Integrated Prevention, Treatment, and Rehabilitation for Toileting-Related Falls

Toileting-related falls are clinically important events that may occur through the interaction of urinary urgency, nocturia, urinary incontinence, impaired mobility, gait and balance dysfunction, reduced muscle strength, cognitive or psychological problems, inadequate caregiver support, and environmental hazards. Conventional fall-prevention programs often focus mainly on mobility or environmental risks, whereas urinary symptoms and toileting-related exposure may not be addressed within the same care pathway.

This study is a multicenter, prospective, single-group interventional study designed to construct, validate, and demonstrate a comprehensive prevention, treatment, and rehabilitation system for toileting-related falls in older adults and people with disabilities. The study integrates urological care, rehabilitation, nursing, psychological support, caregiver involvement, environmental risk management, and longitudinal follow-up within a standardized dynamic management pathway.

The study pathway consists of the following stages:

• Participant screening and enrollment;
• Standardized multidimensional baseline assessment;
• Identification and stratification of modifiable risk factors;
• Development and delivery of an individualized multicomponent intervention plan;
• Follow-up and repeat assessment;
• Adjustment of the intervention plan based on clinical response, adherence, safety, and changes in risk;
• Feedback and continuous improvement of the implementation process.

The multidimensional assessment will cover the following major domains:

Urinary function: urinary frequency, urgency, nocturia, urinary incontinence, voiding difficulty, bladder-related symptoms, voiding diaries, and other clinically indicated urinary function measurements.

Gait, balance, and physical function: muscle strength, muscle tone, joint mobility, transfer ability, sit-to-stand performance, gait, balance, use of mobility aids, and fall risk.

Psychological and cognitive factors: fear of falling, anxiety, depressive symptoms, fall-related psychological responses, cognition, treatment cooperation, and caregiver support.

Activities of daily living and environmental risks: independence in toileting and other daily activities, nighttime lighting, the route from the bed to the toilet, slippery surfaces, handrails, toilet height, thresholds, availability of assistive devices, and caregiver response.

Interventions will be individualized according to the participant's predominant and modifiable risk factors. The intervention package may include behavioral and clinical management of urinary symptoms, bladder training, medication optimization when clinically appropriate, neuromodulation or electrical stimulation when indicated, gait and balance rehabilitation, muscle-strengthening and mobility training, transfer training, assistive-device adaptation, psychological or cognitive support, caregiver education, scheduled or assisted toileting, and modification of environmental hazards.

Not every participant will receive every intervention. The specific intervention combination will be selected according to the standardized assessment, clinical indications, participant needs, safety considerations, and available resources at each participating center.

Participants will undergo longitudinal follow-up to document intervention delivery, adherence, adverse events, repeat assessments, falls, toileting-related falls, nighttime falls, urinary symptoms, physical function, activities of daily living, and fear of falling. Intervention plans may be modified during follow-up when clinically indicated.

The study will assess both implementation outcomes and clinical outcomes. Implementation evaluation will include participant reach, institutional adoption, completion of standardized assessments, delivery of individualized interventions, protocol adherence, staff training, data completeness, follow-up completion, safety, and sustainability of the care pathway. Clinical evaluation will examine changes in toileting-related falls and related risk factors, including urinary symptoms, nocturia, gait and balance, functional independence, and fear of falling.

The overall aim is to determine whether this integrated and dynamically adjusted care pathway can be implemented safely and consistently across different clinical and rehabilitation settings and provide a reproducible model for the prevention and management of toileting-related falls.

Inclusion criteria

• Age 18 years or older, with no upper age limit.
• Presence of physical disability, functional limitation, loss of independence, or a need for assistance with daily activities.
• Presence of at least one risk factor for toileting-related falls, including but not limited to urinary frequency, urinary urgency, nocturia, urinary incontinence, voiding difficulty, overactive bladder, underactive bladder, impaired gait or balance, reduced muscle strength, fear of falling, cognitive or emotional problems, a history of falls, unsafe nighttime toileting, or environmental hazards associated with toileting.
• Able and willing to participate in the study assessments and follow-up procedures, with assistance from a caregiver when necessary.
• Written informed consent provided by the participant or, when applicable, by a legally authorized representative.

Exclusion criteria

• Acute infection or other acute medical condition requiring immediate treatment that would prevent participation in study assessments or interventions.
• Severe or unstable medical condition that, in the investigator's judgment, would make participation unsafe or interfere with study procedures or follow-up.
• Severe disturbance of consciousness or other condition that prevents completion of the required assessments and study procedures, even with appropriate assistance.
• Inability to participate in the planned follow-up or provide sufficient study-related information.
• Any other condition that, in the investigator's judgment, makes the individual unsuitable for participation in the study.