“Even if given the opportunity of saying, ‘These hearing aids are free, just take these, please use them,’ a proportion of them will not,” he said, “mainly due to the stigma around hearing loss and the unaesthetic appeal of many options on the market.”
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December 2024He said the use of OTC hearing aids, including the AirPods, should not come at the expense of hearing evaluations that could detect a deeper medical issue—such as sensorineural hearing loss due to a tumor or neurological disease—or a simple matter that doesn’t require any hearing aid at all. Also, he said, amplification alone does not necessarily equate to better hearing, as some people with hearing loss have very poor speech discrimination, so just being louder doesn’t mean being clearer.
“We have many people come in, and they’re complaining about hearing loss, and they have a wax impaction,” he said. “And they’ve bought over-the-counter hearing aids. And like, no, you just need your wax cleaned out. If you have some element of hearing loss that you want to treat with an over-the-counter solution, I’m okay with that. Make sure you don’t have, A, something really easy and simple to fix and, B, you don’t have something bad.”
If AirPods are going to have the deep impact that is hoped for, there will need to be a culture change in how earphones are perceived socially by others.
After Dr. Chandrasekhar’s initial excitement over Apple’s announcement, she said, she realized that “when I see people with AirPods in their ears, I assume they are not hearing or listening to me, but to whatever they are streaming. My reaction will have to change!”
Dr. Golub said it will require a shift in “what it means to the outside world when you’re wearing something in your ear.” Now, walking around with white AirPods is a telltale sign of seclusion, he said.
“How do people know whether you are in the talk-to-me hearing aid mode, or the don’t-talk-to-me-I’m-listening-to-music mode? You’ll have no idea. It’ll be very confusing.”
Dr. Gantwerker said the AirPods as hearing aids would be most valuable in settings in which it is most odd socially to be seen with them in your ears.
“Most of the time people have problems hearing in noise; it’s in busy environments,” he said. “And so what is going to be said if you’re sitting down in a busy environment and you have two AirPods in? That’s a little odd. It’s like being inside wearing sunglasses.”
Apple’s foray into the sleep apnea sphere brings another set of challenges—clinics and sleep centers potentially overrun by those who may get alerts but who don’t have serious apnea issues, Dr. Gantwerker said.
Because of the extensive resource and time burden of a sleep study—if users pursue one when alerted by their watch—the accuracy of Apple’s sleep apnea feature is crucial.
In a publication on its testing and validation, Apple reports that its accelerometer-based method was designed to detect hypopnea using the stricter 4% oxygen desaturation definition. It checks its breathing disturbances data every 30 days, and if there have been 10 or more sessions with breathing disturbances in those 30 days, users are alerted that they may have sleep apnea; otherwise, it’s silent. The design and testing of the feature was developed with data from more than 2,000 participants and more than 10,000 sleep nights, Apple says ( https://www.apple.com/health/pdf/sleepapnea/Sleep_Apnea_Notifications_on_Apple_Watch_September_2024.pdf).
The test was designed to err on the side of accuracy when a user receives an alert, at the expense of missing some apnea cases, the company says.
“The operating point on the ROC curve was intentionally chosen to favor specificity, understanding that operating point positions with high specificity have lower sensitivity. This choice supported the goal of minimizing the false positive risk, which is particularly important for a feature designed to repeatedly check for signs of possible sleep apnea over time (and in consideration of the cumulative false positive rate) while simultaneously maintaining an impactful true positive rate.”
For moderate to severe sleep apnea, Apple reported that the sensitivity rate was 66.6% and the specificity rate was 95.9%.
Dr. Gantwerker said that is “actually much better than I would think.”
But with only 2,500 sleep centers in the U.S., wait times of months for a sleep study in some parts of the country, and millions of people who wear an Apple Watch, the demand might be a major strain, he said. Cardiology colleagues have said they’ve seen an uptick in patients worried after ECG readings from their Apple Watch, he said, and a similar phenomenon could be seen with the apnea feature.
“We’re just going to have to figure out who among these folks who are screened positive are getting the actual sleep studies, because we don’t have the infrastructure to support it,” he said. If someone wants a continuous positive airway pressure (CPAP) machine, they need a sleep study for it to be covered by insurance, he said.
Robson Capasso, MD, a sleep surgery specialist and professor of otolaryngology–head and neck surgery at Stanford University in Redwood City, Calif., said those who are likely to benefit most from the sleep apnea feature of the Apple Watch are unlikely to have one.
“Who is the user of the Apple Watch?” he asked. “Usually, it’s an urban, younger, healthy person who has a lower likelihood of having moderate to severe sleep apnea, [rather] than an older, more obese, rural user.”
He worried that users might sometimes get an alert that is not indicative of a real medical issue.
“Sleep tests are very commonly positive, especially in adult males—and a broader clinical context is very important to recommend any therapies, as well as adequate follow-up.”
The Apple Watch’s ability to provide sleep metrics, he said, might help provide feedback on whether habit changes have moved sleep routines in the right direction.
Dr. Capasso said that it is important that the Apple Watch update not become yet another source of data that could increase the prevalence of orthosomnia—anxiety over sleep quality generated by sleep scores—which is something that “we are already seeing quite commonly in the clinic.” This phenomenon has been brought about by the explosion of sleep-tracking products—from rings to snoring tracker apps to other wearables without a well-designed consumer feedback interface.
“But I am sure the Apple team, who notoriously excel in design, knows about it,” he said.
“Sleep is counterintuitive,” Dr. Capasso said. “Some users of sleep technologies may go into perfectionist tasks in order to improve sleep scores, and it may actually worsen it as some start catastrophizing and overthinking about their sleep.”
“Sleep became very commercialized,” he said. “It is more Googled than ‘nutrition’ these days and, of course, there is a lot of entrepreneurial mindset around sleep.”
When someone has concerns about sleep, his first inclination is to suggest they adjust the timing and pre- and post-bedtime routines and habits.
“Please stop checking your emails, doing work-related activities, or playing video games just before you go to bed,” he said. “You’re not going to feel refreshed tomorrow.”
Thomas R. Collins is a freelance medical writer based in Florida.