Care of the Aging Voice

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Care of the Aging Voice

• Gina R. Vess, MA CCC-SLP
• Clinical Coordinator
• Duke Voice Care Center
• David Witsell, MD, MHS
• Director
• Duke Voice Care Center

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OUTLINE

• Epidemiology Social Impact
• Normal anatomy biomechanics of voice
• Changes with aging (Medical, behavioral, other
  etiologies)
• Common voice symptoms in aging
• Eval/Treatment/Management
• Case reviews

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EPIDEMIOLOGY

• 29 million people over 65 years of age in the
  United States make up 12 of the total population
• By 2020 this number is expected to increase to
  over 54 million, which will constitute 18 of the
  total population
• There is an increasing trend for older patients
  to feel vigorous and healthy, which is paralleled
  by an increase in the demand to remain physically
  and emotionally healthy.
• Emotional health requires effective social
  interaction

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SOCIAL IMPACT OF COMMUNICATION

• Purpose of communication may change
• Increased incidence of hearing impairment in
  spouses and friends
• Increased dependence on others impacting
  self-esteem.

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OUTLINE

• Epidemiology Social Impact
• Normal anatomy biomechanics of voice
• Changes with aging (Medical, behavioral, other
  etiologies)
• Common voice symptoms in aging
• Eval/Treatment/Management
• Case reviews

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NORMAL ANATOMY/ BIOMECHANICS

• Adequate respiratory drive power source
• Good arytenoid joint mobility
• Intact vocal fold structure
• vocal ligament
• mucosa
• epithelial layers vocal folds
• Adequate resonators
• Coordination of breathing with voice production

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National Center for Voice and Speech
(NCVS)http//www.ncvs.org
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VOCAL FOLD STRUCTURENormals

• Body-cover relationship
• Body Thyroarytenoid muscle
• (7-8 mm thick)
• Cover Superficial through deep layers
• (1-2 mm thick)
• The mucosa
• The epithelium lamina propria

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VOCAL FOLD STRUCTURE
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OUTLINE

• Epidemiology Social Impact
• Normal anatomy biomechanics of voice
• Changes with aging (Medical, behavioral, other
  etiologies)
• Common voice symptoms in aging
• Eval/Treatment/Management
• Case reviews

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Power changes with age
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ALTERED BIOMECHANICSRESPIRATORY DRIVE

• Increased incidence of pulmonary conditions
• COPD
• Neuromuscular conditions
• Treatments related to cancer
• 40 decrease in vital capacity from age 20-80.

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ALTERED BIOMECHANICS CRICOARYTENOID JOINT MOBILITY

• Becomes arthritic and stiff
• Laryngeal cartilages ossify (hyaline cartilages)
• Thyroid
• Cricoid
• Arytenoid

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ALTERED BIOMECHANICS VOCAL FOLDS in AGING

• Cover
• Atrophy (yellowish or grayish color)
• Fatty infiltration
• Decreased lymphatics
• Transition
• Decreased fibroblasts
• Decreased and disordered fibers
• Laryngeal muscles
• Decreased muscle fibers

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Previous studies indicate 60 of individuals 60
years of age show endoscopic evidence of vocal
fold atrophy
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Vocal tremor
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Confounding Treatments POLYPHARMACY

• Antihistamines
• Antitussives
• Antihypertensives
• Diuretics
• ACE inhibitors
• Psychotropic drugs
• Anticholinergics
• Vitamins
• Hormones

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ComorbiditiesNEUROLOGIC DISEASES

• Essential tremor
• Parkinson disease (89 of PD have voice/speech
  problems)
• Focal dystonias
• Stroke
• Amyotrophic lateral sclerosis
• Pseudobulbar palsy

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OUTLINE

• Epidemiology Social Impact
• Normal anatomy biomechanics of voice
• Changes with aging (Medical, behavioral, other
  etiologies)
• Common voice symptoms in aging
• Eval/Treatment/Management
• Case reviews

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VOICE SYMPTOMS in AGING

• Hoarseness
• Loss of volume/ inability to project
• Vocal fatigue
• Change in pitch
• Tremulousness/ wobbly voice
• Loss of singing range
• Pitch breaks

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Voice Characteristics in the Aging

• Vocal quality
• Hoarse
• Breathy
• Diplophonic
• Glottal fry
• Pitch breaks
• Harsh
• Strained/strangled
• Tremor

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OUTLINE

• Epidemiology Social Impact
• Normal anatomy biomechanics of voice
• Changes with aging (Medical, behavioral, other
  etiologies)
• Common voice symptoms in aging
• Eval/Treatment/Management
• Case reviews

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Evaluation Who are the players?

• Primary
• Otolaryngologist
• Speech Pathologist
• Additional specialists
• Singing Voice Specialist
• Allergy Specialist
• Pulmonologist
• Gastroenterologist
• Neurologist
• The patient

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The Medical Evaluation

• Medical history
• Presenting signs and symptoms
• Comorbidities
• Full head and neck exam
• Laryngoscopy
• Comprehensive voice evaluation

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Medical Decision-making

• Correct diagnosis
• Understanding etiology and natural history
• Patient goal and quality of life
• Patient ability to engage in treatment
• Consideration of complicating medical problems
• Treatment trade-offs
• Integrated and comprehensive treatment plan

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SLP Voice Evaluation

• Medical history.
• History of voice problem.
• Patients goals.
• Perceptual characteristics of voice.
• Oral motor exam.
• Acoustic measures.
• Aerodynamic assessment.
• Videolaryngostroboscopy.
• Diagnostic therapy and vocal hygiene counseling.

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VOICE EVAL History

• Medical etiologies / precipitating factors
• Behavioral factors
• Amount/type of voice use/ occupation ( too
  little?)
• Who are the communication partners? HI?
• Phonotraumatic behaviors (throat clearing, cough)
• Other
• Dietary (caffeine/ alcohol/ hydration)
• Medications
• Smoking history

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SLP Role Voice treatment

• Good non-invasive treatment to patients wanting
  to avoid surgery
• Many voice symptoms are not fully improved by
  surgery/medical mgmt alone due to compensatory
  hyperfunction
• Many available efficacious treatment options

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SLP Role in Voice Treatment

• Modify/eliminate etiologic factors.
• Reduce compensatory hyperfunction.
• Optimize vocal efficiency.
• Resolve voice disorder if medical/surgical
  intervention not indicated.

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OUTLINE

• Epidemiology Social Impact
• Normal anatomy biomechanics of voice
• Changes with aging (Medical, behavioral, other
  etiologies)
• Common voice symptoms in aging
• Eval/Treatment/Management
• Case reviews

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Case review Breathiness

• 77 year old female
• Vocal fold atrophy/ bowing
• (L) TVC paralysis following surgery for lung
  cancer
• s/p (L) TVC medialization thyroplasty

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• Voice characteristics
• Hoarse, breathy, high-pitched, strained, tremor
• Cc Hoarseness husband cannot hear her
• Post-op Treatment Voice therapy
• Reduce strain laryngeal resposturing, frontal
  focus
• Increase breath support for voice
• Could have benefited from further surgery but
  patient was satisfied

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Case reviewMuscle tension dysphonia

• History
• 80 year old female
• 1 year h/o hoarseness
• Intermittent then became chronic
• Med hx frequent sinusitis, GERD

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Case Review MTD

• Voice characteristics
• Hoarse, breathy, strained voice, diplophonia,
  vocal fatigue, chronic throat clearing
• Treatment
• Reduce phonotraumatic behaviors (throat clearing)
• Vocal hygiene (hydration, sinus wash, GERD meds)
• Reduce compensatory muscle tension
• Laryngeal reposturing/ laryngeal massage.
• Pitch modification.
• Increased airflow, breath support.

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Case review Complex voice problem

• Tremor component
• SD
• Hoarse vocal quality
• Bowing
• Compensatory maladaptive behaviors
• MTD
• Altered breath flow
• Overarticulation

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Goals

• Improve vocal hygiene (water)
• Decrease laryngeal tension (MTD)
• Pitch variability (SD, MTD)
• Legato speech (SD)
• Vocal function exercises (bowing)
• Decrease overarticulation
• Increase breath flow

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Medical management of speech/voice in PD

• Drugs can improve limb movement, but do not
  improve speech.
• Surgical intervention for voice will not address
  the sensory component of low volume.

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Lee Silverman Voice Treatment - LSVT

• Developed in 1987 by Lorraine Ramig, PhD and
  Carolyn Mead, MA.
• Key components
• Voice focus.
• High effort.
• Intensive treatment
• Calibration.

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LSVT results in

• Slower speaking rate
• Better voice projection and loudness
• Decreased hoarseness
• Decreased slurring
• More pitch variation
• Improved speech intelligibility

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Summary

• Clinical care of voice problems in the aging
  population will an increasing demand.
• Comprehensive evaluation with a team approach is
  necessary for best outcomes.
• It is especially important in the aging
  population to consider all medical factors and
  the patients goals in designing a treatment plan.

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• Coordinated Care
• where everyone has a voice!