Introduction
Natural aging is a process of age transition that is accompanied by declines in physical, sensory, psychomotor, and cognitive states. It is predicted that 30% of the Iranian population will be old by 2031. This transformation brings social, economic, and health challenges, in addition to increasing the prevalence of chronic diseases. The risk of stroke doubles at the age of 55-85; 21-38% of whom experience aphasia. Aphasia in older adults leads to multiple communication problems, resulting in decreased quality of life (QoL). This study aimed to examine the relationship between QoL and the severity of aphasia in Iranian older people with aphasia (PWA).

Methods & Materials
This cross-sectional study was conducted in 2022-2023 with 56 Persian-speaking PWA aged 60 or older. The inclusion criteria were a minimum score of 25 on the Persian diagnostic aphasia battery (P-DAB-1), being a Persian speaker or proficient in Persian (for bilingual participants), no prior history of psychiatric and cognitive issues before the stroke, at least one month post-stroke, and confirmation of physiological stability by the physician. Based on the obtained aphasia quotient (AQ-1), patients were classified into three severity groups: mild (n=21), moderate (n=14), and severe (n=21). It is important to note that a higher AQ-1 score indicates less severe aphasia. Two age groups: Younger elderly (60-69 years old, n=31) and middle-aged (≥70 years; n=25); and three groups based on the time post-stroke: early subacute (1-3 months; n=14), late subacute (3-6 months; n=11), and chronic (> 6 months; n=31) were also used.  Participants were mainly from Tehran, selected using a non-probability sampling method.
The stroke and aphasia QoL scale-39 (SAQOL-39) was completed by the participants. To facilitate the self-reporting process, language facilitators and other supportive communication strategies were utilized. The interviewer presented the questionnaire to the patient, read the questions aloud, and recorded their responses. Descriptive statistics, including Mean±SD, were used to describe the characteristics. The normality of data distribution was assessed using the Shapiro-Wilk test. One-way analysis of covariance (ANCOVA) followed by Tukey’s post hoc test was applied for between-groups comparisons. ANCOVA was used, treating age and time post-stroke as independent variables and QoL as the dependent variable. Additionally, the Pearson correlation test was utilized to examine the relationships between the study variables. Data analysis was conducted in SPSS software, version 26 with a significance level set at 0.05.

Results
The mean age of the participants (including 53.6% males and 46.4% females) was 68.61±6.95 years, with 44.6% classified as young elderly and 55.4% as middle-aged elderly. The mean AQ-1 was 59.72±21.854, and the mean post-onset time was 18.30±26.68 months (Ranged 1-120 months). The participants were 82.14% non-fluent Persian and 17.46% fluent.
The results of the one-way ANOVA showed a significant difference in the total SAQOL-39 score between aphasia severity groups (F=4.06, P<0.05). The mean total score in individuals with severe aphasia was 2.45; with moderate aphasia, 3.08; and with mild aphasia, 3.20. To compare the groups in pairs, Tukey’s post hoc test was used. The results indicated significant differences in the communication domain score between the mild and severe severity groups (F=7.8, P<0.05) and in the physical domain score between moderate and severe groups (F=3.53, P<0.05), while no statistically significant differences were observed in other domains including psychosocial and energy (P>0.05).
ANCOVA was conducted to examine the effect of age and post-stroke time on the QoL of older PWA. The results indicated that age (P=0.466) and post-stroke time (P=0.209) did not have a significant impact on the QoL. The effect size (Eta squared=0.07) indicated a negligible effect of these variables on the QoL.
Pearson’s correlation test results showed a significant positive relationship between the AQ-1 score and the mean total and domain scores of the SAQOL-39. A strong correlation was observed between the communication domain and the severity of aphasia (r=0.51, P<0.001), a moderate correlation between the total score (r=0.37, P<0.001) and psychosocial domain (r=0.36, P<0.001) and the severity of aphasia, and weak correlation between the physical and energy domains (r=0.23 for both, P<0.001) and the severity of aphasia. 

Conclusion
The obtained correlation between aphasia severity and QoL domains in Iranian older PWA in our study indicates that with the increase in the severity of aphasia, the QoL of older people with stroke-induced aphasia declines. These findings highlighted the importance of considering the severity of aphasia in assessing the QoL of older adults, which may serve as guidance for therapeutic and supportive interventions. Additionally, they may be useful for treatment/discharge decision-making. However, further research is needed to explore the links between the severity of aphasia and various dimensions of QoL, and to develop more effective treatments in this area.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.1400.334).

Funding
This study was funded by the Social Determinants of Health Research Center at the University of Social Welfare and Rehabilitation Sciences.

Authors' contributions
Contributed to study design and conceptualization, data collection, data analysis and interpretation, writing, and review: Zahra Babaei and Fariba Yadegari; Contributed to the statistical analysis: Mohsen Vahedi.

Conflicts of interest
The authors declare no conflicts of interest.

Acknowledgements
The authors would like to thank all participants and the personnel of the Rofeideh Rehabilitation Hospital and the Tabassom Stroke Rehabilitation Center for their cooperation and assistance in this research.
 

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