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Alison M. Grimes, AuD University of California, Los Angeles.

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1 Alison M. Grimes, AuD University of California, Los Angeles

2

3  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

4  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”

5  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  Hearing aid selection based on ◦ Specific patient variables and needs/desires ◦ Effectiveness over cosmetics  Verification of audibility using evidence-based procedures  Patient/family counseling

6  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

7  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”

8  CPHI (measure of handicap) scores significantly poorer in non-users than in users ◦ That is, greater handicap in the non-users.  Participants benefited from extensive auditory rehabilitation and expert fitting techniques  Significant long-term subjective benefit and satisfaction with hearing aids.

9  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  Given extended periods of trial use  Able to select their preferred fitting  (This is not how hearing aids are typically fitted and dispensed!)

10  Intensive Management  Patient involvement in the selection and fitting process  Probe Microphone measures to ensure maximum audibility ◦ Every time  “Trial Period”— ◦ What does this mean? ◦ Are we stuck with this forever?  Legally, perhaps  Can we term it something different?

11  Denial/Stigma  Belief that hearing aids are ineffectual  Medical/audiological professionals who downplay significance of hearing loss  Cost  Sales aspects  Cultural/Linguistic Issues

12  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”  Lack of awareness of the psychological, social, emotional, physical and cognitive impacts of untreated hearing loss  Belief that it’s OK to procrastinate

13  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

14  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)

15  Perceived high cost for value  Lack of third-party funding  Bundled hearing aid pricing model ◦ Bad for consumers? ◦ Bad for audiologists?

16  Unrealistic advertising  Confusion about who sells hearing aids ◦ What are their qualifications?  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

17  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

18  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  Negative psycho-social, psychological and cognitive impacts

19  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  Then employ ◦ Other hearing assistance technologies  Auditory Rehabilitation Program ◦ Counseling ◦ Communication Skills Training  (Move to cochlear implant if needed)

20  Patient Preferences ◦ What can the patient manage? ◦ What can the ear canal accept?  Style ◦ Custom vs BTE  Binaural vs Monaural ◦ Or other signal-routing (CROS, BICROS)  Cost

21  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

22  Patient/Family Decisions ◦ Features  VC, PB, remote ◦ Color ◦ Price ◦ To some degree, style and arrangement  Manufacturer ◦ Depends on the reason that a particular brand is requested  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

23 Audiologist Wants – Availability of appropriate gain and output across the speech spectrum based on patient’s hearing loss – 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 Patient Wants – “invisible” – “block out background noise” – “high-fidelity” with near- perfect speech understanding – Larger, longer-lasting battery – Easy to manipulate controls – Or no controls – Sturdy battery case – Inexpensive – Distance hearing – Lack of feedback – Physically and acoustically comfortable and ‘natural’

24 The Noise Problem  The #1 complaint of hearing aid users  Latest MarkeTrak “listening in noise” shows  25% overall dissatisfied  61% overall satisfied  14% neutral  Listening in noise ◦ Related to reduced speech perception  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!)

25  An oversold technology? ◦ May lead to disappointment with hearing aids ◦ Importance of pre-fitting counseling  Better termed “noise management” ◦ Makes listening in noise more comfortable  Definition of noise varies ◦ Noise is the undesired signal ◦ The desired signal may have the same spectrum ◦ Noise is often others’ speech  NR doesn’t improve speech perception ◦ Creates greater listening ease

26 Noise Reduction in Hearing Aids  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  How can this be improved? ◦ Counseling ◦ Remote microphone technologies ◦ Communication strategies

27  Benefit of DNR algorithm is not to make speech more intelligible ◦ Does reduce the cognitive effort involved in performing the task  Shared attention extracting speech from noise ◦ Items presented in noise less likely to be remembered successfully ◦ Listening in noise: increase in listening effort  Noise reduction frees resources for other, simultaneous tasks. ◦ Better auditory memory ◦ Increased speed of response to a visual task ◦ (Sarampolis, et al., 2009)

28  Proven ability to reduce signals at specified azimuths ◦ May or may not be “noise reduction”  Function less well in ◦ 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?

29 Noise Reduction Plus Directional Microphone  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)

30  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 post- treatment ◦ Including realistic expectations counseling  Provide basis for counseling and setting expectations

31 Tool to assist in assessing – Motivation – Interest in different types of hearing aids – Budget 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) Patient has already considered some of the initial questions and developed answers

32  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.  ___Hearing aid size and the ability of others not to see the hearing aids  ___Improved ability to hear and understand speech  ___Improved ability to understand speech in noisy situations (e.g., restaurants, parties)  ___Cost of the hearing aids  Do you prefer hearing aids that:  ___are totally automatic so that you do not have to make any adjustments to them.  ___allow you to adjust the volume and change the listening programs as you see fit.  ___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.  ___Basic digital hearing aids: Cost is between $XXXX to $XXXX  ___Basic Plus hearing aids: Cost is between $XXXX to $XXXX  ___Mid-level digital hearing aids: Cost is between $XXXX to $XXXX  ___Premium digital hearing aids: Cost is between $XXXX to $XXXX

33  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?

34  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

35  “How does that sound?” (important, but insufficient)  “Aided Audiogram” (misleading, unreliable, attractive to lay-person) ◦ Inadequate and inappropriate for making hearing aid adjustments  “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?

36  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

37 SII 75 SII 80

38 SII 41 SII 68

39  Yes!

40

41

42  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  Counsel, counsel, counsel

43  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.

44  Comfort ◦ Physical ◦ Acoustic  Output SPL may be uncomfortably high  Audibility of speech spectrum may be inadequate  Occlusion effect  Feedback  Lack of speech clarity/poor speech perception  Related to auditory impairments not amenable to treatment with hearing aids  Frequency, temporal and amplitude distortion  Environmental Noise ◦ Speech  A primary reason why older adults stop wearing hearing aids ◦ Non-speech

45  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  Ensure return to maximal audibility at a future appointment as acclimatization occurs

46  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

47 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 – 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

48  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

49  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.

50  Possible disappointment that things aren’t perfect ◦ Unlike eyeglasses for myopia  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

51  “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!  Pre-occupation with minimizing how visible hearing aids are  Physical Infirmities—frustration with ◦ Seeing hearing aids ◦ Manipulating controls (dexterity, fine-motor, peripheral neuropathy

52  Improve ◦ Noise ◦ Reverberation ◦ Distance  Bluetooth  FM  Amplified telephone, text, visual telephone (Skype, iChat)  Amplification and Captioning for TV  Signaling devices ◦ Phone ◦ Doorbell

53  (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  Allow patient to experience hearing success via technology ◦ Inform them of all options ◦ Let them make the decision

54  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

55  Hearing aids may be effective treatment for tinnitus ◦ ~50% of HI listeners with tinnitus had tinnitus relief  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

56  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. ◦ 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

57  431 articles  Reported outcomes with hearing aids indicate they are an effective method for treating mild- moderate 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

58  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

59  Our services are underutilized ◦ significant, negative, implications for communicative/QOL/cognitive outcomes ◦ Impacting a large and growing population  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

60  Challenges ◦ Hearing aid features are marketed prior to rigorous testing regarding efficacy ◦ Claims may be made that actually don’t stand up to study  Lag between introduction of signal- processing schemes and validation research  Difficult to provide accurate information about the products offered  Responsibility to acknowledge such

61  Promote the concept that hearing aids work ◦ And that rehabilitation, including hearing aids, is in an individual’s and family’s best interests  Provide hearing aid fittings based on best practices ◦ 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  Need to advocate for adequate and appropriate reimbursement for services ◦ (sales of hearing aids cannot be our sole revenue stream!)


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