Assistive Technology for Adults with Hearing Aids

Abstract

Although there is a strong trend of satisfaction with hearing aids, recent consumer surveys indicate that there are still challenges with understanding speech in background noise and low penetration of wireless technologies using many modern-day communication and audio devices, such as smartphones, tablets, and computers. For some listening and communication settings, many patients could benefit from assistive technology that exceeds the capabilities of their hearing aids. When patients are not wearing their hearing aids, such as during sleep, concerns about environmental awareness and safety begin to arise. This article describes some current assistive technologies and accessories that facilitate accessibility to other devices and to satisfy the patient's listening and communication needs.

STANDARD DISCUSSED

1. 8. Assistive technology and accessories are considered to facilitate accessibility to other devices and to satisfy the patient's listening and communication needs.

Individuals with hearing loss experience one or more challenges to overall hearing abilities, including decreased audibility, reduced dynamic range, and poor frequency and temporal resolution. With these deficits come potential difficulties navigating the acoustical world of spoken communication and awareness of environmental sounds. For most individuals with hearing loss, hearing aids are the primary treatment. ^{1 2} Hearing aids help as a first step to improve audibility, and, secondarily, they can help with other listening needs through various digital processing features, additional built-in hardware components, and the ability to connect to other devices. Unfortunately, hearing aids alone cannot address every listening situation that would be expected to be accessed by someone with normal hearing sensitivity, auditory processing, and cognition. ^{2 3 4 5 6 7} Thus, the Audiology Practice Standards Organization (APSO) includes in its S2.1: Hearing Aid Fitting Standard for Adult and Geriatric Patients ⁸ the following recommendation: Assistive technology and accessories are considered to facilitate accessibility to other devices and to satisfy the patient's listening and communication needs.

There are numerous sources of evidence for the benefits of modern hearing aid use, but here we will briefly re-summarize findings ^{2 6} from the last two MarkeTrak consumer surveys (i.e., MarkeTrak IX [MT9] and X [MT10]), which prove invaluable as we consider assistive technology and related accessories to improve accessibility and patient satisfaction and their listening and communication needs. Respondents in both MT9 and MT10 reported high satisfaction with modern hearing aids and that they are helping to positively impact their overall quality of life by improving listening and communication satisfaction and lowering risk for depression. However, these consumer surveys reveal important areas for improvement. For example, MT9 indicated that hearing aid performance fell short of expectations when there was too much background noise, a finding that continued to be the case in a third of MT10 respondents. Both MT9 and MT10 mention wireless options as an area for improvement, particularly the ability to stream sound from other devices. One surprising finding from MT10 is that although smartphone penetration was high (>80% of respondents younger than 75 years), the use of wireless streaming with smartphones was quite low (13% of respondents). Picou suggested that the low use of streaming with smartphones may be related to technology availability and the timing of the survey, which is expected to change in future years. ⁵ Case in point, one out of five MT10 respondents indicated they were uncertain about less visible hearing aid features such as wireless capabilities and connecting to intermediary devices, and that many hearing aid users continue to struggle to maximize the use of less visible features. Last but not least, nearly half of MT10 respondents reported difficulties with the clarity or loudness of the talker's voice at least occasionally, pointing to possible low telecoil use (26% of respondents) and low streaming use (∼23% of respondents), or other factors (including lack of visual cues). These consumer survey findings point to continued need for technology beyond hearing aids even when consumer satisfaction with hearing aids is high.

Thus, the purpose of this article is to offer some recommendations for audiologists to meet the APSO S2.1 standard for adults with hearing aids by discussing the following:

1. 1. Assessment of listening and communication needs.

1. 2. Modern-day assistive technology and accessories to facilitate accessibility to other devices.

1. 3. Increasing adoption of assistive technology in clinical practice.

ASSESSING LISTENING AND COMMUNICATION NEEDS

Following successful hearing aid verification and validation, audiologists are strongly encouraged to revisit the reasons their patients pursued hearing aids in the first place. Generally, the primary listening and communication concerns expressed by patients are related to audibility and speech communication in background noise. While modern hearing aids can help improve audibility and speech in noise perception, there will always be circumstances where the hearing aid performance will not be satisfactory. Additionally, there are times when patients realistically will not be wearing their hearing aids, such as during sleep. Akin to other health professionals surveying patients about their activities of daily living (ADL) and instrumental ADL, audiologist can help hearing aid users figure how to maximize their hearing-related quality of life and sense of independence.

A useful framework is to consider that the myriad of listening and communication needs could be categorized into four universal areas for receptive communication access: face-to-face, phone, media, and alerting. ^{9 10} Each of those four areas of receptive communication access could be explored for the home; for times of social engagement; for employment, training, and education; and for leisure. As an example, a patient who generally enjoys social activities in one-on-one or group situations may need help interacting with others during volunteer activities (face-to-face), hearing the television (media), communicating on their smartphone (phone), and knowing when their smartphone is ringing or has audible notifications (alerting). Given this example, one can begin to address these needs using easily accessible solutions (e.g., teaching the patient how to turn on smartphone vibration), exploring telecoil and/or streaming options to use with the telecoil and smartphone, and possibly a remote microphone system to improve speech understanding in noise and over distance.

For those who would prefer a more formal approach, the Client Oriented Scale of Improvement (COSI) ¹¹ has long been useful, as it addresses patient's perception of their top-five most difficult communication situations before and after hearing aids. If the COSI is used, audiologists should consider probing possible alerting needs that may not be immediately obvious to patients. Another powerful, perhaps more comprehensive, tool for assessing need is the TELEGRAM, ¹² which is designed to be used after the audiologic evaluation and to generate technology recommendations or other rehabilitative strategies. The TELEGRAM has patients considering their perceptions of difficulty in the following areas: telephone, employment, legislation, entertainment, groups, recreation, alarms, and with members of the family. Audiologists may consider revisiting the completed TELEGRAM following verification and validation of hearing aids (patients may need a small period of acclimatization) to determine any new challenges that had not been considered previously. Regardless of the approach for assessing listening and communication needs, we can work together with each patient and their families to explore areas of needs beyond the capability of the hearing aids.

ASSISTIVE TECHNOLOGIES

It is beyond the scope of this article to survey every conceivable assistive technology for individual with hearing loss, and readers are directed to other wonderful sources. ^{13 14 15 16} Instead, we will focus on some broad categories, particularly those technologies that might provide increased satisfaction with listening and communication above and beyond hearing aids: wireless technologies and alerting technologies.

Wireless Technologies

By no means is wireless technology new, but there are several wireless protocols from which audiologists and their patients will need to explore. Wireless technologies often involve a transmitter and a receiver, and with auxiliary or intermediary devices are used, there may in fact be more than one wireless technologies used in tandem. Wireless technologies can be divided into the following general categories: (1) electromagnetic, (2) frequency-modulated (FM), and (3) digital modulation (DM) systems. ¹⁷ Using one or more of these wireless technologies can a long way help hearing aid users who continue to have difficulties with speech and other sounds of interest in the presence of noise or because of other challenges (e.g., distance or lack of visual cues).

Electromagnetic systems are the oldest comprising a device (e.g., hearing loop) that produces an electromagnetic field that can be picked up with a telecoil receiver, often included in many hearing aids. Here it is incumbent upon the audiologist to ensure that the hearing aid telecoil is programmed and verified in an electroacoustic test box so that the frequency–gain response curve of the telecoil mirrors the same curve of the hearing aid microphone (at least above 1,000 Hz). ¹⁸ When the telecoil is intended to be used for wireless purposes, we can only assume that public or personal hearing loop systems have been appropriately installed. One major limitation of electromagnetic transmission is the slightly buzzing sound that can be detected by the listener. However, the most obvious advantage of the telecoil is that it often does not need additional accessories.

FM systems are the second longest wireless technology used by individuals with hearing loss. Typically, there is a microphone transmitter worn by a speaker, while the listener with hearing aids has an add-on or built-in receiver. The communication between the transmitter and the receiver occurs via designated FM signals usually between wideband (72–76 MHz) and narrowband (216–217 MHz) ranges of frequencies designated by the Federal Communications Commission (FCC) for public use. FM systems are generally best used as personal hearing-assistive devices, but they can also be found in public arenas. To use publicly available FM receivers, the hearing aid user may have to identify a way to couple their hearing aid to the receiver (e.g., headphones or induction neck loop while activating their telecoils).

Lastly, DM systems usually refer to the use of the 2.4-GHz frequency band, also designed by the FCC for public use. Part of the confusion among audiologists and patients alike is that there are more than one transmission protocols operating on the 2.4-GHz frequency band. Some are standardized such as Bluetooth and others are proprietary to specific manufacturers and their devices. Regardless of the transmission protocol, the use of the 2.4-GHz frequency is likely going to be one of the fastest adopted wireless technologies among hearing aid users. Using proprietary devices, hearing aid users may be able to take advantage of remote microphone technologies that can help them overcome speech-related SNR issues or to pair with other audio devices (e.g., Phonak Roger). Likewise, hearing aid users who wish to use stream audio signals via Bluetooth devices (e.g., smartphone, tablets, and computers) may be able to enjoy a more direct, clearer quality sound to enjoy various electronic and digital media. It is important to understand that hearing aid users may require assistance from their audiologist to differentiate the various types of 2.4-GHz technologies and how to properly pair and unpair their hearing aids and other intermediary devices from Bluetooth devices.

Alerting Technologies

Without a doubt, the use of hearing aids may automatically make environmental sounds such as alerts and warnings audible. However, there will certainly be circumstances in which silent notifications are required, and, when not using their hearing aids (e.g., sleeping or napping), other alerting solutions may be helpful to ensure awareness and safety.

For times when patients are asleep and not wearing their hearing aids, audiologists can help patients become aware of a variety of altering devices, including standalone alarm clocks, smoke and carbon monoxide detectors, and even doorbell, baby cry alert, and national weather radio systems that can be set up with flashing and/or vibrating alerts. These can be purchased directly from a variety of commercial vendors. If the patient uses a smartphone, there may be apps or accessories that receive notifications or monitor environmental sounds that can be set up to alert the patient, particularly with smart watches or bands. And although not a technology, some patients may benefit from hearing-related service dog.

For times when the patient is actively using their hearing aids, but may be in the presence of background noise, any of the above alerting options could prove to be helpful. Taken a step further, there may be times with the patient needs to receive alerts in noisy settings or when silence is required, and as an example, they may be able to do so by Bluetooth pairing their hearing aids to their smartphones, tablets, or computers.

INCREASING ADOPTION OF ASSISTIVE TECHNOLOGY

The barriers to adoption of assistive technology by patients may be related to one or more of the same issues described by Atcherson ¹⁹ : (1) issues with cost and availability; (2) issues related to inconvenience, maintenance, and stigma; (3) lack of technical knowledge of application and compatibility of different technologies; and (4) poor understanding of and/or improper shifting responsibility between the audiologist and the patient. Each of these can be addressed in every clinical encounter.

Implementing assistive technology within an audiology clinic can sometimes seem like an overwhelming step to make. Most patients are already being asked to make a significant investment with both their time and money for hearing aids alone. How do we have conversations with patients about additional assistive technologies outside of hearing aids that may allow them to meet more of their listening and communication needs? Some patients may not understand the need for additional technology apart from their hearing aids. Because of this, the responsibility is on us as the audiologist to explain and demonstrate to patients that wireless technology such as remote or partner mics can help make the difference patients need in the most challenging listening environments. However, it should also be said that introducing assistive technology to patients is not limited to discussions with patients post-fitting. These conversations need to occur much earlier through intake, or during completion of the COSI or TELEGRAM.

It is not uncommon for televisions to be present in the waiting rooms of some clinics. What is perhaps less common is for those waiting rooms to have telecoil loops installed in them so that both new and returning patients can have the opportunity to take advantage of the telecoils in their hearing devices. Demonstrating to patients that their hearing devices can do more than passively amplify sounds in their environment is an excellent first step toward helping patients understand that hearing aids alone can only do so much, and that sometimes additional technology is required to help them achieve better communication and listening outcomes. When discussing this concept with patients, it is important to consider how the information is being delivered. Explaining how certain assistive technologies work is a process that can sometimes be difficult for patients to understand. It is for this reason that audiologists should consider having demonstration equipment on hand of the various assistive technologies. Having such equipment on hand can save time because that equipment does not need to be ordered and delivered before a patient has an opportunity to try it. Furthermore, it should be noted that some patients may not be ready to try some technologies, particularly if they are a new patient who is trying hearing aids for the first time. Some patients are already expending a great deal of effort to adapt to the use of their hearing aids and adding additional equipment on top of that may overly stress patients and potentially worsen outcomes. Additionally, demonstrating equipment does not necessarily mean allowing patients to borrow that equipment and take it home for personal use. Sometimes demonstrating the use of that equipment within the clinic is enough for patients to want to order their own.

CONCLUSIONS

At present, patients will often require assistive technology above and beyond the capability of their hearing aids to meet their listening and communication needs, even though there is a strong general trend of satisfaction with modern hearing aid technology. Audiologists are encouraged to continue to assess needs in both new and experienced hearing aid users, particularly to address accessibility to speech and other sounds of interest in background noise or other obstacles. Audiologists are also encouraged to consider needs that allow patients to maximize their awareness of environmental sounds and for personal safety. Assistive technology can help augment sound (acoustic), make otherwise inaudible sounds accessible (acoustic or nonacoustic), or a combination of the two. To assess needs, audiologists can have an informal intake with patients about their receptive communication needs in the home, their social engagements, employment/education/training settings, and for leisure purposes. Formally, these needs could be assessed using tools such as the COSI or TELEGRAM. Regardless of the assessment method used, it should be a goal to meet as many needs as possible without relying solely on the capabilities of hearing aids.