The global population is aging rapidly, leading to a growing number of older adults experiencing age-related communication challenges.¹⁾ Among these, voice disorders (VD) among older adults, commonly referred to as presbyphonia, have gained increasing attention owing to their prevalence and impact on daily life. In addition to individuals with severe VD, self-perceived voice disorders (PVD) among older adults represent a significant concern. The prevalence of PVD among community-dwelling older adults ranges from 8.5% to 32.5%.^2-5)

Given this prevalence, PVD has been associated with mental, social, and physical health domains.^6-8) Deficits in these domains are established correlates of reduced well-being,^9-11) increased dementia risk,¹²⁾ and higher mortality rates.^13-15) Several studies involving patient populations have reported associations between PVD and depressive symptoms,⁶⁾ reduced social participation,⁷⁾ and physical inactivity.⁸⁾ These findings suggest a potential pathway in which PVD impedes effective communication, leading to social isolation and reduced physical activity, which in turn adversely affects overall health and well-being. Therefore, PVD should be recognized not merely as a communication issue but as a significant public health concern in aging societies.

However, most previous research on PVD has focused on clinical populations,^6-8,16) with few investigations targeting community-dwelling older adults with PVD who are not receiving medical care. Among the limited studies, a population-based study reported associations between PVD and depression.^17-19) Among community-dwelling older women, PVD was associated with limitations in activities of daily living and poor physical functioning, particularly mobility, increased physical pain, and limitations in physical roles.²⁰⁾ Moreover, older adults with PVD tend to engage less in social activities that rely on communication.³⁾ Beyond the focus on specific populations, another limitation of the literature concerns the severity of the PVD examined. Existing studies have focused on clinically overt or moderate-to-severe VD, with little attention given to mild or subclinical PVD.^6-8,16) Furthermore, the few existing community-based studies have employed cross-sectional designs,^3,17,18,20) making temporal relationships difficult to infer. Because vocal function and depression are interdependent, longitudinal studies that clarify temporal relationships are warranted.

Moreover, previous research has explored individual correlations between PVD and mental, social, or physical outcomes, although no research has comprehensively and longitudinally investigated their combined impact among independent, community-dwelling older adults. This oversight is significant, as even minor declines in PVD can negatively impact the daily lives of otherwise healthy older adults by hindering communication, reducing social participation, and limiting physical activity. Clarifying these longitudinal associations is essential for identifying early functional changes and for recognizing PVD as a major factor influencing the well-being of older adults who may not have sought medical care.

This study aimed to examine the longitudinal associations of PVD with psychological, social, and physical well-being among community-dwelling older adults. We hypothesized that PVD, even in their mild forms, are associated with greater longitudinal declines in psychological well-being, social networks, physical activity, and physical performance compared with the absence of PVD.

The characteristics of the study participants are presented in Table 1. The average age of the participants was 76.5±5.4 years, and 57.1% were female. Participants were classified as no PVD (n=118, 43.2%), mild PVD (n=116, 42.5%), or PVD (n=39, 14.3%). The variables that showed a significant difference between groups were sex and economic conditions. The proportion of females decreased across groups, with 61.9% in the no PVD group, 58.6% in the mild PVD group, and 38.5% in the PVD group. Similarly, the proportion of participants reporting "poor" economic status was 7.6% in the no PVD group, 12.9% in the mild PVD group, and 28.2% in the PVD group.

Table 2 summarizes the estimated marginal means and mixed effects results for psychological well-being, social networks, and physical activity outcomes over the follow-up period. Significant main effects were identified among the groups for depressive symptoms (GDS score, p=0.012) and social networks (LSNS-6 total, p=0.009; family subscale, p=0.009), with the PVD group consistently having lower values for these outcomes. Friend networks also tended to be lower in the PVD group; however, this difference did not achieve statistical significance (p=0.054). The significant main effects of the groups indicate that outcome levels differed consistently according to PVD status across measurement waves, with the PVD group exhibiting the lowest values at nearly all time points.

Table 3 presents the estimated marginal means and mixed effects results for physical performance measures over the follow-up period. A significant main effect of time was observed for HGS (p<0.001), SLB (p<0.001), sit-and-reach (p<0.001), and 5-mHW (p=0.004), indicating a modest decline in performance with age among participants. Crucially, the sit-and-reach revealed significant group main effects (p=0.042), with the no PVD group outperforming the PVD groups in terms of flexibility over all measurement waves. Other physical performance metrics showed no discernible group differences.

This longitudinal study on community-dwelling older adults demonstrated that PVD is longitudinally associated with higher depressive symptoms, reduced social networks (particularly smaller family networks), and performance in selected physical performance measures. These findings suggest that PVD may serve as an early marker of vulnerability across psychological, social, and physical well-being in later life.

Consistent with previous cross-sectional studies, we found that PVD was associated with increased depressive symptoms.^17-19) The key contribution of this study lies in the longitudinal evidence suggesting that even mild PVD may precede and contribute to the development of adverse outcomes in community settings. A potential psychological mechanism for this association is self-criticism. Previous studies have linked self-criticism to depression,^37,38) and recent studies have proposed that PVD can be conceptualized as forms of self-criticism,¹⁷⁾ where chronic VD is internalized as personal failings, thereby increasing psychological distress. Future research should test this hypothetical pathway by repeatedly measuring PVD, cognitive appraisals, and mood states to examine mediating effects over time.

The social networks analysis revealed significant main effects between groups for the total LSNS-6 score, with participants in the PVD group showing smaller social networks than those without PVD. These findings support previous research demonstrating associations between VD and reduced social networks.^39-41) VD may impose additional communication-related burdens, potentially contributing to social isolation and emotional loneliness among older adults living in communication-dependent societies.⁴²⁾ When examining LSNS subscales, the PVD group exhibited significantly lower family network scores. According to socioemotional selectivity theory, emotionally meaningful relationships, such as family ties, become increasingly important in older adulthood.⁴³⁾ Consequently, reductions in family connectedness may have disproportionate implications for psychological and social well-being. One possible explanation is that the effortful nature of communication associated with PVD may gradually reduce routine verbal interactions within the household, leading to subtle withdrawal over time. Although the friend network score did not reach statistical significance, it appeared lower in the PVD group. According to socioemotional selectivity theory, age-related contractions of social networks occur primarily through the pruning of peripheral social ties, whereas emotionally close relationships remain relatively preserved.^43,44) In addition, speech perception research has demonstrated a "familiar talker advantage," whereby speech produced by familiar individuals is more easily understood than speech from unfamiliar speakers.⁴⁵⁾ These findings suggest that, due to mutual familiarity, socially close relationships buffer against VD, ensuring that communication remains smooth. Moreover, the LSNS was originally developed to assess the extent of social networks and perceived support derived from family and friends.²⁷⁾ It may therefore be less sensitive to subtle changes in more peripheral social relationships. Accordingly, measurement approaches that emphasize network diversity, such as the Social Network Index, may provide additional insight into how communication-related difficulties influence broader social network structures, including social ties beyond close family and friends.

PVD was also associated with poor physical performance, particularly reduced trunk flexibility as assessed by the sit-and-reach test. The link to flexibility may reflect the relationship between general musculoskeletal stiffness and the respiratory muscles essential for voice production.^46-48) Yokoyama et al.⁴⁶⁾ reported that reduced flexibility in intercostal muscles contributes to restrictions in chest-wall range of motion, which is strongly associated with pulmonary function.⁴⁸⁾ Furthermore, our observation indicates that participants with PVD exhibited poorer performance on the sit-and-reach test, which assesses overall flexibility. This performance decline may be indicative of reduced thoracic mobility, thereby suggesting a potential connection between PVD and respiratory impairment. Contrary to expectations, HGS, SLB, or 5-mHW showed no associations with PVD. These measures likely capture global or lower-extremity physical abilities indirectly associated with the respiratory and laryngeal systems involved in voice production. HGS primarily reflects peripheral muscle strength and is a weak indicator of respiratory or phonatory function, whereas multisystem factors such as vestibular function, proprioception, lower-limb strength, and cardiovascular fitness influence balance and habitual walking speed. Consequently, these measures may overlook the more subtle respiratory or thoracic mobility limitations that appear to differentiate individuals with PVD. This interpretation underscores the need for selecting performance indicators that directly reflect the biomechanical demands of voice production, such as measures of flexibility or respiratory mechanics.

From a clinical perspective, the findings of this study indicate that PVD may serve as an early marker of broader declines in psychological, social, and physical well-being. In geriatric practice, PVD is frequently disregarded or attributed to normal aging; however, our findings suggest that these symptoms warrant closer attention as potential indicators for depressive symptoms, social isolation, and diminished physical performance. Early identification of PVD in primary care or community health screenings may, therefore, contribute to timely referral, targeted intervention, and prevention of downstream health risks. From a public health and policy perspective, incorporating basic PVD screening tools like the VHI-10 into community health programs may help identify older adults at increased risk of psychosocial and functional decline prior to the onset of clinical VD. Given the established links among social isolation, physical inactivity, and adverse health outcomes,^49,50) early recognition and intervention for PVD may support healthy aging while facilitating preventable declines in well-being. Future geriatric health policies and community interventions should consider PVD as an important yet underrecognized dimension of functional health.

This study has several notable strengths, including its longitudinal community-based design, which enabled examination of temporal relationships, and its comprehensive assessment of psychological, social, and physical well-being. Nevertheless, the findings should be interpreted in light of several limitations. First, VD was measured solely through self-reporting and was not corroborated by objective acoustic or laryngoscopic measures. Furthermore, while the VHI-10 has been used to assess voice-related outcomes among nonclinical populations, its validity among community-dwelling older adults is yet to be formally established. Second, the generalizability of the results is limited, owing to the single-city setting. Additionally, as the study relied on venue-based health screenings, the sample likely overrepresented healthier, more mobile older adults relative to the general population, thereby introducing selection bias. This sampling frame may have attenuated associations between PVD and study outcomes, effectively biasing estimates toward the null. Third, although our models adjusted for measured covariates, there may be other unmeasured variables (e.g., swallowing function and fluid intake) that could affect the outcomes. Finally, the findings of this study are based on a cohort specifically designed to examine preventive nursing care among community-dwelling older adults. Furthermore, the participants were relatively healthy older adults who were able to attend an on-site survey that involved physical performance measures. Therefore, our findings may not generalize to older adults with greater frailty, such as those receiving long-term care insurance services, who are likely to exhibit greater declines in vocal function. Future research should investigate whether analogous associations are evident in these more vulnerable populations.

In conclusion, the findings of this study suggest that individuals with PVD, even at mild levels, consistently exhibited poorer outcomes across psychological, social, and physical well-being over the follow-up period. Specifically, participants with PVD experienced higher depressive symptom scores, smaller overall social networks with fewer familial connections, and diminished physical performance, as evidenced by lower flexibility in the sit-and-reach test. These findings underscore that the early identification and management of PVD may be a critical step toward supporting broader health and well-being among older adults.