Virtual Staff Training to Support Communication for Older Adults With Untreated Hearing Loss in Care Settings.

PURPOSE: The current quasi-experimental study aimed to develop and evaluate a virtual staff training on age-related hearing loss at a care organization for older adults. METHOD: Training included the use of affordable headset amplifiers and a hands-on activity in which hearing loss was simulated. Staff were encouraged to offer amplifiers to assist in communication given the high prevalence of untreated hearing loss among older adults and the increased communication difficulty that results from mask-wearing. RESULTS: Quantitative results (N = 51) from the pre/post questionnaire suggest that staff members gained knowledge about hearing loss and communication through the training session. Qualitative data over the 6-month post training suggest that some older adults had not only improved speech understanding but also improved quality of interactions with staff. The main reasons for not using the amplifiers were that staff would forget they had access to the amplifiers or the older adult would refuse to use the device. CONCLUSION: This article highlights successes of the training as well as ideas for future trainings suggested by staff members. A key finding was the need to identify a core group of staff members who would be charged with facilitating use of personal amplification for older adults in the organization. In addition, providing multiple brief trainings over time was suggested to improve adoption of good communication practices among staff. [Journal of Gerontological Nursing, 50(4), 48-56.].

Associations Between Age-Related Hearing Loss, Cognitive Impairment, and Multiple Chronic Conditions in a Group Care Setting.

PURPOSE: The purpose of this study was to explore the relationships between hearing loss, cognitive status, and a range of health outcomes over a period of 2 years in a sample of older adults who are enrolled in Program of All-Inclusive Care for the Elderly, which is a Medicare/Medicaid beneficiary program for individuals who are nursing home eligible but living in the community at time of enrollment. METHOD: The sample (N = 144) includes a diverse (47% White/non-Hispanic, 35% Black/African American, and 16% Latin/Hispanic) group of adults ranging from 55 to 93 years old. We used medical chart data to measure respondents' cognitive and health status, including chronic conditions and hospital use. Hearing status was measured once at the beginning of the 2-year review period. We used logistic regression and negative binomial hurdle models for analyses. We used latent class analysis (LCA) to explore the extent to which respondents cluster into a set of "health profiles" characterized by their hearing, cognitive status, and health conditions. RESULTS: We found that hearing loss is weakly associated with heart disease and diabetes and associated with cerebrovascular disease and falls; cognitive impairment is also associated with cerebrovascular disease and the number of falls. LCA indicates that respondents cluster into a variety of health profiles with a consistent pairing of hearing loss and depression. CONCLUSIONS: The results are largely consistent with associations reported in epidemiological studies that include age-related hearing loss. Of particular interest in this study is the LCA that suggested that all of the profiles associated with a high likelihood of hearing loss included a high risk of depression. The co-occurrence of these two factors highlights the need to identify and treat hearing loss in older adults, especially as part of the treatment plan for individuals with depressive symptoms.

A Mixed Methods Study of Hearing Loss, Communication, and Social Engagement in a Group Care Setting for Older Adults.

Purpose: The purpose of this study is to characterize the communication needs of older adults in group care environments and understand the factors that foster engaged communication. Method: This mixed methods study provides an in-depth analysis of communication and engagement for older adults at two Program for All-inclusive Care for the Elderly (PACE) sites. Seventy-two PACE participants (M age = 74 years) completed a hearing test, cognitive screener (MOST™), the Institute of Medicine (IOM) Measures of Social and Behavioral Determinants of Health Questionnaire, and the UCLA Loneliness Scale. Using maximum variation sampling based on hearing status and UCLA Loneliness scores, 19 participants were invited to do (and 11 participants completed) one-on-one semi-structured interviews. In addition, 35 staff members participated in 5 focus groups. Field observations were interspersed throughout the data collection period. Results: Results suggest that communication challenges such as hearing loss, cognitive decline, and social isolation are highly prevalent in this convenience sample. Sixty-seven percent have at least a mild hearing loss in the better hearing ear. Eighty-two percent scored in the "very" or "most isolated" range of the IOM Measures of Social and Behavioral Determinants of Health questionnaire. The mean score on the MOST™ cognitive screener was 17.6, which is below the dementia screening cutoff score of 18 points. A thematic analysis of the qualitative data suggests that the PACE programs support socialization and engagement. A conceptual framework was developed by integrating quantitative and qualitative findings to recognize what contributes to meaningful interactions or engaged communication. Conclusion: Identifying communication challenges can enhance the benefits individuals can experience at care facilities and lessen the burden of the staff members trying to provide safe and effective care. In order to maximize the potential benefit of attending group-based day centers, the communication challenges and motivations of older adults need to be addressed.

A Holistic Approach to Addressing Post-Fitting Needs in the Short and Long Term for New Hearing Aid Users.

Helping your client adjust to being a hearing aid (HA) user and learn to manage their hearing challenges requires a combination of technical skill and psychosocial counseling in the short- and long-term periods. A key aspect of providing support in this time period is to keep the door open for psycho-social-emotional counseling that is often necessary even when the HA user was motivated to make this change, and even when, objectively, they seem to be fit successfully. Another key aspect is not to assume that once they have checked off all the HA fitting boxes, you are done. Over the long term, the user will experience changes in their own hearing abilities and in their life circumstances that will require on-going support to adapt to new communication needs. Approaching the post-fitting period from a person-/family-centered perspective and using a holistic approach to consider how this treatment fits into the HA user's broader life will result in the most success for that person.

Objective and Subjective Benefit of Direct-to-Consumer Hearing Devices in Middle-Aged Adults.

PURPOSE: The purpose of this project was to assess subjective and objective benefit provided by several direct-to-consumer hearing devices for middle-aged adults. The primary goal of this study was to determine the extent to which this type of device can yield benefit when users are listening in a range of acoustic conditions, rather than to compare benefit among devices. METHOD: Participants (M age = 58 years, n = 40) completed a speech perception task with and without one of four direct-to-consumer devices. Stimuli were presented with three types of maskers (steady-state noise, modulated noise, and competing talkers) at two different signal-to-noise ratios and two target levels. Participants also rated the effort required to complete the task with and without the devices and completed a short questionnaire about device comfort and perceived effectiveness. RESULTS: The amount of objective benefit (in terms of speech recognition accuracy) varied among the four products, with two of the four devices yielding statistically significant benefit with medium-to-large effect sizes. Reduction in self-rated listening effort was noted from the use of all four devices, with a moderate effect size. Degree of hearing loss (4-frequency pure-tone average) was not significantly associated with the amount of either subjective or objective benefit. Responses to the posttask questionnaire indicated that many of the participants would be willing to use these or similar devices in the "real world." CONCLUSIONS: Our findings support the concept that direct-to-consumer hearing devices have the potential to improve objective and/or subjective speech recognition in middle-aged adults, at least when fit to prescriptive targets. Benefit from these devices was not related to degree of hearing loss in this sample of participants.

Examining a Fatigue Management Model in Older Individuals.

PURPOSE: The aim of this study was to examine a fatigue model for older individuals based on the theory of unpleasant symptoms. RESEARCH DESIGN: The research design used was a secondary data analysis of the "Patient-Reported Outcomes Measurement Information System Profiles-Health Utilities Index" data set. METHODS: Multiple regression analysis and path analyses were used to examine hypothesized model paths. RESULTS: A number of comorbidities, pain, sleep, depression, anxiety, education, and sensory impairment were significant predictors of fatigue. Higher fatigue scores predicted lower physical, social, and cognitive performances, as well as worse perceived health and quality of life (QOL). In addition, the identified fatigue outcomes mediated the relationship between fatigue and QOL. CONCLUSIONS: Future research should be directed toward exploring other risk factors of fatigue and examining feedback loops depicted in the theory of unpleasant symptoms. CLINICAL RELEVANCE TO THE PRACTICE OF REHABILITATION NURSING: Rehabilitation nurses should closely monitor and manage the identified fatigue-influencing factors to improve older individuals' performance, perceived health, and QOL.

Listening in 2020: A Survey of Adults' Experiences With Pandemic-Related Disruptions.

PURPOSE: The COVID-19 pandemic has introduced lifestyle changes that may negatively impact communication, including the pervasive use of face masks and videoconferencing technology. Here, we examine the effects of age and self-rated hearing on subjective measures of speech understanding via a survey accessed by adults residing in the United States. METHOD: Responses to an online survey were obtained from adults (21 years of age and older) during the summer and fall of 2020. The survey included questions about hearing and speech understanding in a variety of scenarios and different listening conditions, including when communicating with people using face masks in quiet and noisy environments and when using videoconferencing. RESULTS: Data from 1,703 surveys were analyzed. In general, the use of face masks led to the perception of poorer speech understanding and greater need for concentration, especially in noisy environments. When responses from all participants were considered, poorer self-rated communication ability was noted as age increased. However, among people who categorized their overall hearing as "Excellent" or "Good," younger adults rated their speech understanding ability in noisy situations as poorer than middle-age or older adults. Among people who rated their overall hearing as "Fair" or "Poor," middle-age adults indicated having more difficulty communicating with people using face masks, as compared with older adults. Examination of open-ended responses suggested that the strategies individuals use when communicating with people wearing face masks vary by age and self-rated hearing. Notably, middle-age and older adults were more likely to report using strategies that could put them at risk (e.g., asking others to remove their face masks). CONCLUSIONS: Even younger adults with self-perceived good hearing are not immune to communication challenges brought about by face masks. Among individuals with similar degrees of self-rated hearing, the expected increase in communication difficulty with age was not noted among our respondents. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.16528431.

Speech Understanding in Modulated Noise and Speech Maskers as a Function of Cognitive Status in Older Adults.

Objectives The purpose of this study was to investigate the impact of different types of maskers on speech understanding as a function of cognitive status in older adults. The hypothesis tested was that individuals with a diagnosis of mild cognitive impairment (MCI) or mild dementia would perform like their age- and hearing status-matched control counterparts in modulated noise but would perform more poorly in the presence of competing speech. Design Participants (n = 39; age range: 55-77 years old) performed a speech-in-noise task and completed two cognitive screening tests and a measure of working memory. Sentences were presented in the presence of two types of maskers (i.e., speech envelope-modulated noise and two-talker, same-sex competing speech). Two analyses were undertaken: (a) a between-groups comparison of individuals diagnosed with MCI/dementia, individuals who failed both cognitive screeners (possible MCI), and age- and hearing status-matched neurologically healthy control individuals and (b) a mixed-model analysis of variance of speech perception performance as a function of working memory capacity. Results The between-groups comparison yielded significant group differences for speech understanding in both masking conditions, with the MCI/dementia group performing more poorly than the neurologically healthy controls and possible MCI groups. A single measure of working memory (Size Comparison Span [SICSPAN]) was correlated with performance on the speech perception task in the competing speech conditions. Conclusions Adults with a diagnosis of MCI or mild dementia performed more poorly on a speech perception task than their age- and hearing status-matched control counterparts in the presence of both maskers, with larger group mean differences when the target speech was presented in a two-talker masker. This suggests increased difficulty understanding speech in the presence of distracting backgrounds for people with MCI/dementia. Future studies should consider how to target this potentially vulnerable population as they may be experiencing increased difficulty communicating in challenging environments.

The Combined Burden of Hearing Loss and Cognitive Impairment in a Group Care Setting for Older Adults.

Purpose The purpose of the current study is to better characterize the medical and social health characteristics of older adults in a long-term group care setting and consider the impact of the dual burden of hearing loss and cognitive impairment. Method This descriptive analysis of a convenience sample of 160 adults (M age = 74 years, age range: 59.8-99.7) participating in Program for All-inclusive Care for the Elderly programs in Massachusetts and Rhode Island included data from hearing testing, questionnaires, and medical chart review. Using descriptive statistics, groups are compared across a range of demographic and health variables on the categorical bases of hearing loss and cognitive status. Results Results suggest that hearing loss and cognitive impairment are highly prevalent among this sample of older adults. Forty-three percent of this sample has at least a mild hearing loss in the better hearing ear in addition to cognitive impairment. Descriptive analyses across demographic and health variables suggest there are few differences between those with and without cognitive impairment when compared within degree of hearing loss categories in this convenience sample. Across all participants, there was a high prevalence of other chronic conditions, most notably diabetes (59%), hypertension (90%), cardiovascular disease (80%), and depression (67%). Conclusions In this sample, there were not significant differences on demographic and health variables between the cognitive impairment groups when considered within their degree of hearing loss; however, the prevalence of the dual burden of hearing loss and cognitive impairment in this sample is high. Clinicians serving older adults, especially those accessing group care services, should be cognizant of the high burden of multiple chronic conditions and plan care that can be integrated into a comprehensive approach.

Association of Hearing Loss With Neuropsychiatric Symptoms in Older Adults With Cognitive Impairment.

Neuropsychiatric symptoms (NPS) in persons with dementia (PWD) are common and can lead to poor outcomes, such as institutionalization and mortality, and may be exacerbated by sensory loss. Hearing loss is also highly prevalent among older adults, including PWD. OBJECTIVE: This study investigated the association between hearing loss and NPS among community- dwelling patients from a tertiary memory care center. DESIGN, SETTING, AND PARTICIPANTS: Participants of this cross-sectional study were patients followed at the Johns Hopkins Memory and Alzheimer's Treatment Center who underwent audiometric testing during routine clinical practice between October 2014 and January 2017. OUTCOME MEASUREMENTS: Included measures were scores on the Neuropsychiatric Inventory-Questionnaire and the Cornell Scale for Depression in Dementia. RESULTS: Participants (n = 101) were on average 76 years old, mostly female and white, and had a mean Mini-Mental State Examination score of 23. We observed a positive association between audiometric hearing loss and the number of NPS (b = 0.7 per 10 dB; 95% confidence interval [CI]: 0.2, 1.1; t = 2.86; p = 0.01; df = 85), NPS severity (b = 1.3 per 10 dB; 95% CI: 0.4, 2.5; t = 2.13; p = 0.04; df = 80), and depressive symptom severity (b = 1.5 per 10 dB; 95% CI: 0.4, 2.5; t = 2.83; p = 0.01; df = 89) after adjustment for demographic and clinical characteristics. Additionally, the use of hearing aids was inversely associated with the number of NPS (b = -2.09; 95% CI -3.44, -0.75; t = -3.10; p = 0.003; df = 85), NPS severity (b = -3.82; 95% CI -7.19, -0.45; t = -2.26; p = 0.03; df = 80), and depressive symptom severity (b = -2.94; 95% CI: -5.93, 0.06; t = 1.70; p = 0.05; df = 89). CONCLUSION: Among patients at a memory clinic, increasing severity of hearing loss was associated with a greater number of NPS, more severe NPS, and more severe depressive symptoms, while hearing aid use was associated with fewer NPS, lower severity, and less severe depressive symptoms. Identifying and addressing hearing loss may be a promising, low-risk, non-pharmacological intervention in preventing and treating NPS.

Relationship Between Domain-Specific Cognitive Function and Speech-in-Noise Performance in Older Adults: The Atherosclerosis Risk in Communities Hearing Pilot Study.

Purpose The purpose of this study was to investigate associations between performance on a clinical speech-in-noise measure with a comprehensive neurocognitive battery of tests. Method A group of older adults (N = 250, M age = 77 years, age range: 67.3-89.1 years) enrolled in the Atherosclerosis Risk in Communities Neurocognitive Study took part in the hearing pilot study (2013) that included testing for audiometric thresholds and speech-in-noise performance (Quick Speech-in-Noise Test; Killion, Niquette, Gudmundsen, Revit, & Banerjee, 2004). This research study analyzed the associations between domain-specific cognitive function and speech-in-noise performance after adjusting for hearing thresholds and other demographic and cardiovascular factors. Results Multivariable-adjusted associations were found between all cognitive domains and speech-in-noise performance in the full sample, but the observed associations varied when participants with varying levels of moderate to moderately severe hearing loss were excluded from the analysis. Conclusions The findings are discussed in terms considering the cognitive status of older adults in relation to their speech-in-noise performance during audiological evaluation and implications for aural rehabilitation.

Cultural Adaptation of a Community-Based Hearing Health Intervention for Korean American Older Adults with Hearing Loss.

Although hearing loss is known to be associated with many adverse health outcomes in older adults, current hearing healthcare remains expensive and inaccessible to most ethnic minorities in the US. We aim to adapt an affordable, community-based hearing intervention to older Korean Americans (KAs), describe the cultural adaption process, and report pilot trial outcomes. We undertook the first four stages of Barrera & Castro's cultural adaptation framework: information gathering, preliminary adaptation design, adaptation test, and adaptation refinement in 15 older KAs with hearing loss and 15 of their communication partners. We developed a culturally adapted intervention consisting of provision of an affordable listening device and aural rehabilitative training. Six weeks post-intervention, participants' mean hearing handicap score (range: 0-40) reduced from 15.7 to 6.4. Communication partners demonstrated improved social-emotional function. Post-intervention focus group revealed increased hearing benefit, confidence in hearing health navigation, and awareness in hearing health among study participants. The adapted intervention was well-accepted and feasible among older KAs. This study is the first to report the cultural adaptation process of a hearing care model into older KAs and its methodology may be applied to other minority groups.

Perceptual sensitivity to, and electrophysiological encoding of, a complex periodic signal: effects of age.

Objective: The purpose of this study was to investigate perceptual and electrophysiological encoding of complex periodic signals as a function of age. Design: Two groups of adults completed three listening tasks: a behavioural task of detection of a mistuned harmonic component in a complex tone, an electrophysiological measure of speech-evoked auditory brainstem response (sABR), and a speech-in-noise measure. Between group comparisons were undertaken for each task as well as pairwise correlation analyses for all tasks. Study sample: One group of younger adults (n = 20) and one group of older adults (n = 20) participated. All listeners had relatively normal audiometric thresholds (≤20 dB HL) from 250-4000 Hz. Results: Younger adults had better results than the older adults on all three tasks: sensitivity for detecting a mistuned harmonic, spectral encoding for sABR, and release from masking for the speech-in-noise test. There were no significant correlations between measures when evaluating the older adults in isolation. Conclusions: The results are consistent with the body of literature that demonstrates reduced temporal processing abilities for older adults. The combined method approach undertaken in this investigation did not result in correlations between the perceptual and electrophysiological measures of temporal processing.

Age-Related Hearing Loss and the Listening Environment: Communication Challenges in a Group Care Setting for Older Adults.

Ensuring that older adults in long-term care settings can effectively communicate is important. The goal of this study was to characterize key modifiable factors that could affect verbal communication in an adult day care setting, namely prevalence of audiometric hearing loss and the acoustic characteristics in the activity hall. The prevalence of age-related hearing loss among participants (n=51) was 71%, although only 15% of enrollees at the group care setting (n=21 of 140) used amplification. The noise and reverberation characteristics of the activity hall revealed signal-to-noise ratios of -3.1 decibels (dB) and -2.4 dB during morning activity and lunch, respectively, which are poorer than the recommended levels for understanding speech in background noise. Older adults attending adult day services are likely to spend the day in a room with acoustics that are too challenging to understand speech clearly. Opportunities to improve listening environments in group care settings for older adults are discussed.

Hearing Loss Treatment in Older Adults With Cognitive Impairment: A Systematic Review.

Purpose: The purpose of this systematic review was to assess studies of treating hearing loss in older adults with cognitive impairment. Of interest to this review is identifying clinical adaptations that may be used to tailor hearing loss treatment to older adults with cognitive impairment in order to better serve this vulnerable population. Method: A systematic search with controlled vocabulary and key word terms was applied to PubMed, the Cochrane Library, Embase, CINAHL, and PsycINFO. Search concepts included terms related to hearing loss and cognitive impairment. The overall search resulted in 4,945 unique references, 50 of which were eligible for full-text review and 13 of which were included in the final review. Included manuscripts were categorized according to the American Speech-Language-Hearing Association's levels of evidence and the National Institutes of Health Quality Assessment Tools. Results: Only 1 study implemented a randomized controlled trial design to assess cognitive function and behavioral symptoms after treatment with hearing aids. Other quasiexperimental studies evaluated dementia-related symptoms and/or auditory function after treating hearing loss in pre/post research designs. Finally, evidence from case studies suggested that hearing loss treatment is feasible, reduces stressful communication for caregivers, and improves dementia-related behavior problems. Conclusion: Based on the systematic review, evidence suggests that treating hearing loss in persons with cognitive impairment can have benefits to communication and quality of life. Because of the quasi- and nonexperimental nature of most of the evidence found in this review, further studies are necessary to understand the effect of treatment in the context of a variable and progressive disease.

Dementia and Hearing Loss: Interrelationships and Treatment Considerations.

Hearing loss is common among typically aging older adults and those with dementia. In recent years, there has been a renewed interest in the relationship between hearing and cognition among older adults, and in hearing loss as a modifiable risk factor for dementia. However, relatively less attention has been focused on the management of hearing loss among individuals with dementia and the key roles of speech-language pathologists and audiologists in providing such care. In this article, the authors review the literature on hearing loss and dementia, and analyze the research evidence for treatment of hearing loss in the context of major neurocognitive disorders, such as Alzheimer's disease. This article provides an up-to-date review of research evidence for hearing interventions, as well as recommendations for speech-language pathologists and audiologists to work together to ensure access to hearing health care and increased opportunities for meaningful life engagement for people with dementia and hearing loss.

Understanding Hearing Loss and Barriers to Hearing Health Care Among Korean American Older Adults: A Focus Group Study.

Hearing loss is associated with an accelerated decline in social, cognitive, and physical functioning among older adults. However, little is known about its impact and barriers to hearing health care in any ethnic minorities. The aim of this study was to explore experiences related to hearing loss and barriers to hearing health care among older Korean Americans (KAs). We conducted four focus groups with 19 older KAs with hearing loss and four communication partners. Qualitative content analysis revealed four themes: (a) impact of hearing loss, (b) self-perception of hearing loss, (c) coping strategies for hearing loss, and (d) barriers to hearing health care (price, language, lack of collaborative communications, perceptions about hearing aids, and lack of knowledge). Older KAs were significantly impacted by hearing loss but tended not to seek care due to multiple factors. Culturally tailored hearing interventions are urgently needed to promote hearing health in the KA community.

Relating Sensory, Cognitive, and Neural Factors to Older Persons' Perceptions about Happiness: An Exploratory Study.

Despite increased rates of disease, disability, and social losses with aging, seniors consistently report higher levels of subjective well-being (SWB), a construct closely related to happiness, than younger adults. In this exploratory study, we utilized an available dataset to investigate how aspects of health commonly deteriorating with age, including sensory (i.e., vision and hearing) and cognitive status, relate to variability in self-described contributors to happiness. Community-dwelling seniors (n = 114) responded to a single-item prompt: "name things that make people happy." 1731 responses were categorized into 13 domains of SWB via structured content analysis. Sensory health and cognition were assessed by Snellen visual acuity, pure-tone audiometry, and in-person administration of the Brief Test of Adult Cognition by Telephone (BTACT) battery. A subset of eligible participants (n = 57) underwent functional magnetic resonance imaging (fMRI) to assess resting state functional connectivity (FC) within a previously described dopaminergic network associated with reward processing. SWB response patterns were relatively stable across gender, sensory status, and cognitive performance with few exceptions. For example, hearing-impaired participants listed fewer determinants of SWB (13.59 vs. 17.16; p < 0.001) and were less likely to name things in the "special events" category. Participants with a higher proportion of responses in the "accomplishments" domain (e.g., winning, getting good grades) demonstrated increased FC between the ventral tegmental area and nucleus accumbens, regions implicated in reward and motivated behavior. While the framework for determinants of happiness among seniors was largely stable across the factors assessed here, our findings suggest that subtle changes in this construct may be linked to sensory loss. The possibility that perceptions about determinants of happiness might relate to differences in intrinsic connectivity within reward-related brain networks also warrants further investigation.

Pilot Electroacoustic Analyses of a Sample of Direct-to-Consumer Amplification Products.

OBJECTIVE: Recent national initiatives from the White House and Institute of Medicine have focused on strategies to increase the accessibility and affordability of hearing loss treatment given the average cost of $4700 for bilateral hearing aids. More affordable direct-to-consumer hearing technologies are increasingly gaining recognition, but the performance of these devices has been poorly studied. We investigated the technical and electroacoustic capabilities of several direct-to-consumer hearing devices to inform otolaryngologists who may be asked by patients to comment on these devices. PATIENTS/INTERVENTION: Nine direct-to-consumer hearing devices ranging in retail cost from $144.99 to $395.00 and one direct-to-consumer hearing device with a retail cost of $30.00. MAIN OUTCOME MEASURE: Electroacoustic results and simulated real-ear measurements. Main electroacoustic measures are frequency response, equivalent input noise, total harmonic distortion, and maximum output sound pressure level at 90 dB. RESULTS: Five devices met all four electroacoustic tolerances presented in this study, two devices met three tolerances, one device met two tolerances, one device met one tolerance, and one device did not meet any tolerances. Nine devices were able to approximate five of nine National Acoustics Laboratories (NAL) targets within 10 dB while only three devices were able to approximate five of nine NAL targets within a more stringent 5 dB. CONCLUSION: While there is substantial heterogeneity among the selection of devices, certain direct-to-consumer hearing devices may be able to provide appropriate amplification to persons with mild-to-moderate hearing loss and serve as alternatives for hearing aids in specific cases.