Lesson 9: Life Span DevelopmentBy

WILLIAM E. GANDY, JD, LPCreated May 7, 2015. Last revised December 13, 2015.

Copyright William E Gandy 2015

Key Concepts:Upon completion of this chapter you should be able to discuss and define theseconcepts:

Discuss and define the following groups:

Neonate Infant Toddler Preschooler School-age child Adolescent (teenager) Early Adult Middle Adult Late Adult

Describe the major physiologic and psychosocial characteristics of an infant’s life.

Describe the major physiologic and psychosocial characteristics of a toddler andpreschooler’s life.

Describe the major physiologic and psychosocial characteristics of a school-agechild’s life.

Describe the major physiologic and psychosocial characteristics of an adolescent’slife.

Describe the major physiologic and psychosocial characteristics of an early adult’slife.

Describe the major physiologic and psychosocial characteristics of a middle adult’slife.

Describe the major physiologic and psychosocial characteristics of a late adult’s life.

Humans develop in many different ways. They increase in sizeas well as in function and capability.

PHYSICAL GROWTH:

Growth from birth to adolescence has two phases, rapid growth from birth to about twoyears, and slower, sustained growth from age two to puberty. Puberty is the process ofphysical maturation from childhood to adulthood, and it occurs during adolescence.Adolescence is the age span during which puberty occurs.

Terms used to designate age groups:

Neonate - birth to one monthInfant – one month to one yearToddler – 1 to 3 yearsPreschooler – 3 to 6 yearsSchool-age – 6 to12 yearsAdolescent – 13 to 17 yearsEarly Adult – 18 to 40 yearsMiddle Adult – 41 to 60 yearsLate Adult – 61 years and older

NormalVital Signs

Age PulseBeats perminute

Respirationsper minute

BloodPressureSystolic

TemperatureFahrenheit

TemperatureCelsius

InfantAt birthAt 1 year 100-180

100-16030-6030-60

60-9087-105

89-10098-100

36.7-37.836.7-37.8

Toddler 12-36months

80-110 24-40 95-105 96.8-99.6 36.0-37.6

Preschool 3-5years 80-110 24-34 95-110 96.8-99.6 36.0-37.6School-age 6-12 years 65-110 18-30 97-112 86.6 37.0Adolescence13-18 years 60-90 12-26 112-128 98.6 37. 0EarlyAdulthood 19-40 years

60-100 12-20 120/80 98.6 37.0

MiddleAdulthood 41-60 years

60-100 12-20 120/80 98.6 37.0

LateAdulthood 61years andolder

60-100may varywithoverallhealthstatus

12-20may varywith overallhealthstatus

120/80may varywith overallhealthstatus

98.6 37.0

Infants

Pulse and respiratory rates are highest in neonates and infants, and they diminish withgrowth and age, as shown in the table above.

Weight varies between 3.0 and 3.5 kg at birth but may vary upward or downward.Weight usually drops up to 10% during the first week but is regained by the second week.Weight should double by 4-6 months and triple by 9-12 months.

Before the child is able to stand up we measure its length, but as soon as it can stand wedescribe it by height. Healthy term infants grow about 2.5 cm/month between birth and6 months and 1.3 cm/month for the next 6 months. From one year to 10 years growthaverages about 7-8 cm per year depending upon genetic factors. Extremities grow fasterthan the trunk. Boys have a growth spurt between about ages 12 and 17 and in girlsbetween about 9 and 14.

Body water measured as a percent of body weight equals 70% at birth, dropping to about60% at one year, which is about adult weight. Because of the relatively higher bodyweight in infants they are more susceptible to fluid deprivation and dehydration.

Respiratory System

The infant’s lungs are collapsed before birth, so the first breaths must be forceful. Thelungs make surfactant, a complex compound that lowers the surface tension between thewalls of the alveoli and keeps them from collapsing when we exhale. Premature infantsmay not have enough surfactant and must receive surfactant replacement therapyimmediately after birth in order to breathe. Infants are considered premature if they areborn before 37 weeks gestation. Infants born before 35 weeks gestation are likely to needsurfactant replacement therapy. After the first powerful breaths the lungs expand and theinfant can breathe easily.

Infants breathe primarily through the nose for the first 4 weeks of life, making itimportant to keep their nasal passages clear. Nasal congestion can cause breathingdifficulty during feeding. An infant’s airway is shorter, narrower, and more easilyobstructed than an older child’s airway. Because of the small lung size, care must betaken during mechanical ventilations not to hyperinflate and cause a pneumothorax. Thebreathing muscles are immature and tire easily, so that rapid breathing cannot besustained over a long period of time. At rates higher than 60 breaths per minutebreathing becomes inefficient and much of the air never reaches the alveoli. Also rapidrespiration rates lead to heat and fluid losses. Since the intercostal muscles are not welldeveloped, infants are diaphragmatic breathers. When assessing respiratory rates, look atthe abdomen for rise and fall. Infants have higher metabolism than adults, so theyconsume oxygen at higher rates.

Cardiovascular System

There are two structures in the fetal heart that must undergo changes shortly after birth:The ductus venosus, the blood vessel connecting the umbilical vein and the inferior venacava, must constrict; the blood pressure increases and the foramen ovale, the opening inthe septum between the atria closes. The ductus arteriosus, a blood vessel that connectsthe pulmonary artery and the aorta also constricts and closes, which starts the normalcirculation functioning. This happens usually within the first 15 minutes of life, but maynot be complete for up to a year. After closure, the ductus venosus becomes a fibrouscord called the ligamentum venosum that is embedded in the wall of the liver, and theductus arteriosus becomes the ligamentum arteriosum, which connects the arch of theaorta to the left pulmonary vein and is often the site of a tear in the aorta from severeblunt trauma to the chest in adults. Also of note, the ligamentum arteriosum is closelyrelated to the left recurrent laryngeal nerve, a branch of the left vagus nerve. Injury to theaorta that produces bleeding into the mediastinum may cause pressure on this nerve thatshows up as hoarseness, a sign of injury to the aorta.

Nervous System

Infants are able to feel pain but probably not able to localize it. As the child develops, theability to localize pain improves. The cranial nerves are highly developed at birth due totheir important functions such as sucking and gag reflexes, swallowing, and blinking.

Several reflexes are present in the newborn that are specialized, including the Mororeflex, which is normally seen at birth but disappears in 3-4 months. It is an importantreflex to check after birth. When the infant is startled or feels like it is falling it will havea “startled” look and the arms will fling out sideways with the palms up and the thumbsflexed. Absence of this reflex in a newborn is abnormal and may indicate an injury ordisease.

Other reflexes are the palmar grasp, initiated by placing a finger in the infant’s palm, therooting reflex, which causes the hungry infant to turn his head toward the mother’snipple, and the sucking reflex. These also generally subside after 3-4 months.

The Babinski reflex, fanning of the toes and extension of the large toe when the lateralsole is stroked, is a test of lower motor neurons.

The paramedic should check for intact reflexes in the child. A flaccid, limp child isa child in trouble.

Fontanelles

Fontanelles are fibrous tissues in between the bones of the skull that will fuse together.They allow for compression of the head during birth and for rapid growth of the brainearly in life. The posterior fontanelle usually closes first, in 2-3 months, and the anteriorone closes between 9-18 months. The fontanelles can be an important factor indetermining the infant’s degree of hydration: depressed fontanelles indicate dehydration,while bulging fontanelles may indicate rising intracranial pressures and cerebral edema.

Immune System

Some antibodies pass from mother to child through the fetal bloodstream, so the fetus hassome of the mother’s active immunities against pathogens. The fetus is said to havenaturally acquired passive immunity. This remains active for up to a year after birth.A breast fed baby also receives the mother’s antibodies through breast milk.

Renal System

Kidneys are not able to produce enough concentrated urine, so the baby’s urine is arelatively dilute fluid with a specific gravity that seldom exceeds 1.0, which is the samespecific gravity as water. Newborns can easily become dehydrated.

Sleep Patterns

Newborns sleep around 16-18 hours a day, decreasing to 14-16 hours a day with 9-10hour periods at night. Infants usually begin to sleep through the night by the fourthmonth.

Musculoskeletal System

The ends of the infant’s long bones are covered with epiphyseal plates, also called growthplates. Long bones have a growth plate at each end which, as they grow, become solidbone. These plates determine the length and shape of the bone. The epiphyseal plates arethe weakest part of the bone and are easily injured. Many factors affect bonedevelopment, including genetic factors, nutrition, exposure to sunlight, growth hormones,thyroid hormones, and overall health. Growth plate injuries can occur from sportscompetition and from falls, automobile accidents, and so forth. These injuries occurtwice as often in boys as in girls because girls’ bones finish growing sooner and theirgrowth plates are replaced by strong, solid bone sooner than boys. The most commongrowth plate fractures occur in the phalanges and radius but are also common in the tibiaand fibula.

The muscles account for around 25% of the infant’s body weight.

Psychosocial Development

Psychosocial development begins at birth. Instinct and interaction with the environmentand family guide development. Lack of a stable family can interfere with socializationand hinder development.

Newborns communicate through crying. The parent soon becomes able to interpretdifferent crying sounds that signal hunger, discomfort, fear, pain, anger, frustration, andsleepiness. An alarming, distressed cry, is easily interpreted.

Newborns bond with their parents and develop a secure attachment to them that theydepend upon to take care of their needs. An infant who is not certain about whether ornot his caregivers will take care of him may develop another type of attachment, ananxious resistant attachment. This can lead to a child who has separation anxiety andwho becomes anxious about being separated from the parent. This is called anxiousavoidant attachment and occurs when the infant has no confidence that he will be takencare of. This can result in serious personality disorders and often stems from repeatedrejection or institutionalization.

Trust and mistrust develop from experiences from birth to about 1½ years. The infantdevelops trust through consistent parental care, but when there is inadequate care hedevelops anxiety and insecurity which can develop into mistrust and hostility and evenantisocial or criminal behavior later on in life.

Scaffolding

Scaffolding is building on what one already knows. As the child learns and develops, theparent provides opportunities to learn by giving tasks and responsibilities that allow thechild to build on what he knows. This involves giving advice, coaching, and challengesthat are within the child’s abilities to meet.

Temperament

The child’s temperament develops during the first year. Most children are usuallycheerful and quick to warm up and able to adapt to changes easily. However, otherchildren may be difficult or slow to warm up, appear inactive, develop a negative mood,and adjust slowly to changes. Affect is a person’s expression of feelings or emotionthrough facial expressions, gestures, vocal tone, and so forth. It is a person’s emotionaltone. In the first three months infants smile randomly and without apparent stimulation;after that they begin demonstrating emotional expression through a reflexive smile andother interactions such as cooing or mouthing. Continued social interactions drive theinfant’s socialization. The infant’s ability to withstand parental separation is animportant step in development. The first stage of parental separation reaction is protest,the second despair, and the last is detachment or withdrawal. Protest takes the form ofcrying, restlessness and rejection of all adults. If separation continues despair sets in,demonstrated by hopelessness, continuing crying, inactivity, and withdrawal. In the finalstage, the infant displays renewed interest in its surroundings although it may be a remotekind of interest. Failure to exhibit separation anxiety may be indicative of autism.

When the medic needs to examine the child separately from a parent, separation anxietymay be observed. The infant may resort to self-soothing activities such as thumb suckingduring periods of isolation.

Separation anxiety is normal in very young children, and they are often “clingy” andafraid of unfamiliar people and places. Separation anxiety becomes a disorder when itpersists in an older child, is excessive, and lasts for a long time. Fear of separation cancause great distress and interfere with normal activities such as going to school or playingwith other children. It may also manifest as refusal to sleep without the caregiver beingnearby, fear of being alone, bed wetting, and physical manifestations such as headaches,temper tantrums, and pleading.

Age Developmental Milestones (from The Merck Manual, 19th ed)

Birth Sleeps 16-18 hours a daySucksClears airwayCries when disturbed

4 weeks Brings hands toward mouth and eyes

Moves head from side to sideFollows an object moved in an arc close to faceResponds to noise by startling, cryingTurns toward familiar sounds and voices

6 weeks Smiles when spoken toLies flat on abdomenHead lags when in sitting position

3 months Holds head steady on sittingRaises head when lying on stomachOpens and shuts handsPushes down when feet placed on flat surfaceSwings at and reaches for dangling toysFollows an object moved in arc above faceWatches faces intentlySmiles at sound of caretaker’s voiceVocalizes sounds

6 months Holds head steady when uprightSits with supportRolls over from stomach to backReaches for objectsRecognizes people at a distanceSmiles spontaneouslyBabbles

7 months Sits without supportBears some weight on legs when held uprightTransfers objects from hand to handHolds own bottleResponds to nameResponds to being told “no”Plays peek-a-boo

9 months Sits wellCrawlsPulls self up to standing positionGets into sitting position from stomachStands holding on to someone or somethingSays “mama” or “dada” appropriately in reference to parentsWaves goodbye

12 months Walks by holding furniture or handsMay walk 1 or 2 steps without supportStands for a few moments at a timeDrinks from cupSpeaks several wordsHelps dress self

18 months Walks wellSpeaks about 10 wordsPulls toys on string

Partially feeds self2 years Runs well

Climbs stairs aloneTurns single book pagesPuts on simple clothingMakes short sentencesVerbalizes toilet needs

3 years Rides a tricycleDresses except for buttons and lacesCounts to 10 and uses pluralsRecognizes at least 3 colorsQuestions constantlyFeeds self wellBeginning to take care of toilet needs

4 years Alternates feet going up and down stairsThrows a ball overhandHops on one footCopies a crossWashes hands and face

Toddler and Preschool Age

Physiological Development

Vital signs change. See chart above. Years 2-5 exhibit extraordinary growth. Childlearns to run, jump, hop, and throw. Many changes occur in body systems.

Cardiovascular system is better developed. Capillaries are better established and aid inthermoregulation. Hemoglobin levels approach adult levels.

Pulmonary system shows an increase in terminal airways and alveoli establishing moresurfaces for gas exchange. However, chest muscles are still immature and cannot standprolonged rapid respiratory rates. Ventilatory failure is still possible if respiratory ratesare increased for long periods of time.

Renal system is well-developed and urine characteristics similar to adults.

Immune system has lost its passive immunity and child is more vulnerable to community-borne infections. However, the child’s own immune system is improving.

The brain is now 90% of adult weight and myelination of nerves has increased to theextent that fine motor skills are beginning to develop. The child should be walking wellby this time.

Muscle mass and bone density have both increased.

Primary teeth should all have come in by 36 months.

Sight and hearing are improving with hearing reaching maturity at 3-4 years. Sight is20/30.

Toilet training is possible from 18-30 months with age of complete toilet trainingaveraging 28 months.

Psychosocial Development

Cognition

Talking may begin around 10 months but understanding of words comes a little later. Byage 3 or 4 most children should be talking in complete sentences. Cause and effectunderstanding appears between 18 and 24 months, and separation anxiety develops.“Magical thinking” begins around 24-36 months and play-acting comes into play. Thetoddler begins to explore his surroundings and develops competitiveness. Siblingrivalries may develop at this stage. First-born children may find sharing with youngersiblings frustrating, while younger children may develop jealousies of their older siblings.

Toddlers exhibit concrete thinking and cannot think in abstracts. The medic must becareful in how statements and questions are phrased because young children will takethem literally.

Awareness of mathematical relationships begins to develop along with symbolic thought.Language syntax, rules of grammar, and word meanings (semantics) improve steadily.Differences in expression between males and females begins to occur.

Peer-Group Functions

Peer groups become very important in introducing the child to information outside thefamily unit and the world at large. Children learn many skills from each other.

Parenting Styles

Parents come in three basic styles: Authoritarian, Authoritative, and Permissive.

Authoritarian parents are demanding and demand obedience, with little tolerance for thechild’s views. Punishments are often handed out without explanation, and this may leadto low self-esteem, hostility, and shyness.

Authoritative parents are more flexible and attempt to explain the reasons for demandsto children rather than simple demands for obedience that are seen in the authoritarianparent. These parents enforce rules but encourage independence. This style may lead toindependent, self-assertive, friendly, and cooperative children.

Permissive parents tolerate a wider variety of behaviors and rarely punish or demandobedience from children. Children may become impulsive and aggressive with poor self-control, low maturity, and exhibit irresponsible behaviors.

Divorce and Child Development

Divorce can have serious consequences for a child’s psychological life since manychanges may occur. Children may feel abandoned by the parent who is no longer presentin the home and may become depressed. Poor parenting often goes with poor marriages,and the effects on children can be profound, leading to many problems later in life.

Influence of TV, Computers, and Video Games

The influence of television, computers, social media, and video games cannot beunderestimated. It is now common for toddlers and young children to spend many hourswatching television and playing video-based games. Video games may be educationaland help to develop hand-eye coordination but also may introduce the child to influencesthat are harmful. If video games and TV replace quality time spent with parents, socialdevelopment may be affected. Violence on TV and in video games may have an effecton children’s perceptions of social behaviors.

Today’s world exposes children to computer skills early in life. A 2005 study in the U.S.Department of Education reported that 67% of nursery-aged children have used acomputer, while 23% have also used the internet. Keep in mind that this study is 10years old as of this writing. 1

Preschool children routinely know how to do a wide variety of computer functions suchas controlling the cursor with the mouse, using the keyboard in many ways, andidentifying icons that represent different programs.

Sexual Development and Modeling

Toddlers and preschool-age children imitate behaviors they see in their parents, siblings,and peers, becoming aware of gender differences and, through modeling, incorporategender-specific behaviors.

School Age Children

Vital signs continue to change. See chart above for comparisons.

School age children begin to develop a self-concept, self-esteem, and concepts ofpopularity, rejection, emotional support, and neglect. Negative self-esteem may bedamaging to development.

During this period the child focuses on objects and events. Concepts such as spatialrelations, the nature of time, and sequential nature of events and activities are acquired.Language, musical skills, logical skills, and athletic skills develop and improve.

Moral development begins and behavior shifts from external parental control to internalself-control. Psychologist Jean Piaget described a two-stage process of moraldevelopment which was expanded upon by psychologist Lawrence Kohlberg, whotheorized that children develop moral concepts in three levels, each of which has twostages: Preconventional reasoning, conventional reasoning, and postconventionalreasoning.

In preconventional reasoning stage one is punishment and obedience, where rules aresimply obeyed with no concern about morals. Stage two is the state of individualism inwhich children obey the rules but purely for self-interest. They are not much concernedabout others but mostly in avoiding punishment.

In conventional reasoning, stage three, children seek approval of others and concernthemselves with interpersonal relations; in stage four they develop the social system’smorality and become concerned with correct behavior at a societal level. This is the stageof “good boy-good girl” orientation with an emphasis on conformity.

In Postconventional morality, stage five stresses community rights over personal rights,and people learn to appreciate differing values, opinions, and beliefs of others. Rules oflaw are important. Stage six is concerned with universal ethical principles with emphasison principles of justice and an informed conscience. 2

Individuals progress through these stages throughout school age and young adulthood.

Adolescence

Vital signs approach adult levels, reproductive systems mature, and growth is almostcompleted. Secondary sexual characteristics are completely developed. In femalesendocrine hormones follicle-stimulating hormone (FSH), luteinizing hormone (LH),and gonodotropin stimulate estrogen and progesterone production. In males,gonadotropin stimulates testosterone. Voice changes occur, mostly in males.

Muscle mass and bone development are nearly complete. Body fat decreases in earlyadolescence and increases later. Females require 18-20% body fat for menarche to occur.Blood chemistry is essentially at adult levels. Acne sebaceous glands becomeoverproductive, contributing to acne.

Developing Identity

Teens strive for independence and want to be treated like adults but lack the maturity andjudgment to achieve independence.

They may experiment with a variety of “identities” and seek friendship and security ingroups and gangs.

They develop strong sexual drives but lack knowledge and understanding. Teenagepregnancy is a huge problem.

Exposure to the world of drugs, alcohol, and tobacco may lead to dangerous and self-destructive behaviors.

More and more adolescents, along with younger children, now suffer from obesity. Pooreating habits, junk foods and peer pressure lead to obesity, type 2 diabetes, hypertension,and accelerated coronary artery disease. Obesity may lead to depression and eatingdisorders. Anorexia nervosa involves problems with self-image and results in self-starvation. Bulimia involves binge eating and purging through vomiting and, sometimes,use of laxatives and diuretics such as furosemide (Lasix). Mood disorders, anxiety, andcompulsive behaviors indicating poor self-control are common in patients with anorexiaand bulimia. These are psychiatric disorders and require psychiatric care.

Teenage Suicide

Teenage suicide is among the three top causes of death in teens, competing with motorvehicle collisions and homicide. Depression is found in as many as 25% of adolescents.Suicide is the 3rd leading cause of death for kids between ages 10 and 24. Firearms areresponsible for 45% of youth suicides, with suffocation accounting for 40%. 3

Cognitive Development

Teens begin to apply logic to abstract ideas. Math and language skills continue toimprove and develop.

Early Adulthood

Vital signs level off at adult values. Heart rate averages 70 per minute, respiratory rateaverages 12-20 breaths per minute, blood pressure averages 120/80 mmHg, and bodytemperature averages 98.6º F (37.0º C). However, these are averages and fluctuate withinnarrow limits depending on numerous influences.

Physical condition peaks between 19-26 years. After this, the body begins to undergochanges with age. We get shorter because our spinal disks settle; fatty tissue increasesand we gain weight (over ½ of adults are overweight), reaction times slow, we losemuscle mass, and stresses take their toll. Unhealthy behaviors such as ETOH, drug, andtobacco use may begin, sometimes as early as adolescence, and become establishedhabits and addictions.

Children are born, adding to stresses, both good and bad. Many young parents have poorparenting skills and may become frustrated or puzzled by routine illnesses and injuriesthat happen to their children. Medics should expect to be called to see many of thesecases. While we may see them as trivial and an “abuse of the system” they may be realemergencies to the parents. We must understand that we also have a role in educatingparents about routine diseases, issues such as use of antibiotics when not indicated, andoffering emotional support to parents. EMS increasingly becomes a source of emotionaland social support for many segments of society.

The body and mind respond to stresses in both healthy and unhealthy ways. Chronicstress may lead to hypertension from constant stimulation of the sympathetic nervoussystem (adrenalin release), and depression may become problematic.

Divorce occurs in around 50% of initial marriages.

Middle Adulthood

Middle adulthood encompasses the ages of 41 through 60 years. Average vital signs donot change but, with increasing age health factors may act to modify an individual’s vitalsigns.

Routine changes that may be expected are cardiovascular changes with increases in “bad”cholesterol (LDL, or low-density lipoprotein cholesterol), and triglycerides (fats carriedin the blood), and decreases in “good cholesterol (HDL, or high-density lipoproteincholesterol).” Cardiac output may decline and exercise tolerance along with it.Maintaining normal weight becomes more difficult. Cardiovascular disease may developduring this age span. The medic should learn to assess the heart by listening for 3rd and4th heart sounds, murmurs, and other abnormal sounds that may indicate developing heartdisease.

It is also important for providers at the paramedic level to become as familiar as possiblewith ECG interpretation and learn to spot signs of myocardial infarction, ischemia, andmany other signs of heart disease such as left ventricular hypertrophy.

Vision deterioration and hearing loss can cause stresses. Eyesight typically changes inthe early 40’s, sometimes referred to as the far-sighted 40’s when farsightedness(hyperopia or presbyopia) may begin.

While cancer can develop at any age, people in middle adulthood show the mostinstances of cancer.

Women experience menopause, beginning in early 40’s for some and in the 50’s forothers.

Depression sets in for some due to a variety of causes, not all of which are wellunderstood. Some women develop depression during menopause, some because of theirchildren now being grown and living away from the family with independent lives.Grandchildren appear. Some people go through a syndrome sometimes called “theMiddle Aged Crazies” in lay terms. In 1965 psycologist Elliott Jaques coined the term“midlife crisis” in his book “Death and the Midlife Crisis.4

Midlife crisis is not universally recognized as a psychological condition, but we have allseen its manifestations. People start to think about their own mortality, their failed goals,being stuck in jobs they hate, their physical changes, and many other factors.Climacteric is a term meaning decline in sex hormone production both in women andmen. Many sources incorrectly define it as menopause only, but it also refers toandropause, or male menopause where testosterone levels drop. Many men in middleadulthood seek testosterone therapy to replace loss of natural testosterone. There arecurrently questions being raised about whether or not this may increase the risk of cardiacproblems.

Typically, when applied to women, the term climacteric describes conditions thataccompany menopause such as so-called hot flashes, facial flushing, vaginal dryness,urinary incontinence, heart palpitations, insomnia, fatigue, depression, emotionalinstability, reflecting decline in ovarian estrogen production. Some women take estrogenreplacement, which can relieve symptoms but also raises the risk of come cancers,particularly breast cancer. Women who have undergone hysterectomy (removal of allor part of the uterus) or oophorectomy (removal of the ovaries) will have a surgicallyinduced menopause, which is believed to increase the risk of heart disease.

Hysterectomy may be done in several ways: Supracervical (subtotal) hysterectomy, in which the surgeon removes only the

upper part of the uterus, leaving the cervix in place Total hysterectomy, in which the entire uterus and cervix are removed Radical hysterectomy, in which the entire uterus, tissue on the sides of the uterus,

the cervix and the top part of the vagina are removed. This is typically done whencancer is present.

Removal of the ovaries (oophorectomy) and fallopian tubes (salpingectomy) may or maynot be done at the same time as a hysterectomy. The removal of both fallopian tubes andovaries is called salpingo-oophorectomy.

Women who have a hysterectomy without salpingo-oophorectomy may be at risk forovarian and/or peritoneal cancer, cancers that are notoriously insidious and difficult todiscover before physical signs such as ascites appear. Once ascites appears, it is likelythat the tumors have metastasized. Women who have had hysterectomies withoutsalpingo-oophorectomies should maintain careful vigilance with their physicians forsigns of cancer thereafter.

During this period of life some resort to drug or alcohol abuse, often accompanied by theacquisition of expensive toys such as cars, clothing, jewelry, and so forth. Both men andwomen may to seek comfort in plastic surgery and changes in mode of dress to try toreflect a younger image. Divorce may be more common in these years with both menand women seeking so-called trophy spouses.

These changes may result in chance taking, drug and alcohol problems, depression,aggression, and many other manifestations that could generate an EMS call.

Cognitive development may decline in some individuals in late middle adulthood, whilein others there is no sign of it. Some older individuals may have difficulty adapting to theworld’s evolving communications media and resent having to learn new tasks, whileothers may adapt readily. Nothing can be said concretely about cognitive decline withage except that it eventually happens; but at what age varies widely.

As adults age they may find that their rolls with their living parents become reversed;they may now become caregivers and responsible for financial support of their parents.This may lead to frustration and in some cases, elder abuse.

“The professional Paramedic recognizes that aging is not a disease but a developmentevent beginning before birth.” 5

Late Adulthood

People are living longer and longer. Senescence, the process of growing old, at one timewas said to begin at age 65; however, we know this is not true and that it varies fromperson to person and involves processes that may, in fact, begin long before lateadulthood. For example, buildup of plaque in arteries begins shortly after adolescence.

Many of a medic’s patients will be elderly and undergoing aging. Medics must resist thetemptation to fall into “ageism” or stereotyping the elderly. The elderly patients paytheir salaries because they likely have insurance (Medicare/Medicaid) that pays foremergency medical care. A philosopher once said, “If you live long enough, you will beold.”

The current biological limit for life span is approximately 120 years, but few reach thatage due to injury and illnesses.

In late adulthood, from age 61 on, vital signs depend upon the general state of health ofthe person. Changes in heart rate, blood pressure, and respiratory activities may occur;however, body temperature should remain within the normal range near 98.6. Elderlypatients may not produce as high a body temperature or a change in body temperature asrapidly in response to infection as younger patients. Signs of sepsis include bodytemperatures that are both lower and higher than normal. The ability for the medic torecognize sepsis early-on is essential.

Psysiologic Change Resulting Problem

Altered temperature controls fromhypothalamus dysfunction

Heatstroke or hypothermia

Decreased sweating and skin changes Inability to develop a fever when sickLoss of skin collagen and elastin Wrinkles, skin tears, skin breakdown,

The following is taken from a free booklet, Geriatric Emergencies: An EMTTeaching Manual, by Teresita M. Hogan, MD, FACEP, et al, and is availableFREE for downloading from The MedicAlert® Foundation, available at:www.medicalert.org/sites/default/files/document/geriatric_manul.pdf.

skin infectionsLean body mass replaced by fat Prolonged action of lipid soluble drugs

like benzodiazepines and barbituratescausing:

Altered mental status Diabetes Coronary artery disease

Fluid volume changes lead to: Altered thirst GI disorders

DehydrationElectrolyte disturbances

Diuretic use DehydrationElectrolyte imbalanceVolume depletionOrthostatic hypotension and dizziness

Cardiovascular changes lead to: Decreased contractility Coronary artery disease Conduction system abnormalities Reduced postural reflexes

Congestive heart failureAcute coronary syndromesDysrhythmiasAtrial fibrillationHeart blocksDizziness and syncopeFalls

Central nervous system: Decreased brain mass Adherent dura (adheres to skull)

More intracranial bleedsMore room for movement in trauma tothe head, and tearing of arteries (middlemeningeal artery)Adherent dura lessens epiduralhematomas and suggests moreintracranial bleeds, although a hard fallmay result in either or both.

Neuronal transmitter decrease Sensitivity to antipsychotic medicationsParkinsonian rigidity and spasticityDepression

Reduced hearing, sight, smell, and taste Falls and motor vehicle collisionsDepression from realizing these deficits

Deafness causing a music lovernot to be able to hear music well

Partial deafness makingconversations in restaurants andother public places difficult

Having trouble reading menus atrestaurants

Having to have two pairs ofglasses to read and work at thecomputer

Not being to smell the things oneliked to smell, including the smellof food

Not being able to taste food wellGait instability, sluggish reflexes Higher risk of falls

Increased chance of burnsDiminished mobility and depravation ofdriving ability.

Declining immune function Higher risk of bacterial infections, the mostcommon ones being:

Pneumonia Urinary tract infections Skin infections

Nursing home patients presenting oftenwith sepsis that is raging and has not beendetected by the nursing home staff

Other notable changes that should be mentioned are:

Because of decreased contractility of the heart resulting in prolongedcontraction times, decreased reaction to cardiac drugs due to deterioration ofreceptors, and decreased conductivity and excitability of heart muscle cells,the heart loses some of its strength of contractions and the ejection fraction(percent of the blood in the ventricle that is ejected with each systole)declines. Tachycardia is less well tolerated.

Changes in the lungs and respiratory system result in less functioning alveoli,less elasticity in lung tissues, less pliability in the ribs resulting in rigidity ofthe chest wall, weakness of the diaphragm, and a general decline inrespiratory function. Lifelong exposure to pollutants and irritants may causechanges in the interstitial tissues in the lungs and less pliable alveolar walls,thickened alveolar walls resulting in lessened diffusion of gasses, and overalllessened respiratory function.

Glucose metabolism and insulin production decrease. Thyroid functiondeclines, cortisol production is diminished by 25%, and the pituitary gland is20% less effective.7

Peristalsis slows down, and the esophageal sphincter is less effective, leadingto gastroesophageal reflux disease (GERD). It takes longer for food to bedigested and moved through the digestive tract, leading to feelings of fullnessand constipation in patients who do not drink enough fluids.

Diverticula in the colon is a common finding with colonoscopies in patientsover 50, which can lead to diverticulitis. In men and women past menopause,left lower quadrant abdominal pain may be diverticulitis.

Opioid receptors increase with age, so that opioid administration over aperiod of time may cause constipation. Look for this in patients who are onhome morphine administration for conditions such as cirrhosis of the liver orcancers in the abdominal tract.

Many other metabolic changes occur with aging that affect the GI tract.[Explore these changes by Googling “metabolic changes in the elderly.” Youwill find many good articles that illustrate these changes. The professionalparamedic will always seek to improve knowledge about every aspect of hisprofession.]

The kidneys shrink by 25-30 percent in the elderly, and half of one’snephrons are lost by age 80 by some estimates. 8

Decreased renal function may lead to diminished clearance for some drugs,particularly those that are eliminated through the kidneys.

o Example: Morphine is metabolized by the liver to a metabolite that isactive. It is excreted by the kidneys. In elderly patients, excretionmay take longer, leading to prolonged effects from a dose of morphine.Contrast fentanyl, which is not metabolized in the liver and isexcreted in the GI system. This is why fentanyl is the drug of choicefor patients with known renal failure.

Taste and smell decline rapidly after age 50 and at age 80 smell is 50% lessthan at its peak. Taste and smell work together to provide enjoyment of food,and loss of these functions may render the elderly patient unable toappreciate food and discourage him from eating.

Reaction time is diminished, as is pain sense. Hearing loss involves changes in the thickness of the eardrum, arthritis in the

bones of the middle ear, and loss of high frequencies. Since speech involvesmany pitches, elderly patients with hearing loss may find it difficult tointerpret speech. When in an environment with many competing sounds,such as in a restaurant or club, the elderly person may have a hard timeinterpreting the speech of those at his table.

The cerebellum controls coordination. Falls may be more frequent in theelderly because of deterioration of the cerebellum.

Practice Pearl : Any adult male with left lower quadrantpain should be investigated for diverticulitis.

Cognitive Development

Dementia and delirium are two different things. Delirium is an abrupt change in mentalfunction caused by a physical problem such as fever, hypoxia, toxins, drug effects, and soforth. It is usually reversible. Dementia, on the other hand, is a change in mentation

resulting from changes in the brain, usually over a long period of time, but can be causedby strokes, et cetera. Senile dementia is a broad term describing a number of differentconditions and is not a narrowly defined condition. Alzheimer’s disease, one type ofdementia, is a result of changes in the brain’s structure over time. Alzheimer’s has a slowand subtle onset that develops gradually over long periods of time. Elderly patientsexperience some normal loss of short-term memory functions that should not be confusedwith Alzheimer’s signs and symptoms. For example, the elderly patient may notremember someone’s name, but he knows whose name he is trying to remember. TheAlzheimer’s patient neither remembers the name nor the person.

Depression in the Elderly

Aging creates many stresses for the elderly, one of the most serious being loss of controlof one’s life. One cardinal event that elderly patients face is the necessity to stop drivingautomobiles. Loss of mobility is a disastrous event in an aging patient’s life. Otherfactors such as vision and hearing loss, to name just a couple, lead to a high incidence ofdepression in the elderly. Many, particularly men, are never diagnosed nor treated fordepression. Suicidal ideation is increased in elderly, particularly elderly men, who aremore likely to commit suicide than women. Depression is potentially treatable, and theparamedic should be alert for signs of depression.

Death and Dying

Most elderly folks accept the inevitability of death, and many plan for it. Acceptance ofthe inevitability of death is not the same as a death wish. When a terminal disease ispresent, the dying process has already begun. Some people deal with this better thanothers. Kubler-Ross described 5 stages of grief, which can also be applied to acceptanceof the fact that one is dying: denial, anger, bargaining, depression, and acceptance. Notall patients go through these stages, and not necessarily in that order. Some authoritiesdispute the accuracy of Kubler-Ross’s findings, but most will find some validity in them.Kubler-Ross’s views have provoked criticism in that they suggest that every patient mustprogress from one stage to another and that there is no chance of ameliorating them,which is not necessarily true. The paramedic must always consider the patient’s feelingsand offer support.

Some patients will have advanced directives in which they describe the care they wishto receive, or not receive, during their last days. These advanced directives have variousnames, such as Directive to Physicians, Durable Power of Attorney for Health Care,Living Will, and Do-Not-Resuscitate orders. The only one of these that paramedicsmay honor in an emergency situation is a statutorily executed Out-Of-Hospital Do

Practice Tip: Rule out acute and reversible causes of mental function beforeassuming that the patient has some form of dementia.

Not Resuscitate Order (OOH-DNR). These orders become active only on cessation ofpulses and respirations. They have nothing to do with care prior to clinical death such asIVs, pain medications, and so forth. The medic may always render what is calledpalliative care, such as pain relief and correction of hypoxia. One problem occurswhen the paramedic or AEMT decides that the patient needs to be intubated to protect theairway. A Directive-to-Physicians may state that no intubation is to be done, but thatcannot be honored by the paramedic. That is just what it says it is, a directive to thepatient’s physician. If the paramedic has doubts about what to do, contact medicalcontrol for advice. The mere fact of intubation has nothing to do with resuscitationof the patient who has lost pulses and respirations. In that event, if the patient hasan OOH DNR that is present and appears to be properly executed, all care stops atthat moment. Questions arise over out-of-state OOH DNRs. Some states, notablyTexas, have statutes that specifically require EMTs to honor out-of-state OOH DNRsunless there is a valid reason to doubt their validity. Every medic should be aware ofher/his own state’s laws concerning OOH DNRs.

Hospice

The paramedic may be called to a hospice or residence by a hospice nurse to treat apatient with pain medications. Usually this will only occur when the patient is at home,but could happen if the hospice happens to run out of morphine, dilaudid, or fentanyl andthe patient needs pain relief. If the paramedic has questions about whether or not this isappropriate, he or she should contact medical control for advice. Some services prohibittreatment with drugs followed by non-transport; however, there should be flexibility toallow for the situation where the patient needs pain relief but transport to the hospitalwould be inappropriate.

Assessment Pearls :

Your assessment techniques will change depending upon the age and developmentof your patient. Here are some suggested techniques. 6

Toddlers and Preschoolers Avoid medical terminology. Speak softly. Use language the child can understand. Let the child touch equipment before you use it. Parent stays with child during assessment if possible. Praise and reassure child. Allow child to have some control if possible. Use toy to distract and calm.

Start at feet of infants.

School-Age Children Child may fear your assessment and misinterpret what you are doing.

Explain. Communicate at child’s level. Gain history from both child and parent. Provide choices for the child whenever possible.

Adolescents Interview parents and adolescent together first, then gain consent from

parents to continue assessment with patient privately if possible. Conduct assessment as with adult. Remain nonjudgmental and neutral when condition might be the result of

alcohol or drug consumption or sexual activity.

Middle and Late Adulthood Look for signs of hearing loss and/or vision loss. Give the patient time to respond. Be a good listener. History will tell you the diagnosis the majority of the time. Look for medications and look them up if you do not recognize them. Do not call patient by Dear or Honey or Pops. Use Mister, Sir, and

Ma’am. Do not assume that elderly patients have physical or cognitive

impairment. Signs of cognitive impairment may, in fact, signal sepsis. Memorize the

SIRS (systemic inflammatory response syndrome) signs of sepsis andapply them.

Recognize angina equivalents in patients with signs of acute coronarysyndromes and remember that they may not always present in classicfashion.

A basic knowledge of lifespan development is essential for the practice of medicineat any level. Yes, medics do practice medicine, albeit a specialized kind of medicine.The medical professional at any level, from First Responder to the most advancedphysician, will continually strive for mastery of the skills and knowledge necessaryto provide good care for all patients. This requires a commitment to learn as muchas possible while practicing and continually seek new knowledge and information.

This chapter presents the tip of the iceberg of human growth and development.Continue to seek further information, follow up after each patient encounter andseek answers to things that eluded you. Only through a containing, self-imposed

continuing education lifestyle will one achieve mastery of the craft of prehospitalmedicine. The medic whose only contact with continuing education occurs atmandatory CE sessions is not worthy of the title “medic.”

Always feel free to ask your instructor for information, help in finding answers, andinsights into good medical care.

1 U.S. Department of Education National Center for Education Statistics Issue Brief:Rates of Computer and Internet Use by Children in Nursery School and Students inKindergarten Through Twelfth Grade: 2003. http://nces.ed.gov/pubs2005/2005111.pdf

2 Kendra C., Kohlberg’s Theory of Moral Development, available at:http://psychology.about.com/od/developmentalpsychology/a/kohlberg.htm (Accessed 5May 2015).

3 Centers for Disease Control and prevention. Youth Suicide. Available at:http://www.cdc.gov/violenceprevention/pub/youth_suicide.html (Accessed 8 May 2015).

4 Jaques E. Death and the midlife crisis. Int. J. Phycho-Anal., 46:502-514 (1965).

5 Beebe R. Myers J. Professional Paramedic: Foundations of Paramedic Care, Vol. 1. Pp.146-147. Delmar. 2010.

6 Batsie D A, Mistovich J J, Limmer D. Topics for the Paramedic (Transition Series),topic 13, pp. 72-74.

7Bledsoe B, Porter R, Cherry R. Paramedic Care Principles & Practice, 4th ed., Chap. 2,pp. 121-134. Pearson, 2013.

8Weinstein J R, Anderson S. The Aging kidney: physiological changes. Adv ChronicKidney Dis. 2010 Jul; 17(4): 302-307.

Resources: The author of this lesson referred to the following resources in preparation ofthis lesson:

Bledsoe B, Porter R, Cherry R. Paramedic Care Principles & Practice, 4th ed., Chap. 2,pp. 121-134. Pearson, 2013.

Beebe R, Myers J. Foundations of Paramedic Care, Volume 1. Delmar, 2010.

The Merck Manual, 19th ed., Merck Sharp & Dohme, Whitehouse Station, NJ, 2011.

Hogan T M. Geriatric emergencies: an EMT teaching manual, available for download at

http://www.medicalert.org/sites/default/files/document/geriatric_manual%5B1%5D.pdf.