REVIEW URRENT C OPINION

Treatment of dysphonia in older people: the role of the speech therapist Jennifer M. Oates

Purpose of review This review addresses speech therapy interventions for older adults experiencing voice impairments. The prevalence, impact, and nature of voice impairments in older people are outlined. Intervention methods and their effectiveness are discussed, with particular focus on behavioral treatments for presbyphonia. The strength of current evidence is discussed and recommendations for future research are presented. Recent findings There has been a substantial increase in the number of older people seeking voice management over the last 10–20 years. Reduced vocal effectiveness in older people is likely to be multifactorial and associated with normal physiological aging, maladaptive responses to vocal aging, and medical and psychosocial conditions that are common in older age. Although several authors have claimed that behavioral intervention for presbyphonia is effective, few studies were reported until 2008. Since then, 10 studies have been published as to the effectiveness of behavioral interventions for age-related dysphonia. Voice therapy techniques evaluated include vocal function exercises, phonation resistance training exercise, Lessac–Madsen resonant voice therapy, Lee Silverman voice treatment, neuromuscular electrical stimulation, semi-occluded vocal tract, and flow phonation. Findings suggest that behavioral interventions for presbyphonia have the potential to mitigate effects of vocal aging, but the overall evidence base is inadequate to allow definitive conclusions. Summary Because vocal effectiveness diminishes as people age and because diminished vocal capabilities are associated with negative impacts, the importance of establishing whether behavioral interventions are effective is now acknowledged. Although the number of studies on speech therapy interventions has increased, the body of evidence is limited and further research is required. Keywords behavioral interventions, presbyphonia, voice problems, voice-related quality of life

INTRODUCTION The proportion of individuals over 65 years of age in developed countries is increasing rapidly, due in large part to current and projected increases in life expectancy. This increasing population of older people is also participating in the paid and voluntary workforce for longer because of government policies that have extended retirement ages, because of economic necessity, and because of individuals’ desire to remain active in society for as long as possible [1,2]. As a consequence, effective communication is becoming increasingly important for older people, with vocal effectiveness as a key contributor [3,4]. Successful occupational and social participation into older age in contemporary society increasingly requires an effective and robust voice [2,5,6]. There is a considerable research evidence demonstrating that vocal effectiveness diminishes for

many people as they age and that vocal impairment is a common experience [2,7,8]. Reduced vocal effectiveness has been associated with a range of contributing and causal factors, including normal physiological aging processes as well as pathological processes related to vocal misuse, vocal loading, and physical and psychosocial health. In turn, vocal impairment in older people has been shown to be associated with a range of negative impacts on Department of Human Communication Sciences, Faculty of Health Sciences, La Trobe University, Victoria, Australia Correspondence to Jennifer M. Oates, PhD, Department of Human Communication Sciences, Faculty of Health Sciences, La Trobe University, VIC 3086, Australia. Tel: +61 3 94791810; fax: +61 3 94791874; e-mail: [email protected] Curr Opin Otolaryngol Head Neck Surg 2014, 22:477–486 DOI:10.1097/MOO.0000000000000109

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KEY POINTS  Reduced vocal effectiveness is a common experience among older people in developed countries, and this experience is often associated with a range of negative impacts on activity, participation, and psychosocial well-being, as well as on overall quality of life.  Reduced vocal effectiveness in older people is likely to be multifactorial and associated with normal physiological aging processes, maladaptive compensatory responses to vocal aging, and a range of medical and psychosocial conditions that are common in older age.  Since 2008, 10 studies have been published as to the effectiveness of behavioral interventions for presbyphonia (VFE, PhoRTE, Lessac–Madsen resonant voice therapy, LSVT and modified LSVT, NMES, semioccluded vocal tract exercises, and flow phonation).  Findings from these 10 studies suggest that behavioral interventions for adults with presbyphonia have the potential to mitigate the effects of normal vocal aging, but the overall evidence base is weak.  Additional well designed research is required before clear conclusions can be reached as to the effectiveness of speech therapy interventions for agerelated dysphonia.

activity, participation, and psychosocial well-being, as well as on overall quality of life. Knowledge of the potential impacts of vocal impairment has led to a recent focus in the literature on behavioral interventions provided by speech therapists to reduce vocal impairment in older people. It was not until 2010, however, that a body of literature developed sufficiently to allow even tentative conclusions to be reached as to the effectiveness of those behavioral interventions. This article briefly outlines what is known about the prevalence, impact, and nature of voice impairments in older people. Behavioral intervention methods and their effectiveness are then discussed in more detail, with a particular focus on behavioral treatments for presbyphonia. The strength of the currently available evidence is discussed, and recommendations for future research to improve the evidence base for behavioral interventions for older individuals are presented.

THE PREVALENCE, IMPACT, AND NATURE OF VOICE IMPAIRMENTS IN OLDER PEOPLE A comprehensive review of the prevalence, impact, and nature of voice impairments in older people is 478

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beyond the scope of this article. However, a brief outline is provided here by way of background. Readers are referred to the two articles on the epidemiology of dysphonia in aging and histological vocal fold changes associated with aging in this issue for a more in-depth review.

Prevalence of voice impairments in older people Accurate data on the prevalence of vocal impairment among adults aged 65 years and older are not available [3,9]. Although many authors report on the prevalence of vocal dysfunction in older people, no population-based epidemiological studies appear to have been reported. Instead, most recent reports have been based on retrospective chart reviews of adults with voice complaints or prospective studies of small samples of nontreatment-seeking older people. Retrospective studies on individuals referred to voice clinics demonstrate that older people constitute between 30 and 37% of all those referred [5,10 ]. These studies also show that there has been a substantial increase in referrals of older people over the last 10–20 years and that the proportion of referrals for older people is now significantly higher than expected on the basis of their proportion of the total adult population. A retrospective chart review of 6360 patients with a range of otolaryngological complaints conducted by Davids et al. [1], for example, demonstrated that 58% of those aged over 65 years had voice complaints. Prospective studies have yielded lower prevalence rates. Golub et al. [3] demonstrated that 20% of 107 elderly residents of an independent living facility reported voice difficulties. Turley and Cohen [11] examined the prevalence of voice problems among 248 older residents of two independent living retirement communities and concluded that 19.8% had voice problems, with only 22.4% of those having sought intervention. Roy et al. [9] determined that 29.1% of 117 independent living older residents reported a current voice problem. Of these, 60% reported that their voice problems were chronic rather than transient. The prevalence rates reported by Golub et al. [3], Roy et al. [9], and Turley and Cohen [11] for older people living in the community are considerably higher than the 4–7% rates reported for the general adult population [12,13]. Taken together with data showing that older people are overrepresented in the caseloads of voice clinics, these prevalence findings indicate that vocal impairment in older people warrants clinical and research attention. Further research is required, however, to provide more accurate data on the prevalence of vocal impairment in older individuals. &

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Impact of voice impairments in older people Vocal impairment in older people has been associated with a range of negative impacts on activity, participation, and psychosocial well-being, as well as on overall quality of life [9,14 ]. That there is an association between vocal impairment and reduced quality of life in older people is, however, a largely untested assumption. Only a small number of recent studies have investigated this relationship. Golub et al. [3] surveyed 107 elderly residents of an independent living facility, using the voicerelated quality of life measure (V-RQOL) [15] and demonstrated that over half of residents who reported voice difficulties also reported significant negative impacts on their V-RQOL, with 13% reporting moderate-to-profoundly reduced V-RQOL. Using a qualitative method (semi-structured interviews followed by thematic analysis), Etter et al. [16 ] showed that 28 treatment-seeking older people indicated that their voice problems impacted negatively on their communicative effectiveness and satisfaction, emotional health, and social participation. In contrast, a study on 107 older people with no voice complaints demonstrated that most participants reported no or only mildly reduced V-RQOL [17,18]. As suggested by Schneider et al. [18], it may be that older people are not as sensitive to vocal deterioration as younger adults, especially if they are retired and no longer use their voices vocationally. Overall, however, it is clear that additional qualitative and quantitative research is required before we can delineate the impacts of voice change in older people. Readers are referred to Oates [19] for discussion of the impacts of voice disorders in adults in general and for recommendations as to research approaches that may redress the limitations of the current evidence base. &

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The nature of voice impairments in older people Voice impairments in older people may arise as a result of normal structural and neurogenic aging processes affecting the vocal mechanism and/or as a result of pathological processes related to vocal misuse, vocal loading, and physical and psychosocial health [7,9,20]. Those pathological processes may be unrelated to aging (e.g., patterns of vocal misuse developed earlier in life, preexisting vulnerability to psychosocial stress), but could equally be associated with the increased risk of chronic medical conditions that occurs with older age (e.g., stroke, Parkinson’s disease, chronic obstructive airways disease, or depression). Many of those systemic medical conditions increase vulnerability to voice disorders [9,21]. Further, the increased risk of chronic medical

conditions with age is associated with increased use of medications, some of which are associated with the development of voice impairments (e.g., angiotensin-converting enzyme inhibitors used to manage hypertensive cardiac disease) [22,23]. To complicate this picture even further, pathological processes can interact with normal aging processes. This would be the case, for example, when an older individual attempts (consciously or unconsciously) to compensate for age-related vocal deterioration by adopting hyperfunctional voice use patterns [9,24,25]. Whether or not voice impairments due to normal physiological aging can be clearly differentiated from those arising from pathological processes is a moot point because the research base remains incomplete and because it is likely that most voice problems in older people are multifactorial [7,9, 22,26]. As a result, voice impairment due primarily to normal aging processes (variously termed as presbyphonia, presbylarynges, presbylaryngis, presbylarynx, or senile laryngis) appears to be uncommon [9,14 ], although findings have varied according to the inclusion/exclusion criteria applied for presbyphonia. A large body of previous literature has delineated structural and neurogenic changes of the various components of the vocal mechanism associated with normal physiological aging (for summaries of key research findings, see Casper and Colton [22], Ramig et al. [8], Sataloff and Linville [27], and Tanner et al. [28]). Although the evidence base is not yet complete, there is consensus that normal aging is associated with histologic and morphologic changes in connective tissue of the vocal folds (e.g., atrophy of elastic fibers in the superficial layer of the lamina propria, changes in the distribution of hyaluronic acid in the lamina propria, and thinning of the vocal ligament), cartilaginous changes in the larynx (e.g., ossification), atrophy and stiffening of vocal fold muscle, reduction of type II fibers in the thyroarytenoid muscle, and atrophy of mucus glands in the larynx. Similarly, age-related changes in the respiratory mechanism are well documented. These changes include reductions in lung elasticity and recoil, vital capacity, volume and pressure, and strength and control of the respiratory musculature. Neuromuscular degeneration and atrophy and the resulting general slowing of both central and peripheral nervous system functioning have also been documented in older people. These degenerative changes in the vocal and respiratory systems are assumed to result in the wide range of auditory-perceptual, acoustic, aerodynamic, electromyographic, and laryngeal appearance features that have been reported in voices of older

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people (for concise summaries of key research findings, see Ramig et al. [8], Stemple and Dietrich [2], Tanner et al. [28], and Tay et al. [29]). These features include auditory-perceptual changes in pitch and pitch range, loudness, and voice quality (e.g., reduced pitch range and loudness, increased breathiness, strain, or hoarseness and tremor) and their acoustic correlates. Documented aerodynamic changes include reduced maximum phonation time, increased mean airflow rate through the glottis, and reduced syllables per breath, whereas electromyographic changes include increased motor unit amplitudes and durations and reduced firing rates of intrinsic laryngeal muscles. Laryngeal appearance features demonstrated in older people include vocal fold bowing and other incomplete closure configurations, increased vocal fold stiffness, and prominence of the vocal processes of the arytenoid cartilages. Despite consensus that decline in vocal capabilities is associated with normal physiological aging, it has also been demonstrated that vocal aging is not uniform as to the age at which it begins, the extent to which decline in vocal functioning occurs, the rate of vocal change, and the degree to which vocal aging impacts on voice-related quality of life [8,28]. These individual differences in vocal aging have been associated with both genetic and environmental influences [28].

SPEECH THERAPY MANAGEMENT OF VOCAL IMPAIRMENTS IN OLDER PEOPLE Speech therapy interventions for voice impairments due to pathological processes associated with increasing age (e.g., medication use, chronic health conditions, or vocal misuse) are likely to be similar to those used for adults of any age and will not be reviewed here. However, modifications to the overall intervention approach may be required for older people because various factors, such as frailty and physical conditioning, hearing impairment, depression, cognitive decline, and changed levels of social participation, may have a significant influence on the individual’s capacity to benefit from voice therapy and on their motivation to engage in vocal exercise and voice care programs. Although several authors have emphasized that this is the case [20,30], there has been virtually no research as to which intervention approaches and voice therapy techniques are most effective for older people with voice impairments due to these pathological processes.

SPEECH THERAPY INTERVENTIONS FOR PRESBYPHONIA Several authors have claimed that direct and indirect voice therapy is warranted for older people with 480

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a diagnosis of presbyphonia [2,6,7,27,30]. These authors also claim that providing behavioral intervention for people with presbyphonia is effective and rewarding for the clinician. Recommended direct intervention techniques include vocal function exercises (VFE) [31], phonation resistance training exercise (PhoRTE) [32], Lessac–Madsen resonant voice therapy [33], and other resonance enhancement techniques such as Lee Silverman voice treatment (LSVT) [34], breath control and respiratory muscle strengthening exercises, head and neck muscle relaxation, glottal onset training, laryngeal manual therapy, vocal glides and arpeggios, and singing/acting voice training. Recommended indirect methods include general physical/aerobic conditioning and voice care education/vocal hygiene training. To this author’s knowledge, no intervention studies have been published as to the effectiveness of general physical/aerobic conditioning and voice care education/vocal hygiene training for individuals diagnosed with presbyphonia. Until approximately 2008, the evidence for the effectiveness of direct voice therapy was also extremely limited. The available evidence comprised a small number of single-case studies and one prepost observational study of three individuals with age-related voice change who underwent 16 sessions of LSVT over 4 weeks [8]. Improvements in some acoustic, auditory-perceptual, videostroboscopic, and self-report measures of vocal functioning were demonstrated, but the imprecise participant selection criteria, the very small sample size, and the lack of control or comparison groups provided only weak evidence for the use of LSVT for presbyphonia. Since 2008, however, 10 relevant research reports have been published. Only three of those are recent publications (i.e., 2012–2014). Table 1 [21,26,28,29,35 ,36–44] summarizes the designs, participants, behavioral interventions, voice outcome measures, and findings of these 10 studies. Studies are listed in the table beginning with the most recent (in alphabetical order in the case of studies published in the same year). Findings from these 10 most recent research reports indicate that behavioral interventions for adults with age-related voice impairment have the potential to mitigate some of the effects of physiological aging. Although several different voice therapy techniques were trialed, different intervention schedules were applied, and many different voice outcome measures were used across these studies; intervention outcomes were mostly positive. Vocal exercise techniques used in isolation that yielded improved vocal functioning were VFE, PhoRTE, and modified LSVT. Several studies also &&

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Prospective group prepost descriptive study.

Lu et al. [36]

V-RQOL; Perceived phonatory effort; Adherence data; Posttreatment satisfaction questionnaire.

VFE and PhoRTE: 4  45 min sessions over 4 weeks and twice daily home practice.

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LaGorio et al. [40]

Prospective prepost case series with 3-month follow-up.

Six patients (three women, three men) aged 58–81 years with chronic vocal fold bowing (five with presbyphonia).

Two-thirds of patients did not return for treatment after initial session. ‘Low’ rate of treatment success regardless of voice therapy alone, therapy surgery, or surgery alone. Results otherwise unclear.

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(Continued )

5  1 h daily sessions over 3 VHI [41]; Acoustic: highest attain- Note that no separate findings weeks (two NMES ‘accommoreported for patients with presable pitch on sustained /a/ byphonia. VHI improved for five and /i/, loudest phonation on dation’ sessions and 13 treatof six patients, but increase not single phrase; Stroboscopy: ment sessions). Vocal exercises significant. MPT increased, but subjective ratings of glottal clopaired with NMES. Voice only significant for /i/. sure and supraglottic comtherapy comprised progressive Increased glottal closure and pression; Phonatory function: hierarchy requiring patient to reduced supraglottic comsustain phonations incrementally MPT. pression. Inadequate data for longer, louder, and higher analysis of highest attainable pitched. pitch. No loudness data reported.

Auditory-perceptual: breathiness, VFE group: significant improveroughness, strain; Phonatory ments in roughness, MPT, jitter, function: MPT; Acoustic: Phonashimmer, and NHR. VFE pertional frequency range, jitter, ceived as effective. No intervenshimmer, NHR; Participant rattion group: no significant ing of treatment effectiveness. change apart from decrease in jitter and NHR.

Twenty-two community choir singers with no diagnosed voice condition aged 63–83 years pseudo-randomized to VFE or no treatment (seven women and four men in each group).

Tay et al. [29]

VFE group: 5-week VFE program (1.5 h training and 5 weeks twice daily home practice).

Two hundred and seventy-five Individually designed indirect VHI-10 [39]. patients (142 women 133 men) direct voice therapy (LMRVT, aged 55–97 years with vocal flow phonation, semi-occluded fold atrophy no comorbid vocal tract) alone or with injeclaryngeal conditions thought to tion augmentation injection ‘interfere’ with atrophy augmentation alone, or no diagnosis. intervention.

Gartner-Schmidt Retrospective group prepost and Rosen [38] database review.

Prospective single-group prepost descriptive.

PhoRTE and VFE groups increased V-RQOL significantly; only PhoRTE group reduced PPE; Controls showed no change in V-RQOL or PPE; VFE reported slightly greater adherence; PhoRTE reported greater satisfaction than VFE.

Findings

Stroboscopy: vocal fold atrophy/ Both participants significantly improved glottal closure, bowing, glottal closure, vocal phonatory function, acoustic fold pathology, hyperfunction, and auditory-perceptual glottal gap area; Phonatory features. No vocal fold patholfunction: MPT; Acoustic: F0, F0 ogy or maladaptive hyperfuncrange, intensity, jitter, shimmer, tion developed post-LSVT. HNR, SPI; Auditory-perceptual: GRBAS [37].

Voice outcome measures

Behavioral intervention

Two participants (woman, 61 16  60 min LSVT over 4 weeks years and man, 80 years) with and daily home practice. presbyphonia/age-related vocal fold bowing.

Prospective, randomized, and All participants diagnosed with controlled with comparison presbyphonia VFE: six particibetween two treatment pants (two men, four women) methods. aged 60–83 years; PhoRTE: five participants (two men, three women) aged 71–80 years; No-treatment control: five participants (three men, two women) 69–91 years.

Ziegler && et al. [35 ]

Participants

Design

Authors

Table 1. Studies of the effectiveness of behavioral interventions for presbyphonia

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Berg et al. [43]

Retrospective records review with cases and controls.

Nineteen patients (10 women and Vocal education, resonant voice, and VFE for average of 5.1 nine men) with age-related dysmonths (4.1 sessions). phonia who chose to undergo voice therapy, mean age 73 years (6). Six patients (three women and three men) with age-related dysphonia who chose not to have therapy, mean age 66 years (6). No patient had concomitant diagnosis contributing to vocal symptoms.

Two male 79-year-old monozygo- Unsuccessful injection laryngotic twins with severe vocal fold plasty prior to voice therapy bowing, and complaints of and four sessions of VFE with hoarseness, vocal weakness, twice daily home practice. and dysphagia.

54 patients had 1–7 sessions of (mean 2.6) voice therapy: individually designed adapted LSVT, cup bubbles, resonant voice, and flow phonation. Patients with mild bowing underwent VFE.

Behavioral intervention

Tanner et al. [28] Prospective prepost case study.

Sixty-seven patients (34 women and 33 men) aged 56–91 years, all with hoarseness, vocal fold atrophy, and no laryngeal or neurological pathology.

Participants

Nine patients with presbylaryngis 6 weeks VFE (6  60-min ses(bowed vocal folds or dominant sions) and twice daily home open phase and no other practice. laryngeal pathology) (two women and seven men) aged 67–90 years.

Retrospective single-group prepost records review; correlational component.

Design

Sauder et al. [21] Prospective single-group prepost descriptive study.

Mau et al. [26]

Authors

Table 1 (Continued) Findings

V-RQOL

VHI; Phonatory function: MPT; Acoustic: F0, jitter, shimmer, HNR, Spectral mean and SD; Stroboscopy: mid-membranous and posterior glottal closure.

Acoustic: jitter, shimmer, HNR, speaking F0; Phonatory function: MPT; Auditory-Perceptual: overall severity, breathiness, strain; VHI; Self-rated severity and vocal effort; Stroboscopy: percentage of closed phase, percentage of closing phase, ratio of opening to closing phase, degree of glottal closure, glottal gap size, supraglottic compression.

Cases: significant improvement in V-RQOL, with 74% improving, overall change from moderateto-mild perceived dysphonia. Adherent cases improved significantly more than partially adherent cases. Controls: no significant change in V-RQOL (moderate-perceived dysphonia).

Midmembranous and posterior glottal closure increased and VHI improved after VFE (no statistical analysis) for both twins. No substantive improvement in acoustic measures (both twins remained severely impaired).

Significant posttreatment improvement in VHI, reduced self-rated severity and vocal effort, and reduced overall severity, breathiness and strain. No change in acoustic measures, MPT, and stroboscopy measures.

Clinician-rated NOMS: functional Significant increase in NOMS communication measures for scores after treatment (85% voice [42]. improved), regardless of age. Patients with better pretreatment glottal closure achieved higher posttreatment NOMS scores. Patients with higher burden of chronic medical conditions showed significantly less improvement on NOMS scores.

Voice outcome measures

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GRBAS, grade, roughness, breathiness, asthenia, and strain; HNR, harmonic-to-noise ratio; LSVT, Lee Silverman voice treatment; LMRVT, Lessac–Madsen resonant voice therapy; MPT, maximum phonation time; NHR, noise-to-harmonic ratio; NMES, neuromuscular electrical stimulation; NOMS, national outcomes measurement system; PhoRTE, phonation resistance training exercise; RMS, root mean square; SD, standard deviation; SPI, soft phonation index; VFE, vocal function exercises; VHI, Voice Handicap Index; V-RQOL, voice-related quality of life measure.

Gorman et al. [44]

Single-group prepost descriptive study.

Significant increase in MPT and Nineteen male patients aged 60– VFE once/week for 12 weeks Aerodynamic: open quotient, significant changes in aerody78 years with vocal fold bowwith twice daily home practice. maximum flow declination rate, namic measures, indicating ing or anterior glottal gap and minimum and peak glottal flow, reduced glottal airflow, more no respiratory or neurological subglottal pressure, RMS avercomplete glottal closure, and condition or vocal fold patholage (amplitude of acoustic increased subglottic pressure. ogy. energy); Phonatory function: MPT.

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showed that combined approaches incorporating voice care education, resonance, flow phonation, semi-occluded vocal tract postures, and neuromuscular electrical stimulation were associated with improved vocal functioning. Only one of these 10 reports did not yield promising results. The retrospective chart review conducted by Gartner-Schmidt and Rosen [38] demonstrated that two-thirds of older patients with vocal fold atrophy chose not to undergo voice therapy. These authors also concluded that there was a low rate of success for patients who did have therapy. The report provided by GartnerSchmidt and Rosen [38] is, however, inconclusive, so that more weight should be ascribed to the 90% of studies yielding positive results. Despite these promising research findings, the overall strength of the evidence provided by previous research is weak, with most studies providing relatively low-level evidence. Most studies used single-group prepost designs, several of which were retrospective. Such designs yield only weak evidence and are inadequate as a basis for creating clinical guidelines [45–47]. The only reported study in the last 10 years that provides even moderate evidence for the effectiveness of behavioral interventions for age-related dysphonia was conducted by Ziegler et al. [35 ]. This study was prospective and randomized and included both comparison and no-intervention control groups. This study demonstrated significant improvements in voice-related quality of life after both VFE and PhoRTE and no change for control patients, thus indicating that these intervention methods have greater research support than other behavioral methods trialed to date. However, because the effectiveness of alternative voice training methods has not been adequately evaluated or compared directly with VFE and PhoRTE, further investigation is required before the latter can be considered as preferred methods. Many additional limitations are associated with the 10 studies reported here and these must temper conclusions as to the effectiveness of speech therapy interventions for age-related dysphonia. These limitations include the mostly small sample sizes, absence of power analysis to estimate sample size, use of only descriptive statistical analyses, and lack of reporting of effect sizes and confidence intervals. Other deficits of this body of research include application of imprecise inclusion and exclusion criteria for participant selection and for the diagnosis of presbyphonia [14 ]. Some studies restricted participant selection to individuals demonstrating vocal fold bowing and/or atrophy and/or glottal gaps (e.g., [36,38,40,44]), whereas others required participants to demonstrate and/or self-report auditoryperceptual signs of dysphonia in addition to these

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laryngeal signs (e.g., [21,26,28,35 ,43]). One study recruited older individuals but did not require participants to show signs of presbyphonia [29]. It should be noted, however, that the purpose of the latter study was to establish whether vocal exercise could improve vocal functioning in older choral singers rather than to determine the effectiveness of voice interventions in reducing the signs of presbyphonia. Some studies applied inclusion/exclusion criteria to rule out comorbid voice or medical conditions that could have led to vocal impairments (e.g., [21,26,35 ,40,43,44]), yet the selection criteria used in other studies did not allow the researchers to control for such potentially confounding conditions (e.g., [28,36,38]). Taken together, these varying participant selection criteria make it difficult to directly compare findings across studies. Another relevant consideration is whether or not vocal fold bowing, atrophy, and other patterns of incomplete glottal closure are sufficiently specific and sensitive for a diagnosis of presbyphonia [25]. It is well known that these laryngeal signs can arise from pathological processes other than normal physiological aging [9,10 ,14 ,22,48]. It is therefore possible that the vocal signs of some participants in the studies reviewed were due to pathological processes associated with age rather than aging per se. In some reports there is imprecise reporting of intervention procedures and intervention schedules and lack of comprehensive measures of vocal functioning. The former limits the extent to which studies can be replicated or applied in clinical settings, as well as our ability to determine what amount, duration, and intensity of voice therapy is most effective. In terms of the adequacy of measures of vocal functioning, several studies used self-reported or clinician-rated measures of symptoms or V-RQOL as their only outcome tool (e.g., [26,35 ,38]). Others have used differing combinations of patients’ reports of symptoms and their impacts, auditory-perceptual, acoustic, aerodynamic, and videostroboscopic measures (e.g., [21,28,36,40,43,44]). This heterogeneity again makes comparison of findings across studies difficult. Further, whether or not the outcome measures used in these studies are sufficiently sensitive and specific to vocal functioning in presbyphonia is not clear. Further, although a no-intervention control group was included in the study reported by Ziegler et al. [35 ], none of these 10 studies included an experimental treatment control group (e.g., a sham treatment group). It is therefore not possible to evaluate whether a placebo effect may account for vocal improvements following intervention [29,35 ]. The lack of no-treatment control groups in most studies also means that it is not possible to determine &&

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whether the interventions used in those studies were better than no treatment. Because recent studies rarely incorporate even medium-term follow-up evaluations, whether or not intervention gains can be maintained in the longer term remains unknown [21,35 ,36]. In addition, this body of research has yielded little evidence as to the predictors of successful intervention for older people with presbyphonia. Although Mau et al. [26] demonstrated that patients with a smaller number of comorbid medical conditions and smaller glottal gaps achieved greater gains after voice therapy, there has been no rigorous and systematic investigation of who is likely to do best through behavioral interventions. Finally, at an even more fundamental level, although the authors of some studies have selected voice interventions on the basis of evidence as to specific underlying physiological mechanisms for presbyphonia and/or on the basis of evidence as to effective approaches to mitigating aging effects on general physical functioning (e.g., [21,29,35 ]), most have simply taken what is known about the vocal consequences of aging as their general rationale (e.g., [26,36,38,43,44]). It may be that the former would lead to the development of better-targeted intervention methods [48]. &&

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RECOMMENDATIONS FOR FUTURE RESEARCH TO STRENGTHEN THE EVIDENCE BASE FOR SPEECH THERAPY INTERVENTIONS FOR PRESBYPHONIA Because the strength of the evidence for the effectiveness of behavioral interventions for presbyphonia is weak in several respects, substantial additional research effort is warranted. Stronger research designs are essential. Adequately powered randomized controlled trials, or at the very least, quasiexperimental studies with control and comparison groups, are required. Different behavioral techniques should be directly compared and incorporation of sham interventions as an additional control condition should be considered. Consideration should also be given to multivariate predictive designs that will allow clinicians to determine which older people are most likely to benefit from intervention. Predictive designs would also allow conclusions as to what clinician and intervention factors (e.g., amount and intensity of vocal exercise) are associated with the best treatment outcomes. Participants’ selection criteria need to be more specific, with clearer operational definitions of presbyphonia and more precise inclusion and exclusion criteria applied. Comprehensive voice outcome measures should be carefully selected, preferably Volume 22  Number 6  December 2014

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Speech therapy treatment of dysphonia in the elderly Oates

on the basis of new research as to which combination of voice measures is most sensitive and specific for presbyphonia and on the basis of the measures’ responsiveness to voice change in older people. Similarly, the intervention methods trialed should be selected with stronger rationales, preferably rationales derived from what is known about the underlying physiological mechanisms of vocal impairment in presbyphonia rather than assumptions derived from what is assumed about the consequences of vocal aging. Voice training methods and treatment schedules should be described in sufficient detail to allow replication and clinical application and medium and longer term followups should be incorporated.

CONCLUSION It is clear that older people represent an increasing proportion of those referred to voice clinics in developed countries and that behavioral interventions have the potential to improve the vocal functioning of these individuals. At this time, however, the evidence base for the effectiveness of voice therapy and other behavioral interventions is not sufficiently strong. It is not yet clear which voice therapy methods are most effective, which older people are likely to benefit most from speech therapy management, or what amount and intensity of voice training is required. Although previous research indicates that behavioral interventions, such as VFE, PhoRTE, and adapted LSVT, are very promising, further research is required before clinicians can be confident in developing vocal exercise programs and selecting voice therapy methods for their older patients. Acknowledgements No funding has been received by the author for work on this manuscript. Conflicts of interest The authors have no conflicts of interest to declare.

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Treatment of dysphonia in older people: the role of the speech therapist.

This review addresses speech therapy interventions for older adults experiencing voice impairments. The prevalence, impact, and nature of voice impair...
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