Second edition

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Various forms of aprosodia may also be seen in dementia,
as for example Alzheimer’s disease (Perez-Trullen and
Modrego Pardo 1996); however, here associated cognitive
deficits, such as disorientation and short-term memory
loss, will suggest the correct syndromal diagnosis.
Differential diagnosis
Motor aprosodia must be distinguished from flattened
affect and hypophonia. Flattened affect is typically accompanied
by a monotone voice; however, here there is also a
‘flattening’ of the patient’s feelings: patients with flattened
affect typically report having no feelings and this is in
contrast with motor aprosodia wherein patients, although
speaking in a monotone, still have feelings, sometimes
quite strong ones. Hypophonia, as seen in parkinsonism, is
a speech deficit characterized by whispering and low volume,
which stands in contrast with the normal volume
seen in motor aprosodia.
Sensory aprosodia must be distinguished from emotional
incontinence and from inappropriate affect. Emotional
incontinence, as discussed in Section 4.7, is characterized
by episodes of involuntary laughing or crying (accompanied
by, respectively, a mirthful or sad tone of voice) during
which the patient has no feelings, except, perhaps, a
sense of consternation at being unable to control the emotional
display. This, superficially, is similar to the ‘mismatch’
seen in sensory aprosodia; however, on closer
inspection there are differences. First, there is, in fact, no
actual ‘mismatch’ in the sense of a patient feeling one thing
and displaying a discordant tone of voice as he reports that
feeling, for in emotional incontinence patients often are
emotionally neutral during the episode. Second, in contrast
with aprosodia, which in almost all cases is constant
and more or less chronic, emotional incontinence occurs
in discrete episodes, in between which there is a congruence
between what the patient feels and the tone with
which that feeling is reported.
Inappropriate affect is very similar to sensory aprosodia,
in that in both these signs there is a mismatch between
what the patient feels and the tone of voice in which that
feeling is expressed. Differentiating between the two
requires attention to comprehension of prosody, which is
present in patients with inappropriate affect, and absent in
those with sensory aprosodia.
Finally, aphasia must be clearly distinguished from
aprosodia. Aphasia represents a disturbance in what is said,
aprosodia a disturbance in how it is said. Consider, for
example, two patients who are both grief-stricken over a
recent loss. The first one, having a motor aphasia (Broca’s
aphasia), although restricted to simply repeating the word
‘sad . . . sad . . . sad’ over and over again, might yet say it so
lugubriously that the listener has no doubt about the depth
of the patient’s grief. By contrast, the second patient, with
a motor aprosodia, although able to say the words ‘I’ve
never felt so sad in my entire life’, would say them in such
2.8 Apraxia 55
a monotone that the listener might well doubt whether the
patient was, in fact, really feeling any sadness.
Treatment
Speech therapy may be helpful in addition to treatment, if
possible, of the underlying condition.
2.8 APRAXIA
Apraxia is said to be present when, despite preserved
strength, sensation, and coordination, patients are unable
to carry out purposeful activities. In the literature, there are
a large number of different kinds of apraxia described;
in this chapter, four of these are considered: ideomotor,
ideational, constructional, and dressing.
Clinical features
Each of the four kinds of apraxia is described below.
IDEOMOTOR AND IDEATIONAL APRAXIA
Ideomotor and ideational apraxia both have to do with the
use of tools, considered in a broad sense, such as combs,
knives and forks, and scissors. Bedside testing is readily
accomplished using either some plastic knives/forks from
the hospital cafeteria or a plastic blunt-ended pair of scissors
carried discreetly in the pocket of one’s white coat.
Begin first by asking the patient to pantomime the use of a
knife and fork, or perhaps a pair of scissors, and observe
the performance. In some cases, the evidence for apraxia is
obvious, as patients appear perplexed and are unable to
make any appropriate movements. In other cases, there
may be some doubt, as for example when patients use a
body part as the tool itself. An example of this might be
when, in attempting to pantomime using scissors to cut an
imaginary piece of paper, the patient moves the index and
middle fingers as if they were the blades of the scissors,
rather than making a repetitive, squeezing kind of motion
with the hand, as one does when the scissors are actually
present. Some authorities consider this an example of
apraxia; however, in this author’s experience normal individuals
are as likely to use their fingers as scissors as not. If
the patient does display significant difficulty in mimicking
the use of a tool, the next step is to provide the tool and ask
the patient to use it; in this case, one pulls out the scissors
and offers them, along with a piece of paper, and observes
the response. In some cases, patients are able to pick up the
tool and use it with little or no difficulty. In others, however,
the perplexity persists: patients may pick up the scissors
by the wrong end, turn them upside down, or
otherwise hold them in a useless position. Cases wherein
patients are unable to pantomime use of a tool but then go