Chapter 8: Disorders of Skilled Movements - Apraxia
The skilled movements needed to use tools are critical to carrying out many daily activities. When performing skilled movements, a person learns how to use muscles, joints, and limbs in a series of coordinated steps that lead to the desired goal. First the person learns how to reach for the tool, to hold the tool, and then to move the tool to get a job done. A tool can be any object or device, such as a toothbrush, comb, fork, or a hand saw.
A person with brain damage may become unable to do activities that require skilled movements. Apraxia is the word used to describe a person having a problem using an object or tool to perform a job or action. In right-handed people, apraxia is caused by damage to the left side of the brain. Apraxia may result from a stroke or a disease, such as Alzheimer's disease.
TYPES OF APRAXIA
There are 3 different kinds of apraxia. These include:
- Difficulty remembering which tool or object to use for a task, such as knowing a comb is for the hair on one's head. (This problem is called conceptual apraxia.)
- Difficulty remembering all the steps and the order of steps needed to complete a task, such as writing a letter, putting the letter in an envelope, and then mailing it. (This problem is called ideational apraxia.)
- Difficulty moving the correct joints of the body or coordinating joint movement such that the tool makes the correct movement in space. For example, when slicing bread, instead of making the proper movements at the elbow and shoulder, one may use only the elbow and therefore make chopping rather than cutting movements. (This is called ideomotor apraxia.)
A person with dementia may also struggle to learn new movements.
WAYS TO HELP APRAXIA
Familiar is Easier!
It is easier for a person to work on something that has been used over and over again for many years than to learn to do something new. For example, an old coffee maker used each morning for years is easier to use than a new one, even if the new machine is simpler. It is better to repair an old television that breaks down; if a new television is necessary, it should be as close as possible to the old one in appearance and in the way it operates.
Simple Works Better Than Complex!
The simpler the tool or the easier it is to work, the more likely a person with dementia will be successful. A tool should be used for the same task each time and not for a new task. For example, a fingernail file should be used on the fingernails only and not as a screwdriver or a lever to pry open a bottle cap. Showing different ways to use the same tool may confuse someone with a memory disorder.
Do One Kind of Task at a Time!
It is better not to give the person too many things to work on at one time. Set up one tool next to one object, such as one spoon next to one serving of food on the dish at dinner time.
Have the person fold laundry, one kind of item at a time: First folding all the towels and putting them away, then folding all the socks and putting them away.
Do One Step at a Time!
Avoid asking the person to do a job that needs many steps to finish. Start with a job that takes only one step, or separate a big job into small steps. For example, raking the yard may be divided into four different jobs: (1) getting the rake; (2) raking the leaves into a pile; (3) bagging the leaves; (4) carrying the bag to the trash pile.
Start by asking the person to get the rake. After the first step is done, give praise for doing that job. Then have the person start the second step (rake the leaves into a pile), etc.
It Is All Right Not to Use Tools! Use Fingers!
It is all right for a person who cannot use a fork or spoon to pick up foods such as string beans or carrots with their fingers. The caregiver should cut up large pieces of food, such as meat, before it is brought to the table or before it is served to the person. Vegetables should be cut up as finger foods to help the person with apraxia feed themselves. Feeding themselves helps people with dementia feel self sufficient longer.
People who have difficulty feeding them-selves often spill food on their clothing. Spilled food or liquid is less noticeable on flowered, checkered, or dark clothing. The spill blends in with the pattern. It also helps the person, especially when eating out, to sit in a corner of the restaurant and face the wall so as to avoid distracters such as rushing waitresses.
SPEAKING WITH GESTURES
Many people use hand and arm gestures as part of their communication. The gestures often add to the meaning and intensity of the message. Brain cell changes may affect the way an arm moves or the way the arms and hands work together. For example, an arm gesture to wave goodbye may move awkwardly. The movements may be confusing. The person with apraxia may be unable to control such movements and may stop using gestures.
The person with the memory disorder may no longer understand the gestures of others. For example, arms raised to express helplessness may be interpreted as arms raised to strike out. Some suggestions for the person with a memory disorder:
- Remain calm and relaxed.
- Say the words again. Focus on the words and forget the arm movements.
Some suggestions for the caregiver:
- Keep eye contact and smile.
- Relax and use fewer, smaller arm gestures.
- Ask the person to repeat the words. Say the words you understand and ask for more information.
For safety purposes, lock up sharp tools or dangerous objects, such as knives, power tools, scissors, razors, needles, safety pins, toothpicks, or electrical appliances. If there is a question of safety, supervise use of the tool, such as cutting paper coupons or scheduling a friend to "help" mow the lawn. The person with apraxia may be safer eating with a spoon or trying finger foods if awkward movements may risk a fork jab by the side of the mouth or on the face.
It is up to the doctor to advise the person with dementia not to drive a car. This advice means not driving any motor vehicle, including a truck, boat or lawn mower. Power tools, an electric sewing machine, or kitchen hand mixer also may be dangerous.
Skilled movements using tools, such as combing one's hair or using a spoon to eat, are important to everyday life. Changes in the left side of the brain may result in apraxia, the inability to perform skilled movements with tools. The problem may be holding and moving the tool correctly. Or when one must perform a series of skilled acts, the steps of the activity may be in the wrong order.
To help people with apraxia, use acts that call for simple movements when-ever possible. If using a tool is difficult, allow the person to use their hands and fingers when possible. It also helps to break down tasks into one step at a time or one type at a time.
Safety is important. Sharp objects, such as knives and electrical appliances, should be locked up. The person with memory loss and apraxia should not drive a car or any other motor vehicles.
The Next Chapter contains a discussion of vision changes that may be associated with dementia. Several ideas are suggested to help families deal with these changes.
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Material taken from
"Helping People with Progressive Memory Disorders: A Guide For You And Your Family, 2nd ed." (University of Florida Health Science Center). Used with permission from the authors: K. M. Heilman, MD, L. Doty, PhD, J. T. Stewart, MD, D Bowers, PhD, & L. Gonzalez-Rothi, PhD. (1999).