Cognitive impairment and fear of falling in elderly with different social support levels: Findings from a community survey in Central Vietnam

doi:10.21203/rs.2.13296/v1

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Cognitive impairment and fear of falling in elderly with different social support levels: Findings from a community survey in Central Vietnam

https://doi.org/10.21203/rs.2.13296/v1

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published 16 Apr, 2020

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Background

Fear of falling (FoF) in the elderly is one of the major public health concerns in this era of aging of the population. Identifying risk factors is a step towards devising interventions for FoF. The aim of this study was to determine the prevalence of FoF and the associations between cognitive impairment and FoF by the social support level, after adjustments for potential confounders.

Methods

Data from the “Health needs assessment of elderly in Thua Thien Hue Province, Vietnam in 2018” survey of 725 elderly aged 60 years or older were used for analysis. FoF was assessed using the Fall Efficacy Scale - International. High FoF was defined as a score above 28. The Multidimensional Scale of Perceived Social Support was used to measure the perception of support. Logistic regression analysis was performed to investigate the factors that might be significantly (p <0.05) associated with the FoF.

Results

The prevalence of high FoF among the elderly was 40.8%. Female gender, advanced age, a marital status of single or formerly married, living alone, history of injury, history of falls, chronic diseases (arthritis and/or hypertension), limitations of the IADL and BADL, visual difficulty and walking difficulty, low social support, and cognitive impairment were all significantly associated with a high FoF. After adjustments for the age, gender, marital status, history of falls and health-related factors, cognitive impairment remained significantly associated with a high FoF among the elderly with a low to moderate social support level (OR = 2.97, 95% CI 1.49-5.89), but not in those with a high social support level.

Conclusions

Impairment of cognitive function was associated with a high FoF among the elderly who perceived themselves as having low or moderate support levels, even after adjustments for socio demographic and physical functional factors. However, this association was not observed among the elderly who perceived themselves as having high social support levels. Fall prevention programs for the elderly with various levels of social support should be carefully devised, keeping in mind the cognitive function levels of the target recipients.

Geriatrics & Gerontology

fear of falling

cognitive impairment

social support

elderly

Globally, falls account for 40% of all deaths from injuries, and affect one-third of the elderly population each year [1]. Fatal falls rates are highest among adults over the age of 60 years [1].

Considering the implications of falls in older persons, fear related to falls should also not be neglected. Fear of falling (FoF), defined as a lasting concern about falling that leads to avoidance of daily activities [2], is also a highly prevalent problem [3]. FoF increases with age and is associated with adverse consequences among the elderly, including a poor quality of life [4], mental and functional decline [4–8], a lower level of satisfaction with life [9], and restricted social interactions [7, 10]. As falls and FoF are closely linked with each other by virtue of each increasing the risk of the other [11], recent research has been focused on investigating the determinants of FoF, in an effort to prevent both FoF and falls in the community-dwelling elderly.

A number of studies have already been published on the FoF in the elderly. Although cognitive impairment has frequently been mentioned a factor that is significantly associated with the FoF, reports on the relationship between cognitive impairment and FoF are conflicting. In some previous studies, impaired cognition was identified as a predicted of FoF [4, 5, 12], while in others, no association between cognitive impairment and FoF was identified in a frail older population [13]. Thus, reports on the effect of cognitive impairment on FoF differs depends on study design, characteristics of participants and how the cognitive function level has been measured. Therefore, it is crucial to obtain a clearer understanding about this association in a large population-based sample.

Social support is well-known to play a vital role in old age, however, few studies have investigated the difference in the relationship between cognitive function and FoF according to the level of social support available to the elderly. Since higher cognitive function is known to be associated with a higher level of social support [14], and good social support is known to be associated with a lower odds of the FoF [15–17], the level of social support available may have influence on the association between cognitive impairment and FoF.

In developing countries where the population is rapidly ageing, fall-related issues have yet to receive adequate attention. Vietnam is among the countries with fastest rates of ageing in Asia [18] and it is predicted that the proportion of persons aged 60 years old or older will reach 20% of the total population by the year 2038 [19]. A community survey in 2015 showed that the prevalence of high FoF among Vietnamese elderly was high, at 64% [6]. Although the risk factors of FoF have been widely explored, there are many aspects of FoF that still remain to be investigated further, and how factors influencing the FoF might have different levels of influence depending on the social support available to the elderly remains unknown in the context of Vietnam.

Thus, this study was performed to investigate the prevalence of FoF and the differential associations between cognitive impairment and FoF depending on the social support level in a community of elderly in Vietnam.

Study area

The study was performed in Thua Thien Hue Province, Central Vietnam. The province comprises 9 districts and 152 communes with a total population of 1,154 million people as of a census conducted in 2017 [20].

Sample size and sampling method

Participants from Hue city and Phu Vang district were recruited by a two-stage random cluster sampling method. In the first stage, two quarters among the 27 quarters of Hue city (urban area) and three communes out of 20 communes in Phu Vang district (rural area) were randomly selected. In the second, in each of the selected quarters and communes, 146 households with people aged 60 years old or over were randomly selected based on a list of households held in the commune health centers. Finally, 730 participants were selected.

Data collection

A cross-sectional study was conducted in the elderly individuals living in their own households in Thua Thien Hue Province between June and July 2018. Face to face interview using a structured questionnaire was performed to collect data from the selected households. We excluded participants who refused to take part in the survey or were unable to speak. Data of a total of 725 participants were finally included in the analysis, representing a response rate of 99% (725/730).

Survey instruments

The data collection instrument was adapted from a reference questionnaire developed by a research team from the Tokyo Medical and Dental University, and containing questions pertaining to the characteristic of the participants, health-related information, etc.

Ethical consideration

Ethical approval was obtained from the Ethics Committee of the Biomedical Research of College of Medicine and Pharmacy, Hue University (Ethics Approval No. H2018/148 dated 12 May 2018). Written informed consent was obtained from each of the participants prior to the interviews. Study ID numbers were assigned to all the participants to protect their confidentiality.

Study variables

Fear of falling

FoF was assessed using the Falls Efficacy Scale-International (FES-I), which contains 16 items. The overall scores can range from 16 to 64, with higher scores indicating a higher FoF. Scores of 16-19 represent low levels of concern; scores of 20-27 represent moderate levels of concern, and scores of 28-64 represent high levels of concern. Good validity and reliability ofFES-I have been demonstrated in a previous study [21].

Perceived social support

Perceived social support was measured by The Multidimensional Scale of Perceived Social Support (MSPSS), to assess the participants’ perception of support from three sources: family, friends and significant other. Mean scores in the range of 1.0 to 2.9 represent low levels of support, scores of 3.0 to 5.0 represent moderate levels of support, and scores of 5.1 to 7.0 represent high levels of support [22]. A high internal consistency and reliability of MSPSS has been shown in a previous study [22].

Cognitive function

The Mini-Mental State Examination (MMSE) was used to evaluate the cognitive function. Cognitive impairment was defined as a score lower than the cutoff point of 23, which is the most commonly used cutoff score to detect cognitive impairment [23].

Functional limitation

Performance in the activities of daily living was assessed by the Barthel ADL index and Lawton Instrumental Activities of Daily Living Scale (IADL), as follows:

The IADL scale measured eight domains of function: use of telephone, shopping, food preparation, housekeeping, laundry, mode of transportation, medication, and managing finance with the possible summary score ranging from 0 (low function) to 8 (high function).
The Barthel ADL scale pertained to 10 items: feeding, bathing, grooming, dressing, bowels, bladder, toilet use, transfers, mobility, and use of stairs. Response categories were scored based on each item and total possible score ranges from 0 to 20.

Higher total scores in both scales indicate a greater level of independence. Total independence was categorized as ‘no limitation’, and partial dependence and complete dependence were categorized as ‘limitation’ [24, 25] .

Socio-demographic characteristics and physical functional status

The questionnaire consisted of a variety of socio-demographic characteristics, including the age, gender, residential area, education level, marital status and living arrangement. Physical functional status variables included experience of injury, chronic diseases (arthritis and hypertension), visual ability and walking ability.

Data analysis

Data were summarized using descriptive analysis and differences in the levels of FoF by the participants’ characteristics were analyzed using the Chi-square test. The dependent variable “Fear of falling” was categorized as “high FoF” and “not high FoF”. The associations between the independent variables and the dependent variable “Fear of falling” were investigated by bivariate analysis. Multivariate logistic regression analysis was used to examine the association between cognitive impairment and FoF, after adjustments for socio-demographic factors and the physical functional status.Data analysis was performed using SPSS version 22. P-values of less than 5% were considered as indicative of statistical significance.

The characteristics of participants by three levels of FoF were shown in Table 1. The total sample size was 725 elderly persons aged 60 or over, of whom 423 were females. The prevalence of elderly with a high FoF was 40.8%. The overall prevalence of a high FoF was greater among the cognitive-impaired elderly than among those with normal cognition (76.4% and 33.6%, p < 0.001).

Table 1: Baseline characteristics of the participants according to fear of falling status

Characteristics of participants

All

(n =725)

Low FoF

(n = 272)

Moderate FoF

(n = 157)

High FoF

(n = 296)

P value

Socio-demographic characteristic

Gender

Female

Male

423

302

28.1

50.7

20.8

22.8

51.1

26.5

<0.001

Age (yr)

60-69

70-79

≥ 80

340

209

176

51.2

30.6

39.3

21.5

25.8

17.0

27.4

43.5

63.6

<0.001

Residential area

Hue City

Phu Vang District

443

282

38.8

35.5

23.0

19.5

38.1

45.0

0.173

Marital status

Married

Single or formerly married

524

201

42.4

24.9

22.5

19.4

35.1

55.7

<0.001

Education level

Low education

Primary to high school

College and higher

195

468

22.6

42.3

52.7

16.4

23.3

25.5

61.0

34.4

21.8

<0.001

Living arrangement

Alone

Living with others

660

24.6

38.8

15.4

22.3

60.0

38.9

0.004

Physical functional status

Experience of injury

Yes

665

39.7

13.3

22.6

11.7

37.7

75.0

<0.001

History of fall

Yes

671

14.8

39.3

7.4

22.8

77.8

37.9

<0.001

Arthritis

Yes

243

482

30.9

40.9

18.9

23.0

50.2

36.1

0.001

Hypertension

Yes

318

407

32.7

41.3

21.1

22.1

46.2

36.6

0.022

Limitation of the IADL

Yes

484

241

50.6

11.2

24.8

15.4

24.6

73.4

<0.001

Limitation of the BADL

Yes

598

127

43.5

9.4

24.7

7.1

31.8

83.5

<0.001

Visual ability

No difficulty

Have difficulty

370

355

50.3

24.2

21.9

21.4

27.8

54.4

<0.001

Walking ability

No difficulty

Have difficulty

503

222

48.3

13.1

26.6

10.4

25.0

76.6

<0.001

Social support

Low

Moderate

High

352

302

25.4

35.8

42.4

16.9

26.1

17.5

57.7

38.1

40.1

0.002

Cognitive function

Normal

Impairment

602

123

43.2

9.8

23.3

13.8

33.6

76.4

<0.001

Table 2 showed the results of bivariate analysis, which revealed the existence of an association between the participants’ characteristics and the degree of FoF. Factors that were significantly associated with a high FOF among all subjects included: female gender, age 80 years or over, marital status of being single or formerly married, living alone, and a low social support level (p < 0.05). A positive history of fall was associated with a higher likelihoods of high FoF among the elderly (OR: 5.75, 95% CI: 2.97-11.12). Physical functional status variables, including experience of injury in the last 12 months, presence of arthritis and hypertension; limitations of IADL and BADL; visual and walking ability showed significant association with a high FoF (p < 0.01).

Table 2: Unadjusted logistic model to determine the associations between the participants characteristics and the FoF (n = 725)

Fear of falling

95% CI

Socio-demographic characteristic

Gender

Male

Female

2.90***

(2.11-3.89)

Age (yr)

60-69

70-79

≥ 80

2.05***

4.65***

(1.43-2.94)

(3.15-6.86)

Residential area

Hue city

Phu Vang District

1.33

(0.98-1.80)

Marital status

Married

Single or formerly married

2.33***

(1.67-3.24)

Education level

College and higher

Low education

Primary to high school

5.61

1.88

(2.78-11.32)

(0.96-3.66)

Living arrangement

Living with others

Alone

2.35**

(1.40-3.96)

Physical functional status

Experience of injury

Yes

4.95***

(2.70-9.06)

History of fall

Yes

5.75***

(2.97-11.12)

Arthritis

Yes

1.79***

(1.31-2.44)

Hypertension

Yes

1.49**

(1.11-2.01)

Limitation of the IADL

Yes

8.48***

(5.96-12.07)

Limitation of the BADL

Yes

10.84***

(6.58-17.85)

Visual ability

No difficulty

Have difficulty

3.09***

(2.27-4.21)

Walking ability

No difficulty

Have difficulty

9.78***

(6.75-14.17)

Social support

High

Low

Moderate

2.04**

0.92

(1.21-3.45)

(0.67-1.26)

Cognitive function

Normal

Impairment

6.42***

(4.10-10.06)

OR = Odds Ratio; 95% CI = 95% Confidence interval

*p < 0.05; ** p < 0.01; *** p < 0.001

As shown in Table 3, after adjustments for socio - demographic factors and the physical functional status, elderly with impaired cognition had an approximately 3 times higher likelihood of having a high FoF as compared to those without cognitive impairment among those with low and moderate perceived levels of social support (AOR: 2.97, 95% CI: 1.49-5.89). In contrast, in the group with a high perceived social support level, cognitive impairment was not significantly associated with a high FoF. Female participants with low and moderate perceived levels of social support were 1.9 times more likely to have a high FoF as compared to males of the same group (AOR: 1.99, 95% CI: 1.10-3.59). History of fall, limitation of the IADL, limitation of the BADL and difficulty in walking were statistically significant associated with a high FoF in the entire sample.

Table 3: Fully adjusted model to determine the associations between the participants’ characteristics and the FoF by the social support level

Fear of falling

Model 1

Low - moderate social support level

(n = 423)

Model 2

High social support level

(n = 302)

AOR (95% CI)¹

AOR (95% CI)

Gender

Male

Female

1.99 (1.10-3.59)*

1.91 (0.93-3.92)

Age (yr)

60-69

70-79

≥ 80

1.13 (0.63-2.02)

1.55 (0.77-3.10)

1.61 (0.77-3.33)

1.79 (0.73-4.40)

Marital status

Married

Single or formerly married

1.23 (0.72-2.12)

0.62 (0.25-1.53)

History of fall

Yes

3.36 (1.30-8.68) *

4.61 (1.09-19.57) *

Arthritis

Yes

1.36 (0.80-2.33)

0.82 (0.41-1.62)

Hypertension

Yes

0.62 (0.37-1.01)

1.06 (0.56-1.99)

Limitation of the IADL

Yes

2.40 (1.31-4.39) **

3.41 (1.51-7.71) **

Limitation of the BADL

Yes

2.35 (1.11-4.98)*

4.68 (1.56-14.03)**

Visual ability

No difficulty

Difficulty

1.40 (0.84-2.33)

1.73 (0.94-3.21)

Walking ability

No difficulty

Difficulty

2.58 (1.37-4.86) **

4.62 (2.17-9.82) ***

Cognitive function

Normal

Impairment²

2.97 (1.49-5.89)**

1.04 (0.38-2.82)

¹AOR: Adjusted odd ratio; 95% CI = 95% Confidence interval

Adjusted for age, gender, marital status, history of fall, arthritis, hypertension, limitation of the IADL, limitation of the BADL, visual ability, walking ability and cognitive function.

² Cognitive impairment was defined by a score lower than the cut-off score of 23.

*p < 0.05; ** p < 0.01; *** p < 0.001

Discussion

The results of the current study suggested that 40.8% of the participants had a high FoF. The factors associated with a high FoF varied with the perceived level of social support. Among the participants with perceived low and moderate levels of social support, cognitive impairment was associated with a high FoF, whereas in the participants with a high perceived level of social support, this relationship of the FoF with cognitive function was not observed.

Prevalence of high FoF

This study conducted in a population-representative sample of 725 Vietnamese elderly living in rural and urban areas revealed a high prevalence of FoF. Overall, 40.8% of the elderly were identified as having a high FoF. This considerably high prevalence as compared to previous reports might need to be interpreted from the perspective of the study location, age of the participants (mean age: 72 ± 8.8) and standardized measurement of the FoF. Another possible reason is Thua Thien Hue’s long rainy season, which normally lasts for four months, from September to December, with a large amount of rainfall [26], which leaves surfaces slippery and unsafe for the elderly to perform their daily activities. This finding suggests the high level of concern for falls among Vietnamese elderly living in the community. Therefore, attention should be paid to this population in terms of falls and fall-related issues.

Cognitive impairment and FoF among different perceived social support levels

The univariate analyses in the present study indicated that elderly persons with impaired cognition had a higher odd of experiencing a high FoF. With advancing age, attention and memory are the two aspects of cognition that are the most severely affected [27]. Impairment of cognitive function in the elderly, characterized by a poorer performance in memory, executive functions, attention and information processing, has been reported as a predictor of the onset of FoF [5] and to also be associated with higher levels of anxiety [28], which, in turn, was shown to be associated with a FoF [29]. Furthermore, in the logistic regression model with adjustments for confounding factors performed to determine the association between the participant’s characteristics and the likelihood of a high FoF (appendix table), elderly with cognitive impairment were approximately 2 times more likely to have a high FoF than those with normal cognition. This finding confirmed the effect of cognitive impairment on the high FoF among the study participants.

An even stronger association between cognition and FoF was observed among the elderly with low and moderate perceived levels of social support in the fully adjusted model: elderly with cognitive impairment in this group had a nearly 3 times higher likelihood of having high a FoF. This result can be explained by the observed characteristics of the study participants with two different perceived levels of social support, as well as by the two-way relationship between the perceived social support level and the fear of falling. A lower perceived social support level among the Vietnamese elderly might be one of the consequences of social modernization, which is currently spreading quickly in Vietnam; the younger generation tends to migrate to bigger cities and leave older persons on their own [30]. Moreover, Vietnamese elderly are exposed to less social interactions due to the limited social activities held by the local authority as compared to other developed countries [6]. Elderly with lower levels of social support are more likely to be physically inactive [31], depressed [29, 32, 33], which are reported to be closely related to FoF [16, 34]. In addition, we found that the mean MMSE score of the participants with low-moderate perceived social support levels was 25.46, which was lower than that of those with a high perceived level of social support (26.6). This was also in line with a prior finding in an Asia setting of a positive relationship between better cognitive function and a higher social support level [14]. On the other hand, a high level of concern for falls is also known to be associated with a lower perceived level of social support [7], presumably by restricting the elderly from leaving their homes [35] and taking part in social activities [7, 10]. Additionally, in the current era of social transformation of Thua Thien Hue province, construction of many roads and facilities has increased from year to year, and together with the long rainy season, this may also contribute to a risk of falls and an intense FoF among the elderly when they leave their homes, especially for those who already have cognitive impairment [5] and limited social support [14]. Accordingly, cognitive impairment is an issue that needs to be paid attention, especially in the elderly with limited social support, in order to prevent the FoF. An ageing-friendly environment, such as the availability of wide sidewalks, a proper rainwater drainage system and traffic safety, and establishment of more social activities for the elderly in the community may represent some solutions to prevent FoF in old age.

However, this association between cognitive decline and the FoF was no longer seen in participants with perceived high social support levels. A possible explanation for this finding is that social support plays a beneficial role in enhancing wellbeing and physical health [36, 37], particularly in reducing life stress in the elderly, by improving their self-esteem [36] and promoting healthy behaviors [37]. The cultural norm among the Vietnamese people is to respect the older generation and take care of the elderly until the end of their lives. In the community, there is a tendency for the elderly to reside with their spouse and children, or live close to their descendants’ homes. This was verified by the low rate of elderly living alone in our study (9%). Furthermore, although the total percentage of elderly living alone is low, it is noteworthy that the percentage of people who were living alone among the elderly with a high perceived social support level (5.6%) was only half of that of the elderly with lower perceived social support levels living alone (11.3%). Considering the close-knit community culture in Thua Thien Hue province, older adults with a high perceived level of social support are more likely to be surrounded by their families, neighbors and/or friends with adequate financial and spiritual support, which is beneficial for maintaining the cognitive function [14], as well as for reducing the odds of FoF [15–17]. Thus, it can be inferred that good social support is valuable for eliminating the FoF in the elderly, irrespective of whether they suffer from cognitive impairment or not.

Other factors associated with the FoF

It is also important to highlight our findings regarding the strong bivariate associations between socio-demographic factors, as well as physical functional factors, and a high FoF. This finding is in line with previous studies. Female gender, older age, history of fall, living alone, the marital status of being single, functional limitations, and cognitive impairment are commonly accepted as risk factors for FoF [4–9, 12, 16, 17, 28, 38–42]. Our results also showed an association between the presence of chronic disease and a high FoF. Hypertension [6, 16], as well as arthritis [16], has been reported as a risk factor for FoF in several studies.

In this study, elderly with a perceived low level of social support were more likely than those with a perceived high level of social support elderly to have a high FoF. It has been reported previously that a high level of social support is associated with a lower likelihood of FoF, as an environmental factor [16]; in particular, frequent interactions with friends have been shown to protect against FoF [17].

To the best of our knowledge, the current study is the first study conducted in Vietnam to assess the association between FoF and cognitive function in the elderly according to their social support status. The study was conducted on a large representative sample of Vietnamese elderly, with a high response rate and an appropriate sampling method. FoF, perceived social support and cognitive function were measured using standardized and validated scales. However, being a cross-sectional study, no causal inference could be drawn and the results should therefore be interpreted with caution. A further longitudinal study is needed to investigate the two-way associations between the FoF and other factors. In addition, it is possible that the number of previous falls was underreported, because there was no direct question addressing this, and a history of fall was explored based on the types of bodily injury experienced by the participants during the last 12 months. However, we still found a significant association between a history of fall and a high FoF.

Our results highlight the important implications of the FoF for the vulnerable elderly living in the community. Although cognitive or functional impairment in older adults is inevitable with advancing age, factors such as the social support status are modifiable. FoF can be prevented in the elderly, regardless of their cognitive function level, if the elderly could be provided adequate support. Despite the fact that from a cultural perspective, Vietnamese elderly are respected and well supported, more than a half of the elderly (423/725) in this study perceived low or moderate level of social support in this study. With the recognition of this emerging issue, identification of isolated elderly in the community might be one of effective approaches for addressing individuals with a high risk of FoF. Therefore, both caregivers and local stakeholders (e.g., Associations of the Elderly, commune health centers, provincial People’s Committees) should contribute to improving the social support status of the elderly, by developing public programs focusing on social relationships and interactions, along with strengthening of the infrastructure in community to encourage more participations from the elderly.

In summary, our study confirmed a high prevalence of a high FoF in an aging Vietnamese, and a number of factors associated with a FoF were identified. Our findings also indicated that cognitive impairment exerted differential effects on the likelihood of a high FoF in the elderly depending on the perceived social support levels. These findings are expected to be useful not only to screen for people who may benefit from fall-related programs, but for health care providers to devise well-targeted strategies towards prevention of falls and provide satisfactory interventions for the elderly residing in the community.

CI: confidence interval; OR: odds ratio; AOR: adjusted odd ratio; FoF: fear of falling; FES-I: Fall Efficacy Scale – International; MMSE: Mini-Mental State Examination; IADL: Instrumental Activities of Daily Living Scale; BADL: Barthel Activities of Daily Living index; MSPSS: Multidimensional Scale of Perceived Social Support.

Acknowledgments

We gratefully acknowledge College of Medicine and Pharmacy, Hue University (Hue CMP) and KOBE WHO Centre for Health Development for their support of this study. We deeply thank all local organizations, provincial Department of Health, participants in Thua Thien Hue province and especially Dr. Vo Nu Hong Duc and staffs from Institute for Community Health Research (ICHR) and Faculty of Public health of Hue CMP for data collection in fieldwork.

Funding

This study was supported by the grant of ICHR and KOBE WHO Centre for Health Development.

Availability of data and materials

Datasets used for this study are not publicly shared due to participants’ confidentiality.

Authors’ contributions

All authors contributed to the critical revision of the manuscript and approved the final version.

Ethics approval and consent to participate

This study was conducted according to the approval of the Ethics Committee in Biomedical Research of College of Medicine and Pharmacy, Hue University (No. H2018/148 12 May 2018). Written informed consent was obtained from all participated subjects. The participants understood that the survey would be done anonymously and the data would be used for research purposes only.

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Author details

¹Department of Global Health Entrepreneurship, Division of Public Health, Graduate School of Tokyo Medical and Dental University, Tokyo, Japan

² Faculty of Public Health, College of Medicine and Pharmacy, Hue University, Vietnam

³The Institute for Community Health Research, College of Medicine and Pharmacy, Hue University, Vietnam

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Cognitive impairment and fear of falling in elderly with different social support levels: Findings from a community survey in Central Vietnam

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