On The Cover

Elizabeth Briand

For millennia, when people lost their hearing, it was gone. The sound of rain, of their grandchildren’s voices, all of the day-to-day noises that make up humankind’s auditory life—they were either gone or radically altered, leaving communication challenging at best.

For centuries, inventors have sought new technologies to address hearing loss, helping people retain or reclaim this vital sense. Today, with the advent of so many OTC hearing aids, the options for care are greater than they have ever been—and pharmacists are finding a larger role in helping bring back clear, joyful sound into people’s lives.

The opportunity to provide assistance is a significant one with nearly 15% of Americans aged 18 or older reporting at least some difficulty with hearing, according to the National Institute on Deafness and Other Communication Disorders (NIDCD). Hearing loss becomes more common as people age.

Finding the right solution

With so many health issues and concerns tied to loss of hearing, it might seem that people coping with even mild hearing loss would seek assistive devices to restore this most important sense. It is not, however, that simple.

“It can be difficult to help people come to terms with hearing loss,” said Lucas Berenbrok, PharmD, associate professor and vice chair for education of pharmacy and therapeutics at the University of Pittsburgh.

Although approximately 28.8 million adults in the United States could benefit from hearing aids, a startlingly low percentage actually use them, according to NIDCD. For adults aged 70 or older who have hearing loss, fewer than one in three have ever used them. That number plummets even further for younger adults, with only 16% of adults aged 20 to 69 years who could benefit from hearing assistance ever using them.

“A lot of people don’t want to be bothered by them,” said Lindsay Creed, AuD, associate director, audiology practices at the American Speech-Language-Hearing Association. “And a lot of it is psychological. Accepting a device means admitting there is a problem. We need to educate on how easy it can be to use one and how life-changing they can be.”

In other instances, that reluctance to seek help may be less psychological and emotional and more that the person simply may not realize they need assistance.

“Hearing loss is a little more complicated than being able to hear or not hear,” said Elaine Mormer, PhD, director of audiology clinical education at the University of Pittsburgh’s Department of Communication Science and Disorders. “Some people might be able to hear sounds, but they can’t understand clearly what’s being said. Or they may hear part of a word but not all of it. People don’t know what they’re missing—they can’t know if they can’t hear it. With gradual hearing loss, they won’t notice it. Other people around them will notice it first,” said Creed.

When patients or family members do identify a need, pharmacists can play a significant role in helping to address it. In part, this is because pharmacies are more accessible for individuals than their physicians’ offices and because people often have closer relationships with their pharmacists than their physician.

This role can include encouragement and support for patients who may be uncertain whether they want to take the plunge and get a hearing aid. To help people overcome apprehensions, pharmacists can take a “motivational approach, asking ‘have you ever thought about your hearing?’” said Berenbrok. “It takes an average of 7 to 10 years after noticing they have hearing loss before people get help.” For a person coming to terms with their own unique situation, having the support of a health care provider they trust can make all the difference.

Beyond advice, pharmacists can also offer patients access to the latest OTC hearing aids. In 2017, legislation was passed that authorized FDA to create a new classification of OTC hearing aids. Called the Over-the-Counter Hearing Aid Act, the law was designed to improve affordability and increase access to hearing aids. FDA finalized regulations in 2022, ensuring standardized levels of quality. Today, OTC hearing aids are available in a broad range of price points, starting at just a couple of hundred dollars.

“Now that OTC devices are on the shelves, people can grab and go,” said Berenbrok. “They don’t need a hearing test or clearance from a physician to get a hearing aid.”

That said, patients may still have a lot of questions and require assistance in either deciding to purchase a hearing aid or knowing which device to choose. Pharmacists who are prepared and well-versed in the options available to consumers will be an invaluable resource for their patients.

“There’s a wide range of devices that are FDA-registered, from low-end amplifiers to devices having very high-end sophisticated features,” said Mormer.

“[Pharmacists] are really willing and excited to expand the portfolio of ways to help their patients,” said Creed. And they can best provide help to those patients by understanding a few key facets of hearing aid care.

“Knowing who is a candidate for an OTC device and who may need an audiologist is important,” said Creed. It is also helpful for pharmacists to familiarize themselves with the different products so they can answer questions such as how a device’s return policy might work or how the purchaser can get tech support if they need it.

Pharmacists should know, also, that OTC devices “are only FDA approved for people 18 years and older who have self-perceived mild to moderate hearing loss,” said Mormer. “They should know, too, that there are a number of exclusions for self-care and be familiar with them.”

Manufacturers also have worked to give pharmacists a multitude of ways to sell the devices, including the ability to give patients a tablet on which they can conduct a self-hearing test, be matched with the correct device, order it on the tablet itself, and have it drop-shipped directly to the patient. Certain insurers may provide coverage or partial coverage for hearing aids, giving people a broader range of devices to consider.

“Over-the-counter devices are like cars—there are some very basic ones and others that have more sophisticated technologies with lots of different features,” said Mormer.

Beyond the devices offered at local retailers and pharmacies, there is another new player on the block that can help people experiencing hearing loss: the Apple AirPods Pro2, which offers clinical-grade hearing aid capability for perceived mild to moderate hearing loss and allows individuals to take a hearing test on their iPhone and adjust sounds to their unique hearing needs.

Creed noted the fact that so many people already have AirPods, meaning that “instead of going and getting something else, they can take the screening and then turn the feature on,” she said. “I also love it from a stigma perspective. If people are worried about wearing a hearing aid, no one will know if you have this feature turned on or not. They just look like AirPods, which everyone has.”

Hearing and good health

The ability to address hearing loss is of vital importance, given the association between poor hearing and ill health.

“Often we take hearing for granted until we start to lose it,” said Creed. “Hearing is tied very closely to our ability to engage with those around us. [Losing one’s hearing] can lead to isolation, loneliness, and even depression. That, in turn, affects our physical health.”

Researchers at Johns Hopkins University tracked more than 600 adults for 12 years and found that mild hearing loss appeared to double the risk of dementia, moderate hearing loss tripled it, and severe hearing impairment quintupled it. They found that hearing loss may also affect balance, leading to more falls. The loss of balance appeared to be caused by the fact that the brain has to work harder and multitask in order to process sound, ultimately interfering with some of the mental alertness needed to walk safely.

Mormer noted other complications that can arise from hearing loss as well.

“If you go to the doctor and you can’t hear what they’re saying, there’s a high risk of communication breakdown in an important health care discussion,” she said. For example, if a physician speaks quickly or in a low tone and is trying to get across important information, the patient either may not hear it correctly or not hear it at all. When that happens, all sorts of misunderstandings—including those that may put the patient’s health at risk—can occur.

The same issue can happen when someone is speaking to their pharmacist. Especially in a crowded store, there may be lots of background noise and the patient may not hear or understand important instructions. “People often don’t want to make it obvious that they can’t hear so they bluff,” Mormer said.

In addition, poor hearing can lead to misdiagnoses, often for dementia. When people take cognitive tests, they are asked questions verbally. If the person cannot hear the question or misunderstands the question, their confusion can be taken as a sign of a cognitive issue.

“I’ve seen people in nursing homes who have been diagnosed with dementia, and we go in, test them and find there is hearing loss,” said Mormer.

Audiologists and pharmacists: Partners in patient care

Because hearing loss can cover such a wide spectrum of severity, OTC devices will not meet the needs of every patient. That is where a healthy and substantive partnership between pharmacists and local audiologists can help.

“Though over-the-counter hearing aids are available straight to consumers, they are only intended for mild to moderate hearing loss,” said Creed. Anything more significant will require a hearing test and the more complex types of devices available from an audiologist or a hearing instrument dispenser.

Audiologists and hearing instrument dispensers will be able to accurately assess the level of hearing assistance that a patient will need. They also will be able to give access to a broader range of devices that can be adjusted for different frequencies. “Support is a big difference,” said Creed. “When people get a prescription device, the audiologist can provide a fitting and tweaking that they can’t get with OTC devices.” For patients with significant hearing loss, this level of care is necessary to achieve their best outcomes.

Berenbrok and Mormer have been working together for a number of years to build relationships between the worlds of pharmacy and audiology. Their collaborative research has shown, though, that nearly 70% of pharmacists surveyed in a recent study could not make recommendations to their patients for a local audiologist.

The goal is to help connect pharmacists and audiologists. “Nearly 90% of Americans live within 5 miles of a pharmacy, but that’s definitely not true of audiologists,” said Mormer.

“There are some rural communities with no access to audiologists at all—they might have to travel 200 miles to find one.” These statistics underscore the vitally important role that pharmacists are now playing in the hearing health of their patients.

For pharmacists who want to improve their understanding of hearing loss, hearing aids, and how they can best help, training is available via an interprofessional, competency-based advanced program on OTC hearing aids developed by Berenbrok and Mormer and licensed by APhA. (Please visit apha.us/HearingAidsTraining to learn more or register for the advanced training program.)

The goal of the program is to prepare pharmacists and student pharmacists to support patients safely and effectively in the selection of OTC hearing aids. The self-paced course is 3 hours long, and those who complete it earn a certificate of completion demonstrating their knowledge of hearing health care.

In addition, Mormer and Berenbrok hosted the inaugural OTC Hearing Aid and Hearing Self-Care Symposium at the University of Pittsburgh in 2024, bringing together thought leaders from pharmacy, audiology, and public health to discuss the latest in OTC hearing aids and how the professions can work together to support the safe and effective use of these devices.

Audiology professionals are also encouraging their colleagues to reach out directly to pharmacists in the communities they serve, to help build those connections that will directly benefit patients in need.

Working together, pharmacists and audiologists can help restore the gift of hearing, improving both physical and emotional health for millions of adults nationwide. ■

A long history

The first known device to aid in the amplification of sound was the ear trumpet, with the first known mention of it dating back to 1634 in France. This tubular device was designed to funnel sound waves into the ear and could be custom-made for individual users.

More than 250 years later, the Akouphone became the first portable hearing aid. Comprised of a separate microphone, amplifier, headphones, and battery, the Akouphone used a carbon transmitter through which an electric current could take a weak signal and turn it into a strong signal.

Despite the fact that very few people purchased the Akouphone, which was expensive and difficult to use, engineers and manufacturers continued to work on creating smaller, more affordable devices that could be used by millions of people instead of just the few hundred who could afford and operate a device as complex as the Akouphone.

The 1920s saw the creation of the first vacuum-tube hearing aid, which used a telephone transmitter to convert sound into amplified electrical signals. The vacuum-tube versions required the user to wear the amplifier and batteries around their neck and hold up a microphone to capture sound — not the most convenient set-up if someone wanted to move around or converse on the go. Still, the technology took off, and the race was on to make an even smaller and simpler device.

For the next 80 years, the makers of hearing aids continued to innovate, moving from transistor hearing aids in the late 1940s to microprocessor and compression hearing aids in the 1970s—models that allowed audio signals to be separated into frequency bands, making it possible to amplify certain sounds and not others.

In the late 1980s, the first fully digital hearing aids came to market, and today, devices are benefiting from technology such as Bluetooth connections and rechargeable batteries as well as new gadgets such as hearing amplifiers and personal sound amplification products, not to mention some Apple AirPods, which are now offering hearing assistance.

In short, hearing aids have come an extraordinarily long way since the invention of the ear trumpet. Today, people have a wide range of options from which to choose and can base their decision on specific auditory needs, availability, accessibility, and price.

Much of this availability is due to the advent of OTC hearing aid and amplification devices, allowing people who have self-diagnosed hearing loss to attempt to remedy their situation simply by going to their local pharmacy and choosing a system off the shelf. ■