Age Specific Practice - 3 Contact Hours

The period between 1 month of age and 12 years of age is rapid change. Infants and children should be routinely assessed to determine if they are growing normally. The periodic evaluation of physical, emotional, and social development is one of this patient population's most important healthcare issues. These assessments are performed by comparing the patient to developmental milestones, defined as abilities and behaviors that are normal for a specific age group. When a developmental milestone assessment is done, the patient:

• Will meet the standard, and growth and development are 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 will develop at their own pace, and failure to meet a developmental standard may simply reflect that child's individual rate of growth and development.
• Failure to meet the standard is a warning sign of a serious problem with the patient's growth and development.

Several developmental milestones and assessments are provided here (CDC, 2015). Notice that in infants and very young children, cognitive and language abilities and hand/finger motor abilities are assessed, but visual and perceptual abilities are not.

The assessment and examination process applied to an infant or a child must be adapted to the patient's behavioral, emotional, and intellectual development.

Infants and children - and all age groups - should be vaccinated for protection against infectious diseases. Vaccination schedules for infants and children are different from those for other age groups. Current recommendations for patients aged 0 to 18 years can be found on the Centers for Disease Control and Prevention website (CDC, 2019). The schedules can be found here.

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 from which they are likely to suffer.

Examples:

• Infant universal screening for congenital hypothyroidism and phenylketonuria (PKU is mandated in all 50 states and the District of Columbia).
• City and state agencies typically generate recommendations for screening infants and children for lead poisoning. 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 where a certain percentage of children have elevated blood leads levels.

Organizations such as the American Academy of Pediatrics (AAP), the CDC, and the US Preventive Services Task Force (USPSTF) have recommendations for universal and targeted population-specific screening. There are also a city, school board, state, and federal mandates and regulations for pediatric health screening. There is some disagreement among these sources regarding who should be screened, for what, and when. Table 2 lists the American Academy of Pediatrics (Bright Futures, 2019).

The nutrition and eating issues 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 for other age groups. Still, some specifics are important to know, and there are guidelines for the daily caloric intake for infants and children (USDA, 2015). Example: For a 12-month-old child who weighs 20 pounds/9 kg, multiply the child’s weight times 89, subtract 100 and add 22 – 9 x89 = 801, 801-100 = 701 +22 = 723 calories a day (USDA, 2019).

Macronutrient requirements differ by age, as well. Daily intakes listed below are summarized/compiled from recommendations from the AAP, the American Heart Association (AHA), the American Dietetic Association, and the United States Departments of Agriculture and Health and Human Services (USDA/HHS). (Duryea, 2019).

• Carbohydrates: These should be 45-65% of the daily caloric intake in all children.
• Fats: Fat intake should not be restricted in children 0 – 2 years of age. From age 2 to 3, fat intake should be 30-35% of daily caloric intake, and from age 4 to age 18, fat intake should be 25-35% of the daily caloric intake.
• Protein: From age 1 to 3, protein should be 5-20% of daily caloric intake. From age 4 to 18, protein should be 10-30% of daily caloric intake.

Infants and children up to 2 years should drink whole milk, not skim or 2%. (Duryea, 2019). 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. Still, supplementation to ensure adequate micronutrients is not needed if the infant/child gets a varied diet and sufficient exposure to sunshine.

Exceptions to this would be vitamin D supplementation for breastfeeding infants and children at risk for vitamin D deficiency due to their nutritional intake and/or lack of exposure to sunlight (CDC, 2019b). Breast milk does not have enough vitamin D to meet the nutritional requirement of a breastfeeding infant. The AAP recommends that breastfeeding infants should be given 400 IU of vitamin D every day (Voortman et al., 2015) Premature infants, infants who are exclusively breastfed, exclusively breastfed and premature infants who are not getting vitamin D supplementation, and infants and children who have low dietary vitamin D intake should be screened for vitamin D deficiency (Misra, 2018).

The daily recommended intake for 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 are available at the website of the U. S. Department of Agriculture (USDA) here.

Other sources that are useful for determining nutrition needs are the US Department of Health and Human Services/National Institutes of Health (US DHSS/NIH)

website, Health Information, Fact Sheets for Professionals. The Dietary Reference Intakes and the Daily Values can also be used. They are both available at the National Institutes of Health website using these links:

• Nutrient Recommendations: Dietary Reference Intakes
• Daily Values

The eating patterns and habits of infants and children are quite different from 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 necessary. Food disinterest and food fussiness are eating patterns that most children exhibit at some time.

Food safety for infants and children is concerned with choking hazards and foodborne infections. Choking can occur in infants and children because:

• They may not have full dentition
• They may not have learned how to chew foods thoroughly
• They can be easily distracted while eating
• They 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.

Foodborne illnesses are a papillomavirus 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. The United States Department of Agriculture (USDA) estimated in 2018 that 11.1% of American households were in a state of food insecurity at some time during the year (DHHS, 2019). Food insecurity is not a problem specific to infants and children. However, 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 have traditionally not been tested in children (Chitty et al., 2018). and pediatricians had to prescribe doses and dosing schedules with information using/extrapolating from adult doses/dosing. It is often said that when it comes to drugs, children are not small adults, and this has been proven true in many ways. For example, in 2017, the FDA issued a warning stating that codeine and tramadol should not be used in children < 12 years old. Adverse reactions to these drugs, some quite serious, were reported in this patient population and may have been caused by a difference in the activity of the CYP2D6 enzyme that resulted in high serum drug levels (Chitty et al., 2018).

The primary safety issues of infancy and childhood are child abuse, accidents, and poisonings.

Height and weight gain, the onset of sexual maturity, and cognitive, emotional, and social maturation are adolescents' biggest growth and development changes. Each adolescent should be examined to ensure that they are growing as expected, sexual maturation is developing as expected, and cognitive, emotional, and social maturation are proceeding normally.

Height and weight should be assessed in all adolescents periodically. Approximately 17-18% of adult height is gained during puberty, and the growth spurt typically occurs earlier in girls than in boys. Puberty is also when body weight and lean body mass increase. Bone growth and bone density increase, 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, 2018). Height and weight should be evaluated with each visit to a primary care physician (Bright Futures, 2019). and adolescents should be screened for eating disorders. The USPSTF recommends that "clinicians screen for obesity in children and adolescents six years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status (USPS. 2019)."

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 (Poison Control, 2019). The development of secondary sexual characteristics can be assessed using Tanner's sexual maturity rating scale, e.g., certain changes in breast development by a certain age (Poison Control, 2019).

The adolescent's cognitive, emotional, and social maturation assessment should focus on how the adolescent's development in these areas affects their adjustment at home, in school, and in society.

Two important issues of the adolescent assessment and examination process are confidentiality, consent, and autonomy.

Confidentiality and consent and the adolescent patient are complex topics, and each state has different laws regarding these issues. In general, adolescents are entitled to confidentiality when it comes to information about their health status and health care delivered with their consent. In most cases, parental consent is required for medical/surgical treatment to be delivered to anyone under age 18. However, there are exceptions: emergencies, emancipated minors, low risk/minor illnesses, mental health issues, and care involving contraception, pregnancy, and sexually transmitted diseases. For example, teenagers can be tested and treated for an STD, and this information is kept private, even from parents.

Autonomy is defined as the quality of being free and independent. The establishment of autonomy is one of the significant developmental challenges of adolescence. Encouraging autonomy for an adolescent during the assessment and examination process is highly recommended. This can be done by including the adolescent, to an appropriate degree, in all parts of the assessment and examination process, e.g., providing the patient with information (not just the parents) asking the patient about their health concerns. Encouraging autonomy is important for several reasons. It encourages the adolescent to view health as their responsibility and as something that can be positively influenced - or negatively influenced - by their actions. It also gives valuable adolescent experience in decision-making and planning. Including the adolescent in the assessment and examination process is far more likely to increase compliance with treatment, and it encourages the patient to seek help if needed.

The energy requirements of an adolescent, especially a physically active adolescent, are higher than that of a child and somewhat different than those of an adult or an older adult. However, aside from certain nutrients, the dietary requirements of adolescents are not significantly different. Two specific nutrition issues of adolescence and specific nutrition recommendations for adolescents are listed below. Readers can go to the Office of Dietary Supplements, a section of the USDHHS/NIH website. There are Fact Sheets for Professionals on all the vitamins and minerals, including recommended daily intake. The website link is here.

Calcium: Adolescence is a critical time for bone growth, and the recommended daily calcium intake for adolescents aged 13-18, male and female, is 1300 mg a day compared to 1000 mg a day for adults (USDHHS, 2019)

Iron: Iron needs increase during adolescence as blood volume and muscle mass increase. Additionally, females have the onset of menarche, and adolescents, especially adolescent girls, are at risk for iron deficiency. Adolescent girls should be screened for iron deficiency starting at age 13. The recommended daily intake of iron for adolescent females aged 14 to 18 is 15 mg (up from 8 mg in the previous years). For adolescents aged 19, the daily intake should be 18 mg (USDHHS, 2019b).

Safety issues of particular concern with adolescents are sexually transmitted diseases, alcohol, drug, and tobacco abuse/use, depression and suicide, accidents and unintentional injuries, especially automobile accidents,4 and interpersonal and sexual violence (CDC, 2016).

Health assessment of the adult is, in many ways, less complex than health assessment of other age groups. Physical, emotional, and social development continues. However, 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 identifying 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 the health assessment of this age group.

The 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 caused by aging have affected older adults. A commonly used approach is the Comprehensive Geriatric Assessment (CGA). The CGA is defined as "a multidisciplinary diagnostic and treatment process that identifies medical, psychosocial, and functional limitations of a frail older person (Emory, 2019)." and it assesses four aspects of the older adult's health: Functional status, physical health, psychological health, and socioenvironmental health. The CGA can be structured in different ways. Still, it typically includes an assessment of the abilities and health status parameters listed in Table 7.

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 the performance of the activities of daily living.

Assessment and examination are processes of information gathering and information exchange. With this in mind, they must be adjusted to accommodate the aging adult.

A family member may well accompany the aging adult, and evidence indicates that this improves patient satisfaction with the assessment and examination and improves the amount and quality of informant retained by the patient.

As with other age groups, health screening and preventive care for aging adults should be universal and patient-based. Given the prevalence of certain diseases in the general population (e.g., cardiovascular disease) and the physical and physiological changes, it is advisable to screen all aging adults for certain conditions.

Healthy lifestyle:

Older adults should be encouraged to follow a healthy lifestyle. Exercise can improve functional ability. It is protective against depression. It reduces the severity of depression and can also help prevent falls (Miller et al., 2019).

Patients who smoke should be offered behavioral and pharmacological smoking interventions. The health benefits of smoking cessation are evident and significant even for long-term smokers who are elderly (Heflin, 2019).

Alcohol use disorder is less common in older adults than in many other age groups. However, as many as 14.5% of older adults in the United States have a harmful pattern of alcohol consumption (Ritchie, 2019). Clinicians should assess patients for problematic alcohol consumption. Multiple screening tools are available, e.g., the Audit-C or the CAGE tool.

The nutrition needs and issues specific to aging adults are vitamin B12, vitamin D deficiency, and malnutrition (Ritchie, 2019).

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 (Ritchie, 2019).

Weight loss is clinically significant if there has been ≥ a 2% percent decrease from baseline body weight in one month; ≥ a 5% decrease in three months, or; ≥10% decrease in six months (Ritchie, 2019).

The prevalence of vitamin B12 deficiency in the elderly has been reported to be as high as 23% and approximately 15% of older adults in the United States (Cham et al., 2018). The elderly are at a higher risk for B12 deficiency because of decreased intake, malabsorption, and a higher incidence of pernicious anemia (Sukumar, 2019). and B12 deficiency in the elderly can contribute to the development of anemia, cognitive decline, and dementia (Orces, 2019). Oral supplements or IM injections can be used to treat B12 deficiency. There is no universal recommendation to screen older adults for B12 deficiency.

Vitamin D deficiency is a common problem in older adults in the United States due to inadequate intake and exposure to the sun. Low vitamin D levels have been associated with many health problems. Clinicians should consider screening older adults for vitamin D deficiency. It is not clear what blood level of vitamin D supplementation should be started. Adults aged 51 and up should consume 800 IU of vitamin D a day.

Malnutrition:

Malnutrition is a state of nutrition in which energy, protein, and other nutrient deficiencies have a measurable adverse effect on the body, functional ability, and clinical outcome (Volkert et al., 2019). Malnutrition is common in older adults, occurring in up to 10% of older adults living independently and much higher percentages in older adults hospitalized or living in a long-term care facility (Reuben et al., 2019). Malnutrition in older adults occurs for many reasons, including (but not limited to) chronic diseases, dysphagia, poor intake, socioeconomic factors, dental issues, depression, loss of taste, financial constraints, and adverse drug effects (Volkert et al., 2019). Older adults appear to adapt less well to poor nutrition, and malnutrition in the elderly increases morbidity and mortality and has many other serious consequences like decreased muscle mass, diminished functional abilities, impaired recovery, and diminished immune function (Volkert et al., 2019).

Volkert85 recommends that all older adults be routinely screened for malnutrition.

Age-related medication issues in aging adults are pharmacokinetics, adverse drug reactions, polypharmacy, the inappropriate use of medications, co-morbidities, and the need for a medication review.

Pharmacokinetics change as we age (Rochon, 2019). The size and capabilities of blood flow to organs responsible for absorption, metabolism, and excretion of drugs diminishes significantly. Body fat increases, body water content decreases, and the level of serum proteins decreases, all of which affect drug distribution.

The most obvious practical consideration for these differences in pharmacokinetics is the dosage. For example, benzodiazepines are typically prescribed in lower doses for aging adults. Close monitoring of the patient during treatment with these drugs is recommended as benzodiazepines in this population are strongly associated with falls. Decreased renal clearance, decreased hepatic metabolism, and greater absorption into fat stores can cause high plasma levels of benzodiazepines, increasing the risk for sedation and other adverse effects.

Adverse drug reactions are defined as an injury caused by a medication (Gray et al., 2018). Adverse drug reactions are widespread in aging adults (Gray et al., 2018). These patients are at 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 pre-dispose to adverse drug reactions; the difficulty in recognizing an adverse drug reaction in this population; improper prescribing and monitoring, and lack of regular medication reviews (Gray et al., 2018).

Polypharmacy is not universally defined, but five or more medications in active use is an often used and practical definition (Rochon, 2019). Polypharmacy is common in the elderly adult, with nearly 20% of community-dwelling adults 65 years of age and older taking ten or more medications.

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. For example, anti-Parkinson's drugs may be started to treat symptoms caused by antipsychotics, adding to the risk for adverse effects and drug-drug interactions.

There are significant consequences and many potential problems associated with polypharmacy in aging adults. Polypharmacy in this population often means patients have a higher risk for adverse effects and drug-drug interactions. Patients may be taking drugs that they no longer need or drugs with the same clinical effect; this can increase non-adherence to the medication regimen and is associated with increased morbidity and mortality, increased risk of hospitalization, and emergency room visits (Beuscart et al., 2019).

Potentially inappropriate medications should not be used or avoided in older adults because the risk of adverse effects is greater than the benefits, and safer alternatives may be effective (Roux et al., 2019). The use of potentially inappropriate drugs has been reported as high as 53.7%. These drugs are a significant cause of adverse drug effects, hospitalizations, and mortality in this patient population (Roux et al., 2019). The American Geriatric Society has a list of medications considered potentially inappropriate for older adults. This list is called the BEERs Criteria (AGS, 2019). It includes medications like benzodiazepines (risk of cognitive impairment and falls), antipsychotics (increased risk for stroke), peripheral alpha 1 blockers used for hypertension (risk of orthostatic hypotension), and long-acting sulfonylureas (prolonged half-life in older adults can cause hypoglycemia).

Co-morbidities have a noticeable effect on medication uses in aging adults. The greater the number of medical problems, the greater the number of medications is 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. Medications reviews are time-consuming, and it is not clear who would most benefit from them. However, a medication review may help reduce the incidence of common problems such as cognitive dysfunction, incontinence, and falling associated with polypharmacy and inappropriate use of medications in aging adults.

Multiple safety issues 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 pervasive and serious safety issue for aging adults. According to the National Council on Aging, approximately 1 of every 10 Americans 60 years of age or older have experienced elder abuse. It has been estimated that only 1 out of 14 cases of elder abuse are reported (NCA, 2019).

Elder abuse has been defined in different ways. However, it is typically considered intentional actions that either cause harm or a risk of harm done by a caregiver or someone in a position of trust (NCA, 2019). There are five types of elder abuse, listed and defined below (CDC, 2019e).

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 (NCA, 2019). Signs of elder abuse vary depending on the type of abuse. For example, physical abuse can be characterized by bruises, burns, fractures, pressure ulcers, neglect by weight loss, unexplained illnesses, or an unexplained worsening of a chronic health condition (Haphen & Dyer, 2019). Screening patients for elder abuse is recommended by several professional organizations. Still, there is no evidence that this screening is helpful or effective (Feltner et al., 2018). Screening tools that can be used include the Brief Abuse Screen for the Elderly (BASE) and the Elder Assessment Instrument (EAI).

A fall is described as an unexpected event in which someone comes to rest on the floor or the ground (Lord, 2017). Falls are a common event in older adults, and it has been estimated that falls occur in up to 40% of adults 65 years of age and older. The incidence is higher for residents of long-term care facilities and adults over age 75 (Lord, 2017). Multiple risk factors contribute to falls in the elderly, including (but not limited to) medical conditions like dementia or stroke; adverse effects of medications, polypharmacy, or the use of specific medications that cause CNS depression, orthostatic hypotension, or affect balance; advanced age, living alone, sedentary lifestyle; muscle weakness and impaired vision, and; environmental hazards (Lord, 2017).

Falls in the elderly can cause serious injuries and other consequences like impaired mobility. A fall assessment is recommended for all older adults, at least once a year, and more frequently for at-risk patients (Lord, 2017). Screening involves questioning about fall history, e.g., do you have difficulty with balance or gait, have you had a fall in the past 12 months; if the patient or caretaker reports positively to the questions, a more formal fall assessment can be done. There are several well-validated screening tests for fall assessment, like the Timed, Get Up, and Go (Lord, 2017).

Fall prevention strategies can prevent falls. Given the multitude of possible causes, the interventions are done case-by-case. The patient may need a medication review and adjustment; exercise has been shown to reduce the risk of falls; the patient may need a psychological intervention, or an environmental intervention is necessary (Lord, 2017).