Many people often assume that the most expensive hearing aid will automatically provide them with the best results. However, in reality the performance of the hearing aids depend not only on the technology itself, but also on how well it is programmed, the acoustic coupling selection, and how it is all adjusted to the individual wearing it. This article will cover the importance of the fitting process.

The Same Hearing Aid Can Perform Very Differently

This is something that I saw often not only in my hearing aid manufacturer-side role in which I would provide fitting support, but in my clinical experience overall. Someone might complain that they bought the 'best hearing aids' and they don't sound good, meanwhile there is another patient saying how much these exact same hearing aids have changed their life for the better.

The hearing aid technology does play a large role in the outcomes - don't get me wrong. The technology available in the hearing aids set some limits on how much they could help you in a variety of listening environments, the degree of which the signal-to-noise ratio can be improved (the level of speech relative to noise), how well they might work to automatically analyse and classify environments - among a number of other features and parameters depending on the devices.

However, what ultimately matters is how the hearing aids are professionally fitted. Every hearing loss is unique. Every individual's lifestyle and listening needs are unique. Initial manufacturer 'first fit' settings are only meant to be a starting point. Hearing aids are medical-grade devices which require professional prescription and fitting.

What Does Programming Actually Do?

Adjust Amplification for Different Pitches

Hearing aids will try and predict how much amplification is needed for each pitch in each ear, but every ear is completely unique, so this is not going to be an accurate prediction for the vast majority of people.

The gold standard process for programming hearing aids is to use a process called Real Ear Measurements. This is a process that applies a fitting prescription (i.e. prescribed gain or volume that the hearing aid should be providing at each frequency or pitch, based on your specific hearing loss in each individual ear).

This of course, first requires a full diagnostic hearing assessment to get all of your hearing thresholds at the different pitches in each ear.

We then apply the prescription target which tells us how much gain the hearing aids need to produce at each pitch and can adjust this in real-time with the hearing aids in your ears. We can read the response on a live graph and make adjustments accordingly in the hearing aid software, with measurements being read by the same small microphone tube placed in your ear for the duration of the test.

Now, as I mentioned this is widely regarded as the gold standard - and it is. However, this should just be the start.

Adjusting the gain at each frequency to match prescription is absolutely necessary, but its also such a simplified view of what hearing aids can do - especially when you're talking about having access to the best technology we've every had.

Programming Is More Than Just Volume

There are many other factors that need to be considered by your audiologist in a personalised hearing aid fitting.

• Acoustic Coupling: Do you need a custom ear mould made? If so, what type, shape, and retention options? Which vent size, type, and shape do you need? Or is a dome recommended? If so, which size and type - do you need extra retention support? The acoustic coupling should be based on your hearing loss, your ear anatomy, dexterity and visual needs, outer and middle ear health, and also consider things like any material allergies. The acoustic coupling should also fit snug in your ear canal (not too loose, not too big) to sit comfortably and securely whilst minimising any risk of feedback (i.e. whistling hearing aids!)

• Basic Features/Tools: There are a number of 'basic' core hearing aid technologies that must be optimised to truly allow the sound to be clear and comfortable. For example, consider the hearing aid compression (makes soft sounds louder and louder sounds more comfortable). Whilst this technically will be adjusted if the Real Ear Measurements are performed at multiple volumes/inputs, I found in my experience that it often needs to be optimised and personalised further. It has a significant impact on speech clarity and the naturalness of sounds around you. There are a number of other 'core' hearing aid technologies that should be personalised to suit your specific ears and needs - such as feedback cancellation and frequency lowering, just to name a couple.

• Advanced Features: These days, you will probably struggle to find a hearing aid that doesn't use some form of Artificial Intelligence (AI). The way this presents itself and what it is used for will vary from hearing aid brand-to-brand, as they will all have their own goals and philosophies. Generally speaking though, these features can also be programmed to best suit your needs. This might be the strength/effectiveness of the feature, the way it behaves in the hearing aids, and much more. Other advanced features which have been around for some time now, include microphone beamforming and directional microphones, sound cleaning features (i.e. noise reduction), automatic adaptation, Bluetooth connectivity, and accelerometers used as motion sensors - plus much more. A number of blogs could be written on just these alone, but the take home message is that your audiologist should understand and know how and when to adjust these features to personalise your hearing aids for your unique needs.

• Instruction and Counselling: All of the above is absolutely useless if you're not taught how to maintain and use your hearing aids! Your audiologist should allow and spend the time to go through what you need to know and make this a shared experience - this is really key to succeeding with your hearing aids and aural rehabilitation. If you don't feel confident or comfortable using your hearing aids, you won't wear them - and they are of no use to anyone in the drawer. Part of counselling also includes openly discussing expectations. Outcomes can and do vary depending on a number of factors, and its important that this is discussed openly and honestly. Follow-up appointments are also crucial, especially for a brand new fitting. This is why we call it rehabilitation. Ensure you check what your aftercare service is like. This isn't just "x number of months", don't feel shy to ask for clarity. It's also great if you do get along with your audiologist, you might see them a few times - especially in the early months!

Why Do Some People Think Hearing Aids Don't Work?

Some people might think hearing aids don't work for a number of reasons. They may have never had their hearing aids properly adjusted. In my experience, when a new patient has moved to my clinic or someone has sought my assistance for a hearing aid fitting, in the vast majority of cases there is always something or a number of things that can be improved. At Solo Audiology and Hearing, we have our 'Save My Hearing Aid!' appointment exactly for this reason.

Sometimes, it may have nothing to do with the actual fitting of the hearing aid - perhaps its already perfect. But the hearing aid wearer might not have had their discussion about expectations or counselling. They might be expecting the hearing aids to do something they can't do. Or, their speech understanding and processing ability might be impacted making the hearing aids helpful - but limited compared to what others might 'hype' them up for. This is something we can already get an idea about at the diagnostic hearing assessment, where speech in quiet and speech in noise is assessed, and it is discussed accordingly.

Perhaps they've done all this, but they didn't receive training/education or had insufficient follow-up appointments and don't know how to clean or maintain the hearing aids properly - so they keep sounding 'dull'.

For the most part, hearing loss changes gradually over time. This is why regular reviews are required (annually is generally recommended). So if some people you've met don't like their hearing aids, it might even be that they've not been back for adjustments and reprogramming in years!

Programming Is An Ongoing Process

That last point naturally brings us into this section - programming is an ongoing process. There is a significant importance of hearing aid fitting follow-up appointments and further fine-tuning after real-world use. The hearing aids might sound wonderful in the clinic! But what about when it gets to the weekend and you go somewhere different? Or perhaps a monthly commitment or social group finally comes up and you're finding things aren't sounding quite as good as they have been?

A beautiful side effect of hearing rehabilitation is that you may start feeling more socially confident to re-engage or try new things, so naturally we do expect that there might be some adjustments for these new challenges, and this is all part of the process. This is the perfect time to come back for hearing aid optimisation, new communication strategies, or counselling.

Take Home Message

Modern hearing aids are remarkable pieces of technology, but technology alone does not guarantee success. The fitting, programming, and ongoing optimisations are often what makes the difference between a hearing aid that sits in the drawer and one that genuinely improves communication and quality of life.

Written by Daniel Gerace, Clinical Audiologist and Owner of Solo Audiology and Hearing.