Sunday, April 15, 2018

"She STILL can't hear me!"

This is going to be a much more personal, passionate post than past blog entries. The issues discussed below are obstacles I face everyday as a Doctor of Audiology and they aren't solved by slapping a widget on someone's ear and yelling "next!". I hope you will stick with me through it and return frequently for other entries regarding hearing healthcare.


I fit numerous sets of hearing aids each week. Most of them on new users who have never worn hearing aids before. I always encourage my patients to bring someone with them to this visit. I find people respond better when they have a familiar voice to hear first through their hearing aid versus MY voice that they may not be familiar with beyond our first visit at their hearing test and subsequent hearing aid evaluation. I find that most people do not bring a communication partner with them. Whether is is because their adult children don't live here or are at work and can't break away or because they are trying to keep their hearing loss and decision to wear hearing aids--I'm not sure. Regardless of the reason, this can sometimes make adjustment to the devices more difficult than it has to be. But we adapt and hopefully overcome.  This isn't a post about the importance of bringing a communication partner with you to the hearing aid fitting, although that IS important and should be done if at all possible. This post dives a little deeper into hearing loss, what happens when it goes untreated, and what hearing aids can and cannot do.

Hearing Loss

Ask anyone if they know someone with hearing loss and they will most likely tell you emphatically, "YES!"  Hearing loss is the THIRD most common chronic health condition behind arthritis and heart disease. Yet only 1 in 5 people who would benefit from amplification actually use it. Perhaps it is because it is largely an "invisible" disability. It may also be due to the fact that it can be an expensive out-of-pocket investment not typically covered by private health insurance or Medicare. Perhaps it is the perceived stigma of hearing loss and it being "an old person's problem." I could spend all day hypothesizing on the reasons. I've heard so many of them over my career as an Audiologist. The bottom line is this: the average person waits 7-10 years from the time they think they have a hearing loss until the time they actually take steps to do something about it. What I've found in my office is there is some precipitating event that brings about the decision to FINALLY do something about their hearing loss. Some of the more common ones I've heard over the years are:
  • Finally having health insurance that covers part of the cost.
  • Losing a promotion or job (or the threat of it) due to the untreated hearing loss.
  • Losing a marriage or relationship (or the threat of it) due to the untreated hearing loss.
  • An embarrassing event that occurred because of the untreated hearing loss.
There are many, many more but these are the ones that come to mind immediately. People typically wait a long time, longer than they should, to do something about their hearing loss. It isn't just that it irritates family members, co-workers, or employees. It isn't just the social or emotional toll the hearing loss can take on a person. The problem goes much deeper. 

How we hear

While we tend to think the ears are responsible for hearing, they really only play a small part in hearing. In the most simplistic explanation, the ears capture the sound, sound waves then vibrate the eardrum, which then transmits the sound through mechanically moving the three bones in the middle ear. This starts a traveling wave of fluid, causing tiny nerve fibers (hair cells) to move along the cochlea and this movement of the hair cells change this movement to an electrical signal. This electrical signal then transmits the sound to the acoustic nerve where the information is sent to the brain. The brain perceives these electrical signals as sound. The brain then decides what the sounds mean and how to respond.  That is how we hear in a very simple nutshell. 

But what happens when the ear itself is damaged? Well, then you have hearing loss. In cases of sensorineural hearing loss, the most common type of hearing loss, there is some type of damage along the cochlea or acoustic nerve which impacts the electrical signal that gets sent to the brain. The hair cells in the cochlea, they all don't move at the same time. Certain hair cells move at certain times when a sound that is a specific pitch or frequency activates it. Because of the anatomic arrangement of the cochlea, the hair cells that pick up high frequency/high pitch sounds are at the entrance of the cochlea and they curl around, just like a snail's shell going from highs to lows at the center of the cochlea. For this reason, high pitched sounds like jets, jackhammers, and gun shots can irreversibly damage the delicate hair cells. This may occur over time or it may take just one exposure to cause damage. As for how this relates to how we hear this is the over-simplified reason why people say "It's not that I can't hear, it's that I can't understand what they said!" Hair cells that contribute to understanding, sounds like /t/, /f/, /s/, /th/ which are high-frequency sounds. When those hair cells are damaged and/or destroyed, one may hear someone speaking, but not be able to understand what the speaker is saying.  

While the brain actually does the heavy-lifting when it comes to figuring out what needs to be done with the sound when it comes into the brain via the electrical signal, the ears do play a vital role. And if the ears are "broken", meaning the hair cells are damaged or destroyed, the brain is getting a garbled signal which effects how the brain processes the sound coming into it. Hearing aids help--but they aren't the great equalizer.

So what can hearing aids do to help?

Modern digital hearing aids improve everyday! When I think back to the beginning of my career to now, I'm overjoyed with the advancements that have been made in hearing aid technology. Hearing aids used to just amplify sounds. Which was great if you needed everything overall louder. But in the cases of those with primarily just high-frequency hearing loss, volume and loudness isn't what is needed; clarity and understanding is what is needed. Today's modern digital hearing aids can be programmed based off the prescription, which is the hearing test.

It is important to note that hearing aids are just that--aids.  They use the residual hearing, which is the hearing someone has left, to process sound. Hearing aids are not restoring the hearing someone has lost.  In a hearing aid fitting, we are attempting to use the remaining hearing to maximum capacity to make sounds louder when needed and brighter, sharper, clearer to improve the understanding of speech. This won't restore speech understanding to 100%. There is no visual equivalent of 20/20 in hearing loss. Hearing aids will not make someone hear perfectly with hearing aids. Even individuals with hearing loss don't hear and understand 100% of what is said.

"She STILL can't hear me!"

I recently fit a second pair of hearing aids on a long-time patient. Her first set of hearing aids were over 8 years old! They had long seen better days! (The average life span of a pair of hearing aids is about 4-6 years.) Sadly, in the past eight years, her overall health has declined dramatically. She has a caretaker that assists her and her husband a few days a week and on this day, the caretaker brought her in for a hearing aid check to see how the hearing aids were working for her. She was quite despondent when she arrived and her caretaker was expressing frustration that she wasn't hearing well with her new hearing aids. 

We first addressed a fit issue. The new set of hearing aids are a different style than her first pair so I had to counsel her again on proper insertion and removal. We made some adjustments and she was pleased with what we did. The next issue was that her caretaker said she wasn't hearing her and she wasn't hearing her husband. Issues like this often take several questions to unpack and figure out what the actual issue is. At one point, her caretaker got quite upset with me and said "I've helped three grandparents with hearing aids and they could all hear me! She has brand new hearing aids and she STILL can't hear me!" This is where I realized we needed to take a step back and discuss things unique to my patient that couldn't be compared to anyone else the caretaker had ever helped. That hearing loss, environment, other health conditions, and cognitive issues needed to be discussed. What hearing loss is and how the hearing aids are trying to "fill-in-the-gaps" where damage has occurred and that often means that someone will still miss parts of the conversation even with great hearing aids. 

First and foremost, even if someone's audiogram (their hearing test) looks identical to another person's, you cannot make generalizations about their hearing ability based on the test alone. I have no idea what the audiograms looked like of the three grandparents the caretaker helped; what I do know is that MY patient has a significant hearing loss as well as a number of other health problems. I know her husband has breath-support issues and is often in another room entirely when he attempts to talk to his wife. I know from my interactions with her caretaker that she (the caretaker) has a very low voice that even I have struggled to hear in the past, and I have normal hearing. I know that because of her other heath issues she doesn't get out as much as she used to and watches a lot of TV now. This is what I do know. 

More than anything else, I want patients to be successful with amplification. I want them to have the confidence to return to activities they once loved but shied away from due to their hearing loss. I want relationships restored and improved that struggled due to a hearing loss. I want people to get new jobs and promotions because they are hearing better, understanding directions, and contributing to their team. I want people who were once plagued with overwhelming feelings of listening fatigue more present in their life because they are now able to listen with less effort. I want so much for my patients. But we have to first tackle the realistic expectations of what hearing aids can and cannot do. There are an infinite number of scenarios regarding background noise, male versus female speakers, ceiling height, carpet versus hard floors, distance from the speaker, room acoustics, etc. that can impact how successful someone is with hearing aids. This is one reason hearing aids aren't something you just go pick off a shelf at a big-box store. It is a face-to-face discussion about listening needs, struggles, other health conditions, and more so I can assist with choosing the technology I feel will best meet someones needs and wants. Success isn't achieved by picking the least expensive, the most expensive, the one your insurance will pay for, or what your best-friend's-aunt's-neighbor's-sister-in-law was fit with last year! It needs to be decided after a thorough hearing evaluation and a hearing aid evaluation where YOUR listening troubles and needs are discussed and a solution that may best suit YOU is recommended. Only then can you begin a (hopefully) successful journey to better hearing. 

                                       

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              

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