Dementia Care Across Viet Nam’s Care Continuum: Building Person-Centered, Safe and Coordinated Support Beyond Diagnosis
INTEGRATED CARE & CARE TRANSITIONSLONG-TERM CARE QUALITY


Dementia Care Across Viet Nam’s Care Continuum: Building Person-Centered, Safe and Coordinated Support Beyond Diagnosis
DEMENTIA CARE, INTEGRATED CARE & LONG-TERM CARE QUALITY
Last reviewed: October 2026
A dementia diagnosis matters. A careful diagnostic assessment can help explain concerning changes, identify potentially reversible or contributing problems, clarify the likely cause and open the door to appropriate treatment and support. But diagnosis is only the beginning of dementia care.
For many people and families, the more difficult questions come afterward. How can the person continue doing what still matters to them? What should the family do when medicines become difficult to manage, eating changes, the person becomes disoriented or gets lost, sleep becomes disrupted or behavior changes? Who coordinates care when the person moves between hospital, home, rehabilitation, primary or community care and, eventually for some people, residential or long-term care? How can safety be protected without unnecessarily taking away independence and dignity?
These are not questions that one specialist clinic can answer alone. Dementia can progressively affect cognition, function, communication, behavior and the ability to perform everyday activities. Good dementia care therefore has to extend across the care continuum—from recognition and diagnosis to living well in the community, support for family caregivers, management of increasing dependency, transitions between settings and care through the later stages of disease. The challenge for Viet Nam is not simply to identify more dementia. It is to build a system capable of supporting people and families well after diagnosis.
Dementia is not a normal part of aging, and it is not one disease
Dementia is an umbrella term for conditions caused by diseases and injuries that damage the brain and affect memory, thinking and the ability to perform everyday activities. Alzheimer disease is the most common form and contributes to approximately 60–70% of cases, but vascular dementia, dementia with Lewy bodies, frontotemporal dementia and mixed forms are also important. Dementia becomes more common with age, but WHO is clear that it is not an inevitable part of aging. In 2021, an estimated 57 million people worldwide were living with dementia, more than 60% in low- and middle-income countries, with nearly 10 million new cases occurring each year.
This distinction matters in practice. Forgetfulness should not automatically be dismissed as “just getting old,” but neither should every memory complaint be labeled dementia. Delirium, depression, medication effects, sensory impairment, sleep problems, metabolic disorders and other medical conditions can contribute to cognitive symptoms. Assessment therefore needs to look beyond a cognitive test score and consider function, medical history, medicines, mood, hearing and vision, neurological findings, social circumstances and the pattern and speed of change.
Screening and diagnosis are also different. A brief cognitive screening tool can identify people who may need further assessment, but it does not by itself determine the cause of impairment or establish a definitive dementia diagnosis. This distinction will become increasingly important as cognitive screening moves further into community-based older-person care in Viet Nam.
The burden in Viet Nam is growing, even though national estimates remain imperfect
Viet Nam is moving rapidly into the demographic conditions in which dementia will become increasingly important. Global Burden of Disease modeling estimated approximately 532,000 people living with dementia in Viet Nam in 2019 and projected approximately 1.76 million by 2050 if demographic and epidemiological trends continue. These are modeled estimates rather than counts of clinically diagnosed patients, but they illustrate the scale of potential future need. A more recent analysis based on GBD 2021 estimated an age-standardized prevalence of Alzheimer disease and other dementias in Viet Nam of approximately 649 per 100,000 population, with the burden concentrated among older age groups.
Recent Vietnamese studies add important local evidence, but they also show why prevalence figures need careful interpretation. A 2025 study of 762 older people in two communes in Thai Binh found that 22.7% met the study's HDS-R screening threshold. A separate 2026 study of 763 adults aged 60 years and older from one urban ward and one rural commune in Hanoi found cognitive impairment in 70.4% using the Montreal Cognitive Assessment. These are findings from cognitive screening in selected study populations, not national estimates of clinically diagnosed dementia, and the different instruments, thresholds and study populations make direct comparison inappropriate.
The most defensible conclusion is therefore not that Viet Nam has one precisely established national dementia prevalence figure. It is that rapid population aging, international modeling and a growing body of Vietnamese research all point in the same direction: cognitive impairment and dementia will require substantially greater health, social and long-term care capacity.
Viet Nam now has stronger building blocks for dementia care
The policy environment has changed meaningfully. The National Strategy on Older Persons to 2035, with a vision to 2045, approved by Decision No. 383/QĐ-TTg in February 2025, calls for stronger healthcare, social-care, rehabilitation and care services for older people and improved service quality. Importantly for dementia care, the Strategy sets a target that at least 50% of families with an older person experiencing memory impairment, severe disability or other significant difficulties receive training and guidance to improve their knowledge and skills in care, assistance and rehabilitation during the 2025–2030 period.
Decision No. 1116/QĐ-TTg of 22 June 2026 provides an even more explicit health-system signal. From 2026, it provides for older people to receive free periodic health examinations or screening at least once a year and to have health-monitoring records established. By 2030, it sets a target that at least 90% of older people have major noncommunicable conditions detected, treated and managed, with dementia explicitly named in the Decision. It also expands policy attention to community clubs, day-care facilities and other models of older-person care.
Decision No. 1976/QĐ-BYT of 1 July 2026 is particularly relevant at the practical level. The Ministry of Health's professional guidance for caring for older people at home and in the community incorporates the ICOPE approach. Its initial assessment covers six domains: cognition, mobility, nutritional status, vision, hearing and depressive symptoms. Trained professionals and community-based personnel—including staff at commune-level health stations, population collaborators, village health workers, social workers and volunteers—can participate in initial screening, with results transferred to the commune health station for further assessment of impairments, care needs and possible referral. Circular No. 34/2026/TT-BYT subsequently connects Decision 1976 to training and community implementation under the National Target Program on Health, Population and Development.
These are important building blocks, but the instruments themselves do not establish a single national dementia pathway connecting cognitive screening, diagnostic assessment, specialist care, primary and community care, rehabilitation, caregiver support, hospital care, residential care and later-stage support. The next challenge is therefore not only to expand individual services, but to connect them.
The broader policy direction also matters. At the national conference reviewing implementation of the Law on Older Persons on 30 September 2026, the Ministry of Health proposed developing a comprehensive long-term care system that prioritizes care within families and communities, diversifies services, standardizes the quality of care establishments and strengthens workforce capacity. These remain proposals for future revision of the Law rather than enacted requirements, but dementia is likely to be among the conditions most affected by how that future long-term care system is designed.
A diagnosis should lead to a care plan, not simply another appointment
After dementia is diagnosed, care can easily become fragmented into separate medical problems: hypertension at one clinic, diabetes at another, treatment for cognitive or behavioral symptoms from a specialist, a fall treated in an emergency department and behavior discussed only when the family can no longer cope.
The person experiencing all of this has only one life.
A dementia care plan therefore needs to look beyond the disease label. It should consider cognition, function, mobility, medicines, nutrition, hearing and vision, sleep, continence, mood, behavior, social connection, home safety, caregiver capacity and the person's own goals and preferences. WHO's ICOPE approach similarly emphasizes assessment of intrinsic capacity, social-care and support needs, personalized care planning and ongoing follow-up rather than managing individual conditions in isolation.
For someone in the earlier stages of dementia, the priority may be continuing to shop independently, see friends, work where appropriate or manage familiar household activities with modest support. Later, priorities may shift toward help with medicines, meals, personal care, mobility and supervision. As dependency increases, comfort, communication, eating and swallowing, pain, prevention of avoidable distress and family support may become increasingly important.
Person-centered care does not mean that one goal remains appropriate throughout the disease. It means that care continues to adapt to the person rather than expecting the person to adapt to a fixed service.
Person-centered dementia care starts with the person, not the diagnosis
Cognitive impairment can change how a person remembers, communicates or manages complex decisions. It does not erase their identity.
Good dementia care therefore asks questions that a conventional problem list may not capture. What did this person do for work? What routines are familiar? What foods do they prefer? Who matters most to them? What makes them anxious? What helps them feel secure? What time do they normally sleep? Do they prefer quiet conversation or activity? What cultural, spiritual or family practices are important?
These details are not decorative. They can directly affect quality and safety. A person repeatedly trying to leave a residential facility in the afternoon may be following a lifelong routine of leaving work at that time. Someone resisting bathing may be frightened by an unfamiliar person or environment. Someone described as “aggressive” may be in pain, constipated, hungry, frightened, overstimulated or unable to understand what another person is trying to do.
Person-centered dementia care changes the question from “How do we stop this behavior?” to “What might this person be experiencing or communicating, and what can we change?”
Dementia does not automatically remove a person's legal autonomy
This point is particularly important in Viet Nam. A medical diagnosis of dementia is not, by itself, the same as a legal determination that a person has lost civil act capacity. Under Articles 22 and 23 of Viet Nam's Civil Code, a declaration that a person has lost civil act capacity, or has difficulty in cognition and control of behavior, requires a court decision under the conditions and procedures provided by law, based on the relevant forensic psychiatric assessment.
Clinical decision-making ability can also vary according to the decision and stage of disease. A person may have difficulty understanding a complex property transaction while still being able to communicate meaningful preferences about meals, clothing, daily routines, visitors and aspects of their healthcare. Dementia services should therefore support participation in decision-making for as long and as far as the person's abilities allow rather than unnecessarily replacing the person's voice.
The Law on Medical Examination and Treatment No. 15/2023/QH15 adds important healthcare-specific provisions. Article 8 regulates representation of patients, while Article 15 addresses how healthcare rights are exercised for adults who fall within the legally defined categories of loss of civil act capacity, difficulty in cognition or control of behavior, or limited civil act capacity. Where such a patient had previously made a lawful written statement of wishes concerning medical examination and treatment, the Law provides for those wishes to be followed. Where no such statement exists, decision-making follows the statutory framework for representation and, in specified circumstances, the responsible clinical or leadership authority of the healthcare facility.
The practical principle is therefore not simply “family decides.” Services need to understand the person's legal status, identify the appropriate representative where required, respect applicable prior lawful wishes and continue involving the person themselves as meaningfully as possible.
Preserving autonomy is not the opposite of protecting safety. Good dementia care tries to achieve both.
Safety should not mean eliminating every risk
Dementia creates genuine safety concerns. A person may become lost, forget medicines, fall, leave cooking unattended, have difficulty swallowing, become vulnerable to exploitation or fail to recognize dangerous situations.
But a system that responds by removing every possible choice can create another kind of harm. Restricting movement, routinely locking people into spaces, using sedating medicines primarily for convenience or preventing all independent activity may reduce some immediate risks while increasing immobility, distress, functional decline and loss of dignity. WHO continues to identify extensive use of physical and chemical restraints in dementia care as an important human-rights concern.
The better principle is proportionate risk management. If someone becomes lost outdoors, ask whether identification, accompaniment, familiar routes, environmental design or appropriate technology could reduce risk before automatically preventing them from going outside. If someone repeatedly falls, investigate mobility, medicines, vision, footwear, blood pressure, toileting needs and environmental hazards rather than simply telling them not to walk.
Safety in dementia care is not zero risk. It is thoughtful management of risk while preserving as much function, autonomy and ordinary life as reasonably possible.
A sudden change is not always “the dementia getting worse”
One of the most important safety principles in dementia care is recognizing change from the person's usual state. Dementia generally worsens over time, but a substantial change over hours or days—new confusion, unusual sleepiness, agitation, reduced eating, inability to walk or a sudden decline in communication—should not automatically be attributed to dementia progression.
Acute changes can reflect delirium associated with infection, dehydration, medication effects, metabolic problems, pain or other acute illness. Viet Nam's 2026 professional guidance on care for older people at home and in the community recognizes acute confusion and the need to consider acute medical and medication-related contributors.
This is why every setting caring for someone with dementia should know that person's baseline. “More confused than usual” becomes clinically useful information only when someone knows what usual looks like. Families, home-care workers, community providers, residential-care staff and hospital teams therefore need clear escalation pathways when there is sudden deterioration.
Changes in behavior should trigger assessment before medication
Changes in behavior and psychological symptoms can be among the most difficult aspects of dementia for families and professionals. Agitation, repetitive questioning, resistance to care, sleep disturbance, hallucinations, apathy or repeated walking may cause substantial distress and sometimes create safety concerns.
These symptoms should not automatically trigger sedating medication. A first question should be whether there is a modifiable contributor: pain, infection, constipation, urinary symptoms, hunger, thirst, medication effects, sensory impairment, disrupted sleep, an unfamiliar environment, excessive noise, boredom, loneliness, fear or communication that the person cannot understand.
WHO's current dementia guidance emphasizes non-pharmacological interventions—including rehabilitation, psychoeducation, physical activity, social engagement, cognitive stimulation and caregiver support—as ways to improve quality of life and daily functioning. Where a person is at risk of harming themselves or others, WHO recommends trying non-pharmacological approaches first; medicines such as haloperidol or risperidone should be considered only when clearly needed, cautiously and under close supervision.
For Viet Nam, this has direct implications for workforce development. Dementia competence cannot mean only recognizing memory loss. Staff and caregivers need practical skills in communication, interpretation of behavior, environmental modification, pain recognition, de-escalation and recognition of acute deterioration.
Home and community should be core parts of the dementia pathway
For many Vietnamese families, home is where dementia care happens for years. This makes the expansion of community-based older-person care particularly important.
Decision No. 1976/QĐ-BYT provides a practical foundation for identifying declines in cognition and other aspects of intrinsic capacity closer to where older people live. Initial screening can be performed by appropriately trained health and community personnel, with results sent to the commune health station, which is responsible for identifying impairments and care needs and advising on referral where appropriate.
But cognitive screening should lead somewhere. If a person screens positive and the family receives only the message that “memory is declining,” little has been achieved. A functioning pathway needs clarity about what happens next: who performs further assessment, when specialist evaluation is needed, how potentially reversible or contributing problems are investigated, how a personalized plan is created, where caregivers receive training, and who follows the person when needs change.
Community dementia care therefore requires more than screening capacity. It requires referral capacity, care coordination and longitudinal support.
Family caregivers are part of the care system, not an unlimited resource
Families will remain central to dementia care in Viet Nam. That reality should be recognized, but it should not be romanticized.
Care can involve supervision throughout the day and night, repeated communication, assistance with bathing and toileting, medication management, behavioral changes, appointments, falls, eating difficulties and financial decisions. Over time, a family member may effectively become an unpaid care coordinator, nursing assistant, safety monitor and advocate without formal training.
Globally, WHO reports that women provide approximately 70% of care hours for people living with dementia. Dementia caregiving can affect caregivers' physical health, psychological well-being, employment, relationships and finances.
Importantly, Viet Nam now has local evidence that structured caregiver support can help. The culturally adapted REACH VN intervention was evaluated in a cluster randomized controlled trial involving 350 caregivers across 40 communes in northern Viet Nam. At three months, caregivers receiving REACH VN had lower psychological distress, perceived stress and somatic symptoms than the enhanced-control group. Caregiver burden was not significantly lower at the conventional threshold at three months but was lower at six months, while most of the other benefits were not sustained at the later assessment.
The lesson is not that one intervention solves caregiver burden. It is that caregiver support can be deliberately designed, delivered and evaluated rather than reduced to asking families to cope better.
A future dementia pathway in Viet Nam should therefore treat caregiver education, practical skills, psychological support, opportunities for respite where available and referral for caregivers' own health needs as part of dementia care itself. Decision 383's explicit target for training families caring for older people with memory impairment is particularly relevant in this respect.
Transitions are high-risk moments
Dementia care becomes particularly vulnerable when a person moves between settings. Consider an older person with moderate dementia admitted to hospital with pneumonia. During admission, medicines change, mobility declines and sleep becomes disrupted. Family members may provide much of the person's orientation and reassurance. At discharge, the pneumonia may have improved, but the person may now be weaker, more confused and eating less.
If the discharge information communicates only the pneumonia diagnosis and a medication list, the transition is incomplete. The receiving family or service may also need to know the person's pre-admission cognitive and functional baseline, current mobility, swallowing or nutritional concerns, recent behavioral changes, medication changes, warning signs, follow-up plan and how much assistance the person now requires.
The same principles apply when moving from home to respite or residential care, from residential care to hospital, or from hospital back to community services. Dementia magnifies the consequences of fragmented information because the person may be unable to reliably reconstruct their medical and functional history.
Quality dementia care therefore requires handover of the person, not only handover of the disease.
Hospitals need to become dementia-capable as well
Dementia is not confined to memory clinics or long-term care settings. People living with dementia will be admitted to hospital for infection, fractures, stroke, surgery, heart disease and many other conditions.
An unfamiliar hospital environment can itself be destabilizing. Noise, sleep interruption, moving between wards, unfamiliar staff, sensory impairment and loss of normal routines can increase distress and contribute to delirium. Communication can fail if teams depend only on the patient's recall or fail to involve family members and caregivers appropriately when they hold important information about the person's baseline.
A dementia-capable hospital does not require a dedicated dementia ward for every patient. It requires staff who can recognize dementia and delirium, communicate appropriately, assess pain, avoid unnecessary restraint, review medicines, support mobility and nutrition, involve caregivers appropriately and plan discharge with cognition and function in mind.
The same quality principles therefore need to follow the person across hospital, home, community and long-term care rather than remaining confined to the service that made the diagnosis.
Residential care requires more than a safe building
As long-term care services expand in Viet Nam, some people living with dementia will eventually require residential support because their needs become too complex for the care available at home.
A facility can be physically attractive and still provide poor dementia care. Quality depends on whether staff understand dementia, whether staffing and competencies reflect residents' dependency, whether behavior is understood rather than simply suppressed, whether medicines are reviewed, whether falls and pressure injuries are monitored, whether eating and swallowing difficulties are recognized, whether unnecessary restrictions are avoided, and whether families remain meaningfully involved.
The environment also matters. Lighting, visual contrast, signage, noise, predictable routines and access to safe movement can affect orientation and distress. A person who repeatedly walks around a facility does not necessarily need to be stopped; the environment may need to make walking safer and easier to navigate.
Residential providers should therefore be able to measure dementia-related quality rather than relying only on occupancy, licensing documentation, facility appearance or the absence of formal complaints.
Advanced dementia still requires active care
As dementia progresses, people may lose mobility, communication, continence and the ability to eat independently. Swallowing difficulties, recurrent infections, weight loss, pain and increasing dependency may develop.
At this stage, care is sometimes framed as though “nothing more can be done.” That is not an appropriate quality standard. There is still a great deal to do: identify and manage pain, maintain comfort, provide careful oral and skin care, support appropriate positioning and movement, assess eating and swallowing, avoid interventions whose burdens do not match the person's goals, support the family and respond to psychological, social and spiritual needs.
Palliative care principles can be introduced according to need throughout the course of illness and often become increasingly important as dementia advances. WHO's dementia framework emphasizes respecting autonomy from diagnosis through the end of life through integrated, person-centered health, psychosocial, long-term care and support services, with palliative care available when appropriate.
Planning ahead also matters. WHO encourages people living with dementia to identify trusted people who can support decision-making and communicate their choices and preferences for future care. In Viet Nam, such planning needs to operate within the country's legal framework on civil capacity, representation and lawful written wishes concerning medical examination and treatment.
Dementia care quality should be measurable
A serious dementia response needs to ask not only whether services exist, but whether they work.
Useful measures might include whether people with concerning cognitive changes obtain appropriate assessment; whether personalized care plans address function and caregiver needs; recurrent falls; medication review; use of restraint; pressure injuries; nutritional decline; potentially avoidable emergency transfers; hospital readmissions; continuity after discharge; caregiver distress; and the experience of people living with dementia and their families.
Measurement also needs to distinguish disease progression from preventable poor care. A person's cognition may decline despite excellent care. That does not mean quality improvement has failed. Conversely, progression of dementia should not be used to explain away dehydration, untreated pain, medication errors, inappropriate restraint or avoidable injury.
Quality measurement should therefore focus on outcomes and processes that services can reasonably influence: safety, dignity, function, experience, continuity, caregiver support and prevention of avoidable harm.
Recent Vietnamese evidence illustrates why function needs to be part of that discussion. A 2026 BMC Geriatrics study of 399 community-dwelling older adults with diagnosed dementia in Hai Duong found that 56.7% had moderate or severe dementia. After adjustment, lower independence in instrumental activities of daily living and poorer quality of life were associated with greater dementia severity. This is not a national prevalence study, but it demonstrates how closely dementia severity, function and long-term support needs can intersect in Vietnamese communities.
Prevention and care belong to the same continuum
Once a person develops dementia, they still need high-quality care. At the same time, a population response should reduce future risk wherever possible.
WHO published the second edition of its Guidelines on Risk Reduction of Cognitive Decline and Dementia on 15 July 2026. The updated guidance takes a life-course approach and addresses healthy behaviors, management of health conditions associated with dementia risk, environmental risk factors and tailored multidomain interventions. WHO also emphasizes that risk reduction cannot depend only on individual behavior because structural and social conditions shape exposure and access to prevention.
For Viet Nam, this means dementia risk reduction should connect with cardiovascular prevention, hypertension and diabetes management, tobacco control, reduction of harmful alcohol use, physical activity, hearing and vision care, healthy nutrition, social participation and reduction of relevant environmental risks such as air pollution.
This should not be interpreted as suggesting that people are responsible for developing dementia. Risk is influenced by age, genetics, health conditions, social circumstances, education, environment and access to care across the life course. Prevention, early identification and long-term support are therefore complementary parts of the same public-health response.
Viet Nam now needs to connect the pieces
WHO's Global action plan on the public health response to dementia, originally covering 2017–2025, was formally extended by the World Health Assembly to 2031 on 27 May 2025. Its areas for action include dementia as a public-health priority, awareness and inclusion, risk reduction, diagnosis and care, support for caregivers, information systems, and research and innovation.
Viet Nam does not necessarily need to copy another country's stand-alone dementia system. Dementia care can be strengthened within the country's emerging architecture for healthy aging, integrated care and long-term care. But dementia-specific functions still need to be visible.
That means connecting early recognition and assessment with a reliable diagnostic pathway; connecting diagnosis with a personalized care plan; connecting specialist services with primary and community care; connecting healthcare with social and long-term care; connecting families with training and support rather than leaving them to manage alone; connecting hospitals with home and residential care through safer transitions; and eventually connecting financing, regulation and oversight with measurable expectations for dementia care quality.
A practical dementia care pathway could clarify who screens, who performs further assessment, who establishes the diagnosis, who coordinates ongoing care, when specialist review is needed, how potentially reversible contributors are investigated, how caregivers receive support, and what happens when functional dependency increases. Screening without such a pathway risks finding problems without creating a reliable response.
Workforce development is equally important. Geriatricians, neurologists and psychiatrists alone cannot deliver dementia care at the scale Viet Nam is likely to need. Primary-care clinicians, nurses, rehabilitation professionals, pharmacists, social workers, community health workers, home-care workers and residential-care staff all need dementia competencies appropriate to their roles.
Data also need to improve. Vietnamese research on cognition, dementia severity and caregiver interventions is expanding, but stronger population-level surveillance and service-quality data are still needed to understand who receives care, where gaps occur, which models work in Vietnamese settings and whether quality improves as services expand.
Beyond diagnosis
A diagnosis can name the disease. It cannot by itself create a good life or a safe care system.
For a person living with dementia, quality may mean something much more ordinary: being spoken to rather than spoken about; staying safely at home for longer; continuing to walk in the garden; eating familiar food; receiving help without humiliation; avoiding an unnecessary hospital admission; recognizing the voice of someone they trust; or being comfortable when the disease becomes advanced.
For the family, quality may mean knowing what to do when behavior changes, having someone to call, receiving practical training and not carrying every responsibility alone.
For Viet Nam's health and long-term care system, the challenge is to make these experiences less dependent on the individual family, hospital, community or caregiver someone happens to encounter.
As Viet Nam's population ages and its long-term care system develops, dementia should not be treated simply as one specialist diagnosis among many. It is a test of whether care can remain person-centered when cognition declines, safe when vulnerability increases and coordinated when needs cross organizational boundaries.
The question is therefore no longer only: “Can we identify dementia earlier?” A more important question is also: “Once dementia is identified, can the person and family rely on a continuum of care that remains with them as their needs change?”
Building that continuum may ultimately matter as much as improving diagnosis itself.
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