Thursday, 26 July 2012
The 'Art' of fitting, robbed from Hearing aid Forums.
THE ART OF FITTING Those of us who have been around the block have seen the focus of this topic before. Most if not all of us have had classes pertaining to this very subject, not to mention years of experience and basically know how it works. If this were in fact true, then why do we still see clients walk into our office complaining about the size, the comfort, difficult controls, cosmetics etc.? Why are there still “part time users” or people who have never given them a reasonable trial? Even with those patients who report good sound quality of his/her device often qualify their statement with a “but wish the aid was”… (fill in the blank!). Most of these complaints appear to be justified and are real concerns considering what is available in today’s market. The choices available these past several years is amazing with result being more and more people accepting hearing aids due to the better cosmetics and coupling options at hand. However, there are still an unacceptably high number of people unsatisfied with their hearing aids. Our choices then are somewhat critical towards whether a patient is more likely to be happy with the devices and accept the hearing aid(s) or not. What we recommend has to merge with the clients experience, expectations, perceptions and preferences. The inexperienced “first timer” quite often is wrought with anxiety and anticipation having to submit to yet another piece of hardware they have to wear just to get along in their “golden years”. Having little or no knowledge of hearing aids other than what they hear from friends and/or the media, they may defer any recommendation to YOU, the PROVIDER…the EXPERT. We all love the guy who comes in and says …“I don’t care what it looks like as long as it works”…but this happens well below 50% of those seeking hearing aids for the first time! And even those that do sing that “I don’t care as long as it works” song are often subject to a change in heart after the fitting if the device is not what they expected! Therefore the “art” in fitting hearing aids is still a huge part of the process. As is counseling and listening which is an integral part of this process from the second the person walks into your office until well after the fittings. Keep in mind, it is a jungle out there with all the manufacturers, choices in style, ever changing features and technology. As if this were not enough we have to contend with the media that makes our job harder with ads that promise hearing aids will do everything short of walking your dog and cooking you breakfast! Counseling the patient regarding benefits vs. drawbacks of one style/feature over another is therefore so important. I cannot emphasize enough that we are not just here to sell hearing aids but rather here to offer the best hearing solutions for the problems this person is having with his/her hearing. If done right, the device will sell itself. Don’t get me wrong folks, programming the aid(s) for sound quality perfection is without a doubt important but we need to shoot for total perfection and acceptance…nirvana if you will. THE CHALLENGE A. Location, Location, Location So there you are with a hearing aid candidate sitting in front of you. You ask him/her if they have a particular choice in style and they respond…”I don’t know, I never had one but please don’t give me one of those big honkers … but you’re the doc, what do you think”? First, you are looking at the patient thinking ITE vs. BTE… You look at the audiogram: 1. Configuration of loss – Sloping vs. flat 2. Degree of loss – What frequencies are normal/mild, moderate, severe 3. Shape of the ear – Close to head vs. open car doors vs. space behind pinnae. 4. Ability of the patient – Can he/she hold, insert and manipulate the device 5. Speech discrimination – Fair/good/poor 6. Tolerance concerns (acoustically and physically) 7. Active patient vs. not so active or maybe homebound. 8. Cerumen – Prone to large amounts of cerumen? Now remember, you must keep looking back and forth at least five times to make the patient think you are deep in thought about how best to solve the specific problems of hearing (when actually you are pondering what to have for dinner that night or when your next day off may be…) when all of a sudden...BAM!...the patient startles you back to the present by shoving a newspaper in your face with a full page ad about this “ultra invisible hearing aid that only amplifies the one person … what about this one”? After recovering to the task at hand (and deciding to have fajitas that night) you continue by addressing the issues listed above and decide if your choice is compatible with the one he just shoved in your face or another that is more suitable to their needs. Back to a little more counseling… Seriously though, we cannot look at each one of the above aspects without considering the others at the same time. Although my philosophy is to keep a fitting as open as possible with BTE aids (short of feedback) we do have to consider ITE aids at times when given the following conditions: a. Patients inability to handle BTE aids. Keep in mind that older patients may have tremors, neuropathy and spatial difficulties. Also some patients just cannot tolerate something on top of the ear. b. Shape or lack of space around the ear Lack of space behind and/or top of ear due to surgery or just plain genetics. c. Long term user of ITE aids (Unless the patient is really motivated to change to BTE’s). d. Degree/severity of loss. Unless fitting a BTE would be prohibitive due to surgical or traumatic injury to the outer ear, BTE aids will typically be recommended for those with severe/profound losses. B. COLOR First of all, let me vent a little about those color charts from certain manufacturers. Seems what looks good on paper is not always the same shade on the finished product. It is always better to have those little plastic samples on a keychain …much more accurate! Also, identifying some of these colors by name has gotten a bit out of hand over the years with some names better suited to a flavor of ice cream rather than the color of a hearing aid! Now that we are on the subject of color, how many of us have gotten ready to order a specific aid in a certain color just to find the color is not available with that particular model! OK...off the soapbox and ON TO THE ISSUES… So what are we trying to match? Skin tone, hair, ear shadow, glasses. I favor a flat taupe or dark grey as these tend to blend in with the shadow behind the ear, skin tone and glass frames/temples. This is where those little plastic samples come in handy. The patient will often choose a color based on skin tone until he/she is shown other choices. The spouse, if present, is often helpful in this regard as well. Call me biased as an audiologist or a maybe “pinnaephile” but when I am out and about in public my eyes are often drawn to a person’s ears and sometimes it appears I am staring at little “light bulbs” when in fact they are hearing aids up there. A few patients (severe losses) may actually like the fact that others see their hearing impairment thereby causing a louder than average (or shouting) conversation… but my experience tells me most want to keep the devices obscure if at all possible. True, color is becoming less critical these days with smaller/hidden hearing aids but many still need the larger aids with larger controls due to severity of loss, size of hands, neuropathy, tremors etc. …which leads to… C. DEXTERITY/AGE: When dexterity is a concern, I tend to look at ITE aids. Sometimes even CIC aids are a good choice when all he/she needs is amplification and speech discrimination and/or occlusion is not an issue. With CIC aids, all the patient has to do is reach up and push on his ear canal (button) to adjust volume. Lately, I have become a fan of remote controls. I say lately because some manufacturers made such devices almost as complicated as my TV remote (and almost as large!). My experience has been people do not want to carry around extra baggage if they don’t have to … hey, is that a remote control in your pocket …or are ya just happy to see me? These days, however, I see some very basic and simple remotes on the market that are not as intimidating to the patient. Again, remote controls can be a real lifesaver at times. As far as dexterity issues with BTE aids, there are other things to consider i.e. removal strings on earmolds, models with larger volume controls or raised volume controls and don’t forget the earmold as certain styles are easier to insert than others for example half shells versus skeleton molds. D. Comfort vs. Cosmetics Just as a mid size hearing aid can be cosmetically appealing for some, a mini/micro aid can be physically uncomfortable or unappealing to others. These two factors are not mutually exclusive. A patient’s ear can reveal the probability of success with one or the other. Deep/shallow concha, large/small concha, large pinnae/small pinnae, close to head/protrudes from head, small canals/larger canals. Open fit/close fit, slim tube/regular tube, ric/non ric and on and on and on… Choosing the ultimate aid for each individual requires thought and coordination. So putting all these concerns and issues into perspective is where the “art” still applies and if these things are not quite in alignment with what the patient has in mind then again … counseling, counseling, counseling! UNIQUE CHALENGES: Although every patient is unique, below are three patients recently fit at our facility where we had to think outside the box ever so slightly. Patient X. Mr. X, an active 84 Y.O. presents with a flat moderate to moderate-severe symmetrical loss from 250-6000Hz. Discrimination scores were 86% right ear and 80% left ear. Cerumen was not an issue as it is with many of our elderly population. Head had little hair and his ears protruded away from his head to such an extent that the devices were “wobbling” all over the place up there! He was previously fit with two BTE aids with standard half shell earmolds but found them to be “too big and difficult to put on, operate the volume control etc. Mr. X has limited us of his hands due to arthritis and can only use his thumb and index finger on one hand and thumb/ring finger on the other. Cosmetics were a moderate issue with this gentleman. Normally, an ITE aid would have been a good choice especially a half shell with 60dB gain but thought I would go a step further. Due to his discrimination being pretty fair, we decided to go with CIC aids with a button volume control and a remote control (although he was not convinced he needed this). After fitting and programming, he was ecstatic at the fact that he could hear well, insert devices with ease and change the volume by just putting a finger anywhere near his ear canal. He was in cosmetic heaven with the size of these rascals as well. He like the remote but felt he would use it at home if at all. Speech mapping targets were matched quite well. Patient Y: Mr. Y is a 70 Y.O active gentleman with a sloping mild to severe loss from 500-6000Hz bilaterally, slightly worse left ear. Speech discrimination scores were 76% right ear and 72% left ear. He had very small pinnae’s, close to his head with very little if any room behind his ear near the top where the hearing aid would be. In addition, his canals were quite small as well with a lot of dry cerumen. He had not experience with hearing aids but mentioned he saw an “ad” with a small apparently CIC aid. After some counseling about occlusion/comfort/cosmetics we decided to go with a BTE aid. Now, as mentioned, there was very little room behind the top of this gentlemans’s ears (he denied any otoplasty or injury) so normally an open fit BTE aid would have been the choice…and it was…however, it had to be a RIC since cosmetics was an issue. There were no cognitive or dexterity issues with Mr. Y so we ordered the absolute smallest BTE RIC on the market with the smallest canal mold, largest vent possible. We also ordered a slightly longer length RIC (wire) in order to place the hearing aid a little lower behind his ears where there was more room to hide and secure the aids. After fitting and programming, we found the molds too occluding and replaced both with medium tulip domes with no feedback or occlusion. Now, if he were a patient compromised due to cognitive or dexterity issues, RIC aids become less an option when cerumen is a problem. Standard or slim tubing seems to be easier to maintain with this population. Patient Z: Mr. Z is a 57 Y.O. active gentleman with a moderate to severe bilateral loss from 250-6000Hz, slightly worse left ear. Speech discrimination scores were 76% right ear and 64% left ear. He had tried CIC and BTE aids before but could not tolerate the noise due to recruitment both ears. He had not worn any amplification in five years and wants to try something “small like seen in the newspaper”…He was also worried about any amplified sound due to his previous experience. He knew all about compression due his many visits to his provider when he previously wore the aids years ago. He reported the hearing aids did not hurt with all the compression but that he could not hear under that condition…”everything sounded muddy, not clear”…Mr. Z could have been fit with either ITE or BTE aids. Cosmetics were a concern but he stated “I just want to hear clearly without any pain”. He had pinnae’s close to his head and a lot of hair. Cerumen was not an issue. We decided to go with BTE RIC aids with canal molds and 4.0 vents. Objective was to provide a mild/moderate amount of gain with little occlusion or feedback from earmold(s). After fitting and programming devices with a mild/moderate amount of gain, mid to high frequencies, very little compression and MPO reduced significantly, he reported the sound was good, clear without pain. He returned two months later stating some sounds were too sharp and therefore reduced the high frequency gain. Speech mapping targets met at full volume but just short at two thirds volume where he like it. Last report he was doing fine and wearing them every day. Now, it is not my intent to address electro acoustics and/or programming in this article but there is one concern where I would hope all healthcare professionals practice …that concern being to physically listen to each and every hearing aid (power aids excluded) before and during the fitting. We all hook up and listen to hearing aids when a patient comes in complaining about the sound quality, typically by connecting to a listening stethoscope. What we SHOULD be doing is listening to every hearing aid that comes into a clinic, especially new devices during the fitting/programming. Within the past three months I have found three new aids to be “dead”, intermittent, distorted and even the front/back microphones reversed! They were all from one respected manufacturer from whom I continue to place orders. Two of the patients having never worn hearing aid(s) before did not even detect any problem! With a long term users, the patient can usually tell you there is something not right with the sound, however, the new user is without any reference and may be unfamiliar with what amplification is supposed to sound like. Recently, a patient came in for a replacement on his left ear and when listening to his right aid I heard a slight distorted static like sound at the end of each word. Sound was amplified enough and the distortion was not that bad but definitely noticeable compared to his left aid. When questioned he stated the aid was put it through the wash, showered with it, took it to a nice dinner etc. Offered to get it repaired but he did not think it serious enough to part with the aid for 2 weeks! Point being, listen to these devices and get a “footprint” established regarding what sound is like through these devices, what compression sounds like, distortion sounds like, your programming adjustments sound like! Bottom line…the patient will be happier and you will be a better clinician for it.