- 1Department of Nursing, Nanfang Hospital, Southern Medical University, Guangzhou, China
- 2School of Nursing, Southern Medical University, Guangzhou, China
- 3Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
- 4Department of Neurology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
Background: Stroke is the leading cause of death
in China. Older stroke survivors often have other chronic conditions,
not only musculoskeletal deterioration due to age, but also changes in
body image that can be brought on by stroke and other diseases, making
them unable to take good care of themselves and dependent on others. The
degree of dependency affects the rehabilitation progress of stroke
survivors and shows dynamic changes that need to be recognized.
Objectives: This study investigates the
trajectory of dependency changes in older stroke patients with
comorbidities and analyze the influencing factors.
Methods: Grounded in the Chronic Illness
Trajectory Framework (CITF), a longitudinal study was conducted from
February 2023 to October 2023, tracking 312 older stroke patients with
comorbidities admitted to two tertiary hospitals in Guangzhou. Care
dependency levels were assessed using Care Dependency Scale on admission
day 5 (T0), at discharge (T1), 1 month post-discharge (T2), and
3 months post-discharge (T3). Growth Mixture Model were utilized to
identify trajectory categories, and both univariate analysis and
multivariate logistic regression methods were employed to explore
factors associated with different developmental trajectories.
Results: A total of four developmental
trajectories were fitted, C1 (high independence-slow increased group,
52.0%), C2 (moderate independence-rapid increased group, 13.0%), C3
(moderate independence-slow increased group, 25.0%), and C4 (low
independence-increased and decreased group, 10.0%). Length of hospital
stay, place of residence, level of social support, residual functional
impairments, NIHSS score, and BI index independently influence the
trajectory categories.
Conclusion: There is heterogeneity in care
dependency among older stroke patients with comorbidities. Most patients
gradually reduce their dependency and become more independent, but
others remain dependent for an extended period of time. It is
recommended to focus on patients who live in rural areas, have low
social support, have high admission NIHSS scores and have residual
functional impairment, and provide them with personalized continuity of
care and rehabilitation services in order to reduce care dependency and
the burden of care, and to improve patients’ quality of life.
1 Introduction
Stroke is the first cause of death in China (1).
Ischemic stroke, accounting for approximately 86.8% of all stroke types
in the population aged 40 and above, is characterized by high
recurrence, disability, and mortality rates. Factors such as
hypertension, diabetes, hyperlipidemia, heart disease, and
atherosclerosis contribute significantly to the increased risk of
ischemic stroke. These are also major chronic diseases that pose a
significant threat to public health, thus making the prevention and
treatment of ischemic stroke crucial (2, 3).
As of 2022, the population of individuals aged 60 and
above in China exceeded 280 million, accounting for 19.8% of the total
population (4).
The rapid aging of the population has led to a significant increase in
the population requiring complex care, highlighting the importance of
promoting healthy aging and creating elderly-friendly environments to
alleviate the burden of care in China. Stroke is one of the primary
causes of disability in older adults, and the disease causes, for
example, movement disorders, swallowing disorders, and cognitive
disorders that increase the level of dependency in the lives of older
adults. This not only significantly increases the burden of long-term
care but also imposes a heavy socioeconomic burden (5, 6).
Chronic health conditions are common among older adults.
In China, the prevalence of chronic disease comorbidity among older
adults reaches 65.16%, and the majority of them suffer from two chronic
diseases (7).
Compared to those with only one chronic illness, individuals with two
or more chronic diseases face a greater threat to their life safety and
quality of life (8).
A study revealed that at least 90% of middle-aged and older adults
experiencing ischemic stroke suffer from at least one other chronic
disease (9).
Older stroke patients often concurrently experience other underlying
health issues, which not only significantly impact the patients
themselves but also impose economic burdens and psychological stress on
their families and society (10, 11).
This is because, on one hand, the trauma and functional impairments
resulting from stroke severely affect the patients’ quality of life; On
the other hand, the pain and fear brought about by comorbidities, as
well as the prevalent sense of helplessness among older adults, lead
them to seek support from their families and society, making them
inclined to rely on others (12).
Therefore, it is essential to understand the current status of care
dependency among older stroke patients with comorbidities and to
implement corresponding care measures.
In our study, the concept of care dependency is derived from the theories of human need and self-care (13, 14).
Care dependency represents a specific form of reliance, which involves
subjective needs for care support to compensate for deficiencies in
self-care. Therefore, it is essential to assess patients’ psychological
and social behaviors (15, 16).
In previous longitudinal studies focusing on care dependency levels
among stroke patients, the authors have noted that patients’ levels of
care dependency exhibit dynamic changes (17).
Thus, hospitals and communities should continuously monitor patients’
care dependency to adjust care measures in a timely manner.
Traditional analysis methods for depicting the overall
developmental trajectory in research assume that all subjects follow the
same trajectory, but recent studies have shown that the population does
not follow the same development trajectory, and there are unobservable
subgroups in the population, each of which possesses its own different
growth parameters (18).
Growth Mixture Model (GMM) can reflect both inter-individual
differences at different time points and the continuity and trends of
individual changes (19, 20).
GMM has been widely applied in nursing, with research topics focusing
on population quality of life, cognitive function, and psychological
status. By constructing GMM, different quality of life trajectories
during the 12-month recovery process of stroke survivors were
identified. The results indicate that the quality of life trajectory of
stroke survivors is related to the burden, anxiety, and depression of
their caregivers. It is suggested that healthcare professionals pay more
attention to and intervene with survivors and their caregivers
exhibiting moderately low quality of life trajectories (21).
By constructing GMM, the changing trajectory of cognitive function in
Chinese middle-aged and elderly individuals was estimated. The results
show that Chinese middle-aged and elderly individuals exhibit three
heterogeneous trajectories of cognitive function, with an overall trend
of gradual decline, emphasizing the need to focus on groups with lower
education levels and lower self-care abilities (22). In summary, GMM can effectively address the shortcomings of traditional growth models in exploring population heterogeneity.
In this study, we will conduct a longitudinal study to
construct Growth Mixture Model to identify the different developmental
trajectories and influencing factors of care dependency in older
ischemic stroke patients with comorbidities, which will help healthcare
professionals to provide personalized care plans, better nursing
guidance and the basis for developing quality continuity of care
services for patients.
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