Population ageing is a defining trend of our time. It is projected that by 2050, 80% of the world’s older population will reside in low- and middle-income countries, where the most substantial demographic shifts are occurring (1). As a prominent example, China, a typical developing country, is experiencing rapid growth of its older population (2). Within this group, older adults with functional limitations represent a critical sub-population, numbering 40.63 million and constituting 18.3% of all seniors (3). Compared to the general ageing population, this group exhibits poorer health status and faces greater health risks, making them a priority for safety care (4).

In China, community-dwelling older adults represent a core segment of the ageing population (5). Their preference for “ageing in place” (6) is strongly shaped by traditional cultural values, notably the concept of “returning leaves to their roots” and the Confucian ethic of “filial piety” (7). Moreover, living within a community helps older adults maintain family bonds and receive a certain amount of social support through the effective mobilization of family and community resources. Nevertheless, this preferred living arrangement also entails significant risks, with falls being a primary concern for them. The elevated fall risk among community-dwelling older adults stems from multiple factors, including hazardous community environments, insufficient access to professional care, and a general lack of fall awareness.

A fall is defined as “an unintentional loss of balance, in which the individual comes to rest on the ground, floor, or lower level” (ICD-10 codes W00–W19). As a common health and safety incident, falls rank as the sixth leading cause of death among individuals aged 65 and above (8). Statistically, Falls in the older population typically occur in domestic or community settings (9). For community-dwelling older adults, the annual incidence of falls ranges from 14.3% to 19.3% (10), with up to 79.50% resulting in injury (11). This risk is markedly elevated among older adults with functional limitations, who experience falls more frequently, suffer more severe consequences, and are prone to a debilitating “fall–reduced activity–functional decline” cycle (12). Studies indicate that the objectively detected fall risk in this population ranges from 41.3% to 67.97% (13, 14). However, their self-assessed fall risk rate is considerably lower (29.2%–34.8%) (15). This significant discrepancy between objective risk and subjective perception exists a pervasive lack of fall awareness in this high-risk group.

Fall awareness refers to an older adult’s subjective assessment of their own risk of falling (16). This concept encompasses personal evaluations of both the likelihood and potential severity of a fall incident (17). Within the cognitive-behavioral theory, fall awareness acts as a mediating variable, significantly influencing an individual’s decision to adopt fall preventive measures (18). It also elucidates why even those in high - risk categories frequently demonstrate insufficient participation in fall prevention initiatives from the perspective of individual self - awareness (19, 20). Consequently, weak fall awareness leads to inadequate protective behaviors and poor adherence to prevention strategies, thereby substantially increasing the risk of falling (21).

Social support encompasses emotional concern from family members, physical assistance from caregivers, and environmental enhancements combined with community-based health education (22). Scholar indicates that adequate social support can reduce fall risk among older adults (23). For instance, family caregivers can bolster older adults’ vigilance and self-efficacy regarding falls through reminder, companionship, and exercise assistance (24). Similarly, healthcare workers promote realistic self-assessment by conducting risk evaluations and providing health education, which in turn increases fall awareness and motivates behavioral change (25). From a social support perspective, Community-dwelling older adults with functional limitations can benefit from familial emotional concern and optimally utilize family and community resources. Therefore, social support may act as a direct promoter of their fall prevention behaviors and as a psychological empowerment pathway that indirectly strengthens their fall awareness (26, 27).

Current research on fall risk primarily focuses on hospitalized or institutionalized older adults (16, 28), while community-dwelling older adults with functional limitations have received less attention. Moreover, existing work has predominantly focused on physiological risk factors, overlooking the older adults as holistic entities and neglecting a comprehensive assessment of psychological and social factors associated with falls (29, 30). Therefore, this study aims to assess fall risk, fall awareness, and social support among this population and to examine their interrelationships. The findings are expected to provide an empirical basis for developing community-based fall prevention interventions that enhance awareness and social support, thereby reducing falls incidence and promoting healthy aging.

This cross-sectional study evaluated the fall risk among community-dwelling older adults with functional limitations in Western China. The mean total MFROP-com score was 26.51 ± 10.95, indicating a significant overall risk of falls (score > 12). This result falls within the range of risk levels reported in other high-risk older adults, such as those in long-term care facilities, community-dwelling older adults with diabetes, and hospitalized patients with chronic conditions (40–43). While direct comparisons are limited by differences in care settings, health status, and assessment methods, these references collectively underscore that elevated fall risk is a prevalent and serious issue among diverse groups of vulnerable older adults. Notably, the fall risk observed in this study was higher than that reported by Tang (44) involving older adults in first-tier cities. This discrepancy might be attributed to the targeted inclusion of functionally impaired older adults in the present study, who generally experience more severe frailty and functional decline, as well as regional disparities in community infrastructure, medical resources, and economic development between Western and more developed regions. Despite a high average risk, substantial individual variability (SD = 10.95) highlights the presence of a high-risk subgroup within this population that warrants prioritized intervention (45, 46). Evidence supports the effectiveness of functional exercises, such as Tai Chi and balance–resistance training, for fall prevention (47). For those with slight functional limitations, training focused on activities of daily living may be more appropriate. However, adherence is often compromised due to psychological resistance or reluctance to use assistive devices (12). Therefore, it is essential to leverage existing community resources—such as senior centers, neighborhood committees, and community health workers—to implement fall prevention education through both in-person and virtual formats (29). These efforts should aim to improve risk awareness, address cognitive biases, and promote the adoption of preventive behaviors.

Fall awareness is a significant independent predictor of fall risk among community-dwelling older adults with functional limitations, as confirmed by the present study. Multivariate linear regression analysis revealed a substantial negative correlation between SAFE scores and fall risk (B = −0.463, β = −0.565, p < 0.001), suggesting that enhancing cognitive vigilance for falls may be as effective as improving physical function in reducing the risk of falls (48, 49). Notably, the total SAFE scores in this study (57.89 ± 13.35) were higher than those reported for hospitalized older adults with stroke. This difference should be interpreted with caution, as it likely reflects a combination of factors. Distinct health statuses—such as post-acute stroke functional limitation in hospital settings versus community-dwelling functional limitation at home or in the community—may contribute to the observed SAFE score differences. Additionally, in hospitals, safety responsibilities are often delegated to staff, and the focus is on acute treatment, which can lower patients’ self-perceived risk, potentially affecting their SAFE scores (50). These comparisons highlight how both disease stage and living context distinctly influence fall awareness. Disease stage and living environment have a distinct influence on awareness levels. Further analysis of SAFE scores revealed a pattern of “highest awareness of medication and lowest awareness of physical functions,” consistent with findings from studies of rural older adults hypertensive patients (51). This highlights greater awareness of medication risks, frequently emphasized by healthcare providers, while gradual physical decline often goes underestimated due to habituation and cognitive normalization, creating potential blind spots in risk perception. These findings highlight the need for proactive initiatives that foster an objective self-awareness of physical capabilities in older adults, alongside continued medication safety education. At the practical level, this means guiding older adults to develop an objective understanding of their physical capabilities. This can be achieved through methods such as scenario-based workshops and videos of fall incidents, which aim to dispel the misconception that “I will not fall.” Furthermore, conducting home safety assessments can lead to targeted improvements, addressing environmental hazards like missing bathroom grab bars or inadequate nighttime lighting. Collectively, this approach shifts the focus from passive care to proactive risk prevention and control. This study identifies social support as an independent protective factor against fall risk in community-dwelling older adults with functional limitations (B = −0.422, β = −0.190, p < 0.001), a result consistent with Zhao who demonstrated that social support enhances psychological adaptability and behavioral regulation to reduce fall risk (51). Furthermore, correlation analysis revealed a significant negative association between total social support and fall risk (r = −0.348, p < 0.01), supporting Shear’s findings on the foundational role of social support in fall prevention among older adults (15). The protective mechanisms of social support operate through three distinct dimensions. First, subjective support (emotional care and respect) can alleviate anxiety and enhance confidence, thereby reducing fear-driven activity avoidance. Second, objective support (tangible assistance such as environmental modifications and help with daily activities) directly mitigates physical risks. Third, effective utilization of available support (e.g., accessing health education and skill training) improves adherence to preventive measures and enhances self-management efficacy (52, 53). Collectively, social support forms a multidimensional protective chain encompassing psychological, environmental, and behavioral pathways, underscoring the importance of systematically integrating family, community, and professional services to strengthen support networks and improve fall prevention in this vulnerable population.

This study indicates that age, sleep quality, living arrangement, and marital status are significant demographic factors influencing fall risk among community-dwelling older adults with functional limitations. Multiple linear regression indicated that older age was significantly associated with increased fall risk (B = 0.993, β = 0.071, p = 0.004). This association can be attributed to multisystem functional decline, which includes: (1) impaired balance control due to deficits in visual, vestibular, and proprioceptive systems; (2) gait abnormalities arising from sarcopenia; (3) elevated fracture risk from osteoporosis; and (4) diminished emergency response capacity due to neurocardiovascular degradation. These risks are particularly pronounced among adults over 80 years, whose markedly reduced physiological reserves heighten both care needs and fall susceptibility (10, 11, 54). Sleep disorders were also identified as an independent risk factor for falls (B = 3.018, β = 0.097, p < 0.001), since insufficient sleep compromises cognitive awareness, delays neuromuscular responses, and contributes to postural instability, thereby significantly increasing the likelihood of falls (55). Regarding living arrangements, older adults living alone (B = 3.369, β = 0.137, p < 0.001), living with relatives (B = 2.687, β = 0.110, p < 0.001), or living with care worker (B = 2.781, β = 0.099, p = 0.001) all demonstrated higher fall risk compared to those living with a spouse. The reasons for increased fall risk differ across living arrangement. Those living alone lack immediate support. Those living with relatives may face protection gaps due to caregivers’ limited skills or delayed responses. For residents in institutions, risks are heightened by unfamiliar environments—such as new room layouts, communal facilities, and structured routines—and by the functional challenge of navigating a non-personalized space with often-compromised physical abilities.53 Being unmarried was a significant risk factor (B = 2.630, β = 0.088, p = 0.001). This is primarily due to the absence of the marital “support reserve.” In practice, this means lacking the ongoing mutual support and monitoring that typically exists between spouses. Within a marriage, partners engage in shared risk management—for example, by reminding each other of hazards, assisting with challenging activities, and offering emotional reassurance. These interactions help regulate behavior, reduce anxiety, and address gaps in self-monitoring. Without this daily, interactive support system, fall risk may increase (56). To address these factors, we recommend implementing cognitive behavioral therapy combined with light therapy and physical exercise for older adults with sleep disorders to improve circadian rhythm; introducing smart monitoring technologies and strengthening community visit systems for those living alone; and prioritizing age-friendly environmental modifications and caregiver training in households with relatives to effectively reduce fall risk through multidimensional strategies.

The findings of this study should be interpreted in the context of its limitations. Specifically, we employed a convenience sample of community-dwelling older adults with functional limitations from Western China, which may not be representative of older adults in other regions. Future research should aim to include older adults from various regions to gain a more comprehensive understanding of their fall risk and how to address these risks to reduce the likelihood of falls. Secondly, our primary measures (fall risk, fall awareness, social support) relied on self-reported questionnaires. While these are validated scales, responses may be subject to recall bias, social desirability bias, or individual differences in interpretation, which could introduce measurement error. Additionally, the cross-sectional nature of this research precluded causal inference between fall awareness, social support, and fall risk. Future studies would benefit from employing longitudinal designs and mixed-method approaches that incorporate more objective measures and qualitative insights to validate and deepen these findings.

This study surveyed 825 community-dwelling older adults with functional limitations and identified that the current fall risk was relatively high. Factors such as age, sleep quality, living arrangements, and marital status were found to be significant predictors of fall risk. Crucially, fall awareness and social support exert a significant influence on fall risk. These findings underscore the urgent need for multi-dimensional strategies to reduce fall risk and safeguard the well-being of this vulnerable population. We recommend developing integrated interventions among community-dwelling older adults with functional limitations that focus on the following: addressing misperceptions about fall risk through enhanced risk - perception education; cultivating robust support networks that involve families, communities, and health professionals; and implementing practical fall - prevention strategies such as caregiver training and age - friendly home modifications.