Voice in the Aging Population
As we discuss the effects of aging on communication, we will address voice, speech, language, and cognition.
Normal Aging Factors
There are several factors associated with the aging voice (a.k.a presbyphonia). As people age their dentition can change. They may lose teeth, their teeth may have shifted and there may be some decay or wearing down of the teeth. The oral, laryngeal, and glottal muscles weaken somewhat with aging. Vocal folds thin and weaken and laryngeal cartilage will begin to ossify or harden. Respiratory strength is not as strong. Patients will sometimes experience xerostomia, or dry mouth, and they will have increased mucous in the glottic space. However, it's important to note that presbyphonia, normal aging voice, really varies from patient to patient and it is somewhat subjective.
Etiologies of Voice Disorders
If the patient feels like there is a disorder, then there may be more going on than what we would consider to be normal. Some of the co-morbidities that can actually cause or lead to voice disorders include laryngitis, especially chronic laryngitis where the patient does not recuperate. The person continues with vocally abusive behaviors, the laryngitis stays and that can cause permanent vocal pathologies. Other etiologies include GERD or LPR (Laryngopharyngeal Reflux). Superior Laryngeal Nerve Palsy often causes some bowing of the vocal folds and voice disorders. You may see vocal cord paralysis or lesions on the vocal folds, spasmodic dysphonia, or head and neck cancer. So, there are many etiologies, many co-morbidities, that may go along with some of these different types of voice disorders we see in the aging.
Voice Disorders in the Aging: Signs and Symptoms
What are the signs and symptoms of voice disorders in the aging or elderly population? When talking about aging, we are typically referring to age 65 and up. So, signs and symptoms may include hoarseness that doesn't go away, constant throat clearing and pain in the throat or in the neck when regularly phonating. If there has been intensive phonation after speaking for an hour, I may have a bit of throat pain. That's not a disorder. But if I am in pain all the time and I am in that aging population, then there may be a voice disorder present.
A breathy voice can also indicate the potential of a voice disorder. A quivery voice, one that sounds shaky, and difficulty with speaking and breathing patterns are also signs of voice disorders. Most people should be able to say exponentially more words than two, three, or four before they take another breath. If you see a patient who is frequently breathing while they are speaking, they may have a voice disorder.
Vocal Hygiene for Older Patients
So, what can we tell our patients? Research has actually shown that the majority of patients who are referred for voice disorders need to be given tips and treatment ideas at the time of the evaluation because many of those individuals will not be coming back to our clinics or private practices. A SNF environment is different because the patients actually live there. With private practice, hospitals, et cetera, you need to give the patient some strategies, exercises and instructions at the time of the evaluation.
This is the case with vocal hygiene as well. Hydration of at least two quarts of fluids per day is preferable for older patients. We may need to recommend some type of behavioral modification. If there is excessive throat clearing, find out what the source of that is. Is there post-nasal drip and allergies that can be treated with medications? Or is it more of a habitual type thing?
We also want to work with the patient to decrease their vocal straining behaviors. Are they speaking too loud, too long or straining when they are tired? Any of those behaviors are potentially straining for the voice so we want patients to modify them.
Older patients should minimize their exposure to irritants such as tobacco, alcohol or other types of smoke. I teach a graduate course in voice and we talk about the use of marijuana and hookah. As our populations are aging, we are going to have to discuss many different types of irritants as the generations change.
Medications can cause irritation. Alcohol, especially excessive alcohol consumption without proper hydration, and pollutants can cause irritation as well. A lot of allergens, dust, molds, trees, grass, can very much irritate the laryngeal area.
It is also important to minimize reflux, whether that's gastroesophygeal reflux or laryngopharyngeal reflux. This can be accomplished with medication. Of course, the doctor is going to prescribe most of that, although there are some great over-the-counter options now, as well. Reflux precautions include teaching the patient to sit upright during eating, to stay upright after eating and to avoid certain foods. If a person is overweight or morbidly obese, they can decrease their GERD typically with weight loss.
Exercises to Maintain Normal Voice
There are some exercises patients can do to maintain normal voice. It is important to note that we don't always have access to specific instrumental voice assessments. We may see some vocal fold issues during FEES but we can't diagnose that during FEES. So, much of what we are going to do as far as assessment is somewhat subjective if we are in a SNF environment or in some smaller hospital settings. With that in mind, we need to provide patients with exercises that can help them maintain a normal voice as long as possible.
Humming into a straw. You will want to start with a pretty large straw such as an accordion type straw that are used with sports bottles. Gradually, have the patient use straws that are smaller and smaller. For example, you can go from a milkshake straw, then to a regular drinking straw, and then maybe down to a coffee stirrer. What the straw does, is as the patient is humming, their diaphragm muscles are working at increasing rate as the straw gets smaller and smaller in size.
Use it or lose it. Many older patients may not have people who are living with them or individuals who are around them socially all the time and, therefore, they may be at home alone not talking to anyone. Many patients my need to be taught the concept of “use it or lose it” by doing exercises. If they don’t use those muscles they can atrophy or may not be as strong and healthy as they should be. Having patients read aloud or even talking outloud to themselves can be good exercises to maintain normal voicing.
Singing. Singing during activities, at church or synagogues, with choirs or even singing along with a cd or radio can help with maintain normal voicing.
Maintaining overall physical health. If a person’s physiology isn't working and their physical state is deteriorating, typically their voice is deteriorating along with that. Therefore, the healthier a person is, the more likely they are to maintain normal voicing.
Problematic behaviors. If there are problematic behaviors or abusive behaviors, a voice coach or voice therapy is definitely beneficial for patients to maintain or achieve normal voicing.
Speech and the Aging Population
Normal Aging Factors in Speech
With speech, we are looking at respiration, phonation, resonance, articulation, and prosody. Normal aging adults will have decreased respiratory support and fewer syllables or words per breath. Respiratory muscle strength training can be utilized to help combat some of this.
Phonation changes as we age. Typically, men's pitch actually rises and women's pitch lowers usually after menopause. There may be some increased jitter and shimmer, which is the stability of pitch and stability of loudness. For example, if a person has a shaky voice that isn’t staying on a single pitch or if they are asked to prolong a vowel sound and the pitch changes, you are hearing some differences in jitter and shimmer.
In regards to resonance, we talked about the anatomical changes such as laryngeal cartilage ossification and changes in dentition. Those changes can lead to alterations in how the sounds are produced orally and resonance-wise. Vowel sounds become more centrally produced as patients age.
Along with anatomical changes, there may be changes in articulation; with changes in the manner, place and voicing of sounds as well as reduced articulatory precision in normal speech. If you are hearing dysarthria, that is abnormal.
There can also be changes in prosody. Normal prosodic changes include increased intonation and reduced rate of speech. It is normal to see older individuals have a slower rate of speech and less fluent speech.
Cognition and the Aging Population
Normal Aging Factors on Cognition
As people age, brain plasticity continues. Brain volume is going to slightly decrease, more so after age 60. However, there should not be extreme atrophy. That could be an indication of Alzheimer's type dementia. In addition, information processing skills, specifically short-term memory, may slightly decrease. One of my favorite sayings is, “If you forget where your car keys are, you don't have dementia. If you forget how to use them, you may have it.” Even personally, as I am aging, I find that my brain just isn't carrying quite as much memory. I have to list and write things down. Just yesterday at work, I had to go back to someone and say, "What was it that I was supposed to do for you?" because I was interrupted by three different people right after we discussed it and that information processing overload caused me to forget what I was supposed to do. So, some of that is normal. My Mom laughs and says she has “Sometimers”. Sometimes she remembers and sometimes she doesn't.
We can't talk about cognition or memory without addressing dementia and it's important to note that when talking about dementia, we are not talking about a specific disease. There are specific diseases that lead to dementia such as Alzheimer's. Furthermore, research shows that Parkinson's, Huntington's and HIV all progress into dementia; and there are specific timelines for that.
But dementia, in general, is a group of symptoms. Typically, for a patient to have a diagnosis of dementia, they need have a loss of function in at least two of the following areas: language, judgment, memory, spatial ability and visual ability. This is not referring to minor loss, minor forgetfulness or minor lapses in judgment. This is recurrent, more major types of losses in function.
There are two primary categories of dementia, reversible and nonreversible. Reversible dementias can be caused by things such as infections, anesthesia and sensory loss. Non-reversible categories such as Alzheimer's, Huntington's and Parkinson's are types of disease-related dementias and are considered non-reversible because they are always progressive. Therefore, our goal isn't to cure it, it's to slow it down.
Unrecognized Cognitive Impairment
When we talk about unrecognized cognitive impairment, there is increasing evidence that dementia is often unrecognized. We see patients come in after having surgery and their cognition has declined drastically. It has been my experience that when I meet with the family and ask questions such as, “Was Mom leaving the stove on?” “Was Mom turning the heat on instead of the air conditioning?” “Do you think Mom was taking her medications?” “Were you worried about her safety?” the patient does not have a diagnosed dementia but there are signs and symptoms. Many times, what I see with patients with hip fractures and hip surgeries, is that there may have been some baseline decline occurring, which possibly could have led to the fall that caused the fracture. Then, add anesthesia from surgery on top of that as well as the prolonged hospitalization. Those factors can increase the cognitive impairment, sometimes three and four-fold.
Why is unrecognized cognitive impairment potentially harmful? If we have patients who have decreased safety, there could potentially be catastrophic events. There is a window of opportunity in the earliest stages where some of the effects may be somewhat reversible or you may be able to slow progress. When I think about unrecognized cognitive impairment, many times patients and their families don't want to hear the “D” word. So, I try not to use the word “dementia” when speaking to them, especially in those earlier stages. What I may say is, "Your Mom is showing some symptoms of some cognitive impairments that may be related to her recent hospitalization and anesthesia. If we don't treat these symptoms then there is a distinct possibility, a good 50/50 shot, that she may end up progressing into further cognitive impairment or even dementia down the road." Sometimes, just taking the “D” word out of the conversation helps a person to be less defensive.
It is important to get that communication going with the patient and their family. We talked about counseling in a different course. It’s important to give facts but to give them in a way that the family is going to listen, accept, give feedback and give information.
My next question is, do you utilize cognitive staging in your current work setting? A little over half of you say that you do not use cognitive staging. I am going to discuss how it can be etremely beneficial to use cognitive staging with your patients.
Global Deterioration Scale
Cognitive staging can be extremely beneficial to our patients. The main method that I use to stage a person's cognition is the Global Deterioration Scale. It is a negative correlational scale, which means that as the number increases, cognition decreases. It is kind of an inverse scale.
There are seven different stages in the Global Deterioration Scale.
- Stage 1 is normal adults
- Stage 2 is some basic forgetfulness, normal aging. The person may not have had enough sleep or took too much antihistamine so their “brain is foggy”
- Stage 3 is progressing into early or mild cognitive impairment
- Stage 4 is showing mild dementia
- Stage 5 is moderate dementia
- Stage 6 is severe dementia
- Stage 7 is end stage, late/severe dementia
If you are interested in learning more about staging, I do have a series on speechpathology.com called "Forget Me Not" that discusses it in greater detail.
Language and the Aging Population
Language vs. Cognition
It is extremely difficult to separate language and cognition into distinct areas because in many aspects language and cognition are intertwined. It is very rare that I treat a patient who's having early signs of dementia or early cognitive impairment that I would just call it a cognitive disorder. ASHA and most local coverage determinations for Medicare actually list it as “cognitive communicative” or “cognitive communication disorders”. They also may be called cognitive linguistic disorders.
Changes in Language
Normal changes in language with aging can typically be less obvious if you are a casual observer or the average listener who doesn’t really judge syntax or vocabulary. As SLPs, we can't walk into a room and ask a patient what their name is and where they are without actually judging their language, their orientation, et cetera.