Hearing Aids For Adults

Incidence and Prevalence

Hearing loss of at least 25 dB at the speech frequencies has been reported in 29% of adults 50­­­–59 years old, in 49% of adults 60–69 years old, and in 63.1% of adults ages 70+ (Agrawal, Platz, & Niparko, 2008; Lin, Thorpe, Gordon-Salant, & Ferrucci, 2011). Despite the high prevalence of hearing loss, only approximately 1 in 7 adults (14%) over the age of 50 with a hearing loss use a hearing aid. The percentage of use increases with age. Whereas only 4.3% of adults with hearing impairment ages 50 to 59 have been reported to use a hearing aid, 7.3% ages 60 to 69, 17% ages 70 to 79, and 22% age 80 years or older use a hearing aid (Chien & Lin, 2012). Adults with hearing impairment who have greater levels of self-perceived hearing loss are more likely to seek help for a hearing impairment and to adopt hearing amplification. Help-seeking and hearing-aid uptake do not appear to be impacted by age or gender (Knudsen, Öberg, Nielsen, Naylor, & Kramer, 2010).

Roles and Responsibilities

Audiologists play a central role in the screening, assessment, diagnosis, and treatment of persons with hearing loss. The professional roles and activities in audiology include clinical/educational services (diagnosis, assessment, planning, and treatment), prevention, advocacy, education, administration, and research. See ASHA's Scope of Practice in Audiology (ASHA, 2004).

Appropriate roles for audiologists include

  • educating other professionals about the symptoms of hearing loss, the specific needs of persons using hearing aids,and the role of audiologists in the fitting and management of hearing aids;
  • conducting a comprehensive hearing assessment;
  • diagnosing the presence of hearing loss and determining the need for amplification;
  • referring to appropriate professionals to rule out other conditions, determine etiology, and facilitate access to comprehensive services;
  • developing an appropriate and comprehensive audiologic rehabilitative management plan, which may involve
    • recognizing and responding to the influence of cultural background on the patient and family/caregivers;
    • providing recommendations for selection, fitting, and dispensing of amplification;
    • educating the consumer and family/caregivers in the use of and adjustment to hearing aids;
    • offering skills training and consultation related to effective communication strategies;
    • offering options for auditory training;
    • identifying other appropriate HATS;
    • conducting an evaluation and modification of the audiologic management plan;
  • counseling persons with hearing aids and their families on the importance of social engagement in contributing to healthy aging;
  • consulting and collaborating with other professionals, family members, and caregivers to facilitate program development and to provide supervision, evaluation, and/or expert testimony, as appropriate;
  • remaining informed of research in the area of amplification and helping to advance the knowledge base related to hearing aids;
  • advocating for individuals with hearing aids and their families at the local, state, and national levels;
  • serving as an integral member of an interdisciplinary team working with individuals with hearing loss, those who are using hearing aids or HATSand their families/caregivers;
  • providing quality control and risk management;
  • providing consultation regarding accessibility for persons with hearing aids in public and private buildings and in relation to program participation and service provision;
  • performing case management and serving as a liaison between the consumer, family, and agencies in order to monitor audiologic status and to make recommendations as appropriate.

As indicated in the Code of Ethics (ASHA, 2010), audiologists should be specifically educated and appropriately trained to provide these professional services.


See the Assessment section of the Hearing Loss (Adults) Evidence Map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

The initial step in the hearing-aid-fitting process is the completion of a comprehensive assessment to determine the patient's type and magnitude of hearing loss, communication needs, audiologic rehabilitation needs, and potential candidacy for amplification. An individual's cognitive function, readiness for treatment, and self-efficacy may also be considered. As a result of the comprehensive assessment, referrals may be made for additional services (e.g., electrophysiological tests, medical or surgical intervention, etc.) to be completed before further audiologic management takes place.

Components of the comprehensive assessment for hearing aid fitting may include

  • thorough case history,
  • otoscopic inspection,
  • audiologic assessment,
  • cognitive screen,
  • needs assessment.

The audiologic assessment process may result in

  • identification of the type and extent of hearing loss;
  • referral to a licensed physician for medical/surgical treatment;
  • provision of comprehensive results and recommendations provided through appropriate patient and family/caregiver counseling;
  • determination of candidacy for audiologic rehabilitation, including motivation, lifestyle factors, and cognitive factors;
  • determination of unaided loudness discomfort levels (LDL) or thresholds of discomfort (TD) for use in selecting the output and/or compression levels of the hearing aid;
  • completion of speech-in-noise (SIN) testing for use as a counseling tool as well as future performance comparison at hearing aid fitting and/or follow-up appointments;
  • consideration of guidance as outlined by the U.S. Food and Drug Administration (2009) in Guidance for Industry and FDA Staff: Regulatory Requirements for Hearing Aid Devices and Personal Sound Amplification Products and/or state laws and regulations as referenced in ASHA's state-by-state pages;
  • referral to other professionals as appropriate.

The following conditions require immediate referral to a physician and medical clearance before hearing aids may be fitted, per U.S. Food and Drug Administration (2014) CFR—Code of Federal Regulations Title 21:

  • visible congenital or traumatic deformity of the ear;
  • history of active drainage from the ear within the previous 90 days;
  • history of sudden or rapidly progressive hearing loss within the previous 90 days;
  • acute or chronic dizziness;
  • unilateral hearing loss of sudden or recent onset within the previous 90 days;
  • audiometric air-bone gap equal to or greater than 15 dB at 500, 1000, and 2000 Hz;
  • visible evidence of significant cerumen accumulation or a foreign body in the ear canal;
  • pain or discomfort in the ear.

Considerations For Cognitive Screening

A patient's cognitive ability (e.g., working memory) may impact his or her use of and benefit from hearing aids (Gatehouse, Naylor, & Elberling, 2003; Lunner, 2003), including the response to hearing aid parameters such as frequency compression and compression processing release time in relation to the understanding of speech (Arehart, Souza, Baca, & Kates, 2013; Cox & Xu, 2010; Lunner & Sundewall-Thoren, 2007). In correspondence with previous research, Souza and Sirow (2014) found that for fast-acting compression, individuals with high working memory demonstrated better speech recognition than those with lower working memory. Regarding speech recognition in noise, older adults (both with and without hearing loss) may require more listening effort and, thus, use more cognitive resources than younger listeners to achieve similar results (Desjardins & Doherty, 2013). An individual's working memory and processing speed may be significantly related to speech recognition in background noise (Desjardins & Doherty, 2013).

Audiologists may choose to include a cognitive screen as part of the assessment process. Akeroyd (2008) reported that when considering the link between cognitive ability and speech reception "no single cognitive test always gives a correlation", though "tests of working memory have, mostly, given significant results" (p. S66).

The results of a cognitive screen may provide the audiologist with an opportunity for open discussion with the patient regarding the complexity of communication. The audiologist can emphasize that consideration of the whole individual, rather than the exclusive results of any specific audiologic measure, may help to provide the best outcomes for that individual. Audiologists may be in the unique position to uncover a patient's change or decline in cognitive abilities and, thus, "need to anticipate, identify, and manage mild cognitive impairment in the patients they serve and, perhaps, play a significant role in delaying its onset" (Remensnyder, 2012, p. 25).

Considerations For Bilingual Speakers

Dialectal differences in phonetics/phonology and lexicon may impact word recognition performance (Liu & Shi, 2013; Shi & Canizales, 2013). A significant difference in performance has been found between Spanish-English bilinguals and English monolinguals on English speech recognition tasks at the phoneme (Garcia Lecumberri & Cooke, 2006), word (Cooke, Garcia Lecumberri, & Barker, 2008; Rogers, Lister, Febo, Besing, & Abrams, 2006), and sentence (von Hapsburg, Champlin, & Shetty, 2004) levels. In quiet, bilingual listeners significantly underperformed their English monolingual peers in English discourse recognition (Shi & Farooq, 2012). As the level of noise increased, the bilingual speakers' performance decreased significantly (Cooke et al., 2008).

In regards to hearing aid fitting of patients who are bilingual, preliminary research has suggested implications in the areas of phonetic inventory, phonology, and syntax. Using only English words to evaluate bilingual listeners may lead to faulty clinical impressions. Evaluating bilingual speakers in both languages or the "better" language will give the most accurate picture of the speaker's speech recognition ability.

Candidacy/Needs Assessment

A needs assessment is conducted to determine hearing aid candidacy and to develop patient-specific fitting goals, which are essential in measuring the benefits of amplification. In addition to assessing the impact of an auditory impairment on everyday listening situations, the needs assessment gathers information regarding each patient's unique circumstances, which are considered before a treatment program is designed.

Factors impacting candidacy for hearings aids may include

  • physical status (craniofacial status, general health, visual status, manual dexterity, other otologic conditions);
  • psychological status (cognitive and mental status, motivation, attitude, personality);
  • sociological status (social and physical environments);
  • communication status (auditory speech perception, auditory-visual speech perception, conversational fluency);
  • prior experience with amplification;
  • cultural influences.

Patient self-assessments can be used as patient-centered measures of self-perceived communication needs, and the results may be helpful in establishing goals and expectations for amplification. Results of self-assessments are beneficial to the planning, implementation, and evaluation of any audiologic intervention program.

Treatment Planning

At the completion of the assessment process, the audiologist, patient, and family/caregivers review the findings and identify areas of need. Based on analysis of the results and further discussion, priorities and specific goals for intervention are jointly agreed upon, with the patient at the center of the decision-making process.

Treatment planning may result in a decision to include hearing aid fitting as one component of the management program. The sequencing of rehabilitative strategies is then established, including when and how to evaluate the benefit of amplification. Treatment planning may also include counseling, decisions regarding aural rehabilitation, and recommendations for HATS and/or other professional services as appropriate.

It is important for the patient and family/caregivers to gain a realistic understanding of the potential benefits, limitations, and costs associated with amplification options prior to the initiation of hearing aid fitting. This understanding is established through discussion, counseling, information sharing, demonstration, and education. Saunders, Lewis, and Forsline (2009) recommended that the audiologist be cautious when addressing unrealistic expectations prior to fitting hearing aids so as not to discourage or demotivate the patient.

When fitting hearing aids is part of the treatment plan, a number of preliminary decisions are required, including decisions about specific aspects of electroacoustic performance and hearing aid features. These choices, along with all other planning decisions, are to be made jointly, and active participation of the patient and family/caregivers is strongly encouraged.

The Hearing Aid Fitting Process

See the Treatment section of the Hearing Loss (Adults) Evidence Map for pertinent scientific evidence, expert opinion and client/caregiver perspective.


Hearing aid selection includes the identification of the appropriate physical features and electroacoustic characteristics of the desired hearing aids for a particular individual. Proper and careful selection will facilitate ordering, verification, and validation of the devices.

Nonelectroacoustic Characteristics

Decisions about the nonelectroacoustic characteristics of the hearing aid are based on goals established in the treatment plan and ongoing interaction with the patient. Characteristics may include

  • style—canal receiver technology (CRT), receiver-in-canal (RIC), receiver-in-the-ear (RITE), behind-the-ear (BTE), in-the-ear (ITE), completely-in-canal (CIC), deep fitting, contralateral routing of signals (CROS), binaural CROS (BICROS), bone conduction;
  • binaural or monaural fitting;
  • earmold/shell selection and configuration;
  • number and size of user controls;
  • volume control preference;
  • compatibility with HATS, bluetooth technology, personal FM systems, direct audio input, and remote control.

Factors impacting style choice include ease of insertion and manipulation, ear canal shape and size, skin sensitivity, comfort, occlusion considerations, and cosmetic concerns. For example, open-style fittings or earmolds with large vents can greatly reduce occlusion effect.

Electroacoustic Characteristics

The audiologist determines the requisite electroacoustic characteristics using methods that are based in current scientific knowledge. Decisions are reached in collaboration with the patient and family/caregivers. Compatibility of the electroacoustic specifications with the auditory characteristics and the personal needs of the patient are considered. To adequately define the desired electroacoustic characteristics, decisions are made regarding frequency-gain characteristics, maximum output sound pressure level (OSPL90), and input-output characteristics (ANSI, 2014). In the hearing aid selection process, electroacoustic test box data (based on ANSI standards) and additional hearing aid features may be reviewed.

Examples of electroacoustic characteristics include

  • gain-frequency response,
  • output and output sound pressure level with a 90 dB input (OSPL90),
  • input/output functions,
  • compression types/settings,
  • directional/omnidirectional microphone,
  • remote microphone,
  • distortion,
  • internal noise,
  • number of bands/channels,
  • receiver bandwidth,
  • feedback management,
  • frequency lowering,
  • background noise suppression,
  • transient noise suppression,
  • wind noise suppression,
  • attack and release times,
  • telecoil and telecoil sensitivity,
  • multiple memories,
  • dedicated music program.

Hearing aids are primarily designed to amplify speech signals. Because music characteristics differ from those of speech, amplified music can sound distorted or unpleasant. A listener's perception of music quality may be impacted by hearing aid features, such as fast versus slow wide dynamic range compression (Croghan, Arehart, & Kates, 2014). Musicians or music lovers may benefit from a dedicated music program to enhance listening enjoyment (Chasin & Hockley, 2014).

As hearing aid technology has become more advanced, more adaptive features have become available for the user. These features can include adaptive directional microphones, multiple channels, multiple memories, and noise reduction options, to name a few. "In point of fact, it is the number of these features and the extent that listening decisions are automatically selected that define a 'premium' hearing aid" (Ross, 2009, p. 19).

Fitting and Verification

Once the hearing aid has been selected and received, the fitting and verification process begins. This is a multistep and in-depth process. It is beneficial for the patient and/or family members to be highly involved.

Quality Control

Upon receipt of the device(s) from the manufacturer, quality control measures are taken to rule out any defects. Before fitting the hearing aids, the audiologist conducts a listening check using a stethoscope or other coupling device to rule out excessive circuit noise, intermittency, and/or negative impressions of sound quality. During the listening check, the operation of features such as volume control and directional microphones are verified as applicable. If earmolds or custom hearing aids are ordered, characteristics (e.g., type of tubing, venting, earmold style and material) are verified against the initial order.

Electroacoustic Analysis (Test Box)

Electroacoustic measurements should be performed according to ANSI-S3.22 (ANSI, 2014, or current standard) to determine whether the hearing aids meet their intended performance measures. Coupler measures of gain, frequency response, maximum output, battery drain, telecoil function, and distortion should conform to the manufacturer's published specifications (within stated tolerances) for the given brand and model. If the electroacoustic performance of the hearing aids does not adhere to ANSI S3.22-2014 or current standard, they can be returned to the manufacturer for adjustment or replacement.

Performance of the hearing aids may also be measured according to ANSI-S3.42 (ANSI, 2012, or the current standard). This standard provides guidance for evaluating hearing aids in a test box using broadband or speech-like signals.

Other electroacoustic test box measures not currently included in ANSI standards, such as directionality and noise reduction measures, can offer additional information about the function/dysfunction of the hearing aids (e.g., reversed function of front and back microphones when in directional mode).

Of concern for the audiologist is that current hearing aids have various types of signal processing parameters, which may interact with the test signal during verification. Also, measurements taken in the test box are not equivalent to real-ear measures of hearing aid performance.

Physical Fit

The audiologist determines the physical fit of the earmolds or hearing aids with patient input by assessing cosmetic appeal, physical comfort, absence of feedback, ease of insertion and removal, security of fit, microphone(s) location, and ease of operation of hearing aid controls.

Fitting Approaches

The most commonly used independent prescriptive fitting algorithms are DSL (desired sensation level) v5 and NAL-NL2 (National Acoustic Laboratories). Both the NAL and DSL prescriptions seek to optimize speech intelligibility while maintaining patient comfort regarding loudness level. NAL-NL2 uses a loudness equalization method, while DSL strives to normalize the loudness. For most patients, a prescriptive formula offers only an initial starting point for the fitting process. Fine tuning of the hearing aid parameters is often required after verification of the fitting.

Hearing aid manufacturers may also offer their own proprietary algorithms for fitting, which allows them to adjust for any variables that may impact the manufacturer's overall fitting goal for a specific device. When fitting a hearing aid, audiologists may choose to use a prescriptive fitting method, such as NAL-NL2, or a manufacturer's "first fit" setting. Verification of a prescriptive target may result in better patient-perceived outcomes than a manufacturer's first fit approach (Abrams, Chisholm, McManus, & McArdle, 2012).

Within most hearing aid manufacturer's fitting options is an NAL-NL2 fitting formula. For several manufacturers, the actual output of the manufacturer's formula may vary considerably from prescriptive NAL-NL2 targets (Sanders, Stoody, Weber, and Mueller, 2015). If "the fitting is to provide the patient with the gain and output of a validated prescriptive method such as the NAL-NL2, then the dispensing professional cannot rely on the manufacturer's software version of this algorithm" (Sanders et al., 2015, p. 24).


Real-ear measures, described in detail by Mueller (2001), are a means of verifying prescriptive fitting targets as well as various hearing aid features. With real-ear testing, the clinician is able to measure the actual sound delivered by a distinct hearing aid to a specific individual, thus allowing for a more accurate fitting. Real-ear measures are completed using probe tubes placed in the ear canal and can be done with or without hearing aids in place. The majority of adults can tolerate the completion of probe microphone measures with the use of prescriptive targets based on independent research (e.g., current NAL or DSL targets). However, other verification measures may be necessary for patients who have conditions or devices that prohibit probe microphone measures (e.g., excessive cerumen, deep-fit completely-in-the-canal aids, or bone-anchored devices).

Real-ear examiners must have a clear understanding of possible sources of measurement error (including insertion depth of the probe tube, stability of the probe tube location between measures, loudspeaker and reference microphone locations, calibration methods, etc.(Mueller, Hawkins, & Northern, 1992).

Real-ear measurement and/or verification of several features may be considered. Probe microphone measures can be used to verify improved speech audibility with amplification and avoidance of loudness discomfort as discussed below. Other measures, such as those regarding occlusion effect, telecoil, and directional microphones, may be of benefit in some fittings. Mueller (2005) proposed that "the more complex the processing of the hearing aid and the more automatic, adjustable, and adaptive features it has, the more important to determine how this hearing aid is functioning in the real ear for different inputs" (p. 22).

Mueller and Ricketts (2006) described special considerations to be made when using probe microphone verification testing on an open-canal fitted hearing aid, specifically in the areas of calibration of the input signal and the differences between the use of concurrent and stored equalization.

Advanced Features: Probe microphone measures can be used for the verification of advanced hearing aid features, such as digital noise reduction and directional microphones, as outlined by Younk (2007). Beyond verification, these real-ear measures can be used to educate patients about how the advanced features work (Younk, 2007).

Audibility: Verification of audibility is often confirmed for soft and conversational levels of speech/speech type signals (e.g., 50 dB SPL or 65 dB SPL). The recording of aided sound pressure levels at or above threshold are evidence of audibility.

Comfort: Probe microphone measures using speech/speech type signals at average intensity levels (e.g., 65 dB SPL) can be used to confirm appropriate speech audibility based on the prescriptive target selected (i.e., based on comfort data) and to confirm patient comfort by verbal report.

Directional Microphones: Effectiveness of the directional microphones can also be measured. Typically, directivity is measured by presenting the same non-speech stimulus to achieve a front-to-back ratio (FBR) or a front-to-side ratio (FSR). Based on their research results, Wu and Bentler (2012) suggested that "clinicians use the FSR to monitor hearing aid directivity as it was shown to more accurately predict DI (directivity index) and HINT (Hearing in Noise Test) measurements than was FBR" (p. 44).

Occlusion/Ampclusion: The occlusion effect occurs when the outer ear canal is blocked, and the blockage causes a distortion in the way a person perceives his or her own voice. Ampclusion refers to occlusion in addition to low-frequency amplification.

If the hearing aid user has complaints regarding the perception of his or her own voice, the effect can be measured objectively, using either probe microphone measures or a device designed for this purpose (Mueller, Bright, & Northern, 1996). Choosing the optimal hearing aid for the patient can minimize perceptual problems.

Speech Mapping: Speech mapping is a real-ear aided response (REAR) measurement. "A major advantage of the speech mapping approach is that the effective amplification provided by the hearing aid can be assessed using realistic signals such as speech or music and with the aid in its normal mode of operation" (Moore, 2006). The clinician has the opportunity to use generated live speech signals or even the speech of a loved one to represent everyday use of the hearing aid. Speech mapping can also be used as a tool for demonstration, education, and counseling by providing visual data and comparisons for the patient and/or family members.

Telecoil: When verifying the telecoil feature, the audiologist may consider how the feature will be used (i.e., for telephone only or in conjunction with other technology; Mueller, 2001). If the telecoil is going to be used with other technologies, there may be benefit in "using the procedures that include that technology during probe microphone testing" (Mueller, 2001, p. 65).

Tolerance: Verification that high-level stimuli will not exceed the threshold of discomfort may also be accomplished. A real-ear saturation response (RESR) is obtained with the hearing aid set either at a user volume control position or at a volume control setting just below audible feedback and using an 85 dB SPL or 90 dB SPL swept pure tone signal. The output targets or actual thresholds of discomfort are not to be exceeded at any frequency.

Aided Soundfield Testing

Aided soundfield verification measures of gain may be used when probe microphone measures cannot be completed (e.g., due to excessive cerumen or when devices do not permit, such as deep-canal fit aids or bone-anchored devices). Measurements taken within the audiology booth may not accurately approximate real-life listening situations.

Audibility: Dependent upon the degree of hearing loss, sound-field thresholds can be obtained. Sound field thresholds in this context are not constructed as a measurement of gain for all inputs. Rather, they are a measure of audibility of very soft inputs.

Comfort: A calibrated average speech signal (ANSI, 2010, or the current standard) presented in the sound field (60 dB SPL–65 dB SPL) can be used to elicit from the aided listener a subjective rating of "comfortable, but slightly soft", "comfortable", or "comfortable, but slightly loud"—descriptors from the Independent Hearing Aid Fitting Forum (IHAFF) protocol (Valente & Van Vliet, 1997).

Tolerance: A calibrated speech signal (ANSI, 2010, or the current standard) presented in the soundfield (80 dB SPL–85 dB SPL) can be used to elicit a subjective rating from the aided listener of "comfortable, but slightly loud", "loud, but OK", or "uncomfortably loud"—descriptors from the IHAFF protocol (Valente & Van Vliet, 1997).

Alternatively, an estimation of aided speech audibility can be obtained based on the Speech Intelligibility Index (SII; ANSI, 2012).

Speech In Noise (SIN)

While speech audibility may be confirmed using probe microphone measures or aided soundfield thresholds, measures of aided speech recognition may also be important when the audiologist is measuring or confirming hearing aid benefit. For many people with hearing loss, the main complaint is problems understanding speech in noise. The results of speech testing with background noise may be quite different from results obtained in a quiet environment. SIN testing may assist the audiologist in making decisions about certain hearing aid characteristics to consider with the patient.

A number of speech tests are available and can be used to assess aided versus unaided speech perception ability, as well as levels of noise that a patient may deem acceptable or annoying. The audiologist must consider stimulus (phonemes, nonsense syllables, words, sentences), presentation level(s), noise type(s), and signal-to-noise ratio (SNR). The clinician may keep the SNR fixed during testing, with the speech intensity level and noise intensity level remaining the same throughout. However, there may be benefit to taking a different approach. An adaptive approach to SIN testing allows the clinician to systematically change the intensity of the speech or the noise during testing and pinpoint the SNR where communication begins to be impacted. Allowing for sufficient time to test with enough items to get an accurate assessment is important in SIN testing.

SIN testing is another area of assessment where the audiologist may consider the patient's cognition as a contributing factor to patient performance. A study of 120 older adults found that cognitive function was predictive in regard to a significant proportion of SIN performance variations among participants (Anderson, White-Schwoch, Parbery-Clark, & Kraus, 2013).

Hearing Aid Orientation and Rehabilitation

Audiologists provide appropriate training, counseling, referrals, and periodic monitoring to individuals fitted with hearing aids during a given trial period. The audiologist must be familiar with state regulations and federal guidelines concerning minimum trial periods for hearing aids.

Audiologic rehabilitation can be accomplished in a variety of ways, with consideration given to a manner and method appropriate for and preferred by the patient and family/caregivers. In addition to a verbal explanation, audiologists may present patients with written and/or visual materials in the appropriate language and with consideration given to the patient's reading ability. See ASHA's Health Literacy page for more information on this topic.

This part of the process may include information on device use and care, counseling for realistic expectations, and counseling on listening strategies. Patient and family/caregiver questions, concerns, and feedback are also to be addressed.

Hearing Aid Use and Care

Information provided to the patient and family/caregivers regarding hearing aid use and care may include

  • battery management/safety,
  • instrument features and landmarks,
  • use and routine maintenance/cleaning,
  • description of hearing aid components,
  • HATS coupling,
  • telephone use,
  • storage,
  • wearing schedule,
  • insertion and removal of instruments,
  • feedback,
  • warranty information.

Expectations for Performance

Information provided to the patient and family/caregivers regarding realistic expectations for hearing aid performance may include

  • adjustment/acclimatization period;
  • some degree of visibility (from any style of hearing aid);
  • improved, but not perfect, communication;
  • more benefit in quiet than in noise.


Counseling begins during the initial patient contact and continues through the hearing aid fitting and the entire treatment process. Counseling is necessary to achieve communication success with hearing aids. Patients must learn to overcome their maladaptive listening behaviors and to employ new strategies to become successful hearing aid users. Counseling a patient with hearing loss may require making information available and understandable as well as providing support for adjustment to hearing loss and/or amplification. ASHA provides a number of patient information handouts that can be found at Patient Information Handouts—Audiology Information Series and may be helpful during patient and family counseling activities.

Topics addressed in counseling may include

  • adjustment to amplification;
  • listening/communication strategies;
  • self-management of hearing loss;
  • environmental issues (e.g. restaurants, movies, groups);
  • issues related to work or educational settings;
  • speechreading;
  • emotional factors concerning hearing loss;
  • impact on significant others;
  • hearing protection.

"Clinician behaviors related to patient-centered care may be of particular importance during moments when patients express emotional reactions to their hearing rehabilitation" (Ekberg, Grennes, & Hickson, 2014, p. 338).

Auditory Training

For many individuals with hearing loss, communication challenges are not fully resolved with the addition of one or more hearing aids. Patients with hearing aids may continue to present with challenges understanding speech in environments with a degraded signal-to-noise ratio or even demonstrate poor speech understanding despite adequate speech audibility. Auditory training is a technique used to maximize the listener's use of available speech information. There are two main approaches to auditory training: an analytic approach and a synthetic approach. The analytic approach targets the listener's perception of individual speech sounds, in isolation or within words, to improve understanding at the word level; the synthetic approach focuses the listener on the meaning and context of the message as a whole in order to improve interpretation of misheard information. Several computer-based auditory training programs are available (e.g., Miller, Watson, Kistler, Wightman, & Preminger, 2007; Sweetow & Sabes, 2006).


Validation measures are necessary to determine the outcome and impact of the amplification intervention. It is important to include validation that disability has been reduced and that appropriately established goals have been addressed in each comprehensive hearing aid selection and fitting process.

Self-Reported Outcomes

It has been well-documented that hearing loss can impact a person's quality of life. The impact of hearing loss on communication, relationships, and social activity can lead to feelings of isolation and depression (Arlinger, 2003). Objective measures of hearing aid benefit taking place in an audiometric booth do not always mirror a patient's real-world experiences and/or perceptions (Cox, 2003). Hence, self-report outcomes measures with known psychometric properties can be useful for determining the benefits and effectiveness of hearing aids and the impact on the patient's quality of life. Self-report measures typically address handicap reduction, acceptance, benefit, and satisfaction. A number of generic and disease-specific self-report measures based on normative data are available. Research has shown that disease-specific health-related quality of life (HRQOL) outcomes measures are more sensitive to the impact of hearing loss interventions than generic HRQOL measures (Chisolm et al., 2007). Several specific outcomes measures are available (Bentler & Kramer, 2000).

International Classification of Functioning, Disability, and Health (ICF)

The World Health Organization (WHO) published the International Classification of Functioning, Disability and Health (ICF) in 2001 as a classification of health and disability based upon functional status. This classification system can be used to assist clinicians in patient care management, both in establishing goals and also in determining specific outcomes that can be measured through patient report.


Hearing aids are not covered by Medicare; however, Medicaid or private insurance plans may cover the cost of hearing aids in whole or in part. Regardless of insurance type, patients must be offered the same services, the cost of the services must be equitable, and national procedure codes must be used for requesting reimbursement. See practice considerations for dispensing audiologists and insurance and hearing aids for more information. See also state insurance mandates for hearing aids.

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.