Journal of Gerontological Nursing

Evidence-Based Protocol: Identification, Referral, and Support of Older Adults with Genetic Conditions?

Debra L Schutte, PhD, RN

Abstract

The understanding of the "structure and function of the human genome, and subsequently human disease, is expanding exponentially. The Human Genome Project, a massive international initiative to provide technologies to map, sequence, and characterize the human genome, continues to contribute considerably to this explosion m genetic knowledge. The recent availability of the full human genome sequence further enables scientists to identify relationships between rare gene mutations and rare disease, as well as the relationships between common gene variations and susceptibility for common complex disease (Collins et al., 1998).

One outcome of new genetic knowledge and ongoing genetic research is the realization that genes influence health and disease across the life span. Relationships between gene mutations and adult and late-adult onset disease are increasingly common. For example, altered genes contribute to many cancers common in older adults, including breast and ovarian cancer (Castilla et al., 1994), colon cancer (Groden et al., 1991), and prostate cancer (Ostrander & Stanford, 2000). Altered genes also contribute to many neurodegenerative disorders common in older adults, including Huntington's disease, Alzheimer's disease, and Parkinson's disease. Furthermore, altered genes contribute to eye conditions common in older adults, including age-related macular degeneration (Allikmets et al., 1997) and adult-onset primary open angle glaucoma Stoilova et al., 1996; Wiggs et al., 2000).

TABLE 1

SELECTED ADULT AND LATE ADULT-ONSET CONDITIONS WITH KNOWN GENETIC COMPONENTS

TABLE 2

FAMILY HEALTH HISTORY ASSESSMENT GUIDE

TABLE 3

GENETICS PSYCHOSOCIAL ASSESSMENT GUIDE

TABLE 4

FEATURES OF COMMON MENDELIAN INHERITANCE PATTERNS

TABLE 5

GENETIC ASSESSMENT FLOWSHEET

TABLE 6

GENETIC CONDITIONS IN OLDER ADULTS OUTCOMES MONITOR…

The understanding of the "structure and function of the human genome, and subsequently human disease, is expanding exponentially. The Human Genome Project, a massive international initiative to provide technologies to map, sequence, and characterize the human genome, continues to contribute considerably to this explosion m genetic knowledge. The recent availability of the full human genome sequence further enables scientists to identify relationships between rare gene mutations and rare disease, as well as the relationships between common gene variations and susceptibility for common complex disease (Collins et al., 1998).

One outcome of new genetic knowledge and ongoing genetic research is the realization that genes influence health and disease across the life span. Relationships between gene mutations and adult and late-adult onset disease are increasingly common. For example, altered genes contribute to many cancers common in older adults, including breast and ovarian cancer (Castilla et al., 1994), colon cancer (Groden et al., 1991), and prostate cancer (Ostrander & Stanford, 2000). Altered genes also contribute to many neurodegenerative disorders common in older adults, including Huntington's disease, Alzheimer's disease, and Parkinson's disease. Furthermore, altered genes contribute to eye conditions common in older adults, including age-related macular degeneration (Allikmets et al., 1997) and adult-onset primary open angle glaucoma Stoilova et al., 1996; Wiggs et al., 2000).

In some cases, such as Huntington's disease, a single gene mutation causes the disorder (The Huntington's Disease Collaborative Group, 1993). In other cases, specific gene mutations cause the disorder in some families experiencing atypical features (e.g., earlier than expected onset age, more severe disease progression), such as early-onset Alzheimer's disease (Goate et al., 1991; Levy-Lahad et al., 1995; Mullan et al., 1992; Rogaev et al., 1995; Schellenberg et al., 1992; St. George-Hyslop et al., 1992; Van Broeckhoven et al., 1992) or BRCAl gene-associated breast cancers (Castilla, et al., 1994). In soll other cases, such as the more common late-onset Alzheimer's disease (Pericak- Vanee et al., 1991) and Parkinson's disease (Nussbaum & Polymeropoulus, 1997), common genetic variations may increase susceptibility to the disease, but are not singularly causative.

The identification of gene mutations associated with disease promises improved therapeutics in the long term. In the short term, however, gene identification enables genetic testing for the purposes of diagnosis, prognosis, prediction, and screening with or without the availability of improved therapies. Regardless of the scenario, genetics is currently the domain of all health care providers, including gerontologists. This article provides an overview of an evidencebased protocol (EBP) to assist in the identification, referral, and support of older adults who are experiencing, or at risk for experiencing, a genetic condition. The full EBP, entitled "Identification, Referral, and Support of Elders with Genetic Conditions," is a resource for those health care providers who are faced with the integration of genetic information and technologies into their professional practice with older adult populations. (The full EBP is available from the following Web site: http://www.nur s i ng.uiowa.edu/gnirc /rddc_protocol.htm.)

PURPOSE

Gerontological nurses and other providers, regardless of setting, need to provide a basic level of genetics services for their clients as genetic research describes the contribution of genes to more and more common complex diseases. The purpose of this EBP is to provide guidelines for the assessment and management of clients who are either experiencing or at risk for experiencing a condition with genetic components. It is intended for use by gerontological nurses who are not genetic specialists.

DEFINITION OF GENETIC CONDITIONS IN OLDER ADULTS

Genetic conditions are defined as "variations, disorders, or diseases that are caused or influenced by genes and require nursing or medical intervention" (International Society of Nurses in Genetics, 1998, pg. 2). Genetic conditions common to, or occurring primarily in, the older adult population are the focus of this protocol. Genetic nursing interventions are aimed at actual or potential health responses, variations, disorders, or diseases caused or influenced by genes.

Table

TABLE 1SELECTED ADULT AND LATE ADULT-ONSET CONDITIONS WITH KNOWN GENETIC COMPONENTS

TABLE 1

SELECTED ADULT AND LATE ADULT-ONSET CONDITIONS WITH KNOWN GENETIC COMPONENTS

INDIVIDUALS AT RISK FOR GENETIC CONDITIONS

Several factors may indicate an older adult is at increased risk for a genetic condition or the need for genetic services (Lea, Jenkins, & Francomano, 1998; Nussbaum, Mclnnes, & Willard, 2001). These factors include the following:

* Diagnosis of a health response,' disorder, or condition with a known genetic contribution.

* Asymptomatic adults with a positive family history of a health response, disorder, or condition with a known genetic contribution.

* The presence of any disorder or condition that displays a recognizable inheritance pattern within a family history.

* Actual diagnosis or family history of a common health condition with an earlier than expected age at onset.

* Individual, family, or community anxiety or knowledge deficit about the role of genetics in a health condition of interest.

ASSESSMENT CRITERIA

The following assessment criteria indicate clients who are likely to benefit the most from the use of this EBP (Nussbaum et al., 2001):

* Older adults diagnosed with a health response, disorder, or condition with a known genetic component.

* Asymptomatic adults with a positive family history of a condition with a known genetic component.

* Older adults diagnosed with or exhibiting a positive family history of common health conditions with atypical features, such as an early-onset age or more severe disease progression.

Table

TABLE 2FAMILY HEALTH HISTORY ASSESSMENT GUIDE

TABLE 2

FAMILY HEALTH HISTORY ASSESSMENT GUIDE

* Older adults diagnosed with or exhibiting a positive family history of a neurodegenerative disorder.

Genetic research continues to implicate specific genes in many disorders common in older adults. A selected list of these conditions is found in Table 1, along with their On-line Mendelian Inheritance in Man (OMIM™) reference number. The OMIM Web site provides a convenient and comprehensive searchable catalog of human genes and genetic disorders (http://www. ncbi. nlm.nih.gov/omim).

ASSESSMENT FOR GENETIC CONDITIONS IN OLDER ADULTS

An exhaustive, comprehensive genetics assessment is outside the scope of practice for non-genetic specialist health care providers (International Society of Nurses in Genetics, 1998). However, gerontological nurses can screen clients for genetics-related health care needs by initiating a family health history; by assessing the client's knowledge and readiness to learn about the actual or potential condition and its genetic components; and by exploring the individual, family, or community's self-defined goals and desired outcomes.

DESCRIPTIONOF I INTERVENTION

The Scope and Standards of Genetics Clinical Nursing Practice (ISONG, 1998) describes a role for all licensed registered nurses in the delivery of genetic services and the management of genetic information. The three key aspects of this role include the identification, referral, and support of individuals affected by or at risk for manifesting or transmitting a genetic condition. These three key aspects of basic genetic services are described further.

Identification of At- Ris k Clients

Identification of individuals or families experiencing or at risk for experiencing a genetic condition is an important contribution of gerontological nurses. Assessment of the family health history, family knowledge and readiness to learn, and family goals and desired outcomes are important elements of screening for genetic risks and initiating appropriate interventions (Lea et al., 1998).

Comprehensive Family Health History. A complete family health history is recommended for every elderly client in every setting if one is not already available (Williams & Guthrie, 1995). If a family health history is present, updated family health information should be obtained. The family health history is obtained by interview to construct a picture of the client's family health for three to four generations when possible. A guide for eliciting family health history data is provided in Table 2.

Family histories are best recorded as pedigrees so common, recognizable patterns of inheritance or clustering of traits and conditions can be identified (Nussbaum, et al., 2001). Autosomal dominant, autosomal recessive and X-linked patterns of inheritance characterize diseases in which a mutation in a single gene is responsible for the pathophysiology. Multifactorial diseases, in which genetic and environmental factors influence the development of the disease, may cluster or aggregate in families, but may not necessarily demonstrate the classic Mendelian inheritance patterns. Pedigrees use a standardized set of symbols to show relationships between individuals, as well as their health status. Complete instructions for constructing and interpreting a pedigree are described in the full protocol.

Genetics Psychosocial Assessment A second important element of an assessment for genetics -related health needs is the determination of an individual or family's current level of knowledge, readiness to learn, coping strategies, and communication styles (Schutte, Williams, Schutte, & Maas, 1997). Questions to elicit a genetics psychosocial assessment can be found in Table 3.

Mutual Goals. A third element of an assessment for genetics-related health needs includes discussion with the individual, family, or community regarding their goals to determine meaningful and mutually acceptable genetics-related health outcomes. Not every client may be ready or willing to seek or use genetic information in their health care decision-making (Lea et al., 1998).

Table

TABLE 3GENETICS PSYCHOSOCIAL ASSESSMENT GUIDE

TABLE 3

GENETICS PSYCHOSOCIAL ASSESSMENT GUIDE

The content collected througn these three assessment strategies provide the information upon which to determine whether specialized genetics services may be useful. Indications for referral for specialized genetic counseling services include (Nussbaum et al., 2001):

* Family history of a condition with a known genetic component (e.g., Huntington's disease, AIzheimer's disease).

* Presence of a condition that follows a recognizable pattern of inheritance (Table 4 shows the features of Mendelian inheritance patterns).

Table

TABLE 4FEATURES OF COMMON MENDELIAN INHERITANCE PATTERNS

TABLE 4

FEATURES OF COMMON MENDELIAN INHERITANCE PATTERNS

* New diagnosis or family history of an earlier-than-expected age at onset in common illnesses (e.g., breast, ovarian, prostate, or colon cancer; cardiovascular disease; and Alzheimer's disease).

* Requests for information related to genetic testing or gene therapy options.

Referral to Specialty Genetics Services

After the identification of a client who is experiencing or at risk for experiencing a genetic condition is made, gerontological nurses may find it necessary to refer their clients to other providers to assure the accuracy of diagnosis, as well as to provide specialty genetics or mental health services (Schutte, 1998b).

Confirmation of Diagnosis. Accurate genetic counseling depends on accurate diagnoses (Lea et aL, 1998; Nussbaum et al., 2001). Individuals or families may need referral to their primary care provider or specialist for a comprehensive evaluation of the condition of concern.

Specialized Genetic Services. Individuals or families meeting the criteria for referral for specialized genetic services can be referred to genetic specialists for further evaluation. A number of strategies can be used to find local genetic specialists, including (Lea et al., 1998):

* Contacting the genetics division of a regional tertiary care facility.

* Contacting the State Department of Public Health for information about outreach genetic services.

* Accessing die following Web sites for information about genetic specialist providers: http://nursing. creighton.edu/isong (The International Society of Nursing in Genetics) and http://www.nsgc.org (National Society of Genetic Counselors).

After the referral is initiated, clients may benefit from anticipatory guidance about their upcoming genetic counseling encounter (Lea et al., 1998). For example, the genetic specialist will likely contact the client by telephone to obtain supplementary family history and health history information. Clients may be asked to release medical records to the genetic specialists prior to their evaluation. Following the evaluation, the client and referring provider will receive a summary letter of the visit, including information about the known inheritance of the condition, genetic testing options, if available, and recommendations for further evaluation or follow-up care.

Specialty Mental Health Services. Individuals or families who demonstrate ongoing difficulty in processing or coping with genetic information may require referral to specialty mental health services if their counseling needs are beyond the skills of the primary care provider or genetics specialist providers (Lea et al., 1998).

Table

TABLE 5GENETIC ASSESSMENT FLOWSHEET

TABLE 5

GENETIC ASSESSMENT FLOWSHEET

Support of Clients with Genette Conditions

The third key element of the gerontological nurse's role in caring for clients affected by genetic conditions is the provision of ongoing support. This support may take the form of a general advocacy role or through more specific interventions, such as reinforcement of specialty recommendations, teaching, psychosocial counseling, and follow-up assessments and goal setting.

Advocacy. Gerontological nurses are in important positions to advocate for their clients in relationship to genetics by assuring that clients are referred for comprehensive services; by assuring that clients are fully informed regarding genetic information, genetic testing, and genetic therapies; and by assuring their clients* genetic information, like other health information, remains confidential (Scanlon & Fibison, 1995).

Reinforce Specialty Interventions. Gerontological nurses can review and clarify information and recommendations provided by the genetic specialist providers with their clients. Facilitation or implementation of specialist recommendations may be another important activity for gerontological nurses related to genetics services (Schutte, 1998b).

Teacfomg. In addition to clarifying information provided by other specialty providers, teaching related to a health condition or disease process, therapeutic options, and availability of resources is another potential nursing intervention for gerontological nurses supporting individuals with, or at risk for, genetic conditions (Lea et al., 1998; Schutte, 1998b).

Psychosocial Counseling. Individuals and families provided with new information about the genetics of a health condition may be faced with unique challenges as they synthesize the meaning of this information for their health, life planning, and reproductive planning. In addition, individuals who have sought specific genetic information through genetic testing are faced with both benefits and burdens of this information (Williams & Schutte, 1997; Williams, Schutte, Evers, & Forcucci, 1999).

Consequently, gerontological nurses can provide ongoing supportive psychosocial interventions. The Nursing Interventions Classification (NIC) provides several interventions and activities, which may benefit clients who are sorting through the meaning of genetic information for themselves and their families, such as Coping Enhancement, DecisionMaking Support, and Family Integrity Promotion (McCloskey & Bulechek, 2000).

Ongoing Assessment and Goalsetting. The chronic nature of many health conditions of older adults, as well as the lasting and multigenerational nature of genetic information, necessitates that gerontological nurses maintain continuing contact with clients for assessment of outcomes and modification of the care plan based on mutual goal-setting.

Identification, referral, and support are three important basic nursing genetics interventions appropriate for all gerontological nurses (ISONG, 1998; Schutte, 1998a). However, nurses who consistently work with clients experiencing known genetic conditions may benefit from formal continuing education or advanced academic preparation m genetics nursing to provide basic and advanced genetics nursing interventions.

EVALUATION OF CLIENT OUTCOMES AND PROCESS FACTORS

To monitor the use and effectiveness of this protocol among older adults at risk for genetic conditions, both process factors and client outcomes can be evaluated.

Process Factors

Provider knowledge of family history assessment, pedigree interpretation, and referral indications can be evaluated following an initial training session on the use of this protocol through a knowledge test, case study interpretation, or return demonstrations. Adherence to the protocol recommendations can also be monitored as an indication of provider knowledge and skill readiness.

Client Outcomes

To document the impact of the Identification, Referral, and Support of Elders with Genetic Conditions protocol on client outcomes, please use or adapt the Family Health History Assessment Guide (Table 2), as well as the Genetics Psychosocial Assessment Guide (Table 3). These tools allow ongoing client assessment and audit. In addition, a Genetics Assessment Flowsheet (Table 5) may be used to track completion of the assessment, family history interpretation, and any subsequent referrals and interventions. The Genetic Assessment Flowsheet can be modified to meet the needs of any individual organization, unit, or client populations.

Finally, the Genetic Conditions Outcomes Monitor (Table 6) provides an additional outcome measurement strategy. This tool recommends client interviews to determine satisfaction with the assessment strategies, as well as chart review to determine evidence of family history documentation and follow-up.

Table

TABLE 6GENETIC CONDITIONS IN OLDER ADULTS OUTCOMES MONITOR

TABLE 6

GENETIC CONDITIONS IN OLDER ADULTS OUTCOMES MONITOR

REFERENCES

  • Allikmets, R., Shroyer, N.F., Singh, N., Seddon, J.M., Lewis, R.A., Bernstein, P.S., Peiffer, A., Zabriskie, N.A., Li, Y, Hutchinson, A., Dean, M., Lupski, J.R., & Leppert, M. (1997). Mutation of the Stargardl disease gene (ABCR) in age-related macular degeneration. Seien«, 277(5333), 1805-1807.
  • Castilla, L.H., Couch, FJ., Erdos, M.R., Hoskins, K-F, Calzone, K., Garber, J.E., Boyd, J., Lubin, M.B., Deshano, M.L., 8e Brody, L.C. (1994). Mutations io the BRCAl gene in families with early-onset breast and ovarian cancer. Nature Genetics, i(4), 387-391.

Collins, F.S., Patriaos, A., Jordan, E., Chakravarti, A., Gesteland, R., & Walters, L. (1998). New goals for the U.S. Human Genome Project: 1998-2003. Science, 2*2(5389), 682-689.

  • Goate, A., Chartíer-Harlin, M.C., Mullan, M., Brown, J., Crawford, F,, Fidani, L., Giuffra, L., Haynes, ?., Irving, N-, James, L., Mant, R., Newton, P., Rooke, K., Roques, P., Talbot, C., Pericak-Vance, M., Roses, A., Williamson, R., Rossor, M., Owen, M., & Hardy, J. (1991). Segregation of a missense mutation in the amyloid precursor protein gene with familial Alzheimer's disease. Nature, 549(6311), 704-706.
  • Groden, J., Thliveris, A., Samowitz, W., Carlson, M-, Gelbert, L., Albertsen, H., Joslyn, G-, Stevens, J., Spirio, L., & Robertson, M. (1991). Identification and characterization of the familial adenomatous polyposis coli gene. Ce//, 66(3), 589600.
  • Huntington's Disease Collaborative Research Group, The. (1993). A novel gene containing a trirtucleotide repeat that is expanded and unstable in Huntington's disease chromosomes. Cell, 72(6), 971-983.
  • International Society of Nurses in Genetics (ISONG). (1998). Statement on the scope and standards of genetics clinical nursing practice. Washington, DC: American Nurses Publishing.
  • Lea, D.H., Jenkins, J.F., & Francomano, C.A. (1998). Genetics in clinical practice: New directions for nursing and health care. Sudbury, MA: Jones and Bartlett Publishers.
  • Levy-Lahad, E., Wìjsman, E.M., Nemens, E., Anderson, L., Goddard, K.A., Weber, J.L., Bird, T. D., & Schellenberg, G.D. (1995). A familial Alzheimer's disease locus on chromosome 1. Science, 269(5226), 970-973.
  • McCloskey, J.C., & Bulechek, G.M. (Eds.). (2000). Nursing interventions classification (NIC) (3rd ed.). St. Louis: Mosby-Year Book.
  • McKusick, VA. (Ed.). (2000, January). On-line Mcndelian inheritance in man, OMIM™ [On-Line]. Available: http:www.nchi.nlm nih.gov/Omim .
  • Mullan, M., Houlden, H., Windelspccht, M., Fidani, L., Lombardi, C., Díaz, P., Rossor, M., Crook, R., Hardy, J., Duff, K... & Crawford, F. (1992). A locus for familial early-onset AJzheimer's disease on the long arm of chromosome 14, proximal to the alpha 1 -antichymotrypsin gene. Nature Genetics, 2(4), 340-342.
  • Nussbaum, R.L., Mclnnes, R.R., & Willard, H.F. (2001 ). Thompson & Thompson genetics in medicine (6di ed.). Philadelphia, PA: W.B. Saunders Company.
  • Nussbaum, R.L., & Polymeropouhis, M. H. (1997). Genetics and Parksinsoo's disease. Human Molecular Genetics, 6(10), 16871691.
  • Ostrander, E.A., & Stanford, J.L. (2000). Genetics of prostate cancer: too many loci, too few genes. American Journal of Human Genetics, 67(6), 1467-1375.
  • Pericak-Vance, M.A., Bebout, J.L., Gaskell, P.C., Jr., Yamaoka, L.H., Hung, W.Y., Alberts, M.J., Walker, A.P., Bartlett, RJ-, Haynes, C.A., Welsh, K.A., Earl, N.L., Heyman, A., Clark, C.M.,& Roses, A.D. (1991). Linkage studies in familial Alzheimer disease: evidence for chromosome 19 linkage. American Journal of Human Genetics, 48(6), 1034-1050.
  • Rogaev, E.I., Sherrington, R., Rogaeva, E.A., Levesque, G., Ikeda, M., Liang, Y-, Chi, H-, Lin, C., Holman, K., Tsuda, T., Mar, L-, Sorbi, S., Nacmias, B., Piacentini, S., Amaducci, L., Chumakov, I., Cohen, D., Lannfelt, L., Fraser, P.E., Rommens, J.M., & St. George-Hyslop, RH. (1995). Familial Alzheimer's disease in kindreds with ??'sense mutations in a gene on chromosome 1 related to the Alzheimer's disease type 3 gene. Nature, 376(6543), 775-778.
  • Scanlon, C., Sc Fibison, W. (1995). Managing genetic information: implications for nursing practice (ANA Pub. No. NP102). Washington, DC: American Nurses Association.
  • Schellenberg, G.D., Bird, T.D., Wijsman, E.M., Orr, H.T., Anderson, L., Nemens, E., White, J.A., Bonnycasde, I~, Weber, J.L., Alonso, M.E., Potter, H., Heston, L. L., & Martin, G-M. (1992). Genetic linkage evidence for a familial Alzheimer's disease locus on chromosome 14. Science, 255(5082), 668-671.
  • Schutte, D.L. (1998a). Genetic testing in Alzheimer disease: Benefits, risks, and public policy. The Journal of Gerontological Nursing, 24(S), 17-23.
  • Schutte, D. L. (1998b). The impact of Alzheimer Disease genetics on expert and advanced gerontological nursing practice. AACN Clinical Issues, 9(4), 513-523.
  • Schutte, D.L., Williams, J., Schutte, B.C., & Maas, M. (1997). Alzheimer's disease genetics: Practice and education implications for special care unit nurses. The Journal of Gerontological Nursing, 24(1), 40-48.
  • St. George-Hyslop, P., Haines, J., Rogaev, E., Mordila, M., Vaula, G., Pericak-Vance, M., Foncin, J. F., Montesi, M., Bruni, A., Sorbi, S., Rainero, L, Pinessi, L., Pollen, D., Polinsky, R., Nee, L., Kennedy, J., Macciardi, F., Rogaeva, E., Liang, Y., Atexandrova, N., Lukiw, W, Schlumpf, K., Tanzi,R., Tsuda, T, Fairer, L., Canni, J.M., Duara, R-, Amaducci, L., Bergamini, L., Gustila, J., Roses, A, & McLachlan, D.C. (1992). Genetic evidence for a novel familial Alzheimer's disease locus on chromosome 14. Nature Genetics, 2(4), 330-334.
  • Stoilova, D., Child, A., Trifan, O.G., Crick, R.P., Coakes, R.L., & Sarfarazi, M. (1996). Localization of a locus (GLClB) for adultonset primary open angle glaucoma to the 2cen-ql3 region. Genomici, .36(1), 142-150.
  • Van Broeckhoven, C., Backhovens, H., Cruts, M., De Winted G-, Bruyland, M" Cras, P., & Martin, JJ. (1992). Mapping of a gene predisposing to early-onset Alzheimer's disease to chromosome 14q24.3. Nature Gaelics, 2(4), 335-339.
  • Wiggs, J. L., Alfingham, R.R., Hossain, A., Kern, J., Auguste, J., DelBono, E.A., Broomer, B., Graham, F.L., Hauser, M., Pericak-Vance, M., Haines, J.L. (2000). Genome-wide scan for adult onset primary open angle glaucoma. Human Molecular Genetics, 9(7), 1109-1117.
  • Williams, J.K., & Guthrie, S. (1995). Family history and pedigree construction self-study workbook. Iowa City, IA: The University of Iowa Book Store.
  • Williams, J.K., Oc Schutte, D.L. (1997). Benefits and burdens of genetic carrier identification. Western Journal of Nursing Research, 19(1), 71-81.
  • Williams, J.K., Schutte, D.L., Evers, C., & Forcucci, C. (1999). Adults seeking presymptomatic gene testing for Huntington disease. Image: Journal of Nursing Scholarship, 31(2), 109-1 14.

TABLE 1

SELECTED ADULT AND LATE ADULT-ONSET CONDITIONS WITH KNOWN GENETIC COMPONENTS

TABLE 2

FAMILY HEALTH HISTORY ASSESSMENT GUIDE

TABLE 3

GENETICS PSYCHOSOCIAL ASSESSMENT GUIDE

TABLE 4

FEATURES OF COMMON MENDELIAN INHERITANCE PATTERNS

TABLE 5

GENETIC ASSESSMENT FLOWSHEET

TABLE 6

GENETIC CONDITIONS IN OLDER ADULTS OUTCOMES MONITOR

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