Anticipatory guidance assists patients and caregivers to better anticipate unwanted conditions or events, being more able to prevent adverse outcomes. In pediatric and adolescent medicine, anticipatory guidance typically involves guidance based on the age and developmental stage of the patient (e.g., at age 6 months/crawling – install gates near stairs).  In the adult population, because the heterogeneity of aging and disease makes anticipatory guidance by age alone less helpful, recommendations should be based on disease or medical condition.  Disease/condition-based anticipatory guidance items may overlap if multiple conditions are present.  

Cognitive disorders are frequently chronic progressive degenerative conditions, requiring supervision and safety requirements to increase as the disease progresses.  The categories below contain specific items of safety guidance for injury prevention.  This listing may be printed and given to patients and their caregivers at clinical visits, or the clinician and health care team members may choose to focus on a pertinent area of concern.

1. Medications

• Check medications against provider lists, focusing on both generic and brand names and indications.
• Use pill boxes to track appropriate utilization and dosing. This will allow tracking of missed doses and help prevent double dosing.  Removing pills from the pill bottle at each dosing time is not recommended.
• Make a medication “map” – identifying the medication and time of day it should be taken. Use specific dosing times and numbers of pills taken.  This may require frequent reassessment as brands and dose forms change with changes in pharmacy formularies.
• Keep a list of medications accessible on a phone, or in a plastic sleeve in a wallet or purse, for reference in an emergency.
• Remove any unused, old, or redundant medications to avoid confusion.

2. Burn prevention

• Set water temperature at 120˚ F / 49˚ C or to low setting. Use thermometers in full immersion baths – safe bath temperature is 95 to 100˚ F/ 35-38˚ C.
• Avoid unsupervised use of heating devices such as electric blankets or pads. 
• Avoid heating devices such as stoves, space heaters, or fireplaces. Unplug heat sources when needed.
• Quit smoking. If this is not possible, avoid unsupervised smoking or smoking in areas with fire hazards (e.g., bed, upholstered furniture, near oxygen) or during use of sedative medications.

3. Fall prevention

• Consider a home safety evaluation by an Occupational Therapist to identify hazards unique to the individual’s home.
• Remove area rugs or secured them to the floor using double-sided tape.  Pile height should be low to medium to avoid tripping. Avoid carpet protectors as these tend to bunch up.
• Cords should be secured or wrapped to prevent snagging or catching.
• Adaptive equipment should be evaluated for the environment used. Unwheeled walkers may be hazardous in high traction or irregular surface areas (e.g. multiple door thresholds, area rugs, split level environments), or where movement paths are cluttered.
• Limit stair access. Ideally, doors to stairways should be locked, not simply closed. If using child gates, these need to be set at chest/torso level to prevent falling over the top.  
• Increase lighting to avoid hazards.
• Use an automatic fall alert system in case the individual cannot press the alert due to either injury or poor cognition.  Do not rely on cell phones or cordless phones as alternative alarm systems.
• Depending on the municipality, door key boxes may be available that are installed, and used by, first responder personnel to expedite home entry in an emergency. 

4. Wandering

• Install door locks and alarms – use two door locks to increase difficulty in leaving the home.
• Use safe return bracelet/watch and use of a wander guard or alarm system (may be GPS linked) to assist if a search is needed.

• Communicate with local police and emergency services to alert them of wandering risks and to help identify the individual.
• Use bed or chair alarms to alert for unsafe movement. Motion sensors can help avoid someone rising at night alone.

5. Firearms

• Disable and remove firearms.

6. Travel

• Keep emergency contacts, medications, allergy and medical problems lists in a prominent place with the individual when traveling (e.g. in a document envelope on a lanyard).
• Cognitively impaired travelers should ideally have a “travel buddy”, chaperone, or assistance from the travel service (e.g. planned assistance from the airline) and should have a direct (“warm”) hand-off at each stage of travel. The individual should never be assumed capable of navigating a complex itinerary independently.