They had been waiting for the outing for weeks. Mary and Anne had been friends in high school 50 years ago. They hadn't seen each other for years! Finally, they were going to meet for lunch at a Greek restaurant. They greeted one another happily, sat down at a table, and proceeded to catch up on old times. Greek music played in the background and other diners conversed animatedly.
Anne tried to hear what Mary had to say, but found herself struggling. Her hearing loss was ruining her long-awaited reunion in this reverberant, noisy place.
Mary saw Anne having difficulty. "Just a moment, Anne," she said. "My grandson got this for me for my birthday. Here, try it!" Mary tapped the screen, and handed Anne her iPod and headphones.
Anne looked down. "Ear Trumpet?" she asked. "What does it do?" Mary said, "It's going to help you hear what I'm saying!"
Mobile devices such as smart phones, tablet computers, and MP3/iPods can be used as hearing assistive technology (HAT). The potential uses are continually growing as new apps and updates are introduced. Current models of mobile devices pick up sound through an internal microphone or through added external remote microphones. Sound output is possible through the built-in speaker of the devices or by connecting transducers, including earphones, earbuds, or telecoils such as the TecEar Music Link T-coil. The actual devices, when used with appropriate apps, can enhance or modify the incoming sound or convert it to a visual signal.
Mobile Devices and Older Adults
Many features of mobile devices may appeal to older adults. The Apple devices, in particular, have a simple and intuitive interface that uses a keypad instead of a mouse or keyboard. (Note that information provided here about Apple products focuses on the most current models, namely the iPad 2, the iPhone 4, and the iPod 4. Earlier models of the devices may support the apps discussed and the technical information provided, either with or without modifications.) Because these devices have few controls and there is no need to "tap twice," they are easier to use than traditional computers.
Fear of use is reduced—if users become "lost," all they need to do is hit the "home" button. Rechargeable batteries also appeal to cost-conscious individuals. Devices that have a bright, large (e.g., 10-inch) display and a large keypad are ideal for use by individuals with impaired dexterity or visual problems.
The downside of using devices with a large display, like tablet computers, is their size. Although these devices weigh only about 1.5 pounds, they are still large enough to discourage being carried about. Conversely, iPods and smartphones are small and eminently portable.
Results of the recent Pew Research Center's Internet and American Life Project concerning "Generations and Their Gadgets" (Zickuhr, 2011; see Table 1 [PDF]) offer insights into the use of technology across age groups. For the study, telephone interviews were conducted among a sample of 3,001 randomly chosen adults. Although individuals aged 75 and older were found to be less likely than younger generations to own devices such as MP3 players and tablet computers, some older adults are using the devices.
There also is documented evidence of a trend toward increased use among those older than 47 years. Increase in use is especially likely as baby boomers continue to age and take their places among "the elderly," costs of the devices drop, and appropriate apps are introduced. (When considering the take-up rates seen in Table 1, note that the Apple iPad was introduced on Jan. 27, 2010, and went on sale, in stages, beginning April 3, 2010. The results shown in Table 1 are based on a survey conducted between August and September 2010. A more recent Pew survey published in July 2011 found that Smartphone ownership among individuals aged 50 to 64 was 24%, whereas among those 65 years and older it was 11%.)
Similar to other traditional HATs such as the Pocket Talker, mobile devices can be used as portable listening devices. Several amplification apps are available, with some of the more popular ones shown in Table 2 [PDF]. The apps range from those that provide simple amplification of sounds to those that allow selective amplification across frequencies. Ear Trumpet, for example, includes a hearing test and, based upon results, will adjust the frequency response. Some apps also have recorded buffers that allow listeners to replay conversations they may have missed.
The electroacoustic measures shown in Table 2 were obtained with a single iPod and standard earbud, measured in a HA1–2cc coupler in a Frye Model 7000 Hearing Aid Test system using standard ANSI measuring techniques. It is significant to note the excessive maximum SSPL 90s that were generated. Of the tested apps, four yielded maximum outputs above 132 dB SSPL. If these results were obtained from a hearing aid, the FDA would require a warning to the dispenser to dispense with care since additional hearing damage may result from use.
A major problem with all of these apps is that no information is provided about their electroacoustic characteristics, including gain, frequency response, distortion, or SSPL 90. No tolerances are given, so the degree of variability associated with different mobile devices, or between similar models, or when using different input or output transducers (Fligor, 2007) is unknown.
Without knowing the output characteristics of these apps or doing real-ear testing, fitting them is the equivalent of fitting a hearing aid with unknown characteristics. This lack of information highlights the fact that apps should ideally be recommended by an audiologist (even though they are not marketed as hearing aids but as listening aids) who should measure the devices' outputs. Regulation concerning the maximum output and, at a minimum, a warning to consumers are needed about potential damage to their remaining hearing.
The first goal of any HAT should be to make sounds audible. When that goal is not possible, changing the sound to a visual signal is often a solution. Using Dragon Dictation and/or the device's keypad accomplishes this goal.
Dragon Dictation is a free voice-recognition app that converts speech to text. The app converts speech samples into text with a 60-second maximum recording period. If additional text is to be converted, the first 60-second segment must be converted and then additional recordings made.
To ensure accuracy, speech must be clear and sufficiently intense. A VU meter is included, and the talker should be no more than seven inches from the microphone. If the signal-to-noise ratio is poor, the accuracy of the speech recognition will be negatively affected. Dragon Dictation involves cloud computing technology that requires network connectivity by WiFi or 3G. Cloud computing uses Internet and remote servers that maintain data and applications so that programs can be used without having to install them on the user's personal computing devices.
The keypad and screen are displayed when using Dragon Dictation. Our clients use Dragon when they experience a communication breakdown and have exhausted their repertoire of communication repair strategies. If Dragon does not provide a successful translation, patients ask the communication partner to type the message.
An alternative to using a speech-to-text conversion app is to have the communication partner type using the keypad of the mobile device. Although all of the mobile devices offer this option, the iPad is an ideal choice because of its larger keypad and display.
Telecommunication for individuals with hearing impairment presents several challenges, especially if visual or audiovisual inputs are needed.
Face Time is an easy-to-use method for making video calls. With audiovisual connectivity, individuals can benefit from seeing the talker's face and hearing the talker's voice. Face Time requires communication between devices that run iOS, the Apple operating system, and that have a camera input. No special account or setup is needed. Because calls are made over the Internet, only an e-mail account—but no telephone connection—is necessary. Using Face Time does not involve any additional charges. Skype also can be used with mobile devices and the download is free. Skype works over 3G or Wi-Fi and charges may apply.
For individuals who are deaf or hard of hearing, a voice-to-text service known as IP-Relay can be used with mobile devices. IP-Relay is a federally funded service that provides the user access to a certified IP-Relay operator. The user types the message and the operator relays the information to the communication partner and also types the communication partner's response. There are no costs involved.
Subtitles included on movies or TV shows can now be played on Apple devices with the 4.3 iOS operating system. Open- and closed-captioned movies also may be rented or purchased from the iTunes store; Netflix has a listing of available movies with subtitles. Captioned radio is also possible through the use of the TuneWiki app; songs and Internet radio and music videos can be seen with timed, subtitled lyrics. The lyrics also can be translated into 40 different languages.
The Future of Mobile Devices
Although mobile devices can be useful as HAT, several issues regarding their use must be addressed—most importantly, excessive outputs of amplification apps. As with hearing aids, manufacturers need to provide warnings about possible damage to residual hearing when apps are downloaded. Variability across devices and input/output transducers should be investigated. We also look forward to remote microphone compatibility in the near future. Communication between audiologists and app developers can only help to facilitate development.
The proliferation of devices of varying quality and complexity has also contributed to the reluctance of patients to use the devices. HAT devices have not typically been multifunctional but rather have been dedicated to specific tasks. As such, their utility has been limited to fairly specific situations, and the patient must purchase and learn to master multiple devices. The simplicity, portability, and multi-functionality of mobile devices now provide a viable alternative for older adults.
Audiologists have been reluctant to recommend and dispense HAT for several reasons: cost of devices and lack of profit associated with their dispensing, perceived competition to hearing aid sales, and difficulty stocking and keeping track of large numbers of devices that have fast changeover. Using one device to solve communication problems is beneficial for the patient and also to audiologists by simplifying the delivery of comprehensive treatment (Lesner, 2003).
Older individuals who don't own their own devices can use mobile devices as HAT—for example, audiologists working in nursing homes or at community centers may bring a tablet computer and provide it to individuals who are having difficulty hearing. Professionals such as speech-language pathologists or physicians who need to communicate with individuals who are hard of hearing or deaf may be able to use the amplification apps or auditory-to-visual translation app capabilities.
Any communication partner of an individual with hearing impairment may make use of the devices when situations demand. It is easy to envision a child or grandchild using a personal device to facilitate a conversation with an older relative.
Consideration of the use of MP3 players, tablet computers, and smartphones as HAT is timely and will become even more important in the future as apps are introduced and refined and as costs associated with the equipment decrease. The use of integrated wireless technology associated with hearing aids as a possible solution to difficulties encountered by individuals with hearing impairments is a real possibility.
Although that day is in the future, the technology associated with mobile devices is here now. The use of these devices is not appropriate for everyone, as Ross has emphasized (2004), but HAT is not a luxury item for individuals with hearing impairments—it is a necessity.
Use of mobile devices is not a substitute for well-fit hearing aids, but is a viable solution for problems that are not or cannot be solved with hearing aids. Whether it is traditional HAT or mobile devices, older adults may be reluctant to accept and use any technology until they experience its benefits. We encourage audiologists to consider how mobile devices can be integrated into the treatment of individuals who are deaf and hard of hearing. If not, individuals with hearing impairments will either use the apps on their own, possibly inappropriately, or fail to receive the potential benefit the devices can provide.