The National Council on Aging (NCO) says hearing loss affects nearly 20 million Americans aged 45 and older, yet most of those people don't use hearing aids. Either they're embarrassed about being perceived as handicapped or they think it makes them look old. Insurance seldom covers the cost of hearing aids, and people who do get them complain about inconsistent sound quality and feedback. They argue that if the people around them would just speak up, they wouldn't need a hearing aid, and everything would be fine.

Well, it won't. A recent NCO survey found those with untreated hearing loss are much more likely to be depressed, anxious and even paranoid than those who use hearing aids. Only 32 percent of those with untreated hearing problems participate in regular social activities, compared to 42 percent of hearing-aid wearers.

That's too bad, says Dr. Roger Shea of the Shea Enterology Clinic here in Sarasota, because innovations are making hearing aids better than ever. "Digital aids can provide excellent sound amplification with more clarity and less distortion," he says. "Directional microphones can target noise and keep it in the background." Some aids now disappear into the ear canal, making them invisible and eliminating nuisance feedback. Moreover, considering the benefits they offer, hearing aids are not outrageously expensive. They range from $500 for the most basic to $3,000 or more for more sophisticated versions. The type of device a person needs depends on the amount of hearing loss and its cause.

But getting people to use them, or even to get tested if they suspect hearing loss, remains problematic, says David Myers, a Michigan psychologist who has authored a book about his own experiences: "A Quiet World: Living with Hearing Loss." Myers' hearing loss is congenital (both his mother and grandmother lost their hearing), but Shea says the majority of adults suffer from something called sensori-neural loss. While infection, trauma or the use of certain drugs can cause this, it is also a common result of aging. "After years of listening to all kinds of noise, sound pressure simply starts to wear (our ears) down," says Shea.

The process is so gradual that many people avoid seeking help. "If our hearing loss occurred abruptly from one moment or day to the next, we'd be stunned," says Myers. "We'd visit a physician or audiologist pronto." Instead, people attribute the insidious changes to aging and their own natural awareness that hearing varies with situations.

Even if people understand that they can't hear as well as they once did, they may not understand how profoundly this affects all aspects of their lives. What Myers missed most, he says, is not sound, but understanding. Many hearing-impaired people can still "hear" sound, but they have lost the ability to distinguish what is being said. Myers says conversation in large groups can be so indecipherable that hearing people may as well be speaking another language. Being with others when jokes are told can be excruciating. "Everyone laughs appropriately, and I feel left out of what they are saying," he says.

Sign language can be just as confusing. Like English, it contains its own vernacular and slang, which can be tough for older adults to master.

In the end, those who refuse to wear aids struggle with the perception that they no longer belong to either the hearing world or the deaf. Instead, they exist in a sort of nether world of languages, between those who sign and read lips and those who speak. Breaking out of this insular existence is not as simple as buying an aid, however. It often requires exhaustive trial-and-error to determine which hearing aid works and how to use it most effectively.

Myers says that for many the temptation to give up listening can be overwhelming, because they feel "it's just not worth the effort and energy required." Fortunately, a host of medical breakthroughs are making it easier to treat adult hearing loss.

Directional and Voice-Activated Hearing Aids. The most sophisticated hearing aids do more than amplify sound. Digital aids can be tuned to reduce background noise, and their users can learn to tune them to directional sound. For example, at a dinner party, a user can tune her aid to listen to the person in front of her and avoid distraction from conversation behind or beside her. Myers says it works like a charm, but it takes practice.

Taking this one step further, the Food and Drug Administration has just authorized the first ever voice-activated hearing aid. The Adapto' uses a computer chip that detects human speech. When no speech is detected, it operates in a "listening mode" like existing hearing aids. The second a person starts talking, it automatically switches to a mode that filters out all ambient noise and gives priority to human speech.

Cochlear implants. Cochlear implants as we know them today have existed for about 15 years, but this ground-breaking science got its biggest exposure last year when radio talk show host Rush Limbaugh uttered the sentence heard round the world: "I am, for all practical purposes, deaf." Over the next several months he mesmerized listeners with his odyssey of losing, then treating, and ultimately, regaining his hearing through an implant. Admired for his candor and determination to persevere in a medium defined by communication, Limbaugh became the poster child for adults everywhere who are losing their hearing to age or disease. A portion of his Web site has become a virtual textbook on cochlear implant technology.

Unlike traditional hearing aids, cochlear implants are covered under most insurance policies. That's good, since the entire process can cost as much as $40,000. While traditional hearing aids merely amplify sound, implants work by stimulating the auditory nerve. With most models, a tiny external microphone is held against the head by a magnetic receiver coil that is inserted under the skin behind the ear. A wire connects the microphone to a small speech processor that can be worn in a pocket or clipped to a belt. The processor converts sounds into electrical signals that travel to the receiver coil, and electrodes implanted in the inner ear send those signals to the brain.

Cochlear implants are for the profoundly deaf, and their effectiveness can vary. They seem to be most effective for people who lost their hearing after learning how to speak. The surgery lasts from two to three hours, and patients must wait four to six weeks before their implant can be programmed to transmit sound.

This technology is advancing at a staggering pace. A Canadian firm has created an implant called "the Epic" that has no external parts at all. The entire implant operates from within the middle ear by using a microphone placed in the ear canal. Its developers say it can fit into a newborn's ear. It's now being tested on human subjects.

Implantable hearing aids. Dr. Herbert Silverstein of the Florida Ear and Sinus Center in Sarasota says new implantable aids offer an excellent alternative for people with moderate hearing loss. "Their sound quality is much better than current aids," he says. "There's no feedback and no blocking of the ear canal."

Last year, the Food and Drug Administration approved two such devices. Both work by converting sound into mechanical vibrations that stimulate bones in the middle ear.

The first is the Vibrant Soundbridge, by Symphonix. With this device, a microphone held against the head transmits sound to a receiver that has been implanted under skin behind the ear. A wire leads from the receiver to a small electromagnet implanted in the middle ear.

The surgery is usually performed on an outpatient basis. Just as in cochlear implants, patients must wait several weeks before the Soundbridge can be programmed to receive sound, but during that time, they can still use their other hearing aids.

In studies conducted by the manufacturer, nearly 90 percent of patients with a Soundbridge implant reported better hearing. They also reported significantly reduced feedback, which is a common complaint with older aids.

The Soundbridge has one major drawback: It costs $16,000 and is not covered by most insurance companies. Silverstein hopes that will change soon. Right now, he advises clients that this is considered a cosmetic procedure and they are responsible for the cost.

A second implantable aid, the Direct System by Soundtec, won fast-track approval from the FDA last September and is even simpler in design. With this implant, doctors pass a tiny magnet through a flap cut in the eardrum. A sound processor worn in the ear canal or behind the ear transmits sound to the magnet, which vibrates the bones of the middle ear in the same fashion as the Soundbridge. Surgery takes place in the doctor's office and lasts a mere 30 minutes. This aid costs about $5,000, about the same as existing digital aids.

Assisted listening devices. People who had shunned church services, movie theaters and musical performances because they couldn't hear the words or lyrics are rushing back down the aisles thanks to two innovative assisted listening devices.

In "looping," wires connect microphones on stages or podiums to an amplifier that circulates their sound throughout a room. Hearing aids equipped with a "telephone switch" or a "telecoil" device can pick up that sound clearly and without excessive background noise.

Looping systems are already in place in many public facilities, from theaters to churches. They also can be installed in private homes or automobiles. Boston's Logan Airport has installed them so hard-of-hearing travelers can receive transmissions of public address announcements and flight information. They're also being installed in taxi cabs and tour buses in Boston and Washington, D.C.

Myers says his "looped" TV room at home puts the speakers "right in my ears." He's leading an initiative to make his home town of Holland, Michigan, a model "looped community," where all the churches, school auditoriums, courts, theaters, even drive-up windows at banks and fast food places, are looped to broadcast sound via telecoil-equipped hearing aids.

Because looping systems operate on FM radio frequencies and are vulnerable to outside interference, many cultural venues are turning to infrared broadcasting (IB), a system that transmits sound via invisible infrared light signals to a portable headset worn by the listener. It doesn't require a hearing aid, so it's ideal for people with low to moderate hearing loss.

The only problem with either system is that so few people know they're available. According to Frank Stocco, president of the Sarasota Chapter of Self-Help for Hard of Hearing People (SHHH), many local churches are looped. The Asolo, Hollywood 20 and Players Theater are just a few of the venues here in Sarasota equipped with infrared amplification systems.

Given all these opportunities to continue participating in the world around us, how can you convince someone you love-or even yourself-to seek help? Myers says to start by getting your foot in the door: "People who agree with a small request often later become more willing to comply with a bigger one." Ask the person if they'll at least consider seeking help, then offer to make a hearing test appointment for them.

Myers' wife Carol finally convinced him to seek help by painstakingly pointing out every hearing omission. "It was my version of 'tough love,'" she says. Myers says people assume they hear the world as it really is. "It's only when I find myself not hearing a musical instrument that the soloist seems to be playing that I am forced to stop and realize others are experiencing a different world."

When all else fails, Myers suggests reminding the person that others don't care whether we have visible prosthesis for our ears. "Moreover, our hearing loss may, unknown to us, be more conspicuous than any hearing aid." He cites a recent study at Cornell University that asked students to wear Barry Manilow T-shirts into a classroom. The self-conscious students guessed at least half of their peers would notice the shirts. "In reality, only 23 percent did," he says. "Whether we're wearing mismatched clothes or a hearing aid, relax. Fewer people notice or care than we imagine."

An estimated 30,000 people in Sarasota County are hearing-impaired. If you need support dealing with hearing loss, contact the Sarasota Chapter of Self-Help for Hard of Hearing People (SHHH). They meet the third Wednesday of every month at Selby Library. They also bring open-captioned first-run films to the Hollywood 20 cinema. Visit their Web site at www.shhhsarasota.org.

Other valuable resources:

"A Quiet World: Living with Hearing Loss," by David Myers.

The Alexander Graham Bell Association for the Deaf and Hard of Hearing, www.agbell.org.