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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 22  |  Issue : 2  |  Page : 116-122

Development and standardization of Indian aphasia battery


1 Clinical Neuropsychology, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
2 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication2-Apr-2018

Correspondence Address:
Ashima Nehra
Room Number 718, 7th Floor, Neurosciences Center, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmhhb.jmhhb_45_16

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  Abstract 


Background: Aphasia is a language disorder which may disrupt an individual's functioning. To plan a mode of therapeutic/rehabilitative work, it is important to assess problems from a neuropsychological perspective focused on remediation of the impaired processes or compensation through the intact processes or both. Aim: Due to the paucity of tests available for the assessment of aphasia in the Indian population with specific colloquial expression, the aim of the present study was to develop an aphasia test for Hindi-speaking population and to provide evidence with its reliability and validity. Methods: The conception of the test took place in two phases: Phase 1 was the development of Indian Aphasia Battery (IAB) and Phase 2 was its standardization. IAB was administered along the Hindi adaptation of the Western Aphasia Battery (WAB-H) on participants with aphasia, probable aphasia, and healthy volunteers. Outcomes and Results: Based on the results of this study, IAB has a high concurrent validity and test–retest reliability in comparison to WAB-H. The subtests are sensitive enough to contribute to global aphasia quotient as a functional measure of aphasia in Indian brain-damaged patients. Conclusion: IAB is a quick and easy to administer measure for assessment of aphasia in Hindi-speaking population with high reliability and validity.

Keywords: Aphasia, aphasia quotient, India, language, neuropsychology


How to cite this article:
Kaur H, Bajpai S, Pershad D, Sreenivas V, Nehra A. Development and standardization of Indian aphasia battery. J Mental Health Hum Behav 2017;22:116-22

How to cite this URL:
Kaur H, Bajpai S, Pershad D, Sreenivas V, Nehra A. Development and standardization of Indian aphasia battery. J Mental Health Hum Behav [serial online] 2017 [cited 2018 Nov 20];22:116-22. Available from: http://www.jmhhb.org/text.asp?2017/22/2/116/229107




  Introduction Top


The yesteryears of aphasia assessment closely mirror the history of our understanding of the neurological foundations of language. To determine the type and severity of aphasia, the evaluation is done by assessing the areas of communication including its production and its comprehension, as well as other related abilities such as reading and writing.[1],[2]

One major complication of language assessment is that there are many reasons to undertake language assessments, each of which may have different methods and goals. Aphasia assessment started in the 1950s since then many tests have developed, e.g., the examining for aphasia, language modalities test for aphasia, Minnesota test for differential diagnosis of aphasia, Porch Index of Communicative Ability, Boston Diagnostic Aphasia Examination, Western Aphasia Battery, comprehensive aphasia test, and many more came up.[3],[4],[5],[6],[7],[8],[9] The available tests for assessing aphasia in Hindi are the Hindi adaptation of the Western Aphasia Battery (WAB-H), Bilingual Aphasia Test, Boston Diagnostic Aphasia Examination, All India Institute of Medical Sciences Diagnostic Test of Aphasia, and Communicative Abilities in Daily Living.[9],[10],[11],[12],[13],[14],[15] However, these tests are not free from limitations for administration in Indian population. They have little or no normative data and test items are not easily comprehended by Indian population speaking Hindi, all of them are quite lengthy and time-consuming, and experimenter bias may creep in due to the difference in administration.[16]

Language assessments developed in other countries are not able to assess the Indian population, speaking diverse languages. Taking all the above limitations in consideration, there was a need to develop a tool for the assessment of aphasia in the Indian population in colloquial Hindi which is easy to administer, a reliable, and valid measure of assessing aphasia.

The present study aims to develop and standardize the Indian Aphasia Battery (IAB) in the Hindi language.


  Methods Top


Patients and instruments

The patient populations for the study were brain damaged suffering from language problems which were recruited from two tertiary care centers, and the healthy volunteers were recruited from the community settings of Northern India. This was done on the basis of a clinical interview of the patients, their caregivers, and medical records. The diagnosis of the patients was done by the neurologist (consultant in charge). Neuropsychiatric issues were evaluated by the consultant neuropsychiatrist. Detailed neuropsychological assessments were carried out by the clinical neuropsychologist. This study does not have any ethical issues as all the data have been anonymized and does not pose any risk/threat to the participants. There are no direct identifiers of patients whose data have been used in the study.

Inclusion and exclusion criteria for aphasics

All consenting patients who were suffering from language problems caused due to stroke were included in the study. Patients who were above 18 years of age, with zero (illiterates/ no formal schooling) to more than 15 years of education (post-graduation and above), rural and/or urban background, both males and females were included. Excluded were patients suffering from any other systemic medical conditions, any major psychiatric disorder, and use of psychoactive drugs.

Instruments used

  1. Sociodemographic sheet including personal details of the patient such as name, age, gender, address, languages known, education, occupation, family type, and familial history
  2. Edinburgh Handedness Inventory [17]
  3. Aphasia assessment by WAB-H
  4. IAB.


Development of Indian Aphasia Battery

The conception of the test took place in two phases: Phase 1, i.e., development of test and Phase 2, i.e., standardization of the test.

IAB was developed as a formalized quantitative scale for finding the impairment in language functions, including comprehension, fluency, naming, reading, writing, and mathematical ability. The initial, qualitative design phase focused on item generation and construction. Creation of the test took place with the help of a Linguistic Expert with whose expert guidance, a list of test items were selected keeping in mind the colloquial background of the patients to be assessed. Creation of test material/picture cards was done with the help of an artist. The pictures were drawn manually and were chosen on the basis of easy colloquial background/recognizing ability of the population to be assessed. We generated several preliminary versions of the scale, which were evaluated internally and then refined because of the following weaknesses: (1) too lengthy to administer (too many items); (2) in the naming task, inadequate use of real daily objects such as watches and pens, instead of images, which are less ambiguous (for example, the pen of one examiner is different from the pen of another one); and (3) in the picture recognition task, inadequate use of color pictures, which may provide semantic clues. We selected the items by consensus and eliminated any ambiguities by administering the scale to fifty healthy volunteers (data not shown). Keeping these considerations, a final pilot try-out was done on thirty aphasics and fifty healthy volunteers. After the rigorous process for the development of the test, 5 test domains finalized were: (1) acoustic problems (APs) relating to impartment in auditory comprehension. The subtests were identifying common words, distinguishing between paired words [Appendix 1], understanding meaning of sentences, following commands, and understanding passage; (2) speech and language problems (SLPs) relating to impairment in naming, repetition [Appendix 2], and fluency. The subtests were copying gross movements, quick alternating movements, imitating phrases, counting numbers to 20, naming days of week, answering easy questions, giving personal information, describing photographs, identifying pictures, and description of words; (3) simple mathematical problems (SMPs) relating to impairment in calculation having subtests handling money, setting time [Appendix 3], and simple numerical calculations; (4) perceptuomotor and writing problems relating to constructional and writing impairment. The subtests were imitating Greek letters, writing till 20, immediate memory [Appendix 4], and making sentences from words; and (5) visual and reading problems relating to impairment in reading having subtests word picture match [Appendix 5], comprehending passage, and reading words.



Standardization of the test

The initial step of validating the developed battery was carried out by testing its face validity by administering the battery on aphasics and healthy controls. One hundred and seventy-nine participants (105 aphasics and 74 healthy volunteers) aided in the measuring the face validity of IAB for discriminating between persons suffering from language problems and healthy volunteers. The concurrent validity was established by administering IAB on 61 patients who were having to suffer from aphasia or were suspected to be having language problems poststroke. IAB was administered against the gold standard, WAB-H. Furthermore, the test–retest reliability was initially carried out on 48 participants where they were assessed on IAB. After a time gap of 15 days, IAB was re-administered on 27 aphasics who had come at the follow-up.

Statistical analysis used

Qualitative variables were expressed as proportions (percentage) and quantitative variables as mean ± standard deviation (SD). The discriminating ability of the total IAB score and its specific domains is assessed by receiver operating characteristic curve (ROC) analysis. The best cutoff for each domain and the total IAB score was obtained. Further, the sensitivity and specificity were determined. The test–retest reliability of IAB scores was assessed using paired t-test/signed rank test as well as visually by a scatter plot. The validity of IAB was assessed using a Spearman's rank correlation. The performance of IAB vis-a-vis WAB-H was assessed through a scatter plot. P < 0.05 was considered statistically significant. All statistical analysis was done using Stata Version 12.1 (StataCorp. 2011, TX, StataCorp LP).


  Results Top


[Table 1] shows that the sociodemographic details of the participants recruited for the standardization of the battery describe that majority of the patients were males than females and aged between 30 and 69 years. The mean age (in years) of the sample for testing the test–retest reliability was 49.0 ± 13.01 (mean ± SD), and for validity, it was 45.7 ± 12.7 (mean ± SD). The education level of the present study participants ranged from no schooling to more than 15 years of schooling, i.e., they had completed graduation.
Table 1: Sociodemographic details of the participants for Phase 2

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[Table 2] shows the results of the sensitivity and specificity of IAB when administered on aphasics and healthy volunteers. All five domains have a good sensitivity and specificity of the developed test. Global aphasia quotient (GAQ) reveals the presence and severity of aphasia with 91.8% sensitivity and 93.2% specificity.
Table 2: Face validity of Indian Aphasia Battery

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As shown in [Figure 1], area under the curve = 97.9% of the participants could be discriminated between the groups by the IAB total score. About 97.9% of aphasics had scored more than the healthy volunteers who are indicative of very high discriminating ability of the IAB scores between aphasics and healthy volunteers.
Figure 1: The sensitivity and specificity of Indian Aphasia Battery

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The validity of IAB as against WAB is assessed by administering both tests on 61 brain-damaged individuals where 46 were suffering from aphasia and 15 were nonaphasics. [Table 3] shows the average of the total IAB score, or the GAQ was compared between the two groups, i.e., aphasics and nonaphasics, and a significant difference in the GAQ was observed among aphasics (16.33 ± 7.77 vs. 129.14 ± 58.62; P < 0.001) as compared to the nonaphasics.
Table 3: Prospective validation of Indian Aphasia Battery

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As shown in [Figure 2], the area under the ROC curve = 98.62% and the cutoff when kept at >30, it was found that IAB was 91.30% sensitive and 100% specific in discriminating between the aphasics and the nonaphasics showing a very good discriminative ability.
Figure 2: The sensitivity and specificity of Indian Aphasia Battery for discriminating aphasics and nonaphasics

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For assessing the concurrent validity of the battery, the scores on the individual domains of IAB and the GAQ when compared to the aphasia quotient from WAB-H were compared. Spearman's rank correlation was calculated and it was observed that the GAQ of IAB was highly correlated with the Aphasia Quotient of WAB-H (−0.89) which was highly significant (P< 0.001). The individual domains of IAB were also found to be having a good correlation with the Aphasia Quotient of WAB. APs was found to have −0.73 correlation (P< 0.001), SLPs was −0.87 (P< 0.001), SMPs was −0.63 (P< 0.001), PMWP was −0.65 (P< 0.001), and VRPs was −0.67 (P< 0.001).

The performance of IAB on test and retest is shown in [Table 4]. As can be seen, there are no significant differences between test and retest done 15 days later. For example, total IAB or the GAQ score at the test was 110.27 ± 83.06, which was 106.55 ± 74.23. This difference was statistically not significant (P = 0.23). A similar trend was also observed for individual domains of IAB.
Table 4: Results showing the test-retest reliability of Indian Aphasia Battery

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The test–retest performance was also assessed by a scatter diagram [Figure 3]. As can be observed, the test scores and retest scores fall very close to the 45° diagonal, indicating that the scores on two occasions for each patient are very close to each other.
Figure 3: The scores for test–retest reliability of five individual domains and total Indian Aphasia Battery scores

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  Discussion Top


We developed and validated an aphasia assessment measure for use in the Hindi-speaking population. IAB is a comprehensive battery that taps the following domains of language: comprehension, naming, fluency, repetition, mathematical ability, perceptual ability, reading, and writing. It is a quick, simple, and culturally appropriate tool for assessing language functioning in the Indian population.

From the demographic perspective, we do not yet have any clear picture of the epidemiology of aphasia in India. Prevalence figures of stroke, the major cause of aphasia, vary from 220 per million to 557.5 per million. As to incidence, an annual stroke incidence of 145/100,000 is reported. While not all these stroke patients become aphasic, aphasia can also be consequence of neurogenic disorders other than stroke. By all accounts, the number of persons with aphasia in the country will be close to a million. The prevalence rate for aphasia is approximately 1 in 240 persons or on an average of 0.37% people in India. (extrapolated prevalence will be 3,915,700. Population estimated used, 1,065,070,607). About 15% of individuals under the age of 65 experience aphasia; this percentage increases to 43% for individuals 85 years of age and older. No significant differences have been found in the incidence of aphasia in men and women. However, some data suggest that differences may exist by type and severity of aphasia. These findings are consistent with the existing literature on the epidemiology of stroke in India and around the world.[18],[19]

The resulting testing performance of the normal and aphasic participants on the IAB was dramatically different. The normal participants achieved lower scores, which are typical in this condition, demonstrating the specificity of the testing protocol [Table 2]. In addition, the aphasic participants not only achieved higher scores on subtests but also achieved scores that are typical of their diagnosis. This performance indicated a basis for the sensitivity of the IAB [Table 2].

Among the present international aphasia batteries, Western Aphasia Battery as a clinical tool has been used routinely and widely to evaluate adult language deficits in English and some other languages like Hindi (WAB-H) and has been reported to have high internal consistency, test–retest reliability, and validity.[10],[11] Hence, it has been used as a gold standard for the present study.

One of the main findings of this study was that IAB can be used as a valid measuring clinical tool to assess language impairments in patients with brain damage and quantify their impairment based on an operational GAQ index proposed by Kertesz.[8]

On assessing the concurrent validity of the battery, the patients suffering from aphasia and probable aphasia (nonaphasics) were assessed on WAB-H and IAB which shows that the GAQ of IAB was highly correlated with the Aphasia quotient of WAB-H (−0.89) which was highly significant. The subdomains of IAB were also found to be having a high correlation with the Aphasia quotient of WAB-H.

The current battery was subjected to test–retest reliability with a time gap of 15 days, and the results were found out to be highly reliable as there was no significant change in scores from test to retest assessment (110.27 ± 83.06; 106.55 ± 74.23; P = 0.23). The amount of time between measures was critical because two observations are related overtime – the closer in time we get the more similar the factors contribute to error. In specific to aphasia, there is a dynamic change in the pattern of the severity of aphasia from the time of onset. Therefore, there is no substantial change in the construct being measured at the two occasions.

As it can be seen in the variation of the test-retest scores in some cases caused due to the changes in language functioning. These changes can be attributed to spontaneous recovery, neural plasticity and other physical conditions associated with post-stroke aphasia which has been picked up by the Indian Aphasia Battery suggesting that it is sensitive enough to identify these changes.[8],[20],[21],[22],[23]

While reliability is necessary, it alone is not sufficient. For a test to be reliable, it also needs to be valid. The results are indicative of a good correlation between IAB and WAB-H (area under the ROC area = 0.986). Along with the high sensitivity and specificity, IAB was also found to be a valid tool when it was tested against the WAB-H. The GAQ was compared between the two groups, i.e., aphasics and nonaphasics, and a significant difference in the GAQ was observed among aphasics as compared to the nonaphasics.


  Conclusion Top


IAB is an upcoming tool which can be helpful in assessing aphasia in the Hindi-speaking population. It is a validated aphasia assessment tool for patients suffering from language difficulties including post-stroke which can be administered in a short span. IAB can be helpful in giving information about the level of impairment persisting in the assessment of language functioning.

Limitations and future directions

Due to the limited sample size the effect of different education levels, age and other neurological conditions could not be assessed. Age and gender matching of the healthy volunteers is one of the major limitations of the present work. The present work done only aids in quantifying the level of impairment inlanguage deficits but fails to make a differential diagnosis for aphasia. Future research on this protocol should include a full translation of the IAB in other Indian languages as well as a larger sample size to further fortify the validity and reliability of this aphasia test so that it can categorize the severity level and provide us with differential diagnosis. It was also found that age was a significant influencing factor, and more research should be done to investigate and to validate the battery on elderly. These methodological limitations should be surmounted in the future research for a computerized version for IAB that can be prepared so that it can become an easy to administer, bedside assessment measure.

Acknowledgments

Authors are thankful to the faculty members including Prof. Kameshwar Prasad, Prof. Padma Srivastava and Prof. Rohit Bhatia, and senior residents from the Department of Neurology, AIIMS (New Delhi) for referring in patient recruitment for this research work. Finally, we are indebted to all our patients included in the study for their whole hearted cooperation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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