Falls in elderly and senile patients: clinical guidelines

List of Abbreviations

АГ        -        arterial hypertension

АД        -       blood pressure

БФА     -       basic functional activity

ВОЗ    -        World Health Organization

ВТЭО   -        venous thromboembolic complications

ГС        -        geriatric syndrome

ИФА     -       instrumental functional activity

КБТФФ   -     Short Physical Performance Battery (SPPB)

НПВП      -     nonsteroidal anti-inflammatory drugs

НФГ        -      unfractionated heparin

RFLS - Refracture Prevention Liaison Service

25(OH)D   -    25-hydroxyvitamin D (calcidiol)

CKD-EPI   -    Chronic Kidney Disease Epidemiology Collaboration equation

FRAX        -    Fracture Risk Assessment Tool

START -   Screening Tool to Alert to Right Treatment

STOPP       -    Screening Tool of Older Persons' Prescriptions

Terms and Definitions

Autonomy – independence from outside assistance and the ability to make decisions independently.

Geriatric syndrome - a multifactorial age-associated clinical condition that impairs quality of life, increases the risk of adverse outcomes (death, dependence on outside assistance, readmissions, need for long-term care) and functional decline. Unlike a traditional clinical syndrome, a geriatric syndrome is not a manifestation of pathology in a single organ or body system, but reflects a complex of changes across multiple systems. The onset of one geriatric syndrome increases the risk of developing others.

Fall - an event which results in a person coming to rest inadvertently on the ground or other lower level, excluding intentional changes in position to rest on furniture, walls or other objects, and cases resulting from a blow, loss of consciousness, sudden paralysis, or epileptic seizure.

Pre-frailty - a state preceding the development of frailty syndrome, characterized by the presence of individual signs of frailty that are quantitatively insufficient to diagnose frailty.

Elderly age - 60–74 years according to the 2012 World Health Organization age group classification.

Polypharmacy – simultaneous prescription of 5 or more drug items to a patient, or over 10 items during a course of treatment.

Polymorbidity (multimorbidity) - the presence of two or more chronic diseases in a single patient, regardless of the activity of each.

Sarcopenia - a geriatric syndrome characterized by age-associated progressive generalized loss of skeletal muscle mass and strength.

Frailty - a geriatric syndrome characterized by an age-associated decline in physiological reserve and functions across multiple systems, leading to increased vulnerability of the older person to endogenous and exogenous stressors and a high risk of adverse health outcomes, loss of autonomy, and death. Frailty is closely linked to other geriatric syndromes and polymorbidity, is potentially reversible, and influences patient management tactics.

Old age – 75–89 years according to the 2012 World Health Organization age group classification.

Physical activity - any bodily movement produced by skeletal muscles that requires energy expenditure.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

A fall is an event which results in a person coming to rest inadvertently on the ground or other lower level, excluding intentional changes in position to rest on furniture, walls or other objects, and cases resulting from a blow, loss of consciousness, sudden paralysis, or epileptic seizure [1]. Falls in elderly and old age are one of the main geriatric syndromes (GS) determining the prognosis of a patient's life and autonomy regardless of the consequences. Falls are closely associated with other GS. Falls are preventable. Fall prevention is an integral part of managing elderly and older patients.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Falls in older age are a multifactorial syndrome resulting from a complex interaction of biological, behavioral, environmental, and socio-economic factors (Table 1). Etiological factors for falls include intrinsic predisposing factors (person-related) and extrinsic factors (environment-related) [1,2].

Risk factors for falls with injuries and falls without injuries do not differ [3,4].

Table 1. Factors involved in the etiopathogenesis of falls in elderly and older patients

Biological risk factors include an individual's personal health and bodily condition issues. For example, age, sex, and race are non-modifiable factors. This same group of factors includes age-related changes: a decline in physical and cognitive functions, and multiple chronic conditions. The interaction of biological factors with behavioral and environmental factors increases the risk of a fall. For example, decreased muscle strength leads to reduced functionality and increases the risk of falls due to environmental factors.

Behavioral risk factors include a person's actions and daily choices in performing certain activities, as well as their emotions. This group includes, among other things, taking a large number of medications, excessive alcohol consumption, and insufficient physical activity. These risk factors are potentially modifiable through strategies aimed at changing human behavior.

Environmental risk factors reflect the interaction between a person's individual physical condition and their living environment, including unsafe living conditions and the external space. By themselves, these factors do not lead to falls, but they create conditions for them to occur. This group of risk factors includes narrow steps, slippery floor surfaces, lack of handrails, insufficient lighting in the apartment or house, building layout, potholes on the pavement, etc.

Socioeconomic risk factors are associated with a person's social conditions, economic status, and social interactions.

Key protective factors against falls include ensuring an accessible and safe environment. Behavioral modifications are a key component of healthy aging and fall prevention. Smoking cessation, moderate alcohol consumption, maintaining a normal body weight during middle and older age, and physical exercise help prevent falls.

1.3 Epidemiology of the Disease or Condition

According to expert estimates, 33% of individuals aged 65 and older have a history of falls, with 50% of them falling more than once a year [5]. The prevalence of falls depends on the living conditions of the older adult: it is more than 10 times higher in nursing homes and hospitals than among those living at home [6]. In individuals aged 65 and older, falls are the most frequent cause of injury and the leading cause of death due to traumatic injuries. Fall-related mortality increases with age, ranging from 50 per 100,000 population at age 65 and reaching 150 per 100,000 population at age 75 and 5,252 per 100,000 population at age 85 [7]. Unintentional injuries are the fifth leading cause of death in older adults after cardiovascular disease, cancer, stroke, and lung disease, with falls accounting for 2/3 of these fatal injuries. Non-fatal injuries and fractures significantly affect the quality of life, life prognosis, and autonomy of elderly and senile individuals. The most frequent fractures resulting from falls are femoral fractures (2%), proximal humeral, wrist, and pelvic fractures (5%) [8].

1.4 Features of Coding the Disease or Condition

W00 Fall on the same level involving ice or snow

W01 Fall on the same level from slipping, tripping and stumbling

W02 Fall involving ice skates, skis, roller skates or skateboards

W03 Other fall on same level due to collision with or pushing by another person

W04 Fall while being carried or supported by other persons

W05 Fall involving wheelchair

W06 Fall involving bed

W07 Fall involving chair

W08 Fall involving other furniture

W10 Fall on and from stairs and steps

W11 Fall on and from ladder

W17 Other fall from one level to another

W18 Other fall on same level

W19 Unspecified fall

R29.6 Tendency to fall, not elsewhere classified (Tendency to fall due to old age or other unclear health issues)

1.5 Classification of the disease or condition

Falls are classified depending on the factors associated with them (Table 2) [166, 175] and the presence of injuries (Table 3).

Table 2. Classification of falls according to the factors that led to the fall

Table 3. Classification of falls according to the presence of injury and its severity.

1.6 Clinical presentation of the disease or condition

The clinical presentation of a fall, characterized by a specific pattern, makes it possible in some cases to suggest the cause of the fall and can help guide the diagnostic workup (Table 4) [9]. In addition, the clinical presentation of a fall depends on the presence, localization, and severity of fall-associated injuries (Table 3).

Table 4. Clinical patterns of falls

2. Diagnostics, medical indications and contraindications for diagnostic methods

A diagnosis of a fall is established when both criteria are met:

1. A documented fall (in the medical history or as the reason for the current medical visit, regardless of the presence and severity of injury)
2. Exclusions: external impact (e.g., being struck by another person or a motor vehicle), loss of consciousness (due to any cause), epileptic seizure

Thus, establishing a diagnosis of a fall may require examination according to other clinical guidelines (e.g., to diagnose the causes of syncopal states, detect carotid artery stenosis, aortic valve stenosis, etc.).

In older adults, a priori the risk of falls and associated fractures is higher than in young and middle-aged adults. To reduce individual risk and develop an effective fall prevention plan, the following system of sequential actions must be implemented:

1. identification of patients at high risk for falls (screening);
2. comprehensive assessment of fall risk factors in identified patients;
3. referral of patients for appropriate correction of identified potentially modifiable fall risk factors.

The algorithm of diagnostic procedures is presented in Appendix B.

2.1 Complaints and Anamnesis

Taking the history and anamnesis helps identify patients with a history of falls, assess fall risk, and identify potentially modifiable and non-modifiable risk factors. Fall risk assessment is mandatory for outpatients and hospitalized elderly and senile patients.

According to clinical guidelines KR 613 "Senile Asthenia", all patients aged 60 years and older seeking medical care in outpatient or inpatient settings must be screened for senile asthenia using the questionnaire "Age is No Obstacle", which includes a question about the history of falls over the past year (Appendix G1).

1. Have you had any fall-related injuries or falls without injuries in the past year? (question from the questionnaire "Age is No Obstacle")
2. Do you feel unsteady when standing up or walking?
3. Do you have a fear of falling? [167-169]

GRC ALEL 2Grade of Recommendation A (Level of Evidence 2)

Comment: A positive response to at least one of the specified questions indicates a risk of falls and requires a gait assessment. It is useful to use self-assessment questionnaires for fall risk (Appendix B). If a history of falls is reported, it is recommended to detail their number, circumstances, place and time of the fall, pre-fall symptoms (dizziness, palpitations, chest pain, etc.), events during the fall, presence and severity of injuries, and fear of falls in order to determine the future risk of falling and select diagnostic measures [10]. When assessing fall risk factors, the results of the "Age is No Barrier" screening questionnaire should be considered both overall and in the context of identifying specific geriatric syndromes that may increase fall risk (visual and hearing impairment, urinary incontinence, cognitive impairment, depression, decreased mobility). If individual geriatric syndromes are identified, measures should be taken to correct them. A thorough history of physical activity and nutrition, cardiovascular and cerebrovascular diseases, musculoskeletal disorders, osteoporosis, chronic pain, and an analysis of medications taken are required.

2.2 Physical Examination

During the physical examination of a patient with a risk of falls/history of falls, attention should be paid to the state of the musculoskeletal system (signs of sarcopenia, spinal deformities, changes in the knee and hip joints, foot joints), the state of the cardiovascular system (bruits over the carotid arteries, heart area), orthostatic blood pressure response, the use of assistive devices, vision and hearing, and the state of the central and peripheral nervous system.

• Patients with a positive response to at least 1 of the 3 key questions are recommended to perform the "Timed Up and Go" test with time recording (Appendix G4) to assess fall risk [10-13].

GRC ALEL 2Grade of Recommendation A (Level of Evidence 2)

Comment: performing the "Timed Up and Go" test makes it possible to detect gait and balance disorders, as well as assess the patient's leg strength

• In elderly and senile patients with an identified high risk of falls, the general practitioner/primary care physician is recommended to analyze the risk factors for falls [10-13].

GRC CLEL 5Grade of Recommendation C (Level of Evidence 5)

Comment: to ensure in-depth correction of modifiable fall risk factors, the patient can be referred for consultation to specialist physicians (geriatrician, trauma and orthopedic surgeon, neurologist, ophthalmologist, clinical pharmacologist, physical therapy physician, and others depending on the clinical situation).

• Patients at high risk of falls referred for a geriatrician consultation undergo a multifactorial assessment of fall risk as part of a comprehensive geriatric assessment, and an individualized fall prevention program is developed [10,11, 14,16].

GCR ALEL 2Level of Recommendation A (Level of Evidence 2)

Comment: research methods for multifactorial fall risk assessment are presented in Table 5.

Table 5. Recommended research methods for multifactorial fall risk assessment

• In patients at high risk of falls, the geriatrician is recommended to conduct a thorough gait assessment, involving neurologists, trauma and orthopedic surgeons, or rheumatologists if necessary, in order to develop an individualized fall prevention plan [10,11,17-21]

GCR ALEL 3Level of Recommendation A (Level of Evidence 3)

• In all elderly and senile patients, a thorough analysis of medication prescriptions is recommended for their potential impact on fall risk [21-27].

GCR BLEL 2Level of Recommendation B (Level of Evidence 2)

Comment: the analysis of medication prescriptions is carried out taking into account the provisions of Methodological Recommendations MR103 "Pharmacotherapy in Elderly and Senile Patients". Table 6 lists the drug classes associated with the risk of falls

Table 6. Medications associated with the risk of falls in elderly and senile patients used for the treatment of various diseases

• In all elderly and senile patients, it is recommended to assess the presence of sensory deficits (visual and hearing impairment) and the adequacy of their correction by appropriate medical specialists (ophthalmologist, otorhinolaryngologist, audiologist if necessary) to assess the associated risk of falls [28-31].

Leveled Recommendations BLevel of Evidence 2Level of recommendation validity B (level of evidence 2)

2.3 Laboratory Diagnostics

• In patients with a high risk of falls, a set of laboratory and instrumental studies is recommended to assess the presence of conditions that are potentially modifiable risk factors for falls and to develop an individual fall prevention plan [11].

Leveled Recommendations CLevel of Evidence 5Level of recommendation validity C (level of evidence 5)

Comment: conditions whose correction reduces the risk of falls include anemia, vitamin D deficiency, heart failure, diabetes mellitus, chronic kidney disease, malnutrition syndrome, thyroid dysfunction, and electrolyte disorders.

• Patients with a history of unexplained falls and specific fall patterns are recommended to undergo examination, with consultation of relevant specialists if necessary, for differential diagnosis with syncope as a cause of falls [10, 11, 165].

Leveled Recommendations CLevel of Evidence 5Level of recommendation validity C (level of evidence 5)

• All elderly and senile patients are recommended to determine serum creatinine with GFR calculation using the CKD-EPI formula to assess renal function and diagnose chronic kidney disease as a factor increasing the risk of falls and fractures, as well as to select the appropriate drug dosing regimen [35-44].

GCR ALEL 2Level of Recommendation A (Level of Evidence 2)

Comments: in addition to calculating GFR using the CKD-EPI formula, it is advisable to calculate creatinine clearance using the Cockcroft-Gault formula, since this parameter is used for dose adjustment in the instructions for many medicinal products.

• All elderly and senile patients are recommended to perform a complete blood count and assess the presence of anemia (by hemoglobin level) for timely correction to reduce the risk of falls [45-52].

GRL CLEL 4Grade of Recommendation C (Level of Evidence 4)

• In patients with a high risk of falls due to gait disorders, it is recommended to evaluate thyroid function (study of serum TSH concentration) to diagnose the cause of gait disorders and develop an individual fall prevention plan [53,54].

GRC BLEL 2Grade of Recommendation B (Level of Evidence 2)

• In all patients with a high risk of falls, it is recommended to evaluate the level of total serum protein and albumin to identify malnutrition as a risk factor for falls [55-59].

GRC BLEL 3Grade of Recommendation B (Level of Evidence 3)

• In patients with a high risk of falls, it is recommended to test blood levels of 25-OH vitamin D to identify a potentially modifiable risk factor for falls and develop an individual prevention plan [60,61].

Leveled Recommendations ALevel of Evidence 1Level of recommendation validity A (level of evidence 1)

2.4 Instrumental Diagnostics

If falls are suspected to be due to syncopal states, hypoglycemia, stroke, myocardial infarction, epileptic seizure, etc., necessary instrumental diagnostic studies provided by relevant clinical guidelines are performed to clarify the association of falls with musculoskeletal or central and peripheral nervous system pathology, and to assess the presence of injuries and trauma resulting from the fall. Advanced age should not be a barrier to performing tests to determine the cause of falls.

2.5 Other Procedures

• In patients with chronic pain syndrome, it is recommended to thoroughly assess pain intensity using the visual analogue scale (Appendix G5) and the presence of a neuropathic pain component to develop an individual fall prevention program [62-67].

Leveled Recommendations ALevel of Evidence 2Level of recommendation validity A (level of evidence 2)

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

The individual fall prevention program should be comprehensive, take into account the multifactorial nature of the fall syndrome, individual risk factors for falls in a specific patient, and necessarily include patient education and educational materials for patients and relatives/caregivers.

The individual fall prevention plan is implemented by the supervising physician (general practitioner, family physician) in cooperation with a geriatrician if frailty syndrome is detected. To correct identified potentially modifiable fall risk factors, the supervising physician may consult relevant specialists (ophthalmologist, neurologist, audiologist, trauma surgeon, rheumatologist, cardiologist, urologist, etc.).

The individual fall prevention plan should include general recommendations and differentiated correction measures for identified fall risk factors, goal-directed treatment of existing chronic diseases and geriatric syndromes (Table 7).

For optimal correction of individual fall risk factors, additional laboratory and instrumental examinations may be included in the individual plan, and specialists matching the profile of identified individual risk factors (neurologists, cardiologists, endocrinologists, podiatrists, clinical pharmacologists, rheumatologists, urologists, otorhinolaryngologists, audiologists, ophthalmologists, trauma surgeons, exercise therapy specialists, and medical rehabilitation specialists, etc.) can be engaged in the multidisciplinary team [10,11, 68, 69].

Table 7. General and differentiated measures for fall prevention

3.1 Non-pharmacological measures for fall prevention

• All elderly and senile patients are recommended regular physical activity in a volume and intensity depending on the patient's functional capabilities, for the purpose of primary and secondary prevention of falls [10,11, 68-73].

GCP ALOE 2Grading of Recommendations Assessment, Development and Evaluation (GRADE) level A (level of evidence 2)

• All elderly and senile patients are recommended strength exercises for the main muscle groups of the lower extremities, endurance aerobic training; balance training exercises to reduce the risk of falls [10,11, 68-73].

Leveled Recommendations ALevel of Evidence 1Level of recommendation validity A (level of evidence 1)

• All patients at high risk of falls are recommended nutritional counseling focusing on adequate dietary protein and fluid intake to prevent malnutrition, sarcopenia, and dehydration as factors increasing the risk of falls [59,74].

GRC CLEL 5Grade of Recommendation C (Level of Evidence 5)

• Patients at high risk of falls and with syndromes of geriatric frailty, malnutrition, and sarcopenia are recommended to increase protein intake to 1.0–1.5 g/kg of body weight per day and nutritional support if necessary to increase muscle mass and reduce the risk of falls [59, 75-83].

GCP BLOE 1Grading of Recommendations Assessment, Development and Evaluation (GRADE) level B (level of evidence 1)

• All elderly and senile patients are recommended counseling on organizing a safe living environment for primary and secondary prevention of falls [11, 84-86].

Leveled Recommendations ALevel of Evidence 1Level of recommendation validity A (level of evidence 1)

Comments: Assessment of the safety of the living environment along with behavioral modification have proven effective in reducing both the number of falls and the number of elderly and senile people who fall. Multifactorial interventions to organize a safe home environment should be carried out with the participation of a geriatrician and other specialists (nurse, social worker) after assessing the patient's living conditions.

Recommendations that can be given:

• selection of comfortable furniture height (beds, armchairs, toilet, etc.);
• ensuring furniture stability;
• installation of handrails, especially in the bathroom;
• use of non-slip floor coverings;
• selection of non-traumatic floor covering (e.g., wall-to-wall carpeting);
• elimination of thresholds where possible;
• adequate, but not too bright, lighting;
• contrast markings on stairs and steps.
• All elderly and senile patients are recommended counseling on footwear selection for the prevention of falls [87-91].

GRC BLEL 2Grade of Recommendation B (Level of Evidence 2)

Comments: The reliability and adaptive capabilities of footwear are essential in comprehensive fall prevention programs. It is necessary to explain to the patient the importance of using specialized footwear and help them choose a suitable model. Footwear is considered improperly selected if it has a heel height exceeding 4.5 cm; footwear without a back; footwear with a back that can be compressed by more than 45%; completely worn-out footwear or footwear with a completely flat sole.

• Elderly and senile patients are recommended to wear individually selected specialized insoles to correct certain gait abnormalities and ensure proper foot position in order to reduce the risk of falls [96].

GRC CLEL 5Grade of Recommendation C (Level of Evidence 5)

Comment: Clinical effects of using specialized insoles include: supporting adaptive ankle joint angles to prevent falls; shock absorption through the use of low-elasticity materials in the heel; increasing the speed of the proprioceptive response by stimulating skin receptors; maintaining dynamic balance using pressure control centers located in the sole of the foot.

• Elderly and senile patients are recommended to use insoles with an improved texture that reduces foot sliding and prevents excessive lateral deviation of the foot in order to reduce the risk of falls associated with balance impairment [97].

GCP BLOE 2Grading of Recommendations Assessment, Development and Evaluation (GRADE) level B (level of evidence 2)

• Patients at high risk of falls for walking long distances are recommended to wear specialized orthopedic footwear in order to increase gait stability and prevent falls [98,99].

GRC BLEL 3Grade of Recommendation B (Level of Evidence 3)

• Patients at high risk of falls due to balance impairment are recommended to use ankle braces to reduce the risk of falls [104].

GCP BLOE 2Grading of Recommendations Assessment, Development and Evaluation (GRADE) level B (level of evidence 2)

• Patients at high risk of falls without ankle injuries are recommended to use ankle braces during exercise to reduce the risk of falls [105].

GCP BLOE 2 Grading of Recommendations Assessment, Development and Evaluation (GRADE) level B (level of evidence 2)

• Elderly and senile patients at high risk of falls living in long-term care facilities are recommended to use impact-absorbing or force-distributing hip protectors as a cost-effective measure for the prevention of proximal femur fractures in the event of a fall [106-108].

GCP ALOE 1Grading of Recommendations Assessment, Development and Evaluation (GRADE) level A (level of evidence 1)

Comment: Hip protectors cushion a lateral fall onto the hip. Foam hip protectors are preferred, as plastic shields can displace the impact force, thereby increasing the risk of pelvic bone injury

• Patients at high risk of falls with identified vertebral compression fractures are recommended to use orthopedic corsets with rigid stays (for the lumbar or thoracic spine) in the first 8 weeks after the diagnosis of a vertebral body compression fracture in order to expand rehabilitation measures, reduce back muscle fatigue, decrease pain syndrome, and lower the risk of falls [109-111].

GCP BLOE 1Grading of Recommendations Assessment, Development and Evaluation B (level of evidence 1)

• Older and geriatric patients with nonspecific musculoskeletal back pain are not recommended to use orthopedic corsets to reduce the risk of falls [109-111].

GCP BLOE 1Grading of Recommendations Assessment, Development and Evaluation B (level of evidence 1)

3.2 Pharmacological measures for fall prevention

• Patients at high risk of falls should undergo medication review to reduce polypharmacy and analyze the impact of drugs used for acute and chronic conditions on the risk of falls [10, 11, 21-27].

GRC BLEL 2Grade of Recommendation B (Level of Evidence 2)

Comment: when reviewing medications and prescribing drugs, it is recommended to follow clinical guidelines CR 613 "Frailty" and Methodological Recommendations MR 103 "Pharmacotherapy in Older and Geriatric Patients"

Comments: Vitamin D deficiency corresponds to a blood 25(OH)D₃ concentration of <20 ng/mL (50 nmol/L), vitamin D insufficiency to 25(OH)D₃ from 20 to 30 ng/mL (from 50 to 75 nmol/L), and an adequate level to more than 30 ng/mL (75 nmol/L). The recommended target level of 25(OH)D₃ during vitamin D deficiency correction is 30-60 ng/mL (75-150 nmol/L).

3.3 Features of the treatment of comorbid diseases and conditions in patients with a high risk of falls

3.3.1 Arterial hypertension

• Older and geriatric patients for whom antihypertensive therapy is prescribed or modified should be informed about the increased risk of falls in the first 2-4 weeks after the start/intensification of antihypertensive therapy and recommended non-pharmacological measures to reduce the risk of falls for their prevention [117-119].

GCP BLOE 2Grading of Recommendations Assessment, Development and Evaluation B (level of evidence 2)

• In patients with a high risk of falls and frailty, it is recommended to achieve a systolic blood pressure level of 140-150 mm Hg and its reduction to <130 mm Hg is not recommended in order to reduce the risk of cardiovascular events without increasing the risk of falls [119-122].

GCP BLOE 2Grading of Recommendations Assessment, Development and Evaluation B (level of evidence 2)

• In older and geriatric patients, it is recommended to assess the presence of orthostatic hypotension before prescribing, after starting antihypertensive therapy, and when changing it, to ensure treatment safety in the context of fall risk [123-125].

GCP ALOE 2Grading of Recommendations Assessment, Development and Evaluation A (level of evidence 2)

3.3.2 Anticoagulant therapy

• In older and geriatric patients with atrial fibrillation receiving anticoagulant therapy, it is not recommended to discontinue it due to fear of falls, but active fall prevention measures are recommended to reduce their risk [126-128].

GCP BLOE 3Grading of Recommendations Assessment, Development and Evaluation B (level of evidence 3)

Comment: In older and geriatric patients with atrial fibrillation and a high risk of falls, the administration of dabigatran etexilate** is preferred for the prevention of thromboembolic stroke due to the presence of an antidote that allows rapid reversal of the anticoagulant effect in the event of bleeding associated with a fall or the need for surgical intervention.

3.3.3 Diabetes mellitus

• In older and geriatric patients with a high risk of falls, lowering glycated hemoglobin levels below 7.0% is not recommended due to an increased risk of falls [129-133].

GCP CLOE 4Grading of Recommendations Assessment, Development and Evaluation C (level of evidence 4)

Comment: When choosing drugs for the treatment of diabetes mellitus, it should be taken into account that the highest risk of falls is observed with insulin therapy and its analogues

3.3.4 Pain syndrome

• In patients with a high risk of falls and chronic pain syndrome, it is recommended to use non-pharmacological (exercise, educational programs) and pharmacological treatments for pain syndrome to reduce the associated risk of falls, giving preference to non-pharmacological interventions [134-138].

GCP ALOE 1Grading of Recommendations Assessment, Development and Evaluation A (level of evidence 1)

Comment: The physician should explain to the patient that low adherence to non-pharmacological treatments significantly reduces the likelihood of achieving adequate pain control

• In patients with a high risk of falls and chronic pain syndrome associated with musculoskeletal disorders, the use of cholecalciferol** as baseline therapy for chronic pain is recommended to increase the effectiveness of measures to reduce pain and decrease the risk of falls [138-141].

GCP BLOE 1Grading of Recommendations Assessment, Development and Evaluation B (level of evidence 1)

• In patients with a high risk of falls and pain syndrome, it is recommended to use the least invasive route of analgesic administration, including the widespread use of topical forms [142,143].

Leveled Recommendations CLevel of Evidence 5Level of recommendation validity C (level of evidence 5)

• In patients with a high risk of falls, NSAIDs are recommended to be used only on demand and in short courses due to the high risk of adverse events, including an increased risk of falls [137,144-146]

GCP BLOE 3Grading of Recommendations Assessment, Development and Evaluation B (level of evidence 3)

• In patients with a high risk of falls and chronic pain syndrome, paracetamol** monotherapy is not recommended. Combination therapy with paracetamol** and NSAIDs or opioids may be considered as a method to intensify the analgesic potential, provided that liver and kidney functions are carefully monitored [147,148].

GCP BLOE 1Grading of Recommendations Assessment, Development and Evaluation B (level of evidence 1)

• In patients with polyarthrosis, coxarthrosis, gonarthrosis, or degenerative changes in the bone-joint structures of the spine, it is recommended to consider prescribing chondroitin sulfate or glucosamine to slow down disease progression, reduce the frequency of pain exacerbations, and decrease the associated risk of falls:
• chondroitin sulfate at a dose of 100-200 mg intramuscularly every 48 hours for 25-30 injections [Russian Ministry of Health Clinical Trial Protocol Identification Number: KI/1216-1] or in an oral form of 1000 mg daily for at least 6 months [149, 150]
• glucosamine 400-600 mg parenterally every 48 hours until pain subsides [Russian Ministry of Health Clinical Trial Protocol Identification Number: No. KI/0113-1] or orally at a daily dose of 1500 mg for at least 2 to 4 months [151, 152]
• diacerein 100 mg daily for 2 to 4 months [152-154]
• sodium hyaluronate for intra-articular and peri-articular injections [155]

Leveled Recommendations ALevel of Evidence 1Level of recommendation validity A (level of evidence 1)

• In patients with a high risk of falls and pain syndromes, psycholeptics and psychoanaleptics are not recommended due to an increased risk of falls [156]

Level of Evidence CGrade of Recommendation 3Level of Evidence C (Grade of Recommendation 3)

• Patients with a high risk of falls and chronic pain syndrome are recommended to have anxiety and depressive disorders corrected by selecting appropriate pharmacotherapy and cognitive-behavioral therapy, taking into account medical history, to increase the effectiveness of measures aimed at reducing pain and decreasing the risk of falls [157-160].

GCP CLOE 3Grading of Recommendations Assessment, Development and Evaluation C (Level of evidence 3)

Comment: in patients with a psychogenic component of pain, it is advisable to hold a medical panel involving a geriatrician, general practitioner, cardiologist, neurologist, and psychiatrist to develop an optimal management plan

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Patients with a history of falls need rehabilitation to improve physical functioning, maintain independence from external assistance, or reduce the need for care.

Rehabilitation can be carried out in a rehabilitation center/department or geriatric department after receiving specialized or high-tech medical care and should include measures for physical activity, maintenance of nutritional status, social adaptation, and selection of means and methods that adapt the environment to the patient's functional capabilities and (or) the patient's functional capabilities to the environment. Due to the possible development of fear of falling syndrome, which leads to the patient limiting their physical functioning disproportionately to their functional capabilities, it is recommended to include a medical psychologist in the multidisciplinary team.

5. Prevention and Dispensary Observation

During preventive counseling for older and geriatric individuals, it is necessary to provide recommendations on regular physical activity, nutrition, organizing a safe living environment, and refer them to specialized medical professionals for the correction of sensory deficits (hearing and vision loss).

• For community-dwelling older and senile adults with preserved autonomy, group and individual educational programs are recommended for the prevention of falls [161-164].

GCR ALEL 2Level of recommendation credibility A (level of evidence 2)

Dispanserization (active clinical monitoring) of a patient at high risk for falls and with frailty syndrome is carried out by a geriatrician in accordance with an individual management plan. Patients at high risk for falls without frailty or with prefrailty are monitored by a general practitioner (district physician) in accordance with the established routine for preventive examinations and clinical screening. During patient follow-up, the general practitioner assesses the dynamics of fall risk factors, implements measures for their correction, and evaluates the effectiveness of these measures.

6. Organization of Medical Care

Healthcare organizations providing primary and specialized medical care to adults must implement and enforce protocols for fall prevention (an example is provided in Appendix G6), take measures to ensure a safe environment, and inform visitors about the risk of falls and basic prevention measures. Information for patients scheduled for elective hospitalization must include recommendations regarding appropriate footwear during the hospital stay. Nursing staff play a vital role in fall prevention and patient education on its fundamentals.

Suspicion of a fracture of any localization resulting from a fall in an older or senile adult is an absolute indication for consultation with an orthopedic trauma surgeon. If a proximal femur fracture is suspected and its diagnostic criteria are identified, an ambulance team must be called for the patient without fail. The ambulance team ensures the transportation of the patient to a medical facility providing specialized care in traumatology and orthopedics for older and senile patients in accordance with the regional routing plan. A patient with a proximal femur fracture cannot be denied hospitalization. Patients with a proximal femur fracture are subject to surgical treatment no later than 48 hours from the moment of the fracture, provided there are no absolute contraindications. Medical care for such patients is provided in accordance with current clinical guidelines CG614 "Pathological fractures complicating the course of osteoporosis" [177].

For the further follow-up of patients aged 60 and older with low-energy fractures, it is recommended to establish Fracture Liaison Services (FLS), an integral part of which is the assessment of fall risk and the implementation of prevention measures with the active participation of a geriatrician.

7. Additional Information

An increased risk of falls is an adverse outcome associated with the hospitalization of older and senile patients, especially in the presence of frailty syndrome.

Environmental modifications, bed rest, new medications, catheterization, sensory deprivation, disruption of the habitual sleep-wake cycle, dietary changes, functional, physical, and cognitive decline are all predisposing factors for an increased risk of falls. It is necessary to minimize these risks, including by reducing the duration of intravenous drug administration and catheter use as much as possible, early patient mobilization, implementing nursing fall prevention protocols in ward operations, and incorporating physical exercises for fall prevention as early as the patient's clinical condition allows.

Patients should be encouraged to spend time out of bed to reduce the risk of muscle weakness and orthostatic reactions. Patients with a high risk of falls may require supervision when moving.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Tkacheva, O.N. – MD, Professor, Director of the Russian Clinical and Research Center of Gerontology, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Head of the Department of Aging Diseases, Pirogov Russian National Research Medical University of the Russian Ministry of Health, President of the Russian Association of Gerontologists and Geriatricians
2. Kotovskaya, Yu.V. – MD, Professor, Deputy Director for Scientific Work, Russian Clinical and Research Center of Gerontology, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians
3. Milto, A.S. – MD, Chief Physician of the Russian Clinical and Research Center of Gerontology, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians
4. Runikhina, N.K. – MD, Deputy Director for Geriatrics, Russian Clinical and Research Center of Gerontology, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Professor of the Department of Aging Diseases, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians
5. Frolova, E.V. – MD, Professor of the Department of Family Medicine, North-Western State Medical University named after I.I. Mechnikov of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians
6. Naumov, A.V. – MD, Head of the Laboratory of Musculoskeletal Diseases, Russian Clinical and Research Center of Gerontology, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians
7. Dudinskaya, E.N. – PhD, Head of the Laboratory of Age-Related Metabolic Endocrine Disorders, Russian Clinical and Research Center of Gerontology, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians
8. Makhokhina L.V. – Cand. of Sci. (Med.), Junior Research Associate, Laboratory of Age-Related Metabolic and Endocrine Disorders, Pirogov Russian National Research Medical University of the Russian Ministry of Health (RGNKC branch), Member of the Russian Association of Gerontologists and Geriatricians
9. Vorobyeva N.M. – Dr. of Sci. (Med.), Head of the Laboratory of Cardiovascular Aging, Pirogov Russian National Research Medical University of the Russian Ministry of Health (RGNKC branch), Member of the Russian Association of Gerontologists and Geriatricians
10. Rozanov A.V. – Cand. of Sci. (Med.), Senior Research Associate, Laboratory of Cardiovascular Aging, Pirogov Russian National Research Medical University of the Russian Ministry of Health (RGNKC branch), Member of the Russian Association of Gerontologists and Geriatricians
11. Ostapenko V.S. – Cand. of Sci. (Med.), Assistant Professor, Department of Ageing-Related Diseases, Faculty of Additional Professional Education, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians
12. Mkhitaryan E.A. – Cand. of Sci. (Med.), Senior Research Associate, Laboratory of General Geriatrics and Neurogeriatrics, Pirogov Russian National Research Medical University of the Russian Ministry of Health (RGNKC branch), Associate Professor, Department of Ageing-Related Diseases, Faculty of Additional Professional Education, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians
13. Sharashkina N.V. – Cand. of Sci. (Med.), Senior Research Associate, Laboratory of General Geriatrics and Neurogeriatrics, Pirogov Russian National Research Medical University of the Russian Ministry of Health (RGNKC branch), Member of the Russian Association of Gerontologists and Geriatricians
14. Khovasova N.O. – Cand. of Sci. (Med.), Associate Professor, Department of Ageing-Related Diseases, Faculty of Additional Professional Education, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians
15. Tyukhmenev E.A. – Cand. of Sci. (Med.), Associate Professor, Department of Ageing-Related Diseases, Faculty of Additional Professional Education, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians
16. Babenko I.V. – Cand. of Sci. (Med.), Research Associate, Laboratory of Age-Related Metabolic and Endocrine Disorders, Pirogov Russian National Research Medical University of the Russian Ministry of Health (RGNKC branch), Member of the Russian Association of Gerontologists and Geriatricians
17. Lesnyak O.M. – Dr. of Sci. (Med.), Professor, Professor, Department of Family Medicine, North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, President of the Russian Osteoporosis Association, Member of the Association of Rheumatologists of Russia
18. Belova K.Yu. – Dr. of Sci. (Med.), Head of the Regional Diagnostic and Treatment Center for Osteoporosis and Osteoarthritis, Solovyov Clinical Hospital of Emergency Medical Care; Associate Professor, Professor E.N. Dormidontov Department of Therapy, Yaroslavl State Medical University, Member of the Presidium of the Russian Osteoporosis Association, Member of the Association of Rheumatologists of Russia
19. Evstigneeva L.P. – Dr. of Sci. (Med.), Head of the Rheumatology Department, Sverdlovsk Regional Hospital No. 1, Associate Professor, Department of Therapy, Faculty of Advanced Training and Professional Retraining of Specialists, Ural State Medical University, Chief freelance specialist rheumatologist of the Ministry of Health of Sverdlovsk Region, Member of the Presidium of the Russian Osteoporosis Association, Member of the Commission for the Organization of Rheumatology Care of the Association of Rheumatologists of Russia
20. Ershova O.B. – Dr. of Sci. (Med.), Professor, Professor, Professor E.N. Dormidontov Department of Therapy, Yaroslavl State Medical University; Vice-President of the Russian Osteoporosis Association, Head of the Osteorus Osteoporosis Patient Society, Member of the Association of Rheumatologists of Russia

All members of the Working Group have confirmed that they have no financial support or conflicts of interest to disclose.

The draft clinical guidelines were available for public discussion on the website www.rgnkc.ru starting from June 6, 2019. The draft was discussed by the participants of the All-Russian Congress of Gerontology and Geriatrics on May 16–21, 2019 (Moscow), and the II All-Russian Forum "Russia – Territory of Care" on October 10–11, 2019 (Moscow).

Appendix A2. Methodology for Developing Clinical Guidelines

The clinical guidelines were developed by expert specialists of the Russian Association of Gerontologists and Geriatricians.

This version of the clinical guidelines is based on the following resources and documents:

- VA National Center for Patient Safety, https://www.patientsafety.va.gov

- STEADI - Older Adult Fall Prevention, https://www.cdc.gov/steadi

- Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons. JAGS 59:148–157, 2011

Sources for recent updates included journal publications in reputable peer-reviewed journals indexed in Russian and international citation databases.

Target audience for these clinical guidelines:

1. Geriatrician providing medical care in outpatient and inpatient settings.

2. Physician (General Internist) providing medical care in outpatient and inpatient settings.

3. General Practitioner (Family Physician).

Scale for determining levels of evidence for diagnostic interventions

Scale for grading levels of recommendation evidence for diagnostic interventions

Scale for determining levels of evidence for therapeutic, rehabilitative, and preventive interventions

Scale for determining levels of recommendation grades for therapeutic, rehabilitative, and preventive interventions

Procedure for updating clinical guidelines

Clinical guidelines are updated once every 3 years, taking into account new Russian and international data on the epidemiology of disease forms, diagnostic methods and tactics, pharmacological treatment options, and indications for surgical interventions.

[1] The generally accepted standard for clinical studies of diagnostic interventions is a cross-sectional study design in which each included patient undergoes both the evaluated diagnostic method and the reference method (the "gold standard" for diagnosing the studied disease or condition) in parallel and under identical conditions. The evaluated and reference methods must be applied independently of each other (i.e., the evaluated method cannot be part of the reference method) and must be interpreted by the investigator without knowledge of the results of the other method (blinding is recommended).

Appendix A3. Reference Materials

Related Documents

Order of the Ministry of Health of the Russian Federation No. 38n dated January 29, 2016, "On Approval of the Procedure for Providing Medical Care in the Field of 'Geriatrics'."

Order of the Russian Ministry of Health No. 1067n dated December 20, 2019, "On Amendments to the Procedure for Providing Medical Care in the Field of 'Geriatrics' approved by Order of the Russian Ministry of Health No. 38n dated January 29, 2016"

Clinical Guidelines "Frailty"

Methodological Guidelines MP 103 "Pharmacotherapy in Elderly and Senile Patients"

CG 614 "Pathological Fractures Complicating Osteoporosis"

Clinical Guidelines "Osteoporosis"

Clinical Guidelines "Chronic Pain in Elderly and Senile Patients"

Clinical Guidelines "Malnutrition in Elderly and Senile Patients"

Clinical Guidelines "Cognitive Impairment in Elderly and Senile Patients"

Clinical Guidelines "Urinary Incontinence"

Colecalciferol doses** for correcting vitamin deficiency and insufficiency D

Appendix B. Physician Action Algorithms

Fig. 1. Assessment of fall risk in patients aged 60 years and older in primary care by a district general practitioner, general practitioner, or family physician

Fig. 2. Fall risk assessment in hospitalized patients aged 60 and older

Appendix C. Patient Information

Why are falls dangerous?

Falls are dangerous because they can cause injuries of varying severity. The most formidable consequences of falls are head trauma with cerebral hemorrhage or even death, and hip fracture. A fall can be a sign of a serious problem, even if it does not lead to injury. After a fall, a fear of falling may develop, causing the elderly person to significantly reduce their physical activity, which they could well have continued if the fall had not occurred. For example, out of fear of falling, a person may become less likely or even stop leaving the house. This will lead to less frequent shopping and a decline in the quality of nutrition, less communication with friends and relatives, and fewer visits to places that were previously of interest and value to them (the theater, museums, cinema, church services, etc.). All of this will negatively affect health, as well as the quality and fullness of life.

Take ALL falls seriously. Tell your doctor about every fall, even if you were not injured. A fall can be a serious problem. Your doctor will advise you on how to prevent future falls.

Why do elderly people have an increased risk of falling?

With age, muscle strength decreases, the ability to maintain balance declines, and vision and reaction time deteriorate. As a result, even for a quite healthy elderly person, a small obstacle—such as stepping up onto a curb, tripping over an object on the floor unnoticed due to poor lighting, or catching the edge of a rug—can lead to a fall with severe consequences.

Elderly people often take a large number of medications, both prescribed by a doctor and on their own initiative. Some medications can increase the risk of falls, so be sure to inform your doctor about all the medications you are taking.

Certain medical conditions can also be the causes of falls—such as cardiac arrhythmias, cerebrovascular disorders, and others. However, elderly people fall much more frequently for the simpler reasons listed above.

Falls are not an inevitable companion of old age. Falls can and must be prevented.

How to assess fall risk?

Do not hush up your falls, even if they seem to you to be explained by external circumstances and did not lead to bruises or more serious injuries. Always inform your doctor about any instance of a fall.

Assess your risk of falling:

Count your points___________A score of 4 points or more indicates a high risk of falls.

Show your answers to these questions to your attending physician. You may need a consultation with a geriatrician. A geriatrician is a specialist who provides medical care to older adults.

Can falls be prevented in an elderly person?

Falls can and must be prevented!

Regular physical activity and exercise are a crucial method for preventing falls. Physical activity includes walking, strolling for at least 30 minutes a day, swimming, gardening and housework, etc. At least 150 minutes of moderate-intensity physical activity per week is required, with each bout lasting at least 10 minutes. To prevent falls, balance exercises must be performed at least 3 days a week. To increase muscle strength, strength exercises are needed 2 or more days a week (but not 2 consecutive days). Exercises to strengthen the ankle joint are beneficial.

Chronic diseases are not a contraindication to moderate physical activity, but it is best to perform them under the supervision of a specialist—a therapeutic exercise instructor.

Vision and glasses. Regularly (at least once a year) check your vision and change your glasses if necessary. Do not wear glasses with bifocal lenses.

Safe home environment. Tidy up your home: remove items from the floor that you could trip over (wires, cords, etc.), make sure nothing clutters the walkways, and eliminate thresholds where possible. Furniture (beds, armchairs) and toilets should be of a comfortable height and stable. Remove rugs or secure their edges with tape. Use non-slip mats in the bathroom. Install handrails, especially in the bathroom. Lighting should be adequate and easy to turn on without getting out of bed. If you get up at night to use the toilet, leave a nightlight on to illuminate your path.

Do not lock yourself in the bathroom or toilet.

Get into the habit of always carrying your mobile phone with you so you can call if you happen to fall and cannot get up. Program speed dial buttons for the phone numbers of close relatives, a social worker, rescue services, or an ambulance. Install at least one telephone in such a way that you can reach it without getting up from the floor.

Footwear. Improperly fitted footwear increases the risk of falls. Footwear is considered improperly fitted if it has a heel height exceeding 4.5 cm; is backless; has a back that can be compressed by more than 45°; is completely worn out; or has an absolutely flat sole. If you have foot deformities, contact an orthopedic salon to select orthopedic shoes, insoles, and devices that will make walking easier and your gait more stable.

Assistive devices. If you are advised to use a cane or walker, do not refuse. These devices significantly reduce the risk of falls and will give you the opportunity to move around the house more easily and go out more often for walks and errands. Pay attention to their convenience and proper selection.

Medication use. It is very important to use medications correctly, as taking a large number of drugs can lead to an increased risk of falls. Sleeping pills and sedatives, as well as drugs that impair concentration, are especially dangerous. Be sure to inform your doctor about all the medications you are taking, or better yet, bring them with you to the appointment and show them. Sometimes a doctor may discontinue medications, even those you are used to and have been taking for a long time, in order to reduce the risk of falls and fractures.

Vitamin D. Many people develop a vitamin D deficiency with age, which increases muscle weakness, difficulty in walking and maintaining balance, and increases the risk of falls and fractures. Take vitamin D after consulting a doctor.

What to do if you fall?

1. Do not panic. Remain calm and try to figure out if you have been injured.

1. Slowly turn over and try to sit up. Slow movements will prevent dizziness.

1. Look around and find the nearest stable support—an armchair, bed, sofa—preferably resting on a carpet. Crawl to it. Do not try to get up in the bathroom, where the floor may be wet and slippery.

1. If you are able, get up first on one knee, then on the other.

5. Stand up, leaning on your stronger leg. Use a stable armchair, bed, couch, or sofa for support.

1. Carefully turn around and sit down.

What to do if you fall and cannot get up?

Call for help. If you are home alone, crawl to the phone and call relatives or emergency services (112). It is important that at least one telephone can be reached from the floor, or that your mobile phone is always with you.

If you cannot sit up, pull a bedspread, pillows, towels, or clothing off the bed, sofa, or armchair. Wrap yourself in them or pile them around you to keep warm.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Fall risk screening

Russian title: "Age is No Obstacle"

Original title (if applicable): "Age is No Obstacle"

Source (official developer website, validation publication):

Developer: Pirogov Russian National Research Medical University of the Russian Ministry of Health – Russian Gerontology Clinical Research Center, www.rgnkc.ru

Tkacheva O.N., Runikhina N.K., Ostapenko V.S., Sharashkina N.V., Mkhitaryan E.A., Onuchina Yu.S., Lysenkov S.N. Validation of a questionnaire for screening geriatric frailty syndrome in outpatient practice. Advances in Gerontology. 2017. Vol. 30. No. 2. P. 236-242.

Type: questionnaire

Purpose: screening for geriatric frailty syndrome

Content (template):

Scoring key (interpretation): 1 point is awarded for each "yes" response. A score of 2 points or less indicates no frailty, 3–4 points indicate probable prefrailty, and 5–7 points indicate probable frailty.

Comments: Patient routing shall be carried out in accordance with Clinical Guidelines CR 613 Geriatric Frailty

Appendix G2. Morse Fall Scale for assessing the risk of falls in hospitalized elderly and senile patients

Russian title: Morse Fall Scale

Original title (if applicable): Morse Fall Scale

Source (official developer website, validation publication):

Morse JM, Morse RM, Tylko S. Development of a scale to identify the fall-prone patient. Can J Aging. 1989;8(4):366-77.

Type: rating scale

Purpose: assessment of fall risk in hospitalized patients

Content (template):

Key (interpretation): 0-24 points – no risk of falls, 25-50 – low risk of falls, 51 points and more – high risk of falls

Appendix G3. Delirium screening

Russian name: Confusion Assessment Method

Original name (if any): Confusion Assessment Method (CAM)

Source (official developer website, validation publication):

Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method: a new method for detection of delirium. Ann Intern Med. 1990;113(12):941–948.

Type: rating scale

Purpose: screening and monitoring of delirium in elderly and senile patients

Content (template):

Richmond Agitation-Sedation Scale (RASS)

+4 COMBATIVE: overtly combative, violent, immediate danger to staff (notify physician immediately)

+3 VERY AGITATED: pulls or removes tube(s) or catheter(s); aggressive (notify physician)

+2 AGITATED: frequent non-purposeful movement, fights ventilator

+1 RESTLESS: anxious, non-aggressive movements

0 ALERT AND CALM

-1 DROWSY: not fully alert, but has sustained awakening to voice (eye opening and contact) ≥ 10 seconds

-2 LIGHT SEDATION: briefly awakens to voice (eye opening and contact) < 10 seconds

-3 MODERATE SEDATION: movement or eye opening to voice (but no eye contact)

Appendix G4. Timed Up and Go (TUG) test

Russian title: test “Timed Up and Go”

Original title (if applicable): Timed “Up and go” test

Source (official developer website, validation publication):

Mathias S, Nayak USL, Isaacs 8. Balance in the elderly patient: The "Get-up and Go" test. Arch Phys Med Rehabil 1986;67:387.

Type: other - test

Purpose: assessment of gait, balance, and fall risk

Content (template):

Required equipment: chair with armrests, tape measure, colored tape or marker, stopwatch. Measure a distance of 3 meters from the chair and mark it with a marker or colored tape so that the mark is visible to the patient.

Testing conditions. The patient should be instructed that the test is timed. The first trial run can be performed without timing.

During the test, the patient should wear their usual footwear and may use any assistive devices they normally rely on (e.g., cane or walker). If necessary, the patient may pause to rest during the test.

Procedure

• The patient should sit in the chair with their back against the backrest and thighs fully supported by the seat. The chair must be stable. The patient is allowed to use the armrests when sitting and standing up.
• Patient instructions: When I say “Go”, you will stand up, walk the marked distance, turn around, walk back to the chair, and sit down. Walk at your normal pace.
• Start the timer after saying “Go” and stop the timer when the patient is seated properly back in the chair with their back against the backrest.
• During the test, observe for signs of gait and balance abnormalities.

Scoring (interpretation): Healthy older adults typically complete the Timed Up and Go test in 10 seconds or less. A TUG result of more than 14 seconds in community-dwelling older adults, along with signs of gait and balance impairment, indicates a risk of falls.

Appendix G5. Visual Analog Scale for pain intensity assessment

Russian title: Visual Analog Scale for pain

Original title (if applicable):

Source (official developer website, validation publication):

Huskisson EC. Measurement of pain. Lancet 1974;2:1127–31.

Downie WW, Leatham PA, Rhind VM, Wright V, Branco JA, Anderson JA. Studies with pain rating scales. Ann Rheum Dis 1978;37:378–81.

Scott J,Huskisson EC. Graphic representation of pain. Pain 1976; 2:175-84

Joos E,Peretz A,Beguin S,et al. Reliability and reproducibility of visual analogue scale and numeric rating scale for therapeutic evaluation of pain in rheumatic patients. J Rheumatol 1991; 18:1269-70

Type: rating scale

Purpose: assessment of pain intensity

Content (template):

Scoring (interpretation): higher scores indicate greater pain intensity. Effective pain reduction is defined as a decrease of 50% or more from the baseline score.

Notes: the patient is asked to rate their current pain intensity from 0 (no pain) to 10 (worst imaginable pain).

Appendix G6. Standard operating procedure for fall prevention in a medical organization

Regulations for Fall Prevention in Older and Senile Age Groups in a Medical Organization

1. Goal

Prevention of falls among patients, visitors, and staff of the medical organization.

1. Scope

Premises of buildings and structures of the medical organization.

1. Responsibility

All staff of the medical organization, employees of outsourcing companies working on the premises of the medical organization

1. Resources/Equipment

Information posters for patients providing information on fall risk factors, fall prevention measures, physical activity, and exercises for fall prevention

Information brochures for patients providing information on fall risk factors, fall prevention measures, physical activity, exercises for fall prevention, home safety, proper footwear selection, and what to do after a fall

Information leaflet for hospitalized patients

Red wristband for patients at high risk for falls

Red sticker on the patient's medical record for high fall risk

Red sign/sticker on the door of a patient at high risk for falls

“Caution, Wet Floor!” sign

1. Documentation

Morse Fall Scale in nursing care charts

Fall incident report form

Departmental fall logbook

1. Activities aimed at raising awareness among patients, their relatives, and other visitors about fall risks

Information posters regarding fall risk factors, fall prevention measures, physical activity, and exercises for fall prevention are placed in the lobbies and corridors of the medical organization.

When visiting the medical organization, older and senile patients or their relatives/caregivers are provided with information on fall risk factors, fall prevention measures, physical activity, exercises for fall prevention, home safety, proper footwear selection, and post-fall behavior.

If hospitalization is planned, the patient/relatives/caregivers are given an information leaflet which, among other information, contains friendly recommendations:

- on choosing appropriate footwear to bring for the stay (prohibition of backless slippers, flip-flops; necessity of athletic shoes for physical exercises);

- a reminder to bring glasses and hearing aids (if used in daily life).

7. Fall Risk Assessment and Prevention Measures

7.1. Admission Department

The admitting nurse must ensure that the patient's footwear for use in the ward is properly selected, and that the patient has brought athletic shoes for physical exercises, as well as glasses and a hearing aid if needed. If any issues are identified, the nurse asks an accompanying person to bring the necessary items during their next visit.

7.2. Initial Fall Risk Assessment for Hospitalized Patients in the Ward

Conducted in the ward immediately upon admission by nursing staff using the Morse Fall Scale. For patients identified as high risk for falls according to the Morse Fall Scale, the nurse places a red wristband, marks the medical record and nameplate with a red sticker, and marks the room with a red sign.

The nurse instructs all patients and caregivers on the internal regulations and trains them in fall prevention. The fact of instruction is documented by the nurse in the nursing care plan. It is recommended that the patient and/or caregiver sign to confirm that they have read the internal regulations and fall prevention rules.

The nurse educates the patient and caregivers on fall prevention:

Get up slowly: do not get out of bed/chair alone, do not stand up abruptly, especially in case of dizziness, after anesthesia/surgery, or after taking medications.

Call for help from the caregiver or summon medical staff using the call button if you need to use the toilet, shower, or leave the room.

Recommends wearing non-slip shoes with closed backs and a 1.5–3 cm heel.

Draws attention to the importance of clean and dry floors: the patient/caregiver must look out for the "Caution, wet floor!" sign and ensure there are no wires or cords from personal electronic devices (cell phone chargers, laptops, etc.). If liquid is spilled on the floor of the room or corridor, immediately notify the medical staff and ask to wipe the wet area.

7.3. Reassessment of Fall Risk

Fall risk reassessment is performed by nursing staff using the Morse Fall Scale according to the criteria listed below (Table 1). The results are documented in the nursing care plan.

Table 1. Criteria for fall risk reassessment

7.4. Fall Risk Assessment in Outpatients

Fall risk assessment in outpatients is performed by a nurse or physician. Each patient should be interviewed regarding: 1) a history of falls with or without injuries over the past 12 months, specifying the number and circumstances; 2) gait changes and onset of balance impairments; 3) presence of a fear of falling.

The facility's medical staff should pay attention to any patient who is visibly frail, has low mobility, uses assistive devices (crutches, cane, walker, etc.), has obvious visual and balance impairments, has just undergone a procedure that may cause dizziness or weakness (invasive procedure, intravenous infusions, blood draw, dental services, etc.), or is visiting the physiotherapy or rehabilitation department as an outpatient. Even if the patient believes they can walk independently without assistance, the staff member assessing the fall risk must consider the adequacy of the response and, using clinical judgment, ensure fall prevention measures are implemented if necessary.

8. Measures to Reduce Fall Risk

8.1. General Measures

Ensuring adequate lighting in all areas where patients stay. It is advisable to use motion-sensor lighting

Ensuring a safe environment in all patient areas, removing obstacles along potential patient pathways (wires, etc.)

Chairs and couches intended for patients must be stable.

Doors of unused rooms must be locked

Equipping stairs with handrails of sufficient length and with a non-slip surface

Equipping corridors with handrails on both sides.

Equipping toilets with handrails on both sides and installing a high toilet bowl

Timely repair of floor damage

Equipping patient rooms, toilets, and showers with nurse call buttons

Staff call buttons and light switches must be easily reachable when the patient is in bed

Shower and bathroom floors must be non-slip

Equipping patient rooms, dining areas, and recreation areas with stable chairs and tables. Chairs must be of sufficient weight and have armrests

Sharp furniture corners must be protected

Beds must be height-adjustable to match the patient's height and ensure safe transfer to a chair and/or stretcher

Bed wheel brakes must be engaged

All assistive devices used in the department must be in good working order, and their technical condition must be regularly monitored

­8.2. Hospitalized Patients with Low Fall Risk

Set the bed height to a comfortable position for the patient

Secure bed wheels, walker, and wheelchair in a stable position

Place the wheelchair and other assistive items near the patient

Ensure good lighting

Report malfunctions to the maintenance department (e.g., if the call button does not work, light bulbs are burned out, etc.)

Check the patient's shoes and remind them of the selection rules (non-slip sole, closed back, low heel)

When accompanying a patient, inform the staff of another department about his/her fall risk

8.3. Hospitalized Patients with High Fall Risk (51 points and above on the Morse Scale)

Place a red wristband on the patient

Whenever possible, place the patient in a room closest to the nurses' station. Attach a red sign to the room door

Attach a red sticker to the patient's medical chart

Attach a red sticker to the patient's nameplate

Conduct additional training for the patient/caregiver

Try to ensure the constant presence of a caregiver or nursing assistant

Round on rooms housing high-fall-risk patients every 2 hours, especially at night and during awakening periods

Raise the side rails/bed guards

Accompany the patient to the toilet

To accompany the patient to procedures and examinations, transportation in a wheelchair is advisable

Inform the patient and/or caregivers about the medications being taken and their effect on the risk of falling (dizziness, weakness)

Mid-level medical staff conduct a reassessment of fall risk using the Morse Fall Scale and fill out the corresponding form

9. Responsibilities of personnel at various levels and departments

9.1. Head of the medical organization

Approves by order the regulations for fall prevention, appoints the person responsible for fall prevention and registration in the medical organization, and establishes the composition of the committee for analyzing cases of near-miss falls and actual falls

9.2. Person responsible for fall prevention and registration in the medical organization

Organizes the work of the committee for analyzing cases of near-miss falls and actual falls

Organizes educational events for employees of the medical organization on fall prevention at least once a year.

9.3. Heads of departments

Organize the registration of falls within the department

Are responsible for the timely submission of information regarding fall incidents to the person responsible for fall prevention and registration in the medical organization

Monitor compliance with fall prevention regulations by department staff

Ensure the participation of department staff in educational events on fall prevention

9.4. Attending physicians

Assess the risk of falls and fractures, and carry out medical interventions to reduce the risk of falls and related injuries

Take into account the clinical pharmacologist's recommendations on drug selection considering their impact on fall risk, and conduct a medication review jointly with the clinical pharmacologist

Involve physical therapy physicians/rehabilitologists to select and conduct an individualized physical exercise program for fall prevention

9.5. Clinical Pharmacologist

Conducts an additional patient interview and compiles a list of outpatient medications taken by the patient, compares it with outpatient medical records and data obtained by the attending physician

Analyzes medication prescriptions in the context of fall risk

Jointly with the attending physician, adjusts medication prescriptions to reduce fall risk

9.6. Head Nurse of the Department

Conducts training for nursing staff and nurse aides on the care of patients at high risk for falls

Where possible, ensures that patients at high risk for falls are placed closer to the nursing station

Ensures monitoring/escorting of patients at high risk for falls to examinations and procedures, to the toilet, bathroom/shower room

Reports additional fall hazards to technical services (e.g., uneven flooring, loose tiles, etc.)

9.7. Housekeeper

Checks the operation of the call button and informs technical services in case of malfunction

9.8. Nurse Aide

Accompanies the patient upon the nurse's instructions or at the patient's request

Responds promptly to patient calls

Keeps the areas surrounding patients clean

Immediately wipes up spilled liquid and ensures the floor is dry

Places a warning sign for wet/newly washed floors during cleaning.

Removes cords, wires, and other objects from patient pathways, and informs the senior nurse of the department if technical assistance is required

Adjusts the bed height and engages the brakes upon the nurse's instructions.

Turns on lights for patients in poorly lit areas (ensures adequate lighting)

9.6. Paraclinical service personnel

Pays attention to surface conditions (floor integrity, absence of wires and cords on the floor, spilled liquids, etc.), handrails, banisters, and lighting, and immediately informs technical services of any identified damage and potential fall hazards.

9.7. Technical/engineering services

Respond promptly to information regarding technical problems and malfunctions and rectify them

Conduct regular inspections of the premises and territory of the medical organization to actively identify floor or step damage, lighting malfunctions, etc.

9.8. Head of Human Resources

Ensures that new employees of the medical organization are familiar with the fall prevention regulations within the medical organization

10. Procedures upon discovering a patient at risk for falls

Upon discovering an unaccompanied patient wearing a (red) alert bracelet or lacking assistive devices for safe movement (crutches, cane, etc.), stop the patient and accompany them to the nearest chair or bench.

Ask passing staff to summon an attendant with a wheelchair from the department where the patient is located

Stay with the patient until the arrival of the security attendant with a wheelchair

Report the prevented fall risk to the senior nurse of the patient's department

11. Procedures upon discovering a patient/employee/visitor fall

Assess the condition of the patient/employee/visitor and call for help from the staff of the department where the fall occurred. Report the patient's fall to the senior nurse of the department

If the fall occurred in a public area or on the grounds of the medical organization, call for assistance from a passing medical worker / summon a medical worker

The arriving medical staff transports the patient to the department if there are no injuries

In the event of an employee fall without injuries, transport them to their workstation

In the presence of injuries: transport the patient to the specialized department to provide care; transport the employee/visitor to the Emergency Department. Emergency department staff take further actions depending on the clinical situation.

Within 24 hours, complete a fall incident report and submit it to the person responsible for registering and preventing falls in the institution.