The Basis of Hearing Aid User Dissatisfaction (1993)
Thanks to the cries of hearing impaired adults and their organizations such as AARP and SHHH, much needed attention is now focused on hearing impairment in the elderly. The AARP report presented at the Senate Special Committee on Aging indicated "the relatively low level of satisfaction among long-time, regular users of hearing aids."
People are justified in believing that there are some practices, some individuals, and a lack of effective national regulation in the hearing aid industry, which exacerbates the hearing healthcare delivery system. This must be corrected. However, I wish to address a deeper question to try to understand why more people are dissatisfied with their hearing aids than with their eyeglasses even when they are fit in the most responsible of ways.
Why, fundamentally, do people complain that they are dissatisfied with their hearing aids? To understand the answer to this question requires a deep appreciation of what is occurring to the ear and brain of the "hearing impaired" elderly.
A story might help. Mr. LC comes into my office with the common complaint, "I hear, but I don't understand" and I fit him with a hearing aid that allows him to hear the sound of every letter from A to Z, even if whispered. This I verify with both sound field and real ear testing. He tells me he perceives no distortion of sounds, and every sound, both inside and on the street outside my office appears natural. I declare a perfect hearing aid fitting.
I then ask him, "Does my voice sound good?"
"Yes," he says.
In surprise I ask him, "Didn't you hear me? I said distinct!" and he says, "I heard you, I just didn't understand what it was you asked."
Every day, every hearing aid dispenser hears this their client's most common complaint. The client, dragged into a hearing aid office by a family member complains, "I hear, but I don't understand, especially if it's noisy." The dispenser measures the client's hearing levels and finds a common hearing loss; the client hears certain sounds, yet does not hear others. The dispenser then draws the conclusion, "This client needs a hearing aid."
The client gets a hearing aid, and still as every dispenser can attest, many will return to the office with their hearing aids in their hands or ears and say, "things are louder, I hear, but I still don't understand, especially in noise."
When surveys are taken of hearing aid users they say for the most part that they like their hearing aid dispenser, but they still dislike their hearing aids.
Now the big question: why do they dislike their hearing aids? The answer is that the hearing aid did not solve their problem. Did it not make them hear better? Yes it did. But what it didn't do was solve the problem they stated in the first place. They said on that first day that they are already hard, their real problem was that they couldn't understand.
The reason many long-term users are dissatisfied with their hearing aids is because hearing aids can only contribute so much towards improving an individual's ability to understand speech, especially in the presence of competing noise.
To make this point explicitly clear I wish to make a comparison of a person's expectations with regard to receiving eyeglasses (vision correction) and receiving hearing aids (hearing correction).
When a person gets vision correcting eyeglasses, they rightfully expect that, when words are placed in front of them they will be able to see and understand what they see. When a person gets hearing correcting hearing aids, they also expect, in this case mistakenly for very many people, that when words are spoken in front of them they will be able to hear and understand what they hear.
This error of expectation occurs because the hearing aid wearer does not appreciate, know about, nor easily accept (1) what has occurred in their impairment, and (2) the differences underlying how we understand language through our eyes, and how we understand language through our ears.
The cause of the visual impairment is a physical abnormality regarding the physical shape of the cornea or lens. The visual correction is a mechanical correction for a mechanical abnormality of the eye. Once properly corrected, the "undamaged" nerve mechanisms of the eye send the correct shape information to the brain for interpretation.
The cause of the common form of hearing loss in the elderly is damage not to a physical structure in the ear equivalent to the lens of the eye. The damage occurs to the nerve cells of the ear. Depending upon the extent of nerve damage, there can be damage or loss of not only those nerves that respond to the different tones, but also to other nerve cells that interrelate different tones to construct the qualities of the letters and words we hear.
The hearing aid while providing amplification so that the individual can now hear the sounds does not, of course, correct the "damaged nerve cell mechanisms" of the ear. When sound enters this damaged ear the remaining nerve cells send incorrect or incomplete information about the words coming in to the brain for interpretation. The person hears the sounds but misunderstand the words.
The location and extent of nerve damage in the ear will contribute to the misunderstandings the hearing aid user will continue to experience even after obtaining the best form of hearing correction.
It must also be appreciated, that when a vision impaired individual reads and understands a book, he has control of the pace and situation of his reading. However, when a "hearing impaired" individual hears speech, he does not have control of the pace and situation of the speaker. Compound that with problems of the aging brain of the hearing impaired elderly: slower rate of processing speech, reduced ability to separate speech from noise, etc. It is excruciatingly frustrating to be hearing impaired, to be able to hear, yet not understand. The dissatisfaction runs deep, and appropriately so.
I cannot emphasize enough, that people do not go to hearing aid offices because they want to hear better. They go in because they want to understand better. And the bottom line is that the hearing aid can only go so far in achieving a solution to that problem.
Therefore, in practice, we cannot compare the methodology of fitting hearing aids to the fitting of eyeglasses. (1) Unique strategies are required for addressing each individual client's hearing problems. (2) Compassionate human counseling is required to a much greater extent than with eyeglasses.
It is admirable that rather than faulting their hearing aid dispensers, the vast majority of hearing impaired individuals in the AARP report appreciate the time and effort spent by their hearing aid dispenser as he or she does their best to serve and counsel this difficult population.
There is however, an appropriate example of a reasonably valid comparison of hearing and vision impairments. This is in the comparison of sensorineural hearing loss with macular degeneration. In macular degeneration there is degeneration of the sensory nerve cells of the eye. Individuals with such an impairment have nerve cell damage to the part of the eye responsible for the sharpness of the image and for color vision. Severe cases of macular degeneration result in a non-detailed, uncolored image of the world. While eyeglasses may correct for the mechanical problems of the eye, they can never restore visual acuity or color vision. So too with hearing aids and the difficulty of obtaining good understanding ability with the more severe cases of sensorineural hearing loss.
No matter how good we make a hearing aid, no matter how detailed our knowledge is of the information processing abilities of the brain, the final success at serving the hearing impaired will primarily be accomplished by individuals capable of compassionate communication and care and the creation of alternative strategies for hearing.