Assessment and therapy of complex activities of daily living in apraxia

Four complex activities of daily living (ADL) such as preparing coffee or fixing and starting a tape recorder were assessed in six patients with chronic apraxia after left hemisphere infarction, six patients with left hemisphere infarction but without apraxia, and controls using only their left hand. Performance was rated for the number of errors and for the amount of assistance needed to complete the task, and errors were categorised. Whereas there was good inter-rater agreement on the total numbers of errors and amount of assistance, reliability of error categorisation was low. Apraxic patients had more difficulties than left brain damaged patients without apraxia, who in turn had more difficulties than the healthy controls. The six apraxic patients were part of a therapy study aimed at restoring the ability to perform the four ADL. Two methods of treatment were compared: Direct training of the activity based on the guided performance of the whole activity and exploration training aimed at teaching the patient structure-function relationships underlying correct performance but which did not involve actual completion of the activity. Performance improved with repeated testing of untrained activities during an initial baseline, but there was no reduction of errors or amount of assistance required for untrained activities during training of other activities. Exploration training had no effect on performance, whereas direct training of the activity reduced errors and need for assistance. Training effects were largely preserved at follow up, but the rate of errors increased when the trained activities were tested with a partially different set of objects. As therapeutic results were restricted to the trained activity and to some degree even to the very objects that were used for training, therapy of complex ADL should be tailored to the specific needs and desires of patients and their relatives, and it should be tied as closely as possible to the normal routine of the patient's daily life.