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| Rose L. Allen,
Ph.D., CCC-SLP/A, Assistant Professor of
Audiology, East Carolina University, Dept. of
Communication Sciences & Disorders |
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Editor?s
Note: This article was the winning submission
for the Audiology Online (www.audiologyonline.com)
contest sponsored by Rayovac Ultra Pro Line, for
the best new article written for consumers and
patients, titled "Hearing Aids: Reasonable
Expectations for the Consumer." We offer Dr.
Allen our congratulations for her excellent
work, and we invite the readers to download (in
it?s entirety) and distribute this article to
their patients for educational purposes.
---Editor
INTRODUCTION:
Since you are considering the purchase of
hearing aids, it?s important for you to
establish reasonable expectations from these
highly sophisticated, miniature devices.
Acquiring hearing aids is not merely a simple
act of going to a store and purchasing a
product.
Rather, it is a complex process - one that
evolves over time and begins with the
hearing-impaired individual accepting the
realization that hearing impairment has
detrimental effects on interpersonal
relationships and safety. The hearing impaired
person?s motivation to hear well is the single
most important factor in determining the success
of the hearing aid fitting. It is important to
realize that you will not experience the exact
same benefits from your hearing aids as your
neighbor does. This individuality is a critical
component, and I want to emphasize that your
expectations should be based on you, your type
and degree of hearing loss, your past
experiences, and the improvements you personally
receive from amplification.
The title of this article implies there are
"reasonable expectations" for the consumer.
Therefore, there must also be "unreasonable
expectations". For the most part, there is only
one totally unreasonable expectation - do not
expect normal or perfect hearing.
It is my hope that this point-by-point tutorial
will help guide you in establishing realistic
and reasonable expectations from hearing aids,
from the professionals you interact with,
through the process of acquiring hearing aids,
using them effectively, maintaining them, and
living the fullest life possible.
1. Expect others to notice your hearing loss
before you do! A common complaint of
hearing-impaired individuals is that other
people mumble - and if they would just speak up,
it would be easier to hear them! This is placing
the "blame" externally, rather than accepting
the reality that your ears are not as good as
they used to be. Realize that it is your
hearing. Take that step to have your hearing
tested before you blast your loving spouse out
of the den with the blaring sound of the TV set.
Seek the advice of your local audiologist or
hearing instrument specialist (HIS), who you
will find listed in the yellow pages under
"audiologists" or "hearing aids". Of course,
another option is to go to the Healthy Hearing
website (www.healthyhearing.com),
and if you enter your city and state, or just
your zip code, a list of professionals will be
created for you.
2. Expect your audiologist/hearing instrument
specialist to be knowledgeable, courteous, and
accommodating. Your audiologist/HIS will
take a thorough case history. He/She is
searching for information about your hearing
loss, it?s probable cause, and whether your
offspring may be affected. It is important to
establish the presence of any medical condition
associated with your hearing loss as this will
trigger a medical referral. Comprehensive
hearing and hearing aid evaluations will be
conducted. These evaluations will provide
information about the degree and nature of your
hearing loss, as well as your ability to process
and discriminate the fine sounds of speech.
Comfortable listening levels will be defined, as
well as a determination about how well you
tolerate loud, intense speech and other sounds.
These findings are very important as they allow
the professional to pre-set some of the
characteristics of the hearing aid?s circuitry.
You will have time to talk with the
audiologist/HIS about the differing styles of
hearing aids (in-the-ear, in-the-canal,
completely-in-the-canal, behind-the-ear), the
advantages and disadvantages of each style, and
maintenance issues and costs involved.
Approximately 80% of all hearing aids sold fit
in the ear1. After you and your
hearing professional determine the best style of
hearing aid for your needs, an ear impression
will be obtained. The ear impression is a
plastic cast of your ear which reveals the exact
shape of your ear, so the laboratory can place
circuitry in a hearing aid shell that will fit
your ear(s) only.
3. Expect differing opinions. If you
choose to seek the advice of two or more
audiologists/HISs, you may get differing
opinions about the "best aid" for you. Everyone
in the hearing aid industry acknowledges the
fact that there is not a single "best" hearing
aid. Rather, there are many excellent hearing
aid brands available, and there are many
different types of circuitry that may benefit
you. Your audiologist/HIS uses the case history
information and the evaluation results to make
the best recommendation for you and your
lifestyle. Expect a recommendation to
purchase two hearing aids if both of your ears
are hearing impaired and are "aidable."
There are many benefits to binaural (two ear)
hearing, including being better able to
understand speech in noise, and being better
able to localize sound. Your audiologist/HIS
will explain the advantages of a binaural
fitting versus a monaural fitting in more detail2.
Nonetheless, it is very important to understand
that if you have two ears with hearing loss, and
you only wear a hearing aid on one ear, you will
still have significant hearing problems, even
under the best of circumstances. A reasonably
good analogy is to consider wearing a single eye
glass (monocle) for a two-eye vision problem,
such as being near-sighted or far-sighted ? it
simply will not work well for very long!
4. Expect your audiologist/HIS to assess your
hearing difficulties in several environments and
define individual goals for you. Although
there are many self-assessment scales available,
a popular one is the Abbreviated Profile of
Hearing Aid Benefit (APHAB) developed by Cox and
Alexander3. It may be administered to
you prior to and following the hearing aid
fitting to identify the benefits you receive
from the hearing aids and to measure the
reduction of any disabling effects of your
hearing loss. The COSI (pronounced "cozy") is
the Client Oriented Scale of Improvement which
was developed by Dr. Dillon and colleagues at
the National Acoustics Laboratory in Australia
4. As you will remember from my
earlier comments, I emphasized that benefits
from hearing aids are highly individualized. The
COSI allows the audiologist/HIS to determine,
based on your input, five major goals or changes
you want to occur as a result of wearing hearing
aids. These goals may include hearing your
spouse better in the car, hearing your friends
better on the phone, or any others that relate
to you and your hearing difficulties. These
assessments are not like the hearing evaluation
given by the audiologist/HIS. These are tools
that allow us to measure your self-perception of
how your hearing loss affects your activities of
daily living and how amplification can improve
your quality of life.
5. Expect to be offered a 30 day trial
period. Although not always required by law,
many audiologists/HISs offer a trial or rental
period of 30 days for you to adapt to
amplification. You may be asked to pay a
non-returnable fee during this time. Ask about
this trial period, and if not offered, seek a
second opinion. Use this 30 day period to test
the hearing aids in the environments that are
typical of your lifestyle - not only at home,
but also at your friends? and relatives? homes,
your favorite restaurant, shopping center,
grocery store, or place of worship.
6. Expect a referral to a physician to rule
out any medical condition that may contribute to
your hearing loss. All hearing aids are
medical devices and, as such, are governed by
regulations of the Food and Drug Administration
(FDA). The FDA requires that all users of
hearing aids be examined by a physician,
preferably one who specializes in diseases of
the ear. If you are over the age of 18 years,
you may be given the opportunity to sign a
medical evaluation waiver that will allow the
audiologist/HIS to proceed with your hearing aid
fitting. It is in your best interest to be
evaluated by a physician prior to the hearing
aid fitting, but particularly so if you have a
history of ear problems or hearing loss of
unknown origin.
7. Expect the hearing aids to cost more than
you think they should. There are three
categories of hearing aid technology - analog,
digitally programmable, and digital. Analog
technology has been around for many years. Aids
utilizing this technology are also called
"conventional" hearing aids and they are the
least expensive. According to the most recent
dispenser survey published in the Hearing
Review in June of 2001, the average price of
a hearing aid with analog technology will cost
approximately $900 to $1500 per aid, depending
on the size of the aid - the smaller the aid,
the larger the price1. Digital
hearing aids use digital signal processing - the
newest form of technology on the market. Digital
hearing aids are indeed complete computers,
similar to the PC on your desktop, but they are
the size of a pencil eraser! These aids cost
approximately $2500 per aid, similar to your PC.
Digitally programmable hearing aids will
probably cost somewhere between the conventional
price and the digital price. You may benefit
from any of the three types of technology. Speak
with your audiologist/HIS about the types of
circuitry and which would be best for you.
Importantly, in 2002, some basic digital hearing
aids are available at a lower price than in
previous years. Many of the manufacturers have
switched the focus of their product lines to
completely digital offerings, as digital
products are more efficient and have broader
application. Consequently, as the demand and
sales have increased, the price has gone down a
little. The bottom line is that there are many
more digital hearing aids on the market in 2002
than there was in 1999, and the prices vary
tremendously, as do the products.
8. Expect an initial orientation session with
your audiologist/HIS in which you will learn how
to handle and care for your new aids. You
should invite your spouse or significant other
to attend this first critical session in getting
oriented to your new aids. During this session,
you will be taught how to operate the hearing
aids, how to clean them, and how to change the
batteries. You will receive written information
about your aids - a booklet called a ?User
Instructional Brochure? which is a requirement
of the FDA. Please note, batteries are
particularly important. Please be sure to store
them and use them exactly as your hearing
healthcare professional advises. Please be sure
to keep all batteries way from pets and
children. It may be difficult for you to
remember all the things the audiologist/HIS
tells you during this first session, so don?t
leave the office without your instructional
brochure! It will be very valuable to you,
particularly during the first weeks of owning
your new hearing aids.
9. Expect a period of adjustment.
Remember the 30-day trial or rental period
mentioned earlier (see point 5 above)? Once you
get your new hearing aids, expect an adjustment
period of several days to many weeks to get used
to the daily care and maintenance of the hearing
aids.
You?ll need time to learn how to; insert and
remove the hearing aids from your ears, learn to
adjust the volume control (some hearing aids
have volume controls, other are automatic),
learn how to clean them, learn how to open and
close the battery door, learn to change the
battery, get accustomed to placing the hearing
aids in a dry-aid kit for the times when they
are not in your ears. As you can see, there is a
lot to learn, and people learn at different
speeds. I recommend that you go slowly, learn
one thing at a time, practice, and stay in
contact with your hearing healthcare
professional.
Many times, a spouse (or significant other) is
very useful in helping you adjust to the new
responsibilities of ownership of hearing aids.
The largest adjustment you will go through is,
of course, listening with your new hearing aids.
You will hear sounds that you have not heard for
a long, long time. Some of these will be "good
sounds", like the songs of the birds or
high-pitched voices of children. Other sounds,
the "obnoxious ones", are sounds we need to hear
for our safety and/or general knowledge of what
is happening around us. These are sounds like
the refrigerator or air conditioning units
humming and buzzing, the sound of our footsteps,
or a "knock" in the sound of the car engine.
Research in this area has shown that this
adaptation or adjustment period may last a few
months. It takes time for the brain to re-learn
all these sounds. Be patient!
10. Expect your voice to sound different.
For many reasons, your voice will sound strange
to you at first - like being in a barrel. This
is a normal early perception and it is often
called the ?occlusion effect?. If you don?t
adjust to this after a few days, discuss this
with your audiologist/HIS. Many times, this
feeling can be alleviated through changing the
vent size in your hearing aids or changing the
amount of amplification you are getting for
low-pitched tones. Your audiologist/HIS deals
with this issue regularly, and they will be able
to solve this with you, over a short period of
time.
11. Expect a good, comfortable fit.
Initially, it will take a while to get used to
having the hearing aids in your ears. You may
experience a little soreness or irritation at
first, but after a few days or a week or so, you
should be able to wear the aids for several
hours per day without any pain or discomfort. I
always find it reassuring when patients tell me
they often forget that they are wearing their
aids. Remember - even though the audiologist/HIS
will make your ear impressions so your hearing
aids will be custom fit, many things can happen
in the manufacturing process and any discomfort
should be reported to your audiologist/HIS
immediately. If your aids are not comfortable,
you will not get the maximum benefit from them,
and you should not wear them. Report all
discomfort or irritations to your hearing
healthcare professional, and do not wear the
hearing aids until he/she advises you as to how
to best address the problem.
12. Expect multiple follow-up appointments.
The greatest advantage of digital hearing aid
technology is the flexibility in programming the
sound quality, as well as many other
electro-acoustic characteristics of your hearing
aids. These hearing aids are highly
sophisticated instruments with many features.
The computer software that is used to program
your hearing aids allows the audiologist/HIS to
make a multitude of adjustments while the aids
are in your ears. You can actually hear many of
the changes as the audiologist/HIS is adjusting
different features or characteristics. Other
features will only be noticeable in other
environments. So, be sure to tell your
audiologist/HIS as much as you can about your
listening experiences in many environments. If
you are a new user, you may get an initial
setting of about two-thirds of the amplification
that will be ideal for you. As you get used to
your aids, the audiologist/HIS will increase the
amount amplification over several visits. This
will help in your adjustment period and lessen
the chances of rejection due to
over-amplification.
13. Expect your audiologist/HIS to evaluate
the benefits provided by your hearing aids.
This is normally done in at least two ways.
First, electronic measurements of "real ear"
performance give the audiologist/HIS an idea of
how the aids are functioning when the hearing
aids are in your ears. Your audiologist/HIS may
make measurements in which a small microphone is
placed in your ear to measure what is happening
in your ear canal with and without the hearing
aids in place. This is an objective measure and
a starting point for successive changes in the
performance of your aids. Secondly, the APHAB,
COSI, or other assessment scales may be repeated
so the audiologist/HIS can help you evaluate
pre- and post-fitting hearing difficulties.
These two evaluation methods are important in
establishing the benefits you personally receive
from amplification. If there are no significant
changes in these measures, your audiologist/HIS
will need to make additional changes in your
hearing aid fitting.
14. Expect to be able to hear well, but not
perfectly, in quiet one-to-one situations and
most small group settings. In order for you
to hear well, we must make sound audible, then
comfortably loud. Your hearing aids will amplify
sound so speech will become comfortably loud.
You should be able to hear most of what is said
without having to watch a person?s lips all the
time. However, even people with normal hearing
watch the person speaking in order to gain more
information! Even when wearing the hearing aids,
you should combine your vision and your hearing
to maximize your benefits from the hearing aids.
When sound is comfortably loud, it will be
easier for you to listen and the stress of
straining to hear rapidly diminishes. Therefore,
listening in social situations becomes
pleasurable again. If everyday sounds are
uncomfortably loud, report this to your
audiologist/HIS immediately.
15. Expect an optimal "distance for hearing".
The best distance for hearing with your aids
will be dependent on the type of microphones in
your hearing aids, and other factors. The
hearing aids may be directional or
omni-directional. Find out from your
audiologist/HIS which type of microphones you
have, and the effective listening range or
effective "distance for hearing". People within
this distance will be the most audible to you.
Once you increase the distance from the source
you want to listen to, it will get increasingly
difficult to hear - just like without the
hearing aids.
16. Expect to have difficulty hearing in
noisy situations. You may say that you can
hear fine in quiet and that the noisy situations
are the ones in which you need the most help.
This is a common statement made by individuals
who have presbycusis (hearing loss due to
aging), noise-induced hearing loss, or any
hearing loss where the
high-pitched tones are affected the most.
Eventually though, as your hearing loss
progresses, your ability to hear in quiet
settings is also affected. Background noise is a
nuisance for everyone, even normal hearing
individuals. As sophisticated as today?s
technology is, hearing aids still cannot
eliminate background noise for you. Some of the
more sophisticated digital circuitry can
effectively reduce (although not eliminate)
background noise. If you are in a lot of noisy
environments, it is important to discuss this
with your audiologist/HIS when discussing your
case history and setting your goals for
improvement.
17. Your hearing aids may squeal (also called
"whistle," or "feedback") under some
circumstances. If a hearing aid is somewhat
functioning and has a good battery in it, this
squeal (acoustic feedback) will occur when the
hearing aid is cupped in the hand. Most users
find that this helps determine the status of the
battery and it is a good sign! However, you
should be able to wear your hearing aids at a
comfortable loudness level and not experience
this squeal. If you do not have a volume control
on your aids, they will squeal when you place
them in your ears - until you get them placed
comfortably. Sometimes, your aids will squeal if
you press the phone too tightly to your ear.
Report these events to your audiologist/HIS and
determine what is normal, what is abnormal, and
what can be done to reduce unnecessary acoustic
feedback.
18. Expect repairs. You should realize
that hearing aids are incredibly sophisticated
devices being inserted in the ear canal where
moisture and cerumen (ear wax) is waiting to
attack any foreign object! Hearing aids are also
prone to being dropped if our fine motor
dexterity is a little compromised. Microscopic
solder joints that connect the tiny wires of the
microphone and receiver to the computer chip in
the hearing aid can be jarred loose. All repairs
cannot be avoided, but the majority of repairs
can be avoided with regular and careful
maintenance! Being careful and establishing and
maintaining a good preventive maintenance
schedule, at home and at your audiologist?s/HIS?s
office, can significantly reduce the number of
repairs on hearing aids. Your aids will probably
come with a standard one year warranty, and
after that, you can purchase hearing aid
insurance from a number of companies. Talk to
your audiologist/HIS about additional warranty
options when you purchase the aids.
19. Expect to buy batteries. Hearing aid
batteries will probably last a week or two in
the hearing aid. Hearing aid battery service
life varies based on the hearing aid circuit and
the quality and type of battery and is also
dependent on environmental conditions
(temperature, humidity etc.). Some people ask
why hearing aid batteries don?t last as long as
watch batteries. The answer is the hearing aid
battery accomplishes a great deal more work and
requires much more electrical energy than does a
watch battery. The information you receive
during the hearing aid orientation session will
define a reasonable length of time for your
batteries. When your hearing aids are new, you
might want to keep a calendar indicating the
days you change batteries. Report any
significant changes in battery usage to your
audiologist/HIS. Many professional offices offer
battery promotions or special programs for their
patients. Ask your hearing healthcare
professional about this.
20. There are two ?NEVERs? with
batteries. NEVER keep batteries with your
medicines, as you might accidentally ingest one.
NEVER allow young children to handle batteries,
as they might ingest them. All hearing aid
batteries are toxic if swallowed. Keep them in a
safe place and be sure to recycle your batteries
properly.
21. Expect to purchase new hearing aids every
5 years. This may come as a surprise,
particularly if you just purchased a set of
digital hearing aids! However, hearing aid
technology changes rapidly, just like computers,
and new technology may benefit you greatly. Some
people may keep the same pair of hearing aids
for 10 to 12 years, particularly if their
hearing loss remains stable over time and if
they do a great job with maintenance, but the
average life expectancy is about five years.
22. Most importantly, expect to enjoy the
sounds of life again! Your hearing aids are
a key ingredient to staying active and improving
the quality of your life. You will once again
enjoy social events, leisure activities, and
conversations with your family, friends, and
co-workers. Your hearing aids will also help you
hear sounds to keep you safe and well.
References
1. Strom, K. E. (2001). The HR 2000 dispenser
survey. The Hearing Review, 7 (6), 20-42.
2. Staab, W. J. (2000). Hearing aid selection:
An overview. In Sandlin, R. E. (Ed.),
Textbook of Hearing Aid Amplification: Technical
and Clinical Considerations (pp 63-64). San
Diego, CA: Singular Thomson Learning Publishing
Group.
3. Cox, R. M. and Alexander, G. C. (1995). The
abbreviated profile of hearing aid benefit.
Ear & Hearing, 16 (2), 176 - 186.
4. Dillon, H., James, A. and Ginis, J. (1997).
Client Oriented Scale of Improvement (COSI) and
its relationship to several other measures of
benefit and satisfaction provided by hearing
aids. Journal of the American Academy of
Audiology, 8 (1), 27-43.
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