Alison M. Grimes, AuD
University of California, Los Angeles
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They work!
People who wear properly fitted hearing aids, and who
have been counseled regarding reasonable
expectations, and who have undergone audiologic
rehabilitation, are satisfied with hearing aids
Hearing aids do not mean that you’re getting old,
senile, incapable, stupid, infirm and all of those other
negative stereotypes
Their hearing aid is less obvious than their hearing loss
Lots of people wear hearing aids, but lots more need to
and don’t
The cost of NOT wearing hearing aids is potentially
much greater than the dollars spent to purchase them
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Denial
Stigma
Unawareness that there is a problem
Avoidance of Diagnosis
◦ Subsequent avoidance of treatment
Minimizing the Problem
Friend/relative who had hearing aids that “didn’t
work”; subsequent generalized belief that hearing
aids don’t work
Confusion and distrust about hearing aid salespeople
Cost vs perceived benefit
“My hearing is normal for my age”
“I don’t have a hearing loss—s/he mumbles!”
“I hear what I need to hear”
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First, get them through the door!
Appropriate and thorough counseling following
diagnosis, prior to hearing aid selection
◦ Reasonable expectations
◦ Listening strategies
◦ Other hearing assistance technologies
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Hearing aid selection based on
◦ Specific patient variables and needs/desires
◦ Effectiveness over cosmetics
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Verification of audibility using evidence-based
procedures
Patient/family counseling
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NIDCD/VA Hearing Aid Trial (Larson, et al., 2000)
published in Journal of the American Medical
Association
Landmark clinical study
Double-blind, three-period, three treatment crossover
design.
Conclusion: Hearing aids work!
No significant difference among three hearing aid circuits
◦ WDRC
◦ Linear compression-limiting
◦ Linear peak-clipping
Subjects showed significantly improved aided vs unaided
communication
◦ In Quiet
◦ In Noise
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Kricos, et al., 2007 (part of the report of the
update of JAMA 2003 NIDCD/VA Study)
“Despite considerable evidence regarding the
detrimental effects of untreated hearing loss,
…there continues to be an underutilization of
hearing aids by adults”
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CPHI (measure of handicap) scores
significantly poorer in non-users than in
users
◦ That is, greater handicap in the non-users.
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Participants benefited from extensive
auditory rehabilitation and expert fitting
techniques
Significant long-term subjective benefit and
satisfaction with hearing aids.
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Subjects weren’t different—but their
management was
Intensively managed by Audiologists
Patients afforded the opportunity to evaluate
different hearing aid fittings
◦ Fittings based on prescriptive targets verified with
probe-microphone measures
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Given extended periods of trial use
Able to select their preferred fitting
(This is not how hearing aids are typically fitted
and dispensed!)
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Intensive Management
Patient involvement in the selection and
fitting process
Probe Microphone measures to ensure
maximum audibility
◦ Every time
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“Trial Period”—
◦ What does this mean?
◦ Are we stuck with this forever?
 Legally, perhaps
 Can we term it something different?
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Denial/Stigma
Belief that hearing aids are ineffectual
Medical/audiological professionals who
downplay significance of hearing loss
Cost
Sales aspects
Cultural/Linguistic Issues
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Hearing aids = badge of aging and senility
Denial
◦ Hearing loss is gradual in onset
◦ Don’t know what you don’t hear because you can’t hear it!
◦ Tendency to externalize problem
 “she mumbles”
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Lack of awareness of the psychological, social,
emotional, physical and cognitive impacts of
untreated hearing loss
Belief that it’s OK to procrastinate
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Perceived poor performance in noise
Friend/family member who has had poor
outcomes with hearing aids
Real-world performance doesn’t match
exaggerated advertising claims
Lack of pre-fitting counseling regarding
reasonable expectations
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Physicians fail to inquire or screen for hearing
loss
“It’s normal for your age”
If not surgically treatable, HNS physicians
may be uninterested
Audiologists may downplay significance of
“mild” hearing loss
◦ (tentative counseling)
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Perceived high cost for value
Lack of third-party funding
Bundled hearing aid pricing model
◦ Bad for consumers?
◦ Bad for audiologists?
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Unrealistic advertising
Confusion about who sells hearing aids
◦ What are their qualifications?
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From whom should hearing aids be purchased?
 Audiologist?
 Hearing aid salesperson?
 Physician?
 Internet?
 Mail-order?
Any device that’s sold with a 30-day “trial period”
sets up expectation of failure
Long history of sales abuses
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Well known that intervention including
hearing aids underutilized
◦ Lack of providers with cultural/ethnic/linguistic
match
◦ Poverty
◦ Lower utilization of health systems overall
◦ Unwilling/”inappropriate” to discuss perceptions
and feelings about hearing loss
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Auditory Deprivation: ARHL is gradually
progressive
◦ Becomes a greater issue as period of time of
deprivation grows
◦ Creates challenges when hearing aids first fitted
 Immediate restoration of sound
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Negative psycho-social, psychological and
cognitive impacts
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Necessary
Not sufficient to completely address multiple
problems associated with speech understanding
Necessary to first have audibility
◦ Insofar as properly fitted hearing aids provide audibility
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Then employ
◦ Other hearing assistance technologies
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Auditory Rehabilitation Program
◦ Counseling
◦ Communication Skills Training
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(Move to cochlear implant if needed)
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Patient Preferences
◦ What can the patient manage?
◦ What can the ear canal accept?
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Style
◦ Custom vs BTE
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Binaural vs Monaural
◦ Or other signal-routing (CROS, BICROS)
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Cost
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Program and/or Volume buttons?
◦ Multiple memories or programs—necessary or confusing
Custom earmold/insert vs “dome”?
Remote Control Device(s)
Ear-to-ear communication—necessary or confusing?
Bluetooth?
Telecoil—mandatory? Auto-telecoil?
“Noise reduction”?
Directional microphones?
Frequency transposition/compression?
◦ Insufficient evidence to judge efficacy/benefit relative to
degree/configuration of hearing loss and age
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Patient/Family
Decisions
◦ Features
 VC, PB, remote
◦ Color
◦ Price
◦ To some degree, style
and arrangement
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Manufacturer
◦ Depends on the reason
that a particular brand is
requested
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Audiologist’s Decisions
◦ Signal processing scheme
 WDRC vs Linear
 Frequency Transp/Comp
◦ Gain/output requirements
to assure audibility and
comfort/safety across the
speech spectrum
◦ To some degree, style
and arrangement
 Based on patient needs
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Audiologist Wants
– Availability of appropriate gain and
output across the speech spectrum
based on patient’s hearing loss
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Flexibility to manipulate by multiple
frequency bands
– Growth-room – reserve gain/output
– Features and signal-processing options
that are familiar and with which
audiologist has had previous success
– Good feedback algorithm
– Responsive and responsible
manufacturer with good customer
support
– Price that is justified by features offered
– Rapid and successful patient acceptance
– Cords/cables that work every time
– Software that makes sense
– Ability to see what the hearing aid is
doing when changes are made
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Patient Wants
– “invisible”
– “block out background noise”
– “high-fidelity” with nearperfect speech understanding
– Larger, longer-lasting battery
– Easy to manipulate controls
– Or no controls
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Sturdy battery case
Inexpensive
Distance hearing
Lack of feedback
Physically and acoustically
comfortable and ‘natural’
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The #1 complaint of hearing aid users
Latest MarkeTrak “listening in noise” shows
 25% overall dissatisfied
 61% overall satisfied
 14% neutral
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Listening in noise
◦ Related to reduced speech perception
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The greater the degree of hearing loss, the
greater the handicap associated with listening in
noise
Counseling to ensure reasonable expectations
◦ (the advertisements don’t tell the whole story!)
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An oversold technology?
◦ May lead to disappointment with hearing aids
◦ Importance of pre-fitting counseling
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Better termed “noise management”
◦ Makes listening in noise more comfortable
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Definition of noise varies
◦ Noise is the undesired signal
◦ The desired signal may have the same spectrum
◦ Noise is often others’ speech
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NR doesn’t improve speech perception
◦ Creates greater listening ease
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Highest negative rating is “use in noisy
situations”
Latest MarkeTrak “listening in noise” shows
 25% overall dissatisfied
 61% overall satisfied
 14% neutral
◦ 39% neutral to dissatisfied – not a stellar statistic
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How can this be improved?
◦ Counseling
◦ Remote microphone technologies
◦ Communication strategies
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Benefit of DNR algorithm is not to make speech
more intelligible
◦ Does reduce the cognitive effort involved in performing
the task
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Shared attention extracting speech from noise
◦ Items presented in noise less likely to be remembered
successfully
◦ Listening in noise: increase in listening effort
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Noise reduction frees resources for other,
simultaneous tasks.
◦ Better auditory memory
◦ Increased speed of response to a visual task
◦ (Sarampolis, et al., 2009)
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Proven ability to reduce signals at specified azimuths
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Function less well in
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◦ May or may not be “noise reduction”
◦ Distance
◦ Reverberant environment
Function less well when the head is not upright
Function less well when speech and noise are moving targets
May be a detriment when desired signal is from sides or rear
Age does not have a significant effect on directional
benefit/preference, but older adults have a lower perception of
benefit in the directional mode as compared with younger listeners
(Wu, 2010)
Solutions?
◦ Manual switching?
◦ “Smart” automatic algorithms?
◦ What makes most sense for older user?
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Common in contemporary hearing aids
Patient may be unaware that processing is
happening
Automatic vs Manual Switching?
Possible disadvantages?
How can we better understand how the
hearing aid is working
◦ To counsel patients
◦ To manipulate variables (if possible)
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Assists in setting expectations and in making selection
COSI
Hearing Demand, Ability and Need Profile
SAC/SOAC
Patient Expectations Worksheet
◦ Compares what situation patient is successful in or
wants to be more successful in
◦ Pre-treatment success vs level of success posttreatment
◦ Including realistic expectations counseling
Provide basis for counseling and setting expectations
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Tool to assist in assessing
– Motivation
– Interest in different types of hearing aids
– Budget
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Helps quickly move through some of the initial
decision-making
– Opportunity to discuss reasonable expectations (e.g.,
patient with severe-profound hearing loss wants ITC
hearing aids)
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Patient has already considered some of the initial
questions and developed answers
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Please list the top three situations where you would most like to hear better. Be as specific as possible
How important is it for you to hear better?
How motivated are you to wear and use hearing aids?
How helpful do you think hearing aids will be?
What is your most important consideration regarding hearing aids? Rank order the following factors
with 1 as the most important and 4 as the least important.
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Hearing aid size and the ability of others not to see the hearing aids
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Improved ability to hear and understand speech
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Improved ability to understand speech in noisy situations (e.g., restaurants, parties)
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Cost of the hearing aids
Do you prefer hearing aids that:
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are totally automatic so that you do not have to make any adjustments to them.
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allow you to adjust the volume and change the listening programs as you see fit.
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no preference
Look at the pictures (photos of hearing aid styles) of the hearing aids. Please place an X on the picture
or pictures of the style you would NOT be willing to use. Your audiologist will discuss with you if your
choices are appropriate for you – given your hearing loss and physical shape of your ear.
How confident do you feel that you will be successful in using hearing aids.
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Basic digital hearing aids:
Cost is between $XXXX to $XXXX
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Basic Plus hearing aids:
Cost is between $XXXX to $XXXX
___
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Mid-level digital hearing aids:
Premium digital hearing aids:
Cost is between $XXXX to $XXXX
Cost is between $XXXX to $XXXX
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Physical fit
Acoustical fit
◦ Probe microphone measures with modifications in
gain/output to achieve maximum audibility and
safe/comfortable MPO at initial fitting?
 YES!
◦ Permitting overall gain/output reduction on day one?
 YES
 Just don’t forget to subsequently increase
Selection/deselection of features/options
◦ i.e, how many programs does a person need on day 1?
Counseling, counseling, counseling
Reasonable expectations
Wearing schedule?
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No…
If you want to ensure audibility
If you want to ensure that OSPL is set
appropriately
Yes…
If you want to get the patient out the door in a
hurry
If you want the hearing aids to sound
“comfortable, natural” from the first wearing
If you are satisfied with fitting earplugs
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“How does that sound?” (important, but
insufficient)
“Aided Audiogram” (misleading, unreliable,
attractive to lay-person)
◦ Inadequate and inappropriate for making hearing aid
adjustments
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“First-Fit” (generally inadequate gain and
output, generally greater insufficiency in the
high frequencies, reducing Aided Intelligibility
Index)
Manufacturer’s proprietary fitting algorithms
◦ Where is the independent research validating?
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Desired Sensation Level
NAL-NL1/NAL-NL2
Ample and robust independent evidence
◦ Not just for pediatric fittings
Assures maximal audibility
◦ Within the limitations of the hearing aid circuit and
transducers
Assures safe and comfortable OSPL
Can measure the effects of features
◦ Directionality
◦ Noise reduction
◦ Amplitude Compression by frequency band
◦ Frequency transposition/compression with high frequency
inputs
SII 75
SII 80
SII 41
SII 68
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Yes!
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Yes!
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Yes!
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Aided Audibility Index vs “Aided Audiogram”
Use of Estimated AAI in real-ear system as
counseling tool
Aided vs unaided speech perception
Post-fitting hearing aid outcomes measures
◦ APHAB
◦ IOI-HA
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Counsel, counsel, counsel
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1. Conduct first-fit programming using a
method that prescribes gain for
average input similar to that prescribed by
the NAL-RP/NL1.
2. Verify the fitting using real-ear aided
response (REAR).
3. Use an authentic speechlike signal (or
real speech) at an input of 65 dB SPL.
4. Adjust gain/compression parameters
until a match to NAL target (or similar)
within 2–3 dB has been obtained at all key
frequencies.
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Comfort
◦ Physical
◦ Acoustic
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Output SPL may be uncomfortably high
Audibility of speech spectrum may be inadequate
Occlusion effect
Feedback
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Lack of speech clarity/poor speech perception
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Environmental Noise
 Related to auditory impairments not amenable to treatment
with hearing aids
 Frequency, temporal and amplitude distortion
◦ Speech
 A primary reason why older adults stop wearing hearing aids
◦ Non-speech
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First, fit the right hearing aids
◦ Appropriate style and arrangement for hearing
loss
◦ Selection of features necessary; avoid
unnecessary features
Second, program hearing aids to ensure maximal
speech audibility, comfortable/safe OSPL
Ensure good feedback reduction without
unnecessarily reducing high-frequency audibility
If gain/output reduced to accommodate initial
acceptance
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Ensure return to maximal audibility at a future
appointment as acclimatization occurs
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Hearing aids don’t do it all
◦ We lose credibility and patient confidence if we declare
otherwise
◦ Need to clearly outline reasonable expectations
Educate patient/family that some component of hearing loss
is/may be central/cognitive
◦ We hear with our brains, not our ears
Importance of counseling, auditory rehabilitation
Additional steps patient/caregiver/spouse can take
◦ Assistive devices
◦ Regular follow-up appointments (hearing changes)
◦ Patient/family counseling
◦ Acclimatization
Referral to support group
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Important for patient and spouse/family alike
Receptive strategies: Environmental manipulation
• Noise
• Reverberation
• Distance
Interactive strategies
– Repeat/rephrase
– Key words
– Identify change in subject or topic
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Use of “Clear Speech” by communication partner
– This is trainable
At least familiarize patient/family with other hearing
assistance technologies
– Let them make the choice whether to take up
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Assertive
◦ “own” the hearing loss
◦ Take responsibility for successful communication
Aggressive: identify behaviors that are consistent with
◦ External locus of control
◦ “it’s your fault I can’t hear”
◦ Control the conversation—never need to listen
Passive: identify behaviors that are consistent with
◦ Bluff, “smile and nod”
◦ Let others be the “ears”
◦ Withdraw, deny problems
Counsel patient/family how to move to assertive
communication
◦ This may be quite difficult to change
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Accommodation to new sensory stimuli
Effects are measureable and greater in high
frequencies where more “new” information is
provided to the brain via the ears
Evidence that this is a real phenomenon
◦ Occurs over a period of time after amplification
◦ Perceptual, physiological, neurophysiological and
attitudinal
How to encourage patient to persevere?
◦ Importance of counseling
◦ Gradual increase in daily wear
◦ “Train your brain”
◦ Analogies—bifocals, new dental appliances etc.
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Possible disappointment that things aren’t
perfect
◦ Unlike eyeglasses for myopia
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Everything is “too loud”
Occlusion effect
Environmental noises
Low-level noise (e.g., air-conditioning)
Sounds that aren’t identifiable
◦ Turn indicator in car
◦ Refrigerator motor
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“I’m old”
One more device to fumble with
◦ Eyeglasses, dentures, cane, medications, wig,
sensible shoes, wheelchair, compression stockings,
adult diapers and now HEARING AIDS!
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Pre-occupation with minimizing how visible
hearing aids are
Physical Infirmities—frustration with
◦ Seeing hearing aids
◦ Manipulating controls (dexterity, fine-motor,
peripheral neuropathy
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Improve
◦ Noise
◦ Reverberation
◦ Distance
Bluetooth
FM
Amplified telephone, text, visual telephone (Skype,
iChat)
Amplification and Captioning for TV
Signaling devices
◦ Phone
◦ Doorbell
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(Enlist the help of the child/grandchild in
anything involving a computer)
Don’t assume patient “can’t afford”
Demonstrate devices connected to hearing aids,
in real-world environments
◦ Increases confidence in hearing aids
◦ Overcomes obstacles that hearing aids along often
cannot
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Allow patient to experience hearing success via
technology
◦ Inform them of all options
◦ Let them make the decision
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Great improvements in QOL shown for CI in
adults
Under-utilized technology
Audiologists may be too slow to refer
◦ “try a better hearing aid”
◦ Lack of knowledge of referral and implantation
criteria
◦ Don’t want to “lose” a HA patient
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Hearing aids may be effective treatment for
tinnitus
◦ ~50% of HI listeners with tinnitus had tinnitus
relief
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Tinnitus causes psycho-social handicap in
some cases (high THQ scores)
Use of hearing aids can reduce psychosocial
handicap and tinnitus-hearing handicap
◦ Counseling alone ineffective
◦ Counseling plus hearing aid use resulted in
significant improvement
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Elderly individuals with hearing loss
Assessed at baseline, 4, 8, and 12 months after
hearing aid fitting.
All quality-of-life areas improved significantly from
baseline to 4-month post-hearing aid fittings.
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Social and emotional (HHIE)
Communication (QDS)
Depression (GDS) benefits
All were sustained at 8 and 12 months
Cognitive changes (SPMSQ) reverted to baseline at 12
months.
Hearing aids provide sustained benefits for at least
a year in these elderly individuals
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431 articles
Reported outcomes with hearing aids indicate
they are an effective method for treating mildmoderate HL in cases where the patient is
appropriately fitted and is willing, motivated,
and able to use the device.
Very positive QoL and speech perception
outcomes have been documented in treating
severe-profound presbycusis with CIs. In some
studies, QoL outcomes have even exceeded
expectations of elderly patients.
Sprinzl & Riechelmann, 2010
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Ensure maximal speech audibility
Find a revenue stream in addition to hearing aids
Spend as much time on…
◦ Realistic expectations
◦ Limitations of amplification
◦ Communication strategies
◦ …as on benefits of hearing aids, “new features”,
“smaller size”, “cosmetically appealing”
Ensure that hearing assistance technologies other than
hearing aids are also provided
Engage the patient in individual and/or group
rehabilitation, or peer support group, or all to the
extent that they are willing
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Our services are underutilized
◦ significant, negative, implications for
communicative/QOL/cognitive outcomes
◦ Impacting a large and growing population
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We need to move the focus from “the device”
to a program of
◦ Identification – encouraging individuals to seek
services
◦ Accurate and thorough diagnosis
◦ Comprehensive rehabilitation
 Of which hearing aids are a necessary, but not
sufficient, solution to the problem
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Challenges
◦ Hearing aid features are marketed prior to rigorous
testing regarding efficacy
◦ Claims may be made that actually don’t stand up to
study
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Lag between introduction of signalprocessing schemes and validation research
Difficult to provide accurate information
about the products offered
Responsibility to acknowledge such
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Promote the concept that hearing aids work
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Provide hearing aid fittings based on best practices
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◦ And that rehabilitation, including hearing aids, is in an individual’s
and family’s best interests
◦ That means real-ear verification to validated targets
Need to grow population of cultural/linguistic audiologists
Need to educate public/physicians/mental health workers
about relationship of untreated hearing loss to mental and
physical health impairments
Advocate for low-cost solutions for those who cannot
afford hearing aids
◦ While advocating for third-party reimbursement for hearing aids
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Need to advocate for adequate and appropriate
reimbursement for services
◦ (sales of hearing aids cannot be our sole revenue stream!)