对跌倒的恐惧和社会支持对心血管多发病老年患者跌倒自我意识的影响：一个多重中介模型

摘要(中文译文)

构建并验证心血管共病（CMM）老年患者跌倒自我意识的多重中介模型，阐明跌倒恐惧和社会支持对跌倒自我意识的直接效应，以及情绪和认知功能在这些关联中的中介作用。采用横断面研究设计。于2025年9月至2026年2月，通过便利抽样从安徽省8个社区招募358名心脏代谢共病老年患者。使用一般资料问卷、跌倒自我意识量表（SAFE）、国际跌倒效能量表（FES-I）、医院焦虑抑郁量表（HADS）、领悟社会支持量表（PSSS）和蒙特利尔认知评估量表（MoCA）收集数据。采用SPSS 26.0进行单因素分析、Pearson相关分析和多元线性回归分析。采用AMOS 26.0进行结构方程模型构建和路径分析，并应用偏差校正Bootstrap法检验中介效应。CMM老年患者跌倒自我意识总分为61.27 ± 9.28。结构方程模型显示拟合良好（χ²/d = 1.517，CFI = 0.962，TLI = 0.974，RMSEA = 0.038），可解释跌倒自我意识62.9%的变异。跌倒恐惧（β = 0.411）和社会支持（β = 0.356）均直接正向预测跌倒自我意识。中介分析表明，焦虑和认知功能在两个自变量与跌倒自我意识之间均起显著的平行中介作用。（1）路径“跌倒恐惧→焦虑→跌倒自我意识”（间接效应 = 0.043，95% CI：0.009-0.087）：跌倒恐惧与焦虑呈正相关（β = 0.187），提示跌倒相关担忧与中度风险焦虑相关，而焦虑又与较高的跌倒自我意识相关。（2）路径“跌倒恐惧→认知功能→跌倒自我意识”（间接效应 = 0.055，95% CI：0.025-0.102）：跌倒恐惧与认知功能呈显著正相关（β = 0.252），提示认知功能较好的个体对自身跌倒风险有更准确的感知。（3）路径“社会支持→焦虑→跌倒自我意识”（间接效应 = 0.083，95% CI：0.040-0.144）：社会支持与焦虑呈显著负相关（β = 0.287），焦虑与跌倒自我意识呈正相关（β = 0.490，P < 0.01），提示社会支持可能通过风险感知激活路径与跌倒自我意识相关，焦虑在其中起正向中介作用。（4）路径“社会支持→认知功能→跌倒自我意识”（间接效应 = 0.068，95% CI：0.025-0.134）：社会支持与认知功能呈显著正相关（β = 0.295），提示社会支持可能通过促进认知储备增强个体识别跌倒风险的能力，从而与跌倒自我意识相关。在CMM老年患者中，跌倒自我意识与跌倒恐惧和社会支持均呈直接正相关，焦虑和认知功能分别作为中介变量。临床干预应针对焦虑进行精准管理：在利用恐惧的警示功能的同时，努力加强社会支持网络和认知维护，以协同改善患者的跌倒意识。

Abstract

To construct and validate a multiple mediation model of self-awareness of falls in older adult patients with cardiovascular multi-morbidity (CMM), and to elucidate the direct effects of fear of falling and social support on self-awareness of falls, as well as the mediating roles of emotion and cognitive function in these associations. A cross-sectional study was conducted. From September 2025 to February 2026, 358 older adult patients with cardio-metabolic multi-morbidity were recruited from 8 communities in Anhui Province by convenience sampling. Data were collected using a general information questionnaire, the Self-Awareness of Falls Scale (SAFE), the Falls Efficacy Scale-International (FES-I), the Hospital Anxiety and Depression Scale (HADS), the Perceived Social Support Scale (PSSS), and the Montreal Cognitive Assessment (MoCA). Univariate analysis, Pearson correlation analysis, and multiple linear regression analysis were performed using SPSS 26.0. Structural equation modeling and path analysis were conducted with AMOS 26.0, and the bias-corrected Bootstrap method was applied to examine the mediating effects. The total score of self-awareness of falls in older adult patients with CMM was 61.27 ± 9.28. The structural equation model showed excellent fit ( /d = 1.517, CFI = 0.962, TLI = 0.974, RMSEA = 0.038) and accounted for 62.9% of the variance in self-awareness of falls. Both fear of falling ( = 0.411) and social support ( = 0.356) directly and positively predicted self-awareness of falls. Mediation analysis indicated that anxiety and cognitive function served as significant parallel mediators between the two independent variables and self-awareness of falls. (1) Pathway "fear of falling → anxiety → self-awareness of falls" (indirect effect = 0.043, 95% CI: 0.009-0.087): fear of falling was positively correlated with anxiety ( = 0.187), suggesting that fall-related concern is associated with moderate risk anxiety, which in turn is associated with higher self-awareness of falls. (2) Pathway "fear of falling → cognitive function → self-awareness of falls" (indirect effect = 0.055, 95% CI: 0.025-0.102): fear of falling was significantly positively correlated with cognitive function ( = 0.252), suggesting that individuals with better cognitive function have a more accurate perception of their own fall risk. (3) Pathway "social support → anxiety → self-awareness of falls" (indirect effect = 0.083, 95% CI: 0.040-0.144): social support was significantly negatively correlated with anxiety ( = 0.287), and anxiety was positively correlated with self-awareness of falls ( = 0.490, < 0.01), suggesting that social support may be associated with self-awareness of falls through a risk perception activation pathway, mediated positively by anxiety. (4) Pathway "social support → cognitive function → self-awareness of falls" (indirect effect = 0.068, 95% CI: 0.025-0.134): social support was significantly positively correlated with cognitive function ( = 0.295), suggesting that social support may enhance individuals' ability to identify fall risks by promoting cognitive reserve, thereby associating with self-awareness of falls. In older adult patients with CMM, self-awareness of falls is directly and positively associated with fear of falling and social support, with anxiety and cognitive function serving as mediator variables, respectively. Clinical interventions should target precise management of anxiety: while utilizing the alerting function of fear, efforts should be made to strengthen social support networks and cognitive maintenance, so as to synergistically improve patients' fall awareness.

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