Voice disorders afflict up to 12% of the elderly population (Shindo and Hanson, 1990). Voice disorders in elderly persons can result from normal age-related changes in the voice production mechanism or from pathological conditions separate from normal aging (Linville, 2001). However, distinguishing between pathology and normal age-related changes can be difficult. Indeed, a number of investigators have concluded that the vast majority of elderly patients with voice disorders suffer from a disease process associated with aging rather than from a disorder involving physiological aging alone (Morrison and Gore-Hickman, 1986; Woo, Casper, Colton, and Brewer, 1992). Therefore, a thorough medical examination and history are required to rule out pathological processes affecting voice in elderly patients (Hagen, Lyons, and Nuss, 1996). In addition, stroboscopic examination of the vocal folds is recommended to detect abnormalities of mucosal wave and amplitude of vocal fold vibration that affect voice production (Woo et al., 1992).

A number of pathological conditions that affect voice are prevalent in the elderly population simply because of advanced age. Such conditions include neurological disorders, benign lesions, trauma, inflammatory processes, and endocrine disorders (Morrison and Gore-Hickman, 1986; Woo et al., 1992). Carcinoma of the head and neck occasionally occurs late in life, although more commonly it is diagnosed between the ages of 50 and 70 (Leon et al., 1998). Interestingly, multiple etiologic factors related to a voice disorder are more common in elderly patients than in younger adults. In addition, elderly persons are at increased risk for laryngeal side effects from pharmacological agents, since prescription and nonprescription drugs are used disproportionately by the elderly (Linville, 2001).

Elderly patients often exhibit neurological voice disorders, particularly in later stages of old age. Estimates of the incidence of peripheral laryngeal nerve damage in elderly dysphonic patients range from 7% to 21%. Generally, peripheral paralysis in the elderly tends to be associated with disease processes associated with aging (such as lung neoplasm), as opposed to idiopathic peripheral paralysis, which occurs infrequently (Morrison and Gore-Hickman, 1986; Woo et al., 1992). Symptoms of peripheral paralysis include glottic insufficiency, reduced loudness, breathiness, and diplophonia. Voice therapy for peripheral paralysis frequently involves increasing vocal fold adductory force to facilitate closure of the glottis and improving breath support to minimize fatigue and improve speech phrasing. After age 60, central neurological disorders such as stroke, focal dystonia, Parkinson's disease, Alzheimer's disease, and essential tremor also occur frequently. Treatment for central disorders involves attention to specific deficits in vocal fold function such as positioning deficits, instability of vibration, and incoordination of movements. Functioning of the velopharynx, tongue, jaw, lips, diaphragm, abdomen, and rib cage may also be compromised and may require treatment. Treatment may focus on vocal fold movement patterns, postural changes, coordination of respiratory and phonatory systems, respiratory support, speech prosody, velopharyngeal closure, or speech intelligibility. In some cases, augmentative communication strategies might be used, or medical treatment may be combined with speech or voice therapy to improve outcomes (Ramig and Scherer, 1992).

A variety of benign vocal lesions are particularly prevalent in the elderly, including Reineke's edema, polypoid degeneration, unilateral sessile polyp, and benign epithelial lesions with variable dysplastic changes (Morrison and Gore-Hickman, 1986; Woo et al., 1992). Reineke's edema and polypoid degeneration occur more commonly in women and are characterized by chronic, diffuse edema extending along the entire length of the vocal fold. The specific site of the edema is the superficial layer of the lamina propria. Although the etiology of Reineke's edema and polypoid degeneration is uncertain, reflux, cigarette smoking, and vocal abuse/misuse have been mentioned as possible causal factors (Koufman, 1995; Zeitels et al., 1997). Some degree of edema and epithelial thickening is a normal accompaniment of aging in some individuals. The reason why women are at greater risk than men for developing pathological epithelial changes as they age is unknown, although differences in vocal use patterns could be a factor. That is, elderly women may be more likely to develop hypertensive phonatory patterns in an effort to compensate for the age-related pitch lowering that accompanies vocal fold thickening and edema (Linville, 2001).

The incidence of functional hypertensive dysphonia among elderly speakers is disputed. Some investigators report significant evidence of phonatory behaviors consistent with hypertension, such as hyperactivity of the ventricular vocal folds in the elderly population (Hagen, Lyons, and Nuss, 1996; Morrison and Gore-Hickman, 1986). Others report a low incidence of vocal fold lesions commonly associated with hyperfunction (vocal nodules, pedunculated polyps), as well as relatively few cases of functional dysphonia without tissue changes (Woo et al., 1992). Clinicians are in agreement, however, that elderly patients need to be evaluated for evidence of hypertensive phonation and provided with therapy to promote more relaxed phonatory adjustments when evidence of hypertension is found, such as visible tension in the cervical muscles, a report of increased phonatory effort, a pattern of glottal attack, high laryngeal position, and/or anteroposterior laryngeal compression.

Inflammatory conditions such as pachydermia, laryngitis sicca, and nonspecific laryngitis also are diagnosed with some regularity in the elderly (see infectious diseases and inflammatory conditions of the larynx). These conditions might arise as a consequence of smoking, reflux, medications, or poor hydration and often coexist with vocal fold lesions that may be either benign or malignant. Age-related laryngeal changes such as mucous gland degeneration might be a factor in development of laryngitis sicca (Morrison and Gore-Hickman, 1986; Woo et al., 1992). Gastroesophageal reflux disease (GERD) is another inflammatory condition that is reported to occur with greater frequency in the elderly (Richter, 2000). Since GERD has been present for a longer time in the elderly in comparison with younger adults, it is a more complicated disease in this group. Often elderly patients report less severe heartburn but have more severe erosive damage to the esophagus (Katz, 1998; Richter, 2000).

Because of advanced age, elderly patients may be at increased risk for traumatic injury to the vocal folds. Trauma might manifest as granuloma or scar tissue from previous surgical procedures requiring general anesthesia, or from other traumatic vocal fold injuries. Vocal fold scarring may be present as a consequence of previous vocal fold surgery, burns, intubation, inflammatory processes, or radiation therapy for glottic carcinoma (Morrison and Gore-Hickman, 1986; Kahane and Beckford, 1991).

Age-related changes in the endocrine system also affect the voice. Secretion disorders of the thyroid (both hyperthyroidism and hypothyroidism) occur commonly in the elderly and often produce voice symptoms, either as a consequence of altered hormone levels or as a result of increased pressure on the recurrent laryngeal nerve. In addition, voice changes are possible with thyroidectomy, even if the procedure is uncomplicated (e.g., Debruyne et al., 1997; Francis and Wartofsky, 1992; Sataloff, Emerich, and Hoover, 1997). Elderly persons also may experience vocal symptoms as a consequence of hypoparathyroidism or hyperparathyroidism, or from neuropathic disturbances resulting from diabetes (Maceri, 1986).

Lifestyle factors and variability among elderly speakers often blur the distinction between normal and disordered voice. Elderly persons differ in the rate and extent to which they exhibit normal age-related anatomical, physiological, and neurological changes. They also differ in lifestyle. These factors result in considerable variation in phonatory characteristics, articulatory precision habits, and respiratory function capabilities among elderly speakers (Linville, 2001).

Lifestyle factors can either postpone or exacerbate the effects of aging on the voice. Although a potentially limitless combination of environmental factors combine to affect aging, perhaps the most controllable and potentially significant lifestyle factors are physical fitness and cigarette smoking. The elderly population is extremely variable in fitness levels. The rate and extent of decline in motor and sensory performance with aging varies both within and across elderly individuals (Finch and Schneider, 1985). Declines in motor performance are directly related to muscle use and can be minimized by a lifestyle that includes exercise. The benefits of daily exercise include facilitated muscle contraction, enhanced nerve conduction velocity, and increased blood flow (Spirduso, 1982; Finch and Schneider, 1985; De Vito et al., 1997). A healthy lifestyle that includes regular exercise may also positively influence laryngeal performance, although a direct link has yet to be established (Ringel and Chodzko-Zajko, 1987). However, there is evidence that variability on measures of phonatory function in elderly speakers is reduced by controlling for a speaker's physiological condition (Ramig and Ringel, 1983). Physical conditioning programs that include aerobic exercise often are recommended for aging professional singers to improve respiratory and abdominal conditioning and to avoid tremolo, as well as to improve endurance, accuracy, and agility. Physical conditioning is also important in nonsingers to prevent dysphonia in later life (Sataloff, Spiegel, and Rosen, 1997; Linville, 2001).

The effects of smoking coexist with changes related to normal aging in elderly smokers. Smoking amplifies the impact of normal age-related changes in both the pulmonary and laryngeal systems. Elderly smokers demonstrate accelerated declines in pulmonary function, even if no pulmonary disease is detected (Hill and Fisher, 1993; Lee et al., 1999). Smoking also has a definite effect on the larynx and alters laryngeal function. Clinicians must consider smoking history in assessing an elderly speaker's voice (Linville, 2001).

Clinicians also must be mindful of the overall health status of older patients presenting with voice disorders. Elderly dysphonic patients often are in poor general health and have a high incidence of systemic illness. Pulmonary disease and hypertensive cardiac disease have been cited as particularly prevalent in elderly voice patients (Woo et al., 1992). If multiple health problems are present, elderly dysphonic patients may be less compliant in following therapeutic regimens, or treatment for voice problems may need to be postponed. In general, the diagnosis and treatment of voice disorders are more complicated if multiple medical conditions are present (Linville, 2001).