Journal of Voice

Vol. II, No. 2, pp. 156-160

© 1997 Lippincon-Raven Publishers. Philadelphia

The Three Ages of Voice

The Aging Adult Voice

Robert T. Sataloff, *Deborah Caputo Rosen, *Mary Hawkshaw, and Joseph R. Spiegel
Department of Otolaryngology--Head and Neck Surgery, Thomas Jefferson University: and *American Institute for
Voice and Ear Research, Philadelphia, Pennsylvania, U.S.A.

Summary: Advancing age produces physiologic changes that may alter voice.
Some of these changes are inevitable; others may be avoidable or reversible. In
addition, many treatable medical conditions may cause voice changes similar
to those of aging. It is essential that all voice care providers be familiar with the
expected changes of aging, and be alert to reversible conditions that may
adversely affect phonation and be mistaken for presbyphonia. Key Words:
Age--Presbyphonia--Aging voice--Dysphonia.

Advancing age produces physiologic changes that
may alter the voice. These changes involve all parts
of the vocal tract, and they occur from birth to
death. This paper focuses on issues involving ma-
ture and aged adults.
Throughout adult life, mean fundamental fre-
quency of the speaking voice drops steadily in fe-
males from -225 Hz in the aged 20 to 29 years
group to -195 Hz in the aged 80 to 90 years group
(1). In males, fundamental frequency of the speak-
ing voice drops until roughly the fifth decade, after
which it rises gradually (2). It is important to be
aware of normal changes in the speaking voice, as
unskilled conscious or subconscious attempts to al-
ter the quality and frequency of the speaking voice
often are abusive and may produce problems re-
flected in speech or singing. It is interesting that the
age-related changes in speaking habitual frequency
noted seem to be less prominent or absent in trained
voice professionals, especially singers (authors' ob-
servations and personal communication with Harry
Hollien). This phenomenon, which the authors ob-
served more than a decade ago, led to some of the
therapeutic principles and techniques that we have
found to be successful for treating geriatric voice
changes.
Like death and taxes, most people have consid-
Accepted December 29, 1995.
Address correspondence and reprint requests to Dr. R. T.
Sataloff, 1721 Pine Street, Philadelphia, PA, 19103, U.S.A.
156
ered aging changes in the voice inevitable. Indeed,
as we get older, there are certainly fundamental
changes in the body that often modify the sound of
the singing voice. Typically, we are not surprised to
hear breathiness, loss of range, change in the char-
acteristics of vibrato, development of tremolo, loss
of breath control, vocal fatigue, pitch inaccuracies,
and other undesirable features in older singers (3-
9). While some of these alterations cannot be
avoided in specific individuals, not all of them are
manifestations of irreversible deterioration. In fact,
as our understanding of the aging process improves,
it is becoming more apparent that many of these
changes can be forestalled or even corrected. Woo
et al. reached similar conclusions and recognized
that "presbylarynges is not a common disorder and
should be a diagnosis of exclusion made only after
careful medical and speech evaluation" (5). As phy-
sicians and teachers, we need to look closer before
concluding, "I can't help your voice; you're just
getting older."
AGING: AN OVERVIEW
The aging process is being researched extensively
because of the importance of aging on the heart,
brain, and all other body systems. No natural pro-
cess has greater impact on our lives. Much of the
pioneering work in vocal aging is being performed
by scientists, such as Robert L. Ringel and Wojtek
Chodzko-Zajko (10), who have dedicated their lives
to this subject. We are beginning to learn much
 AGING VOICE
more about the aging voice by combining general
knowledge about the aging process with specific
knowledge about laryngeal aging, such as that pro-
vided through microscopic studies of the vocal folds
by scientists such as Joel Kahane (11) and Minoru
Hirano. This interdisciplinary approach helps us
understand our perceptions of voices over the years
and helps explain our recent observations that some
" o l d " voices can be made " y o u n g " again.
Aging is a complex conglomeration of biological
events that change the structure and function of
various parts of the body. There are many theories
of aging that focus on processes of individual cells,
on molecules responsible for the genetic transmis-
sion of our characteristics, and on changes in vari-
ous organ systems. The details of specific theories
are beyond the scope of this article. However, their
principles and solutions show great promise for
clinical application not only in the physician's of-
rice, but also in the voice studio. All theories and
approaches to study of the aging process recognize
well-established and predictable changes through-
out the body. Although various mechanisms are in-
volved in causing these changes, the effects are re-
markably similar among various organ systems. As
body structure changes, so does performance. Ag-
ing is associated with deteriorating bodily func-
tions. Among them are accuracy, speed, endur-
ance, stability, strength, coordination, breathing ca-
pacity, nerve conduction velocity, heart output,
and kidney function. Muscle and neural tissues at-
rophy, and the chemicals responsible for nerve
transmission change. Ligaments atrophy, and car-
tilages turn to bone (including those in the larynx).
Joints develop irregularities that interfere with
smooth motion. The vocal folds themselves thin
and deteriorate, losing their elastic and coUagenous
fibers. This makes them stiffer and thinner and may
correlate with voice changes often noted with aging
such as breathiness, slightly decreased volume,
"thinning" of the voice, and loss of vocal effi-
ciency. The not-so-cheery picture is one of inevita-
ble decline for all of us. The vocal fold edge also
becomes less smooth. However, the notion that this
decline occurs gradually and progressively (linear
senescence) is open to challenge. It appears possi-
ble that many of these functions can be maintained
at a better level than expected until near the end of
life, perhaps allowing a high quality singing or
speaking career to extend into or beyond the sev-
enth decade.
We have not yet stated how old " o l d " is. One
157
cannot simply categorize people on the basis of
their chronological age. Biological age is a more
useful measure, taking into account the condition
and functioning of each individual's body. The de-
sired result is to slow biological aging while chrono-
logical age advances inexorably. Although the aging
process is inevitable, there are great differences
among individuals in the rate and extent of bodily
changes. Although more study is needed, physi-
cians and voice teachers already have some tools
for intervention to slow the effects of aging.
INTERVENTION: GENERAL PRINCIPLES
Certain aspects of the aging process are relatively
easy to control medically. For example, as female
singers reach menopause, estrogen deprivation
causes substantial changes in the mucous mem-
branes that line the vocal tract, as well as changes in
the muscles, and other areas throughout the pa-
tient's body. These and other hormonal effects are
frequently reflected in the voice but can be fore-
stalled for many years with estrogen replacement
therapy. Dosage is best determined by checking es-
trogen levels before menopause. Preparations con-
taining androgens should be avoided if possible, be-
cause they can cause masculinization of the voice.
However, treating physicians must be aware of con-
traindications to hormone replacement, especially if
there is a history of other health problems such as
breast cancer. Expert advice is always essential
when weighing the risks and benefits of any treat-
ment, including hormone replacement.
Systematically attacking the aging process in
other areas is more novel and controversial. The
bodily changes characteristic of aging are not
unique. In many ways, they are identical to those
seen in disease and in disuse such as prolonged bed
rest or immobilization of a limb. In particular, mus-
cle disuse causes loss of muscle fibers indistinguish-
able from that seen with advanced age. Exercise
avoids or reverses many of these changes in the
young, and it appears to have the same effect when
the changes are caused by aging. Appropriate exer-
cise may not only help maintain muscle function
and coordination, but it should also help the vascu-
lar system, nervous system, and especially the re-
spiratory system. Proper nutrition and weight con-
trol are also important. Respiratory function nor-
mally decreases with advancing age. In particular,
residual volume increases, with a consequent de-
crease in vital capacity, tending to undermine the
Journal of Voice, Vol. I1, No. 2, 1997
158 R. T. S A T A L O F F E T A L .
primary respiratory improvements resulting from
earlier voice training. So, as a speaker's or singer's
respiratory potential diminishes, it is essential that
he or she remain as close as possible to optimum
respiratory conditioning.
We find it helpful to think of each individual as
having a performance range from poorest perfor-
mance to optimal performance. Audiences have es-
tablished a certain level of performance that is ac-
ceptable for a professional singer. For example, at
age 18, singers with an excellent voice may perform
at only 50% of current potential. Yet, they may get
away with it, because the condition of their body is
above the acceptable performance standard. How-
ever, as they age, their physical abilities deterio-
rate. If they still perform at only 50% of their new
ability, they will fall below the acceptable perfor-
mance standard. However, if through appropriate
training, exercise, medication, and other factors,
they are able to reach 70, 80, or 90% of potential
performance level, they may maintain profession-
ally acceptable performance standards for many de-
cades. For this reason, in treating age-related dys-
phonia, we combine traditional voice therapy, sing-
ing training, acting voice techniques, and aerobic
conditioning to optimize neuromuscular perfor-
mance. In general, rehabilitation is sufficient to re-
store acceptable voice function and to eliminate
most of the auditory information perceived as
" o l d . " However, occasionally substantial tissue
changes prevent therapy and medical management
alone from restoring satisfactory voice, and some
such patients may benefit from laryngeal surgery.
Nevertheless, surgery is unnecessary for the vast
majority of patients with age-induced dysphonia.
We are accustomed to thinking of older people as
having greater latitude in most things by virtue of
experience and in deference to their age. When we
hear a 60-year-old tenor develop a "wobble," we
write it off as "getting old" and are reluctant or
embarrassed to challenge him, because, after all, he
cannot help aging. We also do not often think of
prescribing exercises such as swimming, walking,
or jogging or other aerobic exercises for people with
gray hair and a little extra weight. However, this
reticence is unfair and unproductive. To the con-
trary, as lungs lose their elasticity and distensibility
and as abdominal muscle mass begins to deterio-
rate, it is even more important for a professional
voice user to be in peak physical condition. A singer
whose respiratory and abdominal conditioning is
not good enough to allow walking up a few flights of
Journal of Voice, Vol. 11, No. 2, 1997
stairs without becoming winded is probably unable
to maintain good abdominal support throughout a
recital or opera. When the power source of the
voice is undermined in this way, excessive muscle
use in the neck and tongue usually supervenes.
Conditioning muscles gradually, in a disciplined
fashion under medical supervision, restores good
support. Regular vocal technical training can elim-
inate the tremolo and improve agility, accuracy,
and endurance in the older singer as it can in the
beginner.
PSYCHOLOGY AND INTELLECT
Other age-related medical changes may also be
significant to vocal function in some people. Per-
sonality has been most commonly described in
terms of a five-factor model: extroversion, emo-
tional stability, agreeableness, conscientiousness,
and culture. In their 1989 study, Peabody and Gold-
berg described the five replicable factors that
emerge from factor analysis of a large number of
personality traits (12). In general, personality traits
are stable after approximately age 30, and it is use-
ful for the physician to understand personality traits
and their tendency for stability. These may be help-
ful in interpreting other psychological changes as-
sociated with aging. Certain mental disorders are
more common in the elderly, including Alzheimer's
disease, a disorder of memory and mood. Alzhei-
mer's disease is a diagnosis that can only be made
with certainty by postmortem examination of the
brain, which reveals characteristic neuritic plaques
and neurofibrillary tangles. However, clinical ob-
servation and decline in cognitive function docu-
mented by neuropsychological batteries over time
are commonly used to make a presumptive diagno-
sis. Impairments in cognitive function and other
neurological sequelae are also seen in multiinfarct
dementia, which presents with increasing frequency
correlated to age.
Mood disorders, including major depression, are
not unusual in the elderly and may account for sig-
nificant decline in cognitive, affective, and behav-
ioral function. In addition, elderly people have a
higher incidence of risk factors associated with
mental illness, including poverty, bereavement, iso-
lation, sensory deficits, and physical illness. It
should also be noted that older people perform dif-
ferently on some psychodiagnostic tests, and such
studies must be interpreted with great caution es-
pecially when attempting to distinguish between de-
 AGING VOICE
mentia and expected mental changes such as benign
senescent forgetfulness. In IQ testing of the elderly,
research indicates that age-related decrements on
tests such as the Weschler Adult Intelligence Scale-
Revised (WAIS-R) are primarily in the speed tests
measuring perceptual-motor skills. There are more
often decrements in fluid abilities (such as reaction
speed) than in crystallized abilities (such as fund of
knowledge). Verbal ability is retained until very old
age. With renorming of the WAIS-R to age-
appropriate populations, IQ changes in the elderly
are now clearly seen as functions of educational
opportunity and health status (13,14). Alterations in
cognition, especially memory, and changes in per-
sonality secondary to mood disorders and delusion-
ality may impair a person's ability to concentrate,
consistently perform vocal tasks, and cooperate op-
timally with voice rehabilitation.
ENDOCRINE SYSTEM
In addition to the estrogen deprivation discussed
earlier, thyroid disease in the elderly deserves spe-
cial mention. Both hyper- and hypothyroidism are
notoriously difficult to diagnose during advanced
age. The elderly patient with hypothyroidism does
not frequently display the "typical" features en-
countered in younger people with hypothyroidism.
These features include mental slowing, loss of en-
ergy, neurotic behavior, hearing loss, weight gain,
musculoskeletal discomfort, dry skin, changes in fa-
cial appearance, and other problems. The diagnosis
of hypothyroidism in the elderly is often missed be-
cause many of the symptoms of hypothyroidism
may be inaccurately attributed to age. In addition,
elderly patients often have other problems to which
their difficulties are ascribed in the absence of clear
diagnostic clues to hypothyroidism. Alterations in
thyroid function frequently produce substantial
changes in vocal quality, including loss of range,
efficiency, and "muffling" of the voice. These vo-
cal derangements generally resolve when the thy-
roid abnormality is treated.
HEAD A N D N E C K CHANGES
Oral cavity changes associated with aging may be
particularly troublesome to actors and singers. Loss
of dentition may alter occlusion and articulation and
cause especially disturbing problems for profes-
sional voice users and wind instrumentalists. These
difficulties may be avoided to some extent by hav-
ing impressions made while dentition is still normal.
159
Dentures can then be fashioned that are more sim-
ilar to the person's natural teeth. Although salivary
glands lose -~<30% of their parenchymal tissue
over a lifetime, salivary secretion remains adequate
in most healthy, nonmedicated people throughout
life. It is essential that the otolaryngologist obtain
an exhaustive list of current and recent medications
during history taking and physical examination of
older voice professionals. Like the aging population
generally, these patients will commonly be in treat-
ment with multiple physicians for impaired function
in many organ systems. This predisposes to poly-
pharmacy. Often, patients are unaware of drug in-
teractions or side-effects that may contribute to
their vocal complaints (15). Changes in the oral mu-
cosa similar to those occurring in the skin (thinning
and dehydration) may render oral mucosa in the
elderly more susceptible to injury, and the sensa-
tion of xerostomia may be especially disturbing to
the singer. Oral cancers comprise - 5 % of all ma-
lignancies, and 95% of oral cancers occur in people
aged >40 years. Cancers of the head and neck may
result in profound voice dysfunction.
OTHER FACTORS
Many other factors must also be taken into ac-
count in diagnosis and treatment of elderly patients.
These include coronary artery disease, cerebrovas-
cular disease, hypertension, obesity, stroke, diabe-
tes, cancer, diet, osteoporosis, hearing loss, vision
loss, swallowing dysfunction, anemia, arthritis,
neurological dysfunction (including tremor and in-
continence), gastrointestinal disorders, and other
conditions. Most of these may have adverse effect
on the voice or voice performance either through
action on the larynx or through impairment of the
voice-producing mechanism at another anatomical
site,
Because older singers and other voice profession-
als have considerably less natural reserve and resil-
ience than youthful performers, we need to be par-
ticularly demanding in our therapy with them. They
cannot compensate for or tolerate weaknesses as a
teenager can. Nor can they recover as quickly from
injuries to vocal apparatus. However, with optimal
physical and vocal conditioning; proper medical su-
pervision of cardiac and respiratory function; and
appropriate medication, weight control, and nutri-
tion, it appears likely that a great many singers,
actors, and others may enjoy extra years or decades
Journal of Voice. Vol. 11, No. 2, 1997
160 R. T. SA T A L O F F E T A L .
of performance that are gratifying to them and their
audiences.
REFERENCES
1. McGIone R, Hollien H. Vocal pitch characteristics of aged
women. J Speech Hear Res 1963;6:164-70.
2. Hollien H, Shipp T. Speaking fundamental frequency and
chronologic age in males. J Speech Hear Res 1972;15:155-9.
3. Morrison MD, Gore-Hickman P. Voice disorders in the el-
derly. J Otolaryngol 1986;15:231-4.
4. Sindo ML, Hanson DG. Geriatric voice and laryngeal dys-
function. Otolaryngol Clin North Am 1990;23:1035-44.
5. Woo P, Casper J, Colton R, Brewer D. Dysphonia in the
aging: physiology versus disease. Laryngoscope 1992;102:
139--44.
6. Orlikoff R. The atherosclerotic voice. Ear Nose Throat J
1990;69:833-7.
7. Ward PH, Colton R, McConneU F, Malmgren L, Kashima
H, Woodson G. Aging of the voice and swallowing. Oto-
laryngol Head Neck Surg 1989;100:283-6.
Journal of Voice, Vol. 11, No. 2, 1997
8. Wilcox KA, Horii Y. Age and changes in vocal jitter. J Ger-
ontol 1980;35:194--8.
9. Tanaka S, Hirano M, Chijiwa K. Some aspects of vocal fold
bowing. Ann Otol Rhinol Laryngol 1994;103:357-62.
10. Special issue on vocal aging. J Voice 1987;1:2-67.
1I. Kahane JC. A survey of age-related changes in the connec-
tive tissues of the human adult larynx. In: Bless DM, Abbs
JH, ed. Vocal cord physiology. San Diego: College Hill
Press, 1983:44-9.
12. Peabody D, Goldberg LR. Some determinants of factor
structures from personality trait descriptors. J Pers Soc Psy-
chol 1989;57:552-67.
13. Botwinic J. Aging and behavior. New York: Springer-
Verlag, 1978:22-30.
14. Anastasi A. Psychological testing. 6th ed. New York: Mc-
Millan, 1988:347-51.
15. Sataloff RT, Rosen DC, Hawkshaw MJ. Medications: ef-
fects and side-effects in professional voice users. In: Sataloff
RT, ed. Professional voice; the science and art o f clinical
care. 2nd ed. San Diego: Singular Publishing Group (in
press).