California RN and LPN Nursing CEUs
Meet Your California RN or LVN Continuing Education Requirements Quickly & Affordably.

Authors: Dana Bartlett (RN, BSN, MA, MA, CSPI)

Outcomes

90% of participants will know what screening tests and preventive care are specific for four age groups: children, adolescents, adults and the elderly.

Objectives

After completing this course, the participant will be able to:

  1. Identify three screening tests used for each age group

  2. Discuss the rationale for the screening tests

  3. Discuss health needs for each age group

  4. Identify two safety issues for each age group

  5. Discuss the importance of safety issues based on the needs of the age group

Age Specific Competency: Health Assessment and Preventive Care

Significant physical and developmental differences exist between infants and children, adolescents, adults, and aging adults. 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. Nutrition and medication issues of adults will not be covered.

There are many authoritative sources for screening and preventive care guidelines, e.g., the Centers for Disease Control and Prevention, professional organizations like the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, the American Cancer Society, and the United States Preventive Services Task Force Association. These organizations are not always completely on the best way to screen for and prevent diseases. Although differing recommendations can be confusing for clinicians when making decisions about a patient's health, screening and preventing specific conditions/diseases are never significantly different from one source to another.

Infant and Children: Ages 1 Month to 12 Years

An infant or child's anatomy and physiology differ 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 adults and have a proportionally higher oxygen requirement. They can maintain central organ perfusion during a period of 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, 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.

Temperature, pulse, respiratory rate, and blood pressure considered normal for infants and children vary by age.

Table 1: Vital Signs – Infants and Children
Age Temperature Pulse Respiratory Rate Systolic Blood Pressure
1-12 months 97.2 - 99.4 80 -140 20 -30 70 -100
1-3 years 95.9 - 99 80 -130 20 -30 80 -110
3-5 years 95.9 - 99 80 -120 20 -30 80 -110
6-12 years 95.9 - 99 70 -110 20 -30 80 -120

Assessment of Growth and Development of Infants and Children

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.

Assessment and Examination Processes in Infants and Children

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

Preventive Care and Health Screening: Infant 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 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).

Table 2: Health Screening for Infants, Children and Adolescents
Screening Recommendation Additional Resources
Alcohol, drug, and tobacco use Starting age 11 Patients should be assessed for the risk of use and screened if necessary.
Anemia 4 months – assess for the risk

12 months – screen

After 12 months – assess for risk
Screen as necessary.

The current edition of the American Academy of Pediatrics’ Pediatric Nutrition: Policy of the American Academy of Pediatrics, chapter on iron.
Autism 18 and 24 months Visit Source
Bilirubin Newborns  
Blood Pressure All patients ages 3-21 Prior to 3 – risk assessment should be done

Guideline for Screening and Management in Children and Adolescents. These guidelines can be viewed here.
Body Mass Index (BMI) 24 months to age 21  
Critical Congenital Heart Defect All newborns using pulse oximetry For more details, see Endorsement of Human and Health Services recommendation for pulse oximetry screening for critical congenital heart defect
Depression Starting age 12 The USPDTF recommends screening for depression in all patients 12 to 18 years old, and resources should be in place for follow-up and treatment if needed.
Developmental screening 9, 18, and 30 months The Medical Home: An Algorithm for Developmental Surveillance and Screening, and they can be viewed here.
Developmental surveillance Annual for all patients  
Dyslipidemia Ages 24 months, 4 years, 6 years, and 9 years to 21 years- Assess for risk Follow up if needed.

For more information, see the recommendations of the National Heart, Lung, and Blood Institute, Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. These can be viewed here.
Hearing screen All newborns and 3-5 days old. It should be confirmed that the initial screen was done, the results of this screen should be verified

4 months to 3 years assess for risk

After 3 years – assess for risk
Screen and follow up as needed

See these guidelines for more information:
  • 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs. View here.
  • After age 3. View here.
Height and weight All patients, newborn to age 21  
HIV infection Starting age 15 Assess for risk and screen as necessary. The CDC recommends HIV testing in all adolescents who have contact with the healthcare system unless the patient opts out.
Lead Age 6 months and 9 months – assess for risk

Age 12 months, 24 months – measure blood lead or assess for risk

Age 3, 4, 5, 6 years – assess for risk
Screen as needed

To do determine what kids are at risk visit Prevention of Childhood Lead Toxicity or the CDC’s Low Lead Level Exposure Harms Children: A Renewed Call for Primary Prevention.
Physical Examination Annual for all patients  
Psychosocial behavioral assessment Annual for all patients  
Newborn blood panel Age 3 or 5 days – blood sample of uniform screening panels The uniform screening panel tests for genetic disorders, e.g., phenylketonuria and sickle cell disease. Details about the screening can be viewed here.
Sexually transmitted Infections Starting age 11 Assess for the risk of STIs and screen as necessary.

See the AAP’s Red Book: Report of the Committee on Infectious Diseases for guidelines on risk assessment.
Skin cancer Start at 6 Months educate and counsel USPSTF recommends parents of children 6 months of age and older, who have fair skin, be counseled about minimizing exposure to ultraviolet radiation as a way of reducing skin cancer.
Tuberculosis Ages 1 month, 6 months, 12 months and every year from 2 years of age and up – assess for risk Screen as necessary. Use the AAP Red Book for guidance.
Vaccinations Follow current CDC recommendations The CDC recommended vaccination schedule for adolescents 18 years of age and younger can be viewed here.

Vaccination for preventing infection with the human papillomavirus (HPV) is discussed later in this section of the module.
Vision Screen Newborn and up to 30 months - assess for risk

Age 3 and beyond – annual vision testing
Screen as necessary.

See Visual system assessment in infants, children, and young adults by pediatricians.

Infant and Children: Nutrition and Eating

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:

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.

Infant and Children: Medications

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).

Infants and Children: Safety Issues

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

Adolescence

Adolescence is a time of significant physical, emotional, and social change (Biro & Chan, 2018). Adolescents grow in spurts, mature physically, and can reproduce. Mentally, they become more abstract thinkers, consider many options, choose their own values, and challenge authority. Socially and emotionally, adolescents develop their own identities and build 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 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.

Assessment and Examination Process and the Adolescent

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.

Health Screening and Preventive Care for Adolescents

Table 2: Health Screening for Infants, Children and Adolesents
Screening Recommendation Additional Resources
Alcohol, drug, and tobacco use Starting age 11 Patients should be assessed for the risk of use and screened if necessary.
Anemia 4 months – assess for the risk

12 months – screen

After 12 months – assess for risk
Screen as necessary.

The current edition of the American Academy of Pediatrics’ Pediatric Nutrition: Policy of the American Academy of Pediatrics, chapter on iron.
Autism 18 and 24 months Visit Source
Bilirubin Newborns  
Blood Pressure All patients ages 3-21 Prior to 3 – risk assessment should be done

Guideline for Screening and Management in Children and Adolescents. These guidelines can be viewed here.
Body Mass Index (BMI) 24 months to age 21  
Critical Congenital Heart Defect All newborns using pulse oximetry For more details, see Endorsement of Human and Health Services recommendation for pulse oximetry screening for critical congenital heart defect
Depression Starting age 12 The USPDTF recommends screening for depression in all patients 12 to 18 years old, and resources should be in place for follow-up and treatment if needed.
Developmental screening 9, 18, and 30 months The Medical Home: An Algorithm for Developmental Surveillance and Screening, and they can be viewed here.
Developmental surveillance Annual for all patients  
Dyslipidemia Ages 24 months, 4 years, 6 years, and 9 years to 21 years- Assess for risk Follow up if needed.

For more information, see the recommendations of the National Heart, Lung, and Blood Institute, Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. These can be viewed here.
Hearing screen All newborns and 3-5 days old. It should be confirmed that the initial screen was done, the results of this screen should be verified

4 months to 3 years assess for risk

After 3 years – assess for risk
Screen and follow up as needed

See these guidelines for more information:
  • 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs. View here.
  • After age 3. View here.
Height and weight All patients, newborn to age 21  
HIV infection Starting age 15 Assess for risk and screen as necessary. The CDC recommends HIV testing in all adolescents who have contact with the healthcare system unless the patient opts out.
Lead Age 6 months and 9 months – assess for risk

Age 12 months, 24 months – measure blood lead or assess for risk

Age 3, 4, 5, 6 years – assess for risk
Screen as needed

To do determine what kids are at risk visit Prevention of Childhood Lead Toxicity or the CDC’s Low Lead Level Exposure Harms Children: A Renewed Call for Primary Prevention.
Physical Examination Annual for all patients  
Psychosocial behavioral assessment Annual for all patients  
Newborn blood panel Age 3 or 5 days – blood sample of uniform screening panels The uniform screening panel tests for genetic disorders, e.g., phenylketonuria and sickle cell disease. Details about the screening can be viewed here.
Sexually transmitted Infections Starting age 11 Assess for the risk of STIs and screen as necessary.

See the AAP’s Red Book: Report of the Committee on Infectious Diseases for guidelines on risk assessment.
Skin cancer Start at 6 Months educate and counsel USPSTF recommends parents of children 6 months of age and older, who have fair skin, be counseled about minimizing exposure to ultraviolet radiation as a way of reducing skin cancer.
Tuberculosis Ages 1 month, 6 months, 12 months and every year from 2 years of age and up – assess for risk Screen as necessary. Use the AAP Red Book for guidance.
Vaccinations Follow current CDC recommendations The CDC recommended vaccination schedule for adolescents 18 years of age and younger can be viewed here.

Vaccination for preventing infection with the human papillomavirus (HPV) is discussed later in this section of the module.
Vision Screen Newborn and up to 30 months - assess for risk

Age 3 and beyond – annual vision testing
Screen as necessary.

See Visual system assessment in infants, children, and young adults by pediatricians.

Adolescent: Nutrition

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).

Adolescent: Safety Issues

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).

Adults: Ages 21-64 Years

Adults are sexually and physically mature. Their nutritional needs are for maintenance, not growth. Chronic illnesses are either evident at this time of life or have yet to develop. Adults face 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-enabled young adults to form 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 commit to starting a family and becoming an active member of his community.

The middle-aged adult develops physical changes and (possibly) chronic health problems. Women go through menopause. Mentally, they use past experience to learn, create and solve problems. People of this age are concerned about staying productive. They hope to contribute to future generations and strive to balance dreams with reality. They start planning for retirement and may take 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. 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 Aging Adult: 65 and Older

The later years are significant physical and physiological changes for adults 65 years and older. These physical and physiological changes, 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 specific to this age group.

The physiological, physical, and cognitive changes associated with aging are of particular interest. Some of the physiological and physical changes associated with aging are listed in Table 6 (CDC, 2019d).

Table 6: Physiological and Physical Changes Associated with Aging
Atrophy of sweat glands
Decreased bladder muscle tone
Decreased bone density
Decreased immune system function
Decreased liver size
Decreased muscle mass
Decreased production of skin oils
Decreased renal mass and loss of glomeruli
Decreased sensitivity of baroreceptors
Decreased strength of respiratory muscles
Decreased visual acuity
Hearing difficulty
Loss of muscle strength

Cognitive changes in aging adults are universal and individual. The cognitive decline that is noticeable and problematic is not an inevitable consequence of aging. However, cognitive ability does change with aging (Kane et al., 2019). Some of the changes are listed below, and clinicians would do well to remember these when assessing an older patient.

  • Memory of recent events may not be as good.
  • Divided attention, the so-called multi-tasking, is less easily done by older adults.
  • Verbal ability is preserved, but it may take an older adult more time to recall a word or remember a name.
  • Problem-solving that requires a new and unfamiliar approach may take longer.
  • Information processing slows down with age.

Aging Adult: Health Assessment

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.

Table 7: Comprehensive Geriatric Assessment
Cognitive abilities
Co-morbidities
Dentition
Emotional status
Fall risk
Functional capacity: ADL and self-care
Family status
Incontinence
Medication review
Mobility status
Nutritional status
Physical activity status
Vision and hearing status

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.

Aging Adult: Process of Examination

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.

Aging Adult: Health Screening and Preventive Care

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.

Table 8: Health Screening and Preventive Care for the Aging Adult
Screening Recommendation
Abdominal aortic aneurysm The American Academy of Family Physicians (AAFP) recommends a one-time ultrasound screening test for al meg aged 65 to 75 who are smokers or have a family history of an abdominal aortic aneurysm that has to be repaired.
Bone density The USPSTF recommends that women 65 years of age and older should be screened for osteoporosis using central dual-energy x-ray absorptiometry (DXA) of the hip and lumbar spine. There is no evidence that screening older men for osteoporosis provides any significant benefit.
Breast cancer The USPSTF concluded that there is insufficient evidence to recommend breast cancer screening in women 75 years of age and older. The ACS notes that breast cancer screening in women aged 40 to 69 has been associated with a decrease in deaths from breast cancer, and women who are at average risk should have screening mammography starting at age 45, and this should continue if the patient is likely to live 10 years or more.
Carotid disease A one-time carotid ultrasound to detect the presence of carotid disease should be considered for patients who are > age 65 and who have a bruit and have coronary artery disease, need a coronary bypass, have symptomatic lower extremity arterial occlusive disease, and/or have high cholesterol or a history of smoking.
Cervical cancer screening Women 65 years and older do not need screening for cervical cancer if they have had three consecutive normal Pap smears within a 10 years period or if they have had a hysterectomy for a benign condition. Screening should be considered for women older than age 65 if their screening history is unknown or inadequate or who are at high risk, e.g., a compromised immune system, a history of high-grade precancerous lesions or cervical cancer.
Colon cancer Screening for colorectal cancer should begin at age 45 and should continue if the patient is expected to live 10 years or more until age 75. From 76 to 85, the need for screening should be determined on a case-by-case basis, and after age 85, screening should not be done. For people who have an above-average risk (e.g., IBD, family history of colorectal cancer) may need to begin screening before 45 and be screened more often.
Cognitive impairment and dementia The USPSTF recommends against routine screening for cognitive impairment in older adults as there is insufficient evidence about benefits and harm.
Depression The USPSTF recommends screening for depression in the general population and in pregnant and postpartum women. Depression is common in older adults, and depression in older adults is often unrecognized and under-diagnosed. The PHQ-2 screening test can be used to screen for depression. If the results are positive, follow up with the PHQ-9.
Hearing impairment Hearing loss is a common problem in older adults. Up to one-third of all adults 65 years of age and older report some degree of hearing loss, and hearing loss is the third most prevalent chronic health condition in this patient population. However, routine screening of older adults for hearing loss is not recommended.
Lung cancer Recommendations for lung cancer screening in older adults differ, but they all agree that screening should be considered in older adults (55 to 74 or 55 to 80, depending on the source) who have a 30+ pack per year history of smoking. The screening test would be a low-dose CT scan.
Prostate cancer Recommendations for and against screening for prostate cancer in men ages 50-69 are controversial, and there is no universal agreement on the topic. The U.S. Preventive Health Services Task Force notes that the “reduction in prostate cancer mortality 10 to 14 years after PSA-based screening is, at most, very small, even for men in the optimal age range of 55 to 69 years.” The American College of Physicians recommends that the prostate-specific antigen (PSA) test should be used to screen men ages 50-69 only in certain circumstances and men > 69 or men who have a life expectancy of < 10 years should not be screened with the PSA test.
Statins and prevention of CVD disease The USPSTF recommends that adults aged 40-75 years of age who do not have a history of cardiovascular disease (CVD) but have 1 or more risk factors for CVD like dyslipidemia, diabetes, HTN, obesity, or smoking or have a calculated 10-year risk of developing CVD that is ≥ 10% should be prescribed a statin drug. Patients who have < 10% risk may be considered for statin therapy; the decision to do so should be made on a case-by-case basis. There is insufficient evidence to determine the balance of benefits versus risks for starting statin therapy in adults ≥ 76 years old.
Vision screening The American Academy of Ophthalmology recommends performing an eye examination every one to two years for all adults 65 years of age and older. For certain ocular disorders like glaucoma, for patients at risk for diabetic retinopathy, and for people who have a high-risk for developing an ocular disorder, screening should be done more often and started at an earlier age.

Aging Adult: Preventive Care

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.

Aging Adult: Nutrition

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.

Aging Adult: Medications

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.

Aging Adult: Safety Issues

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).

Financial exploitation: Misusing and or exploiting an older adult's financial resources.

Neglect: Failing to provide the necessities of life.

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 (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).

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