Hickson, L., Meyer, C., Lovelock, K., Lampert, M. & Khan, A. (2014) . Factors associated with success with hearing aids in older adults. International Journal of Audiology 53, S18-S27.

This editorial discusses the clinical implications of an independent research study and does not represent the opinions of the original authors.

There is a saying in real estate that the three most important factors determining property value are location, location, location.  A similar argument could be made for hearing aid fitting. Three of the most important factors in hearing aid success may be follow-up, follow-up, follow-up. Certainly, success cannot be expected without appropriate selection and verification, but thorough training, counseling and consultation after the fitting can have a huge impact on the comfort and perceived benefit of new hearing aids.

Hearing aid success can generally be defined as an outcome in which the patient wears the instruments regularly and reports benefit from them.  Knudsen et. al. (2010) reviewed several studies and a few factors emerged that were consistently related to success with hearing aids.  In general, the individuals most likely to do well were those who had positive attitudes about hearing aids prior to fitting and a greater degree of self-reported hearing difficulty (et al., 2010; Hickson et al., 1986, 1999; Cox et al., 2007).  In studies examining why people don’t use their hearing aids, the most commonly cited reasons were lack of perceived benefit and problems with the fit and comfort of the aids (McCormack & Fortnum, 2013).

A better understanding of how these factors interact will help clinicians guide their patients to become consistent, successful hearing aid users. Defining success as a combination of regular use and self-reported benefit, Hickson and her colleagues examined the association between audiological and non-audiological factors and successful hearing aid outcomes.  The audiological factors they studied were duration and degree of hearing loss, presence of tinnitus, style of hearing aid and insertion gain with hearing aids. Non-audiological factors were grouped into four categories: attitudes and cues to action, demographic characteristics, psychological factors and age-related factors.

One hundred and sixty adults over age 60 participated in the study, with a mean age of 73 years. All had hearing loss greater than 25dB HL and fewer than 2 years of experience with hearing aids. Of the 160 subjects, 75 were classified as unsuccessful hearing aid users and 85 were classified as successful users.  Unsuccessful users were defined as those who reported little or no use and/or benefit with their hearing aids.

Subjects participated in one session at which they completed audiological testing, real-ear measurements, cognitive testing, a case history and a general health questionnaire. Two weeks prior to the session they were given 8 self-report questionnaires to complete at home:

1.              Hearing Handicap Questionnaire (HAQ; Gatehouse & Noble, 2004)

2.              Self-Assessment of Communication (SAC; Schow & Nerbonne, 1982)

3.              Attitude to Hearing Aids Questionnaire (VanDenBrink, 1995)

4.              Measure of Audiologic Rehabilitation – Self-Efficacy for Hearing Aids (MARS-HA; West & Smith, 2007)

5.              Coping Strategy Indicator (CSI; Amirkhan, 1990)

6.              Locus of Control scales (Levenson, 1981; Presson et al., 1997)

7.              Auditory Lifestyle & Demand Questionnaire (ALDQ; Gatehouse et al., 1999)

8.              Social Activities Survey (SOCACT; Cruice et al., 2001)

Data analysis revealed that four factors were significantly related to hearing aid success. In order from strongest to weakest associations, these factors were positive support from others, hearing difficulties in everyday life, insertion gain (for 55dB input level) and the interaction between attitude toward hearing aids and advanced handling (e.g., identification of different components of a hearing aid and how confident the user was in manipulating the aids). Overall, hearing aid users were more likely to achieve success if they had support from friends and family, perceived greater difficulty hearing, their insertion gain matched target, they possessed a positive attitude about hearing aids and had greater confidence in their ability to use the hearing aids. Conversely, almost 25% of unsuccessful hearing aid users reported that their hearing aids didn’t help them hear better or were too noisy.  Less common responses from unsuccessful users were that they didn’t need hearing aids, had difficulty manipulating or adjusting to the aids or obtained no benefit from the aids.

The factor most strongly related to success was the support of significant others, as indicated by statements such as “The people around me think it was wise to obtain a hearing aid” or “The people around me think I hear better with my hearing aid”: underscoring the importance of involving spouses, family members or friends in the hearing aid fitting process, so that their observations and comments can be considered and discussed at the initial consultation, fitting and follow-up appointments.  Having support at the initial consultation also helps the potential hearing aid user realize their need for help. As many clinicians know, the hearing-impaired individual is often less aware of their communication difficulties than their close associates are. Friends and family members who support the need for and the observed success with hearing aids can be influential in the patient’s own motivation and perceived benefit.

Detailed discussion of test results and administration of hearing handicap questionnaires can also motivate potential hearing aid users to proceed with an evaluation and fitting. It is common for people with hearing loss to think that other people mumble or that the source of communication difficulty is external rather than related to their hearing loss. Seeing the configuration of the hearing loss, perhaps in the context of speech and familiar sounds can help them understand what they are missing. Hearing handicap questionnaires illuminate some of the familiar challenges that hearing impaired individuals experience. Clinicians are familiar with the scenario in which hearing impaired patients feel they don’t really have hearing loss because “they can still hear, they just don’t understand”.  Simply explaining the audiogram illustrates how their hearing differs from normal hearing can help them understand the implications of the loss and the need for amplification.

A positive attitude about hearing aids was related to increased use and perceived benefit. This is a harder goal to achieve, but should be addressed at the initial consultation and consistently thereafter. Every clinician has met patients who know a friend or neighbor who doesn’t like their hearing aids and it can be challenging to persuade skeptics that there is reason to expect improvement from hearing aids. It may be helpful to have testimonials from satisfied patients available on the clinic website or in written materials in the office.  I also find it helpful to simply assure people that with the quality of today’s hearing aid technology, there are very few problems that can’t be solved with thorough assessment, training and follow-up.

The issue of hearing aid stigma and negative associations is not an easy problem to overcome, but it has improved over time and will likely continue to improve. Clinicians should encourage successful hearing aid users to share their positive experiences with friends, family and co-workers, to act as advocates for the benefits of hearing aids. Similarly, friends and family of those who have experienced hearing aid success should spread the word whenever possible. The most powerful endorsements come from people who have experienced better communication with their own hearing aids. As a clinician, patients often tell me that hearing aids make their lives easier. Others tell me that they can’t imagine trying to function without their hearing aids. The more these hearing aid success stories circulate among the general public, the more motivated hearing-impaired individuals will be to pursue hearing aids for themselves.

Individuals who had greater confidence in their ability to use the hearing aids were more likely to be successful, regular users. This is another factor that can be addressed through training, guided practice, and clearly written materials. Many new patients are overwhelmed by the extent of information is covered during the hearing aid fitting; informing the patient that you have a plan for training during later visits will ease any anxiety with retaining all of the information shared at the time of the first fitting. Including friends or family members at the fitting also contributes to success as these individuals may contribute to use and care during the adjustment period.

The responses of the participants in this study illuminate many of the factors that affect hearing aid success. With an understanding of these factors and thorough follow-up care, clinicians can avoid or solve most problems and most hearing aid users should perceive benefit from their instruments. Because hearing aids are medical devices, they require comprehensive care from trained professionals. Time spent on fine tuning, training and counseling during the first few weeks after the fitting can have long-term impact on usage patterns, satisfaction and perceived benefit. Clinicians and experienced hearing aid users should share stories of positive outcomes to counterbalance negative perceptions so that new and potential users can embark upon hearing aid fittings with expectations of success.

This Article was first published in the Starkey Evidence Blog


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By Jason Galster