방법 논문

입원 노인을 위한 3단계 낙상 위험 평가 방법: 포괄적 노인 평가에 기반한 실무 프로토콜

85 조회수

⸱

DOI:

10.3791/71845

⸱

2026년 8월 28일

 ,  ,  ,  , 
1Hangzhou Wuyunshan Hospital (Hangzhou Institute for Health Promotion), 2Hangzhou Qingchun Taoyuan Nursing Home, 3Zhejiang Chinese Medical University

이 논문에서

요약

이 프로토콜은 낙상 심각도 스크리닝, Morse Fall Scale, FRAIL 노쇠 스크리닝 및 다요인 평가를 통합하여 표준화된 위험 분류를 지원하고 위험 요인 맞춤형 중재를 안내하는, 입원 노인을 위한 3단계 낙상 위험 평가 경로를 설명합니다.

초록

고령자의 낙상은 여러 요인의 상호작용으로 인해 발생하므로, 단일 평가 도구만으로는 낙상 위험을 종합적으로 식별하기 어렵습니다. 본 연구는 입원한 고령자를 대상으로 점진적인 낙상 위험 식별과 표준화된 위험 분류를 지원하기 위해 포괄적 노인 평가를 기반으로 한 3단계 낙상 위험 평가 프로토콜을 설명합니다. 전향적으로 수집된 임상 데이터를 바탕으로 151명의 입원 고령자를 대상으로 단일 센터 소급적 기술 분석을 수행하였습니다. 1단계에서는 Morse 낙상 척도(MFS)와 낙상 심각도 선별 검사를 결합하여 시행하였습니다. 2단계에서는 1단계에서 저위험군으로 분류된 대상자를 대상으로 FRAIL 척도를 사용하여 보충적인 노쇠 선별 검사를 수행하였습니다. 3단계에서는 1단계에서 중등도 또는 고위험군으로 분류된 대상자와 2단계에서 전노쇠 또는 노쇠로 판명된 대상자를 대상으로 다요인 낙상 위험 평가를 적용한 후 최종 위험 분류를 수행하였습니다. 1단계에서 94명(62.2%)은 저위험군으로, 57명(37.7%)은 중등도 또는 고위험군으로 분류되었으며, 17명(11.3%)은 낙상 심각도 선별 검사에서 양성 반응을 보였습니다. 2단계로 진입한 94명의 대상자 중 23명(15.2%)이 FRAIL 척도 결과에서 이상을 보였습니다. 총 80명의 대상자가 3단계로 진행하였습니다. 최종 위험 분류 결과 80명(53.0%)은 저위험군, 22명(14.6%)은 중등도 위험군, 49명(32.5%)은 고위험군으로 식별되었습니다. FRAIL 척도 결과가 비정상이었던 23명의 대상자 중 15명은 3단계 평가 후 중등도 또는 고위험군으로 분류되었습니다. 이러한 결과는 본 프로토콜이 과소 식별을 줄이면서 중등도 및 고위험군 입원 고령자의 식별률을 향상시킬 수 있음을 시사하나, 그 성능에 대해서는 추가적인 검증이 필요합니다.

서론

낙상은 노인에게 발생하는 가장 흔한 안전 사고 중 하나이며, 부상, 장애, 사망 및 의료 자원 이용 증가와 관련이 있습니다1,2. 따라서 낙상 위험 평가는 낙상 예방의 핵심 요소입니다1. 여러 국제 가이드라인에서 다요인 평가와 개별화된 중재를 권장하고 있음에도 불구하고, 낙상은 여전히 노인들에게 주요한 안전 문제로 남아 있습니다2,3,4,5. 낙상은 생리학적, 임상적, 약물 관련, 기능적, 행동적 및 환경적 요인의 상호작용으로 인해 발생합니다. 단일 위험 평가 도구는 낙상 위험이 높은 일부 개인을 빠르게 식별할 수 있지만, 단일 도구만으로 낙상과 관련된 다수의 위험 요인을 종합적으로 평가하기는 어렵습니다6,7,8. 따라서 체계적인 다단계 낙상 위험 평가 접근 방식을 확립하는 것은 노인의 낙상 예방 및 관리에 있어 여전히 중요한 과제로 남아 있습니다.

모든 입원 고령 환자에게 포괄적 평가를 적용하는 것은 자원 소모가 클 수 있으며, 반면 단일 스크리닝 점수에만 의존할 경우 관련 위험 요인을 충분히 평가하지 못할 수 있습니다. 단일 평가 도구에 기반한 접근 방식과 달리, 제안된 3단계 방법은 신속한 1차 스크리닝, 보완적인 노쇠 스크리닝, 그리고 추가 평가가 필요한 개인을 위한 표적 다요인 평가를 결합합니다. 이러한 단계적 접근 방식은 1차 스크리닝의 효율성을 유지하는 동시에, 필요한 경우 더 포괄적인 평가를 가능하게 하려는 목적을 가지고 있습니다. 점진적 스크리닝과 표적 평가를 통합함으로써, 본 프로토콜은 체계적인 위험 식별과 최종 위험 분류를 지원하며 위험 요인 기반의 중재를 안내하는 표준화된 워크플로우를 제공합니다.

~에 근거하여 고령자를 위한 낙상 예방 및 관리에 관한 세계 가이드라인3, 포괄적 노인 평가 및 임상 실무를 바탕으로, 본 연구는 입원 노인 환자를 위한 3단계 낙상 위험 평가 방법 및 운영 프로토콜을 개발하였습니다. 이 프로토콜의 전반적인 목표는 점진적인 낙상 위험 식별, 최종 위험 분류 및 위험 요인 중심의 층화 중재를 위한 표준화되고 재현 가능한 워크플로우를 제공하는 것입니다. 모든 입원 노인 환자에게 포괄적 평가를 적용하거나 단일 스크리닝 도구에만 의존하는 것과 비교하여, 이 단계별 프로토콜은 추가 평가가 필요한 경우에만 표적화된 포괄적 평가를 수행함으로써 평가 효율성과 정밀 평가 사이의 균형을 맞추고자 합니다. 본 프로토콜은 숙련된 평가자와 필요한 평가 도구를 갖춘 입원 노인 간호 및 기타 병원 환경에서 사용하도록 설계되었습니다.

프로토콜

The protocol and analysis were approved by the Medical Ethics Committee of Wuyunshan Hospital, Hangzhou (Hangzhou Health Promotion Research Institute) (Ethics Approval No. 2023 Medical Research Review No. 007). Written informed consent was obtained from all participants or their legal representatives before enrollment. Participant identity information was stored separately from the research dataset to maintain confidentiality. All methods were performed in accordance with the relevant guidelines and ethical standards, including the 1964 Declaration of Helsinki and its later amendments. The study was registered with the National Medical Research Registry (MR-33-23-035548).

1. Participant Preparation

  1. Inclusion Criteria
    1. Include a participant only if all of the following criteria are met: (1) age ≥65 years; (2) clear consciousness and ability to complete the assessments independently or with the assistance of a caregiver; and (3) agreement to undergo fall-risk assessment and related intervention management.
  2. Exclusion Criteria
    1. Exclude a participant if any of the following conditions is present: (1) a severe acute illness or critical condition that prevents completion of the assessment; (2) severe cognitive impairment or abnormal mental behavior that prevents cooperation with the assessment; or (3) incomplete required data.

2. First-Level: Initial Risk Screening

  1. Use the Morse Fall Scale (MFS) as the universal first-level screening tool for every eligible participant. If a fall history is identified, conduct the fall-severity screening.
    ​Morse Fall Scale (MFS)
    1. Administer the MFS to every eligible participant. Assess and record all six MFS items before calculating the total score and applying the routing rules9.
    2. Assess Indicator One: Fall History. Ask whether the participant has fallen during the previous 3 months. Assign 25 points if yes and 0 points if no. Record any falls that occurred during the previous year for the fall-severity screening described in Step 2.2.
    3. Assess Indicator Two: Secondary Medical Diagnosis. Determine whether more than one medical diagnosis is documented. Assign 15 points if yes; otherwise, assign 0 points.
    4. Assess Indicator Three: Use of Walking Aids. Ask and observe whether the participant uses crutches, a cane, or a walker. Assign 15 points if any of these devices are used. Assign 30 points if the participant walks while holding onto furniture.
    5. Assess Indicator Four: Intravenous Therapy. Determine whether the participant has an intravenous line or is receiving an intravenous infusion. Assign 20 points if yes; otherwise, assign 0 points.
    6. Assess Indicator Five: Gait and Mobility. Observe the participant’s gait during safe mobilization. Assign 10 points for a weak gait and 20 points for an impaired gait according to the MFS definitions.
    7. Assess Indicator Six: Awareness of Limitations. Determine whether the participant recognizes personal mobility limitations and the need for assistance. Assign 15 points if the participant overestimates or forgets personal limitations; otherwise, assign 0 points.
  2. Fall-Severity Screening
    1. Perform the fall-severity screening for participants who report one or more falls during the previous year10.
    2. Determine whether the participant experienced two or more falls during the previous year.
    3. Determine whether any fall caused an injury requiring medical attention.
    4. Determine whether the participant was unable to rise independently after a fall and required assistance from another person.
    5. Determine whether loss of consciousness or suspected syncope occurred during a fall.
    6. Record the fall-severity screen as positive if any criterion in Steps 2.2.2–2.2.5 is met. Otherwise, record the result as negative.
  3. Calculate the MFS Score and Apply the Routing Rules
    1. Calculate the total MFS score after completing all six MFS items.
    2. Classify the participant as low risk if the MFS score is 0–24, moderate risk if the score is 25–44, or high risk if the score is ≥459.
    3. Apply the predefined three-level routing rule after recording the standard MFS risk category.
    4. Route the participant to the Third Level if the total MFS score is ≥25 or the fall-severity screen is positive.
    5. Route the participant to the Second Level if the total MFS score is <25 and the fall-severity screen is negative.

3. Second Level: Frailty Supplementary Screening

  1. Apply the Second Level to participants with an MFS total score of <25 and a negative fall-severity screen.
  2. FRAIL Frailty Scale
    1. Administer the Chinese-language version of the FRAIL Scale translated and validated by Wei et al.11 Assess and record all five items before calculating the total score. Score each item as 0 or 1. Base the assessment on participant self-report without using measurement equipment.
    2. Assess Indicator One: Fatigue. Ask whether the participant felt tired most or all of the time during the previous week. Assign 1 point if yes.
    3. Assess Indicator Two: Resistance (Stair Climbing). Ask whether the participant has difficulty climbing one flight of stairs without using an assistive device, assistance from another person, or resting midway. Assign 1 point if yes.
    4. Assess Indicator Three: Ambulation. Ask whether the participant has difficulty walking one block (100 m) without using an assistive device or assistance from another person. Assign 1 point if yes.
    5. Assess Indicator Four: Disease Status. Use the verified diagnosis list recorded in Step 2.1.3 and ask only about physician-diagnosed conditions that are not already documented. Determine whether the participant has more than five of the following conditions: hypertension, diabetes, myocardial infarction, stroke, cancer other than minor skin cancer, congestive heart failure, asthma, arthritis, chronic lung disease, kidney disease, or angina. Assign 1 point if the participant has more than five conditions.
    6. Assess Indicator Five: Weight Loss. Ask whether the participant experienced a ≥5% decrease in body weight during the previous year or a shorter period. Assign 1 point if yes.
  3. Calculate the FRAIL Score and Determine Routing
    1. Calculate the total FRAIL score after completing all five assessment items.
    2. Classify the participant as not frail if the FRAIL score is 0, prefrail if the score is 1–2, or frail if the score is 3–511.
    3. Retain participants with a FRAIL score of 0 in the direct low-risk pathway.
    4. Route participants with a FRAIL score of 1–5, indicating prefrailty or frailty, to the Third-Level multifactorial fall-risk assessment.

4. Third Level: Multifactorial Risk Assessment

  1. Enter the participant into the Third Level if the fall-severity screen is positive.
  2. Enter the participant into the Third Level if the fall-severity screen is negative and the total MFS score is ≥25.
  3. Enter the participant into the Third Level if the fall-severity screen is negative, the total MFS score is <25, and the FRAIL score is 1–5.
  4. Multifactorial Fall Risk Assessment for Older Adults
    1. Administer the published Chinese-language Fall Risk Assessment Scale for Older Adults developed by Chen et al.12.
    2. Assess all 10 primary indicators and 36 secondary indicators before calculating the total score.
      ​NOTE: The instrument was evaluated in 200 hospitalized older adults. The original study reported Cronbach’s α values of 0.714–0.789, S-CVI/Ave values of 0.962–1.000, KMO values of 0.698–0.791, and significant Bartlett’s tests (P < 0.001)12.
  5. Assessment Precautions
    1. Verify Assessor Qualifications
      1. Use four registered nurses holding the professional title of nurse-in-charge or higher with at least 10 years of clinical experience.
      2. Provide a 3-day training program led by the head nurse of the rehabilitation department before beginning the assessments.
      3. Include training on the MFS, FRAIL Scale, Fall Risk Assessment Scale for Older Adults, body mass index (BMI), handgrip strength, calf circumference, the five-times sit-to-stand test, the 3-m Timed Up and Go test, and the standing balance test.
      4. Use standardized operating procedures and demonstration videos throughout the training.
      5. Require each assessor to pass a practical examination and demonstrate agreement with the training leader on assessment procedures and scoring.
    2. Use Paired Assessment and Standardized Instructions
      1. Assign two nurses to assess each participant.
      2. Assign one nurse to complete the interview- and record-based assessments.
      3. Assign the second nurse to complete the instrument-based assessments.
      4. Review the combined assessment results before assigning the final risk level.
      5. Use the same standardized instructions and operating procedures for every participant.
    3. Maintain Safety and Participant Tolerance
      1. Complete all interview and observational assessments before performing the instrument-based assessments.
      2. Allow a caregiver to remain nearby for safety but do not allow the caregiver to assist with test completion.
      3. Maintain fall-prevention precautions throughout the assessment.
      4. Complete the assessment within 30 min.
      5. Document the reason if the participant cannot complete an instrument-based assessment because of a physical limitation, and assign the prespecified score rather than recording the result as missing data.
  6. Assessment Materials
    1. Use a height and weight scale, handgrip dynamometer, tape measure, one standardized chair with armrests, one standardized chair without armrests (seat height: 46 cm; armrest height: 21 cm), a 3-m walkway marker, a timer, assessment forms, paper, and a pen.
    2. Use the manufacturers, models, specifications, and access information listed in the Table of Materials.
  7. Conduct the Multifactorial Assessment
    1. For diagnosis-based items, use diagnoses made by the attending physician based on specialist documentation and reverify them during the current admission.
    2. Use the verified medical record as the scoring source if the participant’s report differs from the medical record.
      1. Indicator One: Age (Maximum 6 Points)
        1. Verify the participant’s age from the clinical record.
        2. Assign 2 points for participants aged 65–74 years.
        3. Assign 4 points for participants aged 75–84 years.
        4. Assign 6 points for participants aged ≥85 years.
      2. Indicator Two: Fall History (Maximum 10 Points)
        1. Use the verified fall history recorded in Step 2.1.2.
        2. Assign 5 points if the participant experienced one fall.
        3. Assign 10 points if the participant experienced two or more falls.
    3. Indicator Three: Cognitive Function (Maximum 8 Points)
      1. Use the assessment result recorded in Step 2.1.7 to determine whether the participant overestimates personal ability or forgets personal limitations.
      2. Assign 4 points if either condition is present.
      3. Administer the locally adapted Chinese Mini-Cog procedure described in Table 113.
      4. Assign 6 points if the Mini-Cog score is ≤3.
        1. Assign 8 points instead if dementia has been diagnosed by the attending physician based on specialist documentation and reverified during the current admission.
        2. 4 Indicator Four: Mental/Psychological Status (Maximum 6 Points)
        3. Ask, “Are you afraid of falling?”
        4. Assign 2 points if the participant answers “Yes.”
        5. Ask, “Do you feel easily emotionally agitated?”
        6. Assign 2 points if the participant answers “Yes.”
        7. Ask, “In the past month, have you often felt down, depressed, or hopeless?”
        8. Ask, “In the past month, have you often felt little interest or pleasure in doing things?”
      5. Assign 2 points if the participant answers “Yes” to both questions.
        1. Assign diagnosis-based points only if depression has been diagnosed by the attending physician based on specialist documentation and reverified during the current admission.
        2. Indicator Five: Disease-Related Symptoms (Maximum 20 Points)
        3. Ask, “Do you experience dizziness or vertigo?”
        4. Ask, “Do you experience dizziness, vertigo, or darkening of vision when changing positions (e.g., standing after squatting)?”
        5. Assign 5 points if the participant answers “Yes” to either question.
        6. Ask, “During the past week, have you felt tired most or all of the time?”
        7. Ask, “Do you need to stay in bed or sit in a chair for more than half of the daytime?”
        8. Assign 5 points if either condition is present.
        9. Alternatively, administer the 10-item, 100-point Chinese Barthel Index12,14 as described in Table 2.
        10. Assign 5 points if the Barthel Index score is ≤70.
        11. Ask, “Do you have numbness, tremors, or stiffness in your lower limbs?” or observe whether either lower limb shows deformity, hemiplegia, disability, or an unsteady gait.
        12. Assign 4 points if any finding is present.
        13. Ask, “Do you have diarrhea, frequent urination (daytime >6 times), urgency, or increased nocturia (≥2 times)?”
        14. Assign 2 points if any condition is present.
        15. Ask, “Do you have difficulty falling asleep, early awakening, repeated awakening, excessive daytime sleepiness, or insufficient sleep?”
        16. Assign 2 points if any condition is present.
        17. Assign diagnosis-based points only if a sleep disorder has been diagnosed by the attending physician based on specialist documentation and reverified during the current admission.
      6. Assess Pain
        1. Ask, “Are you experiencing pain?”
        2. Administer the 0–10 Numeric Rating Scale (NRS-11) if the participant reports pain15. Refer to Table 3 for the NRS-11.
        3. Ask, “If 0 represents no pain and 10 represents the most severe pain imaginable, what number best describes your pain?”
        4. Assign 2 points if the NRS-11 score is ≥3.
        5. 6 Indicator Six: Auditory and Visual Function (Maximum 6 Points)
  8. Assess Vision
  9. Ask, “Can you see the small print in a newspaper clearly?”
  10. Ask, “Do you wear glasses?”
  11. If the participant wears glasses, ask, “Can you see clearly while wearing your glasses?”
  12. Apply the World Health Organization (WHO) classification of vision impairment as described in Table 416.
  13. Assign 2 points for unilateral visual impairment.
  14. Assign 4 points for bilateral visual impairment.
  15. Do not assign an additional unilateral score if the participant meets the criteria for bilateral visual impairment.
  16. 2 Assess Hearing
  17. Ask, “Can you hear me clearly?”
  18. Ask, “Do you wear a hearing aid?”
  19. Assess hearing during routine communication by using whispered speech, with reference to the study-specific communication assessment described in Table 517. Consider difficulty hearing whispered speech as evidence of hearing impairment.
  20. Assign 1 point for unilateral hearing loss.
  21. Assign 2 points for bilateral hearing loss.
  22. Do not assign an additional unilateral score if the participant meets the criteria for bilateral hearing loss.
  23. 7 Indicator Seven: Medication Factors (Maximum 6 Points)
  24. Review the participant’s medication record for sedative-hypnotics, antiepileptic drugs, antipsychotic agents, narcotic analgesics, diuretics, antihypertensive drugs, antiarrhythmic agents, antidiabetic drugs, laxatives, or mydriatics.
  25. Assign 2 points if one medication class is identified.
  26. Assign 6 points if two or more medication classes are identified.
  27. 8 Indicator Eight: Personal and Environmental Factors (Maximum 12 Points)
  28. 1 Assess Footwear and Clothing
  29. Observe whether the participant’s footwear and clothing meet fall-prevention requirements.
  30. Assign 3 points if the requirements are not met.
  31. 2 Assess Catheters, Drainage Tubes, and Intravenous Lines
  32. Determine whether the participant has an indwelling catheter, drainage tube, central venous catheter, or is receiving intravenous infusion therapy.
  33. Assign 3 points if any of these are present.
  34. 3 Assess the Use of Mobility Devices
  35. Determine whether the participant uses a cane, walker, or wheelchair.
  36. Assign 3 points if any mobility device is used.
  37. 4 Assess Living Situation and Caregiver Support
  38. Determine whether the participant lives alone.
  39. Determine whether the participant has no caregiver.
  40. Determine whether the participant’s caregiver is unable to provide adequate daily care or safety support because of insufficient knowledge, skills, physical capacity, or psychological capacity.
  41. Assign 3 points if any condition in Steps 4.7.8.4.1–4.7.8.4.3 is present.
  42. 9 Indicator Nine: Nutrition and Physical Function (Maximum 20 Points)
  43. 1 Assess BMI
  44. Measure the participant’s height and weight.
  45. Calculate the BMI as weight (kg)/height (m)2.
  46. Assign 2 points if the BMI is >25 kg/m2 or the body weight is <44 kg12.
  47. 2 Assess Handgrip Strength
  48. Measure handgrip strength using a handgrip dynamometer.
  49. Position the participant upright with the arms extended and without flexing the wrist or elbow.
  50. Instruct the participant to exert maximum grip strength.
  51. Measure each hand once and record the higher value.
  52. Discontinue the measurement if the participant is unable to cooperate.
  53. Assign 2 points if handgrip strength is <28 kg for males or <18 kg for females12,18.
  54. 3 Assess Calf Circumference
  55. Seat the participant on a standardized chair with a seat height of 46 cm.
  56. Position the hip and knee joints at 90°.
  57. Measure the maximum circumference of each calf using a measuring tape.
  58. Record the larger measurement.
  59. Assign 2 points if calf circumference is <34 cm for males or <33 cm for females12,18.
  60. 4 Assess Lower Limb Muscle Strength
  61. Measure the time required to complete the five-times sit-to-stand test.
  62. Allow safety guarding but do not allow another person to assist with the movement.
  63. Assign 4 points if the completion time is ≥11 s or the participant is unable to complete the test because of a physical limitation12.
  64. Refer to Table 6 for the detailed testing procedure.
  65. 5 Assess Mobility
  66. Measure the time required to complete the 3-m Timed Up and Go (TUG) test.
  67. Assign 5 points if the completion time is ≥12 s, the participant demonstrates an unsteady gait, or the participant is unable to complete the test because of a physical limitation12.
  68. Refer to Table 7 for the detailed testing procedure.
  69. 6 Assess Balance Ability
  70. Measure the length of time that the participant can stand with both feet together.
  71. Assign 5 points if the standing time is <10 s or the participant is unable to complete the test because of a physical limitation12.
  72. Refer to Table 8 for the detailed testing procedure.
  73. 10 Fall-Related Health Competence (Maximum 6 Points)
  74. 1 Assess Understanding of Fall Risk Factors
  75. Ask, “Do you know what risk factors could lead to a fall?”
  76. Calculate the proportion of personal risk factors correctly identified by the participant.
  77. Assign 2 points if the participant answers “I don’t know” or identifies <60% of the risk factors identified during the assessment.
  78. Calculate the proportion of correctly identified risk factors as (number of correctly identified personal risk factors ÷ total assessed personal risk factors) × 100%.
  79. Classify the participant as having insufficient understanding if the calculated proportion is <60%.
  80. 2 Assess Understanding of Fall Prevention Measures
  81. Ask, “Do you know how to prevent falls?”
  82. Calculate the proportion of applicable fall-prevention measures identified by the participant.
  83. Assign 2 points if the participant answers “I don’t know” or identifies <60% of the prevention measures applicable to the participant’s identified risk factors.
  84. 3 Assess Knowledge of Emergency Response After a Fall
  85. Ask, “If you fall, do you know what to do?”
  86. Compare the participant’s oral response with the five predefined knowledge points listed in Table 9. Do not require a physical demonstration.
  87. Assign 2 points if the participant answers, “I don't know,” or identifies fewer than 3 of the 5 knowledge points (<60%).
Test ItemAdministrationScoring
MemorySelect three unrelated words (e.g., red, flag, tree). Read the words aloud and instruct the participant to repeat them immediately and remember them for later recall.Immediate word registration is not scored.
Clock DrawingAsk the participant to draw a clock showing a specified time (e.g., 11:10) on a blank sheet of paper.Award 1 point for a complete clock face, 1 point for the correct placement of all numbers, and 1 point for the correct placement of the hour and minute hands.
Delayed RecallAfter completion of the clock-drawing task, ask the participant to recall the three previously presented words.Award 0 points if no words are recalled, 1 point if 1–2 words are recalled, and 2 points if all 3 words are recalled. Add the delayed-recall and clock-drawing scores to obtain a total score of 0–5 points.

Table 1: Standardized Mini-Cog Administration and Scoring. Administration procedure and scoring criteria for the locally adapted Chinese Mini-Cog procedure used in this protocol. The scoring method reflected the version implemented by the study hospital and differed from the standardized Mini-Cog algorithm. The total score was used during the multifactorial assessment.

No.ActivityCompletely IndependentRequires Some AssistanceRequires Substantial AssistanceCompletely Dependent
1Eating1050—
2Bathing50——
3Grooming50——
4Dressing and Undressing1050—
5Bowel Control1050—
6Bladder Control1050—
7Toileting1050—
8Bed-to-Chair Transfer151050
9Walking on Level Surface151050
10Climbing and Descending Stairs10500

Table 2: Chinese Barthel Index (10-Item, 100-Point Version). The Chinese 10-item, 100-point Barthel Index used to assess functional dependence. Total scores range from 0 to 100, with higher scores indicating greater independence. In this protocol, participants with a Barthel Index score ≤70 were assigned 5 fall-risk points during the multifactorial assessment. This prespecified, study-specific cutoff was used as an objective alternative to the subjective questions concerning persistent tiredness and prolonged bed or chair rest because clinical observation indicated that some participants understated the severity of their weakness, fatigue, or functional limitations during self-report. It should not be interpreted as a standard Barthel dependency-category cutoff. The Chinese version used was the validated 10-item, 100-point Barthel Index reported by Hou et al.14.

ScorePain Severity
0No pain
1–3Mild pain
4–6Moderate pain
7–10Severe pain

Table 3: Chinese Numeric Rating Scale (NRS-11). The Chinese-language 11-point Numeric Rating Scale (NRS-11) used to assess current pain intensity. Participants rate their current pain from 0 (no pain) to 10 (the most severe pain imaginable). In this protocol, participants with an NRS-11 score ≥3 were assigned 2 fall-risk points during the multifactorial assessment. The assessment was based on the standardized NRS-11 described by Hjermstad et al.15.

Visual Acuity GradeBest-Corrected Visual Acuity in the Better-Seeing EyeVisual Field (Better-Seeing Eye)Functional Impact
Mild visual impairment<6/12 (0.5) but ≥6/18 (0.3)No restrictionSlight impairment of fine activities (e.g., reading small print)
Moderate visual impairment<6/18 (0.3) but ≥6/60 (0.1)No restrictionImpairment of daily activities (e.g., cooking and traveling)
Severe visual impairment<6/60 (0.1) but ≥3/60 (0.05)≤20°Severe limitation of self-care ability
Blindness<3/60 (0.05)≤10°Unable to live independently without assistance or assistive devices

Table 4: World Health Organization Classification of Vision Impairment. Classification criteria for visual impairment based on the World Health Organization (WHO) classification using best-corrected visual acuity in the better-seeing eye and, where applicable, visual field criteria. In this protocol, the WHO classification was used to identify unilateral or bilateral visual impairment. Participants with unilateral visual impairment were assigned 2 fall-risk points, whereas those with bilateral visual impairment were assigned 4 fall-risk points. These fall-risk scores are study-specific operational criteria and are not part of the WHO classification.

Hearing GradeAverage Hearing Threshold in the Better-Hearing Ear (dB HL)Study-Specific Impact on Daily Communication
Normal hearing<20No or very limited listening difficulty.
Mild hearing loss20 to <35May have difficulty hearing soft speech or speech in noisy environments.
Moderate hearing loss35 to <50Difficulty hearing normal conversational speech.
Moderately severe hearing loss50 to <65Difficulty participating in conversations without amplification.
Severe hearing loss65 to <80Usually hears only loud speech in the better-hearing ear.
Profound hearing loss80 to <95Very limited perception of speech sounds.
Complete (total) deafness≥95No perception of speech sounds.

Table 5: World Health Organization Hearing-Loss Categories and Study-Specific Communication Descriptions. The hearing-loss categories and threshold ranges are based on the World Health Organization classification.17 The communication descriptions were adapted by the study team and are not WHO definitions; pure-tone audiometry was not performed. In this protocol, unilateral hearing impairment was assigned 1 fall-risk point and bilateral hearing impairment 2 fall-risk points. These fall-risk scores are study-specific operational criteria and are not part of the WHO classification.

Testing RequirementsPrecautions
1. Seat the participant on a chair without armrests, with the trunk as upright as possible and the hips and knees flexed to approximately 90°. Cross the arms over the chest, with each hand resting on the opposite shoulder.
2. Instruct the participant to stand up completely and sit down again as quickly as possible for five consecutive repetitions.
3. Start timing when the participant's buttocks leave the seat after the start command.
4. Stop timing when the participant reaches a full standing position at the completion of the fifth repetition.		1. Use a chair without armrests with a seat height of 46 cm.
2. Discontinue the test if the participant requires physical assistance to stand or is unable to complete the procedure safely.
3. If the recorded time is 10–11 s, repeat the test once after a 1-min rest and record the better result.

Table 6: Five-Times Sit-to-Stand Test Procedure. Standardized procedure for performing the Five-Times Sit-to-Stand Test (FTSST) to assess lower-extremity functional strength. Timing begins when the participant's buttocks leave the seat following the start command and ends when the participant completes the fifth standing movement. In this protocol, a completion time of ≥11 s indicates reduced lower-extremity strength and an increased risk of falling. The testing procedure, including the 10–11 s repeat-test criterion, follows the method reported by Chen et al.12.

Testing RequirementsPrecautions
1. Instruct the participant to wear regular footwear. Assistive devices may be used if normally required for ambulation.
2. Seat the participant in a standard chair with armrests, with the back resting against the backrest.
3. Start timing when the participant's buttocks leave the seat following the start command.
4. Instruct the participant to walk as quickly and safely as possible to the 3-m mark, turn after both feet have crossed the line, return to the chair, and sit down.
5. Stop timing when the participant returns to the seated position.		1. Use a chair with armrests, a seat height of 46 cm, and an armrest height of 21 cm.
2. Discontinue the test if the participant is unable to cooperate or complete the procedure safely.
3. If the recorded time is 11–12 s, repeat the test once after a 1-min rest and record the better result.

Table 7: Three-Meter Timed Up and Go Test Procedure. Standardized procedure for performing the Three-Meter Timed Up and Go (TUG) Test to assess functional mobility and fall risk. Timing begins when the participant's buttocks leave the seat following the start command and ends when the participant returns to the seated position. In this protocol, a completion time of ≥12 s indicates an increased risk of falling. The testing procedure, including the 11–12 s repeat-test criterion, followed the method reported by Chen et al.12.

Testing RequirementsPrecautions
1. Feet Together Test: Instruct the participant to stand with both feet together and side by side, and maintain the position for up to 10 s.
2. Semi-Tandem Stand: Instruct the participant to stand with the instep of one foot touching the big toe of the opposite foot, and maintain the position for up to 10 s.
3. Tandem Stand: Instruct the participant to place one foot directly in front of the other so that the heel of the front foot touches the toes of the back foot, and maintain the position for up to 10 s.		1. Remain beside the participant throughout the assessment to guard against falls.
2. Remove walking aids only when it is safe to do so.
3. Do not provide physical assistance while timing the test.
4. Discontinue the assessment if the participant is unable to cooperate or cannot safely stand without a walking aid.

Table 8: Progressive Standing Balance Test Procedure. Standardized procedure for assessing static standing balance using progressively more challenging standing positions. The assessment consists of the Feet Together, Semi-Tandem, and Tandem standing positions. In this protocol, inability to maintain any test position for 10 s indicates impaired balance and an increased risk of falling. Throughout the assessment, the examiner remains beside the participant to guard against falls. Walking aids may be removed only when safe to do so, and no physical assistance should be provided while timing the test. The procedure and interpretation were adapted from Chen et al.12.

Fall Self-Rescue Knowledge PointsSeeking-Assistance Knowledge Points
1. Recognize when the participant may attempt to get up: If there is no difficulty moving and no pain, the participant may perform self-rescue or stand up with assistance.
2. Recognize when the participant should not attempt to get up: If movement is difficult or painful, the participant should remain in the original position, avoid unnecessary movement, and call for help while awaiting assistance.
3. Describe how to get up safely: The six-step self-rescue procedure consists of: (1) remaining in a flexed position after the fall; (2) gradually rolling into a prone position; (3) locating a stable chair or handrail; (4) using the support to stand up slowly; (5) sitting in the chair; and (6) seeking assistance.		4. Recognize the need to seek assistance: The participant should seek assistance when unable to get up safely or when movement is difficult or painful.
5. Describe how to seek assistance in the relevant setting:(1) Home: Seek assistance from family members, neighbors, or community workers. (2) Community or public setting: Seek assistance from family members, nearby individuals, police, or emergency medical services. (3) Hospital: Seek assistance from healthcare professionals, caregivers, or nearby patients.

Table 9: Knowledge Assessment of Emergency Response After a Fall. Study-specific emergency-response knowledge points used to assess participants' understanding of fall self-rescue and assistance-seeking during the multifactorial assessment. The table summarizes recommended self-rescue actions following a fall and appropriate methods for seeking assistance in home, community, and hospital settings. Participants responded orally, and no physical demonstration was required. The table was not used as an educational tool during the assessment. These procedures were developed from the study protocol and hospital emergency response procedures and are not part of a standardized or independently validated assessment scale.

5. Assign the Final Risk Level and Configure Interventions

  1. Assign the Final Risk Level
    1. Classify the participant as low risk if the fall-severity screen is negative, the total MFS score is <25, and the FRAIL score is 0.
    2. Classify the participant as low risk if the fall-severity screen is negative and the Third-Level multifactorial assessment score is 0–20.
    3. Classify the participant as moderate risk if the fall-severity screen is negative and the Third-Level multifactorial assessment score is 21–40.
    4. Classify the participant as high risk if the fall-severity screen is positive.
    5. Classify the participant as high risk if the Third-Level multifactorial assessment score is ≥41.
    6. Assign the participant to the higher risk level if different assessment criteria indicate different risk levels3,10,12.
  2. Configure Interventions
    1. Determine the intervention intensity according to the participant’s final risk level.
    2. Select intervention components according to the specific risk factors identified during the Third-Level multifactorial assessment.
    3. Provide baseline fall-prevention education to every participant.
    4. Provide exercise guidance to every participant.
    5. Provide environmental safety guidance to every participant.
    6. Provide targeted interventions for participants classified as moderate risk.
    7. Provide multidisciplinary management for participants classified as high risk.
    8. Refer to Figure 1 for the complete final risk-classification algorithm.
    9. Refer to Table 10 for the intervention strategy corresponding to each final risk level

Flowchart of fall-risk assessment process using MFS for hospitalized older adults; decision paths.
Figure 1. Three-Level Fall Risk Assessment and Classification Algorithm. Please click here to view a larger version of this figure.

Flowchart illustrating the three-level fall risk assessment pathway for hospitalized older adults. Eligible participants first undergo fall-severity screening and assessment using the Morse Fall Scale (MFS). Participants with a positive fall-severity screen or an MFS total score ≥25 proceed directly to the Third-Level multifactorial assessment. Participants with a negative fall-severity screen and an MFS total score <25 undergo FRAIL (Fatigue, Resistance, Ambulation, Illnesses, and Loss of Weight) screening. Participants with a FRAIL score of 0 are classified as low risk, whereas those with a FRAIL score of 1–5 proceed to the Third-Level multifactorial assessment. Final risk classification is based on the multifactorial assessment score, with a positive fall-severity screen overriding other classifications and assigning the participant to the high-risk category. Abbreviations: FRAIL, Fatigue, Resistance, Ambulation, Illnesses, and Loss of Weight; MFS, Morse Fall Scale.

StageConditionActionFinal Risk Implication
Level 1Fall-severity screen positiveEnter Level 3High-risk override applies.
Fall-severity screen negative and any single MFS item score ≥25 or cumulative MFS score ≥25Enter Level 3Final risk category determined after Level 3 assessment unless a higher-priority rule applies.
Fall-severity screen negative, no single MFS item score ≥25, and cumulative MFS score <25Proceed to Level 2 (FRAIL screening)Risk category not yet determined.
Level 2FRAIL score = 0Exit pathwayAssign low risk.
FRAIL score = 1–5Enter Level 3FRAIL determines eligibility for further assessment but does not determine the final risk category.
Level 3Multifactorial assessment score 0–20Assign low riskFinal classification unless superseded by the high-risk override.
Multifactorial assessment score 21–40Assign moderate riskFinal classification unless superseded by the high-risk override.
Multifactorial assessment score ≥41Assign high riskFinal classification.
Final ReviewMore than one risk criterion is metApply the higher risk categoryFollow the higher-risk principle.

Table 10: Three-Level Routing and Final Risk-Stratification Algorithm. Decision algorithm summarizing the three-level fall-risk assessment pathway used in this protocol. Participants first undergo the fall-severity screen (Level 1). Those with a positive fall-severity screen proceed directly to the multifactorial assessment (Level 3), and the high-risk override is applied. Participants with a negative fall-severity screen are routed according to the Morse Fall Scale (MFS) and FRAIL assessment. Completion of all six MFS items is required. A single MFS item scored 25 or 30 points satisfies the ≥25-point routing threshold because the cumulative MFS score has already reached that threshold; otherwise, the cumulative MFS score is used. This routing threshold is a study-specific operational decision rule within standard MFS scoring and does not represent a separate MFS risk-category cutoff. Standard MFS categories are 0–24 (low risk), 25–44 (moderate risk), and ≥45 (high risk). A positive fall-severity screen is defined as two or more falls during the previous year, a fall-related injury requiring medical attention, inability to rise without assistance after a fall, or loss of consciousness or suspected syncope. The algorithm was developed from the study protocol and adapted from Chen et al.12.

6. Reassess Fall Risk Dynamically

  1. Perform fall-risk screening and assessment at least once annually for all older adults.
  2. Reassess community-dwelling older adults classified as high risk at least once every 6 months.
  3. Perform fall-risk screening and assessment at the participant’s first hospital admission or first institutional admission.
  4. Monitor participants classified as high risk daily.
  5. Reassess participants classified as high risk within 1 month.
  6. Reassess the participant within 24 h after a fall.
  7. Reassess the participant within 24 h after a significant change in disease status.
  8. Reassess the participant within 24 h after a relevant medication adjustment.
  9. Revise the intervention program according to the reassessment results.
  10. Follow the reassessment process provided in Figure 1.

결과

연구 설계 및 참가자 특성

본 연구는 2023년 6월 1일부터 2024년 12월 31일 사이의 경로 구현 과정에서 전향적으로 수집된 임상 데이터를 분석한 단일 센터 소급적 기술 분석 연구였습니다. 원천 모집단은 입원 환자 350명으로 구성되었습니다. 분석을 위해 152건의 기록을 편의 표집하였습니다. 이 중 개인 정보 및 기초 정보가 불완전한 기록 1건을 제외하여, 최종적으로 151건의 완전한 기록을 분석에 사용하였습니다. 참여자의 평균 연령은 77.66 ± 10.58세였으며, 남성 106명(70.2%)과 여성 45명(29.8%)이 포함되었습니다. 평균 체질량 지수(BMI)는 23.36 ± 3.14 kg/m2였으며, 평균 총 입원 기간은 20.91 ± 17.79일이었습니다. 평가는 입원 후 1.10 ± 0.43일(범위, 1–4일)에 수행되었습니다. 참여자들은 외래 서비스를 통해 노년내과 또는 재활의학과로 입원하였습니다. 주요 진단명으로는 관상동맥성 심장질환, 고혈압, 당뇨병, 만성 심부전, 폐기종, 만성 담낭염, 폐암 및 골다공증이 포함되었습니다. 교육 수준과 기초 거주 상황은 수집되지 않았으며, 현재 분석을 위한 완전한 동반 질환 프로필은 확보되지 않았습니다. 총 151명의 참여자가 평가 경로를 완료하고 최종 낙상 위험 분류를 받았습니다. 참여자 특성은 Table 11에 요약되어 있습니다.

특성범주/통계n% / 요약
연령 (years)Mean ± SD15177.66 ± 10.58
성별남성10670.2
여성4529.8
체질량 지수 (kg/m²)Mean ± SD15123.36 ± 3.14
거주지시설151100
주요 간병인있음10468.9
없음4731.1
만성 질환 수Mean ± SD1512.53 ± 1.51
096
13523.2
23623.8
≥37147
지난 1년간 낙상 경험있음1912.6
지난 1년간 2회 이상의 낙상 경험있음74.6
낙상 위험 증가 약물 사용있음12683.4
총 입원 기간 (days)Mean ± SD15120.91 ± 17.79
입원 후 평가일Mean ± SD (range)1511.10 ± 0.43 (1–4)

표 11: 참가자 특성 (n = 151). 연구 참가자의 기본 인구통계학적 및 임상적 특성. 연속형 변수는 평균 ± 표준편차(SD)로, 범주형 변수는 빈도(n)와 백분율(%)로 표시함. 모든 참가자는 시설에 수용된 고령자였음. 교육 수준, 주요 진단명 및 입원 경로는 분석 데이터셋에서 구조화된 변수로 제공되지 않았으므로 원고 내에서 서술형으로 기술함.

3단계 위험 평가 및 분류 결과

1단계에서는 MFS와 낙상 심각도 스크리닝을 결합하여 94명의 참가자(62.3%)를 저위험군으로, 57명의 참가자(37.7%)를 추가 평가가 필요한 군으로 분류했습니다. 이 57명의 참가자 중 17명은 낙상 심각도 스크리닝 결과가 양성이었으며 곧바로 3단계로 진행했습니다. 낙상 심각도 스크리닝 결과가 음성인 참가자 중 MFS 점수가 중등도 또는 고위험군이었던 40명 또한 곧바로 3단계로 진행한 반면, MFS 점수가 저위험군이었던 94명은 2단계(FRAIL 스크리닝)를 거쳤습니다.

레벨 2 스크리닝을 받은 94명의 참가자 중 71명(75.5%)은 FRAIL 결과가 정상으로 나타나 저위험군으로 분류되어 경로를 종료하였으며, 23명(24.5%)은 FRAIL 결과가 비정상으로 나타나 레벨 3로 진행하였습니다.

낙상 심각도 스크리닝 양성 반응자 17명, 낙상 심각도 스크리닝 음성이면서 MFS 점수가 중등도 또는 고위험군인 40명, 그리고 FRAIL 결과가 비정상인 23명을 포함하여 총 80명의 참가자가 레벨 3 다요인 평가를 받았습니다. 다요인 평가 결과, 9명(11.3%)은 저위험군, 23명(28.8%)은 중등도 위험군, 48명(60.0%)은 고위험군으로 분류되었습니다. 레벨 3 점수를 기준으로 중등도 위험군으로 분류된 참가자 중 1명은 낙상 심각도 스크리닝에서도 양성 반응을 보였으며, 이에 따라 사전에 정의된 고위험군 우선 적용 규칙에 의해 고위험군 카테고리로 배정되었습니다.

최종 경로를 통해 80명의 참가자(53.0%)는 저위험군, 22명(14.6%)은 중위험군, 49명(32.5%)은 고위험군으로 분류되었습니다. FRAIL 결과가 비정상이었던 23명의 참가자 중 8명(34.8%)은 최종적으로 저위험군, 10명(43.5%)은 중위험군, 5명(21.7%)은 고위험군으로 분류되었습니다. 3단계 평가 경로를 통한 대표적인 참가자 흐름과 최종 위험 분류는 그림 2 및 표 12에 요약되어 있습니다. 본 연구 과정에서 생성되거나 분석된 모든 데이터는 게시된 이 논문에 포함되어 있습니다.

figure-results-1
그림 2. 3단계 낙상 위험 평가 경로를 통한 참여자 흐름. 이 그림의 더 큰 버전을 보시려면 여기를 클릭하십시오.

3단계 낙상 위험 평가 경로를 통한 참가자 선택 및 진행 과정을 나타내는 흐름도입니다. 대상 모집단, 제외 대상, 1단계 평가 완료 참가자, FRAIL 선별 검사 또는 3단계 다요인 평가로의 배정, 그리고 최종적인 저위험, 중위험, 고위험 분류가 제시되어 있습니다. 다요인 평가 결과 중위험으로 분류된 한 명의 참가자가 사전 정의된 고위험 우선 적용 규칙에 따라 낙상 중증도 선별 검사 양성 반응을 보여 고위험군으로 재배정되었습니다. 약어: FRAIL, Fatigue, Resistance, Ambulation, Illnesses, and Loss of Weight; MFS, Morse Fall Scale.

단계 / 경로합계n%
스크리닝된 문헌 수152152100
분석 완료된 전체 기록15215199.3
레벨 1 평가151
낙하 중증도 스크리닝 양성1711.3
낙상 위험 스크리닝 음성 + MFS 중등도/고도4026.5
낙상 심각도 스크리닝 음성 + MFS 낮음9462.3
레벨 2 평가94
FRAIL 정상7175.5
FRAIL 비정상2324.5
레벨 3 평가80
낮은 다요인 점수911.3
중등도 다요인 점수2328.8
높은 다요인 점수4860
최종 위험 분류151
저위험8053
중간 위험도2214.6
고위험4932.5

표 12: 대표 표본 흐름 및 위험 분류. 3단계 낙상 위험 평가 경로를 통한 참가자 흐름과 그에 따른 최종 위험 분류. 백분율은 각 평가 단계에 진입한 참가자 수를 분모로 하여 단계별로 계산되었습니다 (1단계, n = 151; 2단계, n = 94; 3단계, n = 80). 데이터 미비로 인해 참가자 1명이 제외되었으며, 최종 분석에는 151명의 참가자가 포함되었습니다. 최종 위험 분류는 본 프로토콜에 기술된 사전 정의된 3단계 평가 알고리즘에 따라 할당되었습니다.

토론

본 연구에서 설명한 3단계 낙상 위험 평가 방법은 몇 가지 운영적 특성과 실용적 장점을 가지고 있습니다. 첫째, 이는 MFS, FRAIL 척도 및 CGA 기반의 다요인 낙상 위험 평가 척도를 2022년의 낙상 중증도 선별 검사와 체계적으로 결합합니다. 고령자를 위한 낙상 예방 및 관리 세계 가이드라인그리하여 점진적인 평가 경로를 구축하였습니다. 둘째, 단일 낙상 위험 스크리닝 도구에 기반한 접근 방식과 달리, 초기 위험 스크리닝, 보충적 노쇠 스크리닝, 그리고 최종 위험 계층화를 포함한 다요인 평가로 구성된 명확하게 정의된 워크플로를 제공합니다. 셋째, 본 프로토콜은 주요 평가 절차를 표준화함으로써 절차적 일관성과 재현성을 향상시킵니다. 이 경로는 입원한 고령층을 대상으로 예비 적용되었으며, 대표적인 결과들은 이것이 잠재적인 과소 식별을 줄이면서 중등도 및 고위험 낙상 대상자의 식별력을 향상시킬 수 있음을 시사합니다. 다만, 진단 성능과 임상적 유용성에 대해서는 추가적인 전향적 검증이 필요합니다.

3단계 경로 내에서 각 평가 도구는 뚜렷하고 상호 보완적인 역할을 수행합니다. MFS는 일반적인 입원 환자의 낙상 위험 요인을 평가하고 초기 위험 범주를 제공하므로 표준화된 1단계 선별 도구로 선택되었습니다9. 낙상 중증도 선별은 반복적인 낙상, 의료적 처치가 필요한 부상, 낙상 후 독립적인 기상 불능, 의식 소실 또는 실신 의심 등 이전 낙상의 임상적으로 중요한 특성을 식별하기 위해 도입되었으며, 이러한 요인들은 MFS 총점과 관계없이 독립적으로 고위험군 분류의 근거가 될 수 있습니다10. 초기 평가 후 저위험 경로에 머무는 대상자의 경우, FRAIL Scale을 통해 허약함과 생리적 예비능 저하에 대해 간단하고 자가 보고 기반이며 장비가 필요 없는 평가를 제공합니다11. 사전 정의된 경로 기준을 충족하는 대상자는 이후 CGA 기반의 다요인 평가를 받게 되며, 이는 인지, 심리, 질환 관련, 감각, 약물 관련, 개인 및 환경, 영양 및 신체 기능, 그리고 낙상 관련 건강 역량 영역을 평가하여 최종 위험 분류와 개인별 위험 요인 맞춤형 중재를 지원합니다12. 따라서 이러한 도구들은 서로 대체 가능한 평가 도구가 아니라, 초기 선별, 보충 경로 지정, 그리고 종합적인 특성 분석을 위해 순차적으로 적용됩니다.

현재의 국제 가이드라인은 낙상 위험이 높은 고령자를 대상으로 한 다요인 평가와 개별화된 중재의 중요성을 강조합니다3,5. 본 프로토콜은 이러한 원칙과 일치하며, MFS에 의해 초기에 저위험군으로 분류된 참가자들을 위한 보조 전략으로 노쇠 선별 검사를 포함합니다. FRAIL 결과가 비정상이었던 23명의 참가자 중 15명은 Level 3 평가 후 중등도 또는 고위험군으로 분류되었습니다. 이는 보조적인 FRAIL 선별 검사가 초기 MFS 평가만으로는 저위험 경로에 머물렀을 일부 참가자들을 식별하는 데 도움이 될 수 있음을 시사합니다. 하지만 대표 결과에서는 FRAIL 결과가 정상인 일부 참가자들 사이에서도 잔여 중등도 위험이 나타났습니다. 따라서 FRAIL 척도는 경로 배정을 위한 보조 정보를 제공하는 것으로 간주해야 하며, 미식별 사례를 완전히 제거하거나 경로의 진단 민감도를 확립하는 수단으로 보아서는 안 됩니다. 마찬가지로, 최종적으로 저위험군으로 분류된 참가자의 비율은 입원한 고령자의 예상 낙상 저위험 유병률이 아니라, 미리 정의된 분류 알고리즘의 결과로 해석해야 합니다19,20,21. 전반적으로, 이 프로토콜은 초기 선별 전략의 효율성을 유지하면서 낙상 예방과 포괄적 노인 평가의 통합을 지원합니다.

프로토콜의 재현성을 위해서는 라우팅 및 최종 분류 규칙의 일관된 적용이 필수적입니다. 총점을 계산하고 ≥25점의 라우팅 임계값을 적용하기 전에 6가지 MFS 항목을 모두 완료해야 합니다. 단일 MFS 항목에서 25점 또는 30점이 나왔다는 것은 누적 합계가 이미 이 라우팅 임계값에 도달했음을 의미하며, 이를 별도의 위험 분류 컷오프로 해석해서는 안 됩니다. 마찬가지로, 낙상 심각도 스크리닝 결과가 양성인 경우 다요인 평가 결과보다 우선하여 고위험군으로 분류되며, FRAIL 결과가 비정상인 경우는 레벨 3 평가를 진행해야 함을 나타낼 뿐 최종 위험 분류를 결정하지는 않습니다. 서로 다른 출처에서 얻은 정보가 일치하지 않거나 참가자가 수행 기반 평가를 완료할 수 없는 경우, 평가자는 가용 기록을 확인하고 그 이유를 문서화한 후, 미리 지정된 점수 산정 규칙을 적용하여 최종 위험 범주를 지정해야 합니다3,10,12. 이러한 운영 단계는 프로토콜의 핵심 구성 요소이며, 일상적인 임상 적용 시 평가자 간의 일관성을 향상시키기 위한 것입니다.

본 연구에는 몇 가지 제한점이 있습니다. 단일 센터의 입원 환자군을 대상으로 편의 표집을 이용하였으므로, 연구 결과의 일반화에 한계가 있을 수 있습니다. 독립적인 참조 표준이나 동시 대조군이 포함되지 않았기 때문에 진단 정확도와 예방 효과를 평가할 수 없었습니다. 외부 검증, 평가자 간 신뢰도, 비용 효율성 및 전향적 낙상 결과 또한 향후 조사가 필요합니다. 또한 개별 평가 시간이 기록되지 않았으므로, 30분 이내에 프로토콜을 완료하는 것이 가능한지 여부와 일상적인 시행을 위해 필요한 인력 요구 사항에 대한 평가가 남아 있습니다. 따라서 이 경로의 신뢰성, 진단 성능, 실행 가능성 및 임상적 유용성을 결정하기 위해 더 많은 전향적 다기관 연구가 필요합니다.

향후 연구에서는 동적인 낙상 위험 모니터링과 조기 경보를 지원하기 위해 인공지능(AI) 및 웨어러블 기기와 같은 기술의 통합을 탐색할 수 있습니다22. 또한, 실질적인 근거를 축적하고 평가 경로의 지속적인 최적화 및 개선을 지원하기 위해 병원, 지역사회 보건 서비스, 장기 요양 기관을 포함한 다양한 환경에서 이 프로토콜에 대한 추가적인 검증과 적용이 필요합니다. 요약하자면, 포괄적 노인 평가에 기반한 이 3단계 낙상 위험 평가 프로토콜은 입원한 고령 환자들 사이에서 점진적인 위험 식별 및 분류를 위한 구조화된 워크플로우를 제공합니다. 이 프로토콜은 통합된 프레임워크 내에서 초기 스크리닝, 보조적 노쇠 평가 및 포괄적 다요인 평가를 통합하는 동시에 평가 절차를 표준화합니다. 이 방법은 잠재적인 임상 적용 가능성을 보여주지만, 광범위한 시행에 앞서 진단 성능, 타당성, 신뢰도 및 더 넓은 적용 가능성에 대한 추가 검증이 필요합니다.

공개 사항

저자들은 상충하는 이해관계가 없음을 밝힙니다.

감사의 글

본 연구는 Hangzhou Health Science and Technology Plan(그랜트 번호 ZD20230125)의 지원을 받아 수행되었습니다.

재료

이 논문에 사용된 재료 목록
이름회사카탈로그 번호댓글
팔걸이가 있는 안락의자현지 공급 병원 가구해당 없음좌석 높이 46cm, 팔걸이 높이 21cm. 3m Timed Up and Go 검사에 사용됨.
바델 지수, 중국어판해당 사항 없음중국어 10문항, 100점 버전 (Hou et al., 2012)기능적 의존도를 평가하는 데 사용됨.
팔걸이 없는 의자현지 공급 병원 가구해당 사항 없음좌석 높이 46 cm. 5회 앉았다 일어나기 검사에 사용됨.
노인 낙상 위험 평가 척도, 중국어 버전해당 사항 없음Chen 외 (2024)3단계 평가에 사용된 기출판 평가 도구.
FRAIL 척도, 중국어판해당 사항 없음Wei 등 (2018), 중국어판2차 단계의 노쇠 선별 검사에 사용됨.
악력계이우 화주HJ-101악력 측정에 사용됨. 양손 중 더 높은 값을 기록함.
신장 및 체중계Zhejiang QidaQD-602BMI 계산을 위한 신장 및 체중 측정에 사용됨.
측정 양식 (평가 기록지)연구 병원 (현지 공급)지류 평가 기록지; 참가자당 1부; 버전 번호 또는 개정일 없음프로토콜 전반에 걸친 평가 결과 기록에 필요함.
미니-코그(Mini-Cog), 중국어판연구 병원병원 종합 노인 평가에서 사용된 중국어 현지 버전; 별도의 버전 번호는 기록되지 않음즉각 단어 등록은 점수를 매기지 않았습니다. 지연 회상은 0점에서 2점까지, 시계 그리기는 0점에서 3점까지 점수를 매겼으며, 총점은 0점이었습니다.–5점.
모스 낙상 척도(Morse Fall Scale, MFS), 중국어판해당 사항 없음Zhou Jungui(2010)가 번역한 중국어 버전이며, 이후 2012년에 검증됨국소적 수정 없이 사용된 6개 항목의 낙상 위험 선별 도구.
수치 평가 척도 (NRS-11), 중국어판해당 사항 없음0–10점 숫자 평가 척도현재 통증 강도를 평가하는 데 사용됩니다.
논문연구 병원 (현지 공급)해당 없음평가 결과 기록에 사용됨.
펜연구 병원 (현지 공급)해당 사항 없음평가 결과 기록용으로 사용됨.
줄자Deli GroupJDDLXC1412종아리 둘레 측정에 사용되는 비탄력성 테이프.
타이머 (디지털 초시계)심천 이성YS-8025회 앉았다 일어서기 검사, TUG(Timed Up and Go) 검사 및 서기 균형 검사에 사용됩니다.
보행로 표시 (3 m)현지 공급해당 사항 없음3m Timed Up and Go 검사 거리를 표시하는 데 사용됩니다.
WHO 청각 장애 분류세계보건기구세계 청각 보고서 (2021)평가 중 청력 분류를 위해 사용됨.
WHO 시각 장애 분류세계보건기구ICD-11 / WHO (2023)평가 중 시각 분류를 위해 사용됨.

참고문헌

  1. World Health Organization. World report on ageing and health. World Health Organization; Geneva; 2015. Available from: https://www.who.int/publications/i/item/9789241565042.
  2. World Health Organization. WHO global report on falls prevention in older age. World Health Organization; Geneva; 2008. Available from: https://www.who.int/publications-detail-redirect/9789241563536.
  3. Montero-Odasso M, et al. World guidelines for falls prevention and management for older adults: a global initiative. Age Ageing. 2022;51(9):afac205. doi:10.1093/ageing/afac205.
  4. Kim KI, et al. Evidence-based guidelines for fall prevention in Korea. Korean J Intern Med. 2017;32(1):199-210. doi:10.3904/kjim.2016.218.
  5. Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1):148-57. doi:10.1111/j.1532-5415.2010.03234.x.
  6. Strini V, Schiavolin R, Prendin A. Fall risk assessment scales: a systematic literature review. Nurs Rep. 2021;11(2):430-43. doi:10.3390/nursrep11020041.
  7. Glass A, Mendelson G, Ben Natan M. Comparison of two fall-risk assessment tools used in a long-term care facility. Int J Health Care Qual Assur. 2020;33(3):237-46. doi:10.1108/IJHCQA-03-2019-0065.
  8. Morris ME, et al. Divesting from a scored hospital fall risk assessment tool (FRAT): a cluster randomized non-inferiority trial. J Am Geriatr Soc. 2021;69(9):2598-604. doi:10.1111/jgs.17125.
  9. Morse JM, Black C, Oberle K, Donahue P. A prospective study to identify the fall-prone patient. Soc Sci Med. 1989;28(1):81-6. doi:10.1016/0277-9536(89)90309-2.
  10. Wu Y, et al. Interpretation of the 2022 edition of the "World Guidelines: Prevention and Management of Falls in Older Adults." Chinese General Practice. 2023;26(10):1159-63, 1171. doi:10.12114/j.issn.1007-9572.2022.0842.
  11. Wei Y, et al. Reliability and validity of the Chinese version of the FRAIL Scale for older inpatients. Chin J Pract Nurs. 2018;34(20):1526-30. doi:10.3760/cma.j.issn.1672-7088.2018.20.002.
  12. Chen X, et al. Construction and validation of a fall risk assessment scale for older adults based on comprehensive geriatric assessment. J Nurs Rehabil. 2024;23(8):26-30.
  13. Borson S, et al. The Mini-Cog: a cognitive "vital signs" measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry. 2000;15(11):1021-7. doi:10.1002/1099-1166(200011)15:11<1021::AID-GPS234>3.0.CO;2-6.
  14. Hou D, et al. Reliability and validity of the Chinese version of the Barthel Index. Clin Focus. 2012;27(3):219-21.
  15. Hjermstad MJ, et al. Studies comparing numerical rating scales, verbal rating scales, and visual analogue scales for assessment of pain intensity in adults: a systematic literature review. J Pain Symptom Manage. 2011;41(6):1073-93. doi:10.1016/j.jpainsymman.2010.08.016.
  16. Fang IM, Fang YJ, Hu HY, Weng SH. Association of visual impairment with cognitive decline among older adults in Taiwan. Sci Rep. 2021;11(1):17593. doi:10.1038/s41598-021-97095-9.
  17. World Health Organization. World report on hearing. World Health Organization; Geneva; 2021. Available from: https://www.who.int/publications/i/item/9789240020481.
  18. Chen LK, et al. Asian Working Group for Sarcopenia: 2019 consensus update on sarcopenia diagnosis and treatment. J Am Med Dir Assoc. 2020;21(3):300-307.e2. doi:10.1016/j.jamda.2019.12.012.
  19. Haines TP, Hill K, Walsh W, Osborne R. Design-related bias in hospital fall risk screening tool predictive accuracy evaluations: systematic review and meta-analysis. J Gerontol A Biol Sci Med Sci. 2007;62(6):664-72. doi:10.1093/gerona/62.6.664.
  20. Kim J, Lee W, Lee SH. A systematic review of the guidelines and Delphi study for the multifactorial fall risk assessment of community-dwelling elderly. Int J Environ Res Public Health. 2020;17(17):6097. doi:10.3390/ijerph17176097.
  21. Aranda-Gallardo M, et al. Instruments for assessing the risk of falls in acute hospitalized patients: a systematic review and meta-analysis. BMC Health Serv Res. 2013;13:122. doi:10.1186/1472-6963-13-122.
  22. Chen M, et al. A systematic review of wearable sensor-based technologies for fall risk assessment in older adults. Sensors (Basel). 2022;22(18):6752. doi:10.3390/s22186752.

재인쇄 및 허가

태그

Morse 낙상 척도FRAIL 척도낙상 중증도 선별다요인 위험 평가위험 분류노쇠 선별후향적 분석

이 논문이 게재되었습니다

동영상 곧 제공

문의하기
도서관에 추천하기

개인정보 처리방침

이용 약관

정책

저작권 © 2026 MyJoVE Corporation. 모든 권리 보유.