Incidence and Prevalence

In the United States, estimates suggest that between 9.7% and 38.4% of adults with hearing loss have hearing aids (Haile et al., 2024; Office of Disease Prevention and Health Promotion, n.d.; Powers & Carr, 2022). One study found that among hearing aid owners, 62.4% regularly used their device, whereas 37.6% infrequently used their hearing aids (Choi et al., 2024). Hearing aid ownership and usage increases across age groups of adults with hearing loss, with 29.2% of those aged 71 years and older, 31.2% of those aged 80–85 years, and 36.9% of those aged 85 years and older using amplification devices (Reed et al., 2023). Among people with unilateral hearing loss, hearing aid use is lower, with only 11% of those with at least moderate subjective hearing difficulties using amplification (Golub et al., 2018). Despite these relatively low utilization rates, research suggests that hearing aid use is increasing over time (Powers & Carr, 2022; Reed et al., 2021; H. C. Wu et al., 2021).

A variety of factors are associated with higher rates of hearing aid ownership. These include having an income greater than the federal poverty level (Choi et al., 2024; Marcos-Alonso et al., 2023; Reed et al., 2023; Yi et al., 2022), having a college degree or greater (Choi et al., 2024; Reed et al., 2023; Yi et al., 2022), and being eligible for Medicare or having access to insurance (Choi et al., 2024; Yi et al., 2022). Individual circumstances—including perceived degree of hearing loss and satisfaction with hearing aids—also influence whether someone uses their device (Marcos-Alonso et al., 2023).

Roles and Responsibilities of Audiologists

Audiologists play a central role in the screening, assessment, diagnosis, and treatment of adults who are deaf and hard of hearing, including those who use hearing aids. The professional roles and activities in audiology include clinical services; prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Audiology (ASHA, 2018).

The following roles and responsibilities are appropriate for audiologists:

• Remain informed of research in the areas of hearing loss and amplification.
• Serve as an integral member of an interprofessional team providing services to persons with hearing loss, those who use hearing aids or hearing assistive technology systems (HATS), and their care partners.
• Educate other professionals about the symptoms of hearing loss, the impact of untreated hearing loss, the specific needs of persons using hearing aids, and the role of audiologists in the fitting and management of hearing aids.
• Conduct a comprehensive audiologic assessment.
• Diagnose the presence of hearing loss and define the nature of hearing (and related) disorders and their effects on an individual.
• Determine the need for hearing intervention, including, but not limited to, amplification.
• Refer to appropriate professionals to rule out other conditions, to determine etiology, and to facilitate access to comprehensive services.
• Develop and implement an appropriate, comprehensive, and patient-centered audiologic rehabilitative plan of care in collaboration with an interprofessional team, including, but not limited to,
• recognizing and responding to the influence of the cultural background of the patient and their family and/or care partners;
• providing recommendations for the selection, fitting, and dispensing of hearing aids;
• educating the patient and their care partners in the use and care of hearing aids;
• counseling the patient and their care partners on the adjustment to hearing aids;
• offering skills training and consultation related to effective communication strategies;
• offering options for auditory training;
• identifying appropriate HATS; and
• conducting ongoing evaluation and modification of the audiologic plan of care.
• Provide quality control and risk management.
• Counsel patients and their care partners on the role of consistent hearing aid use.
• Counsel persons with hearing loss and their care partners on the role of social engagement in contributing to healthy aging.
• Advocate for persons using hearing aids and their families/care partners at the local, state, and national levels.
• Provide consultation regarding accessibility for persons using hearing aids in public and private buildings and in relation to program participation and service provision.
• Perform case management and serve as a liaison between the patient, the family, and agencies to monitor audiologic status and to make recommendations as appropriate.

As indicated in the ASHA Code of Ethics (ASHA, 2023), audiologists should be specifically educated and appropriately trained to provide these professional services.

Roles and Responsibilities of Speech-Language Pathologists

Speech-language pathologists (SLPs) play a role in the identification, screening, assessment, and (re)habilitation of adults who are deaf and hard of hearing, including those who use hearing aids. 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 (ASHA, 2016).

The following roles and responsibilities are appropriate for SLPs:

• Maintain general knowledge of the anatomy, physiology, and pathophysiology of the auditory system and the effects of hearing loss on communication.
• Educate the public and other professionals on the communication needs of persons with hearing loss.
• Conduct hearing screenings.
• Refer to an audiologist for a comprehensive hearing evaluation as indicated.
• Develop and implement an appropriate, comprehensive, and patient-centered plan of care in collaboration with an interprofessional team.
• Provide training in the areas of
• listening and communication behaviors and strategies (e.g., conversational strategies);
• modification of the listening environment;
• hearing protection and noise hazards; and
• self-advocacy.
• Counsel persons with hearing loss and their care partners on the role of social engagement in contributing to healthy aging.
• Advocate for persons using hearing aids and their families/care partners at the local, state, and national levels.

As indicated in the ASHA Code of Ethics (ASHA, 2023), SLPs who work in this capacity should be specifically educated and appropriately trained to do so.

Counseling

Counseling begins during the initial patient contact and continues throughout the hearing aid fitting and intervention process. Counseling may address psychosocial and hearing health concerns expressed by the patient, communication expectations, adjustments to hearing loss and/or amplification, managing difficult listening environments, and achieving personal goals with hearing aids (Ekberg et al., 2014). It is important that information is provided in a format focused on health literacy. See ASHA’s Audiology Patient Education Handouts for several resources that may be helpful during patient and family counseling activities. For more information, see the ASHA Practice Portal page on Counseling in Audiology and Speech-Language Pathology.

Topics addressed in counseling may include, but not be limited to,

• adjustment to amplification,
• emotional responses to hearing loss,
• environmental issues in various settings,
• hearing protection,
• impact on significant others,
• impact of untreated hearing loss,
• issues related to work or educational settings,
• listening and communication strategies,
• self-advocacy,
• self-management of hearing loss, and
• tinnitus management.

Assessment

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.

Comprehensive assessment includes, but is not limited to,

• a thorough case history;
• an otoscopic inspection; and
• an audiologic assessment, including speech testing.

The comprehensive assessment process may result in, but not be limited to, the following items:

• identification of the type and extent of hearing loss
• identification of hearing-related disorders (e.g., tinnitus)
• referral to a licensed physician for medical/surgical treatment and/or additional testing (e.g., electrophysiologic tests, imaging)
• provision of comprehensive results and recommendations to the patient and their family and/or care partners using culturally and linguistically appropriate counseling methods
• recommendation for a comprehensive aural rehabilitation plan of care specific to the patient’s needs and goals
• consideration of candidacy for amplification, including hearing aids, osseointegrated auditory devices, cochlear implants, or other implanted hearing devices
• determination of unaided loudness discomfort levels or thresholds of discomfort for use in selecting the output and/or compression levels of hearing aids
• results of speech discrimination testing (with and without noise) for use as a counseling tool and/or for future performance comparison at hearing aid fitting and/or follow-up appointments
• consideration of guidance and regulatory requirements provided by the U.S. Food and Drug Administration and/or state laws and regulations (see the ASHA state-by-state resource)
• referral to other professionals as indicated

Considerations for Speech Testing (With and Without Noise)

For many people with hearing loss, the main complaint is difficulty understanding speech in noisy settings and situations. The results of speech testing with background noise may be quite different from results obtained in a quiet environment. Fitzgerald et al. (2023) found that speech-in-noise testing is more informative than tests of word recognition in quiet.

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 unacceptable. The audiologist must consider stimulus (e.g., 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. However, 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 using enough items to get an accurate assessment is key.

Speech testing may assist an audiologist in making decisions about hearing aid characteristics (Davidson et al., 2022). A patient’s performance on tests of speech discrimination in noise has a significant association with hearing aid satisfaction and is important to consider in auditory intervention decisions (Billings et al., 2023; Davidson et al., 2021). Speech testing can later be used as a validation measure or to inform the process of program changes.

Considerations for Medical Clearance

When prescribing a hearing aid, several conditions may trigger a prompt referral to a physician for medical clearance depending on your state law. Some states require any adult seeking a prescription hearing aid to be first examined by a physician. Check with your state licensing board for specific requirements. Triggers for medical referral include, but are not limited to, the following conditions:

• visible congenital or traumatic deformity of the ear
• history of active drainage from the ear within the previous 90 days
• history of sudden or rapidly progressive hearing loss within the previous 90 days
• acute or chronic dizziness
• unilateral hearing loss of sudden or recent onset within the previous 90 days
• audiometric air–bone gap equal to or greater than 15 dB at 500 Hz, 1000 Hz, and 2000 Hz
• visible evidence of significant cerumen accumulation (if cerumen management is not provided by the audiologist) or a foreign body in the ear canal
• pain or discomfort in the ear

Considerations for Cognitive Screening

A patient’s cognitive ability may impact their use of and benefit from hearing aids (Gatehouse et al., 2003; Lunner, 2003; Nixon et al., 2021) 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). 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; Shen et al., 2016; Sweetow, 2015).

Results from the Aging and Cognitive Health Evaluation in Elders (ACHIEVE) study (Lin et al., 2023) and the Evaluation of Hearing Aids and Cognitive Effects (ENHANCE) study (Sarant et al., 2024) suggest that the provision of hearing health intervention may delay cognitive decline. Hearing aid use has been shown to positively impact global cognitive function and other factors of well-being (Dillard et al., 2022).

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.

See ASHA’s resource on The Value of Audiology: Hearing Loss and Cognitive Decline/Dementia [PDF].

Considerations for Multilingual Speakers

Linguistic diversity in the United States is rich and growing (U.S. Census Bureau, n.d.). Providing multilingual populations with access to hearing health care is an essential part of culturally responsive and patient-centered care.

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 multilingual individuals and English monolingual individuals on English speech recognition tasks at the phoneme (Garcia Lecumberri & Cooke, 2006), word (Cooke et al., 2008; Rogers et al., 2006), sentence (von Hapsburg et al., 2004), and discourse (Shi & Farooq, 2012) levels.

Research indicates that results of auditory tests involving speech in noise are poorer for bilingual speakers of English than for monolingual speakers (Calandruccio et al., 2014; Cooke et al., 2008; Shi & Farooq, 2012; Stuart et al., 2010). Speech perception difficulty is greater for bilingual speakers when assessed at threshold levels as opposed to suprathreshold levels (Desjardins et al., 2019; Stuart et al., 2010). The differences between monolingual and bilingual English speakers on speech perception tests seem to be smaller for bilingual speakers who acquire English earlier in life, indicate high proficiency in English, and/or have extensive functional use of both languages (Calandruccio & Zhou, 2014). Greater proficiency in the second language corresponds with smaller differences between bilingual and monolingual speakers (of English) on speech perception tasks (Calandruccio et al., 2014; Calandruccio & Zhou, 2014; Cowan et al., 2022). It is important to consider factors such as the age of acquisition of the second language (e.g., English) and experience using the second language (Shi, 2014). Performance differences may also vary depending on stimulus characteristics, such as the presence of linguistic context, noise type, SNR, or the type of speech degradation presented.

Regarding hearing aid fitting of patients who are multilingual 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 materials to evaluate multilingual listeners may lead to faulty clinical impressions. It is important for clinicians to ask about hearing-related difficulties for each of the languages used by multilingual patients. Evaluating multilingual individuals in each of their languages or in their primary or dominant language(s) will give the most accurate assessment of their speech recognition ability.

In efforts to develop a signal that sounds like speech but may be utilized independent of the patient’s language, the International Speech Test Signal (ISTS) was developed. It incorporates spectral and temporal features from six different languages (Holube et al., 2010). The ISTS stimulus has been used in hearing aid verification procedures as it mimics the sound of speech and can be used to approximate gain at multiple input levels when running probe microphone measurements. Further research to develop speech perception materials in different languages (e.g., Barón de Otero et al., 2008) or that are language independent is crucial. Research on speech characteristics (e.g., long-term average speech spectrum, dynamic range) for different languages is also important. Such data can affect hearing aid fittings, aural rehabilitation, and counseling for multilingual individuals (Narne et al., 2021; Shiraishi et al., 2022), as can factors specific to the patient, such as age (Phillips et al., 2024).

See the ASHA Practice Portal page on Multilingual Service Delivery in Audiology and Speech-Language Pathology.

Candidacy/Needs Assessment

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 intervention and amplification. In addition to assessing the impact of hearing loss on everyday listening situations and daily communication, 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 (Nieman et al., 2016). Amlani (2023) reviews various determinants of health and their impact on hearing health care services.

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 (Cassarly et al., 2020). Results of self-assessments are beneficial to the planning, implementation, and evaluation of any audiologic intervention program.

For more information, see ASHA’s page on social determinants of health.

Plan of Care

At the completion of the assessment process, the audiologist, the patient, and their care partners 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. The development of a plan of care 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 care partners to gain an 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 plan of care, 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 with a patient-centered focus and the participation of the patient and their care partners.

The Hearing Aid Fitting Process

Identifying and choosing the appropriate hearing aid is a multistep and individualized process that includes hearing aid selection, fitting, and verification. For additional information, see the hearing aid fitting standards outlined by the Audiology Practice Standards Organization.

Selection

Hearing aid selection includes the identification of the desired electroacoustic and non-electroacoustic characteristics based on shared decision making among the audiologist, the patient, and their care partner(s). Proper and careful selection will facilitate ordering, verification, and validation of the devices.

Non-electroacoustic characteristics of hearing aids refer to considerations other than the hearing aid circuitry. The following are examples of non-electroacoustic characteristics:

• binaural or monaural fitting
• compatibility with HATS, Bluetooth technology, personal FM systems, direct audio input, and/or remote control
• earmold selection (if applicable)
• user controls (e.g., program and/or volume controls)
• style

In addition to audiometric considerations, factors that may impact choices regarding non-electroacoustic characteristics include physical fit and comfort, ease of insertion and manipulation, ear canal shape and size, skin sensitivity, occlusion considerations, and cosmetic concerns.

Nonsurgical hearing aid styles/types include the following options:

• A receiver-in-canal/receiver-in-the-ear (RIC/RITE) hearing aid hooks over the top of the ear and rests behind the ear with a thin wire connecting the hearing aid to a speaker or receiver in the ear canal. The receiver can be affixed to a dome or custom earmold.
• A behind-the-ear (BTE) hearing aid hooks over the top of the ear and rests behind the ear with a tube connecting the hearing aid to a custom earmold.
• An in-the-ear (ITE) custom-made hearing aid sits in the ear canal and can vary in size. The smallest fits completely in the canal (CIC) and is almost, if not completely, invisible. The largest version is a full shell that fills most of the bowl-shaped area of the outer ear.
• The contralateral routing of signals (CROS) style is considered an option for single-sided deafness or asymmetrical hearing loss. It includes a transmitter (with a microphone) that picks up sound from the unaidable ear and transmits it to the receiver in the ear with better hearing.
• The bilateral contralateral routing of signals (BiCROS) style is considered an option for asymmetrical bilateral hearing loss. It includes a transmitter (with a microphone) that picks up sound from the unaidable ear and transmits it to a hearing aid worn on the ear with aidable hearing.
• The bone conduction sound processor style has a sound processor that typically sits on or connects to the skull in the temporal bone area and can vary in size and retention method. The sound processor transfers sound by vibration directly to the cochlea, bypassing abnormalities in the external and middle ear.

If a patient may benefit from a surgical device (e.g., cochlear implant, osseointegrated device), discussion and referral will proceed as indicated. See the ASHA Practice Portal page on Cochlear Implants for information on these devices.

The audiologist determines the requisite electroacoustic characteristics of a hearing aid using methods that are based on current scientific knowledge. They consider the compatibility of the electroacoustic specifications with the auditory characteristics and personal needs of the patient. 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.

The following are examples of electroacoustic characteristics:

• attack and release times
• background, transient, and/or wind noise suppression
• compression types/settings
• dedicated music program
• directional/omnidirectional microphone
• distortion
• equivalent input noise
• feedback management
• frequency lowering
• gain-frequency response
• input/output functions
• multiple memories
• number of bands/channels
• output sound pressure level with a 90-dB input (OSPL90)
• receiver bandwidth
• telecoil and telecoil sensitivity

Hearing aids are primarily designed to amplify speech signals. Music characteristics differ from those of speech. Although hearing aids can be helpful for music listening, amplified music can sound distorted with a reduction in perceived sound quality. Hearing aid users may experience challenges listening to music and participating in musical activities (Vaisberg et al., 2019). 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 or adjustments to hearing aid settings by a trained audiologist (Chasin & Hockley, 2014; Greasley et al., 2020).

Fitting and Verification

Once the hearing aid has been selected and received, the multistep and in-depth process of fitting and verification begins with the participation of the patient and their care partners.

Quality Control

Upon receipt of the device(s) from the manufacturer, quality control measures are taken to rule out any defects. Listening checks may be completed prior to initiating electroacoustic analysis (EAA). 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 Analysis (Test Box)

EAA measurements should be performed as part of best practices (ANSI, 2014, or the current standard) to determine whether the hearing aid meets its intended performance measures. Coupler measures of gain, frequency response, equivalent input noise, 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. Holder et al. (2016) found quality control issues, including noncompliance with ANSI standards, across tested hearing aid brands and emphasized the importance of completing EAA measurements on new hearing aids to ensure proper device functioning prior to dispensing. If the electroacoustic performance of a hearing aid does not adhere to ANSI standards (ANSI, 2014, or the current standard), it can be returned to the manufacturer for adjustment or replacement.

Guidance for evaluating hearing aids in a test box using broadband or speechlike signals is available according to ANSI S3.42-1992 (ANSI, 1992, or the current standard).

Other electroacoustic test box measures such as directionality and noise reduction, although not currently included in ANSI standards, are an essential part of a thorough evaluation of hearing aid technology. These measures offer valuable information about the function or dysfunction of the hearing aid (e.g., reversed function of front and back microphones when in directional mode). EAA measurements can be used to monitor microphone directivity and to verify microphone functionality (Y.-H. Wu & Bentler, 2012).

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 (REMs) of hearing aid performance.

Physical Fit

The audiologist determines the physical fit of the earmold or the hearing aid with patient input on cosmetic appeal, physical comfort, absence of feedback, size of vent, 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).

Fitting Approaches

The most used independent prescriptive fitting algorithms are Desired Sensation Level (DSL) Version 5.0 (Scollie et al., 2005) and NAL-NL2 from National Acoustic Laboratories (Keidser et al., 2011). Both the NAL-NL2 and 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 audibility.

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. 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

REMs are considered the gold standard in hearing aid fitting verification. REMs, also referred to as probe microphone measures, are utilized to accurately verify that the hearing aid is meeting evidence-based prescriptive targets at multiple input levels and across the frequency range of speech sounds (Jorgensen & Novak, 2022). The performance of REMs, described in detail by Mueller (2001), allows the clinician to objectively measure and verify the sound delivered by a distinct hearing aid while accounting for the size, shape, and resonance frequency of each ear canal. This allows for a more accurate fitting. REMs are completed by presenting sound stimuli from a calibrated speaker to a small microphone tube inserted into the patient’s ear canal. The prescribed targets (e.g., DSL, NAL-NL2) and the patient’s audiogram are entered into the real-ear measurement equipment. The programmed hearing aid settings are then adjusted to best match the prescription. For more information, see ASHA’s The Value of Audiologists During the Hearing Aid Fitting Process: Real-Ear Measurement (REM) [PDF].

Historically, tonal or speech simulated sound signals were used in the completion of REMs. Nonspeech stimuli are still an option when performing REMs. However, newer technology provides the option to utilize speech signals to verify hearing aid output in relation to a prescriptive target, sometimes referred to as “speech mapping.” An “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 hearing aid in its normal mode of operation” (Moore, 2006, p. 28).

To ensure the most accurate results with REMs, considerations include the insertion depth of the probe tube, the stability of the probe tube location between measures, the loudspeaker and reference microphone locations, ambient noise levels, and calibration methods (Mueller et al., 1992). Although there is some variability in the research around probe microphone placement depth into the ear canal, the probe microphone should be 10 mm past the medial tip of the earmold or hearing aid (approximately 5 mm from the tympanic membrane) for the most accurate measurement in adult patients (Caldwell et al., 2006). Real-ear-to-coupler difference measurements may be beneficial for adult patients (Jorgensen et al., 2022), including those who cannot tolerate conventional REMs.

Definitions as well as procedural and reporting guidelines to use when completing REMs are available per ANSI S3.46-2013 (ANSI, 2013, or the current standard). It is important to be trained in the use of the specific REM equipment being employed, as slight variations exist regarding the process to achieve accurate results.

Feature verification: Probe microphone measures can be used for the verification of advanced hearing aid features, such as digital noise reduction and directional microphones. 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). As hearing aid technology advances, new features become available to improve comfort, audibility, and listening in challenging environments. Verifying hearing aid settings and features with REMs leads to reduced need for follow-up programming adjustments, higher patient satisfaction, and lower hearing aid return rates (Cunningham et al., 2002; Jorgensen, 2016). REMs may be used to verify the following hearing aid features:

• directional microphones
• telecoil function, if applicable
• frequency lowering/frequency transposition
• connectivity to off-site microphones (e.g., remote microphones, FM systems, CROS device)
• noise reduction algorithms

Sound perception: REMs can be used to verify audibility, comfort, sound tolerance, and occlusion effects. There is not one specific guideline to follow when performing REMs, and tests may include verification of the following features:

• Maximum output level, previously referred to as real-ear saturation response, can be verified by presenting a pure-tone sweep of 85 dB SPL or 90 dB SPL. The output targets or actual thresholds of discomfort should not exceed the listener’s uncomfortable listening levels at any frequency.
• Audibility and comfort of speech can be verified at various volume levels generally representing soft, average, and loud to the hearing aid user (e.g., 50 dB SPL, 65 dB SPL, and 80 dB SPL). Measuring multiple input volume levels also helps verify compression settings of the hearing aid circuitry.
• The occlusion effect occurs when the outer ear canal is blocked by the hearing aid, dome tip, or earmold, causing a distortion in the perception of one’s own voice. This effect can be measured objectively, using either probe microphone measures or a device designed for this purpose (Mueller et al., 1996). REMs can assist the audiologist in making modifications if occlusion is present (e.g., increasing vent size, changing earmold style or material, changing dome size or style).

Hearing Aid Orientation and Education

Audiologists provide appropriate training, education, referrals, and periodic monitoring to patients fitted with hearing aids and their care partners. This includes providing all information regarding state regulations on minimum trial periods for hearing aids.

Hearing aid orientation and education may include topics such as device use and care and expectations for amplification. It is important to provide information and address specific needs, concerns, and questions in the manner and method appropriate for and preferred by the patient and their family and/or care partners. See ASHA’s Health Literacy page for more information.

Hearing Aid Use and Care

Information provided to the patient and their care partners regarding hearing aid use and care may include the following topics:

• battery management (e.g., safety, recharging)
• connectivity to other assistive technologies/HATS
• description of hearing aid components
• device features and landmarks
• feedback management
• insertion and removal of devices
• routine maintenance and cleaning
• storage
• telephone use and connectivity to smart devices
• warranty information
• wearing schedule

Expectations For Performance

Information provided to the patient and their family and/or care partners regarding expectations for hearing aid performance may include the following topics:

• the experience of an adjustment/acclimatization period
• the variable perception of improved communication based on factors such as severity of hearing loss
• the variability of hearing aid benefit across settings (e.g., in quiet vs. in noise)
• the impact of effective communication strategies
• some degree of visibility (from any style of hearing aid)

Aural Rehabilitation

For many people with hearing loss, communication challenges are not fully resolved with the addition of 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.

Auditory training is a technique used to maximize the listener’s use of available speech information. Several computer-based auditory training programs are available (Pizarek et al., 2013; Sweetow & Sabes, 2006). Auditory training, in association with the use of hearing aids in adults, has been shown in some studies to improve speech recognition in noise and subjective self-perceived listening ability (de Miranda et al., 2008; Sanchez et al., 2020; Van Wilderode et al., 2023). A literature review by Lawrence et al. (2018) found that “both auditory and cognitive training are effective for improving cognition in adults with hearing loss” (p. 15).

Validation

Validation measures determine the outcome and impact of the amplification intervention. It is important to include validation that supports beneficial outcomes and ensures that appropriately established goals have been addressed in each comprehensive plan of care. Validation measures can include aided sound-field testing, self-report tools, an estimation of speech audibility using the Speech Intelligibility Index per ANSI S3.5-1997 (ANSI, 1997, or the current standard), or comparisons of speech comprehension in quiet and noise before and after hearing aid fitting (Jorgensen, 2016).

Aided Sound-Field Testing

Aided sound-field testing compares a patient’s hearing with and without hearing aids in a sound field. These measures, also referred to as functional gain measures, may be used when probe microphone measures cannot be completed (e.g., when devices do not permit) or in addition to probe microphone measures. However, measurements taken within the audiology booth may not accurately approximate real-life listening situations.

Although some employers may request aided sound-field testing to determine fitness for work, it is helpful to use sound-field testing in conjunction with REMs when possible.

Self-Reported Outcomes

The Audiology Practice Standards Organization notes that hearing aid outcomes may include validated self-assessment or communication inventories. 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 goals (Holman et al., 2021; Wolff et al., 2024). 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). Hearing aid management skills can also be measured by survey and inventory (Bennett et al., 2018).

International Classification of Functioning, Disability and Health

The World Health Organization (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.

Reimbursement

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 resources on practice considerations for dispensing audiologists, insurance and hearing aids, and state insurance mandates for hearing aids for more information.

ASHA Resources

• ASHA State-by-State
• Audiology Patient Education Handouts
• Health Literacy
• Hearing-Related Topics: Terminology Guidance
• Infection Control Resources for Audiologists and Speech-Language Pathologists
• Insurance and Hearing Aids
• Over-the-Counter Hearing Aids
• Over-the-Counter Hearing Aid Toolkit
• Person- and Family-Centered Care
• Person-Centered Care in Audiology
• Practice Considerations for Dispensing Audiologists
• Social Determinants of Health
• State Audiology Licensure Laws & Regulations for Prescription (Rx) and Over the Counter (OTC) Hearing Aids [PDF]
• State Insurance Mandates for Hearing Aids
• The Benefits of Telepractice in Audiology [PDF]
• The Value of Audiologists During the Hearing Aid Fitting Process: Real-Ear Measurement (REM) [PDF]
• The Value of Audiology: Hearing Loss and Cognitive Decline/Dementia [PDF]

Other Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

• Audiology Practice Standards Organization: Hearing Aid Fitting for Adult & Geriatric Patients
• Code of Federal Regulations 21 CFR 800.30
• Hearing Aid Project
• Hearing Loss Association of America: Hearing Aids
• International Classification of Functioning, Disability and Health (ICF)
• National Institute on Deafness and Other Communication Disorders: Hearing Aids
• U.S. Food and Drug Administration: Hearing Aids
• U.S. Food and Drug Administration: Regulatory Requirements for Hearing Aid Devices and Personal Sound Amplification Products [PDF]

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Acknowledgments

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.

• Jayne Ahlstrom, MS, CCC-A
• Samira Anderson, PhD, CCC-A
• Kathryn Arehart, PhD, CCC-A
• Ruth Bentler, PhD, CCC-A
• Kathleen Cienkowski, PhD, CCC-A
• Deborah Culbertson, PhD, CCC-A
• Alyssa Davidson, PhD, CCC-A
• Shruti Deshpande, PhD, CCC-A
• Jeffrey DiGiovanni, PhD, CCC-A
• Elizabeth Humphrey, AuD, CCC-A
• Jani Johnson, PhD, CCC-A
• Lindsey Jorgensen, PhD, CCC-A
• Francis Kuk, PhD, CCC-A
• Jill Preminger, PhD, CCC-A
• Barbara Weinstein, PhD, CCC-A

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.

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Hearing aids for adults [Practice portal]. www.asha.org/Practice-Portal/Professional-Issues/Hearing-Aids-For-Adults/