Factors associated with voice disorders among the elderly: a systematic review

www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

REVIEW

ARTICLE

Factors

associated

with

voice

disorders

among

the

elderly:

a

systematic

review

夽

Amanda

Cibelly

Brito

Gois

_,

_Leandro

_de

_Araújo

_Pernambuco

_,

_Kenio

_Costa

_de

_Lima

b_{UniversidadeFederaldaParaíba(UFPB),DepartamentodeFonoaudiologia,JoãoPessoa,PB,Brazil}

Received2October2017;accepted24November2017 Availableonline26December2017

KEYWORDS Voicedisorders; Epidemiology; Cross-sectional studies; Aged Abstract

Introduction:Duringtheagingprocess,naturalmodificationsoccurinthelarynxandthe struc-turesinvolvedinphonationwhich explainthespecificcharacteristicsfound inthevoicesof elderlypersons.When,atanymoment,avoicefailsandthereisinterferencewith commu-nication,avoice disorderhasoccurred.This cangeneratedisadvantages incommunicative efficiencyandhaveanegativeimpactonqualityoflife,compromisingmechanismsof social-ization,themaintenanceofautonomy,andthesenseofwell-being.Nevertheless,thereappears tobelittleclarityaboutwhichfactorsareassociatedwithvoicedisordersinthispopulation, especiallyfromanepidemiologicalperspective.

Objective:The presentstudy isaliteraturereviewtoidentifyfactorsassociatedwithvoice disordersamongtheelderlydescribedinpopulation-basedstudies.

Methods:A systematicreview ofelectronicdatabaseswas carried out. The methodological qualityofthestudieswasanalyzedwiththeStrengtheningtheReportingofObservational Stud-iesinEpidemiologyguidelines.Theresearchwasconductedindependentlybytworesearchers. Results:Althoughtwoarticlesmettheeligibilitycriteria,nonefulfilledallthecriteriaforthe evaluationofmethodologicalquality.Accordingtothetwostudiesselectedforthisreview, fac-torsassociatedwithvoicedisordersamongtheelderlyincludedbothphysicalandpsychosocial aspects.However,themethodologicaldiscrepanciesbetweenthestudies,particularlyin rela-tiontosampleselection andtheinstrumentsusedindicategreatvariabilityandcompromise thereliabilityoftheresults.

夽 _{Pleasecitethisarticleas:GoisAC,PernambucoLA,LimaKC.Factorsassociatedwithvoicedisordersamongtheelderly:asystematic}

review.BrazJOtorhinolaryngol.2018;84:506---13.

∗_{Correspondingauthors.}

E-mails:[email protected](A.C.Gois),[email protected](L.A.Pernambuco).

PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial. https://doi.org/10.1016/j.bjorl.2017.11.002

1808-8694/©2017Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

Conclusion: Furtherprevalencestudiesandinvestigationsoffactorsassociatedwithvoice dis-ordersintheelderlyfromanepidemiologicalperspective,andwhichinvolvedifferentcultures, shouldbecarriedout.

© 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/). PALAVRAS-CHAVE Distúrbiosdevoz; Epidemiologia; Estudostransversais; Idoso

Fatoresassociadosaalterac¸õesvocaisemidosos:umarevisãosistemática

Resumo

Introduc¸ão: Duranteoprocessodeenvelhecimento,modificac¸õesnaturaisocorremnalaringe enasestruturasenvolvidasnafonac¸ãoqueexplicamascaracterísticasespecíficasencontradas nas vozes depessoas idosas. Quando,aqualquer momento, a voz falhae háinterferência comacomunicac¸ão,ocorreumdistúrbiodevoz.Issopodegerardesvantagensnaeficiênciade comunicac¸ãoeumimpactonegativosobreaqualidadedevida,comprometendoosmecanismos desocializac¸ão,amanutenc¸ãodaautonomiaeosentidodebem-estar.Entretanto,aindanão estãoclarosquaisosfatoresassociadosaosdistúrbiosdevoznestapopulac¸ão,especialmente considerando-seumaperspectivaepidemiológica.

Objetivo: Opresenteestudoéumarevisãodaliteraturaparaidentificarfatoresassociadosa distúrbiosdevozemidososdescritosemestudosdebasepopulacional.

Método: Foirealizada uma revisãosistemáticadas basesdedados eletrônicas.A qualidade metodológicadosestudosfoianalisadautilizando-seasdiretrizesStrengtheningtheReporting ofObservationalStudiesinEpidemiology.Apesquisafoirealizadadeformaindependentepor doispesquisadores.

Resultados: Emboradoisartigostenhampreenchidooscritériosdeelegibilidade,nenhumdeles preencheutodososcritériosparaaavaliac¸ãodaqualidademetodológica.Deacordocomosdois estudosselecionadosparaestarevisão,osfatoresassociadosaosdistúrbiosdevozemidosos incluíram aspectos físicos e psicossociais.Entretanto, asdiscrepâncias metodológicas entre osestudos,particularmenteemrelac¸ãoàselec¸ãodaamostraeaosinstrumentosutilizados, indicamgrandevariabilidadeecomprometemaconfiabilidadedosresultados.

Conclusão:Devemserrealizadosestudosdeprevalênciaeinvestigac¸õesdefatoresassociados adistúrbios de vozem idososa partirde umaperspectiva epidemiológicae quelevem em considerac¸ãodiferentesculturas.

© 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).

Introduction

Theagingprocessisdeterminedbyfactorsthatarepresent frombirth and develop throughout life according to indi-vidual variations.1 _{During this process, there are natural}

changesinthelarynxandstructuresinvolvedinphonation that can explain the specific characteristics found in the voicesofelderlypersons,2_{suchashoarseness,breathiness,}

aphonia,vocalfatigue,effortrequiredtoimprovevocal pro-jection,areductioninvocalextension,atremulousvoice, difficultyincontrollingvocalintensity,painintheregionof theshoulder girdle,andasensation of burning,odor or a foreignbodyinthelarynx.3

When, at any moment, the voice fails or is perceived by the individualtobe different thannormal, interfering withcommunication,a voicedisorder(VD) hasoccurred.4

The prevalence of VDs amongthe elderly is estimated to rangefrom 4.8%to 29.1%5 _{andhas a greatbiological and}

psychosocial impact,6 _{which can lead todisadvantages in}

communicativeefficiency and have a negative impact on qualityof life,compromising mechanismsofsocialization, themaintenanceofautonomyandthesenseofwell-being.7

Inthissense,itisimportantthatcaringforthevoiceofthe elderlyisbasedonpreventivebehaviorsandthesubsequent increaseofvocalefficiency.8_{Toachievethis,itisimportant}

toknow what factors areassociated withVDs amongthe elderly.

Theliteraturedescribeshowthevoicesofelderlypersons canbeaffectedbythephysical,psychicandlifehistoryof individuals,aswellasbadhabitsandconstitutional,racial, hereditary,alimentary, social and environmental factors.9

Despitethis,thereseemstobelittleclarityaboutwhat fac-torsareassociatedwithVDsin thispopulation,especially fromanepidemiologicalperspective,whichcanguarantee therepresentativeness of a givenpopulation. Considering thisvacuum,theobjectiveofthissystematicreviewof lit-eraturewastoidentifyfactors associatedwithVDsinthe elderlyasdescribedinpopulation-basedstudies.

Methods

Asystematic review of literature published between Jan-uary 1900 and October 2016 was performed, including periodicalsindexedintheMEDLINE/PubMed,Embase, Sco-pus, Web of Science, CINAHL, Cochrane, PsycInfo, PAHO, WHOLIS, SciELO and Lilacs/BIREME electronic databases. Thesearchstrategyinvolvedthefollowingcombinationsof searchdescriptorsbasedontheMedicalSubjectsHeadings (MeSH): (epidemiology) AND (cross-sectional studies) AND (observationalstudies)AND(associatedfactors)AND(voice ORvoicedisorders)AND(agingORage).Thesame combina-tionswereusedinPortuguesewhensearchingthedatabases oftheSciELOandLilacs/BIREMEelectronicdatabases.

The following inclusion criteriawere adopted: original articles published or accepted for publication in English, SpanishorPortuguese,anda populationaged60andover for developing countries and65 years of age or older for developedcountries,inaccordancewithWorldHealth Orga-nizationcriteria.Theexclusioncriteriaappliedwerearticles thatconsideredelderlyindividualsaspartofthesample,but didnotexplicitlydescribetheresultsforthisspecificgroup. Thestudieswereevaluatedindependentlybytwo differ-entresearchers.Afterwards, theanalyses were compared and some divergence was observed, which was resolved by consensus. After the articles were identified in the databases,ascreening phasewascarriedout,which con-sisted of reading the respective titles and abstracts and excluding articlesthatdid notmeet theinclusion criteria mentioned above. In the eligibility phase, the remaining articlesthathad undergonescreening anddealt with fac-torsassociatedwithVDsweresubmittedtoafull-textreview (Table1).

Thefollowingdatawereextractedfromthearticlesthat mettheeligibilitycriteria: locationof study;samplesize; age and gender of participants (minimum, maximum and average);definitionofassociatedfactors;diagnostictools; prevalenceandpossiblebiasesorcomments.Theevaluation ofthemethodologicalqualityofthestudieswascarriedout inaccordancewiththeSTROBEcriteria.10

Results

Amongthe1127initialstudiesidentifiedbythesearch strat-egy,43wereselectedforareviewofthefulltext.Ofthese, twomet theinclusioncriteria. Fig.1shows theflowchart ofthesearchstrategyandTable1presentsthe character-isticsof the studies that met the eligibility criteria. The articlesincludedwerepublishedin2007and2015andwere conductedintheUSAandKorea,respectively.

Thetwostudiesexclusivelyevaluatedelderlypersonsand describeddistributionbasedonage andgender.The asso-ciated factors investigated by the authors in the articles differed.Toobtaintheirdata,theauthorsoftheAmerican articleadaptedaquestionnairetheyhadgeneratedandused inapreviousstudycarriedoutwiththegeneralpopulation. IntheKoreanarticle,datageneratedfromanationalsurvey, entitledtheKoreaNationalHealthandNutrition Examina-tionSurvey(KNHANES)wereused.

InthestudyconductedintheUSA,thefactorsassociated withvoice disorders were found to be relatedto clinical andpsychological conditions,such ascolds, sore throats, gastroesophagealreflux,arthritis,thyroid problems, bron-chitis, sleep disorders and anxiety or frustration. In the Koreanstudy,theassociatedfactorswererelatedtoplace of residence, Body Mass Index (BMI), self-reported gen-eralhealthstatus,asthma, chronic obstructivepulmonary

disease (COPD),thyroid disease,vocal fold disease, cere-brovasculardiseaseanddepression.

Neither of the two studies met all the STROBE crite-ria (Table2)following methodologicalqualityassessment. Seven STROBE items (9, 12.4, 12.5, 13.2, 13.3, 16.1 and 16.3)werenot coveredbyeither article.Inaddition,two furtheritems(7and11)wereonlypartiallyachieved,orthe datawere notclearin botharticles.There were method-ological discrepancies between the studies. Therefore, it wasnotpossibletoperformameta-analysis.

Discussion

According tothetwostudiesselected forthis review,the factorsassociatedwithVDsamongtheelderlyincludedboth physical and psychosocial aspects. One associated factor commontoboth studies wasrespiratory condition, repre-sentedbycolds,bronchitis,asthmaandCOPD.Respiratory diseases are often associated withvoice disordersdue to inflammatoryconditionsandedemapresentinthe respira-torymucosa,11---13_{whichmayaffectthestructuresinvolvedin}

thephysiologyofphonation.Anotherfactorthatmayexplain thisassociationwouldbethesideeffectsproducedbythe drugsusedtocombattheseconditions,whichcanaffectthe salivaryglandsandrespiratorymucusintheelderly.14---16

Another factor associated with voice disorders was gastroesophageal reflux (GER).17 _{It is proven that}

diges-tive systemdisorders,includingGER,18 _{impairtheprocess}

of phonation by preventing the free movement of the diaphragm,favoringtheaspirationofsecretionsand alter-ingvasomotorfunctioningbystimulatingthevagusnerve.19

Physiological changesin the esophagus during aging,such asdecreased salivaflow,reducedmotility andesophageal sphincter pressure and hiatal hernias may influence the prevalenceandseverityofGER.19 _{Inaddition,acidcontent}

may harm the larynx and generate inflammation, which diminishesthecommunicativeefficacyoftheindividualand cancauseoraggravatevoicedisorders.20

Thyroidproblems weredescribed asfactors associated withvoicedisordersinboth studies.Thyroiddiseasesmay beassociatedwithroughnessofvoice,shortnessofbreath whenspeaking,effortwhenspeaking,anduncertaintyabout howthevoicewillemergeat thestartof emission.21 _This

is because deregulation in the production of thyroid hor-monescanleadtochangesinthelaminapropriaorexcess metabolic processes, which leads to wear of the vocal folds.22,23 _{Itcanbeinferredthatregardlessof thetypeof}

thyroiddisease,theremaybephysiologicalchangesrelated tothephonatoryapparatus, either atvocal or respiratory levels.

VDsamongtheelderlywere alsoassociated withplace of residence, BMI and depression.4,24 _{Older people living}

in urban areas are more exposed to air pollution, which canirritatethepharyngealandrespiratorymucosaandthus triggersomekindofvoicedisorder.24_{Bodyweight,another}

factor thatinfluencesthevoice,canaffectvocal function throughchangesintheabdominalrespiratorysupport.When this decreases, the larynx mayalso undergophysiological andstructuralchanges,includinglaryngealmuscleatrophy, thinning ofthe elasticandcollagen fibers, anddecreased amountofhyaluronicacidinthevocalfolds.25

Rheumatoid arthritis was mentioned in the American studyasafactorassociatedwithVDs.Thisdiseasecancause lesions in the larynx, inflammation, edema, swelling and drynessofthevocalfolds,26,27_{withvocalnodulesacommon}

Table1 Characteristicsofstudiesincluded,withmethodologicalqualityevaluatedinaccordancewiththeSTROBEcriteriafor cross-sectionalstudies.

Reference Location Population Sample Gender Age Instrument Factorsassociated withvocal alterations Royetal. (2007) Utahand Kentucky, USA Elderly individuals aged65 yearsor older 117elderly individuals 39 (33.3%) menand 78 (66.7%) women 65---94 years (76.1±8.5) Interview basedon adaptation of instrument usedin previous study(Roy, Merril, Thibeault, Parsa,Gray &Smith, 2004) Colds Sorethroat Gastroesophageal reflux Arthritis Thyroidproblems Bronchitis Sleepdisorders Feeling anxious/frustrated Ryuetal. (2015) Korea Elderly individuals aged65 yearsor older 3759 elderly individuals 1542 (41%) menand 2217 (59%) women 65years andolder (72.4±5.5) TheKorea National Healthand Nutrition Examination Survey (KNHANES) Areaofresidence BodyMassIndex (BMI) Self-ratedhealth status Asthma Chronicobstructive pulmonarydisease (COPD) Thyroiddisease Cerebrovascular disease

Vocalfolddisease Depression

General state ofhealth canbe affectedbythe physio-logicalmodificationsinthecommunicationskillsduringthe courseofaging29_{whentheybegintointerfereinthesocial}

lifeoftheelderly.30_{Alterationsinthevoiceduetochanges}

inthespeechapparatus31_{canhaveaprofoundinfluenceon}

thepsychosocialaspectsof elderlyindividuals,interfering intheirsocialfunctioning.32

VocalfolddiseasewasassociatedwithVDsin thestudy conductedin theUnitedStates.Elderly personswhohave voiceproblemshavediseasesassociatedwithaging,suchas benignvocalfoldlesions,inflammatorydisorders,laryngeal cancerandlaryngealparalysis.33

BMI was also associated with voice disorders in the Koreanstudy.Obeseelderlypersonsmaypresentpathologies suchascardiovasculardisease,metabolicsyndrome, respi-ratorydiseases suchas sleepapnea, psychiatricdiseases, neoplasias, dyslipidemias and others,34 _{demonstrating an}

association withvoicedisorders, astheycan cause physi-ologicalchanges inthe larynxor psychological changesin theindividual.

Neurological lesions can cause voice disorders, as in casesofdysarthria,whichisthespeechdisordercausedby neurologicalinjury,whichaffectsmotorexecution.35 _Voice

disorders caused by brain lesionswill not always be spe-cifictothetypeoflesion,astherecoveryofthefunctions observed in the stable phase of the impairment and the

vocaldeteriorationcommontotheagingprocessareoften associated.36

Sleep disturbance was another factor associated with VDsdescribedinanarticle.Agingmaybringaboutchanges in usual sleep patterns, such as the quantitative reduc-tion of the stages of deep sleep and an increase in the stagesofsuperficialsleep,fragmentationofnocturnalsleep, greaterlatencyinthebeginningofsleepandthereduction of thetotal duration of nocturnal sleep.37 _{These changes}

mayarisefrom other disorderspresent in thisage group, suchasdepression,urinaryproblemsandneurological prob-lems,suchasParkinson’sdiseaseandstrokes,38 _{which are}

extensivelylinkedtovoicedisorders.

In terms of psychosocial aspects, it is known that increasedanxietyandfrustrationnegativelyaffectthe qual-ityoflifeofelderlypersons.4_{Thisassociation revealsthat}

thevoiceisacharacteristicthatreflectsthesocio-emotional andclinical conditionsoftheindividual,andisconsidered highlyimportantinhumanandprofessionalrelationships.39

Becauseofthis,elderlypersonswithvoicedisordershavea higherriskofsocialisolation,unproductiveness,depression, anxietyandadeteriorationofgeneralhealthstatus.40---42

Smoking andalcohol consumption were not associated withvoicedisordersineitherstudy,whichreplicates simi-larfindingsfound in thegeneralpopulation.12 _{The impact}

Articles identified in databases (n=1127)

Articles selected for complete reading of text (n=43)

Included after consulting references of complete text (n=1) Repeated articles excluded (articles

included in more than one database) (n=27)

Articles excluded as lacked objective of analyzing factors associated with

vocal alterations (n=10)

Arti

cles excluded as sample was not

Articles selected for analysis with STROBE criteria (n=2)

Excluded following reading of ti

tle and

criteria (n=1084)

Figure1 Flowchartforselectionofarticles.

lifestyleofeach person,meaningthatsuchdisordersmay notbeperceived,ormaybeassociatedwithotherfactors.43

Althoughthisassociationhasbeenfound toberelevantin otherstudieswithspecificpopulations,thevoicedisorders causedbytobaccooralcoholusemaynotattractthe atten-tionofelderlypersonsastheyaresubtle,ortheindividual mayundergovocaladaptationsthatmeantheydonot per-ceive these changes. Because of this, any voice disorder purelyassociatedwithalcoholortobaccoconsumptioncan besogradualorsubtlethatitdoesnotworryorattractthe attentionoftheindividual.

The form of identification and the recruitment crite-ria of the selected studies were quite different.4,39 _One

methodological limitation was the extensive instruments that were used to obtain the data, which compromises thereliabilityoftheresults,sinceelderlypersonscanlose concentrationmoreeasilyatthemomentoftheapplication ofthequestionnaires.44 _{Theuseofshort,rapidapplication}

instrumentsissuggested,sothatelderlyindividualspresent answerswithahighdegreeofreliabilityandresultsthatare reliablefortherealityofthispopulation.

TheKoreanstudy24_{involvedthelargestpopulation(3759}

elderly individuals) and presented physical, behavioral, socialand clinical aspectsfor the definitionofassociated factors,whichmadethestudymorerobust.

This review also identified a limitation in terms of the diversity of the locations where the studies were conducted. The articles selected included North Amer-ican and Asian populations, but no European, African or South American study was found. Factors associated with voice disorders depend on cultural values, lifestyle, socioeconomic-demographic variables, and local climate, amongother aspects. Therefore,thereis a pressingneed toexpandthescopeofthesestudies.

According to the results of this review, most voice disorders are associated withphysical, social and behav-ioral health status. These findings may help to develop early screeningprocedurestoidentifyindividuals exposed to these factors and thus propose actions and health services aimed at providing elderly persons with bet-ter vocal quality and quality of life during the aging process.

Inadditiontothepreviouslymentionedlimitations,itis worth mentioningthat sixarticles containedsamples that werenot exclusivelycomposedof elderlyindividuals, and couldhave been included iftheyhadexplicitlypresented the outcome for thispopulation (Fig.1). The inclusion of these studies could have altered the results. In addition, thestudiesselectedforthisreviewpresented methodolog-icalbiasinrelationtosampleselection,analysisofresults,

Table2 Essentialitems thatshouldbedescribedinobservationalstudies,accordingtotheStrengtheningtheReportingof ObservationalStudiesinEpidemiology(STROBE)declaration.

Items Royetal.

(2007

Ryuetal. (2015) Titleandabstract

1.1Indicatethestudy’sdesignwithacommonlyusedterminthetitleortheabstract + + 1.2Provideintheabstractaninformativeandbalancedsummaryofwhatwasdoneandwhatwas

found

+ +

Introduction

2.Explainthescientificbackgroundandrationalefortheinvestigationbeingreported + + 3.Statespecificobjectives,includinganyprespecifiedhypotheses. + + Methods

4.Presentkeyelementsofstudydesignearlyinthepaper. − + 5Describethesetting,locations,andrelevantdates,includingperiodsofrecruitment,exposure,

follow-up,anddatacollection.

+ +

6.1Givetheeligibilitycriteria,andthesourcesandmethodsofselectionofparticipants. + + 7.Clearlydefinealloutcomes,exposures,predictors,potentialconfounders,andeffectmodifiers.

Givediagnosticcriteria,ifapplicable.

? ?

8.Foreachvariableofinterest,givesourcesofdataanddetailsofmethodsofassessment (measurement).Describecomparabilityofassessmentmethodsifthereismorethanonegroup.

? +

9.Describeanyeffortstoaddresspotentialsourcesofbias − −

10.Explainhowthestudysizewasarrivedat ? ₋

11.Explainhowquantitativevariableswerehandledintheanalyses.Ifapplicable,describewhich groupingswerechosenandwhy.

? ?

12.1Describeallstatisticalmethods,includingthoseusedtocontrolforconfounding. + + 12.2Describeanymethodsusedtoexaminesubgroupsandinteractions + − 12.3Explainhowmissingdatawereaddressed(‘‘missingdata’’) − − 12.4Ifapplicable,describeanalyticalmethodstakingaccountofsamplingstrategy. − +

12.5Describeanysensitivityanalyses. − −

Results

13.1Reportnumbersofindividualsateachstageofstudy;e.g.numberspotentiallyeligible, examinedforeligibility,confirmedeligible,includedinthestudy,completingfollow-up,and analyzed

? −

13.2Givereasonsfornon-participationateachstage. − −

13.3Consideruseofaflowdiagram − −

14.1Givecharacteristicsofstudyparticipants(e.g.demographic,clinical,social)andinformation onexposuresandpotentialconfounders.

+ +

14.2Indicatenumberofparticipantswithmissingdataforeachvariableofinterest. − − 15.Reportnumbersofoutcomeeventsorsummarymeasures. + + 16.1Giveunadjustedestimatesand,ifapplicable,confounder-adjustedestimatesandtheir

precision(e.g.95%ConfidenceInterval).Makeclearwhichconfounderswereadjustedforandwhy theywereincluded.

− −

16.2Reportcategoryboundarieswhencontinuousvariableswerecategorized. + + 16.3Ifrelevant,considertranslatingestimatesofrelativeriskintoabsoluteriskforameaningful

timeperiod.

− −

17.Reportotheranalysesdone(e.g.analysesofsubgroupsandinteractions),andsensitivity analyses.

+ ₋

Discussion

18.Summarizekeyresultswithreferencetostudyobjectives. + + 19.Discusslimitationsofthestudy,takingintoaccountsourcesofpotentialbiasorimprecision.

Discussbothdirectionandmagnitudeofanypotentialbias.

− +

20.Giveacautiousoverallinterpretationofresultsconsideringobjectives,limitations, multiplicityofanalyses,resultsfromsimilarstudies,andotherrelevantevidence.

+ +

21.Discussthegeneralizability(externalvalidity)ofthestudyresults. + + Otherinformation

22.Givethesourceoffundingandtheroleofthefundersforthepresentstudyand,ifapplicable, fortheoriginalstudyonwhichthepresentarticleisbased.

andtheinstrumentsusedtocollectdata,whichresultedin heterogeneitybetweenthetwo.

Conclusions

Thissystematicreviewrevealedthatfactorsassociatedwith voicedisordersintheelderlyincludedbothphysicaland psy-chosocialsymptoms,althoughonlytwostudieswerefound forspecificpopulations,whichhaddifferingculturalhabits. Themethodologicaldiscrepanciesbetweenthestudies, par-ticularlyinrelationtosampleselectionandtheinstruments usedimplygreatvariabilityandcompromisethereliability of the results found. It is important to carry out preva-lencestudiesindifferentculturesinvestigatingthefactors associatedwithvoicedisordersintheelderlyfroman epi-demiologicalperspective.

Ethical

approval

Thisarticledoesnotcontainanystudieswithhuman parti-cipantsperformedbyanyoftheauthors.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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