Rehabilitation needs of older adults with cognitive impairment following ischemic stroke: a qualitative study

Abstract

Aim

To explore the self-reported experiences of older adults with post-stroke cognitive impairment following ischemic stroke and their needs for cognitive and functional recovery, rehabilitation information, psychological support, daily-life assistance, and healthcare services. The study aimed to generate evidence for improving rehabilitation support and patient outcomes.

Methods

A qualitative descriptive study was conducted using semi-structured interviews. From May to July 2025, older adults with ischemic stroke and post-stroke cognitive impairment were recruited from the Departments of Neurology and Rehabilitation of a tertiary hospital in Jiangsu Province, China. The interviews explored participants’ understanding of cognitive impairment and rehabilitation, psychological responses, difficulties encountered in daily life and treatment, experiences of seeking help, expectations of healthcare support, and hopes for future recovery.

Results

A total of 12 participants were interviewed and included in the final analysis. Data saturation was achieved during data collection. The participants had a mean age of 72.3 ± 5.6 years; 10 were male and 2 were female. Three themes were identified. The first theme was shared and supported rehabilitation goals, referring to needs recognized by both patients and healthcare professionals. The second theme was patient-identified needs beyond current support, describing needs expressed by patients but not routinely addressed. The third theme was undisclosed concerns and potential health risks, encompassing distressing concerns that participants hesitated or were unable to express openly.

Conclusion

Older adults with post-stroke cognitive impairment have multidimensional rehabilitation needs that may not always be expressed spontaneously or clearly. Rehabilitation should therefore adopt a patient-centred, holistic, and cognitively appropriate approach that integrates cognitive and physical recovery, symptom management, health education, emotional support, family involvement, social participation, and identity adjustment. Coordinated support across hospital, community, home, and family settings is essential to ensure continuity of care and promote long-term independence and well-being.

1. Introduction

Stroke remains one of the leading causes of death and disability worldwide, and its overall burden continues to increase with population aging and growth [1]. Ischemic stroke, which results from thrombosis or embolism leading to reduced cerebral blood flow, is the most common type of stroke and accounts for more than 60% of incident stroke cases globally [1,2]. Older adults are particularly vulnerable to ischemic stroke and its long-term consequences. Although stroke incidence declined among individuals younger than 60 years between 1990 and 2019, it continued to increase among those aged 60 years and older, highlighting the growing need to address ischemic stroke and its sequelae in the elderly population [3,4]. Among these sequelae, post-stroke cognitive impairment is a common and clinically important condition that may reduce patients’ capacity for functional recovery and social participation, as well as their quality of life [5].

A 2026 systematic review and meta-analysis reported that the overall prevalence of post-stroke cognitive impairment among first-ever stroke patients was approximately 46%. The prevalence was approximately 44% among patients with ischemic stroke and approximately 44% among patients aged over 60 years [6]. It affects multiple cognitive domains, such as memory, attention, executive function, language, and information processing. Beyond its cognitive manifestations, post-stroke cognitive impairment can adversely affect activities of daily living, social participation, emotional regulation, and treatment adherence, thereby increasing the complexity of rehabilitation for older stroke survivors [7–9]. Post-stroke cognitive impairment is a common neurological complication of stroke. A 2026 systematic review and meta-analysis involving 11 studies and 7,048 patients with first-ever stroke reported a pooled prevalence of post-stroke cognitive impairment of 46% (95% CI, 36%–57%) at approximately 3 months after stroke [6]. Similarly, a large UK multicentre longitudinal study found that cognitive impairment affecting at least one cognitive domain was present in 38.3% of patients at 1 year and 34.7% at 2 years after stroke [10].

Rehabilitation is defined as a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment [11]. It can improve independence and support participation in everyday activities and meaningful social roles. Globally, approximately 2.4 billion people live with health conditions that could benefit from rehabilitation; however, in some low- and middle-income countries, more than half of those requiring rehabilitation do not receive it [11]. In China, the age-standardized prevalence of stroke and stroke-related years lived with disability increased between 1990 and 2019, indicating a substantial and growing need for rehabilitation services [12]. Although the age-standardized burden of ischemic stroke among older adults is projected to decline, the absolute number of cases is expected to increase by 2030 because of population ageing [3].

Previous qualitative studies have identified challenges across different stages and aspects of stroke rehabilitation. Patients receiving care in stroke units regarded physical activity and involvement in the rehabilitation process as important for regaining independence [13]. Patients transitioning from stroke units to skilled nursing facilities and subsequently returning home reported limited involvement in rehabilitation planning and goal setting, insufficient information, and variable levels of rehabilitation support across the care pathway [14]. Similarly, older Chinese patients with stroke described emotional distress, barriers to participation in rehabilitation decision-making, delegation of decisions to family members or healthcare professionals, and decision fatigue associated with a lack of continuity in the rehabilitation healthcare system [15]. Other studies have found that new problems may become apparent after patients return home and that stroke survivors and their caregivers may encounter fragmented follow-up, insufficient information, limited community rehabilitation resources, and psychosocial stress [16,17].

Collectively, these studies demonstrate that stroke rehabilitation needs extend beyond physical and functional recovery to include information provision, participation in rehabilitation planning, continuity of care, access to community resources, and psychosocial support. However, existing studies have primarily focused on general stroke populations or specific aspects of rehabilitation, such as physical activity, care transitions, community-based services, and rehabilitation decision-making. Limited evidence is available regarding the self-reported experiences and perceived rehabilitation needs of older adults with cognitive impairment following ischemic stroke. Consequently, the rehabilitation needs of this population remain insufficiently explored, particularly from the patients’ own perspectives.

To address this gap, this qualitative study aimed to explore the self-reported experiences and perceived rehabilitation needs of older adults with cognitive impairment following ischemic stroke. The findings may inform more patient-centred needs assessment, care planning, and rehabilitation support for this population.

2. Methods

2.1. Design

This study was a cross-sectional qualitative study conducted from May to July 2025 in the Department of Neurology and the Department of Rehabilitation of a tertiary hospital in Jiangsu Province, China. Purposive sampling was used to recruit patients undergoing rehabilitation treatment as participants. Data were collected through semi-structured interviews to gain an in-depth understanding of patients’ needs and experiences during the rehabilitation process. Data were analyzed using content analysis. The interview transcripts were coded, categorized, and synthesized to identify key themes and subthemes.

2.1.1. Participants and setting

This study used a purposive sampling strategy to recruit participants. The specific inclusion criteria were as follows:

1. diagnosis of ischemic stroke;

2. age ≥ 60 years;

3. a Montreal Cognitive Assessment (MoCA) score between 10 and 26;

4. ability and willingness to provide informed consent.

The MoCA assessment was conducted before discharge as part of the routine pre-discharge rehabilitation evaluation. In this hospital, MoCA is routinely administered by rehabilitation therapists from the Department of Rehabilitation Medicine. In the present study, MoCA was assessed by trained interviewers under the guidance of rehabilitation therapists to ensure consistency and accuracy in participant screening.

Participants were excluded if they:

1. had severe hearing or language impairments that would impede cognitive assessment;

2. had a diagnosis of cognitive impairment prior to their stroke;

3. suffered from severe comorbid conditions such as terminal malignancy, advanced cardiovascular disease, or end-stage organ failure.

A total of 12 participants meeting the eligibility criteria were interviewed. Their mean age was 72.3 ± 5.6 years; 10 were male and 2 were female.

2.2. Data collection

This study used semi-structured interviews to collect data. The interview guide was initially developed by the research team through a systematic literature review and group discussions. Before written informed consent was obtained, the researcher explained the study purpose, procedures, voluntary nature of participation, confidentiality, audio recording, and the right to withdraw at any time in plain language. Potential participants were then asked to indicate whether they understood the information and whether they were willing to participate. Only patients who were able to understand the basic study information, communicate their willingness to participate, and provide written informed consent were included. Participants who were unable to understand the study information or express a clear and consistent willingness to participate were not recruited.

Prior to the formal interviews, we invited two inpatients who met the inclusion and exclusion criteria to participate in preliminary interviews. After the pilot interview, the research team held an internal discussion to refine the interview guide. The discussion involved a professor of geriatrics, a rehabilitation therapist, a neurologist, a professor of nursing, and several graduate students. Based on the pilot interview responses and multidisciplinary feedback, the wording and sequence of some questions were revised to make them clearer, more specific, and more suitable for participants with cognitive impairment. All interviews were conducted in Chinese. The final formal interview guide included the following questions:

1. The primary purpose of this interview is to understand the rehabilitation needs of patients with post-stroke cognitive impairment. Could you describe your understanding of post-stroke cognitive impairment?

2. Could you discuss your understanding of post-stroke rehabilitation?

3. Could you share with us the needs you have experienced after the onset of cognitive impairment? Feel free to approach this from any aspect.

4. Can you describe how you felt emotionally after your stroke and during your treatment and rehabilitation?

5. What difficulties have you encountered since your stroke? Have you actively sought any help or support?

6. During your treatment, what type of support or help would you most like healthcare providers to offer?

7. What goals and expectations do you have for the future?

8. Do you have any suggestions or thoughts on rehabilitation services?

Given the participants’ cognitive impairment, several strategies were used to facilitate communication during the interviews. Interview questions were phrased in simple language, and the interviewer repeated or rephrased questions when necessary. Participants were given sufficient time to respond. During the interviews, the interviewer clarified ambiguous responses in real time and avoided leading questions.

During the recruitment and interview process, patients with ischemic stroke first underwent cognitive assessment using the MoCA. Patients who met the inclusion and exclusion criteria were then invited to participate in further interviews. Several patients were excluded during this process. Specifically, two patients refused to proceed to the interview stage during the MoCA assessment. After cognitive assessment, two patients who met the cognitive eligibility criteria were excluded from further participation. In addition, one interview was discontinued because of family intervention; the family member considered that the interview had lasted too long and might cause fatigue for the patient. Most participants sought medical care because stroke-related symptoms had already interfered with their daily activities. Therefore, although many interviews were conducted shortly after stroke onset, the participants had already directly experienced the impact of stroke on their physical functioning and everyday lives. The sample also included two participants attending follow-up visits and one participant in whom a recurrent cerebral infarction was detected during a routine annual medical check-up; these participants had experienced the effects of stroke over a longer period. Ultimately, 12 patients were interviewed and included in the final data analysis, with data saturation achieved during data collection [18]. Each interview was conducted with one patient and two researchers present, including one faculty member and one graduate student.

2.3. Data analysis

Given that elderly patients with cognitive impairment may experience memory decline, after each interview, the two researchers immediately confirmed the content with the interviewee. After each interview, the recording was transcribed on the same day by the graduate student among the interviewers, and the transcription’s accuracy was then checked by the faculty member. Nvivo 20.0 software was subsequently used to identify semantic units, condense the data, and assign initial codes. These codes were then categorized into different categories and subcategories based on semantic similarity and conceptual relevance. To avoid coding errors, all codes were first reviewed by one researcher and then independently rechecked by another researcher with specialized training. Any discrepancies were resolved by a third researcher with extensive coding experience.

3. Results

A total of 12 patients’ interview data were included in the analysis, and participants were assigned identification codes from P1 to P12 according to the order of the interviews. Table 1 presents the demographic characteristics of the participants.

Table 1.

Patient characteristics (N = 12).

ID	Gender	Age	Education Level	MOCA	Residence	Time since stroke onset	Comorbid chronic diseases	Barthel Index	Main symptoms
P1	Female	76	Primary school or below	13	Urban	>2 months	2	40	Leg mobility impairment, cough, and memory decline
P2	Male	76	Associate degree	23	Urban	5 days	1	65	Limb weakness and memory decline
P3	Male	70	Associate degree	24	Urban	13 days	1	70	Dizziness and limited lower-limb mobility
P4	Male	61	Junior high school	22	Urban	9 days	1	85	Memory decline and dizziness
P5	Male	64	Junior high school	19	Urban	3 days	1	60	Lower-limb weakness and memory decline
P6	Male	70	Senior high school	19	Urban	5 days	2	90	Memory decline
P7	Male	77	Senior high school	20	Urban	4 days	1	70	Memory decline and hand dysfunction
P8	Male	77	Primary school or below	10	Countryside	>6 months	2	85	Dizziness and memory decline
P9	Female	71	Primary school or below	14	Urban	8 days	1	45	Memory decline
P10	Male	80	Junior high school	18	Countryside	2 days	1	40	Memory decline, headache and leg numbness
P11	Male	73	University	24	Urban	2 weeks	1	60	Urinary incontinence, numbness of the hands and feet and memory decline
P12	Male	72	Primary school or below	13	Urban	8 days	2	55	Memory decline

MoCA: Montreal Cognitive Assessment.

3.1. Shared and supported rehabilitation goals

This theme reflected rehabilitation priorities that were recognized by both participants and healthcare professionals and had received varying degrees of support during rehabilitation. These priorities primarily involved cognitive and physical recovery, improvement in daily functioning, and guidance from healthcare professionals.

3.1.1. Cognitive function maintenance and recovery

Participants reported specific manifestations of cognitive decline of varying severity. Core concerns centered on preventing further deterioration, maintaining, and improving memory function. Their shared needs converged on memory, driven primarily by tangible losses in everyday life, anticipatory anxiety about disease, and the desire to preserve identity and relationships. In sharing needs related to cognitive function, certain respondents showed a misunderstanding, mixing up Alzheimer’s disease and post-stroke cognitive impairment.

“Please help me improve my cognitive function… I used to have a good memory and strong drawing skills, but now I struggle to draw even basic cubes.” (P3)

“My main need is to improve my memory. I don’t want to have Alzheimer’s.” (P4)

“My memory has worsened compared to before.I don’t expect it to get much better; I just want to maintain my current level and avoid getting worse.” (P5)

“I used to be a top-performing student at school, but now I feel mentally slower and my memory is very poor. I want to return to how I was before I got sick.” (P7)

“I hope to enhance my memory so that I do not forget my family members.” (P10)

3.1.2. Functional recovery and symptom relief

Participants expressed a clear need for both functional recovery and effective symptom management following stroke. Improving stroke-related sequelae, particularly motor and cognitive impairments, was a primary concern. In addition, participants highlighted the burden of coexisting symptoms, including persistent cough, dizziness, and urinary incontinence.

“My main concern is my leg and the cough. After the stroke, my leg stopped moving and feels like it is jumping, and the persistent cough has been disrupting my sleep at night.” (P1)

“My leg doesn’t work, and my brain isn’t good either. I hope everything can recover.” (P2)

“I came primarily to address my dizziness.” (P3)

“I just need to exercise more, even my hands need exercise… It’s just so inconvenient, it’s hard to do things like eating or picking things up.” (P7)

“I hope my legs and memory can be treated and improved.” (P10)

“I experience urinary urgency with urge urinary incontinence and often leak before I reach the bathroom. It happens often, it’s upsetting, and I want it fixed.” (P11)

3.1.3. Restoration of Self-Care Ability and Independent Living

Participants consistently expressed a strong desire to regain independence in daily life. The ability to perform self-care without relying on others was regarded as a key goal, even if full recovery to pre-stroke functioning was not expected. Many participants emphasized difficulties in basic activities such as dressing, which increased their dependence on others and reduced their sense of autonomy. Being able to manage daily routines independently and return to a normal life was closely linked to their sense of dignity and well-being.

“I need to live independently; it’s enough if I can maintain my ability for self-care” (P1)

“I need help from others when getting dressed right now. I hope I can do it by myself” (P2)

“I’m not talking about getting back to where I was before, but at least I want to be able to take care of myself and live a normal life.” (P3)

“I just want to manage daily life on my own, and to be able to enjoy myself.” (P5)

“I want to live independently.” (P8)

3.1.4. Clarification of the disease cause

Participants described uncertainty regarding the cause of their stroke and expressed a need for clearer explanations about its onset. For some patients, understanding the cause of the disease was closely linked to their expectation of receiving targeted treatment.

“I just want to figure out the cause of this disease as soon as possible, so I can get targeted treatment.” (P3)

“I want to know what caused my stroke and why it happened to me.” (P10)

3.1.5. Emotional support

One participant described feelings of loneliness and low mood during hospitalization due to the lack of improvement in their condition, while also noting that the attending physician had provided emotional support through conversation.

“Some time ago, my attending physician noticed I was in low spirits and came to talk with me… I’ve been hospitalized for some time, and my condition hasn’t improved, so I feel very lonely here” (P3)

3.1.6. The need to avoid repeating negative healthcare experiences

During the interview, the participant repeatedly told the researcher about an incident in which healthcare staff at the nursing home forgot to administer insulin. The participant expressed a strong desire to maintain stable blood glucose levels and to avoid experiencing similar negative healthcare events again.

“I need daily insulin injections. A few days ago, I went back to the hospital I usually visit for routine care, but the doctors took my insulin and managed it themselves. However, they did not give me any injections at all, leaving me without insulin for two days… During this hospitalization, I expect the medical staff to maintain my blood glucose at a normal level. I do not want this to happen again.” (P12)

3.2. Patient-identified needs beyond current support

This theme captured needs that participants clearly expressed but that were not routinely or sufficiently addressed within existing rehabilitation services. These needs included individualized rehabilitation information, continuity of professional support, and assistance with adapting to cognitive difficulties in daily life.

3.2.1. Timely communication and feedback on health condition information

Patients delineate a coherent sequence of information needs concerning disease nature, test results, and the treatment plan; nevertheless, essential links are not communicated promptly or clearly.

“This is my third day in the hospital, and my cough still hasn’t been treated. No medication has been prescribed, and no one has told me how it will be treated.” (P1)

“I’d like to know how my stroke can be treated and what is happening with my health.” (P2)

“Can this disease be cured?” (P6)

“I do not know what condition I have.I underwent diagnostic tests, yet I have not been able to access the results.We ought to understand the condition and initiate timely treatment; yet, as things stand, we cannot even ascertain the nature of the disease.” (P10)

“I hope they get closer to us patients, so we can talk to them about anything.” (P11)

3.2.2. Needs related to disease treatment and rehabilitation services

Regarding subsequent rehabilitation, some participants preferred to continue rehabilitation in the hospital, whereas others wished to perform rehabilitation at home. For hospital-based rehabilitation, participants emphasized proximity, accessibility, and cost. For home-based rehabilitation, they focused more on the need for guidance on rehabilitation methods and the availability of exercise facilities in their residential communities. However, some participants reported limited understanding of the subsequent rehabilitation process, indicating unmet needs for pathway guidance, professional instruction, and community-based rehabilitation support.

“I want to do rehabilitation at home, but I don’t know how to do it. If someone could teach me, that would be even better.” (P2)

“Where should I do my rehabilitation?” (P3)

“How should I do rehabilitation, and what are the costs?” (P8)

“I have a suggestion: install exercise equipment in the community, more of them, so I can exercise by myself.” (P11)

3.2.3. Social and recreational needs

The participants indicated that their goals extend beyond survival and the maintenance of basic physiological functions. They articulated a clear desire to return to their previous way of life, to once again be someone who can be invited by friends, go out freely, engage in leisure activities, and exercise agency over everyday routines. Specifically, participants emphasized the importance of maintaining their existing social ties and preserving an active role within their social networks, rather than being positioned passively as patients who are merely cared for.

“I want to stay in touch and keep in contact with my former colleagues and classmates so we can hang out, play cards, talk, and spend time together.” (P2)

“I have many friends. I also wish to participate in social activities… If my health were better, my friends would certainly invite me to go out and spend time with them.” (P3)

“I had a stroke, now I can’t smoke, drink, or go out. I feel like all the fun is gone. I used to be able to jump and dance, and play whatever I wanted. “ (P5)

“Travel around and enjoy life.” (P8)

“I am too old now, and no one is willing to spend time with me anymore because they are afraid that something might happen and they would be held responsible… Still, I want to live the way I used to, to eat, drink, have fun, do whatever I want to do, and enjoy life.” (P10)

3.2.4. Psychosocial needs and self-worth reconstruction

Participants described a range of psychosocial concerns during rehabilitation. Many participants expressed a strong sense of family responsibility and hoped to maintain their family roles, such as caring for family members, doing housework, and contributing to family harmony. Some participants also reported a need for emotional understanding and practical support from their families. Participants described changes in their autonomy, dignity, and family or social roles following stroke and associated functional decline. Some felt that they were no longer able to make decisions for their families, while others reported that their needs were not fully recognized. Several participants reflected on their previous work and social contributions and associated these experiences with their sense of personal value. After stroke, limitations in mobility and daily functioning made some participants feel less useful than before. Emotional distress was also reported during rehabilitation, including fear, anxiety, loneliness, low mood, and concerns about disease progression. These emotional experiences were often described together with physical limitations, such as dizziness, walking difficulties, reduced exercise capacity, and general weakness. Participants also mentioned practical needs during hospitalization, including family support and meals suitable for older adults.

“Now that I am old, when I ask others for help, no one responds to me anymore… and I am no longer able to make decisions for my family….I wish to continue with rehabilitation, but my family is unwilling because it would require additional financial expenditure.” (P2)

“I’m scared… What if my condition gets worse? I still have dizziness, walking is a big problem, I can’t walk much, and can’t exercise, my brain isn’t working well, and my body’s not doing well.” (P3)

“To continue taking good care of my family and to maintain harmony at home… that is my greatest wish…Although I am officially retired, I continue to work… Just a few days ago, I even went to Beijing specifically to receive and assist petitioners. That is work, is it not? Wherever there is a need, I go and provide help.” (P4)

“When I was young, during my working years, I felt my life had meaning… I contributed to the country. Now I don’t have any contributions left.” (P7)

“My biggest hope is to cook, do some housework, and cook for my wife. I make really good meals…The most meaningful thing I did was jumping in the Grand Canal of Beijing-Hangzhou, a provincial-level project. I was a leader, I led the team… there were crowds of people, all jumping in to clear the canal. I made a contribution, it reflects my life’s value… now I’m retired, old, and can’t move anymore, I can’t set a good example for others.” (P10)

“The most meaningful thing is my granddaughter. I love my granddaughter, and when she comes to see me, I’m very happy… I just hope I can recover from my stroke and that my children, daughter-in-law, and son-in-law will help me… I hope they understand us. Don’t look down on us when we’re sick, be more filial. My daughter-in-law even hit my wife and scolded me…One more thing is the food in the cafeteria. As elderly people, we have bad teeth and can’t chew the vegetables properly. I can’t chew the greens, and the meat is also hard to eat.” (P11)

3.2.5. Economic needs

Some participants reported substantial financial burden due to high medical expenses, insufficient insurance reimbursement, and additional family financial responsibilities.

“I am under financial pressure, mainly because my younger son is unemployed and I need to support him. Last month, I spent 10,000 yuan to help him” (P7)

“The financial burden is substantial. Although part of the expenses can be reimbursed, the daily hospitalization costs remain high for my family, resulting in considerable out-of-pocket payments; it would be easier if my pension were higher.” (P8)

3.3. Undisclosed concerns and potential health risks

This theme described distressing concerns that participants hesitated, avoided, or found difficult to express directly. These concerns were related to emotional distress, fear of dependency, perceived burden on family members, and potential risks to health or safety.

3.3.1. Family companionship

Several participants described limited family support during rehabilitation because their children or spouses were occupied with work, childcare, or household responsibilities. Although they hoped to receive companionship and visits from family members, they also expressed reluctance to ask for help, as they did not want to become a burden to their families. Some participants stated that they had to rely mainly on themselves during recovery.

“I don’t need them to accompany me much, it’s not easy for them either. As long as my children are doing well, that’s enough.” (P2)

“My son and daughter-in-law both work in the education sector, and they are very busy. My wife also has to help take care of the grandchildren, so I am often at home by myself. She sometimes comes back for meals and will stay with me for a while. I still hope that my relatives and siblings can come to visit me, but they all have their own responsibilities. I never ask them, as I do not want to be a burden.” (P3)

“My kids are really busy, and my wife still has to take care of the house and me, it’s tiring, I don’t want to burden the kids too much.” (P6)

“My children now have their own businesses and jobs, and they are not able to provide much help. I still have to rely on myself.” (P12)

3.3.2. Enhance health awareness and provide standardized intervention support

Participants described different forms of self-management during rehabilitation. One participant reported that although family members provided dietary supervision, they still found it difficult to follow dietary restrictions and sometimes ate high-fat foods secretly. Another participant described engaging in regular morning walks and other self-initiated physical activities, believing that these behaviors were beneficial for blood glucose control and cerebrovascular health.

“My wife is very concerned about my health, especially my diet. I can’t eat fried food, and she won’t let me eat fried dough sticks or pancakes. I still sneakily eat fried rice with a lot of lard, and I love to eat noodles with pork fat. I can eat noodles three times a day, and sometimes I sneak out to eat.” (P3)

“I know that walking in the morning is good for my blood sugar, so I often go for a walk in the morning and move my waist. I also bump my body against a pole, and I believe this movement is beneficial for the blood vessels in the brain.” (P11)

3.3.3. The need to reconcile the former and current self and the need for protection from a threatening future

Some participants described a perceived gap between their previous abilities and their current abilities following stroke. One participant recalled being physically strong, professionally capable, and skilled in architectural drawing, but felt that declining health and memory had made them very different from their former self. Another participant expressed reluctance to think about future goals or expectations because of fear of disappointment and emotional distress.

“I was once exceptional, strong in body and able to work well into my sixties. Now my health has declined significantly, and my memory fades a little more each day. The person I am today is far removed from who I used to be.When I was in school, I excelled at drawing architectural design plans, and I was the top student in my class. Now, however, I find that I can hardly draw a proper plan at all.” (P3)

“What goals or expectations do I have for the future?… I don’t want to think about it, I don’t dare think about it, I’m afraid of disappointment, I’m afraid that my dreams won’t come true, it’s just really upsetting.” (P5)

3.3.4. The ability and awareness to articulate one’s full symptom experience

One participant reported experiencing shoulder pain during stroke treatment but did not inform the doctor, as they regarded stroke as the primary focus of medical care.

“I have shoulder pain, but I didn’t tell the doctor. I’m being treated for a stroke, so I didn’t mention my shoulder pain.” (P4)

Across the interviews, participants with lower MoCA scores tended to express more concrete and immediate needs, whereas those with higher MoCA scores provided broader and more reflective accounts, including psychosocial, emotional, and future-oriented needs.

4. Discussion

This study aimed to explore the self-reported experiences and expressed rehabilitation needs of older adults with post-stroke cognitive impairment following ischemic stroke, with the intention of generating insights that may inform improvements in rehabilitation conditions and contribute to better patient outcomes. By considering patients’ accounts alongside healthcare professionals’ treatment plans, we identified three categories of rehabilitation needs. Taken together, these findings demonstrate the multidimensional nature of rehabilitation needs after stroke, encompassing functional and symptom-related recovery, information exchange, and psychosocial support, consistent with previous evidence [19]. The findings extend current understanding by showing not only what rehabilitation needs patients expressed, but also how cognitive status may have influenced the expression of these needs. Participants with lower MoCA scores tended to describe concrete and immediate concerns related to physical symptoms and daily functioning, whereas those with higher scores were more likely to articulate psychosocial, emotional, and future-oriented needs. This pattern should not be interpreted as indicating that patients with lower cognitive function had fewer or less complex needs. Rather, cognitive impairment may have limited their ability to recognise, organise, and verbalise complex, abstract, or implicit concerns. Healthcare professionals should therefore avoid relying solely on patients’ spontaneous verbal reports, particularly when working with individuals with greater cognitive impairment. Instead, adapted and flexible communication strategies—including proactive prompting, simplified wording, sufficient response time, repeated clarification and confirmation, and attention to non-verbal cues—should be used to support patients in expressing their experiences, preferences, and less readily articulated needs [20,21]. Overall, the findings support the development of a more patient-centred and integrated rehabilitation approach that addresses functional recovery, information needs, and psychosocial well-being while adapting assessment and communication to patients’ cognitive abilities.

The rehabilitation goals shared by patients and healthcare professionals reflected multiple needs, including maintaining or improving cognitive function, recovering from stroke-related impairments, relieving accompanying symptoms, preserving independence, understanding disease aetiology, and receiving emotional support. These priorities may reflect the combined effects of functional loss, uncertainty, and changes in identity and social roles after stroke [22], including among survivors 1–25 years post-stroke [23]. Cognitive and physical impairments can restrict participation in daily activities, making functional recovery and independence immediate rehabilitation concerns [22,24]. Accompanying symptoms should not, however, be overlooked. Persistent symptoms such as cough, dizziness, and urinary incontinence may interfere with daily functioning and well-being. Post-stroke urinary incontinence, examined in acute stroke care and among men averaging 2.8 years post-stroke, is often under-recognised as a rehabilitation goal despite its association with reduced independence, functioning, and health-related quality of life [25,26]. Patients’ needs for independence, explanations about disease aetiology, and emotional support may also reflect attempts to regain control and adapt to post-stroke uncertainty. Previous research has identified wide-ranging unmet needs after stroke, extending from health-related concerns to information, support, and community reintegration [27]. Moreover, among survivors interviewed more than 6 months after hospital discharge, unclear communication and limited patient involvement in goal setting may result in rehabilitation plans that do not align with patients’ needs [28]. Rehabilitation planning should therefore address functional, symptom-related, informational, and emotional priorities.

Participants’ rehabilitation priorities extended beyond symptom management and functional training to include disease-related information, continuity of care, social participation, family involvement, and emotional well-being. This broader pattern is consistent with evidence that loss of independence, uncertainty, and reduced community participation are important aspects of post-stroke recovery [22]. Participants’ need for timely and understandable information also accords with findings from older survivors of ischaemic stroke at least 1 month post-stroke who experienced difficulties accessing and evaluating health information and required professional guidance [29]. Uncertainty about post-discharge rehabilitation pathways further highlights the importance of coordinated transitional care. Early supported discharge, transitional care, and eHealth-supported models have been examined as approaches to maintaining support across hospital and home settings [30,31]. Rehabilitation planning should therefore consider social participation and independence alongside functional recovery. Family involvement may be important but requires careful communication, as shown in interviews conducted within 2 weeks of admission for major stroke, particularly when patients’ preferences are unclear or difficult to express [32]. Finally, among survivors 2 weeks to 1 year after a first stroke, emotional disturbances and perceived control were associated with post-stroke quality of life, supporting the inclusion of psychosocial assessment and support in rehabilitation planning [33].

The findings also revealed relational and emotional needs that were not always directly articulated. Although participants often described themselves as independent, some appeared to downplay their need for companionship and care because of their families’ work and caregiving responsibilities. This reluctance may reflect concerns about burdening others, which can restrict help-seeking and social participation after stroke, as reported among survivors 2 months to 13 years after their last stroke [34]. Emotional cues during the interviews nevertheless suggested continuing needs for companionship and support. Perceived social support is associated with coping and family resilience among stroke survivors [35,36]. Healthcare professionals should therefore assess relational and emotional needs proactively rather than relying solely on explicit requests. A knowledge–practice gap was also evident. Although participants had basic knowledge of exercise and dietary management, their practices were not always aligned with evidence-based recommendations. Knowledge alone may therefore be insufficient to sustain behavioural change. Structured guidance, follow-up, and professional support are particularly important during the transition from hospital to home, when discontinuities in care and limited supervision may reduce rehabilitation adherence [37]. Stroke also disrupted participants’ sense of identity, reflected in the perceived distance between their former and current selves. This finding is consistent with the concept of biographical disruption and with evidence that identity reconstruction after stroke involves an ongoing negotiation between bodily change and the sense of self [38,39]. Participants also reported symptoms selectively according to whether they considered them stroke-related, potentially leaving other concerns unaddressed. Collectively, these findings support a holistic and proactive rehabilitation approach that addresses relational, behavioural, identity-related, and broader health needs alongside functional recovery.

Although hospital-based rehabilitation provides an essential foundation for functional recovery, symptom management, education, and emotional support, it cannot guarantee the attainment of all rehabilitation goals. Many goals, particularly those related to independence, social participation, and psychosocial adjustment, require continued support after discharge through coordinated hospital, community, and family-based rehabilitation.

5. Limitations

This study has several limitations. First, participants were purposively recruited from a single tertiary hospital, and the sample included only 12 older adults with ischaemic stroke and post-stroke cognitive impairment. The findings may therefore be specific to this clinical setting and may not be transferable to other hospitals, communities, or regions with different rehabilitation resources and care practices. The small sample also limited comparisons by cognitive function, functional status, and stroke severity. Second, cognitive impairment may have affected participants’ memory, comprehension, self-awareness, and ability to articulate their rehabilitation needs. Participants with lower MoCA scores generally provided shorter and less detailed responses, which may have led to the underrepresentation of complex, emotional, psychosocial, or less readily expressed needs. Although communication was supported through simplified wording, repetition, clarification, and sufficient response time, the findings mainly reflect the experiences of patients with mild to moderate cognitive impairment who retained adequate communication ability. The needs of patients with severe cognitive or communication impairment may therefore not have been fully captured. Third, most interviews were conducted during the early stage of recovery, and the small, uneven distribution of participants across recovery stages limited comparison of immediate and longer-term rehabilitation needs. In addition, the cross-sectional design could not capture how these needs change over time. Future longitudinal and multicentre studies should include patients with different levels of cognitive and communication impairment and examine changes in rehabilitation needs from hospitalisation through community reintegration.

6. Conclusion

This study provides insight into the self-reported experiences and rehabilitation needs of older adults with post-stroke cognitive impairment following ischemic stroke. Their needs were multidimensional and interconnected, involving functional recovery, symptom management, accessible information, continuity of care, and psychosocial support. Cognitive status appeared to influence how these needs were recognised and communicated: participants with greater cognitive impairment tended to focus on immediate and concrete concerns, whereas those with better cognitive function more readily expressed emotional, social, and future-oriented needs. This difference may reflect difficulties in identifying and articulating abstract or implicit concerns rather than fewer or less complex needs.

Rehabilitation assessment should therefore not rely solely on spontaneous verbal reports. Healthcare professionals should use proactive, flexible, and cognitively appropriate communication to identify both clearly expressed and less readily articulated needs. A patient-centred and holistic approach should integrate cognitive and physical recovery, symptom management, health education, emotional support, family involvement, and social participation. Coordinated support across hospital, community, home, and family settings is also essential to promote continuity of care, independence, and long-term well-being. Future multicentre longitudinal studies should examine how rehabilitation needs vary across levels of cognitive and communication impairment and change throughout recovery.

Funding Statement

This study was supported by the National Natural Science Foundation of China (82300466, 82370517) and the China Postdoctoral Science Foundation (2025M781411).

Ethical approval

This study was approved by the Ethics Committee of the School of Nursing, Yangzhou University (approval number: YZUHL20240030) and strictly followed the principles of the Declaration of Helsinki.

Consent to publish

All participants signed a written informed consent form and agreed to use their anonymous citations for research publications.

Disclosure statement

No potential conflict of interest was reported by the authors.

Data availability statement

The data that supports the findings of this study are available from the corresponding author, Yuan Yuan, upon reasonable request.