Objective: To explore the status and influencing mechanism of alexithymia in elderly patients with multiple chronic conditions in the community. Methods: A convenience sample of 380 elderly patients with multiple chronic conditions was selected in Nanchong from March to August 2025. Surveys were conducted using the Toronto Alexithymia Scale, Cognitive Emotion Regulation Questionnaire, Health Literacy Management Scale, Self-neglect Scale, and Perceived Social Support Scale. Data were analyzed using correlation analysis, multiple regression, and structural equation modeling. Results: A total of 372 valid questionnaires were collected (97.9%). The alexithymia score was 62.35±10.24, and 51.3% had alexithymia. Alexithymia was negatively correlated with cognitive emotion regulation, health literacy, and social support, and positively correlated with self-neglect (all P<0.01). Regression analysis showed that age, education, number of chronic diseases, medication frequency, self-care ability, health literacy, social support, and self-neglect were the main influencing factors (adjusted R²=0.621). Structural equation modeling showed that health literacy and social support not only directly negatively affected alexithymia, but also indirectly through self-neglect and cognitive emotion regulation. Conclusion: Alexithymia is prominent in this population. Comprehensive interventions integrating psychological support, health education, and family-community collaboration are needed.