This study's results have significant clinical implications. The qualitative analysis showed that risk factors affecting the psychological status of elderly patients with acute stroke are firstly related to a lack of disease cognition, with low educational level, lack of professional guidance from healthcare personnel, and limited channels for obtaining disease-related knowledge being the most critical factors. This is understandable, as nine-year compulsory education only began in the 1980s in China and became widespread in the early 21st century, causing some elderly individuals to miss out on educational opportunities. Another aspect could be related to the older age of the patients, resulting in decreased attention and memory. This study found that patients typically rely on medical staff for disease knowledge, but in practice, due to the acute nature of strokes and the busy nature of medical work, it is challenging to provide personalized knowledge education and one-to-one health education plans. Therefore, medical staff should strengthen disease-related knowledge education and encourage mutual communication for better disease management.
Our study also found that facing disease threats and challenges is another significant risk factor affecting the psychological status of elderly acute stroke patients. The study revealed that most acute stroke patients suffered various sequelae, such as limb immobility, hemiplegia, speech difficulties, blurred vision, incontinence, limited mobility, and sleep deprivation. Coupled with the long recovery duration of the disease, this led to high treatment costs and expenses. Overall, the severity of disease symptoms and the patient's economic capacity are crucial factors affecting their willingness to comply with treatment and their quality of life. Therefore, patients should be encouraged to adopt active coping strategies, develop scientific and reasonable rehabilitation plans, enhance self-management abilities, and promote positive disease development.
The study found that psychological issues and a sense of disease gain were also crucial risk factors. It was discovered that acute stroke patients experienced anxiety and depression, with disease uncertainty causing a strong sense of fear. There is ample reason to believe that approximately 11–41% of stroke patients suffer from post-stroke depression [47], which may be related to the near-death experience during the acute phase. Concerns about disease recurrence leading to fear can also affect treatment adherence, causing severe psychological distress. The study also found that acute stroke patients could benefit from their illness experiences. Compared to younger stroke patients, older individuals reported gaining beneficial skills and qualities from their caretaker roles, such as feeling loved, awe for life, closer family relationships, a sense of being valued, and enhanced self-esteem. Moreover, they enjoyed life more after retirement, willing to spend time changing unhealthy habits, controlling diet, exercising, and adapting to external changes.
In the quantitative analysis, this study found that acute stroke patients had a lower level of Illness perception, suggesting the presence of negative Illness perception needing improvement. One possible explanation is the low educational level of patients and lack of understanding of disease-related knowledge, leading to negative perceptions based on the severe consequences and treatment of the disease. Therefore, medical personnel should provide relevant information to increase patients' understanding of the disease, leading to accurate and positive cognition. Additionally, the study found that psychological resilience levels in acute stroke patients were medium to high, but scores in each dimension were relatively low. One reason could be the acute medical model focusing on the physical health and safety of patients, leading medical staff and caregivers to concentrate on the disease itself, not the patient's psychological state. Another reason could be due to the acute phase of stroke, patients may experience stress responses like fear, anxiety, and depression, with emotions not adequately addressed. This finding is corroborated by Zhang et al.'s research [48]. Interventions to improve psychological resilience during the acute hospitalization phase could help alleviate post-stroke psychological burdens and enhance patients' disease management capabilities.
The study results showed a lower level of rumination among acute stroke patients, differing from other related studies [49]. In this study, patients exhibited low levels of both positive and negative rumination, indicating minimal psychological changes following acute traumatic events. A possible explanation is that older patients did not have persistent negative beliefs about the disease and did not engage in deep cognitive activities when facing trauma. Therefore, considering patients' rumination levels in clinical practice is essential to help them better manage the consequences of stroke, develop problem-solving strategies, and adopt beneficial behaviors.
The study found that education level, Illness perception, and rumination are predictive factors for psychological resilience in acute stroke patients. Notably, Illness perception explained 38.1% of the variance in psychological resilience levels, indicating it is a significant predictive factor. Additionally, the study found that stronger negative Illness perception in patients led to higher levels of rumination and worse psychological health, confirming the hypothesis that Illness perception is negatively correlated with psychological resilience. One possible explanation is that the long recovery period of stroke patients and beliefs about severe disease consequences and recurrent episodes of the disease reduce their confidence in treatment. This theory has been validated in other studies. It was suggested that Illness perception directly and indirectly affects psychological resilience, influencing patients' quality of life through emotional regulation, coping styles, and self-efficacy (Liu et al., 2021). The study found that negative Illness perception is a crucial predictor of depression [50]. Moreover, individuals with high ruminative thinking are more likely to fall into a vicious cycle of negative emotions, focusing on and evaluating traumatic events negatively, reducing the potential for psychological growth. Thus, providing patients with relevant disease information, correcting negative cognitive biases, offering more psychological support, increasing positive disease experiences, and promoting effective self-regulation of traumatic events are necessary. Timely and appropriate clinical interventions, accurately identifying intrusive and deliberate rumination, can mitigate the adverse effects of psychological stress. As stroke is a chronic disease requiring long-term treatment, medical policies should establish and improve guidelines for stroke patients' coping abilities and psychological adaptation. Individuals with stroke need to enhance their adaptability during the illness, reducing the impact of negative Illness perception on their psychology.
The study constructed a mediation model, indicating that rumination mediates the relationship between Illness perception and psychological resilience among acute stroke patients. In other words, Illness perception can influence the level of psychological resilience through rumination. The study found that patients with more negative Illness perception reported less personal and treatment control, significantly correlating with psychological distress [11], leading to intrusive thinking and further affecting psychological resilience. Additionally, research has shown that deliberate rumination is significantly positively correlated with post-traumatic growth [51]. Research found that deliberate rumination helps rebuild an individual's worldview [52]. Calhoun et al.'s [53]study confirmed the significance of deliberate rumination in helping patients positively cope with disease changes. When deliberate rumination dominates, patients find ways to deal with traumatic events, experience positive emotions, understand the adverse impacts of the disease, and integrate new cognitions into their beliefs. Wang et al., also discovered that intrusive and deliberate rumination play different roles in the suicide risk of post-disaster adolescent patients [24]. Seriously, prolonged rumination can lead to decreased attention, more negative emotions, and pessimistic thinking.
In conclusion, medical personnel should provide relevant disease information to patients, correct negative cognitive biases, offer more psychological support, increase positive disease experiences, and promote effective self-regulation of traumatic events. Timely and appropriate clinical interventions, accurately identifying intrusive and deliberate rumination, can alleviate the adverse effects of psychological stress. Additionally, in the clinical management of stroke patients, more attention should be paid to improving patients' psychological states. As stroke is a chronic disease requiring long-term treatment, medical policies should establish and improve guidelines for stroke patients' coping abilities and psychological adaptation. Individuals with stroke need to enhance their adaptability during the illness, reducing the impact of negative Illness perception on their psychology.