Age Specific Practice – CPD: Practice Effectively
The purpose of this course is to prepare the healthcare professional to incorporate differences between age groups in their practice.
After completing this course, the participant will be able to:
- Discuss the developmental issues and health needs of, and preventive care for infants and children
- Discuss developmental issues and health needs of, and preventive care for adolescents
- Discuss developmental issues and health needs of, and preventive care for adults
- Discuss developmental issues and health needs of, and preventive care for aging adults
There are significant physical and developmental differences between infants and children, adolescents, adults, and the aging adult. This module will discuss those differences and how they influence the healthcare needs of these specific populations. As compared to adulthood, the periods of infancy and childhood, adolescence, and old age are times of intense growth and development. Compared to adulthood, the health needs of these age groups will be discussed in greater depth and detail than those of adults, and the nutrition and medication issues of adults will not be covered.
Infants and Children: Ages 1 Month to 12 Years
The anatomy and physiology of an infant or a child differs from an adult’s in many ways other than height and weight, and clinical interventions must be applied with these factors in mind. Children have less pulmonary reserve than an adult and have a proportionally higher oxygen requirement. They can maintain central organ perfusion during significant fluid loss because of powerful peripheral vasoconstriction that shunts blood from the limbs to the central circulation. This leads to the cool, mottled extremities and decreased peripheral pulses which is characteristic of shock in children. Children have less ability to increase cardiac output by increasing cardiac contractility; they maintain cardiac output with tachycardia. Children are more susceptible than adults to heat loss because they have proportionally larger heads and a greater surface-area/body-mass ratio than adults.
The period of time between 1 month of age and 12 years of age is one of rapid change. Infants and children should be routinely assessed to determine if they are growing normally, and periodic evaluation of physical, emotional, and social development is one of the most important healthcare issues of this patient population. These assessments are performed by comparing the patient to developmental milestones, defined as abilities and behaviors that are considered to be normal for a specific age group. When a developmental milestone assessment is done the patient:
- Will meet the standard, and growth and development are considered to be normal.
- Fail to meet the standard, but the assessment parameter is not considered critically important or the patient’s development is otherwise normal. Each infant and child develop at her/his own pace; this situation may simply reflect that particular patient’s individual rate of growth and development.
- Fail to meet the standard and this failure is considered to be a warning sign of a serious problem with the patient’s growth and develop.
Several examples of developmental milestones and assessment are provided here (American Academy of Pediatrics, 2015; Centers for Disease Control and Prevention, 2015; Scudder, 2010) Notice that in infants and very, very young children cognitive and language abilities and hand/finger motor abilities are assessed but visual and perceptual abilities are not.
The Infant at 2 to 3 Months
In terms of movement and physical abilities, an infant 2 to 3 months of age should be able to raise his/her head while lying on the stomach; push up slightly with the arms while on the stomach; open and close the hands, and; hold on to and shake objects.
In terms of perceptual ability, an infant 2 to 3 months of age should be able to follow a moving object with her/his eyes, and respond to a voice and turn his/her head towards the direction of a sound.
In terms of social and emotional development, an infant 2 to 3 months of age will attempt to mimic facial expressions; begins to smile in response to people, and; facial expressions become more numerous and complex.
Warnings signs of a possible serious growth and development issue in this age group include, but are not limited to: failure to respond to loud noises or to voice; inability hold onto and move an object; failure to follow a moving object with the eyes, and; failing to smile at people.
The Child at 3 to 4 Years
Children from the ages of 3 to 4 should have the movement and physical abilities to easily move backward and forwards; walk unassisted up a flight of stairs one step at a time; pedal a tricycle, and; throw a ball overhand. Hand/finger motor abilities considered normal for this age group would be using scissors; drawing a person with 2 to 4 body parts, and; turning a door handle.
The social and emotional development behaviors that are considered normal for this age group would include expression of a wide range of emotions, and; expressing concern for others.
The cognitive and language abilities of the 3 to 4-year-old child should include an increasingly sophisticated sense of time; the ability to follow a short series of instructions; speaking sentences of 5 to 6 words, and; an ability to name familiar objects.
Warnings signs of a possible serious growth and development issue in this age group include, but are not limited to: poor hand and finger motor ability, e.g., cannot hold a crayon; cannot speak in sentences, and; does not interact with, or show interest in other children.
Infants and children should also be assessed for their elimination habits, sleep patterns, social activities, and sibling and parental relationships.
The assessment and examination process when applied to an infant or a child must be adapted to the behavioral, emotional, and intellectual development of the patient (Siegle, 2010; Lewis, 1999).
Infants and toddlers
Approach an infant or toddler in a calm, gentle and slow manner. Have the caregiver hold infant when doing an assessment or treatment if possible. If the child has to lie down, let the parent stay next to the child (Lewis, 1999). Use warm instruments and warm hands and allow the child to handle equipment such as an otoscope or stethoscope if this is safe; some children find this to be reassuring. Assess the respiratory rate and status when the infant is quiet. Explain to the caregiver that the child may cry when a procedure is begun, but that an infant makes no connection between the approaching stimulus and pain. With toddlers, try to make the assessment or treatment a game to reduce fear. Use your imagination and get the toddler involved (example would be using storybooks, dolls or puppets.) Provide reassurance during the assessment/procedure. Praise the child for doing well.
Preschoolers are very active and motor skills are improving. Mentally, they begin using symbols and improving their memory. They have vivid imaginations which may cause unseen fears. The preschooler is beginning to develop independence and is sensitive to other’s feelings.
Speak at the language level the child can understand. Before a procedure begins, explain to the child what is going to be done, using sensory terms when possible. Use games and imagination to gain the child’s cooperation. Allow the child to handle equipment if possible. Enlist the child’s help and allow him to express his feelings. Preschoolers need praise, rewards, and easy to understand rules.
School-Aged Children (6-12)
School-aged children grow slowly until puberty. Mentally they are active, eager learners who can understand cause and effect. Building self-esteem is an important task during this period. The school aged child is developing a greater sense of self, independence, and he wants to fit in with his peers. The school-aged child is beginning to make lifestyle choices, and may act with poor judgment. Peer pressure, alcohol, sex, drugs, and smoking need to be discussed with this age group.
Because of these issues, the school-aged child needs to be allowed to make decisions when feasible. Provide privacy during assessment or treatment and explain all procedures at the child’s level of understanding. Be prepared to listen and be honest. Tell the child how he/she can be involved in his own care, and have children assist you in their care, if possible. Reassure the child that they did nothing wrong. They need to know that the illness or injury is not a punishment.
Preventive Care and Health Screening: Infants and Children
Infants and children – and all age groups – should be vaccinated for protection against infectious diseases. Vaccination schedules for infants and children are different than those for other age groups, and current recommendations can be found on the Centers for Disease Control and Prevention (CDC) website (Centers for Disease Control and Prevention, 01/2015).
Health screening for infants and children should be universal and targeted; all infants and children should be screened for the presence of certain diseases, and specific individuals and populations should be screened for diseases they are likely to suffer from.
Examples: Infant universal screening for congenital hypothyroidism and phenylketonuria. (PKU is mandated in all 50 states and the District of Columbia.) Recommendations for screening infants and children for lead poisoning are typically generated by city and state agencies, and this screening is targeted for at-risk individuals and populations, e.g., infants and children who live in areas with a high concentration of houses built before 1950 or in areas in which it is known that a certain percentage of children have elevated blood leads levels.
Organizations such as the American Academy of Pediatrics (AAP), the CDC, and the U.S. Preventive Services Task Force have recommendations for both universal screening and targeted, population-specific screening (American Academy of Pediatrics, 2014; U.S. Preventive Services Task Force, 2014; Park, 2015). There are also city, school board, state, and federal mandates and regulations for screening. There is some disagreement among these sources regarding who should be screened, for what, and when. Table 2 lists the health screening recommendations that are considered mandatory. Unless noted otherwise, these should be done for each infant and child. The reader can refer to the aforementioned sources for the recommended intervals for these screenings.
Screening for lead poisoning should be done in accordance with state law or the local authorities as the risk factors for lead poisoning are highly specific to where the child lives and other social and demographic parameters (Kelly, 2014).
Nutrition and Eating
The nutrition and eating issues that are specific to infants and children are: caloric, macronutrient and micronutrient requirements; eating habits/patterns; food safety, and; food insecurity. Note: Macronutrients are carbohydrates, fats, proteins, and water. Micronutrients are minerals and vitamins, e.g., calcium and iron, vitamin A and vitamin C.
The caloric, macronutrient, and micronutrient requirements of infants and children will depend on age, gender, and activity level. These requirements are not significantly different from those of other age groups, but some specifics are important to know.
Infants and children do not have the caloric intake needs of other age groups. For example, a 2-year-old boy who is considered to be active needs approximately 1200 calories a day; a 16-year-old female who is sedentary will need approximately 1800 calories a day.
Children 3 years and younger have different macronutrient requirements. These children should take in more of their daily caloric intake from fat and less from protein, e.g., 5-20% from protein and 35-40% from fat. The recommendations for other age groups are, essentially, 10-35% protein and 20-35% (USDA/DHSS, 2010).
Fat and cholesterol intake should not be restricted in children younger than 2 years (Duryea, 2015). After age 2, the percentage of fat in the diet should be restricted to an age-specific percentage (USDA/DHHS, 2010). Infants and children up to 2 years should drink whole milk, not skim or 2%. Exceptions can be made on a case by case basis. Infants and children need fat for the development of the nervous system.
The daily recommended intake for micronutrients is age specific, but supplementation to ensure adequate intake of micronutrients is not needed if the infant/child gets a varied diet and sufficient exposure to the sunshine (Duryea, 2015; Bailey, Fulgoni, Keast, et al., 2012). Exceptions to this would be vitamin D supplementation for breastfeeding infants (Wagner, Greer, American Academy of Pediatrics, 2008) and children who are at risk for vitamin D deficiency due to their nutritional intake and/or lack of exposure to sunlight (Voortman, van den Hooven, Heijboer, et al., 2015). Premature infants and infants who are exclusively breastfed should be screened for vitamin D deficiency (Misra, 2015).
The daily recommended intake of micronutrients is age specific. A dietary reference intake calculator that can be used to determine age and gender-specific caloric intake need and macronutrient and micronutrient requirements is available at the U. S. Department of Agriculture (USDA).
Eating patterns and habits of infants and children are quite different than those of adolescents, adults, and the elderly. Infants and children need to eat quite frequently, up to 7 times a day or more, and frequent snacks are a necessity. Food disinterest and food fussiness are eating patterns that almost all children exhibit at some time.
Food safety for infants and children is concerned with choking hazards and food-borne infections. Choking can occur because infants and children may not have full dentition; may not have learned how to completely chew foods; can be easily distracted while eating, and; may be given foods of a certain size that cannot be chewed or are likely to be swallowed and aspirated such as peanuts, hard candies, and grapes.
Food-borne illnesses are a special concern of this age group because the immune system has not fully developed.
Food insecurity is defined as being without reliable access to sufficient amounts of nutritious food, and the USDA estimated in 2013 that 14.3% of American households were in a state of food insecurity (USDA, 2014). Food insecurity is not a problem specific to infants and children, but the potential effects of food insecurity are worse for this age group because of rapid growth and development at this stage of life.
Medication age-related issues for infants and children include: pharmacokinetics, medication errors, dosing, and administration.
Medications were traditionally not tested on children, and pediatricians had to (and often still do) prescribe doses and dosing schedules with information about the use of a drug in adults. The problem is infants and children are not simply smaller adults.
The absorption, distribution, metabolism, and excretion of drugs in this population can be quite different (Anderson, 2010; Anderson, Lynn, 2009; Benedetti, Whomsley, Baltes, 2005) and simply giving a two-year-old a dose based on his/her body weight is very often not safe or sensible.
Pharmacokinetics refers to the processes by which a drug is absorbed, distributed, metabolized, and excreted. These processes will in large part determine the actions and effectiveness of a drug and pharmacokinetics are influenced by the age of the patient.
- Drug absorption: Drug absorption from the gastrointestinal tract depends on gastric pH, the levels of bile and water in the gastrointestinal tract, intestinal transit time, the rate of gastric emptying, and the activity of drug-metabolizing enzymes and drug transporting proteins in the gastrointestinal tract. The gastric pH of infants and children (until age 3) is lower than that of adults and acid-labile antibiotics such as amoxicillin and penicillin will be more efficiently absorbed, resulting in much higher plasma levels (Funk, Brown, Abdel-Rahman, 2012; Benedetti, Baltes, 2003). Intestinal transit time is relatively shorter for infants and children, thus the absorption of sustained-release products would be expected to be decreased (Benedetti, Whomsley, Baltes, 2005).
- Distribution: A high percentage of an infant’s body weight is water and water-soluble drugs such as gentamycin will thus have a higher volume of distribution and decreased plasma concentration (Funk, Brown, Abdel-Rahman, 2012; Benedetti, Whomsley, Baltes, 2005). Drug distribution also depends on protein binding and protein binding of certain drugs , e.g., barbiturates and opioids, may be decreased in infants, leading to a higher volume of distribution and increased the effect of these drugs (Funk, Brown, Abdel-Rahman, 2012).
- Metabolism: Phase I and phase II drug metabolism can be quite different in infants and children when compared to adults, affecting drug clearance and clinical effects. Plasma clearance of carbamazepine depends on the activity of the cytochrome P-450 enzyme CYP3A4, and this enzyme is comparatively more active in children (Kearns, Abdel-Rahman, Alander, et al., 2003). Children may also metabolize drugs in a way that produces pharmacologically active drug metabolites, e.g., the production of caffeine when neonates receive theophylline (Benedetti, Whomsley, Canning, 2007), something that may be absent in adults.
- Excretion: The kidneys are an important pathway for drug excretion. Renal function changes and mature during the first few years of life (Kearns, Abdel-Rahman, Alander, et al., 2003), and renal function must be considered when using certain drugs such as tobramycin and vancomycin that are primarily eliminated by glomerular filtration (Funk, Brown, Abdel-Rhaman, 2012; Benedetti, Whomsley, Baltes, 2005).
The most obvious practical consideration for these differences in pharmacokinetics is dosage (Note: Dosage refers to the amount of each dose and the frequency with which it is given) and several examples are provided below (Lexi-Drugs, 2015; Pediatric and Neonatal Lexi-Drugs, 2015; Sherwin, Wead, Stocalkmann, et al., 2014; Zakova, Pong, Trope, et al., 2014; van den Anker, Allegaert, 2012; Anderson, 2010; Kearns, Abdel-Rahman, Alander, et al., 2003; Park, 1986; Bendayan, McKenzie, 1983).
- Aminoglycosides: Dosing aminoglycosides for the pediatric population must consider the larger volume of distribution and renal function, which can be quite different – and slower – in infants and children when compared to adults. Gentamicin is dosed in children at 2-2.5 mg/kg, IV, every 8 hours; the adult dose is 1-2.5 mg/kg, IV, every 8-12 hours.
- Carbamazepine: For children who are 2 years of age and older the dose of carbamazepine is comparatively higher than the adult dose because of differences in the activity of specific cytochtome P450 enzymes and protein binding. The initial pediatric dose is 10-20 mg/kg; the initial adult dose is 400 mg.
- Digoxin: The loading dose of digoxin for children up to age 24 months, for the treating of supraventricular arrhythmias, is 30-50 mcg/kg; the dose for adults for this purpose is 8-12 mcg/kg. The difference is accounted for by the higher volume of distribution and more rapid clearance of the drug in the pediatric population.
Medication errors are an important issue for infants and children. Infants and children are especially vulnerable to medication errors, particularly errors of dosing (Glanzmann, Frey, Meier, et al., 2015), and they seem to suffer disproportionately from adverse events from medication errors (Crouch, Caravati, Moltz, 2009). Many medications prescribed for infants and children are used as unlicensed or off-label, which creates obvious risks (Glanzmann, Frey, Meier, et al., 2015). Medications for this patient population are prescribed for each patient individually and the dosage is often based on body weight or body surface area. The amounts that are given to infants and children are also quite small and involve the use of decimal points, the latter presenting a risk for 10-fold or 100-fold errors (Crouch, Caravati, Moltz, 2009; Tzimenatos, Bond, Pediatric Therapeutic Error Study Group, 2009). The incidence of medication errors affecting infants and children is not known, but there is evidence that it is not uncommon. Basco et al. (2015) reported that 2.7% of opioid prescriptions for children 0-36 months were for amounts that were potentially harmful, the average excess amount was 48%, and the younger the child the higher the frequency of prescribing errors.
The best way to avoid treatment and medication errors with children is to keep an equipment-sizing/drug-dosing nomogram on hand. There are also computer programs available that provide pediatric medication dosing and equipment information by weight. A low-tech option is a length-based resuscitation aid, like the Broselow Tape. These aids translate a child’s length into an approximate weight. Appropriate medication doses and equipment sizes appear right on the tape (Salati, 2004).
Dosing can be challenging when prescribing medications for infants and children. As mentioned previously, many medications have not been tested on children and by necessity pediatric doses and dosing schedules are very often derived from information about adult dosing (Johnson, 2008). Drug doses for the pediatric population may be “scaled down” from adult doses by using the pediatric patient’s weight or the dose can be calculated using body surface area. The latter approach appears to be the most accurate (Johnson, 2008), but the method used will depend on the age of the child and the drug.
Medication administration is often traumatic for children. For infants, draw liquid medication into a plastic dropper or disposable syringe. After elevating the infant’s head and shoulders, slowly drop the medication on the middle of the tongue. You may need to depress the chin with the thumb to open the mouth. If a toddler will not drink their medication, you can place a syringe without a needle between the cheek and gum and slowly give the medication.
The small size and underdeveloped musculature of infants and young children increase the risk of hitting nerves and/or blood vessels with an intramuscular (IM) injection. Acceptable injections sites for infants and children are listed below (Siegle, 2010; Paediatric Nursing, 2007):
- Infants: The rectus femoris (anterior thigh, middle third), vastus lateralis (lateral thigh, middle third), or ventrogluteal. The gluteus maximus and deltoid muscles should be not used in this age group.
- Toddlers and school-age children: The posterogluteal can be used but remember that gluteal muscles begin to develop only after a child starts walking. The lateral and anterior aspects of the thigh are acceptable injection sites. The deltoid muscle can be used for older children with relatively developed deltoid muscles.
Safety Issues for Infants and Children
The primary safety issues of infancy and childhood are child abuse, accidents, and poisonings.
Child abuse incidence is difficult to ascertain, but the Centers for Disease Control and Prevention (CDC) noted that in 2012 state and local child protective services (CPS) were involved in 2.4 million cases of child abuse or neglect (CDC, Child Maltreatment). This number is considered to be a small fraction of the actual number of cases (Giardino, 2015), and Finkelhor et al. (2013) found a one-year incidence of 13.8% for child maltreatment, including neglect, physical abuse, sexual abuse, emotional abuse, and custodial interference (Finkelhor, Turner, Ormond, et al., 2013). Child abuse and neglect have significant negative consequences for the behavioral, developmental, and physical well-being of the child (Finkelhor, Turner, Ormond, et al., 2013) and the effects persist into adolescence and adulthood (Christian, et al., 2015).
Risk factors for child abuse and neglect are listed in Table 3 (Christian, et al., 2015; Boos, Endom, 2013.) Histories surrounding child injuries and specific types of injuries that are highly suggested or pathognomonic for child abuse are listed in Table 4. (Christian, et al., 2015).
Accidents and poisonings are two of the most common causes of death and injury in infants and children (CDC, 03/2015; AAPCC), so maintaining a “child-proof” environment and safe handling and storage of medications are crucial issues for the safety of infants and children.
Infants are likely to die from burns, falls, motor vehicle accidents, and suffocation; toddlers and pre-school children are likely to die from burns, drowning, falls, fires, motor vehicle accidents, poisonings, and suffocation; school-age children are likely to die from bicycle injuries, drowning, motor vehicle accidents, pedestrian accidents, and unintentional firearms injuries (CDC, 03/2015). Age-appropriate injury counseling (that include the parents and caretakers) is also recommended by the AAP at every well-child visit and has been shown to be effective (American Academy of Pediatrics. Promoting Safety and Injury Prevention Gardner, 2007; Bass, 1995).
Accidental poisonings in children are the most common between the ages of 1 and 3 years (Michael, Sztaijnkrycer, 2004) and approximately half of the poisoning cases reported each year to the poison control centers in the United States occur in children (AAPCC).
Children are naturally curious and exploration of the environment is part of the growth process. They are much more likely to use hand-to-mouth behavior to determine the nature of an object, and they also lack the caution of older children. Serious harm and death caused by pediatric exploratory behavior are unusual, but children are especially vulnerable to the effects of medications because of body weight and even one to two dose units of certain medications (e.g., calcium channel blockers, oral hypoglycemics, tricyclic anti-depressants) can be enough to kill a child (Matteucci, 2005; Bar-Oz, Levichek, Koren, 2004; Koren, 1991). See Table 5.
Adolescence is a time of significant physical, emotional, and social change (Biroc, Chang, 2015; Forcier, Garofalo, 2015). Adolescents grow in spurts, mature physically, and are able to reproduce. Mentally, they become more abstract thinkers, can consider many options, are able to choose their own values, and challenge authority. Socially and emotionally, adolescents are developing their own identity and building close relationships. Together all of these processes in the adolescent are termed puberty.
Assessment of Growth and Development in the Adolescent
Height and weight gain, the onset of sexual maturity, and cognitive, emotional, and social maturation are the biggest growth and development changes of adolescents. Each adolescent should be examined to ensure that she/he is growing as expected, sexual maturation is developing as expected, and the adolescent’s cognitive, emotional, and social maturation are proceeding normally.
Height and weight should be periodically assessed in all adolescents. Approximately 17-18% of adult height is gained during puberty (Biro, Chan, 2015) and the growth spurt typically occurs earlier in girls than in boys. Puberty is also a time in which body weight and lean body mass increase. Bone growth and bones density increase, as well, and adolescence is an important time for bone health. For girls, one-half of total body calcium is in place during puberty and up to two-thirds in boys, making this a time of life that can affect the future health of the bones (Biro, Chan, 2015). Height and weight should be evaluated with each visit to a primary care physician and obesity screening should be performed, as well (U.S. Preventive Services Task Force, 2014). There are no guidelines for screening for bone health in adolescents. Eating disorders should be screened for if there is a weight loss of > 10%; the patient diets when she/he is not overweight; if he/she has a distorted body image, or; if the body mass index is below the 5th percentile (Elster, 2015).
Sexual maturation for the adolescent is assessed by the development of secondary sexual characteristics: breast changes in females, development of pubic hair in females and males, and development of the genitals in males (Biro, Chan, 2015). The development of the secondary sexual characteristics can be assessed using the sexual maturity rating scale developed by Tanner, e.g., certain changes in breast development by a certain age (Biro, Chan, 2015).
Cognitive, emotional, and social maturation assessment for the adolescent should be focused on how the adolescent’s development in these areas is affecting adjustment at home, in school, and society.
The Assessment and Examination Process and the Adolescent
Two important issues of the assessment and examination process for the adolescence are confidentiality and consent and autonomy.
Confidentiality and consent with the adolescent patient is a complex topic, and each state has different laws regarding these issues. In general, the adolescent is entitled to confidentiality when it comes to information about his/her health status and health care that has been delivered with her/his consent. In most cases, parental consent is required for medical/surgical treatment to be delivered to anyone under age 18, but there are exceptions: emergencies, emancipated minors, low risk/minor illnesses, mental health issues, and care involving contraception, pregnancy, and sexually transmitted diseases (Chaisson, Shore, 2014). Issues of contraception, pregnancy, and sexually transmitted diseases are always considered to be confidential.
Autonomy is defined as the quality of being free and independent, and the establishment of autonomy is one of the major developmental challenges of adolescence. Encouraging autonomy for an adolescent during the assessment and examination process is highly recommended (Chaisson, Shore, 2014). This can be done by including the adolescent, to an appropriate degree, in all parts of the assessment and examination process, e.g., making sure to provide the patient with information (not just the parents), asking the patient about her/his health concerns. This is important for several reasons. It encourages the adolescent to view health as his/her responsibility and as something that can be positively influenced – or negatively influenced – by her/his actions. It also gives the adolescent valuable experience in decision making and planning. Including the adolescent in decision making and planning is far more likely to increase compliance with treatment and it encourages the patient to seek help if needed.
Health Screening and Preventive Care and Adolescents
Recommendations for the frequency of health screening and specific preventive care interventions for adolescents (and the age range at which these should be delivered) differ depending on the source. The AAP and the American Medical Association both recommend annual preventive care services for patients aged 11 to 21 years; the U.S. Preventive Health Service Task Force and the American Academy of Family Physicians recommend that these services be utilized on an individual, as-needed basis (Chaisson, Shore, 2014).
Table 6 lists screening and preventive care services that are recommended by these groups. Some issues such as alcohol use/abuse, drug use and contraception should be discussed at each visit; others should be done on an as-needed basis. For example, physical examination/screening for specific disorders, e.g., HIV, hypertension are done on an as-needed basis while examination for obesity and normal growth and development and other health issues should be done for every patient at every visit. Vaccinations for adolescents should include the human papillomavirus (HPV) vaccine, starting at age 11-12 (CDC, 06/2015; Petrosky, 2015). Some of these issues are discussed at more length in other sections of this module: Alcohol uses/abuse, drug use, injury prevention, sexually transmitted diseases, and tobacco use are covered in Safety Issues for Adolescents; eating disorders, obesity and normal growth and development are covered in Assessment of Growth and Development.
Nutrition and the Adolescent
TThe energy requirements of an adolescent, especially a physically active adolescent, are obviously higher than that of a child and somewhat different than those of an adult or an older adult. However, aside from several specifics, the adolescent diet is not significantly different. Specific nutrition issues of adolescence and specific nutrition recommendations for adolescents are listed below (Abrams, 2015; Biro, Chan, 2015; Butte, 2015; Abrams, 2014; Demory-Luce, Motil, 2014):
- Calcium: Adolescence is a critical time for bone growth and most adolescents do not consume enough calcium. The recommended daily amount for adolescents is 1300 mg. Calcium supplementation is not needed if the diet is normal.
- Iron: Iron needs are increased during adolescence as blood volume and muscle mass increase and females at the onset of menarche. Iron deficiency is quite unusual in adolescent boys but approximately 9-11% of adolescent girls are considered iron deficient. Adolescent girls should be screened for iron deficiency starting at age 13.
- Other micronutrients: Many adolescents do not receive the recommended daily amounts of vitamin A, folic acid, and zinc.
- Fat intake: The total fat intake for adolescents up to age 18 should be 25%-35% of caloric intake.
- Grain: Adolescents should consume whole grain products when possible: one-half off the intake of grains should be whole grains.
Safety issues for Adolescents
Safety issues that are of particular concern with adolescents include reproductive issues including sexually transmitted diseases, alcohol, drug, and tobacco abuse/use; depression and suicide, and unintentional injuries, especially automobile accidents (Elster, 2015).
Reproductive issues including sexually transmitted diseases are a major source of health and social problems in adolescents. The birth rate for teenagers has declined in recent years, but many pregnancies in teenagers are unplanned. It has been estimated that each year one-fourth of all sexually transmitted diseases occur in people aged 15 to 24 and one in four females aged 14 to 19 is infected with a sexually transmitted disease (Forcier, Garofalo, 2015).
Adolescent females who are sexually active should be screened annually for gonorrhea and chlamydia. Adolescent males should be screened for gonorrhea and chlamydia if they have certain risk factors. Screening adolescents for HPV is not recommended. HIV testing should be offered at least once to all adolescents, whether or not they are sexually active, HIV testing should be done if the adolescent has certain risk factors, e.g., multiple sexual partners, exchanging sex for drugs or money, sex with males if the adolescent is male, and if the adolescent patient is being tested for sexually transmitted diseases (Fortenberry, 2015).
Alcohol, drug, and tobacco abuses/use are considered to be significant problems in the adolescent population (Kann, Kinchen, Shanklin, et al., 2014). Approximately 9% of high school students have tried alcohol, smoked a cigarette, or tried marijuana before age 13 (Kann, Kinchen, Shanklin, et al., 2014), and early substance abuse has been associated with injury, mortality, and health and social problems in adulthood. The AAP and the U.S. Preventive Services Task Force recommend that all adolescents be periodically and routinely screened for alcohol, drug, and tobacco abuse/use (American Academy of Pediatrics, 2014; U.S. Preventive Services Task Force, 2014), and the AAP recommends using the CRAFFT screen.
One point for each yes answer. If the score is ≥ 2 then there is a problem with alcohol/drug use and adverse consequences and dependency are likely.
Screening for tobacco use can be done by using the system of 5 As: Ask, Advise, Assess, Assist, and Arrange (Sockrider, Rosen, 2015): ask about tobacco use; advise about the dangers; assess the patient’s risk for using tobacco; assist him/her to avoid its use, and; arrange for smoking cessation intervention if needed.
Depression and suicide are closely linked in adolescents, and suicide is a leading cause of death in adolescents (Kelly, 2015; Kennebeck, Bonin, 2015; Kann, Kinchen, Shanklin, et al., 2014). The Youth Risk Behavior Surveillance found that in the 12 months prior to the survey 8.0% of high school students had attempted suicide one or more times and 17% had seriously considered attempting suicide (Kann, Kinchen, Shanklin, et al., 2104), and surveys have found that almost one-third of high school students reported significant levels of depression (Kelly, 2015). The AAP recommends yearly screening for depression starting at age 11 and continuing to age 21 using the Patient Health Questionnaire-2 (PHQ-2), 2 item screen (American Academy of Pediatrics, 2014).
Factors that predispose an adolescent for suicidal behavior include, but are not limited to: alcohol and drug use; exposure to violence; family history of suicidal behavior; previous suicide attempt; psychiatric disorders, and; social stress (Kennebeck, Bonin, 2015).
Unintentional injuries are the single greatest cause of death and disabling injury in adolescents in the United States (Gill, Kelly, 2014), and many high school students engage in behaviors that place them at risk. For example, the Youth Risk Behavior Surveillance – 2013 found that:
- 67.0% of high school students had ridden a bicycle during the 12 months before the survey and 87.9% had never or rarely worn a bicycle helmet.
- 7.6% of high school students never or rarely wore a seat belt when riding in a car driven by someone else.
- 21.9% of high school students had ridden one or more times in a car driven by someone who had been drinking alcohol.
- 64.3% of high school students had driven a car while drinking alcohol.
- < >7.9% of high school students had carried a weapon (e.g., gun, knife, or club) on at least one day.
Age-appropriate injury counseling (that includes the parents and caretakers) is also recommended by the AAP at every well-child visit and has been shown to be effective (American Academy of Pediatrics. Promoting Safety and Injury Prevention; Gardner, 2007; Bass, 1995).
Adults: Ages 21-64
Adults are sexually and physical maturity. Their nutritional needs are for maintenance, not growth. Chronic illnesses are either evident at this time of life or have yet to develop so the adult faces the threat of illness or death from the impact of unhealthy lifestyles. Mentally, they learn new skills and information to solve problems. They are very concerned about affiliation, love and intimacy. Personal identity and an acceptance of self-enable the young adult to form their own independent decisions. Major stress factors occur as this individual establishes a career and family. Their fears include losing their jobs and status in established social relationships. The young adult chooses a lifestyle and career to fulfill goals, seeks closeness with others and may make a commitment to start a family and become an active member of his community.
The middle-aged adult begins to develop physical changes and (possibly) chronic health problems. Women go through menopause. Mentally, they use past experience to learn, create and solve problems. People in this age are concerned about staying productive, and they hope to contribute to future generations and strive to balance dreams with reality. They start planning for retirement and may end up taking care of parents or children.
Health Assessment of the Adult
Health assessment of the adult is in many ways less complex than health assessment of other age groups. Physical, emotional, and social development continues but these have stabilized to a degree and profound changes in these areas of a person’s life are not as marked as they are in infancy and childhood, adolescence, and old age. The health assessment of an adult then should focus on identification of lifestyle behaviors that may contribute to poor health and management of those disease states/chronic illnesses that have developed. Preventive care, health education, and encouragement of healthy behaviors are key issues for health assessment of this age group.
Health Screening and Preventive Care and Adults
Health screening is one of the primary ways in which illness can be prevented. In infancy, childhood, adolescence, and in the aging adult the specific health screenings that are needed are determined by the physiological, emotional, and social stages of development particular to these age groups. However, as previously mentioned, profound changes in these areas of a person’s life are not as marked in adults as they are in infancy and childhood, adolescence, and old age. Because of those issues, health screening for adults is both broader and more specific, and the questions of for whom and when it should be done, how to interpret results, cost effectiveness, and the proper and most efficacious screening tools are very important. Health screening is a complex topic and cannot be completely discussed in this module. However, several points about health screening in adults deserve mention (Fletcher, Fletcher, 2015; Park, 2015). These apply to the use of screening tools for all populations.
- Health screening tools should be evaluated for their sensitivity and specificity.
- Simplicity and cost: Screening tools should ideally be simple and inexpensive.
- Safety: First do no harm is a guiding principle of all health care and it applies to screening tests. Risk cannot be eliminated but prevention of illness/injury is the primary use of a screening tool; a screening test should prevent, not create problems.
- False positive and false negative consequences.
- Overdiagnosis and overtreatment.
- Acceptability to the patient.
- Utility: The screening test should be able to identify a problem or potential problem for which practical, effective steps can be taken.
There is no universal agreement on adult health screening, but the recommendations in Table 9 are from the CDC, the U.S. Preventive Services Task Force, The Guide to Preventive Clinical Services 2014 and the 2015 review by Park (Park, 2015). The recommendations listed in Table 9 are the ones for which screening advised for the general population without risk factors for specific disease. However, for some diseases, the risk factors are so prevalent that discussion of screening is reasonable, e.g., diabetes, lung cancer.
Aging Adult: 65+
The later years are a time of significant physical and physiological changes for adults 65 years and older. These physical and physiological changes (See Table 4), the increased prevalence of, and risk for acute and chronic diseases, and the emotional, psychological, social issues particular to aging adults require assessment and screening that are specific to this age group.
Of particular interest are the physiological, physical, and cognitive changes associated with aging. Some of the physiological and physical changes associated with aging are listed in Table 10 (Kane, Ouslander, Abrass, et al., 2013).
Cognitive changes in the aging adult are universal and individual, and an individual’s cognitive ability is often negatively influenced by his/her mental and social activity and disease states such as cardiovascular diseases, diabetes, and hypertension. Although it is not possible to categorize all aging adults in terms of cognitive changes, most aging adults do suffer a decline in the speed of processing information; they maintain levels of knowledge and data; attention to details and tasks is slowed if it is required that multiple details and tasks be attended to or switching between tasks is required, and; short-term memory is negatively affected while long-term memory is intact (Riddle, 2007; Anstey, Low, 2004).
Health Assessment of the Aging Adult
TThe health assessment of an aging adult should focus on the issues that are specific to this age group. It should also focus on how the physical and physiological changes of aging have affected the older adult. A commonly used approach is the comprehensive geriatric assessment (CGA). The CGA has been defined as “a multidisciplinary diagnostic and treatment process that identifies medical, psychosocial, and functional limitations of a frail older person” (Ward, Reuben 2015). The CGA can be structured in different ways but it typically includes an assessment of the abilities and health status parameters listed in Table 6 (Abete et al., 2015; Ward, Reuben, 2015; Hamaker, Seynaeve, Wymenga, et al., 2014).
A complete discussion of the methods and tools used to assess these abilities and health status parameters is beyond the scope of this module. Fall risk, assessment, and screening will be discussed in the section Safety Issues in the Aging Adult; medication review will be discussed in the section Medications and the Aging Adult; nutritional status will be discussed in the section Nutrition and the Aging Adult, and; assessment and screening of cognitive abilities emotional status, and vision and hearing will be briefly mentioned in the section Health Screening and Preventive Care for the Aging Adult. There are multiple screening and assessment tools for evaluating performance of the activities of daily living.
The Process of Examination and the Aging Adult
Assessment and examination are processes of information gathering and information exchange and with this in mind they must be adjusted to accommodate the aging adult.
The aging adult may well be accompanied by a family member, and there is evidence indicating that this improves patient satisfaction with the assessment and examination and improves the amount and quality of informant retained by the patient (Wolff, Roter, 2011; Wolff, Roter, 2008).
Aging adults often process information more slowly than do younger people, and they often have multiple and more complex medical problems. Because of this more information must be gathered and given during an assessment and examination so scheduling more time should be done, if possible. Using questionnaires that can be filled out prior to a visit can streamline the process and in some cases, it may be necessary to schedule more than one visit in order to completely address the patient’s issues (Robinson, White, Houchins, 2011). When interviewing the aging adult or when providing information, keep in mind that she/he may have difficulty hearing and/or quickly processing new information so the pace and style of verbal communication may need to be adjusted.
Health Screening and Preventive Care for the Aging Adult
As with other age groups, health screening and preventive care for aging adults should be both universal and patient-based. Given the prevalence of certain diseases in the general population (e.g., cardiovascular disease) and the physical and physiological changes of aging, it is advisable to screen all aging adults for certain conditions. The need for screening and /or routine follow-ups for other conditions/disease can be determined on an individual basis (Heflin, 2014; U.S. Preventive Services Task Force, 2014).
Preventive care should include: smoking cessation, if needed; moderate use of alcohol or abstinence, if appropriate; aerobic and resistance exercise; daily aspirin in selected patients; 1200 mg of elemental calcium and at least 800 IU of vitamin D daily; annual influenza vaccination; herpes zoster vaccination after age 60; tetanus-diphtheria booster vaccination every 10 years, and; pneumococcal vaccine as per the patient’s needs (Heflin, 2014).
Nutrition and the Aging Adult
The nutrition needs and issues that are specific to aging adults are poor nutrition and micronutrient deficiencies (Ritchie, 2014).
- Poor nutrition appears to be relatively common in aging adults (Ritchie, 2014). There are many possible reasons for this, including diseases states such as dysphagia and dementia; poor dentition; emotional and social issues such as depression and social isolation; poverty or financial hardship, and; age-related changes that affect appetite, e.g., decreased taste and smell sensitivity and delayed gastric emptying.
- Micronutrient deficiencies in the aging adult may include deficiencies in vitamins A, B12, C, D, calcium, iron, and zinc (Ritchie, 2014; Elsawy, Higgins, 2011). Deficiencies in these micronutrients are the result of age-related changes in absorption, poor intake, and lifestyle factors (Ritchie, 2014; Elsawy, Higgins, 2011).
Evaluation of the nutritional status of the aging adult should include measurement of weight, a record of the 24-hour nutritional intake, and a physical exam that is focused on signs and symptoms indicative of poor nutrition and micronutrient deficiency. Weight loss is considered to be clinically significant if there has been ≥ 2% percent decrease from baseline body weight in one month; ≥ 5% decrease in three months, or; ≥10% decrease in six months (Ritchie, 2014)
Medication and the Aging Adult
Age-related medication issues in aging adults are: pharmacokinetics; adverse drug reactions; polypharmacy; the inappropriate use of medications; co-morbidities (Davies, O’ Mahony, 2015), and; the need for a medication review (Willeboordse, Hugtenburg, van Dijk L, et al., 2014).
Pharmacokinetics change dramatically as we age. The size and capabilities of, and blood flow to organs that are responsible for absorption, metabolism, and excretion of drugs diminishes significantly (Davies, O’ Mahony, 2015). Body fat increases, body water content decreases, and the level of serum proteins decreases, all of which affect drug distribution (Hubbard, O’ Mahony, Woodhouse, 2013).
The most obvious practical consideration for these differences in pharmacokinetics is dosage. For example, the benzodiazepines are typically prescribed in lower doses for aging adults and close monitoring of the patient during treatment with these drugs is recommended (Geriatric Lexi-Drugs, 2015) as the use of benzodiazepines in this population is strongly associated with falls (Carrière, Mura, Pérès, et al., 2015; Rochon, 2015). Decreased renal clearance, decreased hepatic metabolism, and greater absorption into fat stores can cause high plasma levels of benzodiazepines (Carrière, Mura, Pérès, 2015; Hubbard, O’ Mahony, Woodhouse, 2013), increasing the risk for sedation and other adverse effects.
Adverse drug reactions are common in aging adults (Davies, O’ Mahony, 2015; Hubbard, O’ Mahony, Woodhouse, 2013), and these patients are at a high risk for adverse drug reactions because of polypharmacy; changes in how drugs are absorbed, metabolized, distributed, and excreted; use of inappropriate medications; co-morbidities that affect pharmacokinetics and predispose to adverse drug reactions; the difficulty in recognizing an adverse drug reaction in this population; and lack of regular medication reviews (Davies, O’ Mahony, 2015; (Willeboordse, Hugtenburg, van Dikj, et al, 2014). Drug reactions are also particularly serious in aging adults, e.g., delirium and falls (Davies, O’ Mahony, 2015).
Polypharmacy is not universally defined but 5 or more medications in active use is an often used and practical definition (Rochon, 2015). Polypharmacy is very common in aging adults. Bhavik et al. (2012) noted that older adults are 13% of the US population but one-third of all prescriptions were written for this group, and Qato et al. (2008) found that 29% of the US adults aged 57-85 used five or more prescriptions and they and often used over-the-counter medications and supplements, as well. Polypharmacy is often a natural consequence of the multiple medical problems of the older population. Another common cause is a phenomenon called the prescribing cascade. In the prescribing cascade, a new medication is prescribed to treat signs and symptoms that are presumably from a new illness but are actually an unrecognized adverse reaction from a current medication (Rochon, 2015), For example, anti-Parkinson’s drugs may be started to treat symptoms caused by anti-psychotics, adding to the risk of adverse effects and drug-drug interactions.
There are significant consequences and many potential problems associated with polypharmacy in aging adults. Polypharmacy in this population causes nonadherence to the medication regimen; increased risk for drug interactions; increased risk for adverse drug reactions; increased risk for falls; increased level of disability and mortality; increased rate of hospitalization, and; increased risk for delirium. (Wallace, Paauw, 2015; Bhavik, Shah, Hajjar, 2012; Kojima, Akishita, Nakamura, et al., 2011; Salazar, Poon, Nair, 2007; Prybys, Melville, Hanna J, et al., 2002)
Inappropriate medications are considered those in which the drug is ineffective or there is a significant risk of a serious adverse effect in aging adults (Rochon, 2015), and inappropriate drug use increase the risk for adverse reactions, immobility, incontinence, falls, and cognitive impairment (Willeboordse, Hugtenburg, van Dikj, et al., 2014).
There are many medications which are considered inappropriate for this patient population, and a commonly used list that identifies them is the Beers criteria (Rochon, 2015; American Geriatric Society, 2012) The Beers criteria have been periodically revised and they currently list 53 medications classified into three categories: drugs that should always be avoided; drugs that are potentially inappropriate for aging adults with particular health conditions or syndromes, and; drugs that should be used with caution. Barbiturates are category 1 drugs; anticholinergics are a category 2 drug, and; antipsychotics are category 3 drug.
Co-morbidities have an obvious effect on medication uses in the aging adults. The greater the number of medical problems the greater the number of medications are likely to be prescribed, increasing the risk of adverse effects and drug-drug interactions.
A medication review has been defined as a structured, critical examination of the patient’s medicines intended to optimize the beneficial effects of the medication regimen and minimize drug-related problems (Willeboordse,Hugtenburg, van Dijk, et al., 2014). Medications reviews are time-consuming and it is not clear as to who would most benefit from them, but a medication review may be helpful in reducing the incidence of common problems such as cognitive dysfunction, incontinence, and falling that are associated with polypharmacy and with the inappropriate use of medications in aging adults.
Safety Issues for the Aging Adult
There are multiple safety issues that affect the aging adult: two of the most common and serious that are of immediate concern to nurses are elder abuse and falls.
Elder abuse is a very common and serious safety issue for aging adults. It has been estimated that 10% of all older adults in the US have been victims of elder abuse (Dong, 2015), and there is significant evidence that the actual number of cases is much higher (National Center on Elder Abuse).
Elder abuse has been defined in different ways, but it is typically considered to be intentional actions that either cause harm or a risk of harm, done by a caregiver or someone in a position of trust (National Center on Elder Abuse). There are five types of elder abuse, listed and defined below (Dong, 2015):
- Financial exploitation: Misusing and or exploiting an older adult’s financial resources.
- Neglect: Failing to provide the necessities of live.
- Physical abuse: Inflicting injury or pain.
- Psychological abuse: Threats, verbal assault, harassment, intimidation.
- Sexual abuse: Nonconsensual touching or sexual activities
Factors that increase the risk for elder abuse include, but are not limited to: advanced age; female gender; dementia; inability to provide self-care, and; characteristics of the caretaker (Halphen, Dyer, 2015). It is recommended that all adults 65 and older be screened for elder abuse (Halphen, Dyer, 2015). The Brief Abuse Screen for the Elderly (BASE), the American Medical Association Abuse Screen, and the Elder Assessment Instrument are widely used screening tools for the detection of elder abuse, and a brief review of these and others is provided by Burnett, et al., 2014 (Burnett, Achenbaum, Murphy, 2014).
Falls are the leading cause of fatal injury in the United States in adults ≥ 65 years of age (Kharrazi, Nash, Melenz, 2015), and the incidence of falls increases with age. Approximately one in three US adults in that age group suffers a fall each year (Kharrazi, Nash, Melendez, 2015), and falls are significant causes of morbidity in older adults (Kiel, 2015). Falls are common in the home setting and in the healthcare setting; in the latter, they tend to be more severe (Kiel, 2015).
There are many risk factors that contribute to falls in the aging adult; some of these are listed in Table 13 (Kiel, 2015).
A risk assessment for falls should be done on all geriatric patients. (Kiel, 2015)
The American Geriatric Society and the British Geriatrics Society have published guidelines for assessment and screening for the risk of falls and for older adults who have fallen. (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011).
All aging adults should be asked whether they have fallen in the past year and if they have, how often. Assessment and evaluation of balance and gait and a multi-factor fall risk assessment should be considered, the latter to include: medication review; the presence of acute and chronic medical problems; a detailed history of the falls; a physical examination, and; a functional assessment of the ability to perform activities of daily living. An environmental assessment should be done, as well. Balance and gait can be assessed using tools such as the Get Up and Go test, the Timed Get Up and Go test, the Berg Balance Scale or the Performance-Oriented Mobility Assessment (Kiel, 2015; Moncada, 2011).