6.3 Adult and Geriatric Anticipatory Guidance

Adult and geriatric anticipatory guidance is the same Planning skill with a different clock. Bright Futures no longer sets the agenda. You now counsel disease progression, function, safety, and what matters most across the official age groups: young adult, adult, older adult, and frail elderly. Crisis and end-of-life orders deepen in Chapter 7.1; this section is the planned conversation you start while the patient can still hear it.

Guidance is still prospective. You describe the next complication the current disease is likely to produce, the next skill the patient is about to lose, or the next season that will endanger a frail body. You do not wait for the ICU transfer to mention daily weights.

Disease-progression counseling

Patients cannot adhere to a future they have never been shown.

Prediabetes → diabetes. An A1c of 5.7–6.4%, fasting glucose 100–125 mg/dL, or 2-hour OGTT 140–199 mg/dL is prediabetes, not “a touch of sugar.” Name the trajectory in plain language: many people progress over years; intensive lifestyle change (Diabetes Prevention Program–style: about 7% weight loss and 150 minutes/week of activity) cuts that risk substantially, and metformin is reasonable in selected younger adults with BMI ≥35, history of gestational diabetes, or a rising A1c. Schedule follow-up A1c (often yearly if lifestyle is the plan; sooner if you start drug therapy). This is planning, not a lab courtesy call.

CKD staging. Use KDIGO G and A stages with the patient: eGFR G1 ≥90, G2 60–89, G3a 45–59, G3b 30–44, G4 15–29, G5 <15, and albuminuria A1 <30, A2 30–300, A3 >300 mg/g. A person with diabetes, eGFR 58, and ACR 120 is G3a A2 — not “your kidneys are fine because you do not need dialysis.” The plan: ACE/ARB if albuminuria, blood-pressure and glucose targets, avoid NSAIDs and unneeded contrast and phosphate enemas, review sick-day rules, consider SGLT2 inhibition when indicated, and nephrology referral as stage or trajectory warrants. You are preventing G5, hyperkalemia, and heart failure, not reciting a number.

Heart-failure daily weights. Teach a home scale, same time, same clothes. Call for about 2–3 pounds overnight or 5 pounds in a week (use the threshold your cardiology partner writes; do not invent a different number if the stem gives one). Pair weights with sodium guidance, symptom triggers (orthopnea, swelling, sudden fatigue), and which extra diuretic dose, if any, is already on the written plan. This is tertiary prevention delivered as guidance.

Other high-yield trajectories: recurrent gout if urate stays high; Child-Pugh worsening if alcohol continues in cirrhosis; GOLD-stage COPD exacerbations if inhaler technique and vaccines are ignored; HIV viral rebound if ART is stopped.

Fall prevention

Falls are not an aging tax. They are a preventable injury.

Plan; do not only score. After a positive stay-independent screen or a Timed Up and Go of about 12 seconds or longer, the plan is multifactorial: home hazards (throw rugs, loose cords, poor lighting, missing grab bars, pets), vision correction, footwear, strength and balance programs (tai chi or physical therapy), and a medication review (sedative-hypnotics, anticholinergics, stacked antihypertensives that drop standing pressure, hypoglycemia). USPSTF supports exercise interventions to prevent falls in community-dwelling adults 65 and older who are at risk (Grade B) and multifactorial interventions in selected at-risk older adults. Do not hang the entire plan on a vitamin D pill — routine vitamin D to prevent falls in community-dwelling older adults is not a USPSTF A/B service.

Frail elderly add orthostatic vitals, assistive-device fit, and a night-voiding plan so the 2 a.m. bathroom trip is lighted and unhurried.

Driving retirement

Driving is an IADL and an identity. The conversation is planned guidance, not a surprise confiscation at the first missed Mini-Cog — unless danger is imminent (acute visual loss, unexplained syncope, active intoxication, or a family describing highway wandering).

Start early when you see falling cognition, contrast-sensitivity or field loss, Parkinsonian bradykinesia, residual stroke deficits, or medicines that sedate. Ask about near-misses, getting lost, new dents, and night driving. Offer a stepwise plan: no night or highway driving first, a formal driving-rehabilitation or occupational-therapy evaluation, and a family ride schedule. DMV reporting rules are state-specific — do not invent a national duty. If the patient is an imminent public danger, you protect the public and document; that is safety, not etiquette.

Advance directives and POLST as planned guidance

These documents fail when they are treated as “legal paperwork we scan at 75.” They are anticipatory guidance about future incapacity.

• Healthcare proxy / durable power of attorney for healthcare names a decision-maker.
• Living will / instructional directive states preferences for CPR, ventilation, feeding tubes, and dialysis in states of permanence the patient may never be able to describe later.
• POLST / MOLST / POST (the name varies by state) is a portable medical order for a person with serious illness or frailty, completed by a clinician with the patient or legal surrogate. It travels across EMS, hospital, and nursing home. It is not a standard living will, and it is not appropriate as a blank form for every healthy 50-year-old.

Medicare’s Annual Wellness Visit is a natural planning home. Revisit after a new heart-failure diagnosis, metastatic cancer, recurrent hospitalizations, or a spouse’s death (the named proxy may have died). Chapter 7.1 will take you into active dying; here you start the conversation while the patient can still choose.

Caregiver planning

The identified patient is sometimes the caregiver. Ask who does medicines, finances, bathing, and nights. Offer respite, adult day programs, and the local Area Agency on Aging. A daughter with a rising PHQ-9 and missed own mammograms needs a plan for her health, not only a donepezil refill for her father. Caregiver collapse is a preventable crisis.

Heat, cold, and the frail body

Frail elders lose thermoregulation. Summer planning: air-conditioning access, cooling centers, hold outdoor exertion during heat advisories, and review diuretics, anticholinergics, and beta blockers that impair heat dissipation. Winter planning: working heat, space-heater fire risk, carbon-monoxide detectors, and coats that are actually worn. After a power outage, call the oxygen-dependent and insulin-dependent patients. This is population-level planning executed one chart at a time.

Polypharmacy as planned prevention of harm

A medicine list of five or more is a risk-assessment finding (Chapter 3). The plan is a scheduled reconciliation: indication, dose, duplicate class, Beers potentially inappropriate medicines, anticholinergic burden, bleeding stacks (NSAID + SSRI + apixaban), and hypoglycemia stacks (insulin + sulfonylurea + poor intake). Deprescribing is prevention. “Continue all home meds” is not a plan in an 89-year-old who just fell.

Bone, bladder, and belonging

Bone health. Weight-bearing and resistance exercise, dietary calcium, fall-risk reduction, smoking and alcohol counseling, and — when indicated — DEXA as secondary screening. After a fragility fracture, treatment is tertiary and the guidance is “this break was the disease announcing itself.”

Incontinence. Not a normal price of aging to be endured in silence. Reversible causes first (UTI, mobility, diuretics, constipation, atrophic change); then pelvic-floor training, scheduled voiding, and continence products as a bridge, not a diagnosis.

Social isolation. Living alone plus missed gatherings, no weekday conversation, and unexplained weight loss is a mortality risk. Plan: meal support, hearing-aid repair (isolation is often an ear problem), a senior center, and depression treatment if the PHQ-9 is positive.

Working-age adult guidance the exam still writes

Do not skip the 28-to-52-year-old.

• Occupational injury. Job, shift, PPE, lifting, needlestick, workplace violence, noise, and chemical exposures. A warehouse worker with new low-back pain needs a work-restriction plan and a body-mechanics talk, not only an NSAID.
• Fertility window. Offer a reproductive life plan to people who can become pregnant: desired timing, contraception until then, folate when conception is possible, and honest counseling that fecundity declines across the 30s and more steeply after the late 30s. Do not order random AMH on every 34-year-old as a wellness screen. Refer earlier for infertility when age or known factors warrant — do not burn a year of “keep trying” in a 39-year-old.
• Perimenopause expectations. Cycles shorten or skip; vasomotor symptoms, sleep disruption, vaginal dryness, and mood change can last years. Counsel what is expected and what is not (postmenopausal bleeding is not “hormones being dramatic”). Continue contraception until menopause is established. Shared decision-making for menopausal hormone therapy in appropriate candidates belongs here as a planned conversation; system chapters pick up the regimen.
• Alcohol limits. For healthy adults who drink: no more than 1 drink in a day for women and 2 for men, with weekly caps commonly cited as 7 and 14. Binge is 4 or more drinks for women or 5 or more for men in about two hours. Lower or zero is the plan in pregnancy, liver disease, interacting medicines, a history of use disorder, or frailty. A positive AUDIT-C moves you from guidance to a brief intervention (motivational interviewing is taught in the communication chapter).

Vignette. An 81-year-old with HFrEF, eGFR 44, A1c 6.9% on metformin, and a daughter who hid the car keys after a parking-lot scrape. The plan is not “labs in 6 months.” It is daily-weight teaching with a call threshold, CKD sick-day rules (hold metformin if he is vomiting or volume-depleted), a fall and heat-safety review, a driving evaluation rather than a hallway verdict, a POLST discussion now that heart failure is advanced, and a caregiver appointment for the daughter. That is adult-geriatric anticipatory guidance as Planning.

Write the next expected harm in the note. If you cannot name it, you have assessed but not planned.