with assessing the patient for apraxia.

Medical causes

See Apraxia: Causes and associated findings.

Alzheimer’s disease

Alzheimer’s disease sometimes causes gradual and irreversible ideomotor apraxia. It can also cause amnesia, anomia, decreased attention span, apathy, aphasia, restlessness, agitation, paranoid delusions, incontinence, social withdrawal, ataxia, and tremors.

Brain abscess

Apraxia occasionally results from a large brain abscess; it typically resolves spontaneously after the infection subsides. Depending on the location of the abscess, apraxia may be accompanied by headache, fever, drowsiness, decreased mental acuity, aphasia, dysarthria, hemiparesis, hyperreflexia, incontinence, focal or generalized seizures, and ocular disturbances, such as nystagmus, visual field deficits, and unequal pupils.

Brain tumor

With a brain tumor, progressive apraxia may be preceded by decreased mental acuity, headache, dizziness, and seizures. It may occur with or directly after pupil changes or other early signs of increased ICP. Apraxia may also accompany other localizing signs and symptoms of the tumor, such as aphasia, dysarthria, visual field deficits, weakness, stiffness, and hyperreflexia in the extremities.

Hepatic encephalopathy

Hepatic encephalopathy may cause a gradual onset of constructional apraxia, which may be reversible with treatment. Early associated signs and symptoms include disorientation, amnesia, slurred speech, dysarthria, asterixis, and lethargy. Later signs include hyperreflexia, positive Babinski’s reflex, agitation, seizures, fetor hepaticus, stupor, and coma.

Stroke

The onset of apraxia is typically sudden in stroke; it commonly resolves spontaneously, but may persist in some patients. Associated signs and symptoms vary according to the affected artery, but can include headache, confusion, stupor or coma, hemiplegia, unilateral or bilateral visual field deficits, aphasia, agnosia, dysarthria, and urinary incontinence.

Nursing considerations

Prepare the patient for diagnostic studies, which may include computed tomography and radionuclide brain scans. Because weakness, sensory deficits, confusion, and seizures may accompany apraxia, take measures to ensure the patient’s safety. For example, assist him with gait apraxia in walking.

Patient teaching

Explain the disorder to the patient. Encourage him to participate in his normal activities as tolerated. Help him overcome frustration arising from the inability to perform routine tasks by breaking each task down into separate steps, demonstrating these steps, and having the patient repeat the actions you demonstrated as taught by the physical and occupational therapists. Allow him sufficient time to perform each step. Avoid giving complex directions. Encourage family members to assist in the patient’s rehabilitation.

Pictures

Book Source Details

• Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.

Other Book Chapters Related to Dementia

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Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2008 Williams & Wilkins.

More About Causes of Dementia

• Back to symptom: Dementia: Introduction (review 391 causes)
• Next Book Extract About Dementia: Level of consciousness, decreased (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
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More About This Book: Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-624-5

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