OTC hearing aids and the brain: Interview with Dr. Jack Hitchens

[00:00:00] Dr. Mia: Welcome back to Ask Dr. Mia podcast, Conversations on Aging Well. Today I have a special guest Jack Hitchens is an audiologist and I'm gonna turn it over to Jack to let him introduce himself. 

[00:00:20] Dr. Jack: Thank you so much Dr. Mia. I actually love that you go by Dr. Mia. My name is Jack Hitchens and I'm an audiologist and I have gained the name Dr. Jack for most of my patients as well. I work in an ear, nose, throat facility in Georgia. We see patients of all ages, but especially we see lots of adults with hearing loss .

[00:00:38] Dr. Mia: Thank you for joining us, Jack. Just a quick note of disclosure and neither Jack or I are speaking on behalf of our respective employers. And I will link to Jack's practice in the show notes. So Jack one of the reasons why I wanted to bring you to the podcast is because hearing loss is such a common problem in a lot of the patients I see. And I personally as a physicians have questions about it and I'm sure a lot of our audience also have questions related to hearing. So one of the first questions is, what does an audiologist do besides fitting for hearing aids? I have some patients who say, there's no way I'm gonna wear hearing aids, so there's no need to see an audiologist. Is that true? 

[00:01:30] Dr. Jack: Oh, yes. We see that all the time. I always tell patients and family members of patients, caretakers of patients, I really tell them that the first step in the process is we are assessing the hearing. And so our job is to find out how somebody is hearing and. Before we even mention the word hearing aid or anything like that, we have to know exactly what's going on. A lot of patients will come in, they're scared to come see us, and then their ears are full of ear wax. And that's a real quick fix. They're in and out the door in 15 minutes and they're already hearing better than they were when they came in. For majority of our patients who do have some hearing issues that are permanent in nature, what our job is to really figure out which sounds are they hearing and which sounds are they not hearing. 

[00:02:20] Dr. Jack: We tend to think of hearing as all or nothing. Some people will come in and say, I feel like I hear fine. I hear everything I need to hear. I can hear people talking to me. But the thing that I. Every single day over and over is people will say, I can hear people talking to me, but I don't understand them as well as I used to. Or just, things don't sound as clear as they should. People will kind of sound like the parents on Charlie Brown, bmm bmm bmm bmmm; they'll hear their voice talking, but the words just don't have that sharpness and that clarity that they used to. The reason for that being is that we don't hear all sounds the same way over time.

[00:03:03] Dr. Jack: For most people, if you're looking at a piano and you've got the low pitch sounds on your left, you've got the middle sounds in the middle hole, you've got the high pitch sounds on your right for most people, we start to lose those high pitch sounds over time. That's the most common type of hearing loss we see and the high pitch sounds in terms of human speech.

[00:03:24] Dr. Jack: Those are the c. So if you take the word tree versus free versus three, the only difference between those words are the consonant that starts, or the consonant blend that starts the word. Those words don't really have a whole lot to do with each other, but that one little sound changes the whole word. Most of my patients, they hear the vowels cuz vowels are low pitch in nature and they still hear those sounds great, but they don't hear the consonants as well as they used to. And so that's exactly why they'll say, I hear people talking to me, but. I miss words or I have to ask them to repeat. I have to say, What was that? Or somebody says a joke and everybody laughs and they say, I just missed that last part of it. So our job, again, going back to your original question is we have to find out which sounds are they hearing and which sounds are they not hearing? Because that is gonna determine the course of treatment going forward. 

[00:04:25] Dr. Mia: is that a reason why in older adults, they may have a better chance of hearing male voices that are deeper? 

[00:04:33] Dr. Jack: Absolutely. Absolutely. So more of the male voice is gonna fall lower in that spectrum overall. And so you'll commonly hear people say if I'm watching the news and there's a news anchor and he's a male with a strong, clear voice, they'll say, I really do pretty well in that situation. And then they'll say, I'll go to lunch with my female friends, and I can't understand anything they're saying. And because more of that male speech is falling in the range that they can hear than the female voice overall. So that's definitely something that Is actually true when people will say I feel like I hear men better than women.

[00:05:07] Dr. Jack: The other big time you'll really see it is background noise. The probably the number one thing I hear in my job is people coming to me and they say, If I'm in a quiet room, one on one, speaking with someone where I can see their face, I can see their lips, I can kind of fill in those sounds I missed. But as soon as we get out in the quote unquote real world, they'll say, I really struggle. And that's the same thing. They're hearing the low pitch sounds all around them, all the murmur, all the restaurant noise, all the car noise. They hear that really well, but they're not hearing the consonants, they're not hearing the speech cut through.

[00:05:44] Dr. Mia: And I bet wearing masks for everyone during the pandemic. I've definitely noticed that there's a lot of people who secretly read my lips before I even didn't realize that many people were dependent on reading my lips to be able to really understand what I was saying. I think this is also where some spouses particularly wives, who say that their husbands have selective hearing, and I think it's true because they can't hear the higher pitch female voices as well. 

[00:06:18] Dr. Jack: Oh yeah. The masks were very eye opening to a lot of people. I had several patients come in over the last few years who said, I've noticed some trouble over the last several years, they said, But as soon as everybody started wearing masks, they say, I'm really struggling, because they realized they were. Again, if you think about the difference between the word tree and free, if I was looking at you right now, you could just see the difference in those two words just based off of my lips. And once you take that away, those words, they just blend together. And when it comes to spouses, the people who were around the most tend to be the ones who also be the, I don't wanna say forgetful about being face to face whenever possible. I know my wife and I are guilty of it. One of us will be walking down the hall, doing something in the other room, we'll have our head in the cabinet. The other one's got their head in the, dryer pulling clothes out. And we'll say, what time are we going to dinner tonight? And it's that's not a great communication set up between the two of us.

[00:07:13] Dr. Jack: And so you can imagine if one person is only hearing the vowels in that situation, all they're gonna hear is, [mumble] like you said, they'll say, are you listening to me because you've heard me? And again, they're hearing right part of their voice, but not all of. Yeah it's definitely a problem.

[00:07:30] Dr. Mia: So that, that leads to my second question is, how do audiologists tell what's a cognitive issue versus a hearing issue? I know a lot of people who have both memory problems and hearing problems. How do audiologists figure out what is an issue where they don't hear versus something that they hear but may not comprehend or understand? 

[00:08:22] Dr. Jack: That is a great question. That's one of the things that I really do enjoy about the daily aspect of my job. You can imagine some hearing tests are pretty easy. When somebody comes in and you say, Hey, I'm gonna play some sounds. I'd like for you to let me know when you hear them. We do some tones that they listen for. We do some words that they repeat back to us. We'll do some testing where we'll make it a little more difficult, where we'll play some background noise and they have to identify the speech through the background noise.

[00:08:49] Dr. Jack: As you can imagine when we're dealing with any type of cognitive issue at any level, those tests may not be as straightforward as we're used to, and so it is a matter of really paying attention to the patient. Of course we wanna get as much history from the patient as we can get from them. Generally if there's some cognitive issues involved, they will have somebody else with them at that appointment. We encourage as much as possible any of our patients to bring somebody else with them because communication is a two-way street, obviously. Even before we start testing, we try to gauge what challenges we might encounter in that specific situation.

[00:09:30] Dr. Jack: And at that point it becomes, do we need to modify our test protocols on the fly? And basically we really pay attention to the patient. We pay attention to the responses that they're giving us. The neat thing about our test batteries is that they really do kind of line up. There's some different tests we do that psycho-acoustically should match up together. So if we're getting one test, we're getting a result, and then we're getting on another test, these two results don't really match up. That's a red flag for, okay, we may be dealing with a different issue here other than just a hearing problem. And so there's some tests that we do that are what we call behavioral: where the patient actually responds. And then there's some other tests that we do that are more automated that can test part of the auditory system where the patient doesn't even have to do anything. Same tests we do for very small children, newborns children who are not able to sit and do a hearing test yet. And we can actually use some of those same protocols for some of our aging adults who may have some cognitive issues as well. 

[00:10:38] Dr. Mia: Yeah, that does make me think of young babies, right in the hospital. I still remember my children, getting the hearing test at the bedside. And I've always wondered how do you tell whether they've heard something? Is it, do you see a brain wave ?

[00:10:52] Dr. Jack: There's actually two different tests that most hospitals do. Every state in the US has a newborn screening program and they're all a little different. One test actually checks what's called the cochlear, which is the inner ear for our listeners that you have the sound goes in our ear. That's where everybody thinks the hearing occurs, but obviously there's a lot more going on. Once it goes past that part that we can see from the outside hits our eardrum, sends a little sound way through some bones, and then we have what's called the cochlear, which is a little snail shaped organ. And when the cochlear is working normally, It actually sends that same little sound wave that goes in, it sends a little sound wave back out, and we can measure for that microscopic sound. And when that sound is there it can tell us how the cochlear is functioning. And then exactly what you said, Dr. Mia is exactly right when you asked about brainwaves. 

[00:11:41] Dr. Jack: There's a second test we can do perfectly harmless tests that we can put some small electrodes on a baby as young as one day old, and it will play some sounds in the ear and it will actually measure the response of the hearing nerve and we can measure the waves and see if we're getting some neural response and get a pretty accurate hearing test just from that alone.

[00:12:05] Dr. Mia: That's really neat. Hearing is so interesting and complicated. It's multiple bones and organs and not just the ears that we see on the outside. One other thing that really made me interested in bringing you on, is that I know the FDA has recently changed the sale of hearing aids. Instead of solely under the dispense and evaluation and treatment of audiologists. Starting this month, there are going to be some hearing aids that are going to be over the counter. Can you talk to us a little bit more about the implications of that?

[00:12:46] Dr. Jack: Yeah, that's a very hot button topic in my field right now. It's something that's been going on for a while. I'm sure most listeners out there at some point have probably seen a TV commercial already for hearing aids that you could order over the phone that you can get in touch with somebody online who could help adjust it. So there's already been some companies that have been trying to navigate some of this delivery model even before this new ruling is going into effect. And the new ruling is basically just gonna make it easier for those companies to, like you said, have a product that somebody could basically buy off the shelf without seeing a professional. A lot of people ask me, well, are you worried about this?

[00:13:27] Dr. Jack: Obvious when it comes to any type of healthcare, what we're doing is we're evaluating the pros and the cons as far as the quality of care a patient is receiving versus the access that a patient has to that care. Because you can have the greatest treatment options, and if nobody has access to them, then how great really are they? And the flip side of that, obviously you could have something accessible to everybody, but if it's not actually treating the problem then it's also not beneficial. So we're really trying to find that balancing act of access versus effectiveness. Obviously, when the audiology world on a day to day, when we're seeing patients with all these different hearing issues. We're talking about the little bones of our ear. We're talking about the neural structures. We're talking about processing issues. We're talking about cognitive issues. There's so many things that go into hearing that there are definite reasons somebody should seek professional help before trying a hearing aid as opposed to over the counter options. Hearing aids in general have become just an absolute wonderful tool, a wonderful piece of technology to treat people with hearing loss. but it does come at a price, because in most cases, digital hearing aids dispensed through a professional are on the pricier side compared to something that somebody would just buy over the counter. And so again, the balancing act of is we're trying to figure out how can we get some of this technology that's more affordable, that's more accessible to patients without actually compromising that treatment.

[00:15:09] Dr. Jack: There's other countries out there who, who have been dealing with some over the counter issues for years. We've got these over the counter options out there now that aren't a true hearing aid, but it looks like a hearing aid. It does a lot of the hearing aid things. And again, lots have been out for a while and I see patients every week that have tried something and they come to me and they say, Yeah, this was probably not the best idea, for me. So personally, I think pretty much anybody's gonna benefit from at least seeing a professional from the starting point to figure out what is going on with my hearing. And I should definitely mention that there's some scenarios where, there's some red flags for more medical issues with your hearing. 

[00:15:55] Dr. Jack: We tell people if you ever have a sudden hearing loss, like if you wake up one day and all of a sudden you're not hearing, you don't need to go try to find a hearing aid. You need to, we need you to see a doctor, you need to see a physician. If one ear is not hearing well compared to the other one, that can be a red flag that something may be going on medically. And rather than just putting a hearing aid on the ear, we need to see if we're dealing with a more serious medical issue such as a problem with the nerve or a growth on the auditory nerve, obviously that's something that we need to have addressed by a physician as soon as possible. Obviously anytime anybody is having anything strange as far as their ears, it's hurting, there's draining stuff coming out, we would want you to see a medical professional first. And so that's why, in my opinion, I think anybody would be benefited by starting with a professional. Once you get past that point, I really think this over the counter idea is geared more towards people who are what we'd call the techiest people out there anyways. Right now, the regulations that been presented with are for self perceived mild to moderate hearing loss. So we're not talking about people who are struggling all day every day. For the people who are constantly lip reading, for the people who are having difficulty in all kinds of situations, we're talking about the people who are maybe saying, You know what, I'm fine overall. I just miss something here and there, just every now and then. Whereas most people who fall in that range, if you look at the research out there, most of them aren't quite ready for hearing aids. It's usually when we get into more of that moderate, severe level that patients are coming to us saying, Yeah, it's time to do something. I need to hear better. So I definitely think if, maybe if it was that patient who just had a little bit of an issue every now and then, was very tech savvy, had already seen a professional, and had the kind of motivation to do it on their own, I think that's the probably the patient that it could possibly work for.

[00:18:10] Dr. Jack: Most of the people I don't think are gonna fall into that category, especially our aging adults. Hearing, like you said earlier, it's a process. There's a lot more to it than just what goes into our ear based off the way that our brains work and there's so much on a day to day basis that we need to make sure the patients are doing correctly to make sure they're getting the full benefit out of these amazingly technological devices that they're gonna be wearing every day.

[00:18:42] Dr. Mia: Yeah, let's talk more about the tech side cuz I don't know how many of us really realized the amount of technological literacy that goes into a hearing aid. It's not something that you can just pop into your ear and magically it'll make your hearing better. There's set up and things you need to do outside of putting in a hearing aid. Is that right? 

[00:19:06] Dr. Jack: Like you were saying, when it comes to our actual hearing loss, hearing losses are kind of like snowflakes. They can be different for pretty much everyone. And so the hearing aid itself really needs to be tuned to each patient's specific level of hearing. So when we do our hearing test, that's our starting point, where we're gonna find out where's the patient hearing well, where they're having deficits. And when we program the hearing aids, we're gonna obviously match the programming to that. And that's kind of step one. Beyond that, what type of environments are they in? The hearing aids nowadays, they have little computer chips in 'em that they analyze the sound all the time, and so they can actually detect if somebody in a quiet room is somebody in a noisier place like a car. It's somebody in a really noisy place like they're eating in a really, really busy restaurant, and the hearing aid itself can kind of self-modify based off those levels to help the user in those specific settings. So we really have to not just do a hearing assessment on a patient, we kinda have to do a lifestyle assessment on them as well. And two people who have a very similar hearing loss may still have two very different listening needs. And so absolutely there's a lot more to it than just picking it up and putting it in your ear. You can have the greatest hearing aid in the world, and if it's not set correctly for their hearing loss, it's not gonna help them at all.

[00:20:36] Dr. Jack: So first and foremost, we have to make sure we have the right device, that we have it set for the patient correctly. And then beyond that, we have to make sure the patient knows what they're doing with it on their end. I hate when this happens: I have patients that come to me, they've gotten their hearing aids from somewhere else, or they moved into town and they said, Yeah, they've been sitting in this box in my dresser drawer for the last six months because I'm not really sure what to do with 'em. Or they say, It's got this button on it. I don't know what this button does, or they'll say, You know, I tried wearing it. I couldn't adjust to the sound quality, so I stopped wearing it. And so those are the type of situations where, man, this person, they are having a hearing problem that is affecting their life, they have gone through the effort of saying, "I need to do something about it." and now they're sitting here with a solution. That's not a solution at all. And so that's when we have to really sit down and say, Okay, we've gotta make this work for you. What's gonna give you the benefit here? And I actually love those appointments the most. It's fun to, to see the smiles and , to see people light up when we get 'em, when we get 'em hearing the way they should be hearing. 

[00:21:44] Dr. Mia: So when you said earlier about this new class of hearing aids that it's going to be over the counter I'm guessing that there's not going to be much customization. So are these really small hearing amplifiers, like they just amplified the sound? Just wondering how what makes a hearing aid a hearing aid versus just a sound amplification?

[00:22:07] Dr. Jack: Yeah, that, that's a great question too. For years, if you go to your local pharmacy department store, you'll see, like I said, things that kind of look like an old school hearing aid hanging on the shelf. And for years, those are what we just call amplifiers. And if you read the fine print on the packaging, and the FDA for years has said that an amplifier is designed to make sounds louder, but it's not designed to treat hearing loss. It's not designed to actually be worn by somebody who has a hearing problem. For an example, let's say somebody just wanted to go bird watching and they just wanted to hear a little more enhanced than they normally do, that's the point of an amplifier.

[00:22:49] Dr. Jack: But of course there are people out there with hearing problems who would try them to see, "Hey, maybe this will help me." The newer class of hearing aids, you'll have a couple different versions. One may have some different settings already programmed in it, so rather than turning all the sounds louder, remember how we said most people don't hear the high pitches, they may have a setting that just turns up the high pitch sounds thinking this is gonna fit majority of hearing losses. And if they can find the program that works for them and they can find the volume that works for them, maybe this will fall into the range of that little bit of hearing loss that they've got.

[00:23:29] Dr. Jack: There's some other technology examples where they're saying, Hey, maybe you buy it over the counter. But in today's world, like anything else, you, there's an app you download on your smartphone. You have gone and seen an audiologist, you take your hearing test that they gave you and you plug it in, and you can now do some basic adjustments on your own. Kinda the equivalent of like somebody who's trying to do their prescription glasses through a, do-it-yourself site after you've already gotten the prescription. So I really think it's going to be, interesting time to see what all hits the market at once.

[00:24:04] Dr. Jack: I'm sure there's companies that have been trying to develop these for years waiting to see if this would pass. But at the end of the day, like I said, I think we're talking about such a small amount of people that this would really fall into this category that I, my hope is that people don't spend a lot of time, effort, and money chasing themselves through these rabbit holes when really just seeing a professional would be the best solution for them. The worst case scenario would be somebody who tried something like this, got discouraged and then that actually deterred them from 

[00:24:42] Dr. Mia: wearing a hearing aid. Exactly. Yeah. Yeah, yeah. What about this the hearing aids at Costco? I hear so many of my patients say, Oh, I just got my hearing aid at Costco. I'm like, Really? Does it work for you? 

[00:24:54] Dr. Jack: Yeah. I think a lot of that when we were talking about those profiles, I've seen a little bit of everything from the big box stores. I've seen patients who are really happy and they have a provider who's really good. And then I've seen some horror stories as well.

[00:25:07] Dr. Jack: I think same thing if it, if it's a type of person where they have a more standard hearing loss, more with it technological person, they may be a better candidate for something like that. And then obviously somebody who's got more complicated issues, who needs more professional needs more professional input needs, more instruction, they tend to do better in the seeing the more traditional models, the more medical models. 

[00:25:33] Dr. Mia: Gotcha. What are some common complaints that you hear about from people who do say try out a hearing aid that an audiologist has prescribed or evaluated them for and fitted them for?

[00:25:45] Dr. Jack: I'd say the number one thing people say when they're brand new to trying hearing aids, trying amplification for the first time. Lots of times they'll come back and see me after a week of being fit with the devices and they'll say, "Oh, everything is just very, very pronounced, very, very sensitive." almost like they're hearing "too well". . And at that point is when we'll have to really start getting into discussing the plasticity of the brain and how the brain changes and how the brain recalibrates and the same patients who maybe one weekend are saying, "Oh man, I'm really sensitive to these sounds. I'm not sure I'm gonna be able to adjust to this." They'll come back to me in six months and they're like "I can't go a day without these things." They say, " I wake up in the morning and I wanna put 'em in my ears as, as soon as I get out of bed because I just hear so much better." And so it's just a testament to the human brain and how amazing it is.

[00:26:41] Dr. Mia: Well, Jack, thank you so much. This is such a great, helpful session and I learned a ton of stuff as well. Are there any last minute. Comments or suggestions that you wanna tell the audience? Things that you lie awake at night and think if only everybody in the world knows about blank, my life would be easier as an audiologist?

[00:27:04] Dr. Jack: Like we said earlier, just that first step of assessment. It doesn't hurt at all. Getting a hearing test, I think is a very, very smart thing for who's even noticing just a little bit of difficulty. One of the really hot button issues in our field, a lot of the research that's coming out now, you're probably even more up to speed with it than I am or we are, is the relationship that we're seeing between untreated hearing loss and higher incidence rates of depression, incident rates of dementia in the aging population. And it's one of those things that. , it makes sense. What we see is people who don't hear well, they'll start to say, "Oh, I used to go to my lunch group every Thursday afternoon. I don't really go anymore cause it's just too hard to hear." Or they'll say, "I go, but I just kind of sit there and I just kind of nod my head and I just kind of smile. Cause I don't wanna say the wrong thing." And what we see is people just starting to kind of withdraw more and more and more, and they take themselves out of those engaging situations. And then, and you as a geriatrician, that is just the opposite of what we want people doing. We want them staying engaged. We want them active. And the hearing is think for years, almost just something that people realized but didn't really consider how serious it really is. 

[00:28:27] Dr. Mia: Oh, yeah it is very serious and in fact, it's one of the things that I really harp on with people who come and see me for memory loss, especially if they have very mild memory problems. And I also detect on my exam that they have hearing problems. I make it very clear to them. I said, "If you have both hearing loss and memory problems, I may not be able to do a whole lot for your memory problems, but if you don't get your hearing evaluated, your memory problems are going to decline faster than if you get your hearing treated," and that usually scares them enough to see 

[00:29:05] Dr. Jack: they're coming in front, get that hearing test [laughter] 

[00:29:09] Dr. Mia: It's just such an important, potentially reversible thing. And just as you said too, that the socialization part is very important, even if someone is not necessarily obviously withdrawing from social interactions, I think just we don't realize how much input we are getting from our hearing into our brain, and I'm sure missing a lot of that input, cognitive input is also not good for our brain . So I'm very grateful that you're able to join me on and talking all about hearing today.

[00:29:48] Dr. Jack: Absolutely. And one thing that would make my life easier is if all physicians were as in tune with that as you saying directly to the patient, It's time to go get that hearing test and here's why. 

[00:30:02] Dr. Mia: They know now that how important it is for their overall quality of life, not just their memory, but also social relationships and everything that we do our senses are so important.

[00:30:14] Dr. Jack: Absolutely. 

[00:30:15] Dr. Mia: Great. Thank you so much, Jack. 

[00:30:16] Dr. Jack: You're so welcome. 

[00:30:17] Dr. Mia: If you enjoyed this episode, please gimme a review on whichever podcast platform you're listening or share it with other folks who might wanna hear this particular episode. Thank you so much. Talk to you next time.