The Aging VoiceThe Aging Voice

Presented by Anastasia SerbalikPresented by Anastasia Serbalik

Presented to Rebecca L. Gould, Presented to Rebecca L. Gould, MSC, CCC-SLPMSC, CCC-SLP

Increasing need for Geriatric Increasing need for Geriatric OtolaryngologyOtolaryngology

During the 20th century the number of During the 20th century the number of persons in the U.S. under 65 has tripledpersons in the U.S. under 65 has tripled

The number of people over 65 has increased The number of people over 65 has increased by 11 times during the 20th century!by 11 times during the 20th century!

By the year 2050 1/5 people will be 65 or By the year 2050 1/5 people will be 65 or olderolder

Increasing need for Geriatric Increasing need for Geriatric OtolaryngologyOtolaryngology

Vocal disturbance is among one of the top Vocal disturbance is among one of the top medical complaints of the elderlymedical complaints of the elderly

An estimated 12% of the elderly have vocal An estimated 12% of the elderly have vocal dysfunctiondysfunction

Aging: Changes in Respiratory Aging: Changes in Respiratory SupportSupport

Decreased vital capacity-decrease by one Decreased vital capacity-decrease by one liter for both males and femalesliter for both males and females

Loss of efficiency-loss of elasticity in Loss of efficiency-loss of elasticity in thoracic skeleton, muscular weaknessthoracic skeleton, muscular weakness

Reduction of loudness Reduction of loudness

Aging: Changes in laryngeal Aging: Changes in laryngeal mechanismmechanism

Calcification and Ossification of laryngeal Calcification and Ossification of laryngeal cartilagescartilages

Degeneration of laryngeal musclesDegeneration of laryngeal muscles– Thickening of connective tissue of lamina Thickening of connective tissue of lamina

propriapropria– Thinning of intermediate layer of lamina Thinning of intermediate layer of lamina

propriapropria– ““densening” of deep layer of lamina densening” of deep layer of lamina

propriapropria

Changes in Laryngeal Changes in Laryngeal Mechanism: Males & FemalesMechanism: Males & Females

*In women vocal folds become more edamatous and polyploidy

*In men vocal folds become more thin and atrophied

Aging: Changes in Laryngeal Aging: Changes in Laryngeal MechanismMechanism

Changes in the cricoarytenoid joint Changes in the cricoarytenoid joint - pitch of voice is fine-tuned by control over - pitch of voice is fine-tuned by control over

position of arytenoid cartilage which may position of arytenoid cartilage which may account for pitch variabilityaccount for pitch variability

– Restriction of vocal fold approximationRestriction of vocal fold approximation

Changes in Supralaryngeal Changes in Supralaryngeal MechanismMechanism

Atrophy of facial, pharyngeal, and Atrophy of facial, pharyngeal, and mastication musclesmastication muscles

Weakened esophageal sphincter may lead to Weakened esophageal sphincter may lead to gastro esophageal refluxgastro esophageal reflux

Aging: Changes in Aging: Changes in Supralaryngeal systemSupralaryngeal system

Craniofacial enlargement by 3-5% Craniofacial enlargement by 3-5%

Changes in articulators-loss of teeth, Changes in articulators-loss of teeth, reduced musculature of tongue and reduced musculature of tongue and masticular muscles affect resonation masticular muscles affect resonation

Functional Effects of Age Functional Effects of Age Related changes of the VoiceRelated changes of the Voice

After fifth decade of life increase in male After fifth decade of life increase in male fundamental frequency in males (35 Hz)fundamental frequency in males (35 Hz)

Decrease in fundamental frequency of women Decrease in fundamental frequency of women (10-15 Hz) (10-15 Hz)

Increase in pitch perturbation cycle to cycle Increase in pitch perturbation cycle to cycle variation of fundamental frequencyvariation of fundamental frequency– difficult to maintain a stable tonedifficult to maintain a stable tone

Functional Effects of Age Functional Effects of Age Related Changes of the VoiceRelated Changes of the Voice

Reduced pitch rangeReduced pitch rangeDecreased sound pressure levelDecreased sound pressure levelVocal quality symptoms of vocal Vocal quality symptoms of vocal roughness, aperiodicity, breathinessroughness, aperiodicity, breathiness

Common Vocal Fold FindingsCommon Vocal Fold Findingsin the Elderlyin the Elderly

Bowed cordsBowed cords AtrophyAtrophy EdemaEdema Loss of collagen, ground substance, and Loss of collagen, ground substance, and

cartilage matrix in the cricoarytenioid jointcartilage matrix in the cricoarytenioid joint Atrophy of laryngeal musclesAtrophy of laryngeal muscles

Bowed Vocal FoldBowed Vocal Fold

Most common benign pathology of the Most common benign pathology of the aging voiceaging voice

Gap occurs in the region of the middle one-Gap occurs in the region of the middle one-third of the vocal cord with total or near third of the vocal cord with total or near approximation at anterior and posterior approximation at anterior and posterior commisurescommisures

Atrophic Vocal FoldsAtrophic Vocal Folds

With advancing age With advancing age the vocal fold muscle the vocal fold muscle and mucosal covering and mucosal covering can lose mass, can lose mass, appearing as thinnedappearing as thinned

Incomplete closure of Incomplete closure of vocal folds and vocal folds and irregular vibrationirregular vibration

EdemaEdema

Swelling of the entire Swelling of the entire layer of superficial layer of superficial lamina proprialamina propria

Water balloon effectWater balloon effect Result in irregular Result in irregular

mucosal wavemucosal wave

The Aging Voice: The The Aging Voice: The Challenge of DiagnosisChallenge of Diagnosis

Factors:1. Identification of normal aging voice from pathological condition

2. Inappropriate/insufficient assessments

3. Incomplete/inaccurate Case history

““It is important to remember It is important to remember although vocal changes often although vocal changes often

occur with aging they occur in occur with aging they occur in many other pathological states”many other pathological states”

(Linville, 2004)(Linville, 2004)

Differential Diagnosis: Differential Diagnosis: Pathologic conditions vs. Pathologic conditions vs.

normal aging voicenormal aging voice Inflammatory and Autoimmune diseasesInflammatory and Autoimmune diseases Neoplasms-abnormal new mass of tissue serving Neoplasms-abnormal new mass of tissue serving

no purpose (benign & malignant) can occur in no purpose (benign & malignant) can occur in larynx or thyroidlarynx or thyroid

Functional and psychogenic disorders of speechFunctional and psychogenic disorders of speech May be misconstrued as part of normal agingMay be misconstrued as part of normal aging

Differential Diagnosis: Differential Diagnosis: Pathologic conditions vs. Pathologic conditions vs.

normal aging voicenormal aging voice

Essential tremorEssential tremor Parkinson’s diseaseParkinson’s disease StrokeStroke Myastehnia gravisMyastehnia gravis Amyotrophic lateral sclerosisAmyotrophic lateral sclerosis

Differential Diagnosis:Aging Differential Diagnosis:Aging voice vs. pathologic conditionvoice vs. pathologic condition

HOARSENESS is both a quality frequently HOARSENESS is both a quality frequently found in normal aging voice AND one of found in normal aging voice AND one of the most common symptoms of vocal the most common symptoms of vocal dysfunction…so how do we differentiate dysfunction…so how do we differentiate malignant from benign etiologies of malignant from benign etiologies of hoarseness hoarseness

Diagnosis of the Diagnosis of the Aging Voice:Useful toolsAging Voice:Useful tools

TIMETIME is the most useful therapeutic is the most useful therapeutic measure that may help to distinguish benign from measure that may help to distinguish benign from

malignant etiologies of hoarsenessmalignant etiologies of hoarseness REFERRALREFERRAL to the otolaryngologist to perform a to the otolaryngologist to perform a

thorough laryngeal exam is an invaluable resource thorough laryngeal exam is an invaluable resource in diagnosis and management of hoarsenessin diagnosis and management of hoarseness

CASE HISTORYCASE HISTORY-elements of a patients history -elements of a patients history and symptomology are gateways in forming and symptomology are gateways in forming appropriate diagnosisappropriate diagnosis

Differential diagnosis:Aging Differential diagnosis:Aging voice vs.. disordered voicevoice vs.. disordered voice

Indicators hoarseness is NOT due to BenignIndicators hoarseness is NOT due to Benignchangeschanges

Voice changes of recent onsetVoice changes of recent onset Associated pain with phonationAssociated pain with phonation Pain or difficulty swallowingPain or difficulty swallowing Presence of new neck massPresence of new neck mass Past history of alcohol or tobacco usePast history of alcohol or tobacco use

Diagnosis of the Aging Voice: Diagnosis of the Aging Voice: AssessmentAssessment

Until recently Speech Pathologists had very Until recently Speech Pathologists had very little data to indicate the normal voice and little data to indicate the normal voice and speech patterns of the elderlyspeech patterns of the elderly

TAKE A LOOK AT THIS…..TAKE A LOOK AT THIS…..

The Aging Voice & DiagnosisThe Aging Voice & Diagnosis

19981998 Sinard & Hall reported “there are no Sinard & Hall reported “there are no objective tests that can reliably distinguish voice objective tests that can reliably distinguish voice changes due to normal aging process from disease changes due to normal aging process from disease of the larynx”of the larynx”

19991999 Whitlock reported the need for an acoustical Whitlock reported the need for an acoustical test to accurately monitor potential voice disorderstest to accurately monitor potential voice disorders

20042004 Verdonck-de Leeuw & Mahieu report a lack Verdonck-de Leeuw & Mahieu report a lack of longitudinal studies on the effects of aging on of longitudinal studies on the effects of aging on voicevoice

Diagnosis of the Aging Voice: Diagnosis of the Aging Voice: Advancements in AssessmentAdvancements in Assessment

Recent longitudinal research study Recent longitudinal research study conducted by Verdonck-de Leeuw & conducted by Verdonck-de Leeuw & Mahieu used Multidimensional Voice Mahieu used Multidimensional Voice Program to acoustically analyze eight Program to acoustically analyze eight parameters of voice by digitizing sustained parameters of voice by digitizing sustained vowels and fragments of speechvowels and fragments of speech

Omnidirectional telephonesOmnidirectional telephones Custom-made amplifiersCustom-made amplifiers DAT recorderDAT recorder

Findings of Longitudinal Study Findings of Longitudinal Study on vocal aging and impact on on vocal aging and impact on

daily life:daily life:

Significant deterioration of voice as soon as 5 Significant deterioration of voice as soon as 5 years after age 50years after age 50

Voice instability, changes in fundamnetal Voice instability, changes in fundamnetal frequencyfrequency

Tendency to avoid social parties increase in Tendency to avoid social parties increase in isolating behaviorsisolating behaviors

Male smokers with irreversible lower fundamental Male smokers with irreversible lower fundamental frequenciesfrequencies

(Veronck-de Leeuw & Mahieu, 2004)

Findings of Longitudinal Study Findings of Longitudinal Study on vocal aging and impact on on vocal aging and impact on

daily lifedaily life

THE LATEST NEWS: histological & THE LATEST NEWS: histological & genetic findings of recent studies give rise genetic findings of recent studies give rise to a theory that aging will inevitably lead to to a theory that aging will inevitably lead to a mild-moderate-severe voice impairmenta mild-moderate-severe voice impairment

(Veronck-de Leeuw & Mahieu, 2004)

New Research: How voice gives New Research: How voice gives away a person’s ageaway a person’s age

Researchers identified key indicators of the aging Researchers identified key indicators of the aging voicevoice

Used computer software to speed up and lower Used computer software to speed up and lower voices of older men to sound youngervoices of older men to sound younger

Results found 12/13 old voices were mistook as Results found 12/13 old voices were mistook as “young”“young”

ImplicationsImplications– Criminal forensicsCriminal forensics– Hollywood, aging of actors voicesHollywood, aging of actors voices

(Ascribe Medicine News Service, (Ascribe Medicine News Service, 2003)2003)

Keeping the Voice “Young”Keeping the Voice “Young”

““You are as young as you sound”You are as young as you sound” Eat sensiblyEat sensibly Get plenty of restGet plenty of rest Keep brain and voice well exercisedKeep brain and voice well exercised Use the strong muscles of your lower abdominals Use the strong muscles of your lower abdominals

to support voiceto support voice Keep hydrated-8 a dayKeep hydrated-8 a day Be alert for voice damaging symptoms of GERDBe alert for voice damaging symptoms of GERD

ReferencesReferences

Deem, M. & Miller, L. (2000). Deem, M. & Miller, L. (2000). Manual of Voice Manual of Voice Therapy. Therapy. Austin, TX: PRO-ED, IncAustin, TX: PRO-ED, Inc..

Linville, S. E. (2004, Oct.19) The Aging Voice. Linville, S. E. (2004, Oct.19) The Aging Voice. The ASHA LeaderThe ASHA Leader, p.12, 21 , p.12, 21

Shields, Gordon. (2004, June 16). Geriatric Shields, Gordon. (2004, June 16). Geriatric Otolaryngology Otolaryngology

Spotlight on Special Topics in Voice Disorders Spotlight on Special Topics in Voice Disorders (2004) (2004) In The New York Eye and Ear Infirmary, In The New York Eye and Ear Infirmary, Center for Voice. Retrieved June 10, 2005, from Center for Voice. Retrieved June 10, 2005, from http://www.nyeee.edu/cfv-spotlighthttp://www.nyeee.edu/cfv-spotlight

ReferencesReferences

Ordonez, Ernesto A. (2000)‘Growth of anti-aging Ordonez, Ernesto A. (2000)‘Growth of anti-aging field offers new career option’. A voice of field offers new career option’. A voice of experience p.16, I.12).experience p.16, I.12).

Research uncovers How the voice gives away a Research uncovers How the voice gives away a person’s age. (2003) Ascribe Medicine News person’s age. (2003) Ascribe Medicine News Service.Service.

Sinard, R. & Hall, D. (1998). The aging Sinard, R. & Hall, D. (1998). The aging voice:how to differentiate disease from normal voice:how to differentiate disease from normal changes. changes. Geriatrics,Geriatrics, p.76 p.76

ReferencesReferences

Verdonck-de Leeuw, Irma & Hans F. Verdonck-de Leeuw, Irma & Hans F. Mahieu (study. Mahieu (study. Journal of Voice Journal of Voice 2004). 2004). Vocal aging and the impact on daily life: a Vocal aging and the impact on daily life: a longitudinal, 18, 193-203. 53. longitudinal, 18, 193-203. 53.

Whitlock, Kelly (1999). Age-Related Whitlock, Kelly (1999). Age-Related Vocal Changes Often Misdiagnosed. Vocal Changes Often Misdiagnosed. Science Daily.Science Daily.