The Aging Voice

1. The Aging Voice Presented by Anastasia Serbalik Presented to Rebecca L. Gould, MSC, CCC-SLP

2. Increasing need for Geriatric Otolaryngology • During the 20th century the number of persons in the U.S. under 65 has tripled • The number of people over 65 has increased by 11 times during the 20th century! • By the year 2050 1/5 people will be 65 or older

3. Increasing need for Geriatric Otolaryngology • Vocal disturbance is among one of the top medical complaints of the elderly • An estimated 12% of the elderly have vocal dysfunction

4. Aging: Changes in Respiratory Support • Decreased vital capacity-decrease by one liter for both males and females • Loss of efficiency-loss of elasticity in thoracic skeleton, muscular weakness • Reduction of loudness

5. Aging: Changes in laryngeal mechanism • Calcification and Ossification of laryngeal cartilages • Degeneration of laryngeal muscles • Thickening of connective tissue of lamina propria • Thinning of intermediate layer of lamina propria • “densening” of deep layer of lamina propria

6. Changes in Laryngeal Mechanism: Males & Females *In women vocal folds become more edamatous and polyploidy *In men vocal folds become more thin and atrophied

7. Aging: Changes in Laryngeal Mechanism • Changes in the cricoarytenoid joint - pitch of voice is fine-tuned by control over position of arytenoid cartilage which may account for pitch variability • Restriction of vocal fold approximation

8. Changes in Supralaryngeal Mechanism • Atrophy of facial, pharyngeal, and mastication muscles • Weakened esophageal sphincter may lead to gastro esophageal reflux

9. Aging: Changes in Supralaryngeal system • Craniofacial enlargement by 3-5% • Changes in articulators-loss of teeth, reduced musculature of tongue and masticular muscles affect resonation

10. Functional Effects of Age Related changes of the Voice • After fifth decade of life increase in male fundamental frequency in males (35 Hz) • Decrease in fundamental frequency of women (10-15 Hz) • Increase in pitch perturbation cycle to cycle variation of fundamental frequency • difficult to maintain a stable tone

11. Functional Effects of Age Related Changes of the Voice • Reduced pitch range • Decreased sound pressure level • Vocal quality symptoms of vocal roughness, aperiodicity, breathiness

12. Common Vocal Fold Findingsin the Elderly • Bowed cords • Atrophy • Edema • Loss of collagen, ground substance, and cartilage matrix in the cricoarytenioid joint • Atrophy of laryngeal muscles

13. Bowed Vocal Fold • Most common benign pathology of the aging voice • Gap occurs in the region of the middle one-third of the vocal cord with total or near approximation at anterior and posterior commisures

14. Atrophic Vocal Folds • With advancing age the vocal fold muscle and mucosal covering can lose mass, appearing as thinned • Incomplete closure of vocal folds and irregular vibration

15. Edema • Swelling of the entire layer of superficial lamina propria • Water balloon effect • Result in irregular mucosal wave

16. The Aging Voice: The Challenge of Diagnosis Factors: 1. Identification of normal aging voice from pathological condition 2. Inappropriate/insufficient assessments 3. Incomplete/inaccurate Case history

17. “It is important to remember although vocal changes often occur with aging they occur in many other pathological states” (Linville, 2004)

18. Differential Diagnosis: Pathologic conditions vs. normal aging voice • Inflammatory and Autoimmune diseases • Neoplasms-abnormal new mass of tissue serving no purpose (benign & malignant) can occur in larynx or thyroid • Functional and psychogenic disorders of speech • May be misconstrued as part of normal aging

19. Differential Diagnosis: Pathologic conditions vs. normal aging voice • Essential tremor • Parkinson’s disease • Stroke • Myastehnia gravis • Amyotrophic lateral sclerosis

20. Differential Diagnosis:Aging voice vs. pathologic condition • HOARSENESS is both a quality frequently found in normal aging voice AND one of the most common symptoms of vocal dysfunction…so how do we differentiate malignant from benign etiologies of hoarseness

21. Diagnosis of the Aging Voice:Useful tools • TIME is the most useful therapeutic measure that may help to distinguish benign from malignant etiologies of hoarseness • REFERRAL to the otolaryngologist to perform a thorough laryngeal exam is an invaluable resource in diagnosis and management of hoarseness • CASE HISTORY-elements of a patients history and symptomology are gateways in forming appropriate diagnosis

22. Differential diagnosis:Aging voice vs.. disordered voice • Indicators hoarseness is NOT due to Benign changes • Voice changes of recent onset • Associated pain with phonation • Pain or difficulty swallowing • Presence of new neck mass • Past history of alcohol or tobacco use

23. Diagnosis of the Aging Voice: Assessment • Until recently Speech Pathologists had very little data to indicate the normal voice and speech patterns of the elderly TAKE A LOOK AT THIS…..

24. The Aging Voice & Diagnosis • 1998 Sinard & Hall reported “there are no objective tests that can reliably distinguish voice changes due to normal aging process from disease of the larynx” • 1999 Whitlock reported the need for an acoustical test to accurately monitor potential voice disorders • 2004 Verdonck-de Leeuw & Mahieu report a lack of longitudinal studies on the effects of aging on voice

25. Diagnosis of the Aging Voice: Advancements in Assessment • Recent longitudinal research study conducted by Verdonck-de Leeuw & Mahieu used Multidimensional Voice Program to acoustically analyze eight parameters of voice by digitizing sustained vowels and fragments of speech • Omnidirectional telephones • Custom-made amplifiers • DAT recorder

26. Findings of Longitudinal Study on vocal aging and impact on daily life: Significant deterioration of voice as soon as 5 years after age 50 • Voice instability, changes in fundamnetal frequency • Tendency to avoid social parties increase in isolating behaviors • Male smokers with irreversible lower fundamental frequencies (Veronck-de Leeuw & Mahieu, 2004)

27. Findings of Longitudinal Study on vocal aging and impact on daily life THE LATEST NEWS: histological & genetic findings of recent studies give rise to a theory that aging will inevitably lead to a mild-moderate-severe voice impairment (Veronck-de Leeuw & Mahieu, 2004)

28. New Research: How voice gives away a person’s age • Researchers identified key indicators of the aging voice • Used computer software to speed up and lower voices of older men to sound younger • Results found 12/13 old voices were mistook as “young” • Implications • Criminal forensics • Hollywood, aging of actors voices (Ascribe Medicine News Service, 2003)

29. Keeping the Voice “Young” • “You are as young as you sound” • Eat sensibly • Get plenty of rest • Keep brain and voice well exercised • Use the strong muscles of your lower abdominals to support voice • Keep hydrated-8 a day • Be alert for voice damaging symptoms of GERD

30. References • Deem, M. & Miller, L. (2000). Manual of Voice Therapy. Austin, TX: PRO-ED, Inc. • Linville, S. E. (2004, Oct.19) The Aging Voice. The ASHA Leader, p.12, 21 • Shields, Gordon. (2004, June 16). Geriatric Otolaryngology • Spotlight on Special Topics in Voice Disorders (2004) In The New York Eye and Ear Infirmary, Center for Voice. Retrieved June 10, 2005, from http://www.nyeee.edu/cfv-spotlight

31. References • Ordonez, Ernesto A. (2000)‘Growth of anti-aging field offers new career option’. A voice of experience p.16, I.12). • Research uncovers How the voice gives away a person’s age. (2003) Ascribe Medicine News Service. • Sinard, R. & Hall, D. (1998). The aging voice:how to differentiate disease from normal changes. Geriatrics, p.76

32. References • Verdonck-de Leeuw, Irma & Hans F. Mahieu (study. Journal of Voice 2004). Vocal aging and the impact on daily life: a longitudinal, 18, 193-203. 53. • Whitlock, Kelly (1999). Age-Related Vocal Changes Often Misdiagnosed. Science Daily.