The indirect effects of cognitive function in the association between stroke and quality of life among older adults in a rural community: A cross-sectional study.
Mtambo M, Su T, et al. • Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation • 2026
Reduced cognition partly accounted for associations of stroke with reduced physical QOL and greater pain interference among older adults in a rural Malaysian community.
Key Findings
Results
An indirect association between stroke and physical quality of life via cognitive function was observed.
The indirect effect estimate was β = -0.67 (95% CI -1.30 to -0.18; BH-adjusted p = 0.018).
This indicates that lower cognitive function statistically mediated the relationship between stroke history and reduced physical QOL.
A residual correlation of ρ = 0.16 between cognition and physical-QOL models would attenuate this association to the null, indicating sensitivity to modest unmeasured confounding.
Models were adjusted for sociodemographic and vascular factors and accounted for matching and multiple testing using Benjamini-Hochberg correction.
Results
Reduced cognitive function partly accounted for the association between stroke and greater pain interference with daily life.
The indirect association was β = -0.051 (95% CI -0.113 to -0.009; BH-adjusted p = 0.028).
This finding emerged from an item-level analysis of the physical QOL domain.
The direction of the effect indicates that stroke survivors with lower cognition reported greater interference of pain in daily activities.
Results
The indirect association between stroke and physical QOL via cognitive function did not differ significantly by sex.
The moderated mediation index was β = -0.49 (95% bootstrap CI -1.48 to 0.18; p = 0.164).
There was no statistically significant evidence that the indirect effect differed between males and females.
The sample was 41.6% female and 58.4% male.
Methods
Among 596 participants aged 60 years and older in rural Malaysia, 149 (approximately 25%) reported a history of stroke.
The mean age of participants was 70.36 years (SD 6.81).
Stroke survivors were matched 1:3 with non-stroke participants by propensity scores based on age, sex, and education.
The study was conducted in Segamat, Malaysia, using a cross-sectional survey design.
Cognition was assessed using the Identification and Intervention for Dementia in Elderly Africans (IDEA) instrument, and QOL was assessed using the WHOQOL-BREF.
Results
No statistically significant indirect associations between stroke and other QOL domains (social, environmental, psychological), overall QOL, or overall health via cognition were reported as significant findings.
The study examined four QOL domains, overall QOL, and overall health as outcomes.
Only the physical QOL domain and its pain interference item showed statistically significant indirect associations via cognition after BH adjustment for multiple testing.
Multiple testing correction using the Benjamini-Hochberg procedure was applied to control for false discovery rate.
What This Means
This research suggests that among older adults (aged 60 and above) living in a rural area of Malaysia, difficulties with thinking, memory, and decision-making help explain why stroke survivors tend to report lower physical quality of life compared to people who have not had a stroke. The study compared 149 stroke survivors with 447 similar non-stroke participants and found that the cognitive difficulties associated with stroke appear to be a pathway through which stroke leads to worse physical wellbeing and greater interference of pain in daily activities. This indirect link through cognitive function was found equally in men and women.
However, the findings come with an important caution: the study acknowledges that even a modest degree of unmeasured factors — things the researchers could not account for — could reduce this apparent relationship to zero. Additionally, because this was a snapshot-in-time (cross-sectional) study, it is not possible to confirm the order in which stroke, cognitive decline, and reduced quality of life occur. The authors call for longer-term studies that follow people before and after a stroke to better establish how these factors influence each other over time.
Practically, this research suggests that cognitive difficulties and pain management could be important targets for community-based support services aimed at improving the lives of stroke survivors. Addressing cognitive challenges — such as problems with memory, understanding, and decision-making — in stroke survivors may have downstream benefits for their physical wellbeing and ability to cope with pain in everyday life.
Mtambo M, Su T, Mohan D, Warren N, Quek K. (2026). The indirect effects of cognitive function in the association between stroke and quality of life among older adults in a rural community: A cross-sectional study.. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation. https://doi.org/10.1007/s11136-026-04379-6