What Did You Say?

By MEGAN RUTHERFORD

Elaine White, 60, a professional mediator, remembers the precise moment 10 years ago when she realized she had a hearing problem. She and a colleague were leading a prejudice-reduction workshop in Rochester, Minn. One of the participants uttered a racial slur. "I didn't hear it," White says. "Fortunately, the other facilitator made an appropriate response. But if I had been there by myself, I would have ignored it--and the point of the workshop was to encourage people not to ignore racial slurs." Shortly thereafter, White got her first hearing aid.

White is one of 28 million Americans--about 10% of the population--with hearing loss. That number will only grow as the baby boomers age, since hearing tends to decline over a lifetime: less than 2% of people under age 18 have a hearing impairment, in contrast to more than 40% of those over age 75. Fortunately for White and others like her, hearing-aid technology has vastly improved over the past decade.

White does not know what caused her hearing loss. The likely factors: heredity (her 87-year-old mother is also hearing impaired), cumulative exposure to environmental noise or simply the gradual deterioration of her ears owing to aging--a condition known as presbycusis. Like more than 80% of hearing-impaired people, White cannot be treated medically or surgically because the damage to her ears is sensorineural. That means some of the 30,000 to 50,000 hair cells in the inner ear, which are responsible for transmitting sound information to the auditory nerve, have been injured or destroyed, leaving the ear "like a piano with missing keys," according to David Fabry, director of audiology at the Mayo Clinic and president of the American Academy of Audiology.

The hair cells that respond to higher pitches are the most vulnerable. So White finds women and children particularly difficult to understand. Another early sign is poor discrimination of consonants, which--in both male and female speech--tend to be higher in pitch and lower in intensity than vowels, so that thin, for example, may be indistinguishable from fin or shin or sin.

For most folks with sensorineural hearing loss, the best help is a hearing aid. But only 20% to 25% of those who could benefit from hearing aids actually own them. That can be a tragedy, since studies show that older people with untreated hearing loss suffer disproportionately from depression, anxiety, paranoia, emotional turmoil and reduced social activity. Brenda Battat, 58, acting executive director of Self Help for Hard of Hearing People (SHHH), with headquarters in Bethesda, Md., knows firsthand the psychological costs of going without hearing aids. "I was the queen of denial," she recalls. "It took me a long time to start wearing hearing aids full time, and I got very, very depressed. I became withdrawn. I refused to go out and meet with my friends. Once I started wearing them, I bounced back."

Why don't more people use hearing aids? For most adults, a decline in hearing occurs so gradually as to be imperceptible--except to family and friends who chafe at having to repeat themselves or at being subjected to the blare of a television turned up to accommodate their loved one's poor hearing. Some discover their disability during a physical exam. Fred Smith, 92, a retired San Francisco businessman, got his wake-up call in the Navy. He was taken off sea duty in the Pacific and transferred back to the States during World War II after he failed a hearing test. But only 16% of physicians routinely screen for hearing loss. And even after people realize they are having trouble hearing, many delay--on average 10 years--before seeking help.

Cost is one barrier. Medicare does not cover hearing aids, nor do most private insurers. Hearing aids range in price from $500 to $3,000 or more. "Here's this thing that's the size of a peanut," says Nicolette Toussaint, 49, communications director for a San Francisco nonprofit organization, "and it costs as much as a used car." Toussaint got her first hearing aid more than 15 years ago. It lasted 10 years--until she left it in the pocket of a pair of jeans she threw into the wash. The replacement cost $4,000. For many people the cost is doubled, since audiologists typically advise patients to buy two hearing aids if they have a loss in both ears. But many hearing-aid providers offer installment plans.

Advances in technology cause many to hold out in hopes of getting more for their money. Audiologists caution against waiting too long, however. "It's much easier to get used to a hearing aid when the loss is mild and you're younger," says Susan Rezen, an audiology professor at Worcester State College in Massachusetts and co-author of Coping with Hearing Loss. "If you delay too long, you're taking the chance that your brain may get used to not processing speech."

Another deterrent is fear. Knowing that excessive noise is a major cause of hearing loss, some mistakenly believe that hearing aids, which amplify sound, will cause further damage. Truth is, hearing aids have volume limiters that prevent them from boosting sound to levels capable of causing injury.

Then there's the vanity issue. "I have a real love-hate relationship with my hearing aids. I wear them because I need them. But they're clunky, they're ugly, they look prosthetic," says Battat of SHHH. "I'm longing for Calvin Klein to start designing hearing aids." Many people who have tried hearing aids before the technology surge of the past 10 years found the discomfort and embarrassment of wearing them outweighed the benefit they provided. Bad experience can be contagious as well. "In audiology we say that if someone likes their hearing aids, they tell five people," says Rezen. "If someone hates their hearing aids, they'll tell 20."

Much attention has been paid to improvements in miniaturization. But smaller is not necessarily better. The tinier the aid, the more difficult it is to manipulate the controls and change the batteries. In addition, smaller aids--which fit in the ear, in the canal, or completely in the canal--simply can't pack the power of larger, behind-the-ear or body-aid models.

How hearing aids work is far more important than how they look. Traditional analog aids are technologically the simplest--and the least expensive. They enable the user to adjust the volume of incoming sounds. The newer, programmable analog aids are pricier, but they can be digitally programmed--and reprogrammed as hearing loss progresses--to accommodate individual patterns of hearing loss as well as different listening environments. Fully digital aids offer the greatest flexibility and precision. But the more expensive digitals are not necessarily better for everyone. "Digital aids have gotten a lot of press, but there's little hard research that they're better than the others," says Laurie Hanin, director of audiology for the League for the Hard of Hearing in New York City. "Some people prefer the sound quality of digital aids and feel they help with understanding speech in noisy situations, but many people do very well with conventional analog aids."

Even after a hearing aid is selected, programmed and fitted, a good audiologist will urge patients to return for adjustment and counseling. "Fitting hearing aids is a process, not an event. They're not like a pair of shoes or glasses, where you put them on and walk out," says audiology professor Rezen. "You have to go back and give the audiologist feedback so that they can adjust them. And hearing aids take learning; they take getting used to."

Even the most sophisticated hearing aids cannot restore perfect hearing. In particularly difficult conditions, many people find assistive listening and alerting devices helpful. In her determination not to be sidelined by her profound hearing loss, New Yorker Ruth Bernstein, 67, has become a gadget guru. The lamps in her living room, office and bedroom are wired to flash when the phone rings or the doorbell buzzes. Her telephone has a receiver with a powerful amplifier. Though theaters are required to lend listening systems to hard-of-hearing customers, Bernstein has purchased her own infrared unit. She's also bought a personal fm unit for lectures: the speaker wears a small microphone, which transmits via radio waves to a receiver connected to a loop Bernstein wears around her neck, which sends the signal to the telecoils in her hearing aids. She uses a caption decoder on her television, attends captioned theater performances and asks people to e-mail her messages rather than leave them on her telephone answering machine. Perhaps the most difficult listening environment is a noisy party or restaurant gathering, where many people are talking at once and the clatter of dishes adds to the cacophony. To reduce the background noise and focus on the conversation at hand, Bernstein uses a tiny direct-audio-input microphone connected by wire to her hearing aids.

Though hearing loss remains largely irreversible, it need not be the crippling disability it once was. The advice from hearing experts is loud and clear: There's help out there for those who seek it. And anything that helps you hear is a sound investment.