NoteApraxic disturbances in patients with mild to moderate Alzheimer’s disease
Introduction
Apraxia has traditionally been listed as one of the neuropsychological features of Alzheimer's disease (AD), together with memory deficits, aphasia and agnosia. However, there have been far fewer systematic studies of praxic disturbances than of memory and language deficits. Conflicting results have been obtained in studies on apraxia in Dementia of the Alzheimer Type (DAT), regarding both the frequency of apraxia during the progression of the disease and the relationship between apraxia and the ability to perform activities of daily life (ADL). Ideomotor apraxia (IMA) was diagnosed in 35% of the mildly, 58% of the moderately and 98% of the severely demented patients with Senile Dementia of the Alzheimer Type (SDAT) by Edwards et al. [15]. Similarly, IMA was found in about a third of cases of mild DTA in other studies [8], [47]. However, in one study, all patients achieved significantly lower scores than the controls in tests of various types of gesture associated with IMA [39] and, conversely, another study found no disorders of posture reproduction, symbolic gesture evocation and imitation, or pantomiming in patients with mild DAT [37].
Ideational apraxia (IA) was detected only in cases of moderate or severe dementia in the large series of Edwards et al. [15]. IA was closely associated with IMA in one study [39] but not in another [31]. Such differences in results may be due to the clinical heterogeneity of the disease [22], [27], [40], [50] and the small number of patients included in most studies. However, there is a further source of confusion in the existence of various definitions of IMA and IA [7], [11], [24]. Most authors agree that IMA is defined by difficulty in the imitation of intransitive gestures (symbolic or expressive) and many would include difficulties with transitive gestures or pantomimes of the use of objects [9], [31]. Some authors include impaired gestures on verbal command in the definition of IMA [48]. Others have described difficulties in the imitation of meaningless movements as typical of IMA [9], [31] but some authors consider that imitation of meaningless movements constitutes a particular class of actions [4], [19]. IMA was defined by Rothi et al. [42] as the impairment in timing, sequencing, and spatial organization of gestures by Rothi et al. [42]. Most authors agree on a diagnosis of IA if the patient is requested to manipulate objects and is unable to evoke and organise the appropriate gesture. However, IA is thought by some to be associated with disruption of the sequential organisation of gestures [38] and by others to be associated with a deficit in tool selection and use, not necessarily linked to the use of multiple objects or sequential tasks [12], [34].
Similarly, conflicting results have been obtained in assessment of impairment in the performance of ADL. De Renzi stated that no type of apraxia is related to the performance of activities in a natural context [9]. However, relationships have been demonstrated between ADL and IMA [15] and ADL and IA [31] in AD patients.
Some studies of praxic disturbances have deviated from the traditional approach to studying apraxia and have been based on a cognitive neuropsychological analysis of limb praxis [42], [43]. According to the model of Roy and Square [43] the control of purposeful gestures and movements depends on two processes: (1) a conceptual system thought to incorporate three types of knowledge relevant to limb praxis: knowledge about the actions associated with and the functions of objects and tools, knowledge of actions independent of tools or objects but into which tools and objects may be incorporated, and knowledge relevant to the organisation of single actions into sequences. Disturbances in the conceptual system are thought to result in errors such as omission of the action or the correct performance of an action but in an inappropriate context and (2) a production system concerned with the effecting of actions in the environment. Disturbances in the production system result in errors in co-ordinating the limbs in time and space. Rothi et al. [42] gave a more detailed description of praxis processing to account for the dissociation observed in some patients according to (a) the type of input (visual or verbal); (b) the ability to carry out pantomimes on verbal command but not by imitation in patients with no difficulties in pantomime comprehension (dissociation of the action-lexicon into an input versus an output action-lexicon); (c) the ability to imitate meaningless movements (non-lexical action processing). Ochipa et al. [35] used the model of Roy and Square and showed that all patients with DAT scored lower than controls in conceptual tasks.
The aims of this study were: (1) to describe the praxic disturbances in patients with mild to moderate DAT, using the neuropsychological cognitive model of Roy and Square [43] as developed by Rothi et al. [42] and (2) to determine whether there was dissociation between performances in conceptual and production tasks in individual patients. The absence of motor and sensory deficits in DAT, and the clinical heterogeneity of the disease suggest that studying praxic disturbances in DAT may be a useful way of testing the neuropsychological model, to elucidate the mechanisms underlying these disturbances and to investigate the relationship between praxic disturbances and impairment in the performance of ADL.
Section snippets
Subjects
The study participants were outpatients from the neurological department of a general teaching hospital who were participating in a longitudinal study of dementia at the Hôpital de la Salpêtrière. All met the NINCDS–ADRDA criteria for probable Alzheimer's disease [32]. Extensive neuropsychological assessment, brain imaging by magnetic resonance imaging or CT scan, and biological tests were used to exclude other diagnoses. Patients were included in the study in year 1996, if: (1) they had a mild
Methods
The order of the tests was identical for all controls and patients over two sessions.
General characteristics of the subjects
Twenty-two Alzheimer's disease patients and 10 controls were included in the study. The general characteristics of the subjects are presented in Table 1. According to the scores in the Token Test, 15 patients had no impairment in verbal comprehension (scores 36 and 29), four had mild aphasia (scores 28–25) and three moderate aphasia (scores 24–18). Similarly, according to the Visual Gnosia Test, 19 patients had no deficit in visual gnosia (scores 36–29), two had mild visual agnosia (scores
Discussion
This study investigated praxic disturbances in patients with mild and moderate AD. We used the neuropsychological cognitive model devised by Roy and Square [43] and refined by Rothi et al. [42] as a framework. According to this model, the performance of gestures and purposeful movements involves two systems: a conceptual system, which provides an abstract representation of action (knowledge of action necessary to perform a task or use an object [21], [45]), and a production system, which
Acknowledgements
We would like to thank C. Bergego, E. Durand, P. Pradat-Diehl and P. Gras for providing us with access to their test material. This study was supported by a grant from the Scientific Committee of the Faculty of Medicine Pitié-Salpêtrière, University Paris VI.
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