Nutritional Improvement Correlates with Recovery of Activities of Daily Living among Malnourished Elderly Stroke Patients in the Convalescent Stage: A Cross-Sectional Study



      Whether nutritional improvement correlates with functional recovery in convalescent stroke patients is unclear.


      This study was conducted to examine the relationship between nutritional improvement and recovery of activities of daily living among malnourished elderly stroke patients in the convalescent stage.


      This study used a cross-sectional study design.


      One hundred seventy-eight malnourished stroke patients aged 65 years and older from convalescent rehabilitation wards in Japan between April 2012 and December 2014 were included in the analyses.

      Main outcome measures

      The participants were classified into three groups according to the Mini Nutritional Assessment Short-Form (MNA-SF) score at discharge (0 to 7 as no improvement, 8 to 11 as lesser improvement, and 12 to 14 as greater improvement). The primary outcome was functional independence measure (FIM) efficiency (FIM gain/length of hospital stay). The secondary outcomes were FIM gain and discharge outcome.

      Statistical analysis

      One-way analysis of variance, χ2 test, and Kruskal-Wallis test were performed for univariate analysis. Linear regression analysis was used to adjust for covariates such as age, sex, length of hospital stay, FIM (motor and cognitive) on admission, and lower-order items of MNA-SF. Binomial logistic analysis for discharge outcome (home/others) was performed to adjust for covariates such as age, sex, and FIM.


      Study participants included 85 men and 93 women with a mean age of 77 years. Based on MNA-SF, 16 were classified as no improvement, 113 as lesser improvement, and 49 as greater improvement. The median FIM efficiency and length of hospital stay were 0.27 points/day and 151.5 days, respectively. The greater improvement group had significantly higher FIM efficiency than the other groups (P<0.001). Home discharge rate was also higher in the GI group (P=0.014). Linear regression analysis for FIM efficiency indicated that mobility, neuropsychological problems, and weight loss, which were lower-order items of MNA-SF at discharge, were independent explanatory variables (R2=0.373; P<0.001).


      These findings suggest that nutritional improvement such as maintenance of body weight is associated with the efficient recovery of activities of daily living among malnourished elderly convalescent stroke patients.


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        • Naber T.H.
        • Schermer T.
        • de Bree A.
        • et al.
        Prevalence of malnutrition in nonsurgical hospitalized patients and its association with disease complications.
        Am J Clin Nutr. 1997; 66: 1232-1239
        • Edington J.
        • Boorman J.
        • Durrant E.R.
        • et al.
        Prevalence of malnutrition on admission to four hospitals in England.
        Clin Nutr. 2000; 19: 191-195
        • Fernández A.C.
        • Casariego A.V.
        • Rodríguez I.C.
        • Pomar D.B.
        Malnutrition in hospitalized patients receiving nutritionally complete menus: Prevalence and outcomes.
        Nutr Hosp. 2014; 30: 1344-1349
        • Huong P.T.
        • Lam N.T.
        • Thu N.N.
        • et al.
        Prevalence of malnutrition in patients admitted to a major urban tertiary care hospital in Hanoi, Vietnam.
        Asia Pac J Clin Nutr. 2014; 23: 437-444
        • Foley N.C.
        • Salter K.L.
        • Robertson J.
        • Teasell R.W.
        • Gail M.
        Which reported estimate of the prevalence of malnutrition after stroke is valid?.
        Stroke. 2009; 40: e66-e74
        • Gariballa S.E.
        • Parker S.G.
        • Taub N.
        • Castleden C.M.
        Influence of nutritional status on clinical outcome after acute stroke.
        Am J Clin Nutr. 1998; 68: 275-281
        • The FOOD Trial Collaboration
        Poor nutritional status on admission predicts poor outcomes after stroke: Observational data from the FOOD trial.
        Stroke. 2003; 34: 1450-1456
        • Davis J.P.
        • Wong A.A.
        • Schluter P.J.
        • Henderson R.D.
        • O’Sullivan J.D.
        • Read S.J.
        Impact of premorbid undernutrition on outcome in stroke patients.
        Stroke. 2004; 35: 1930-1934
        • Yoo S.H.
        • Kim J.S.
        • Kwon S.U.
        • Yun S.C.
        • Koh J.Y.
        • Kang D.W.
        Undernutrition as a predictor of poor clinical outcomes in acute ischemic stroke patients.
        Arch Neurol. 2008; 65: 39-43
        • Foley N.C.
        • Martin R.E.
        • Salter K.L.
        • Teasell R.W.
        A review of the relationship between dysphagia and malnutrition following stroke.
        J Rehabil Med. 2009; 41: 707-713
        • Davalos A.
        • Ricart W.
        • Gonzalez-Huix F.
        • et al.
        Effect of malnutrition after acute stroke on clinical outcome.
        Stroke. 1996; 27: 1028-1032
        • Gariballa S.E.
        • Parker S.G.
        • Taub N.
        • Castleden C.M.
        A randomized, controlled, a single-blind trial of nutritional supplementation after acute stroke.
        J Parenter Enteral Nutr. 1998; 22: 315-319
        • The FOOD Trial Collaboration
        Routine oral nutritional supplementation for stroke patients in hospital (FOOD): A multicentre randomised controlled trial.
        Lancet. 2005; 365: 755-763
        • Geeganage C.
        • Beavan J.
        • Ellender S.
        • Beth P.M.
        Interventions for dysphagia and nutritional support in acute and subacute stroke (Review).
        Cochrane Database Syst Rev. 2012; 10: CD000323
        • Kaiser M.J.
        • Bauer J.M.
        • Rämsch C.
        • et al.
        Frequency of malnutrition in older adults: A multinational perspective using the mini nutritional assessment.
        J Am Geriatr Soc. 2010; 58: 1734-1738
        • Jönsson A.C.
        • Lindgren I.
        • Norrving B.
        • Lindgren A.
        Weight loss after stroke: A population-based study from the Lund Stroke Register.
        Stroke. 2008; 39: 918-923
        • Paquereau J.
        • Allart E.
        • Romon M.
        • Rousseaux M.
        The long-term nutritional status in stroke patients and its predictive factors.
        J Stroke Cerebrovasc Dis. 2014; 23: 1628-1633
        • Miyai I.
        • Sonoda S.
        • Nagai S.
        • et al.
        Results of new policies for inpatient rehabilitation coverage in Japan.
        Neurorehabil Neural Repair. 2011; 25: 540-547
        • Nishioka S.
        • Takayama M.
        • Watanabe M.
        • Urushihara M.
        • Kiriya Y.
        • Hijioka S.
        Prevalence of malnutrition in convalescent rehabilitation wards in Japan and correlation of malnutrition with ADL and discharge outcome in elderly stroke patients.
        J Jpn Soc Parenter Enteral Nutr. 2015; 30 ([Article in Japanese.]): 1145-1151
        • Rabadi M.
        • Coar P.
        • Lukin M.
        • Lesser M.
        • Blass J.
        Intensive nutritional supplements can improve outcomes in stroke rehabilitation.
        Neurology. 2008; 71: 1856-1861
        • Kaiser M.J.
        • Bauer J.M.
        • Ramsch C.
        • et al.
        Validation of the Mini Nutritional Assessment short-form (MNA-SF): A practical tool for identification of nutritional status.
        J Nutr Health Aging. 2009; 13: 782-788
        • Guigoz Y.
        The Mini Nutritional Assessment (MNA) review of the literature—What does it tell us?.
        J Nutr Health Aging. 2006; 10: 466-485
        • Rubenstein L.Z.
        • Harker J.O.
        • Salvà A.
        • Guigoz Y.
        • Vellas B.
        Screening for undernutrition in geriatric practice: Developing the short-form mini-nutritional assessment (MNA-SF).
        J Gerontol. 2001; 56A: M366-M372
        • Vellas B.
        • Villars H.
        • Abellan G.
        • et al.
        Overview of the MNA—Its history and challenges.
        J Nutr Health Aging. 2006; 10: 456-463
        • Ottenbacher K.J.
        • Hsu Y.
        • Granger C.V.
        • Fiedler R.C.
        The reliability of the functional independence measure: A quantitative review.
        Arch Phys Med Rehabil. 1996; 77: 1226-1232
        • Chumney D.
        • Nollinger K.
        • Shesko K.
        • Skop K.
        • Spencer M.
        • Newton R.A.
        Ability of Functional Independence Measure to accurately predict functional outcome of stroke-specific population: Systematic review.
        J Rehabil Res Dev. 2010; 47: 17-29
        • Maeshima S.
        • Osawa A.
        • Hayashi T.
        • Tanahashi N.
        Factors associated with prognosis of eating and swallowing disability after stroke: A study from a community-based stroke care system.
        J Stroke Cerebrovasc Dis. 2013; 22: 926-930
        • White J.V.
        • Guenter P.
        • Jensen G.
        • Malone A.
        • Schofield M.
        Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics recommended for the identification and documentation of adult malnutrition (undernutrition).
        J Parenter Enter Nutr. 2012; 36: 275-283
        • Kalm L.M.
        • Semba R.D.
        They starved so that others be better fed: Remembering Ancel Keys and the Minnesota experiment.
        J Nutr. 2005; 135: 1347-1352
        • Wakabayashi H.
        • Sakuma K.
        Rehabilitation nutrition for sarcopenia with disability: A combination of both rehabilitation and nutrition care management.
        J Cachexia Sarcopenia Muscle. 2014; 5: 269-277
        • Yoshimura Y.
        • Uchida K.
        • Jeong S.
        • Yamaga M.
        Effects of nutritional supplements on muscle mass and activities of daily living in elderly rehabilitation patients with decreased muscle mass: A randomized controlled trial.
        J Nutr Health Aging. 2015; ([published online ahead of print July 8, 2015].)
        • Westerterp K.R.
        • Schols A.M.
        • Singer P.
        Energy metabolism.
        in: Sobotka L. Basics in Clinical Nutrition. 4th ed. Galen, Plaugh, Czech Republic2011: 96-103
        • Moore S.A.
        • Hallsworth K.
        • Bluck L.J.
        • Ford G.A.
        • Rochester L.
        • Trenell M.I.
        Measuring energy expenditure after stroke: Validation of a portable device.
        Stroke. 2012; 43: 1660-1662


      S. Nishioka is chief, Department of Clinical Nutrition and Food Services, Nagasaki Rehabilitation Hospital, Nagasaki, Japan.


      E. Nishioka is a registered dietitian, Department of Clinical Nutrition and Food Services, Nagasaki Rehabilitation Hospital, Nagasaki, Japan.


      T. Yoshida is a registered dietitian, Department of Clinical Nutrition and Food Services, Nagasaki Rehabilitation Hospital, Nagasaki, Japan.


      N. Mori is a registered dietitian, Department of Clinical Nutrition and Food Services, Nagasaki Rehabilitation Hospital, Nagasaki, Japan.


      R. Watanabe is a registered dietitian, Department of Clinical Nutrition and Food Services, Nagasaki Rehabilitation Hospital, Nagasaki, Japan.


      H. Wakabayashi is an assistant professor, Department of Rehabilitation Medicine, Yokohama City University Medical Center, Kanagawa, Japan.