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 /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 Findings in 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

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