As audiologists are well aware, even the highest levels of hearing aid technology fit to best practice standards (Academy, 2006; ASHA, 2006) fail to meet the daily listening demands of many patients with hearing loss (Lesner, 2003; Laplante-Levesque et al, 2013). Indeed, as Table 1 reveals, the degree of hearing deficit remaining post-hearing aid fitting can be substantial.
Hearing assistance technologies (HATs)—also known as assistive listening devices (ALDs), designed to improve speech understanding, enhance the reception of auditory media, or heighten the awareness of environmental sounds or warning signals—have been around for many years, and their value in addressing specific listening needs can be substantial. A full review of these device types and their uses can be found in a variety of audiology texts (e.g., Atcherson et al, 2015; Montano and Spitzer, 2014; Tye-Murray, 2014).
Most patients unfortunately do not hear of HATs from their audiologists (Clark et al, 2017; Stika et al, 2002), and their use among adults frequently remains low (Aberdeen and Fereiro, 2014; Hartley et al, 2010). As Atcherson and his colleagues (2015) note, it is indeed unfortunate when hearing loss remediation ends in the fitting of hearing aids or cochlear implantation without further consideration of the limitations of these devices and the further assistance available.
HATs also have been shown to be beneficial to those whose hearing loss has not progressed to a degree warranting amplification. In addition, some form of hearing assistance may be beneficial for the estimated 26 million U.S. adults who have normal hearing thresholds on routine audiometrics in the presence of expressed hearing difficulties (Beck et al, 2018).
|HEARING LOSS LEVEL †||TYPICAL PRESCRIBED GAIN ‡||RESIDUAL HEARING DEFICIT IN dB HL|
|16 to 25 Slight||4 to 10||12 to 15|
|26 to 40 Mild||10 to 20||16 to 20|
|41 to 55 Moderate||20 to 30||21 to 25|
|56 to 70 Mod/Severe||30 to 40||26 to 30|
|71 to 90 Severe||40 to 50||31 to 45|
|91+ Profound||46+||45 to 55|
Source: Clark and English, 2019, used with permission
† Hearing loss levels in dB HL based on 3-frequency PTA using Goodman (1965) descriptors as modified by Clark (1981).
‡ Gain based on sensory/neural hearing loss. Conductive and mixed hearing losses will tolerate more gain and result in less residual deficit.
Full Measure of Assistance Is Not Always Provided
Treatment for those with hearing difficulties should begin with selection of appropriate amplification and HATs (Academy, 2006). In spite of this, when patients come to us for guidance, we often fail to present the augmentative technologies that can improve audition beyond the hearing aid fitting or cochlear implant mapping, or when hearing aids are not yet needed.
In 2002, Stika et al found that only 33 percent of surveyed hearing aid users reported audiologists informed them of HATs. Their finding suggests that either two-thirds of audiologists are not including the topic of HATs in their regular provision of care or are not presenting this information in a meaningful manner that allows for subsequent patient recall.
More recently, Clark et al (2017) found that only 13 percent of surveyed audiologists routinely discuss HATs with their patients (routinely defined as 75 percent to 100 percent of the time). Moreover, only another 38 percent noted they discuss HATs with their patients more than half the time. Yet, Palmer (2009) notes that patients expect that we are availing ourselves of the latest technologies and adhering to established best practice protocols to ensure satisfactory outcomes. There is truly no personal or professional defense that can be given when one fails to meet these patient expectations of professional practice (Clark et al, 2010).
Research shows a clear need for greater inclusion of HAT discussions on a routine clinical basis. By informing patients of the wide array of HATs available, audiologists have the potential to enhance hearing ability for patients, ensure patients are alerted to important signals and warnings in their lives, and improve patients' overall quality of life.
Effective Means to Prompt HAT Discussions
We believe that the relatively infrequent use of HATs is not related as much to a lack of motivation to use HATs as it is to the failure of audiologists to routinely discuss their availability. It is understandable that altering an established clinical routine presses on the time constraints that many face with appointment schedules. There is, however, one simple addition audiologists can include to efficiently and effectively integrate HATs into clinical routines. The Hearing Loss Association of America (2010) recommends the use of a HAT-focused self-assessment tool to determine the need for and selection of a variety of HATs. Unfortunately, the survey by Clark et al (2017) on adult hearing loss rehabilitation practices suggested that 94 percent of audiologists do not use any form of HAT self-assessment tool to facilitate the discussion or selection of hearing assistance technologies.
Each patient we see has a unique set of feelings surrounding the acquisition of hearing loss. Some may feel embarrassment, denial, or discomfort in sharing their perceived communicative struggles in various environments. In addition, some patients may not even realize they struggle in a particular area until prompted. A HAT Needs Checklist (see Table 2, page 77) can be particularly helpful for those patients who may not provide detailed information about the situations in which they struggle to hear or communicate. This checklist ensures that all important areas of life are addressed consistently so that audiologists can make informed recommendations on the potential use of HATs.
A HAT Needs Checklist is an effective means to frame discussions about assistive technologies in a clinically time-sensitive manner. Although a HAT Needs Checklist can be beneficial to use at any point in the treatment process, for those fit with hearing aids, it may be most effective if administered at the patient's final post-fitting appointment.
According to Skafte (2000) and Clark et al (2017), the predominant protocol for hearing aid dispensing brings the process to completion for most patients within three or fewer appointments. After these appointments, audiologist-patient communication may be limited. Once patients have a greater feel for their hearing and communication abilities and limitations with amplification, HAT exploration can be more beneficial. If routine hearing evaluation reveals normal hearing sensitivity in the presence of hearing complaints (Beck et al, 2018), the HAT Needs Checklist may be used most effectively during post-evaluation discussions.
HAT NEEDS CHECKLIST
This checklist is designed to help you identify areas in which you may need additional help. Hearing difficulties may be experienced in the presence of normal hearing, or when hearing aids cannot fully restore existing hearing loss.
It is for these situations that alternative or supportive hearing assistance technologies were developed. To help identify your needs, please complete the following checklist.
Indicate which sounds and situations are difficult for you by using the scale below. If you use hearing aids, complete this checklist indicating difficulties that still remain even with use of your hearing aids.
In completing this form consider how frequently you have difficulty hearing the indicated sound or hearing in the indicated situation. Within the parentheses put an "N" (never), "S" (sometimes), "O" (often) or an "A" (always) to indicate the frequency of difficulty.
|N–Never S–Sometimes O–Often A–Always|
|Hearing my telephone ring|
|Hearing conversations on the telephone|
|Hearing my alarm clock|
|Hearing someone at the door|
|Hearing the television, stereo, or radio|
|Hearing the smoke detector or fire alarm|
|Hearing one-on-one conversation|
|Hearing in small groups (5 or fewer people)|
|Hearing in large groups (6 or more people)|
|Hearing at a meeting with one main speaker|
|Hearing in a place of worship|
|Hearing while driving or riding in a car|
|Hearing the turn signal on my car|
SOURCE: Clark and English (2019). Used with permission.
Discussing HATs with patients gives them a better understanding of devices that will enhance their auditory levels. This may include adults who have normal hearing thresholds on routine audiometrics in the presence of expressed hearing difficulties. Audiologists should make this HAT discussion a routine practice to explore the best remedy for hearing loss.