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“He won’t wear his hearing aids” - refusing to rehabilitate.

Updated: Aug 5, 2023

This is something I hear quite frequently, and please excuse my sexism but it does always seem to be a worried/frustrated wife and a hard of hearing husband!

Common complaints are that the patient doesn't want to hear their footsteps/clock/fridge, they only want to hear speech better. Background noise is intrusive and they don't want to wear the hearing aids out of the house for this reason. Absolutely the number one phrase has to be "there's no point wearing them indoors because there's nothing to hear".

So what happens then, when it's too loud to wear them outside but there's no point wearing them inside? You basically don't want to wear hearing aids, and although you get frustrated sometimes not being able to hear, you'd rather that than wear them.

Let's take this typical patient then, and look at what's happening, so you can understand the issue from the patient, wife and audiologist's perspective. We'll think about the likely future trajectory for them.

Unfortunately when it’s been a problem from the start, people are unlikely to change.  Some rational adults just don’t want to wear hearing aids.  When your hearing has gradually deteriorated, especially if it's a high-frequency loss, it becomes normal to you to live in a dull-sounding world.  Dull equals comfortable.  

As an effect of both progressive wear-and-tear hearing loss and normal ageing, the brain is losing it’s ability to filter out unwanted sounds and focus distinctly on speech. This is directly proportional to the level of background noise, so the more background noise the more difficult it is to hear speech clearly.

With a typical hearing rehabilitation process, the user goes through two key stages:

  1. Hear everything louder and more sharp/clear, all at once

  2. Regain the lost skill of filtering out unwanted sounds from the background.

This process happens over time and the user’s brain adjusts, if the aids are worn consistently. Sounds are still clearer but they become less intrusive. You can even get a sort of selective deafness all over again - the aids are giving you access to the sounds but you can ignore them if you want!

If that rehabilitation process is interrupted (the user continually turns down the hearing aids or wears them only for a couple of hours here and there), they never really adjust and that crucial second step is missed.  Each time they wear the aids is the same as the first time they wore them - things are too loud, too sharp, too unwelcome and they can’t filter out (ignore) background noises.  

Bear in mind “background” noise is often objectively loud.  It can be 65/70 decibels in a restaurant, it's 65 next to a main road. Hearing is psycho-acoustic: someone with good hearing is not experiencing that "background" soundat its full level, they are filtering it out.

Background sound is only in the background because our brains put it there. It's our innate ability to focus on what we want and ignore what we don't want that makes sound comfortable.

With autism, for instance, a person's ability to do this is compromised and they hear everything, all at once, at its actual physical intensity. This causes problems when trying to hear a single voice and reduce distractions. It can also be physically uncomfortable.

It can be quite the eye-opener to use a decibel meter on your phone in a restaurant.  You find out that they really do have the music on way too loud for people to talk!

Hearing aids have limitations, in that they don’t know what you want to hear.  They have a rule of thumb, that the loudest/closest voice is likely the best thing to focus on, but they don’t automatically switch off that 75 decibel "background" noise.  They can and do alter the speech to noise ratio in circumstances where they can figure it out, by up to ~10 decibels.  But ...

Objectively loud noise is still objectively loud, and unless your brain is capable of filtering also, it will always be so.

If you are someone who perceives your poor hearing as comfortable/normal, then noise will be unwelcome and you’ll go to great lengths to avoid getting and using aids.  Unfortunately this is a circular issue, your hearing is poor, noise from aids is too loud, don’t wear the aids, don’t adapt to them, hearing gets worse, aids need to be even louder to compensate the loss, aids too loud, don’t wear the aids… This is disappointing for the patient because they didn't solve their issue, but comforting because they can keep the dull sound they are used to. It can be incredibly frustrating for a spouse, who has seen the patient get close to fixing their disability but then make every effort to avoid using the aids.

With rehabilitation, the audiologist sometimes has to use the stick. “If you don’t wear them, your brain will continue to lose its ability to separate speech from noise and you’ll struggle in social situations forever”.  We don't usually say it like that because it's not polite, but if you water down the message too much it is ineffective. Your doctor or nurse may say "it would be better for you if you ate more fresh vegetables", when what they really mean is "you're likely going to get diabetes, stroke and heart failure if you keep eating rubbish". We know the likely outcomes of the behaviour, and we try to explain, but it falls on deaf ears as it were.

Audiologists must use the carrot if necessary, perhaps giving the patient a volume/sharpness control.  The user has the choice of making aided sound duller when needed, to encourage them to keep them in.  This can backfire if the dullness control is overused, you effectively swap a severe hearing loss for a moderate hearing loss.  You can also interrupt that rehabilitation process, and stage 2 is never achieved.

It’s so difficult to see this happen to my patients. I hear the initial objections, and ensure the aids are physically comfortable, to reduce barriers.  I support them with options to reduce noise discomfort and advise on the outcomes that are likely to happen if advice isn’t heeded.  It’s not pleasant to see those exact outcomes happen when your advice is glossed over, and there's no comfort in knowing you were correct.

My advice to someone who has put off getting aids, then is putting off wearing them whenever possible (and is turning them down when they do wear them), is frank.

It won’t get any better unless you do the work.  It will get worse and you will struggle more and more until you cannot have a conversation in any noisy situation - even with the best hearing aids in the world.  

Your brain will continue to age predictably and the gains you get from hearing aids (in terms of separating speech from noise) will continue to drop. For some people it is easy, but you will have to force yourself to rehabilitate.  The only way to rehabilitate is to wear the aids at the volume level we have chosen, every day, all day.  In exceptional noise situations, use the dullness control.  Do not use it every week, let alone every day.  Quiet rooms still contain sound, and that sound is feeding your brain and keeping it healthy, so wear them all day at home. 

Patients can’t be forced to do this, so I accept that at least they are using the aids some hours of the day.  From a dementia-risk perspective this is way better than not using them at all.

I also know that if they had poor quality, poor technology aids, they likely wouldn’t be using them at all.  That 10dB speech in noise advantage wouldn’t exist, and the background noise wouldn’t just be frustrating, it would be obliterating the speech of their companion.  It’s a comfort, but the patient only knows their current experience is not nice! They don't think "ah well, at least it's not as bad as it could be", not unless they've had NHS aids before, and still remember the experience (I remember being so pleased with my new high-tech aids, but don't really recall how horrible it used to be).

The bottom line is that it’s not possible for an audiologist to remove unwanted sounds and only give back amplified speech on demand.  It would be a very weird experience if we could - like TV shows where the people are in a nightclub but the extras are "partying silently", just pretending to make noise so you can hear the main actors.

It’s just not possible for an audiologist to remove unwanted sounds and only give back amplified speech on demand.

The only good news if you are still refusing to wear your aids regularly and things are still too loud/strange is that it’s still better to start today than to start tomorrow.  If a patient decides they are going to wear their aids daily from now on, they will be in a better position this time next year than if they hadn’t tried.  The fact that they could be in a great position now if they had done it ten years ago… well that’s water under the bridge.


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