Learning Objectives
By the end of this section, you will be able to:
- Identify physiological health risks for young and middle-aged adults
- Recognize psychological health risks of young and middle-aged adults
- Explain psychosocial health risks of young and middle-aged adults
Health risks for young adults and middle-aged adults exist on a continuum. While some health risks are age related, all are influenced by long-term lifestyle choices, genetics, and social circumstances. Nurses must remember the physiological, psychological, and psychosocial differences between young and middle-aged adults, as this age spread significantly affects baseline health and health outcomes. Many health outcomes are related to individual circumstances. Disease prevention and health promotion can be maximized by understanding the wide variation in health risks for adults aged 18 to 65 years. The following are high-risk areas for young adults:
- nutrition
- safety
- healthy habits
- health maintenance
- mental health
For middle-aged adults, nurses can focus on high-risk areas, including the following:
- mobility
- cognition
- psychosocial factors
- mental health
Individualized care is crucial, as health and wellness depend on age, chronic disease, lifestyle choices, and genetics. The range of ages in this category challenges nurses to assess individuals based on the different factors that affect the health and wellness journey and make the experience unique.
Physiological Health Risks
Young and middle-aged adults experience the possibility of many physiological health risks that affect normal biological function. Common risks that develop in these age groups are those associated with metabolic syndrome, a constellation of disorders including high blood pressure, high blood sugar, increasing abdominal obesity, and high cholesterol levels. These conditions significantly increase the individual’s risk of developing diseases such as type 2 diabetes, heart disease, and stroke. Because these conditions and disorders are interrelated, nursing interventions can be tailored to address multiple concerns simultaneously. As adults move through young adulthood into middle adulthood, their risk for various types of cancer also increases.
Malnutrition and Obesity
Adults of all ages are at risk for nutritional concerns, including obesity and malnutrition. In younger adults with poor nutritional habits, the body will counter with effective compensation. However, nutrient deficiencies can develop if individuals maintain a persistently poor diet or enter adulthood with poor nutrition and nutritional habits that began in childhood. Imbalances in nutrient intake can be referred to as malnutrition and encompasses deficiencies and excesses (World Health Organization [WHO], 2024). Malnutrition may occur from inadequate food choices or restrictive dieting, regardless of whether an individual appears underweight. This can include eating disorders such as bulimia and anorexia nervosa as well as other forms of disordered eating, such as binging, fasting, or restricting, that can affect nutrient absorption. Disordered eating can trigger micronutrient deficiencies in vitamin D, calcium, iron, and other important vitamins and minerals. Nutrient imbalances can contribute to or trigger chronic health disorders, such as obesity, diabetes, bone thinning, cardiovascular disease, and certain cancers (WHO, 2024).
To maintain health, the body must use essential nutrients from food and fluids for growth, energy, and bodily processes. Essential nutrients are those necessary for bodily functions. They must come from dietary intake because the body cannot synthesize or make them internally. Essential nutrients include vitamins, minerals, amino acids, and fatty acids. Adults require various protein sources, carbohydrates, and fats to maintain balanced nutrient intake.
Health risks develop when an individual’s intake does not provide adequate nutrients and calories or their diet does not provide essential nutrients. Obesity is the most common type of malnutrition in the United States. The CDC defines obesity as a disorder in which an individual’s weight is greater than the healthy maximum for their age and height (2022a).
By understanding the complex nature of the development of obesity and the metabolic shifts caused by obesity, nurses can provide focused care for patients. Factors that may increase the risk for obesity in otherwise healthy individuals include the following:
- overeating patterns
- poor food choices
- low physical activity
- sedentary lifestyle
- altered sleep routines
- poor sleep quality
- genetics
- low socioeconomic status
There are many health consequences of poor nutrition and obesity. Poor nutrition can lead to hair thinning, kidney failure, liver strain, and gastrointestinal disorders. Severe eating disorders can damage vital organs such as the heart, liver, and gastrointestinal tract (National Institute of Mental Health [NIMH], 2021). Obesity is by far the most widespread nutritional disorder in the United States, with the CDC reporting a prevalence of 41.9 percent in 2017. Between 2000 and 2017, the obesity prevalence increased by 11 percent nationwide. Obesity is the strongest risk factor and predictor of other metabolic disorders, including heart disease, stroke, and type 2 diabetes (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK], 2023). Increased mortality risk associated with obesity is due primarily to the many diseases that develop secondary to obesity, including metabolic disorders, liver disease, sleep apnea, and kidney disease, as well as those already mentioned (NIDDK, 2023).
Type 2 Diabetes
A disease defined by impaired glucose metabolism is type 2 diabetes mellitus. Type 2 diabetes is becoming increasingly prevalent in the adult U.S. population and is directly related to the prevalence of obesity in the nation. The CDC estimates that 38.4 million people have diabetes, whether they have been diagnosed or not. Up to a third of the adult U.S. population has prediabetes, a chronic abnormal elevation in blood sugar levels that is not elevated enough to be considered diabetes (NIDDK, 2024).
Prediabetes serves as the most potent indicator for the development of type 2 diabetes, yet its progression is not inevitable. Without substantial lifestyle adjustments, individuals diagnosed with prediabetes often transition to type 2 diabetes, although the timing varies from person to person. While type 2 diabetes involves chronically elevated blood sugar levels, it is not always permanent. Embracing a healthy lifestyle composed of regular physical activity, a well-balanced diet, weight management, and stress reduction can frequently enhance blood sugar management and potentially decrease or eliminate the necessity for medication in individuals with type 2 diabetes.
The development of diabetes puts individuals at risk for other health concerns that stem from damage to the vascular system. These risks include damage to tiny capillaries that supply organs and nerves. A complication associated with diabetes is end-organ damage caused by damage to vascular organ systems. End-organ damage can lead to or compound other metabolic disorders, significantly raising the risk of mortality in these individuals.
The most common end-organ damage and complications associated with diabetes include the following:
- kidney disease
- peripheral nerve damage
- retinal damage
- heart disease
High Cholesterol
High cholesterol is another component of metabolic syndrome often seen in individuals with diabetes and high blood pressure. Elevated blood lipid levels are highly prevalent in the adult population, with the CDC (2024b) reporting that up to 10 percent of adults have a total cholesterol greater than or equal to 240 mg/dL. Some elevated cholesterol is hereditary, but the single most significant factor affecting cholesterol levels for most people is lifestyle. Lack of physical exercise and high consumption of saturated fat increase total cholesterol. Lifestyle choices, including a high-sugar diet, also increase triglycerides, the most common lipids circulating in the body derived from food intake. As excess sugar is processed by the liver, it is turned into triglycerides that circulate in the bloodstream. All increased lipids put individuals at risk for vascular damage and heart disease. Specifically, fatty deposits, or plaques, develop on the inside of blood vessels. This deposition can happen throughout the body, particularly in the heart vasculature. These deposits slow the flow of blood and limit the oxygenation of heart tissue. The plaques can also break off and travel to distant smaller vessels, completely blocking blood flow. If blood flow is lacking to parts of the brain or heart, it can result in a heart attack or stroke.
Hypertension
Hypertension (HTN) is another vascular risk factor associated with metabolic syndrome. A consistently elevated blood pressure is hypertension. Due to vascular muscle contraction, impaired fluid balance, or other chemical reactions, the blood vessels are less flexible and more rigid. This increases the diastolic blood pressure, the baseline pressure within the vessels. Consequently, the heart must exert more force to pump blood and oxygen to the body’s organs. The systolic blood pressure is the pressure within the blood vessels when the heart contracts and moves blood peripherally. Untreated hypertension puts constant extra strain on the heart muscle, which can lead to a variety of other problems, such as kidney disease, vision loss, aortic aneurysm, peripheral artery disease, and congestive heart failure. Like diabetes, HTN is associated with end-organ damage, and the vascular pressure within the small vessels feeding organs damages the vessels. End-organ damage can be seen in the eyes, kidney, heart, brain, and larger vessels in the chest. Heart enlargement can develop from persistently elevated and untreated HTN. People with HTN are at higher risk for stroke and heart attack.
Cancers
According to the National Cancer Institute, cancer risk steadily increases with age (Figure 40.5). Historically, cancer rates among young adults have been lower than for middle-aged and older adults. However, recent trends in cancer rates between 2010 and 2019 show a significant increase in cancers in younger adults (Koh et al., 2023; Zhao et al., 2023). Studies show that these “early-onset” cancers, particularly breast and gastrointestinal cancers, are becoming more prevalent (Koh et al., 2023). The median age for several common cancers, including breast cancer, lung cancer, and prostate cancer, is between 60 and 70 years old (National Cancer Institute, 2021). Although it is much more common to be diagnosed with cancer in later middle adulthood, cancer is still a risk for adults of all ages.
Link to Learning
Colon cancer is a common and often treatable cancer that typically arises during middle adulthood. New guidelines for colorectal cancer screening were put out in 2021 by the U.S. Preventive Services Task Force (USPSTF). The new recommendations changed from initial screening at age 50 years to age 45 years.
Several known risk factors predispose individuals to certain types of cancer (Table 40.4).
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Clinical Judgment Measurement Model
Recognize Clues: Lung Cancer Risk
When patients seek care for health screenings, nurses must be alert for their specific disease risk factors. Many individuals do not know the recommended guidelines for routine health screenings and rely on nurses and other healthcare providers to recommend screening tests at the appropriate times. In reviewing health history, a patient may inform the nurse that they “quit smoking a while ago.” The nurse will recognize this as a cue to ask for additional information. The patient may then divulge that they made a New Year’s resolution to quit smoking and stopped “cold turkey” two weeks ago. The nurse will have determined the patient had smoked one pack per day for the last twenty-five years. The nurse recognizes that this patient qualifies for a low-dose lung cancer screening CT per USPSTF guidelines. These screening criteria include the following:
- age 50 to 80 years
- twenty-pack-year smoking history
- currently smokes cigarettes or quit within the past fifteen years
Psychological Health Risks
The psychological health risks in young and middle-aged adults encompass many of the same risks as adolescents and older adults, including anxiety, depression, and suicide. However, underlying stressors, mental health challenges, and family dynamics differ significantly between individuals. Factors affecting psychological health for adults include work environment, family dynamics, changes in family structure, financial strain or stress, educational pursuits, social pressures, child-rearing, death of loved ones, and caregiver fatigue in caring for parents. While the causes and contributors can be different, the manifestations of mental health concerns are similar among adults.
Anxiety
According to the American Psychological Association (APA) (n.d.-a), anxiety is a general term used to describe an emotional state in which an individual experiences tension, nervousness, and worry. Common physical symptoms associated with anxiety include elevated blood pressure, sweating, dizziness, and tachycardia (elevated heart rate). Anxiety is typically worry focused on future events or anticipated threats that are not readily identifiable. Anxiety encompasses several mental health disorders, including the following:
- generalized anxiety disorder (GAD)
- panic disorder
- specific phobias
- agoraphobia (fearing places or situations that might cause feelings of being trapped)
- social anxiety disorder
According to the APA (2023), nearly one-third of individuals experience acute or chronic anxiety at some point in adulthood. Data from the CDC in 2022 indicated that 12.5 percent of adults reported experiencing anxiety (CDC, 2022c).
Anxiety may be related to specific life circumstances or develop with other mental health disorders, such as depression. Mild anxiety is more common than severe anxiety and can often be treated without medication, as interpersonal therapeutics and coping strategies are often effective. In moderate to severe anxiety disorders, individuals are limited in their ability to maintain normal daily function due to intrusive thoughts and worries that are out of proportion to actual or perceived threats. These intrusive thoughts are disruptive thoughts or mental images that are associated with anxiety triggers that interrupt normal thought processes. These thoughts, in turn, cause behaviors such as avoiding specific circumstances, individuals, or groups. Treatment is necessary when anxiety levels affect an individual’s ability to perform work, take care of their family, manage daily tasks, or feel contentment.
The APA (2023) lists the percentage of adults who experience common anxiety disorders in adults:
- specific phobias (8 to 12 percent)
- social anxiety disorder (7 percent)
- panic disorder (2 to 3 percent)
- generalized anxiety disorder (2.9 percent)
While specific phobias are highly variable, social anxiety disorder is common among adults. It occurs when a person worries about experiencing embarrassment, humiliation, and rejection from others during social interactions. Common responses to social anxiety are avoidance of activities such as public speaking, participating in activities requiring meeting new people, and significant group situations (Mayo Clinic, 2018).
A panic disorder is characterized by anxiety associated with recurrent panic attacks (Mayo Clinic, 2018). Panic attacks are often associated with other mental health disorders, such as depression. A panic attack may look different for different individuals but typically includes a combination of physical symptoms that may include the following:
- chest pain
- sweating
- trembling
- tachycardia
- dizziness
- throat tightening
- tingling in the face or extremities
- chills
- nausea
Link to Learning
Differences between the symptoms of a heart attack and the symptoms of a panic attack are explained by the American Heart Association. Nurses can educate patients who experience panic attacks on how to read clues from their bodies to help differentiate these symptoms.
Depression
A mental health disorder known as depression is one in which individuals feel persistent and extreme sadness that leads to despair, interferes with normal daily activities, and disrupts sleep and energy patterns. The following are common symptoms experienced by adults with depression:
- trouble sleeping
- lack of interest in previously enjoyed hobbies and activities
- guilt
- low energy
- trouble concentrating
- change in appetite leading to weight loss or weight gain
- symptoms of anxiety or panic
- thoughts of death or suicide
Depression is highly prevalent, with the CDC (2023a) reporting that nearly 5 percent of adults in 2022 experienced depressive symptoms at some point in their lives. In that same timeframe, 11 percent of medical office visits were related to depression.
Anxiety and depression are commonly linked, with these disorders often occurring simultaneously or in succession. Nurses can help identify individuals experiencing depression by administering the Patient Health Questionnaire-9 (PHQ-9), a self-administered screening tool used to assess the severity of depression symptoms in individuals, per facility protocol, and monitoring for changes in patient affect. Monitoring for risk factors such as illness diagnosis, bereavement, significant life transitions, recent traumatic events, medication adverse effects, and substance use, which may exacerbate or precipitate depression, is another proactive approach nurses can take in identifying this mental health condition.
Link to Learning
The PHQ-9 Questionnaire helps nurses and healthcare providers quickly screen individuals for depression whether or not they are actively seeking care for mental health.
Suicide
The National Institute of Mental Health (NIMH, 2023) defines suicide as the act of intentionally causing one’s own death through self-inflicted injury with the intent to end one’s life. Suicide is closely linked to depression, abuse, emotional trauma, and other mental health disorders. Suicide is prevalent in the adult population. Among various demographic groups, adults between 25 and 34 years of age have the highest number of suicide deaths (NIMH, 2023). After the age of 35 years, the suicide rate is similar across adult age categories. Suicide is nearly four times more common in persons AMAB than persons AFAB across all age and racial groups. The overwhelming majority of suicides in the United States occur in White males (CDC, 2023e).
Link to Learning
Nurses in all practice settings should be alert for signs of mental health crisis and encourage patients to use community services in times of crisis, such as the National Suicide Lifeline where help is available.
Psychosocial Health Risks
For young and middle-aged adults, psychosocial health risks are most prominently linked to home and workplace environments. Learning environments, such as college or university settings, are also related to psychosocial risks for adults of all ages. Physical activity and risk-taking are typically higher in younger adults; however, unintentional injuries are common in all adult age groups. Challenges with interpersonal violence can occur at various levels for adults, including domestic abuse, workplace hostility, verbal hostility, or physically violent interpersonal interactions. Substance use and misuse are common among adults and contribute to detrimental effects on mental health disorders, social interactions, mortality rates, and life satisfaction. It also puts individuals at risk for health disorders, both acute and chronic, associated with substance use disorders.
Unintentional Injuries
Unintentional injuries are common in adults (CDC, 2023c). The cause of unintentional deaths has changed over the last forty years, from motor vehicle accidents (MVAs) being the most common to unintentional overdose being the most common in 2021 (CDC, 2023c). Unintentional injuries include injuries and death from, in order of prevalence, unintentional overdose (poisoning), MVAs or traffic accidents, drowning, and falls. Unintentional injuries are accidental but may be related to specific lifestyle risks, including substance use, impaired driving, and activities involving physical risks, such as high-intensity and risky sports.
Interpersonal Violence
The intentional use of physical force or power against another person or group that results in or has a high likelihood of resulting in injury, death, psychological harm, or deprivation is interpersonal violence. It can be associated with both physical and emotional abuse and may be encountered in domestic relationships, the workplace, or altercations with strangers. Homicide has remained one of the five leading causes of death in adults between 1981 and 2021 (CDC, 2023c). The risk of homicide or other interpersonal violence is exacerbated by substance use and misuse.
Domestic or intimate partner abuse can include sexual violence, physical violence, stalking, and psychological aggression. Although this form of violence is more commonly experienced by persons AFAB, it can also be experienced by persons AMAB. Anyone, regardless of sexual identity, can be involved in an intimate relationship that becomes abusive or violent. In addition to intimate partner violence, the workplace is also a common place for individuals to experience violence or hostility.
The Occupational Safety and Health Administration defines workplace violence as the threat of violence or actual violence in the workplace. Workplace violence may include the following:
- physical violence (direct or indirect)
- verbal harassment
- sexual harassment
- threatening behavior or words
Workplace violence can involve coworkers, managers, supervisors, clients, and customers. The following are risk factors:
- exchange of money
- working with unstable individuals
- work environment where alcohol is served
- working alone
- working in isolated areas
- working late at night
- working in high-crime neighborhoods
The following are specific jobs or careers with a higher risk for workplace violence:
- delivery drivers
- healthcare professionals
- customer service agents
- public service personnel
- law enforcement personnel
Nurses can support patients by bringing awareness to workplace violence and ensuring that individuals know their rights to safety and how to seek assistance, when necessary.
Link to Learning
In cooperation with the National Institute for Occupational Safety and Health, the CDC offers a Workplace Violence Prevention for Nurses course.
Alcohol and Drug Use
Alcohol and drug use is prevalent in the United States, and the widespread use and misuse of mind-altering substances are increasing. While moderate alcohol consumption may be safe for some individuals, it is essential to make informed decisions about alcohol use and consider individual circumstances and risks. Alcohol consumption in moderation may be safe for individuals without underlying health disorders such as liver disease, history of substance use or addiction, and mental health disorders. In addition, some medications have negative interactions with alcohol. Excessive alcohol use is associated with 20 percent of deaths in individuals between the ages of 20 and 49 years (Esser et al., 2022).
The CDC (2024a) reports that up to 16 percent of adults binge drink by consuming four to five or more drinks on one occasion; however, many consume up to eight drinks per occasion. The health effects of heavy and binge drinking include increased mortality due to health problems such as the following:
- hypertension
- heart disease
- stroke
- liver disease
- cancer (e.g., mouth, throat, larynx, esophagus, colon, liver, and breast)
- injuries (e.g., MVA, falls, drowning, burns)
- violence (e.g., homicide, suicide, sexual assault)
- poisoning (e.g., overdose with alcohol or combination with another substance)
Legal drugs associated with dependence and misuse include nicotine products such as cigarettes, vaping, and chewing tobacco. Illicit drug use or misuse involves the use of illegal or controlled substances. These include prescription opioids, marijuana, cannabinoids, cocaine, crack, hallucinogens, inhalants, and methamphetamine, among others. Excessive or improper use of drugs or alcohol that may result in physical, mental, and social harm is known as substance misuse or substance abuse. This category also includes the misuse of psychotherapeutic prescription drugs such as pain relievers, stimulants, sedatives, and tranquilizers. The National Institute on Drug Abuse (NIDA) defines medication misuse as using these medications in any way other than as directed by the prescribing healthcare provider (NIDA, 2020).
Between 1999 and 2022, opioid overdose deaths in the U.S. increased by 22 percent, with this significant rise attributable to the use of prescribed or illicitly manufactured synthetic opioids such as fentanyl (NIDA, 2024). While these drugs are commonly implicated in overdoses, drug combinations are frequently suspected in these cases. High-risk medications include other opioids, benzodiazepines, alcohol, psychostimulants, and antidepressants. Up to 40 percent of these deaths also involve stimulants.
Problematic drug use can encompass both prescription and illicit drugs. Illicit drug abuse includes substances such as cocaine, heroin, and fentanyl. The CDC (2023b) reports that between 2006 and 2016, the rate of death from drug overdose in the U.S. population increased by 72 percent (Figure 40.6).
Nurses must consider the impact of the terms used to describe problematic substance use in their interactions with patients, families, and among other professionals. The term "abuse" is accepted and widely used in literature, research, education, and policies. However, the term can associate wrongdoing or blame with the patient, and may lead to explicit or implicit bias on the part of nurses as well as law enforcement, social workers, and others. While "abuse" and "abuser" need not be completely eliminated in the context of substances, they should be used with care, and replaced where possible with words like "misuse," which conveys the same meaning without the same negative stigma.
Patient Conversations
Herbal Substance Use
Scenario: Candace is a 28-year-old patient who lives in a basement apartment of her parents’ home. She moved into this apartment after losing her job as a barista and being unable to make rent payments. She has been looking for employment but is struggling to find a job close to her home because of limited transportation. She presents to her primary care provider’s office to discuss her concerns about anxiety and ADHD. Candace becomes tearful as the nurse takes her vital signs, reporting that she feels out of control and like she can’t get her life on track.
Nurse: How long have you been noticing these symptoms?
Patient: I started feeling anxious when I lost my job as a barista and had to move back in with my parents. Everything is going okay with my parents, they are supportive. But I feel overwhelmed. I wonder if I have ADHD because I just can’t seem to concentrate, and I feel jittery a lot.
Nurse: Did you have any struggles with depression or anxiety when you were younger? Did you ever have to take medications for depression or anxiety?
Patient: No, I always did pretty well in school and was never a worrier.
Nurse: Are you using any legal or illegal drugs like alcohol, marijuana, or prescription medications?
Patient: I drink with my friends occasionally, maybe two drinks per week on average. I haven’t been sleeping very well, so I have been drinking more energy drinks than usual, and I take an herbal supplement that is supposed to help with energy.
Nurse: How many energy drinks do you have in a day? Do you know the name of the herbal supplement or what is in it?
Patient: I have one energy drink per day at the most. The herbal supplement is kratom; it is legal, and I buy it at the convenience store.
Nurse: I am concerned that if you have not struggled with ADHD or anxiety in the past, the kratom may be contributing to your symptoms. When kratom is digested, it affects the brain and body in a way similar to opioid drugs. It could cause you to feel symptoms ranging from jitteriness to alertness and sedation. The preparations available are not standardized, so it is difficult to be sure how much you are taking. Also, since these supplements work on opioid receptors in the brain, they can be hard to stop taking, and sometimes, you begin to feel that you need more to get the same effect. I will make sure your healthcare provider discusses alternatives for you and explains how you can stop taking this supplement without side effects.
Patient: Thank you for explaining this. I thought kratom was pretty safe since it is available everywhere. I hope my symptoms improve when I stop taking this.