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The relationship between communication activities of daily living and quality of life among the elderly suffering from stroke

[Purpose] Disabilities after stroke are known to have adverse effects on the quality of life. This study investigated the relationship between Communication Activities of Daily Living (C-ADL) and quality life of elderly stroke patients to provide basic data for use in enhancing the quality of life. [Subjects and Methods] One hundred sixty five elderly over the age of 60, who were diagnosed as having stroke and receiving treatment in rehabilitation departments of general hospitals were surveyed. Stroke patients’ basic communication ability to survive in daily living was measured using the C-ADL Second Edition, and stroke patients’ quality of life was measured with the Stroke-Specific Quality of Life (SSQOL). The relationship between C-ADL and SSQOL was analyzed using multiple regression analysis. [Results] C-ADL had a significant positive relationship with SSQOL. [Conclusion] This result implies that it is necessary to enhance stroke patients’ communication ability in daily living in order to raise their quality of life.


INTRODUCTION
In line with the worldwide aging trend, Korea became an aging society in 2000 and is expected to become an aged society with an elderly population over the age of 65 of 14% of total population 1) . In addition, the average life span of Koreans was 79.6 years in 2010, 15 years longer than that of 1980 1) . Despite increases in social demands by the elderly for high-quality and satisfactory life, with the increase in the elderly population and their extended average life span, there is a high possibility that the elderly will lives accompanied by more diseases because of the degree of prolongation of their life span 2) . Especially, cerebrovascular diseases are known as typical geriatric diseases that threaten the health of the elderly. According to a survey by the Korea Center for Disease Control and Prevention, 7.2% of the elderly population over the age of 65 had experience of stroke in 2013, which is an 5.3% increase from 2001 3) .
Stroke is a generic term for both cerebral infarction caused by the blockage of a blood vessel in the brain, and cerebral hemorrhage caused by the rupture of a blood vessel in the brain. Stroke is not only the most common of disease, but it also has enormous social costs, such as medical costs. Medicine costs, loss of productivity, and the socio-economic cost of stroke in Korea were estimated to amount to U$ 3.5 billion as of 2010 4) .
Although stroke occurs in all age groups, the elderly are the most susceptible group, since its prevalence rate increases rapidly with every 10 years of age 5) . Twenty-five percent of the stroke patients die within 1 month of stroke onset, and even after survival, it has been reported that 60% of the surviving patients suffer from various disabilities such as paralysis, motor disorder, cognitive impairment and speech disorders, which leave them unable to lead independent daily lives without the help of others. Moreover, 70% of survivors suffer from communication disorders such as dysarthria and aphasia 6) , and among the disabilities resulting from stroke, communication problems frequently occur. According to the American Heart Association and American Stroke Association, among 2 million stroke survivors in 2005, approximately 1 million had aphasia 7) .
Disabilities after stroke are known to have adverse effects on the quality of life 8) , and among them, communication disorders place burdens not only on patients but on their families as well 9) . As the majority of stroke patients have to lead their lives with disabilities, the quality of life including psychological and social aspects should be given consideration.
Especially, Communication Activities of Daily Living (C-ADL) is important, because it examines the basic communication ability necessary for survival in daily living such as social interactions and non-verbal communication 10) . Similarly, although communication is an important factor in terms of quality of life, studies on communication of stroke patients remain limited to the understanding of the linguistic abilities of stroke patients, and there is a lack of studies on the theme of communication. While studies of stroke patients' Activities of Daily Living (ADL) have been regularly conducted, studies of C-ADL are very rare.
This study investigated the relationship between C-ADL and the quality of elderly stroke patients' lives to provide basic data for use in enhancing the quality of life.

SUBJECTS AND METHODS
The present study conducted convenience sampling 4 times from August through December 2014, and surveyed 165 elderly over the age of 60, who were diagnosed as having stroke and receiving treatment in rehabilitation departments of general hospitals located in Seoul, Inchon, Daejeon and Gwangju. One hundred fifty-eight fully completed questionnaires were anaylzed; 7 questionnaires had incomplete answers. As the required minimum number of samples was 88 patients to obtain a significance level of α=0.05, and an effect size of 0.5, with a statistical power of (1-β)=0.95 according to the G-power 3.0 program, the number of subjects in this study was more than sufficient. The subjects were given sufficient explanation regarding the purpose and experimental method of this study before participation and gave their voluntary consent. The study protocol was approved by the Institutional Review Board of N University and was conducted in accordance with the ethical principles of the Declaration of Helsinki. Together with the questionnaire on Communication Activities of Daily Living, a survey of quality of life was conducted via individual interviews.
The inclusion criteria for subjects were: literate patients with consciousness, within 1 year after the onset of stroke, who had no accompanying neurological diseases such as dementia or Parkinson's disease, or apraxia or agnosia. Covariate variables were age, sex, final education (middle school and lower, high school or above), the average monthly income of households (less than 2 million won, 2-4 million won, more than 4 million won), marital status (living with spouse, living without spouse, unmarried person), drinking (non-drinker, former drinker, current drinker), smoking (nonsmoker, past smoker, current smoker), stroke type (cerebral hemorrhage, cerebral infarction), time since onset of stroke (less than 3 months, 3-6 months, 6-12 months), depressive symptoms in the last 1 months (yes, no).
Data was analyzed using SPSS 22.0. First, for subjects' general characteristics, means and percentages were calculated and are presented as descriptive statistics. Second, in order to examine the differences in SSQOL based on subjects' C-ADL characteristics, the independent t-test and one-way ANOVA were performed. Finally, the relationship between C-ADL and SSQOL was analyzed using multiple regression analysis.

RESULTS
The average age of the subjects was 67.5 (standard deviation 6.8 years); 53.8% of the subjects were males, 88.5% were married, 63.6% were middle school graduates or above, 67.0% had cerebral infarction, 61.9% had a monthly household income of less than 2 million won, 26.5% were, past smokers, 38.5% were past drinkers, 68.0% had experience of depression symptoms in the last 1 month, and the majority of the subjects were 6-12 months since the onset of stroke. Subjects' mean C-ADL was 62.3 points (standard deviation 16.5) and mean SSQOL was 149.9 points (standard deviation 35.7).
In the multiple regression analysis, the R 2 of the final model was 0.23 and the explanatory power of the model was 23% with the variance inflation factors (VIF) being all less than 10, proving that there was no problem with multi-collinearity among the independent variables. In the bivariate analysis, a significant positive relationship was found for C-ADL with SSQOL (B=0.54, t=13.28, p<0.05). In model 1, after adjusting for age, sex, final education, the average monthly income of households, marital status, drinking and smoking, the relationship of C-ADL with SSQOL was maintained (B=0.48, t=3.32, p<0.05). In model 2, after adjusting for all the compounding variables, C-ADL had a significant positive relationship with SSQOL (B=0.46, t=3.11, p<0.05).

DISCUSSION
Although communication problems frequently occur due to the after-effects of stroke, there is a lack of studies of stroke patients' communication abilities in daily life. The present study investigated the relationship between elderly stroke patients' C-ADL and quality of life, and found that C-ADL had a significant positive relationship with quality of life.
Numerous studies have reported a relationship between ADL and quality of life. According to these studies, stroke patients' ADL is a significant variable predicting stroke patients' quality of life 13) , and the higher the functions of ADL, the higher the quality of life 14) . These results are similar to the results of the present study that higher stroke patients' ADL indicates higher quality of life.
As disabilities from stroke become chronic, inability to independently perform ADL, such as putting on clothes and eating for an extended period of time, not only causes helplessness and depression in stroke patients 14) , but also inflicts emotional pain, such as intellectual regression, despair and anxiety 10) . That is, functional disorders in daily life cause stroke patients to experience psychological pain and loss of social functions, and if these problems are prolonged, they are likely to cause deterioration in their quality of life and maladjustment in social relationships, changes in role and economic difficulties.
Although it is difficult to directly compare the results of preceding studies 10,13,14) with those of the present study, communication is likely to have a significant effect on quality of life, considering that it is an ability necessary for instrumental daily life. Especially, stroke patients experience deterioration of social functions due to limitation of communication, and when they have difficulty in understanding the meaning of what another party says, or in producing speech, even when they have clear consciousness, it is highly possible that they feel extreme frustration and depression 15) .
Nevertheless, therapeutic rehabilitation for stroke mainly focuses on physical rehabilitation, while linguistic, emotional and social rehabilitation tends to be ignored. As communication problems are likely to lower the quality of life by leading stroke patients to give up their will to live 16) , in order to enhance stroke patients' quality of life, it is necessary to consistently improve communication functions from the early stage after onset of stroke, and to extend support to reduce stroke patients' difficulties in leading their daily lives.
A limitation of this study was the exclusion of patients with severe aphasia, for whom test could not be conducted, therefore, caution should be taken in generalizing the results of this study. Also, since this study was a cross-sectional study, the results cannot be interpreted in causal relationships. Longitudinal studies will be required to verify causal relationships.
A significant positive relationship with SSQOL was found for C-ADL in this study. This result implies that it is necessary to enhance stroke patients' communication ability in daily living in order to raise their quality of life.