Checklist

Most individuals who would benefit from hearing aids never get them. Many who do are amazed at the resulting improvement in their lives. But hearing aids can't fully make up for hearing loss in the same sense that eyeglasses can restore 20/20 vision.

Don't get a hearing aid without first consulting with a medical doctor to be sure your hearing loss is of a type that can be helped by a hearing aid—and that it can't be assisted by medical or surgical treatment.

You will have to decide what matters to you in a hearing aid. Some aids have advanced features that may make them more adaptable to varying hearing environments than basic models, but these features cost more.

In shopping for hearing aids, you will want to consider only businesses that have staff who offer thorough advice and explanations of your options, offer a wide variety of styles and makes of aids, and have flexible policies allowing you to test out aids and return them with little or no fee if you are not satisfied.

our Ratings Tables show how area hearing centers were rated by their surveyed customers. For our survey question on "advice," one firm was rated "superior" by only 15 percent of its surveyed customers; another firm by 94 percent. For our question on "variety of products" offered, scores ranged from 38 percent to 81 percent.

It is essential to get in writing how long you have to test out any aid you purchase; what charges, if any, you will have to pay if you return it; and whether the test period will be extended if instead of returning the aid, you agree to let the dispenser first try to adjust it to suit you better.

Be sure to shop for price. For one hearing aid model, we found that prices among local sellers ranged from $1,400 to $3,100. For another, prices ranged from $1,595 to $3,445.

Is it difficult to hear the TV or radio, so much so that family members often ask you to turn it down? Do you struggle to understand the cashier at the grocery store? Is it difficult to follow conversations at large gatherings? If so, it might be time to get your hearing checked.

Most of us are guilty of "selective hearing" from time to time. But not listening to what you don't want to hear is one thing—not hearing what you want to is another. That's when a hearing aid might be in order.

If you are hearing less than you should be, you can take a measure of comfort in knowing that you're not alone. About 10 percent of Americans have some hearing loss. The figure is more than 30 percent for persons over age 65.

The vast majority of those with hearing loss would benefit from using hearing aids. But most go without these helpful devices either because they are hesitant to acknowledge a handicap or because they don't think the benefit will justify the trouble and cost.

It is true that hearing aids don't fully make up for hearing loss in the same sense that eyeglasses can restore 20/20 vision. They are rehabilitative devices that, when properly programmed and fitted, help their wearers attain their best hearing potential. But this potential varies from person to person, depending on the nature and extent of their hearing loss. Sometimes, persons who wear hearing aids find they can hear sound but they can't always understand the words being spoken. Often this type of experience is caused by damage to the auditory system that can't be helped by a hearing aid.

Although hearing aids can't restore normal hearing, they have still improved the lives of millions of people—enabling them to enjoy their senses more fully and to communicate more effectively with others. Many first-time hearing aid wearers are surprised at the improved quality of their lives. In a study of hearing aids, the American Association of Retired Persons (AARP) reported hearing aid user comments like the following: "It's such a joy to go for my walk in the early morning and hear the birds singing, which I could not hear before. It is also a pleasure to hear all of a sermon at church or someone's conversation rather than parts."

Hearing aids have come a long way from the "ear trumpets" manufactured in the early 1800s—and even from the devices available just a few years ago. Today's hearing aids can do much to meet the needs of their wearers in the complex and varying listening environments they encounter.

As hearing aids grow smaller and more technologically advanced, they are also more convenient and less obtrusive to wear. Today, if you have a hearing loss, you can choose from hundreds of hearing aids with varying degrees of size and sophistication.

How Your Hearing Works

The ear is made up of three parts: the outer ear, the middle ear, and the inner ear.

Sound enters the outer ear canal and strikes the eardrum, which is the outer boundary of the middle ear. A chain of three tiny bones in the middle ear receive sound vibrations from the eardrum and transmit them to the inner ear. The inner ear includes a snail-shaped chamber called the cochlea, which is filled with fluid. The vibrations transmitted by the bones of the middle ear cause movement in the fluid of the inner ear. Thousands of hair cells in the inner ear are stimulated by the movement of the cochlear fluid, sending impulses along the fibers of the auditory nerve, which goes to the brain. The brain processes this information, providing awareness of speech, music, annoying cell-phone ringtone jingles—everything we hear.

How We Develop Hearing Loss

Hearing loss is extremely common. It can be a normal part of the aging process and, for many, an inevitable result of living in a noisy society. There are two primary types of hearing loss: sensorineural loss and conductive loss.

Ninety-five percent of all hearing aid wearers have sensorineural hearing loss, which is characterized by impairment of the inner ear or the neural pathways from the inner ear to the brain.

Most sensorineural loss results from when the tiny hair cells that line the inner ear become damaged and are no longer able to transmit signals accurately to the auditory pathway and the brain. Aging is by far the most common cause of this damage, but other causes include infection, high fever, trauma, noise exposure, genetics, and use of certain prescription drugs.

In rare cases, hearing loss can be the result of damage to the auditory nerve. For example, benign tumors can compress the nerve. If found early, these conditions are often treatable.

Conductive hearing loss, which often can be treated medically or surgically, occurs when something interferes with sound vibrations as they pass through the outer and middle ear. A common cause is a blockage of wax buildup, which can be addressed by using an earwax softener and then flushing out the wax using a kit (both the softener and kit can be purchased from drug stores). A physician or audiologist can also remove the wax.

Conductive hearing loss can also result from the presence of fluid in the middle ear. The fluid disrupts the middle ear's ability to conduct vibrations to the inner ear. This can occur when the eustachian tube (a tiny tube connecting the middle ear to the back of the throat) is not functioning properly, often due to inflammation. This sort of hearing loss, common in children, usually can be treated medically.

A punctured eardrum or problems with the functioning of the small bones in the middle ear can also cause conductive hearing loss. These types of problems are often partially or completely treatable with surgery, but hearing aids may be used if hearing loss remains following the completion of medical intervention.

A combination of conductive and sensorineural hearing loss, called mixed loss, is also possible.

How It Is Diagnosed

If you suspect that you have hearing loss, first consult with a physician. Choose a physician—such as an otolaryngologist—who is knowledgeable about hearing loss and treatments. The right physician will be able to detect medical causes of hearing loss (such as, fluid buildup in the middle ear, a disease, or a tumor), will often be able to treat them, and will be able to recommend hearing aids in cases where that is the best treatment approach. For a list of area otolaryngologists who were most often recommended by their peers in surveys CHECKBOOK conducted, visit the "Top Doctors" section of our website.

It is important to rule out medical problems that may be curable before investing in a hearing aid. Some hearing aid dispensers have been known to sell aids to individuals who did not need them or who would have been better served with other treatments. The U.S. Food and Drug Administration (FDA) prohibits the sale of a hearing aid to anyone who does not present a written statement signed by a licensed physician saying that the patient's hearing has been evaluated. A hearing aid dispenser may lawfully sell an aid to someone without such a statement only if the seller has informed the consumer that getting a medical examination is in the best interest of the consumer's health and if the consumer has signed a waiver of the right to a medical examination. An AARP study conducted in Florida found that dispensers often ignored the FDA requirement. You'll be wise not to; before getting a hearing aid, be sure to have a physician checkup.

If the physician advises that a hearing test is in order to determine the type and degree of your hearing loss and whether or not you are a candidate for a hearing aid, an audiologist or a "hearing aid specialist" can administer one.

An audiologist has extensive training and usually holds a clinical doctor of audiology (AuD) degree but may hold a ScD or PhD. Audiologists may also be identified with the letters CCC-A (Certificate of Clinical Competence in Audiology from the American Speech-Language-Hearing Association). In addition to administering hearing tests, audiologists can give complete diagnostic evaluations of hearing loss. After the hearing tests, audiologists usually help patients select and purchase hearing aids.

Unlike an audiologist, a "hearing aid specialist" is not required to have a degree in the field of hearing. You can check to see that a hearing aid specialist has voluntarily been certified by the National Board for Certification in Hearing Instrument Sciences, indicated by the letters BC-HIS. To receive certification, applicants must have two years of experience selling hearing aids and pass the National Competency Exam.

The Hearing Test

A complete hearing examination must consist of at least the following tests: pure tone air conduction test, pure tone bone conduction test, speech recognition threshold test, and word discrimination test. Additional tests may be given depending on the examiner and the patient's specific needs.

The pure tone air conduction test determines how well a person hears at different frequencies, or "pitches." Hearing threshold is determined by presenting tones at different pitches through headphones or insert earphones and asking the patient to signal when he or she hears the tone.

The pure tone bone conduction test helps determine the nature of the hearing loss (sensorineural, conductive, or mixed). During this test, a bone vibrator is placed against the mastoid bone, located behind the ear. Again, the patient tells the examiner the tones he or she is able to hear.

A comparison of the results of the air and bone conduction tests helps localize the hearing mechanism responsible for the hearing loss. Air and bone conduction thresholds that are the same suggest that the hearing loss is sensorineural. If bone conduction thresholds are better than air conduction thresholds then there is reason to suspect the loss is conductive—that the hearing function is failing in the outer or middle ear, before it reaches the inner ear.

The speech recognition threshold test determines the softest level of sound that can be heard and repeated. Ten to 15 two-syllable words (with equal stress on both syllables) are delivered to the listener at progressively softer volumes. The threshold is the softest point at which the patient is able to repeat words correctly 50 percent of the time. This test is a way to check the reliability of the pure tone air conduction tests.

In the speech discrimination (word recognition) test, 25 to 50 words from a standardized list are presented to the patient at a level identified as "comfortable" for listening. The patient is asked to repeat the words. This test assesses a patient's ability to discriminate speech at his or her most comfortable level for listening. The results can provide an indication of how well a person can be expected to understand words when wearing a hearing aid.

Testing may also be given to determine most comfortable level and uncomfortable level. These are subjective measures that a listener determines based on the level of sound intensity that feels comfortably loud or uncomfortably loud.

Additional testing includes immittance testing, in which a probe tip is inserted into the ear to measure the eardrum's mobility and middle ear functions. This test helps rule out conductive hearing loss.

The examiner should also check a patient's ears to assure that hearing loss is not due to a physical condition of the ear. This is especially important in cases where the patient has waived a medical evaluation. Ears should be checked for visible signs of drainage, blood, wax blockage, or other visible problems in the ear. The examiner should ask the patient about dizziness, tinnitus (ringing in the ears or other "head" sounds), discomfort, and any sudden hearing loss he or she has experienced.

If you buy a hearing aid, you should have your hearing retested periodically to determine if any adjustments might help. How often you should have your hearing retested depends on the extent of your hearing loss and other factors; most hearing aid wearers should be retested at least every other year, but some may need to be retested every six months.

The Audiogram

The results of a hearing test are recorded on an audiogram, a graph showing the patient's thresholds for hearing sensitivity. Several examples are shown here.

The horizontal axis of the graph shows frequency, or pitch, measured in "Hertz" (Hz). The measurement progresses from low pitch to high pitch, left to right, like a piano keyboard.

The vertical axis, often labeled "HL" for "hearing level," graphs the loudness of the test signal, measured in decibels (dB). Softer levels are recorded toward the top of the graph and louder levels at the bottom.

The plots on the audiogram indicate the configuration and degree of the hearing loss. For example, if the markings are farther down on the graph at higher frequencies, this means that the patient has more difficulty hearing high-pitched sounds than low-pitched sounds. This information helps determine what hearing aids will be most appropriate for the patient and also is used later in the programming and adjustment process.

Levels of Loss

The severity of hearing loss is determined by how loud the tone needs to be at various pitches for the patient to hear it. The standard used is:

When hearing is impaired, often some pitches can be heard better than others. You might have normal or near-normal hearing for low-pitched sounds but worse hearing loss for high-pitched sounds. Age-related hearing loss often creates these types of patterns. Hearing deficiencies with varying degrees of loss are given labels such as "mild-to-moderate loss" or "moderate-to-severe loss."

For example, in normal speech, vowel sounds tend to be stronger in presentation than many consonant sounds. Vowel sounds also tend to have most of their energy in the lower pitches (toward the left side of the audiogram). Softer consonant sounds, on the other hand, (such as "s," "t," "f," and "th,") tend to be higher pitched sounds (toward the right side of the audiogram). So if you have mild-to-moderate hearing loss, you may have little or no difficulty hearing vowel sounds, but may lack the ability to hear many of the softer consonants, making it difficult to distinguish between words like "top" and "stop," particularly in the presence of background noise. Knowing these configurations helps in describing—and treating—the problems patients have.

How to Select the Right Hearing Aid

Hearing aids have three main parts: a microphone that takes in sound; a circuit that processes and amplifies sound; and a speaker that conveys sound to the wearer's ear. All of these components are powered by a small battery. Almost all new hearing aids use digital processing technology.

Hearing Aid Styles

Hearing aids vary in shape, size, and how they are worn. They range from tiny devices that nestle completely in the ear canal to larger, more visible models that sit behind the ear. Although many technologies can be put into any style, the smallest aids tend to have less power to address severe hearing loss.

The two general categories of hearing aid styles are behind-the-ear (BTE) and in-the-ear (ITE). Within these two categories, there are a number of subcategories.

Behind-the-Ear

As this figure illustrates, a BTE hearing aid is so named because part of the device—the casing that holds microphone and circuitry components—sits behind the ear. A traditional BTE model is comprised of the behind-the-ear component and a custom-made "earmold" that occupies the entire ear opening to deliver the sound; the two components are linked by a tube.

A relatively new concept for BTE aids is "open-fit," or "open-ear," models. Like a traditional BTE model, an open-fit aid is comprised of components that sit behind the wearer's ear, a speaker placed in the ear opening to deliver sound, and a tube that connects the behind-the-ear piece to the speaker. But instead of using an earmold that takes up the entire ear opening, the microphone for an open-fit model is smaller, leaving the ear opening largely unobstructed and allowing unaltered sounds to enter the ear. These models are particularly useful choices for users who have good or fairly good hearing in certain pitches, but need help in others. Filling these users' ears with earmolds would mean taking away natural sounds that could be heard without the help of hearing aids—often contributing to a disconcerting, inside-a-barrel sense, called "occlusion." Open-fit BTEs allow for a more normal mixture of amplified and natural sound and a more comfortable, less occluded experience for the wearer.

Some open-fit hearing aids simply guide processed sound into the ear canal through a very thin tube, usually ending in a rubber tip. Other open-fit models use a wire instead of a tube, and contain the speaker (or receiver) at the end of the wire, in the ear canal. These aids are referred to as "receiver-in-the-canal" models, and are currently a very popular hearing aid style.

In-the-Ear

With ITE models, the entire aid is worn within the ear opening, or even entirely within the ear canal. Impressions of patients' ears are made and sent to the hearing aid manufacturers, and the aids are custom-molded. As this figure shows, there are several styles of ITE models, ranging in size from "full-shell," which fill the concha (bowl) of the ear, to "completely-in-the-canal" (CIC) styles, which are almost completely hidden inside the ear canal. "Half-shell" styles are a bit smaller than full-shell styles, and "in-the-canal" (ITC) styles are a bit larger than CICs.

A new variation of ITE aids is the extended-wear device. This hearing aid is placed into the ear canal by an audiologist or physician and remains there until the battery expires two or three months later or it fails for some other reason. It is then replaced with a new device. But not all patients are good candidates for this option; so if you're interested in it, you'll want to discuss it carefully with your physician or audiologist.

Choosing a Style

Since ITE aids are smaller than BTE models, they are popular with patients who want a less visible hearing aid. But newer BTE models are now smaller than they once were, and also because of the benefits of open-fit technology, BTE aids are more appealing than before. On the other hand, some patients still prefer ITE aids because they are compact and keep everything contained within the ear.

If you have severe hearing loss, you'll likely be buying a BTE style, since ITE aids can't deliver the power you'll need. Also, BTE aids tend to be more reliable than ITE models, and BTE aids have space for larger, easier-to-operate controls.

Regardless of preference, some patients are limited to one selection over another because of the shape of their ear openings or because their ears secrete too much wax.

Features to Consider

Most new hearing aids come with a number of features, some of which used to come with a hefty price tag. Features you should expect with even a basic new model:

• Directional microphones allow hearing aids to take into account direction and timing cues for sound reaching them. This feature helps enhance speech sounds and reduces noise. It gives the user control over what gets amplified by facing the source. 
• Automatic volume control provides different levels of "gain" for different inputs. In other words, the hearing aid can sense the level of the sound reaching the microphone and adjust amplification accordingly. Most hearing aids also come with an option that lets wearers manually control volume. 
• Feedback cancellation reduces the likelihood of getting that whistling or squealing sound you may have heard coming from a hearing aid at some time. This sound results when a hearing aid re-amplifies sound coming from its own speaker. More expensive models often have more sophisticated controls for this feature, but even a modestly priced hearing aid should have some mechanism for reducing feedback. 
• Multiple processing channels allow a hearing aid to divide up sound processing into separate frequency regions. This allows for more flexibility for programming the hearing aid specifically to take into account a user's different degrees of hearing loss at different frequencies. In general, the more channels, the more advanced the aid, both in terms of performance and price. But even fairly low-priced hearing aids provide processing in at least a few separate channels, and often more. 
• Telephone coils (T-coils) allow hearing aid wearers to use a phone without getting feedback. The coils in the hearing aid pick up the signal from the phone in the form of a magnetic field put out by the phone. This feature now is used with many other forms of assisted living technologies, such as TV and audio equipment listening systems. Many ITE models come with T-coils, and virtually all BTE models have the feature, but the smallest hearing aids can't carry the feature because of size limitations. 
• Multiple programs allow the hearing aid to react to sound differently to accommodate different listening environments. Because no single type of signal processing is ideal for every listening situation, multiple programs are like having several hearing aids in one. Examples of different listening environments, where the user might benefit from different programs, are a noisy restaurant, a meeting, or watching TV at home. Switching among programs may be performed manually by the user or in more advanced aids may be performed automatically. 

The more advanced hearing aid features usually mean advanced prices—the most expensive models can cost $5,000 or more per hearing aid—so you'll want to think carefully about whether or not the added benefit of special features is worth the cost. Factors to consider include the severity of your hearing loss and your lifestyle. For example, if you lead a relatively quiet life and won't often benefit from an aid that has advanced sound processing, your needs will be different from someone who regularly attends noisy parties, attends conferences, or has business dinners in restaurants.

Some of the non-basic features available (usually for extra cost) include—

• Bluetooth connectivity lets the hearing aid receive a Bluetooth signal. This is nice for cell phone use, of course, but some manufacturers also offer systems allowing you to use the Bluetooth signal with a TV or landline phone. 
• Remote controls allow wearers manually to adjust volume, program switching, and other settings using a small remote rather than having to fiddle with controls on the aid itself. 
• Communication between hearing aids is a feature that enables right- and left-side aids to share information that can optimize hearing response in certain settings. Some hearing aids use this communication simply to synchronize manual volume adjustments and program changes, so if the wearer changes a setting on one ear, it will automatically make the same change to the other. 
• CROS adaptation is a system used by persons who have unilateral hearing loss (hearing loss primarily in one ear) whereby a microphone for the ear with poor hearing sends sound it receives to the other ear. The idea is that instead of trying to compensate for hearing loss on one side by amplifying sound on that side, sounds that ear should hear are delivered largely unchanged to the ear that can hear them. But this set-up requires patience—and motivation—from the wearer to get used to a new way of listening. 
• Additional features—There are other features available to make life with hearing aids easier, such as a low battery indicator and a mute feature to reduce feedback during insertion and removal of the aid. 

One Aid or Two?

If you have hearing loss in both ears, it is generally considered a good idea to purchase aids for both ears. Buying two aids will mean you'll probably have to pay twice as much. But the benefits of two aids are significant: they will improve your balance and safety because you'll be more easily able to localize and differentiate sounds, and they'll make it easier for you to understand speech in noisy environments because each aid can be used at lower listening levels.

On the other hand, if most of your hearing aid use will be in a quiet home environment and in one-on-one conversation, you may not benefit much by the extra sound information two aids would supply and you might reasonably decide to just buy one aid. Some patients find it difficult to maintain and manage two hearing aids. Others simply want to minimize the appearance of a handicap, and feel one aid will be less apparent than two.

There are some uncommon instances where using just one hearing aid is preferable; for example, if one ear has poor ability to discriminate speech or if one ear has a medical condition that contraindicates the use of amplification for health reasons.

How to Avoid Being Stuck with the Wrong Aid

Most hearing aid purchases go off without a hitch. But some don't. It's not easy to get it right since each patient's hearing loss is unique and the expectations of each are different. Even if two patients have the same hearing loss on paper, their rehabilitative needs may be very different.

Dispensing hearing aids is also difficult because most hearing aids are custom-molded, so patients can't try out various makes and models exactly as they would fit in their ears. But it is possible to try different technologies. Many BTE models can be fitted with special pliable earpieces and then set up for tests. The sound quality you get in the test should be fairly close to what you will get when fitted with your own device.

Such demonstrations might be helpful in making your selection. But no in-store demonstration will show you what your experience with a particular technology will be once you are in real-life listening environments. Too much depends on your specific hearing loss, and a sample hearing aid will likely sound different from one that is custom-fitted for you. For this reason, some audiologists prefer not to perform these demonstrations, and instead rely on the real-life experiences of the client, making adjustments as necessary. Ultimately, time and experience with a particular hearing aid may be the only way to determine how well it works for you.

When purchasing a hearing aid, you can take steps to protect yourself from bad choices. Fortunately, there are also laws to protect you from being locked into a hearing aid purchase that does not meet your needs.

According to Minnesota law, if requested to do so by the buyer, for 45 days after selling a hearing aid, the dispenser is obligated to accept the hearing aid as a return and refund the total amount paid for the product and service, including the cost of an exam, fitting, or other services connected to the sale of the hearing aid, minus a fee of up to $250. Be sure to get the dispenser's return fee written into the bill or sale.

Some dispensers will extend the mandatory 45-day trial period if more time is needed—it is not unusual for a dispenser to allow 60 days or more days for wearers who have special needs or who have bought particularly complicated hearing aids. Dispensers' flexibility is generally dependent on their willingness and ability to negotiate with the manufacturer to take back aids beyond the usual 45 days. If you feel you might need extra time to decide about an aid, you should ask the dispenser if an extension is possible and get the dispenser's promise in writing.

Hearing aid dispensers usually offer a free adjustment period during which the dispenser will provide assistance after your purchase. We found that this period varies from seller to seller, with some giving free adjustments for six months and others for the life of the aid. If you are buying a hearing aid for the very first time or trying a new type of aid, be particularly aware of the dispenser's policy regarding follow-up appointments.

Also, find out whether your return period will be extended if you need to have adjustments made, and get this promise in writing. You don't want to lose your right to return an aid simply because you have spent weeks or months trying to get it adjusted to meet your needs before determining that it just won't suit you.

To back up newly purchased aids, most manufacturers provide a minimum warranty of one year. Warranties from some manufacturers last two years and for some aids the warranty period is even longer. In most instances, you can buy an extended warranty that keeps the normal warranty in effect for an extra year.

You can also buy hearing aid insurance to cover an aid for damage or loss, either as an add-on to a manufacturer's warranty or as a separate policy. A hearing aid dispenser should be able to provide information about insurance; check also with your homeowners insurance carrier, as you may be able to purchase a personal articles floater for hearing aids as part of your policy. Before buying any insurance, compare the cost of it against the price of the aid. Usually, these types of insurance policies aren't worth their premiums.

With luck and a little effort, you can avoid having to buy new hearing aids often. One way to expand your hearing aid's lifespan is to keep it clean. The industry standard for a hearing aid's lifespan is about four years, but it is not uncommon for a person to use the same hearing aid for much longer than that—sometimes ten or more years. On the other hand, hanging onto the same aid for so long may mean missing out opportunities to try new technologies.

How to Find a High-Quality Seller

Two words of advice for those looking for a good place to purchase a hearing aid: be wary. Because of the "scientific" nature of the purchase, consumers are often vulnerable to misinformation and bad deals.

An AARP study conducted in Florida revealed many shoddy sales practices. AARP had consumer testers make a total of 169 visits to 23 different hearing aid dispensers. The study revealed that half of the dispensers in the study failed to follow the state's minimum hearing evaluation standards before recommending a hearing aid. Of the consumer testers who had not visited a physician prior to their appointment, only 14 percent were advised that it was in their best interest to see a physician before purchasing an aid, despite the federal law requiring that they be so advised. The consumer testers complained of being tested in "noisy" rooms in 11 of the 23 sites. In many instances, sellers recommended hearing aids for persons who did not need them. Overall, dispensers told 57 percent of the consumer testers that they needed a hearing aid. This compares with the 45 percent judged to need an aid by the audiologist hired by AARP to evaluate the study participants. Some dispensers recommended aids to as many as 90 percent of the consumer testers.

The Florida study also found many instances of deceptive sales statements. The most common was the claim that a hearing aid would help slow down hearing loss or ear damage. This is completely misleading, since hearing aids can only make you hear better and will have no impact on your natural hearing capacity. The study also found instances of vague pricing policies. Some dispensers advertised that a hearing aid was on sale, only to reveal a "sale" price that was the same price that the dispenser always charged for the hearing aid. Others advertised "free" hearing evaluations, later adding the caveat that the test was free only if a hearing aid was purchased the same day.

In our own surveys of hearing aid buyers, sellers were for the most part rated favorably by their customers. But we did receive several comments that echo the problems cited in AARP's study:

• "Very pushy people... Hearing test done in five minutes only, very amateurish. I did not feel comfortable with recommendations. Also prices are very high."
• "Attitude of staff seemed more like sales personnel than hearing specialists. I always felt like I was being sold a product rather than feeling that they were trying to help me hear better."
• "Complete used-car sales pitch, taking control of communication to get me to upgrade to a more expensive hearing aid. When I resisted, she got irritated."
• "Pushed me into a product which may or may not be the right product... [O]ffered free hearing test which was perfunctory, done using a portable desktop unit and not conducted by an audiologist."
• "Over-promised the improvement my wife would experience with new digital technology which ultimately showed no benefit for her."
• "I didn't feel that the technician tried to understand what I was telling her and she continued to make things worse. I went back to my 20-year-old aids."

To help you find advice you can trust, our Ratings Tables show how area hearing centers were rated by CHECKBOOK and Consumer Reports subscribers. (For more information on our customer survey and other research methods, click here.)

When shopping, it is important to know as much as possible about the purchase you are about to make, arrive equipped with good questions, and shop around.

Check the dispenser's credentials. You are assured that the person has had substantial training and has demonstrated some level of competence if he or she is a Doctor of Audiology (AuD) and/or holds a Certificate of Clinical Competence in Audiology (CCC-A). If not, look for other evidence of training and several years of experience.

Check the facilities. The room in which a hearing test is administered needs to be quiet. Most hearing test rooms are not actually "sound proof" but they are "sound treated." In order to block out office noise and increase the sound absorption of the room, extra drywall, insulation, and sealant may be used in the construction of the room. The best way for a hearing center to ensure the room is properly soundproofed is to install a "sound booth." There are companies that specialize in the construction of audiometric testing rooms, or sound booths, which can be ordered in a variety of sizes and sound absorption levels and built on-site. While hearing centers can also construct their own booths or sound-treat existing rooms, this does not ensure the reliable construction offered by professionally built booths. It is worth asking about the nature of the testing room used by a facility you might use. While the type of test room is not a definitive indication of whether a hearing test will be performed properly or not, the presence of a professional sound booth at least demonstrates the office is equipped to obtain the most accurate results.

Make your own judgment about the quality of advice the staff provides. Do they seem interested in you? Do they ask detailed questions about the problems your hearing causes you and the circumstances in which you would most benefit from hearing aids? Do they provide a thorough explanation of the testing process and their diagnosis? Do they present several options? Do they give easy-to-understand explanations for any recommendations they make? Are important choices like buying one aid versus two discussed in ways you can understand?

Once your hearing aid has been ordered, make sure it is properly fitted. You should be concerned if staff simply asks "how does it sound?" or asks if you can hear voices from behind you that are whispered. Such tactics are unscientific and can't determine how much you're benefiting from hearing aids. Instead, the staff should use "real ear" measurements, a process that monitors the response of the hearing aid in the ear canal as adjustments and decisions about hearing aid settings are made. This requires special equipment independent of the fitting software and equipment that are used to program the hearing aid. Real ear measurement can use a variety of stimuli to view and manipulate actively the response of the hearing aid in order to maximize access to speech and ensure overall listening comfort. This takes time and expertise, but is critical because simply programming the hearing aid using the manufacturer's software cannot adequately ensure proper hearing aid settings.

The staff can also verify the hearing aid is working optimally using more traditional testing in the sound booth (by repeating portions of the hearing test while the patient wears aids), but the results of such testing provide less specific information.

Staff should also provide you with a full orientation on your new aids, showing you how to insert them, work controls, maintain and care for them, store them, and replace batteries, and should give you strategies to help you get used to hearing with them.

The trial period and refund policy will, of course, be critical, as will the period for you to get free adjustments.

How to Get a Good Price

For some, the costs of buying a hearing aid might not be an important consideration, since some health insurance policies have coverage for hearing aids. But most health insurers don't provide such coverage, and neither does Medicare. So it's likely that you'll have to pay out of your own pocket, probably from $1,500 to $5,000 or more for a single hearing aid.

our Ratings Tables will help you find a seller that's a good bet on price. The table includes a price index score for each firm that was evaluated in our last full, published article. These scores are intended to show how the firm's prices quoted to our shoppers compared to the average prices for the same aids quoted by all the firms that quoted on those aids. The scores are based on prices for a hearing test, fitting, and one hearing aid. CHECKBOOK's shoppers (who did not reveal their affiliation with CHECKBOOK) asked for prices for 12 hearing aid models. A price index score of $110 means a firm, on average, quoted prices ten percent higher than the average of all the firms quoting on the same models. Price index scores ranged from a low of $82 to a high of $127.

The prices quoted for the same aid varied widely, as you can see on Table 1.

While the price index scores on our Ratings Tables are a helpful starting point, to get the best price, you will need to shop. We recommend the following:

• For your hearing test, consider only businesses that will allow you to keep a full, written copy of the results. 
• Find out how much the provider charges for hearing testing if you choose not to buy a hearing aid from it. Find out if the provider charges for the test if you don't keep the written test results or if you do. But be wary of businesses that market heavily using "free hearing screening" ads; these providers usually aren't in the business of providing full, evaluative examinations. 
• After the hearing test, get the seller's price for the aid it recommends and get the full specifications for the device. Also get a full description of return privileges and any follow-up services included. 
• Call or visit other firms to get their prices based on your test results. Compare prices for the hearing aid recommended by the testing firm, but also seek the other firms' recommendations. 

The cost of a hearing test alone will vary from firm to firm. Many firms charge nothing, but some charge $100 or more. While we here at CHECKBOOK usually adore the word "free," in this field it's not necessarily the best choice. A free screening may not be the equivalent of the full evaluation you need to get. Also, be sure that the "free" firm will not charge a "consultation" or "fitting" fee, thereby negating any real savings. And be aware that a dispenser that charges nothing for a test may feel pressure to sell you something and might not be as flexible as you would like about giving you a copy of test results.

In an effort to keep your costs down, you might consider buying via mail order or the Internet. You can send an impression of your ear and a recent audiogram. This purchase option, however, offers little of the support you can get when buying from a local firm. With a local firm, you get to meet with a specialist before and after your aid purchase to ensure that your aid works well. Most hearing aid purchases require several follow-up appointments before customers are comfortable and satisfied with their new aids.

How to Maximize the Benefits

You want to make sure your hearing aid works properly, that you get the maximum benefit it has to offer, and that it lasts a long time.

Judging How Well It Works

Once your hearing aid has been properly fitted and adjusted, it is probably a good idea to hold off on any immediate judgments about how well it works until you have had some time to get used to the new sounds you are experiencing. At first, you might want to wear your aid for short periods of time or in listening environments that aren't taxing. You'll have to learn to integrate background noises—such as the hum of a refrigerator—into the spectrum of other noises you will process. You may need to adjust to the sound of your own voice, which might seem much different when heard through your hearing aid. You may even have to relearn what certain sounds are that you've forgotten.

Once you have given yourself two or three weeks to adjust to your new aid, the following might help you determine whether it is functioning optimally:

• Overall, does the hearing aid seem to be helping you hear better? 
• Does the hearing aid physically feel comfortable when you wear it? 
• Are the sounds that enter your ear from the aid comfortable? Are soft sounds audible? Are loud sounds too loud? 
• Have you been able to adjust to any new sounds you hear from the aid? Does it seem there is an echo or that there are hollow or tinny noises? 
• Have you been able to insert the aid, clean it, and deal with battery changes? 

If at this point (or any other time) you feel the aid is not meeting your reasonable expectations, return to the dispenser. Good sellers will be willing to help. Minor complaints about sound quality or fit usually can be resolved easily. More serious complaints may require that a mold be remade or that sound needs to be delivered to the ear in a different way—maybe by using a different hearing aid model.

If the dispenser wants to make some adjustments, get the dispenser to put in writing that its return period will be extended to allow you time to decide whether any adjustment makes the aid acceptable.

If things just aren't working out and you are still within the period when you are allowed to return the aid, decide whether that is what you want to do.

Caring for Your Aid

Proper care will prolong the life of your hearing aid and keep it functioning as it should.

First, avoid damaging your aid. Although they are built to be durable, hearing aids can be damaged if they are dropped on a hard surface or become wet. It is important to remove them when swimming or showering. Dogs enjoy chewing on hearing aids, so the aids should always be kept in a secure place when they are not being used. Aids' doors for batteries and access to controls should open easily, so if you're having trouble, don't force the issue.

Keep your hearing aid clean. Moisture and wax can clog and damage components. If you can, remove your hearing aid when doing any activity that causes excessive perspiration. Follow the seller's and manufacturer's directions on how to clean the aid—and make a habit of actually doing it. Most aids need to be cleaned every day.

Plan on taking your aid to the seller periodically for more thorough cleaning and maintenance. Some aids will need these tune-ups every three months, others only once per year.

Hearing and Listening Training

Purchasing a hearing aid is one aspect of an overall treatment plan. There are other steps that can be taken—including hearing and listening training and counseling—to help integrate someone with hearing loss into the hearing world by taking full advantage of the person's existing hearing resources. These steps can include learning to use speech reading and other visual cues, understanding how to position oneself in hard-to-hear situations, and learning how to assert one's needs in different hearing environments. Family members can be an integral part of this process.

You may be able to get the needed services from your hearing specialist, but there are other sources available. Community colleges and universities often offer classes in hearing training or aural rehabilitation.

You may also want to consider joining a support group for hearing aid wearers. In addition to providing moral support, the group can share ideas about what does and does not work when wearing an aid. You can contact the Hearing Loss Association of America (HLAA), a national organization with local chapter networks, at 301-657-2248 for more information about the national organization and groups in your area. More information about publications and membership is available at HLAA's website (www.shhh.org).

Listening Strategies

There is only so much that hearing aids can do to improve your ability to hear. The rest is up to you. There are a number of tactics you should use to better your chances of hearing well in difficult listening environments. They require considering the sort of situation you will be in and taking the necessary steps to make it a more listening-friendly environment.

• Lessen background noise. Make sure to create the best listening environment wherever you go. Loud music and televisions can be turned down if they are competing with someone for your attention. At restaurants, ask for a quiet table. At a friend's house, suggest that the conversation be moved into another room if kids are playing games nearby. At the office, move away from the air-conditioning unit when you are trying to have a conversation. 
• Find a good spot. Position yourself in a room so that you minimize the distance between yourself and the speaker. When in a group, seat yourself in the center where you can see and hear everyone. In a large group listening situation, show up early so you can choose a good position in the room. 
• Turn the lights on. To the extent that you can, make sure rooms where you will be listening are well lit. In rooms with poor lighting, find a bright area and ask your speaker to stand there. 
• Plan ahead. If you know you will be in a particularly difficult listening environment, take some steps beforehand to make sure you won't be wasting your time by showing up. You can always call ahead of time and talk to someone who knows the environment in which you will be. Are there quiet tables? Is there front row seating available? Will there be a light shining on the speaker? In a large group listening situation (such as a place of worship or a concert), call ahead to see if assistive listening devices will be made available. These devices transmit sound to a special receiver that you wear, reducing the loss of clarity that occurs when the sound travels a distance through the air. 
• Ask for it. Don't be afraid to politely but firmly assert your needs. Call out from the audience for the speaker to talk into the microphone. If unamplified questions are being asked by audience members, ask that the questions be repeated by the speaker before being answered. If you are in a restaurant where the music is too loud, ask your waitperson if it is possible to turn the volume down so that you can better hear your companion. If need be, ask people to face you head-on when they speak to you. People will appreciate your candor and your hearing will benefit tremendously. 

Signs that You May Have Hearing Loss

If you answer "yes" to some of these questions, it might be time to get your hearing checked.

• Do I often ask people to repeat themselves? Does it often seem that people are mumbling? 
• Do I often feel tired or stressed during conversations? 
• Do I often misunderstand conversations? Do I miss the point of jokes because I miss too much of the story? 
• Do I turn up the volume on televisions or radios so that others complain? 
• Do I have difficulty understanding speech in noisy places? 
• Do I find that when I look at people I can more easily understand what they are saying? 

Hearing Health Resources

AARP
www.aarp.org/health

Academy of Doctors of Audiology
866-493-5544
www.audiologist.org

Alexander Graham Bell Association for the Deaf and Hard of Hearing
202-337-5220
www.agbell.org

American Academy of Audiology
800-222-2336
www.audiology.org

American Academy of Otolaryngology
703-836-4444
www.entnet.org

American Speech-Language-Hearing Association (ASHA)
800-638-8255
www.asha.org

Better Hearing Institute (BHI)
800-327-9355
www.betterhearing.org

Hearing Industries Association (HIA)
202-449-1090
www.hearing.org

Hearing Loss Association of America (HLAA)
301-657-2248
www.shhh.org

International Hearing Society (IHS)
734-522-7200
www.ihsinfo.org

Lions Club Sight and Hearing Foundation
630-571-5466
www.lionsclubs.org