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Thursday, June 22, 2017

Rethinking Hearing Aid Evaluation

B​y Ben Gilham, AuD

Hearing aid evaluation is one of the most common type of appointment that a hearing health care provider encounters in daily clinical practice. The obvious reason for the visit is to select the most appropriate hearing aid for a patient based on case history, audiogram, and patient interview. How the hearing aid evaluation process is completed is highly variable in audiology; often, patients are not provided with other considerations when evaluating the hearing aid recommendation. However, it may be necessary to conduct a more thorough and patient-involved process in selecting amplification.

PRE-FITTING ASSESSMENT

Evaluation beyond the audiogram is critical when choosing the proper hearing aid. The first tool that can provide substantial initial information is a validation measure such as the Hearing Handicap Inventory for the Elderly or Adults screening version (HHIE/A-S). Having a patient complete this questionnaire prior to the appointment gives the clinician a basic idea of the patient's hearing challenges and opens discussions of specific listening situations that otherwise may not be examined. The HHIE/A-S can also be used as a basic pre- and post-hearing aid fitting measure, and provide a data point that can be tracked to determine any hearing improvement since the use of amplification.

The Client Oriented Scale of Improvement (COSI) is also a great way to discuss specific situations wherein patients experience hearing challenges. It also enables clinicians to learn what patients value in hearing aid function. This establishes a more personal connection and helps ensure successful hearing aid use.

Each outcome measure serves a different purpose. When used together, these can provide a great deal of information in a short period of time. Utilizing one outcome measure can already provide meaningful data that may serve as pre- and post-fitting metrics to determine if the goals of the hearing aid fitting were achieved.

OTHER BEHAVIORAL TESTS

These tests are useful prior to discussing amplification options: the most comfortable loudness level (MCL), loudness discomfort level (LDL), and speech-in-noise testing (SPIN). In many states, MCL and other forms of LDL measurement often need to be documented prior to hearing aid fitting. MCL has limited clinical utility for fitting hearing aids, but it may be required depending on the state of practice. Tone-specific LDL measurements are very important to obtain as they account for the individual variability of loudness discomfort to be applied on the maximum power output (MPO) setting of the hearing aids (JAAA. 2005; 16[7]:461). If frequency-specific LDL measurements are not obtained, the clinician can only rely on estimated MPO settings that can greatly impact the outcome of a fitting (JAAA, 2005). Speech LDL is not a useful measurement for programming hearing aids since the measurement cannot be applied to the specific programming of the MPO.

SPIN testing is very important to determine which style of amplification is most appropriate for the patient. There are several speech-in-noise tests available for clinical use, the most commonly used test is the QuickSin due to its efficiency and being widely available in many clinics. Testing speech understanding in noise allows the clinician to determine if directional microphones are required, whether an open or closed dome may be more appropriate, and whether a remote microphone or FM system may be necessary (Audiology Online, 2011). SPIN testing allows the clinician to provide an informed response to the question "What is the best hearing aid for me?" This further allows the clinician to utilize the data obtained to openly discuss the best amplification options given the patient's hearing profile and cosmetic preferences, i.e., RIC vs. CIC. SPIN testing also addresses common hearing difficulties in background noise, giving the provider an opportunity to explain how hearing aids can realistically assist patients in noisy environments.

To provide a thorough evaluation of assistive devices that will address specific patient issues, clinicians may discuss  most common areas of reported difficulty such as television and cell phone use, work accommodations (Bluetooth options for office and web based phones), alarm clocks, and even safety related to fire alarms (for patients with more severe-to-profound hearing profiles). Discussing telecoil and hearing loops is also pertinent as public awareness of loop systems appears to be increasing across the United States. Rechargeable hearing aid options are also becoming more durable and reliable, and are often asked about during consultations.

Many patients who come for a hearing aid evaluation have never worn hearing aids before. As such, giving an in-office demonstration during the consultation can help patients experience hearing with amplification. This gives the provider an opportunity to discuss the acclimatization process, set realistic expectations, and answer questions that the patient may not have thought of before trying on the hearing aids. A hearing aid demonstration is also beneficial primer for patients to determine if they note any hearing improvement. Patients tend to appreciate the opportunity to try hearing aids in the office as they understand more of how these devices may benefit them.

Hearing aid evaluation is an important part of the hearing aid process. Most often, hearing health care providers are under significant time constraint during appointments, but doing more homework prior to the fitting can help reduce hearing aid returns and follow-up visits, and help ensure satisfactory fitting and, ultimately, satisfied hearing aid users.


 ​ben bio photo.png​Dr. Gilham is an audiologist at the University of Washington Medical Center in Seattle, Washington.