Aging Voices

For the past 14 years, Darrell Rodenbaugh has played the lead in Scrooge – The Musical, an annual production by North Texas Performing Arts in Plano. The role is a marathon for 62-year-old Rodenbaugh: the company performs more than a dozen shows on consecutive nights, plus matinees on the weekends, with Rodenbaugh on stage, singing, dancing and speaking, for nearly the entire two-and-a-half-hour show. 

All of which he managed to handle until about five years ago, when his voice began to falter. 

“It was getting a little more raspy,” he said. “I was struggling to enunciate and hit some of the higher notes.” 

Rodenbaugh was noticing presbyphonia, or “aging voice,” changes in vocal quality that occur with aging. As people reach older adulthood, their voices tend to become breathy, weak or hoarse. They may lose the ability to project, and the voice may tire more easily. 

Rodenbaugh relies on his voice professionally, but voice problems can affect any older adult—and they are common. Research suggests that 19-29 percent of adults 64 and older experience a voice disorder at any given time, and for many, it impairs daily function and satisfaction with life. 

“The most common complaints I hear are, ‘People can’t hear me’ or ‘I have to repeat myself all the time,’” said Karen Goins, a speech pathologist who works with older adults in Dallas.

Often folks have no idea that there are voice doctors and things we can do that are specifically geared to helping older patients.

—Lesley Childs, MD

When voice issues make it harder to communicate and to socialize, that can lead to isolation and, in turn, depression and cognitive decline, according to Angela Van Sickle, PhD, a speech pathologist at Texas Tech University Health Sciences Center in Lubbock. 

“If friends or family can’t hear them, or can’t understand them, it’s frustrating, and it’s more work to communicate,” she said. “Some people start to feel like it’s too much work. They start to kind of close in and become more and more isolated.” 

Similarly, older adults who remain in the workforce may feel that voice issues hamper their professional productivity. 

However, while age-related changes may be inevitable, experts say older adults have options for keeping their voices strong, ranging from voice therapy and good health habits to medical interventions like injections and surgery. 

“Often, folks have no idea that there are voice doctors and things we can do that are specifically geared to helping older patients,” said Lesley Childs, MD, medical director at the Clinical Center for Voice Care at UT Southwestern Medical Center in Dallas.  

How Voices Change

The voice functions like a musical instrument. Sound emanates from the vocal folds, or vocal cords, housed in the larynx. Air pumped up from the lungs causes the folds to vibrate, creating sound that resonates in the open spaces inside the mouth, behind the nose and the back of the throat. 

Like the rest of the body, the larynx, vocal cords and lungs change with age. The larynx can become stiff. The vocal folds can atrophy, losing muscle tone, elasticity and moisture. The lungs, which act like a respiratory bellows to power the voice, lose capacity. With these changes, the voice starts to sound raspy, weak or breathy. That’s why it is often easy to tell that you’re talking to an older person on the telephone, just by the sound of their voice. 

Men’s and women’s voices tend to age differently, said Childs, who is also associate professor of laryngology, neurolaryngology and professional voice at UT Southwestern. 

“In men, the vocal folds become thin and slightly bowed, causing the voice to sound more breathy and weaker,” she said. “In females, the vocal folds become more dense, causing the voice to deepen.” 

Hormonal changes—lowered estrogen levels in women, falling androgen levels in men —seem to contribute.

Older people may develop a tremor, making the voice shaky. Neurogenic conditions such as Parkinson’s can impair the vocal cords or cause tremors. A stroke may trigger vocal cord paralysis or affect the part of the brain that controls speech. (Speech, the ability to articulate words, is differentiated from the voice, which produces the sound generated in the vocal cords.) Older adults also take more medications and have more health conditions, both of which can affect voices. 

Age-related voice problems occur at the same time many older adults experience hearing loss, making two-way communication even more difficult. Hearing loss can also contribute to voice issues. A person with impaired hearing may have difficulty calibrating their volume—either causing them to speak too loudly or too softly, depending on how they perceive their own voice. 

How Voice Therapy Works

For those with vocal disorders, the first line of treatment is voice therapy with a speech language pathologist. 

“The exercises aim to restore vocal strength by rebuilding muscle tone,” said Van Sickle.

Just as the abs and glutes need regular exercise to stay strong, so do the muscles in the voice. Voice therapy helps patients learn proper breathing techniques and find ways to optimize volume and reduce strain. Van Sickle often prescribes a series of exercises developed by voice-therapy pioneer Joseph Stemple, with separate regimens for male and female voices. Similar to vocal warm-ups that singers and actors follow, these involve holding a single note or pitch glides—starting low and sliding to a higher note, and vice versa.

Specialized voice-therapy programs are also available for people with Parkinson’s and other age-related voice issues.

“Patients with Parkinson’s may feel like they’re yelling, because they have to put in extra effort to speak, but they’re actually talking too softly,” Van Sickle said. “These programs help people to recalibrate the volume of their voices.” 

Other Interventions

Even at the age of 88, Jan Steele says her voice hasn’t changed much. She credits her 42 years as a member of the Rich-Tones, an 80-person women’s barbershop chorus in Dallas. The group rehearses for three hours each week and performs in concerts and international competitions, three of which they’ve won. 

“I’m very disciplined about my vocal exercise,” Steele said. “I sing in the shower and around the house. I practice scales and repertoire, and of course go to weekly rehearsals. I think a mature voice needs to sing every day. If you don’t use it, you lose it.”

Experts agree: singing can be a form of natural voice therapy. 

“The folks that we see that are doing really well are generally using their voice a fair amount, without overusing it,” said Childs. “Singing is good for expansion of the breath support. We actually recommend singing to a lot of our patients.”  

Here are other steps experts recommend for vocal health and longevity.

Stay hydrated. Drink plenty of water, especially when exercising. Childs likes caffeine-free teas, served warm, not hot. She advises patients to avoid alcohol and caffeine, or to balance intake of either with additional water. 

Practice “external hydration.” A home humidifier, especially in winter or dry climates, can be helpful. (Thirty percent humidity is recommended.) For professionals who use their voices, Childs also recommends a portable saline nebulizer designed specifically for voice support, such as Vocal Mist, to add moisture to the throat. 

Address bad habits. A persistent cough can lead to vocal problems. Some people develop a habit of frequently clearing their throats, for example, which irritates the vocal folds. Van Sickle helps patients in that situation learn to swallow or take other steps when the urge to clear their throat crops up. 

Manage allergies and allergy medicine. Allergies can cause inflammation in the larynx, leading to hoarseness. Antihistamines may dry out the nasal and breathing passages. For people with congestion or post-nasal drip, Childs prefers guaifenesin (Mucinex is a popular brand), an expectorant that helps loosen and clear mucus from the airways. Avoid pseudoephedrine (D) or dextromethorphan (DM) formulations, which can cause dryness.

Use assistive devices. Van Sickle never teaches class for more than an hour or two, even in a small classroom, without a microphone. Personal amplification devices can be used in situations where a public address system is not available. 

Exercise regularly. Exercise increases stamina and muscle tone, as well as improves posture and breathing. 

Practice good breathing techniques. Support the voice with deep breaths from the chest. 

Socialize in quiet places. Trying to talk over a noisy room can cause frustration and strain the voice. Childs encourages patients to consider acoustics when making plans. “If they go out to dinner at a restaurant, for example, I advise them to choose a quiet restaurant, or a booth in the corner, next to a wall, where it’s likely to be easier to hear and be heard,” she said. 

Maintain good posture. Goins works with patients’ posture, because good posture can facilitate better breath support, which helps in speaking. Van Sickle also encourages patients to always face the person they’re speaking with. “There are so many important cues that we get from a speaker’s facial expressions,” she said.

Rest the voice. While exercising is helpful, resting is important, too, especially for anyone who uses their voice extensively. Avoid vocal extremes, such as screaming or whispering. Childs notes that vocal strain is dose related. The longer a person speaks, and the louder, the more likely they are to strain the voice. It’s important to take breaks before and after any challenging speaking situations. 

Medical Interventions 

Most age-related voice issues are not serious and respond well to therapy. But for persistent symptoms, it’s a good idea to see an otolaryngologist or ear, nose and throat (ENT) specialist for a medical evaluation to rule out other medical conditions such as gastroesophageal reflux (GERD) or cancer of the larynx.

Typically, a medical workup for voice issues begins with an examination of the larynx and the vocal folds. This may involve a videostroboscopy, which Childs calls the “gold standard” for a thorough workup. A scope, inserted through the mouth or nose, uses strobe lights to examine vocal tissue. 

For those struggling with atrophy (thinning), Childs may inject fillers to “fatten up” the vocal cords. For a more permanent solution, she can surgically place implants (usually made of Gore-Tex) into the vocal cords to bulk them up. Botox injections may help calm vocal tremors by relaxing overactive muscles. If GERD is diagnosed, dietary changes or medications are recommended to help reduce flare-ups and minimize irritation in the throat. 

“I’m hopeful more people will realize that there are some options for them,” Childs said, adding that most large cities in the United States with major academic medical centers offer voice centers—multidisciplinary teams of fellowship-trained otolaryngologists, speech pathologists and other specialists focused on voice therapies.  

Scrooge’s Redemption 

When his voice issues arose, Rodenbaugh began working with a vocal coach who prescribed voice and breathing exercises. He started exercising with a trainer, adding cardio to boost his breath support. To help prevent sinus infections and inflammation, he irrigates his nasal passages regularly with saline. When he’s performing, he hydrates constantly before, during and after each show. 

Now, Rodenbaugh says, his voice is as strong as ever—he’s even hitting a few high notes he couldn’t hit before. This fall, he’ll return as Scrooge in NTPA’s 15th season, marking the troupe’s record-setting 125th performance of Scrooge: The Musical. 

“At this age, singing is not about pushing harder, it’s about being smarter,” he said. “Caring for your voice really means caring for yourself and your whole body.”