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Speech Communication 56 (2014) 63–69
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The development of the Geriatric Index of Communicative


Ability (GICA) for measuring communicative competence of elderly:
A pilot study
JungWan Kim a, ChungMo Nam b, YongWook Kim c, HyangHee Kim c,d,⇑
a
Department of Speech and Language Pathology, Daegu University, Gyeongsan 712-714, Republic of Korea
b
Department of Preventive Medicine, Yonsei University College of Medicine, Seoul 120-752, Republic of Korea
c
Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul 120-752, Republic of Korea
d
Graduate Program in Speech and Language Pathology, Yonsei University, Seoul 120-752, Republic of Korea

Received 9 April 2013; received in revised form 25 July 2013; accepted 3 August 2013
Available online 9 August 2013

Abstract

A change in communicative ability, among various changes arising during the aging process, may cause various difficulties for the
elderly. This study aims to develop a Geriatric Index of Communicative Ability (GICA) and verify its reliability and validity. After orga-
nizing the areas required for GICA and defining the categories for the sub-domains, relevant questions were arranged. The final version
of GICA was completed through the stages of content and face validity, expert review, and pilot study. The overall reliability of GICA
was good and the internal consistency (Cronbach’s a = .786) and test-retest reliability (range of Pearson’s correlation coefficients: .58–
.98) were high. Based on this verification of the instrument’s reliability and validity, the completed GICA was organized with three ques-
tions in each of six sub-domains: hearing, language comprehension & production, attention & memory, communication efficiency, voice
and reading/writing/calculation. As a tool to measure the communicative ability of elderly people reliably and appropriately, GICA is
very useful in the early identification of those with communication difficulties among the elderly.
Ó 2013 Published by Elsevier B.V.

Keywords: Communicative ability; Elderly; Language; Cognition; Index

1. Introduction and social activity tend to decline, and the elderly have
unique demographic characteristics which differ from those
The number of elderly is increasing rapidly worldwide of younger age groups (The Korean Gerontological Soci-
and aging in Korea is progressing very rapidly (Statistics ety, 2002). The mental health of the elderly has recently
Korea, 2010). The various problems accompanying this attracted both media and research attention. Since the
rapid increase in the elderly population require develop- mental health of the elderly is closely related to successful
ment of numerous services including medical insurance communication, their quality of life can be improved by
and welfare programs. In old age, all kinds of physical examining changes in communicative ability that occur
during the aging process and by using the early identifica-
tion of any problems to ensure the provision of prompt
⇑ Corresponding author. Address: Graduate Program in Speech and therapeutic information.
Language Pathology & Department and Research Institute of Rehabil- The important aspects of speech communication include
itation Medicine, Yonsei University College of Medicine, Seoul, 50 respiration, phonation, articulation, language, and hearing
Yonsei-ro, Sinchon-dong, Seodaemun-gu, Seoul 120-752, Republic of
Korea. Tel.: +82 2 2228 3900; fax: +82 2 2227 7984.
function (Mayerson, 1976). These functions tend to
E-mail address: h.kim@yonsei.ac.kr (H. Kim). degrade in old age, although there is wide individual vari-

0167-6393/$ - see front matter Ó 2013 Published by Elsevier B.V.


http://dx.doi.org/10.1016/j.specom.2013.08.001
64 J. Kim et al. / Speech Communication 56 (2014) 63–69

ation. In other words, the aging of the respiratory system in old age after consulting the category classifications used
relates to the aging of the other bodily systems, so that in the existing measures of communicative ability (Frattali
the smooth flow and rhythm of speech can be degraded et al., 1995; Holland et al., 1999; Lomas et al., 1989) and
with increasing age due to diminished physiologic skills divided the sub-domains into six categories: ‘voice’, ‘hear-
(Burzynski, 1987). The cartilage and muscles involved in ing’, ‘auditory comprehension’, ‘verbal expression’, ‘read-
phonation also undergo structural changes in the elderly, ing/writing/calculation’ and ‘attention/memory’. Then
which leads to changes in vocal intensity, voice quality, various items were prepared within each sub-domain
and pitch. These changes combine to give old people a less through literature review (Brod et al., 1999; Kim and
resonating and more breathy voice (Burzynski, 1987; Muel- Kim, 2009). Consequently, 69 items of the first version of
ler et al., 1984; Watson, 1998). The articulatory function the Geriatric Index of Communicative Ability (GICA)
requires intricate interactions between the speech mecha- were prepared.
nisms of the tongue, lips, jaws, and palate. A structural
change in the speech mechanism resulting from aging can 2.2. Pilot study
thus cause articulatory deviations (Mayerson, 1976).
Language is affected by such skills as perceptual skills, 2.2.1. Exploration of content validity
sensori-motor abilities, intelligence and education. There- To establish the content validity for the first version of
fore, the decline in the elderly’s memory, span of attention, GICA, the 69 items were evaluated by 5 focus groups (2
problem solving ability and perceptual skills makes it diffi- speech and language pathologists with clinical experience
cult for them to understand sounds and words, and the of 5–10 years). The communicative ability in the elderly
syntactic complexity of a message also influences the was evaluated by examining the duplication, representation
abilities of old people to understand language (Frisina and appropriateness of the items in each sub-domain with a
and Frisina, 1997; Gordon-Salant and Fitzgibbons, 1995; 5-point scale. The 69 items were used according to their
Pichora-Fuller et al., 1995; Wingfield et al., 2006; Yonan Content Validity Index (CVI) as follows: those with a
and Sommers, 2000). Riegel (1973) held that in the aging CVI in the range of 0.50–0.799 were modified, those with
process, language was stable, and cognitive decrements a CVI of 0.80 or more were used as they were, and those
were reflected in language outputs. In addition, the with a CVI of less than 0.50 were excluded since validity
elderly’s hearing function often degrades. Hearing impair- was judged as too low (Fehring, 1987).
ment is so common among the elderly that hearing loss
has been reported in 33% (Glorig and Roberts, 1965). Such 2.2.2. Questionnaire construction and expert review
hearing disorders further hinder the hearing and under- By administering the questionnaires at random to 20
standing capability of many elderly as they fail to catch normal elderly (10 men and 10 women; mean age:
important words and are incapable of understanding what 67.3 years; SD: 1.8; mean education: 7.4 years; SD: 3.2),
others say under poor listening conditions such as noisy or we examined for the presence of any hindering factors such
crowded places (Tun and Wingfield, 1999; Versfeld and as ambiguous contents, difficult words, and unnecessarily
Dreschler, 2002; Wingfield and Grossman, 2006). complicated sentence structures (Gronlund, 1988).
Despite the wide individual variation, difficulties in com- Through this process, 31 items were selected for the second
municative ability in old age may arise through respiration, version of GICA, with 5, 4, 5, 8, 5 and 4 questions in the
voice, hearing, language comprehension and language hearing, voice, auditory comprehension, verbal expression,
expression. Therefore, it is needed to develop an index to reading/writing/calculation and attention/memory sub-
measure changes in the communicative ability of the elderly domains, respectively.
by identifying and specifying weaknesses according to var- As for the second preliminary questions that underwent
ious sub-domains. This index can then be used to identify the verification process of content validity, we composed
the areas in which speech and language pathologists can response categories according to the selection type in which
help the elderly to maintain effective communication at the respondents choose one from an answer sheet with 5-
each stage of old age. point scale. In tests for adults, the reliability and consis-
tency are influenced by the number of response categories
2. Methods (Friedenberg, 1995) so that the reliability tends to increase
with increasing number of categories (Thorndike et al.,
2.1. Instrument development 1991). In case of the elderly, however, numerous response
categories, such as a 7-point scale, may cause confusion.
Factors of communicative disorders can be grouped into Therefore, we used a 5-point scale that is generally used
voice, articulation, language, stuttering and hearing in attitude test in self-reporting form or questionnaires of
(Hegde, 2001). In old age, however, calculation, attention, social survey (Likert, 1932; Park, 2001).
working memory, reading and writing abilities, as well as This 5-point scale consisted of ‘1: always agree, 2: fre-
these speech and language abilities, may influence effective quently agree, 3: ordinary, 4: rarely agree, 5: absolutely
communication. Therefore, this study reorganized the do not agree’. After examining the rubrics, conceptual clar-
domains essential for measures of communicative ability ity and briefness of the questions with 5 focus groups as a
J. Kim et al. / Speech Communication 56 (2014) 63–69 65

further part of the reexamination step, two things were investigate hearing disturbance and we examined objective
revised. First, to prevent respondents from replying with hearing threshold (Model: Qualitone Audiometers WR-C,
only one answer insincerely, we described 7 questions in Starkey Laboratories, Inc.) by implementing simple hear-
affirmative form (i.e., I pronounce correctly when speak- ing tests. In addition, were implemented GICA for 60
ing) out of 31 questions in total. Second, while the 5-point elderly people who represent 30% within 2 weeks to exam-
scale of the second version of GICA corresponds to fre- ine test-retest reliability of GICA. As for the scoring
quency-based question, through the evaluation that ‘3 method, summated scale was used for GICA, except 7
points: ordinary’ does not maintain equal interval with 2 items which were changed into affirmative forms, which
points and 4 points which are lied before and after it, we adds score of response scale (1–5 points) of each question.
modified it to ‘3: sometimes agree’. For 7 items in negative form, we scored them with 1–5
points by calculating them in a way of ‘6-(score of relevant
2.2.3. Examine face validity response scale). Through this scoring method, we calcu-
The face validity was verified by placing a tick next to lated total scores which ranged from 31 points at the min-
each question to see if they were properly set for the mea- imum to 155 points at the maximum. At the beginning of
surement of aged communicative ability on 100 elderly in the interview, we notified the subjects that questions
total while executing the second version of GICA. When include affirmative and negative forms. We asked them to
the question ‘Not related or not proper’ was ticked, the rea- listen carefully and answer them.
son was also commented.
2.4. Statistical analysis
2.2.4. Sampling
We recruited 100 community-dwelling elderly subjects. Descriptive and analytic statistics were computed with
This study defined ‘elderly people’ with the following crite- the use of SPSS 17.0 ver (Statistical Product and Service
ria; from (1) those whose residence was the Republic of Solution, SPSS Inc., 2010), and p-values of <.05 were con-
Korea and who spoke Korean as the mother tongue and sidered statistically significant. Test-retest reliability was
were 65 years or older, and we excluded (2) elderly people examined using the Pearson correlation analysis. Internal
who showed performance by 16% or less in criteria of consistency reliability was examined using Cronbach’s
normal group in Korean-Mini Mental State Examination coefficient alpha. Factor analysis (principal axis analysis,
(K-MMSE, Kang, 2006), and (3) elderly people who turned orthogonal factor rotation) was performed to explore the
out to be in depression in Geriatric Depression Scale Short constructs of the scale.
Form-Korea Version (GDSSF-K, KI, 1996), and (4)
elderly people who corresponded to 27 conditions out of 3. Results
29 types of diseases which can be related to decline of cog-
nitive function that Christensen et al. (1991) asserted, 3.1. Characteristics of the study subjects
except questions 28 and 29. It is thought to be meaningless
to develop index of communicative ability by excluding Of 104 elderly enrolled in the study, 100 individuals (50
elderly people who corresponded to ‘hearing impairment’ men and 50 women) were study subjects after excluding 4
of question 28 and ‘illiteracy’ of question 29 since consider- individuals due to missing or incomplete data on GICA.
able number of elderly people in Korea come under these The 8 elderly with hearing impairment showed a mean
conditions. The elderly subjects were selected through threshold of 39.85 dB, indicating that their hearing impair-
interviews and written consent was obtained from each ments were not severe. In addition, since hearing impair-
participant. ment occurs frequently among the elderly, collection of
data excluding those with hearing impairment may be con-
2.3. Methods of administration sidered meaningless. Therefore, the elderly with hearing
impairment were included in the analysis of response data.
Since many of the elderly would have had difficulties in The average score on the K-MMSE was 27.8 (SD = 1.75).
reading the questions and writing their responses by them- The mean age was 69.42 years (SD = 4.43). The mean years
selves, the survey questionnaire was administered by inter- of education was 9.2 (SD = 2.2). The mean GDS score was
view in which the researcher read out the contents and 2.3, indicating that none of the subjects had depression.
wrote the responses down in an answering sheet. In the case
of a respondent struggling to understand the example ques- 3.2. Reliability
tions and three or more items of the main questions, the
survey was continued but the data excluded from the final The internal consistency value, established by means of
analysis. Cronbach’s alpha coefficient, was 0.786. In the internal
We also conducted K-MMSE (Kang, 2006), GDSSF-K consistency analysis among the total score and each ques-
(KI, 1996) and GICA for all elderly subjects. We imple- tion of GICA, the questions whose coefficient alpha a
mented the Hearing Handicap Inventory for the Elderly- increased when they were removed were items 4, 6, 23, 29
Screening Version (Kim et al., 2001) when interviewing to and 30 (Table 1).
66 J. Kim et al. / Speech Communication 56 (2014) 63–69

Table 1
Internal consistency of the GICA.
Sub-domain Item Corrected item-total Cronbach’s alpha if item
number correlation deleted
V (Having a breathy voice when speaking) 1 .615 .736
H (I cannot hear sounds from TV or radio and feel uncomfortable) 2 .517 .736
VE (I use gestures or body language since I cannot express myself well with 3 .549 .738
words)
VE (Interrupting someone who is speaking) 4 .152 .787
RWC (I can read and understand notices and manuals) 5 .545 .738
AM (Bringing up a new story without finishing the previous) 6 .451 .787
AM (I forget what I try to speak while speaking) 7 .587 .738
RWC (I sometimes read signs wrong on the subway or bus and get off at the 8 .441 .741
wrong stop)
H (difficult to hear what others say in a noisy place) 9 .643 .733
AC (I do not understand long and complicated speech well) 10 .607 .736
V (I can adjust the loudness of my voice well) 11 .389 .740
VE (Having difficulty recalling the word intended) 12 .475 .739
AC (I do not understand what I watch and listen on TV) 13 .582 .737
RWC (I can write down personal information such as name and phone 14 .367 .739
number)
H (I cannot hear well when talking on the phone) 15 .632 .734
V (My voice became rough and raspy than before) 16 .507 .736
RWC (When I read a book or newspaper, I have to read the same content 17 .619 .735
many times to understand it)
VE (It is difficult for me to start a conversation) 18 .469 .737
VE (I mispronounce some part of a word) 19 .561 .737
AM (I remember well what I learn or get to know newly) 20 .595 .737
H (Having difficulty understanding what others say in a whisper) 21 .647 .733
VE (I speak in simpler words than before) 22 .469 .737
VE (I say something different from what I intend to say) 23 .443 .788
RWC (My numerical skill was weakened than before) 24 .477 .738
AC (I cannot understand well if people speak fast) 25 .706 .733
V (My voice became heavier or thinner than before) 26 .492 .737
VE (I explain repeatedly even simple things) 27 .344 .740
H (I hear a buzzing in my ears) 28 .732 .735
AC (Having difficulty understanding what others feel, through the looks on 29 .405 .789
their face)
AC (I do not distinguish a joke from a truth) 30 .474 .787
AM (I cannot remember things well in recent days) 31 .513 .738
GICA: Geriatric Index of Communicative Ability; V: Voice; H: Hearing; VE: Verbal Expression; AC: Auditory Comprehension; AM: Attention/Memory;
RWC: Reading/Writing/Calculation.

To assess the test-retest reliability, 30 elderly were asked new story without finishing the previous), 21 (Having diffi-
to complete GICA a second time 2 weeks later. The test- culty understanding what others say in a whisper), and 29
retest reliability results revealed that the range of Pearson’s (Having difficulty understanding what others feel, through
correlation coefficients was 0.58–0.98. As a result of check- the looks on their face). The reasons included such
ing the correlations among the 7 questions that were responses as ‘My ability will be evaluated negatively.’ and
described as a reversible (positively or negatively) among ‘I do not want my measured ability exposed.’ Internal con-
GICA questions, the remaining 5 questions after excluding struct validity was examined through factor analysis.
items 13 and 19 showed high reliability. According to principal axis component, 6 factors
accounted for the total variance in the matrix (Table 2).
3.3. Validity
3.4. Final scale
Content and face validity were checked via focus group
discussion during the stage of instrument development. As Questions were selected in reference to factor analysis,
a result of the content validity verification, the CVIs of all specifically the correlation among the sub-questions
the questions, which ranged from 0.51–0.94, indicated that belonging to each factor, the tendency of the elderly to
none needed to be removed. As a result of face validity ver- respond, and the internal attributes of the applicable ques-
ification, the elderly answered ‘Not related nor proper’ on 5 tions. For instance, question item 2 showed a strong positive
questions: items 1 (Having a breathy voice when speaking), correlation with question items 9 (Difficult to hear what oth-
4 (Interrupting someone who is speaking), 6 (Bringing up a ers say in a noisy place) and 21. In other words, the elderly
J. Kim et al. / Speech Communication 56 (2014) 63–69 67

Table 2 related to communication method were bound in one


Factor analysis results of the GICA. sub-domain. Therefore, the former was named ‘language
Item number Factor comprehension/expression’, and the latter as ‘communica-
1 2 3 4 5 6 tion efficiency’. The 18 questions finally selected were com-
15 .707 posed of 6 sub-domains with 3 questions each. The
2 .687 distribution and contents of the GICA questions are pre-
28 .607 sented in the Appendix.
22 .758
25 .566
10 .536 3.5. Scoring system of GICA
7 .661
20 .564
31 .553
In the final version of GICA, the test questions were
14 .724 arrayed in the same sequential order as in the second ver-
24 .571 sion. The scoring method was such that, like in the pilot
17 .570 test, where scores were assigned from 1 to 5 points based
18 .589 on a 5-point scale, the total score range of this test from
3 .499
27 .395
18 to 90 points, with the higher being the better.
1 .799
26 .731
11 .517
4. Discussions
GICA: Geriatric Index of Communicative Ability.
The proposed GICA, based on instrument development,
pilot study and focus group feedback, demonstrated good
that reported good hearing ability in question item 2 internal consistency, test-retest reliability, and internal con-
responded as having good ability on question items 9 and struct validity. GICA is fast in evaluation, taking only 8–
21 as well, and thus these 3 questions were regarded as mea- 12 min to administer. The tailoring of the items in this
sured repetitively on similar abilities. Question item 9 indi- index to target specifically the elderly is anticipated to iden-
cated that the elderly showed a low level in executing tify the changes in communication ability occurring in the
ability overall regardless of their hearing impairment condi- aging process in detail.
tion. In other words, since the elderly with normal hearing The proposed GICA is a self-reported, subjective ques-
ability also suffered a decrease in speech perception in noisy tionnaire for the elderly. The 69 items of the first version
environments, this question was considered to indicate the of GICA generated at the early stage of instrument devel-
conditions of attention/memory, sound perceiving ability opment were reduced to 18 items through verification of
and language comprehension ability simultaneously. Ques- content validity and face validity, and pilot study and
tion item 21 did not reflect a common situation for the expert review. The variables considered at the time of pilot
elderly, so the hearing impairment experts opined that this testing included whether or not the item is a common def-
question lacked sensitivity as a test question. Therefore, icit that is reported frequently among normal elderly and
question items 9 and 21 were removed through focus group whether or not the item is the same as any of the items
discussion. already included. As the 18 final-version items were
In addition, question item 12 (Having difficulty recalling selected through a multi-step procedure, they need to be
the word intended) is applicable to verbal expression ability measured over time to determine any degradation in the
at a word level, but with healthy elderly, this question may be elderly’s communicative ability resulting from the normal
related to short-term memory ability rather than to verbal aging process.
expression purely in itself. As a result of factor analysis, The tools to measure communicative ability were gener-
question item 12 was classified in the attention/memory ally examined on ability by being divided into linguistic
domain. However, the deterioration of naming ability that comprehension and expression (Hegde, 2001). However,
occurs in the normal aging process is only pertinent to lan- although such classification may provide useful informa-
guage ability in general rather than affecting memory, atten- tion in diagnosing aphasic patients that lack executing abil-
tion or perceiving ability. The tools used in clinical linguistic ity in speaking, hearing, reading or writing, it is not
and psychological evaluations classify naming ability in the suitable for identifying the communicative ability of the
verbal expression area, so this question was deleted based on general elderly. As a result of this study, auditory compre-
the focus group discussion. Thus, through the reliability and hension and verbal expression ability were bound as one
validity analysis and the focus group discussion, 18 ques- factor, and the abilities related to the efficiency of commu-
tions remained in the final version of GICA. nication such as verbal expression and difficulty of dialog
In the sub-domain classes that were used in the first and starting were classified as one factor. This indicated that
second versions of GICA, ‘auditory comprehension’ and language comprehension and verbal expression ability in
‘verbal expression’ were bound in one sub-domain, and ordinary communication situations work simultaneously
among the ‘verbal expression’ sub-domains, 3 questions in a combined manner and that effective communication
68 J. Kim et al. / Speech Communication 56 (2014) 63–69

Appendix
Communication profile for elderly.

H: Hearing; V: Voice; LCP: Language Comprehension/Production; CE: Communication Efficiency; AM: Attention/Memory; RWC: Reading/Writing/
Calculation.
Light shaded item calculated as ‘6-(applicable score)’ (e.g., r ! 6–(1) = 5 rating, s ! 6–(2) = 4 rating).

requires significant consideration for the efficiency of Friedenberg, L., 1995. Psychological Testing: Design, Analysis, and Use.
communication. Allyn and Bacon, Boston.
Frisina, D.R., Frisina, R.D., 1997. Speech recognition in noise and
The reliability and validity of GICA were demonstrated presbycusis: relations to possible neural mechanisms. Hearing
in this study. However, the results are limited because the Research 106 (1–2), 95–104.
study was conducted mostly in large cities of Korea and Glorig, A., Roberts, J., 1965. Hearing levels of adults by age and sex. (US
therefore did not reflect the trends of rural communities. Public Health Services, Series 11, No, 11). Washinton, DC: Depart-
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Gordon-Salant, S., Fitzgibbons, P.J., 1995. Temporal factors and speech
elderly in small medium cities and rural areas, and to inves- recognition performance in young and elderly listeners. Journal of
tigate the differences of communication ability according to Speech and Hearing Research 36, 1276–1285.
gender, age, years of education and hearing impairment. In Gronlund, N.E., 1988. How to Construct Achievement Tests. Prentice-
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