The scope of this page is hearing aids for adult populations aged 18 years and older.
See the Hearing Loss (Adults) Evidence Map for summaries of the available research on this topic.
Hearing aid fitting and verification for adults is a complex process representing one part of a comprehensive aural rehabilitation plan. See the American Speech-Language-Hearing Association (ASHA) Practice Portal page on Aural Rehabilitation for Adults. Through analysis of previous research, Erdman et al. (1994) described a service delivery model for audiologists that engages patients and supports their participation in personal hearing-management decisions. Comprehensive hearing health provision models include patient- and family-centered approaches as well as appropriate use of hearing technology (Grenness et al., 2014; Hickson, 2012; Laplante-Lévesque et al., 2010; Scarinci et al., 2013). To achieve the greatest probability of a successful hearing aid fitting, a rehabilitation plan will incorporate the combined efforts and input of the audiologist, the patient, and the family/caregivers. Visit the Ida Institute for more information.
Hearing aids are considered medical devices and, as such, are regulated by the U.S. Food and Drug Administration. See the ASHA Practice Portal page on Unbundling Hearing Aid Sales for information regarding the dispensing of hearing aids.
According to the 2014 National Health Interview Survey, 16.8% of adults 18 years and older reported trouble hearing without a hearing aid. The rate of reported hearing difficulties increases with age: 5.5% of adults 18–39 years old, 19% of adults 40–69 years old, and 43.2% of adults 70 years and older report hearing problems (Zelaya et al., 2015). 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 (Knudsen et al., 2010; Meyer & Hickson, 2012). According to data from the Healthy People 2020 initiative, 32.46% of adults 70 years and older self-reported that they have used or currently use a hearing aid (Healthy People 2020, 2013), whereas only 16.27% of adults 20–69 years old with hearing loss self-reported hearing aid use (Healthy People 2020, 2007).
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 services (diagnosis, assessment, planning, counseling, and treatment); prevention and advocacy; and education, administration, and research. See ASHA's Scope of Practice in Audiology (ASHA, 2018).
Appropriate roles for audiologists include, but are not limited to, the following:
As indicated in the ASHA Code of Ethics (ASHA, 2016a), audiologists should be specifically educated and appropriately trained to provide these professional services.
Speech-language pathologists (SLPs) play a role in the screening, assessment, and rehabilitation of persons with hearing loss. Professional roles and activities in speech-language pathology include clinical services; prevention and advocacy; and education, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology (2016b).
Appropriate roles for SLPs include, but are not limited to, the following:
As indicated in the ASHA Code of Ethics (ASHA, 2016a), SLPs should be specifically educated and appropriately trained to provide these professional services.
Counseling begins during the initial patient contact and continues throughout the hearing aid fitting and treatment process. Counseling addresses psychosocial concerns expressed by the patient and helps them achieve communication success with hearing aids (Ekberg et al., 2014). Patients can learn to overcome maladaptive listening behaviors and to employ new strategies to become successful hearing aid users. Counseling a patient with hearing loss requires making information available and understandable as well as supporting adjustment to hearing loss and/or amplification. See ASHA's Patient Education Handouts—Audiology Information Series page for a number of patient information handouts that may be helpful during patient and family counseling activities. For more information, see the ASHA Practice Portal page on Counseling For Professional Service Delivery.
Topics addressed in counseling may include, but not be limited to,
See the Assessment section of the Hearing Loss (Adults) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Prior to 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 and preferences, and potential candidacy for amplification.
Components of the comprehensive assessment may include, but not be limited to,
The comprehensive assessment process may result in, but not be limited to, the following:
The following conditions trigger prompt referral to a physician and medical clearance before hearing aid fitting, per the U.S. Food and Drug Administration Code of Federal Regulations (21 C.F.R. § 801.420, 2019):
A patient's cognitive ability may impact their use of and benefit from hearing aids (Gatehouse et al., 2003; Lunner, 2003) as well as appropriate hearing aid parameters (Lunner et al., 2009). Audiologists can incorporate cognitive screening into the comprehensive assessment process (Shen et al., 2016; Souza, 2018). This allows for consideration and discussion of how cognitive decline may impact communication. Information on cognitive screening strategies as well as descriptions of various screening tools that may be helpful to audiologists are available (Cordell et al., 2013; Sweetow, 2015).
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). Referrals to other professionals may be indicated.
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 et al., 2008; Rogers et al., 2006), and sentence (von Hapsburg et al., 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).
Regarding hearing aid fitting of patients who are bilingual in spoken languages, some research has suggested implications in the areas of phonetic inventory, phonology, and syntax. Specific recommendations on how to program a hearing aid for many non-English languages have been offered (Chasin, 2011). Using only English words to evaluate bilingual listeners may lead to faulty clinical impressions. Evaluating bilingual speakers in both their languages or in their primary or dominant language will give the most accurate assessment of the speaker's speech recognition ability.
A needs assessment is conducted, in part, to determine hearing aid candidacy and to develop patient-specific goals, which are essential in measuring the benefits of treatment and 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.
In addition to hearing loss and communication specifics, a variety of factors may impact an individual's candidacy for, and choices regarding, hearing aids. Factors may be cultural, sociological/environmental, physical (e.g., craniofacial, visual, manual), and/or psychological.
Patient self-assessments can be used as 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.
At the completion of the assessment process, the audiologist, the patient, and the 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 include counseling, decisions regarding aural rehabilitation, and recommendations for HATS and/or other professional services as appropriate. Hearing aid fitting may be one component of a holistic plan of care and may include recommendations for unilateral, bilateral, or bimodal options.
It is important for the patient and their family/caregivers to gain a realistic understanding of the potential benefits, limitations, and costs associated with amplification options prior to the initiation of a hearing aid fitting. This understanding is established through discussion, counseling, information sharing, demonstration, and education.
When fitting hearing aids is part of the treatment plan, several preliminary decisions are required (e.g., physical characteristics of the device, specific aspects of electroacoustic performance, hearing aid features, how to evaluate the benefits of amplification). These choices, along with all other planning decisions, are made jointly with the active participation of the patient and their family/caregivers.
See the Treatment section of the Hearing Loss (Adults) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Determining/identifying the appropriate hearing aid is a multistep and individualized process that includes hearing aid selection, fitting, and verification.
Hearing aid selection includes the identification of the appropriate physical features and electroacoustic characteristics of the desired hearing aid. Proper and careful selection will facilitate ordering, verification, and validation of the devices.
Decisions about the nonelectroacoustic characteristics of the hearing aid are based on goals established during treatment planning and ongoing interaction with the patient.
Nonelectroacoustic characteristics may include the following:
In addition to audiometric considerations, factors that may impact choices regarding nonelectroacoustic characteristics include physical fit and comfort, ease of insertion and manipulation, ear canal shape and size, skin sensitivity, occlusion considerations, and cosmetic concerns.
The audiologist determines the requisite electroacoustic characteristics using methods that are based on current scientific knowledge and shares the information with the patient and their 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, per ANSI S3.22-2014, decisions are made regarding frequency-gain characteristics, maximum output sound pressure level (OSPL90), and input–output characteristics (American National Standards Institute [ANSI], 2014, or the current standard). In the hearing aid selection process, electroacoustic test box data (based on current ANSI standards) and additional hearing aid features may be reviewed.
Examples of electroacoustic characteristics include
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 et al., 2014). Musicians or music lovers may benefit from a dedicated music program to enhance listening enjoyment (Chasin & Hockley, 2014).
Once the hearing aid has been selected and received, the multistep and in-depth process of fitting and verification begins. It is beneficial for the patient and/or the family members to be highly involved.
Upon receipt of the device(s) from the manufacturer, quality control measures are taken to rule out any defects. Before fitting the hearing aid, 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 is verified. 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 measurements should be performed according to ANSI S3.22-2014 (ANSI, 2014, or the current standard) to determine whether the hearing aid meets its 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 a hearing aid does not adhere to ANSI S3.22-2014 (ANSI, 2014, or the current standard), it can be returned to the manufacturer for adjustment or replacement.
Performance of the hearing aid may also be measured according to ANSI S3.42-1992 (ANSI, 1992, or the current standard). This standard provides guidance for evaluating hearing aids in a test box using broadband or speechlike 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 aid (e.g., reversed function of front and back microphones when in directional mode).
Current hearing aids have various types of signal processing parameters, which may interact with the test signal during verification. Measurements taken in the test box are not equivalent to real-ear measures of hearing aid performance.
The audiologist determines the physical fit of the earmold or the hearing aid with patient input by assessing cosmetic appeal, physical comfort, absence of feedback, ease of insertion and removal, security of fit, location of microphone(s), and ease of operation of hearing aid controls. If needed, fit may be adjusted by remaking, altering, or exchanging the device(s).
The most commonly used independent prescriptive fitting algorithms are the Desired Sensation Level (DSL) version 5.0 (Scollie et al., 2005) and the NAL-NL2 from National Acoustic Laboratories (NAL; Keidser et al., 2011). Both the NAL-NL2 and the DSL prescriptions seek to optimize speech intelligibility while maintaining patient comfort with the loudness level. NAL-NL2 uses a loudness equalization method, whereas DSL strives to normalize the loudness. For most patients, a prescriptive formula offers an initial starting point for the fitting process. Fine tuning of the hearing aid parameters is often required after verification of the fitting to optimize the adaptation process.
Hearing aid manufacturers may 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. 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 et al., 2015).
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 can 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. Most 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., deep-fitting completely-in-canal aids, bone-anchored devices).
Real-ear examiners must have a clear understanding of the possible sources of measurement error (e.g., insertion depth of the probe tube, stability of the probe tube location between measures, loudspeaker and reference microphone locations, calibration methods; Mueller et al., 1992).
Probe microphone measures can be used to verify improved speech audibility with amplification and avoidance of loudness discomfort. 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).
Advanced Features: Probe microphone measures can be used for the verification of advanced hearing aid features, such as digital noise reduction and directional microphones (Younk, 2007).
Audibility: Verification of audibility is often confirmed for soft and conversational levels of speech/speech-type signals (e.g., 50 or 65 dB SPL). The recording of aided sound pressure levels at or above threshold is 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 nonspeech stimulus to achieve a front-to-back ratio or a front-to-side ratio.
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 et al., 1996). Choosing the optimal hearing aid for the patient can minimize perceptual problems.
Speech Mapping: Speech mapping is a real-ear aided response 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 can use generated live speech signals or even the speech of someone familiar to the person to represent everyday use of the hearing aid.
Telecoil: When verifying the telecoil feature, the audiologist considers how the feature will be used (i.e., for telephones 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: Tolerance refers to verification that high-level stimuli will not exceed the threshold of discomfort. A real-ear saturation response 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 or 90 dB SPL swept pure tone signal. The output targets or actual thresholds of discomfort should not be exceeded at any frequency.
Aided sound field verification measures of gain may be used when probe microphone measures cannot be completed (e.g., when devices do not permit, such as deep-fitting completely-in-canal aids or bone-anchored devices) or in addition to probe microphone measures. However, 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 (per ANSI S3.6-2018; ANSI, 2018, or the current standard) presented in the sound field (60–65 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 protocol (Valente & VanVliet, 1997).
Tolerance: A calibrated speech signal (per ANSI S3.6-2018; ANSI, 2018, or the current standard) presented in the sound field (80–85 dB SPL) can be used to elicit from the aided listener a subjective rating of "comfortable, but slightly loud," "loud, but OK," or "uncomfortably loud"—descriptors from the Independent Hearing Aid Fitting Forum protocol (Valente & VanVliet, 1997).
Alternatively, an estimation of aided speech audibility can be obtained based on the Speech Intelligibility Index (see ANSI S3.5-1997; ANSI, 1997, or the current standard). Subjective measures may also be used to assist in the verification process.
While speech audibility may be confirmed using probe microphone measures or aided sound field thresholds, measures of aided speech recognition and discrimination 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. Speech discrimination testing may assist the audiologist in making decisions about certain hearing aid characteristics.
Several 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. An adaptive approach to speech-in-noise 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 this type of testing.
Audiologists provide appropriate training, education, referrals, and periodic monitoring to persons 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.
Hearing aid orientation and education may include topics such as device use and care and realistic expectations for amplification. Information and education are provided in the manner and method appropriate for and preferred by the patient and their family/caregivers. See ASHA's Health Literacy page. Specific patient and family/caregiver needs, questions, concerns, and feedback are addressed (Bennett, Meyer, Eikelboom, Atlas, & Atlas, 2018). Hearing aid management skills can be measured by survey and inventory (Bennett, Meyer, Eikelboom, & Atlas, 2018).
Information provided to the patient and their family/caregivers regarding hearing aid use and care may include, but not be limited to,
Information provided to the patient and their family/caregivers regarding realistic expectations for hearing aid performance may include, but not be limited to,
For many persons 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 SNR or even demonstrate poor speech understanding despite adequate speech audibility. See the ASHA Practice Portal page on Aural Rehabilitation for Adults for more information on aural rehabilitation.
Auditory training is a technique used to maximize the listener's use of available speech information. Several computer-based auditory training programs are available (e.g., Miller et al., 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 plan of care.
The impact of hearing loss on communication, relationships, social activities, and quality of life can lead to feelings of isolation and depression (Arlinger, 2003). Objective measures of hearing aid benefit taken in an audiometric booth do not always mirror a patient's real-world experiences and/or perceptions (Cox, 2003). Self-report outcome 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. Generic and disease-specific self-report measures based on normative data are available, as well as several specific outcome measures (Bentler & Kramer, 2000).
The World Health Organization (WHO; 2001) published the International Classification of Functioning, Disability and Health (ICF) as a classification of health and disability based upon functional status. This classification system can be used to assist clinicians in patient care management (Grenness et al., 2016), both in establishing goals and in determining specific outcomes that can be measured through patient report.
Regardless of the payment source(s), 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 ASHA's Practice Considerations for Dispensing Audiologists, Insurance and Hearing Aids, and State Insurance Mandates for Hearing Aids pages for more information. Also visit the ASHA Practice Portal page on Unbundling Hearing Aid Sales.
This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.
21 C.F.R. § 801.420 (2019).
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Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Hearing Aids for Adults page.
In addition, ASHA thanks the members of the Ad Hoc Committee on Hearing Aid Selection and Fitting whose work was foundational to the development of this content. Members of the Committee were Michael Valente (chair), Ruth Bentler, Holly S. Kaplan (ex officio), Richard Seewald, Timothy Trine, and Dennis Van Vliet. Lawrence W. Higdon, ASHA vice president for professional practices in audiology (1994-1997), served as monitoring vice president.
The recommended citation for the Practice Portal page is:
American Speech-Language-Hearing Association (n.d.). Hearing Aids for Adults (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Professional-Issues/Hearing-Aids-For-Adults/.