Vocal Loading and Environmental Humidity Effects in Older Adults

doi:10.1016/j.jvoice.2017.02.002

Journal of Voice

Volume 31, Issue 6, November 2017, Pages 707-713

https://doi.org/10.1016/j.jvoice.2017.02.002 Get rights and content

Objective

The goal of this study was to investigate the effects of a vocal loading challenge that combined prolonged speaking, in child-directed voice within a noisy environment, in older adults. An additional goal was to determine whether increased environmental humidity would attenuate the negative effects of this vocal loading challenge.

Method

Thirteen healthy subjects (five males and eight females; >65 years) completed a vocal loading challenge. The challenge involved 45 minutes of child-directed speech in the presence of 65 dB multitalker babble background noise. Subjects completed this challenge in both low humidity and moderate humidity in counterbalanced order. Vocal function was assessed before and after the challenge using phonation threshold pressure (PTP), cepstral peak prominence (CPP), low/high spectral ratio (LHR), perceived phonatory effort (PPE), and perceived vocal tiredness.

Results

Negative changes were observed in the aging larynx following the 45-minute vocal loading challenge. Measures of PTP, PPE, and perceived vocal tiredness demonstrated statistically significant loading effects. Increased ambient humidity significantly alleviated the negative changes observed in PPE and perceived vocal tiredness. Increased humidity significantly improved CPP measures both before and after the vocal loading challenge.

Conclusions

This study furthers our understanding of how older adults respond to a vocal loading challenge of prolonged nonhabitual speech in a noisy environment. Our data suggest that the aging voice is negatively affected by prolonged loud speaking and that humidification may be beneficial in reducing some of these negative effects.

Introduction

Advancing age is a significant risk factor for voice problems.1, 2, 3, 4, 5 The United States had approximately 46 million older adults in 2014 (>65 years old)⁶ and the elderly population is projected to almost double by the year 2050.⁷ To better treat voice problems associated with aging, it is important to understand the factors that increase vulnerability to voice disorders in this population. Both intrinsic (eg, genetic, anatomic, and voicing characteristics) and extrinsic or environmental (eg, ambient hydration level background noise) factors are thought to exacerbate the negative effects of prolonged voice use and increase susceptibility to voice problems. One approach to investigate the effects of these factors is in the context of a vocal loading challenge.⁸ Although there is considerable literature reporting on the effects of vocal loading challenges in young speakers,9, 10, 11, 12, 13, 14 the effects of vocal loading challenges in older adults remain unexplored.

Vocal loading challenges refer to voice tasks that stress the larynx and compromise optimal laryngeal function.⁸ Prolonged loud reading has typically been utilized in vocal loading challenges9, 11, 13, 15 These traditional vocal loading challenges have effectively induced negative voice changes; however, their duration (oftentimes over 90 minutes) renders them impractical for use with an elderly population or for use with patients. As such, producing a vocal loading challenge of shorter duration is a clinically relevant goal. Emerging evidence would suggest that altering vocal quality or suprasegmental speech features may load the larynx more efficiently than habitual speech.¹⁶ Nonhabitual vibratory modes may induce detrimental voice changes more quickly than habitual speech.¹⁶ The suprasegmental features of child-directed speech differ from that of typical adult speech. These differences include elevated pitch and atypical intonation patterns.17, 18, 19 In addition, the effects of child-directed speech in older adults have ecological validity as it may be used by these individuals in conversation with young members of the family. To the best of our knowledge, the laryngeal effects of child-directed speech have not been investigated; however, vocal loading challenges utilizing similar voicing patterns of elevated volume and altered vocal quality have been shown to produce negative laryngeal changes in the healthy, young larynx.¹⁶

Extrinsic variables are often manipulated to exacerbate the detrimental effects of prolonged voice use. Airway dehydration, for example, can negatively impact voice production.20, 21, 22, 23, 24 Increasing systemic hydration may partially attenuate the negative effects of vocal loading challenges; however, results have been mixed and have not been examined in older adults.25, 26 An alternate method to increase airway hydration is to target surface mechanisms. Increasing airway surface hydration by increasing environmental humidity during a vocal loading challenge has only been studied with young subjects.16, 27 Investigating these effects across the life span is an important endeavor, as it is currently unknown how older speakers may respond to increased environmental humidity.

In this study, older individuals (>65 years) completed a 45-minute vocal loading challenge on two consecutive days. The only difference between days was the ambient humidity that was adjusted to low or moderate levels. The literature suggests that the effects of vocal loading are best captured using a combination of acoustic, aerodynamic, and self-reported voice measures.⁸ Emerging evidence suggests that acoustic measures such as cepstral peak prominence (CPP) and low/high spectral ratio (LHR) may be sensitive to subtle laryngeal changes induced by vocal loading challenges. These measures are particularly useful as they can be applied to continuous speech, as opposed to sustained vowels.11, 28, 29, 30, 31, 32 A recent study from our laboratory revealed that CPP was sensitive to the adverse effects of a 30-minute vocal loading challenge.¹⁶ Therefore, these cepstral measures were included in the current study. In addition, the aerodynamic measure of phonation threshold pressure (PTP) was utilized to determine the effects of the vocal loading challenge and humidity. PTP has been observed to be consistently sensitive to the effects of vocal loading challenges in healthy speakers.8, 25, 26 In addition, there is evidence that airway dehydration may increase PTP.21, 22, 33, 34, 35, 36 Self-perceived measures of phonatory effort and perceived vocal tiredness have also been reported to increase following vocal loading challenges9, 14, 37, 38 and airway dehydration.³⁹

This study investigated the effects of a vocal loading challenge in older adults. The vocal loading challenge consisted of 45 minutes of loud, child-directed speech in the presence of background noise. Additionally, we quantified if increased environmental humidity would attenuate the negative effects of vocal loading. Therefore, the vocal loading challenge was completed in low humidity and moderate humidity in counterbalanced order across subjects. It was hypothesized that older adults would be adversely affected following the 45-minute vocal loading challenge and that the detrimental vocal effects would be greater in low humidity as compared to moderate humidity.

Section snippets

Participants

Thirteen healthy adults (five males and eight females) participated in this investigation. Procedures were approved by the Purdue University Institutional Review Board. Participants were between 65 and 78 years of age (mean age: 72 years), reported general good health, and denied a history of laryngeal or respiratory disease.

Screening

Screening protocols included audiometry (Diagnostic Audiometer AD229e, Interacoustics A/S, Assens, Denmark), refractometry (ATAGO refractometer, Bellevue, WA), the Vocal

Effects of vocal loading

Negative voice changes were observed following the vocal loading challenge. Significant main effects for loading were observed for PTP₁₀, PTP_20, PPE, and perceived vocal tiredness. PTP₁₀ increased significantly from baseline (Mean ± SD: 5.50 ± 1.24) to postloading (6.16 ± 1.24; F = 19.92, df = 1, 9, P = 0.002, Figure 1). Similarly, PTP₂₀ significantly increased from baseline (5.21 ± 0.95) to postloading challenge (6.10 ± 0.98; F = 23.86, df = 1, 9, P = 0.001, Figure 2). PPE significantly

Discussion

This study investigated the effects of a vocal loading challenge in older subjects. In addition, we examined whether environmental humidity would mitigate these effects. Changes in voice measures were induced by 45 minutes of loud reading using child-directed speech in 65 dB background noise. Moderate humidity reduced the negative effects of the vocal loading challenge on some voice measures. Specifically, self-reported measures of effort and tiredness improved with increased humidity. In

Conclusions

In conclusion, vocal loading was induced in older adults using a 45-minute vocal loading challenge involving child-directed speech. Measures of PTP, PPE, and perceived vocal tiredness demonstrated statistically significant loading effects. Increased ambient humidity alleviated the loading-induced increases in PPE and perceived tiredness_. Moderate humidity improved CPP data both before and after the vocal loading challenge. Increasing environmental humidity may serve as an option to alleviate

Acknowledgments

We would like to acknowledge the contributions of Abigail Chapleau, Jena Lutz, and Logan Mahoney in data collection and analysis. We would like to thank Barbara Solomon CCC-SLP and Dawn Wetzel CCC-SLP for their assistance with perceptual voice ratings. We would also like to thank Chris Rearick, MSN, RN, Purdue University, for helping in participant recruitment.

References (51)

C. Plank et al.
Voice and health-related quality of life in the elderly
J Voice
(2011)
S. Linville
Changes in glottal configuration in women after loud talking
J Voice
(1995)
L. Enflo et al.
Collision and phonation threshold pressures before and after loud, prolonged vocalization in trained and untrained voices
J Voice
(2013)
J.C. Stemple et al.
Objective measures of voice production in normal subjects following prolonged voice use
J Voice
(1995)
M. Gelfer et al.
Documenting laryngeal change following prolonged loud reading: a videostroboscopic study
J Voice
(1996)
R. Hemler et al.
The effect of relative humidity of inhaled air on acoustic parameters of voice in normal subjects
J Voice
(1997)
JiangJ. et al.
The effects of rehydration on phonation in excised canine larynges
J Voice
(1999)
N. Solomon et al.
Effects of a vocally fatiguing task and systemic hydration on men's voices
J Voice
(2003)
Y.D. Heman-Ackah et al.
The relationship between cepstral peak prominence and selected parameters of dysphonia
J Voice
(2002)
S. Lowell et al.
Spectral- and cepstral-based measures during continuous speech: capacity to distinguish dysphonia and consistency within a speaker
J Voice
(2011)

ChangA. et al.

Perceived phonatory effort and phonation threshold pressure across a prolonged voice loading task: a study of vocal fatigue

J Voice

(2004)

C. Nanjundeswaran et al.

Vocal fatigue index (VFI): development and validation

J Voice

(2015)

P. Belafsky et al.

Validity and reliability of the reflux symptom index (RSI)

J Voice

(2002)

J. Golub et al.

Prevalence of perceived dysphonia in a geriatric population

J Am Geriatr Soc

(2006)

N. Roy et al.

Epidemiology of voice disorders in the elderly: preliminary findings

Laryngoscope

(2007)

J. Marino et al.

The epidemiology of dysphonia in the aging population

Curr Opin Otolaryngol Head Neck Surg

(2014)

S. Schneider et al.

Voice function and voice-related quality of life in the elderly

Gerontology

(2011)

S. Colby et al.

Projections of the size and composition of the U.S. population 2014-2060

(2014)

J. Ortman et al.

An aging nation: the older population in the United States

(2014)

R. Fujiki et al.

A review of vocal loading tasks in the voice literature

J Voice

(2016)

L. Kelchner et al.

Effects of prolonged reading on normal adolescent male voices

Lang Speech Hear Serv Sch

(2006)

E. Lauri et al.

Effects of prolonged oral reading on time-based glottal flow waveform parameters with special reference to gender differences

Folia Phoniatr Logop

(1997)

A.M. Laukkanen et al.

Changes in voice and subjective sensations during a 45-min vocal loading test in female subjects with vocal training

Folia Phoniatr Logop

(2004)

R. Fujiki et al.

The interaction of surface hydration and vocal loading on voice measures

J Voice

(2016)

C. Ferguson

Baby talk in six languages

Am Anthropol

(1964)

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: This study was presented at the 45th Annual Symposium: Care of the Professional Voice, Philadelphia, Pennsylvania, June 1–5, 2016.

¹: These authors contributed equally to this work.

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