Renee Kinder

Good night little Mama, I will be fine.

Those were the last words I heard spoken from my grandfather. His voice was remarkably strong and clear. Sitting up in his hospital bed with 2 cups of vanilla ice cream, John Wall and the Wizards on TV, he was clearly ready to be left alone.

That day had been a whirl wind.  I received a call from my mother, her voice was shaking and she said my grandfather had had a major heart attack, was rushed to the hospital and passed away. For some reason I did not immediately cry because instincts told me something was not completely correct about her statement. Twenty minutes later I received a call that after they turned off all of the monitors and declared him gone, he regained a pulse.

Cue Renee to hit the highway for home.

During the last year of his life I was continuously bothered by the changes in my grandfather’s voice. Not the lapses in memory, or complaints that “You have not called home in a month.” But the distinct voice from the man who joined the Army the day he graduated high school , who worked into his 90s, that I remembered singing with pride “She’s a Grand Ole Flag”, or reciting the Lord’s Prayer, or roaring in laughter when telling stories about my stubborn childhood antics had become soft and breathy.

I recall expressing these concerns, “his PCP needs to refer him to an ENT, or have his home health PT focus on some pushing exercises which will assist with his vocal fold adduction,” following phone calls home during which my grandfather had become a silent participant choosing to “listen in” versus contribute to the conversation.

Loss of muscle mass which occurs with aging is referred to as sarcopenia and results in loss of strength and mobility which typically accelerates around age 75 and often increases the likelihood of falls and fractures. What most folks who work with the geriatrics do not realize is that this same process can impact the muscles we use for voice.

Presbyphonia, aka Aging Voice

The structure of the larynx or voice box sits atop the trachea and is a complex structure consisting of the cartilaginous plates held together by membranes and muscle fibers of which the anterior portion is often referred to as the “Adam’s apple.” Within this structure sits the vocal cords which are attached by muscle groups. Voice is produced when air is expelled by the lungs thru the trachea causing the cords to vibrate.

Presbyphonia is the physiological process of aging voice that includes changes in the coverage mucosa, muscle, and cartilage within the voice box.

Furthermore, presbyphonia results from the loss of respiratory strength which can result in decreased intensity or loudness of the voice and subsequent shortness of breath when speaking.  Therefore consider the additional impact present for individuals with diagnoses such as COPD and CHF who are already functioning with compromised respiratory systems. Finally, this condition causes stiffening of the vibratory portion of the vocal folds.

A 2011 article in Otolaryngology-Head Neck Surgery showed that such changes can affect up to 30 percent of the population and negatively impact quality of life, limit social interaction, and lead to anxiety and depression

Changes that caregivers may notice include altered pitch, hoarseness, breathiness, strained voice and slowed rate. These changes can negatively impact the communication partner’s perception of the speaker and may in turn influence functional use of voice and ultimately quality of life.

What can be done to help?*

Vocal hygiene

Vocal hygiene is often the first approach used when initiating interventions for the voice. This approach aims to discover the behavioral causes of the voice disorder & modify/eliminate of the causes to improve the voice. Considerations for vocal hygiene best practice which include effective hydration, speaking at appropriate vocal intensity, and avoiding substances which may impact vocal mucosa need to take into effect additional considerations when relating to the geriatric population.

  • Hydration

Research in the area of voice has evidenced over 14 clinical studies demonstrating results on the relationship between systemic hydration and voice function. However clinically complex patients, including those with kidney disease may have system impairments which require limitations on fluid intake. Additionally individuals with reduced ability to communicate thirst may have to relying on caregivers to monitor hydration needs and provide fluids on a consistent basis during and in-between meals.

  • Vocal intensity

Vocal intensity produced at either excessive loudness or in a whisper voice can cause damage to the voice. Caregivers in long term care facilities should therefore assess impacts of acoustics in social, dining and activities environments. Noisy dining environments for example could cause individuals to speak in a louder voice than appropriate. Consequently individuals with degenerative disease processes affecting respiratory tolerance and motor planning may fatigue when straining to speak resulting in use of a whisper voice when compensating for reduced respiratory support.

  • Reflux precautions

Poorly managed reflux can result in entry of gastric material into the larynx resulting in significant damage to the vocal folds. Signs that caregivers may note which indicate reduced esophageal function and reflux include: complaints of fullness or a lump in the throat during or after meals; significant phlegm in the the morning; complaints of a sour taste in the mouth; or direct complaints of heart burn and reflux.

Vocal function exercises

Vocal function exercises are a series of direct, systematic voice exercises, similar in theory to exercise programs often prescribed during physical therapy. They are designed to strengthen and balance the laryngeal musculature.

The exercises are often initially recommended to be completed twice in a row, two times per day with regular tapering of repetitions as the voice improves. A pitch pipe can be used to facilitate the appropriate notes defined below.

Exercise 1- Warm-up Exercise:

Sustain the vowel sound “eee” for as long as possible on the musical note F above middle C for women, below middle C for men. The tone should be produced as softly as possible, but without breathiness. A good supported deep breath should precede voice. The “eee” should be produced with an extreme “forward” tone focus; almost, but not quite nasal. The goal is to sustain the sound without breaks for as long as possible.

Exercise 2- Stretching Exercise:

Glide from your lowest to your highest note on the word “knoll” or on a lip or tongue trill. Voice should be soft, and a forward focus used. If breaks occur, continue to glide without hesitating.

Exercise 3 – Contracting Exercise:

Glide from a comfortable high note to your lowest note on the word “knoll” or on a lip or tongue trill. Voice should be soft, and a forward focus used. If breaks occur, continue to glide without hesitating.

Exercise 4 – Low-impact Adductory Power Exercise:

Sustain the musical notes C-D-E-F-G, each as long as possible on the word “ol” (“old” without the “d”). Lips should be rounded; a sympathetic vibration should be felt on the lips.

In closing, simple steps can be taken to help preserve the aging voice.  Consider the impacts of our seniors separated from families by distance with voice being essential to maintain communication across generations.

Additionally, the voice as a muscle does have a “use it or lose it” component, therefore engagement on the caregiver end is essential to prevent muscle wasting of this structure often overlooked, but so crucial in maintaining communication.

*Any interventions should be initiated following consultation with the appropriate medical professionals.

Renee Kinder, MS, CCC-SLP RAC-CT, is a clinical specialist at Evergreen Rehabilitation in Louisville, KY. She also serves as Editor for Perspectives on Gerontology a publication of the American Speech Language Hearing Association.