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journal-of-nursing-sciences/2352-0132

Original Article

Factors associated with activities of daily living

among the disabled elders with stroke

Li Pei, Xiao-Ying Zang, Yan Wang, Qian-Wen Chai, Jun-Ying Wang,

Chun-Yan Sun, Qing Zhang*
School of Nursing, Tianjin Medical University, Tianjin, China

article info abstract

Article history: Objective: To determine the factors associated with activities of daily living (ADL) among the
Received 20 February 2015 disabled elders post-stroke.
Received in revised form Methods: A total of 158 patients were chosen from community health service stations in
7 December 2015 eighteen regions of Tianjin city by convenience sampling from March to November in 2013.
Accepted 26 January 2016 The Barthel Index (BI) and the short-form mini-nutritional assessment (MNA-SF) were used
Available online 16 February 2016 to evaluate the ADL, the nutritional status respectively. Statistical analysis was performed
using independent sample t-test, one-way ANOVA, Pearson correlation and multiple linear
Keywords: regression analysis. Barthel ADL index was the main outcome.
Activities of daily living Results: The mean score of ADL was 50.50 ± 27.125. The multiple linear regression showed
Disabled persons that the factors which had significant impact on ADL were stroke frequency, types of
Frail elders stroke, nutritional status, financial status, and age.
Stroke Conclusions: Disabled elders with recurrent strokes, hemorrhagic stroke, dependent finan-
cial resources, older age, worse nutritional status and living with family had poorer stroke-
related outcome. Healthcare providers can discover the high-risk groups of disability and
implement individualized preventive interventions in accordance with the related factors.
Copyright © 2016, Chinese Nursing Association. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).

disability. Approximately 50 million stroke survivors world-

1. Introduction
Stroke is a medical emergency characterized by the WHO as
“rapidly developed clinical signs of focal (or global) distur-
bance of cerebral function, lasting more than 24 hours or
leading to death, with no apparent cause other than of
vascular origin” [1]. Patients with stroke have a high rate of
wide have physical, cognitive, and emotional problems, about
25%e74% of whom are dependent in activities of daily living
(ADL) [2]. The outcome of stroke is heterogeneous. In China,
approximately 1.5 million patients die and 7 million survive
from stroke each year. Three-quarters of the survivors suffer
from various degrees of sequelae [3]. Furthermore, more than

*
Corresponding author.
E-mail address: snzhangqing@tijmu.edu.cn (Q. Zhang).
Peer review under responsibility of Chinese Nursing Association.
http://dx.doi.org/10.1016/j.ijnss.2016.01.002
2352-0132/Copyright © 2016, Chinese Nursing Association. Production and hosting by Elsevier B.V. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
30 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 3 ( 2 0 1 6 ) 2 9 e3 4
two million patients experience a stroke attack each year, and
the incidence rate increases by 6.7% every year [4].
Age is a known risk factor for stroke; that is, the incidence
of stroke increases with age [5]. Stroke is also more threat-
ening for elders. Elderly stroke patients have a higher mor-
tality and receive a lower quality of care than young stroke
patients [6]. Stroke is a major cause of disability in people
older than 60 years [5]. The population of elders in China had
reached 178 million, accounting for 13.26% of the total popu-
lation in 2010 [7]. In addition, the total number of elders
dealing with stroke-related disability had reached 33 million,
accounting for 19% of the total elderly population [7]. These
data indicate that stroke-related disability is an important
public health problem that requires measures from the gov-
ernment, public, and health service agencies to be solved.
Disability is characterized by a difficulty in doing activities
in any domain of life (from hygiene to hobbies, and errands to
sleep) because of a health or physical problem [8]. Both chronic
and acute conditions could influence the bodily function and
ADL of a patient [8]. Stroke was ranked as the third cause of
disability after musculoskeletal and mental disorders, and it
might be the most common cause of complex disability [9]. On
average, stroke survivors would suffer at least 0.86, 1.24, and
1.39 years with mild, moderate, and severe disabilities,
respectively [10]. Thus, the primary goal of caring for elders
with stroke is to regain their abilities to perform ADL, such as
feeding, dressing, moving in and out of bed, toilet using,
mobility, and bathing, which are necessary for survival [8].
Maintaining independence in ADL is an important factor
for the quality of life. Stroke survivors who need assistance for
ADL always feel socially isolated, overwhelmed, and aban-
doned [11]. Gillespie et al. [12] indicated that patients who are
disabled post-stroke also place burden to their family care-
givers, thereby affecting family relationships.
Stroke is a costly and bothersome disease that entails
serious financial burden worldwide. In 2008, more than $65
billion of direct and indirect costs were consumed by stroke in
the United States [5]. The expenditures included cost from
hospitalization, nursing homes, physicians and other
healthcare professionals, home healthcare, drugs and other
medical durables, and lost productivity because of morbidity
or mortality [5]. Disability also causes a considerable loss of
medical costs. In 2011, the total cost of long-term care for
disabled elders was $57.1 billion in China [13]. However, the
dependence in ADL of elders with stroke can be prevented.
Therefore, exploration of ADL factors and effective measures
to promote stroke recovery is extremely urgent.
Considering that stroke has become the leading cause of
dependence in ADL worldwide in recent years, several
scholars focused on stroke-related disability and factors. Jia
et al. [14] indicated that age, education, caregivers, history of
past illness, history of smoking, and muscle strength are
influencing factors of ADL for stroke patients. Zheng et al. [15]
found that ADL negatively correlates with the degree of
neurological impairment and stroke duration but positively
correlates with the total time of weekly rehabilitation training
for patients post-stroke. Nevertheless, studies on ADL focused
on ordinary old people or stroke patients regardless if they are
disabled or not. A study focusing on the outcome of disabled
elders is lacking. Thus, studies that determine the relevant
factors of ADL for disabled elders post-stroke are needed.
Accordingly, the present study aims to identify the de-
mographic and clinical factors associated with ADL among
disabled elders post-stroke.
2. Methods
2.1. Participants
This study was carried out from March 2013 to November in
2013. A total of 360 disabled elders were chosen from com-
munity health service stations in 18 regions of Tianjin City
through multi-stage cluster sampling; 158 of these elders were
disabled because of stroke. The inclusion criteria for the pa-
tients are as follows: 1) diagnosed with stroke; 2) aged 60 or
over; 3) disabled, which refers to dependence on assistance in
one or more ADL, including feeding, dressing, moving in and
out of bed, toilet using, mobility, and bathing; 4) permanent
residence in Tianjin City; and 5) conscious and can answer
questions clearly. Patients were excluded from the study if
they had mental illness, aphasia, cognitive dysfunction, or
refused to participate.
2.2. Instrument
A structured questionnaire related to the socio-demographic
characteristics, clinical information, nutritional status, and
ADL of the participants was designed by the researchers.
The socio-demographic characteristics of the participants
included age, gender, education level, marital status, number
of children, occupation, living alone or not, and financial
status. The clinical information of the participants included
types of stroke, stroke frequency, medical insurance, number
of chronic diseases, and disability duration. We graded the
nutritional status of the participants using the short-form
mini-nutritional assessment (MNA-SF), which could be
completed in approximately 3 min. The scale consisted of six
items as follows: BMI < 23, recent weight loss >1 kg, acute
illness or stress, housebound, and dementia or depression.
The total score of MNA-SF ranges from 0 to 14. A score within
the range of 12e14 indicates normal status, whereas a score of
11 or less means at risk of malnutrition [16]. The scale was
translated into Chinese by He et al. [17] and validated with
satisfactory reliability and validity. The sensitivity, specificity,
diagnostic accuracy, and correlation coefficient of MNA-SF are
85.7%, 96.0%, 87.5%, and 0.933, respectively [17].
The ADL was measured using the Barthel index (BI), which
assessed 10 aspects of ADL: feeding, moving from wheelchair
to bed and return, personal toilet, getting on and off the toilet,
self-bathing, walking on level surface, ascending and
descending on stairs, dressing, controlling bowels, and con-
trolling bladder. The total score ranged from 0 (total depen-
dence) to 100 (total independence). A higher BI indicates a
higher level of ADL [18]. Participants were classified into four
categories based on their BI scores: severe disability (BI
55),
moderate disability (BI: 60e85), mild disability (BI: 90e95), and
no disability (BI ¼ 100) [10]. BI is widely used for stroke patients
in China. The Cronbach's alpha coefficient and KMO statistical
 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 3 ( 2 0 1 6 ) 2 9 e3 4 31

magnitude of BI were 0.916 and 0.854, indicating the high

Table 1 e Demographic and clinical characteristics of
reliability and validity of this index [18].
participants in Tianjin, China.
Variable Number (%)
2.3. Data collection
Age (years) (mean age, SD) (73.49, 7.922)
Data were collected through a questionnaire survey. Each 60- 50 (32.9%)
70- 60 (39.5%)
survey was conducted at home or at a community health
80- 42 (27.6%)
service station. The survey was conducted by trained workers Gender
to improve the quality of the questionnaire. At the beginning Male 93 (61.2%)
of the study, the researchers introduced the purpose and Female 59 (38.8%)
significance of the study to the participants in detail to obtain Educational level
their informed consent and thus enhance the response rate Illiterate or semiliterate 20 (13.2%)
Primary school 57 (37.5%)
and information accuracy. Subsequently, the participants fil-
Junior middle school 36 (23.7%)
led in the questionnaire. Participants who were unable to read
Senior middle school 29 (19.1%)
or complete the questionnaire independently were assisted by Junior college or over 10 (6.6%)
the researchers through personal interviews. The researchers Marital status
gathered information about the disease of each participant. Single (unmarried, divorced, widowed) 28 (18.4%)
Approximately 30 min were spent on completing the ques- Married 124 (81.6%)
tionnaires of each participant. Occupation
Worker 73 (48.0%)
Farmer 27 (17.8%)
2.4. Statistical analysis
Enterprise and government worker 38 (25.0%)
Free professional 14 (9.2%)
Data were double inputted using SPSS® Version 16 (SPSS Inc., Living alone or not
Chicago, IL, USA). Initially, descriptive statistics were used to No 144 (94.7%)
express variables. Furthermore, the independent sample t-test Yes 8 (5.3%)
and one-way ANOVA were used to examine the differences in Number of children
One or none 32 (21.1%)
ADL between/among participants of different characteristics.
Two or more 120 (78.9%)
Pearson correlation was used to analyze the relationship be- Financial status
tween ADL and age, nutritional status, and stroke frequency. Yes 123 (81.5%)
Finally, multiple linear regression analysis was performed to No 28 (18.5%)
identify the variables associated with ADL. Variables signifi- Medical insurance
cant at p-values below 0.05 in independent sample t-test, one- Yes 146 (96.1%)
way ANOVA, and Pearson correlation were subjected to mul- No 6 (3.9%)
Types of stroke
tiple linear regression analysis, and backward elimination was
Ischemic 128 (84.2%)
performed. Statistical significance level was set at 0.05. Hemorrhagic 24 (15.8%)
Adjusted R2 was used to determine the variance of ADL. Stroke frequency
Once 78 (51.3%)
Twice or more 74 (48.7%)
3. Results Number of chronic diseases
One 55 (36.2%)
Two or more 97 (63.8%)
3.1. Characteristics of participants Nutritional status (mean, SD) (9.41,2.517)
Well-nourished 35 (23.0%)
Among the 158 participants recruited, 6 were excluded Risk of malnutrition 117 (77.0%)
because of an incomplete questionnaire, and the response Disability duration (years)
rate was 96.2%. In the study, about 61.2% of the participants
1 year 45 (29.6%)
were male, and the mean age was 73.76 (SD ¼ 8.212). The 1e5 years 40 (26.3%)
>5 years 67 (44.1%)
majority of the subjects was married (81.6%) and lived with
Barthel index score
their family (94.7%). Most of the participants (96.1%) had Mild disability 13 (8.6%)
medical insurance, and approximately 81.5% had indepen- Moderate disability 59 (38.8%)
dent finance. Ischemic stroke accounted for 84.2% of the Severe disability 80 (52.6%)
stroke lesion types. More than half of the participants (51.3%)
were patients of first-ever stroke attacks. The mean score of
MNA-SF was 9.59 with a standard deviation of 2.41. The MNA-
SF rated 77.0% and 23.0% of the patients as at risk of malnu- score of ADL was 50.50 ± 27.125. Pearson correlation showed
trition and well nourished, respectively (Table 1). that nutritional status (r ¼ 0.563, p < 0.001), age (r ¼ 0.233,
p ¼ 0.004), and stroke frequency (r ¼ 0.452, p < 0.001) were
3.2. Level of ADL among disabled elders post-stroke significantly associated with ADL. Independent sample t-test
and one-way ANOVA revealed significant differences in ADL
Of the participants, 8.6%, 38.8%, and 52.6% were mildly, between/among participants of different levels of education
moderately, and severely disabled, respectively. The mean (p ¼ 0.047), occupation (p ¼ 0.002), financial status (p < 0.001),
32 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 3 ( 2 0 1 6 ) 2 9 e3 4

types of stroke (p < 0.001), and living alone or not (p ¼ 0.022),

Table 3 e Multiple linear regression analysis for disabled
(Table 2).
elders with stroke.
Variables Beta t p value
3.3. Multiple linear regression analysis of ADL level
Stroke frequency 0.426 8.003 p < 0.001
Types of stroke
The independent variables in the multiple linear regression Ischemic stroke 0.320 6.356 p < 0.001
analysis were nutritional status, age, stroke frequency, edu- Hemorrhagic stroke e e e
cation, occupation, living alone or not, financial status, and Nutritional status 0.326 6.068 p < 0.001
types of stroke. Categorized variables, such as education, Financial status
Financial independence 0.369 4.337 p < 0.001
occupation, living alone or not, financial status, and types of
Financial dependence e e e
stroke, were translated into dumb variables for use into the Age 0.205 3.784 p < 0.001
regression equation. Finally, stroke frequency (t ¼ 8.003, Living alone or not
p < 0.001), types of stroke (t ¼ 6.356, p < 0.001), nutritional Yes 0.033 0.653 0.515
status (t ¼ 6.068, P < 0.001), age (t ¼ 3.784, p < 0.001), and No e e e
financial status (t ¼ 4.337, p < 0.001) were revealed as signifi- Educational level
Illiterate or semiliterate 0.185 2.044 0.043
cant risk factors for ADL. The multiple correlation coefficient
Primary school 0.149 1.290 0.199
(R) was 0.825, and the adjusted R2 was 65.0% (F ¼ 22.564,
Junior middle school 0.135 1.310 0.192
p < 0.001) (Table 3). Senior middle school 0.116 1.283 0.202
Junior college or over e e e
Occupation
Worker 0.042 0.360 0.719
4. Discussion Farmer 0.087 1.075 0.284
Enterprise and government worker 0.049 0.436 0.663
This study examined factors influencing ADL among disabled Free professional e e e
elders post-stroke. Based on our study, stroke frequency, Multiple correlation coefficient (R) ¼ 0.825, Adjusted coefficient of
types of stroke, nutritional status, age, and financial status determination (R2) ¼ 0.65.
were predictors of ADL. Stroke frequency emerged as the most
important factor affecting ADL. Stroke frequency is related to
disability [19,20]. Patients of recurrent strokes are more
disabled and severe than those of first-ever strokes [19]. This the recurrence of strokes and thereby avoid the further dete-
observation could be attributed to the fact that recurrent rioration of ADL among disabled elders.
strokes could cause more serious necrosis of neurologic cells Hemorrhagic stroke causes more serious disability than
and tissues than first-ever strokes; hence, the recovery of ischemic stroke for disabled elders. However, data on the
neurological deficits would be worse than those of first-ever functional outcome according to the types of stroke are
strokes, resulting in poor functional outcome [21]. Mutai inconsistent in present studies [23,24]. Although patients of
et al. [20] also indicated that recurrent strokes could increase hemorrhagic stroke show a faster increase in BI scores, the
the risk of developing subsequent strokes or other underlying time window for recovery is more restricted for patients of
mechanisms. In addition, the average risk of recurrent strokes hemorrhagic stroke than those of ischemic stroke [24]. Hem-
is 4% in the first year for patients after first-ever strokes [22]. In orrhagic stroke is more severe [25] and deadly [26] than
the present study, almost half of the patients had recurrent ischemic stroke, which may explain why disabled elders with
strokes, which could lead to poor ADL. Therefore, health care ischemic stroke have better ADL.
providers should strengthen the health education to prevent Nutritional status exerts a positive impact on ADL [27, 28].
To€ rma€ et al. [28] found that the deteriorated nutritional
status of elders could cause dependence in ADL and thereby
Table 2 e Univariate analysis and Pearson correlation of increase care needs. This finding may be attributed to the
different variables with activities of daily living. fact that poor nutritional status exacerbates brain damage
Variables t/F r p value and thus causes adverse outcome [29]. In addition, malnu-
Gender 1.729 0.086
trition and disability are strictly interconnected; in specific,
Educational level 2.469 0.047 poor nutritional status influences functional disability, and
Marital status 0.937 0.350 vice versa [27]. Active nutritional interventions could pro-
Occupation 5.173 0.002 mote the recovery of neurocognitive function [29]. Most of
Living alone or not 2.313 0.022 the participants in the present study were at risk of malnu-
Number of children 0.723 0.396
trition, which could explain their poor ADL. Thus, nurses
Financial status 4.872 <0.001
should emphasize the importance of nutrition and take
Medical insurance 0.866 0.388
Types of stroke 3.991 <0.001 effective intervention measures to increase awareness on
Number of chronic disease 0.48 0.631 achieving a balanced nutrition and thus improve the ADL of
Disability duration 1.283 0.280 patients with stroke.
Age 0.233 0.004 Age and ADL showed a negative correlation. This finding
Nutritional status 0.563 <0.001 agrees with previous results [30,31]. Older patients experi-
Stroke frequency 0.452 <0.001
enced a different set of stroke risk factors (more likely to
 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 3 ( 2 0 1 6 ) 2 9 e3 4
have a history of atrial fibrillation or hypertension and less
likely to be current/recent smokers) and were more likely to
suffer from complications compared with younger patients
[32]. Furthermore, aging was associated with declined
physiological function, physical endurance, and compensa-
tory capacity. By contrast, some studies reported that age is
not a significant factor of functional outcome [33]. This
discrepancy in results might be attributed to the different
participants enrolled. In the present study, we recruited
patients of first-ever and recurrent strokes who were
disabled, whereas Lee et al. [33] considered individuals who
experienced first-ever ischemic stroke. Thus, further studies
are needed to investigate the relationships between age and
ADL. Nurses should concentrate on older patients and
strengthen the health education to improve the ADL of these
patients.
Socioeconomic status could also influence the outcome of
patients with stroke [34]. Financial status is associated with
ADL for disabled elders post-stroke [31]. Stroke could endow
high financial burden on patients [5]. Patients who have an
independent financial status have the medical resources and
the capacity to cope with stroke and disability. In addition,
patients with a low financial pressure could receive more
rehabilitation exercises and live healthier lives compared with
their counterparts [35]. Therefore, the government should
take endeavors to improve the poor financial status and
enhance the ADL of patients with stroke.
The present results showed no association between ADL
and gender [36], which is inconsistent with the study by
Petrea et al. [37]. The reason for such a difference could be
that all patients in their study are within 3e6 months post
first-ever stroke attack. Hence, further studies are required
to explore the relationship. Multiple linear regression results
showed that living alone or not was not a risk factor for
disability. By contrast, data from the Chinese Longitudinal
Healthy Longevity survey showed that patients living alone
are less likely to be disabled and have a higher recovery rate
of ADL compared with those not living alone [38]. They
showed that patients who are living alone have no children
or their children live far from them, which force them to
take care of themselves [38]. The reason for the difference
may be that very few of the patients enrolled in the present
study lived alone, which possibly influenced the statistical
results. We also found no statistically significant difference
in ADL based on the number of chronic diseases [39].
Although the reasons are not entirely clear, the fact that
most of the participants in the present study had at least
one comorbid disease might attenuate the association be-
tween the number of chronic diseases and ADL. Therefore,
further studies with a large sample size are needed to focus
on this issue.
In conclusion, dependence in ADL among elders post-
stroke is common in China. Stroke patients with older age,
recurrent strokes, hemorrhagic stroke, dependent financial
resources, and risk of malnourishment had poorer ADL
compared with their counterparts. Therefore, healthcare
providers can discover the high-risk groups of disabled elders
and implement individualized preventive interventions to
improve the ADL for disabled elders with stroke in consider-
ation of the aforementioned factors.
33
5. Study limitation
Some limitations of our study should be considered. First, the
cross-sectional design of this study limited its ability to pre-
dict the causal relationship among variables. Thus, further
studies should be carried out to confirm this relationship.
Second, patients who had mental illnesses or cognitive dys-
functions were excluded. Therefore, further research should
focus on these patients to discover the possible influencing
factors of ADL.
6. Funding statement
The study was funded by Tianjin Science and Technology
Association, China (TJSKX2013-JC06).
7. Conflict of interest
The authors declare no conflict of interest.
Acknowledgments
We are grateful to all the patients and staff of the community
health service station for their assistance during data
collection.
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