Developmental trajectory of care dependency in older stroke patients

 Totally wrong research; survivors want recovery, NOT 'CARE'. Your research should have been;'Recovery trajectory in older stroke patients'! You're fired!

Developmental trajectory of care dependency in older stroke patients

Qinger Lin^1,2Xiaohang Dong³Tianrong Huang⁴Hongzhen Zhou^1,2*

• 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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