Apraxia is the inability to perform purposeful movements in the absence of significant weakness, sensory loss, poor coordination, or lack of comprehension or motivation. This neurologic sign 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 apraxia 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.)
If you detect apraxia, ask about previous neurologic disease. If the patient fails to report such disease, begin a neurologic assessment. First, take the patient’s vital signs and assess his level of consciousness. Be alert for any evidence of aphasia or dysarthria. Ask the patient if he has recently experienced headaches or dizziness. Then test the patient’s motor function, observing for weakness and tremors. Next, use a small pin or another pointed object to test sensory function. Check deep tendon reflexes for quality and symmetry. Finally, test the patient for visual field deficits.
Be alert for signs and symptoms of increased intracranial pressure (ICP), such as headache and vomiting. If you detect these, 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.
If the patient is experiencing seizures, stay with him and have another nurse notify the physician immediately. Avoid restraining the patient. Help him to a supine position, loosen tight clothing, and place a pillow or other soft object beneath his head. If the patient’s teeth are clenched, don’t force anything into his mouth. If his mouth is open, protect the tongue by placing a soft object, such as a washcloth, between his teeth. Turn the patient’s head to provide an open airway.
After completing the examination and ensuring the patient’s safety, take a history. Ask about previous cerebrovascular disease, atherosclerosis, neoplastic disease, infection, or hepatic disease. Then assess the apraxia further to help determine its type. (See Apraxia: Causes and associated findings, page 72.)
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.
Apraxia occasionally results from a large brain abscess but usually 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.
In a brain tumor, progressive apraxia may be preceded by decreased mental acuity, headache, dizziness, and seizures. It may occur with or directly after early signs of increased ICP, such as pupil changes. It may also occur with other localizing signs and symptoms of the tumor, such as aphasia, dysarthria, visual field deficits, weakness, stiffness, and hyperreflexia in the extremities.
Hepatic encephalopathy may cause 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 commonly causes sudden onset of apraxia, which typically resolves spontaneously but may persist. 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.
Prepare the patient for diagnostic studies, such as computed tomography and radionuclide brain scans. Because weakness, sensory deficits, confusion, and seizures may accompany apraxia, take measures to ensure safety. For example, assist the patient with gait apraxia in walking.
Explain the patient’s apraxia to him, and encourage his participation in normal activities. Help him to overcome his frustration at being unable to perform routine tasks by demonstrating each step in these tasks and giving him sufficient time to imitate each step. Avoid giving complex directions, and enlist the help of family members in rehabilitation. Also, refer the patient to a physical or occupational therapist.
Detecting apraxia in children can be difficult. However, any sudden inability to perform a previously accomplished movement warrants prompt neurologic evaluation because a brain tumor—the most common cause of apraxia in children—may 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, dancing, or hitting or kicking a ball. When caring for a child with apraxia, provide an environment that’s conducive to rehabilitation while remaining aware of his limitations. Also provide emotional support because playmates may tease a child who can’t perform normal physical activities.
Read excerpts from these other book chapters related to Apraxia:
Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
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Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9 
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