98

Japanese Journal of Comprehensive Rehabilitation Science (2017)

Original Article

Differences in FIM improvement rate stratified by nutritional status
and age in stroke patients in kaifukuki (convalescent) rehabilitation
ward
Yuta Fujitaka, PT, MS,1 Naojiro Tanaka, PT, MS,1 Hisae Nakadai, PT,1 Rina Sato, PT,1
Mitsuko Watanabe, ST, MS,1 Noriko Kageyama, RD,1 Takatsugu Okamoto, MD, PhD1
Nishi-Hiroshima Rehabilitation Hospital, Hiroshima, Japan1

ABSTRACT
Fujitaka Y, Tanaka N, Nakadai H, Sato R, Watanabe
M, Kageyama N, Okamoto T. Differences in FIM
improvement rate stratified by nutritional status andage in stroke patients in kaifukuki (convalescent)rehabilitation ward. Jpn J Compr Rehabil Sci 2017; 8:
98-103.
Purpose: This study aimed to investigate the differencesin improvement rate of Functional Independence
Measure score (FIM) stratified by nutritional status
and age in stroke patients admitted to a kaifukuki(convalescent) rehabilitation ward (KRW).
Methods: Stroke patients aged 60 years or older
admitted to the KRW in our hospital between May
2013 and February 2015 were studied. Patients with
Mini Nutritional Assessment-Short Form (MNA-SF)
score 7 or below at admission were classified in themalnutrition group, and those with score 8 or above in
the normal nutrition group. Each group was further
stratified by age into 60s, 70s, and 80 and older, with a
total of 6 groups. FIM effectiveness was calculated as
an indicator of FIM improvement rate, and multiple
comparison was conducted among groups.
Results: FIM effectiveness did not differ among age
groups in the normal nutrition group, but wassignificantly lower in patients aged ≥80 compared tothose aged 60s and 70s in the malnutrition group.
Conclusion: In stroke patients with malnutrition, theFIM improvement rate decreased as age increased.
This finding suggests that in order to conduct
Correspondence: Yuta Fujitaka, PT, MS
Nishi-Hiroshima Rehabilitation Hospital, 6-265
Miyake, Saeki-ku, Hiroshima, Hiroshima 731-5143,
Japan.
E-mail: wel@welnet.jp
Accepted: September 25, 2017.
No benefits in any form have been or will be received
from any commercial party related directly or indirectly
to the subject of this manuscript.
©Kaifukuki Rehabilitation Ward Association 2017
doi.org/10.11336/jjcrs.8.98

rehabilitation efficiently, the nutritional status should
be taken into consideration when planning therehabilitation program, especially in patients ofadvanced age.
Key words: Kaifukuki rehabilitation ward, stroke,
nutritional status, age groups, FIM improvement rate
Introduction
In the fiscal 2016 medical fee revision for kaifukuki(convalescent) rehabilitation ward (hereinafter
abbreviated as KRW), the KRW achievement
index(KRW-AI) was introduced using the Functional
Independence Measure (FIM) as outcome evaluation.
In the calculation of KRW-AI, the length of hospital
stay (days) and the gain of FIM motor subscale score(difference between score at discharge and that at
admission) are used. Therefore, efficient rehabilitationthat improves FIM gain within a short hospital stay isincreasing in importance. While appropriate nutritional
management is considered necessary to achieve such
efficiency [1], study has indicated that 43.5% of stroke
patients in the KRW have malnutrition [2], implyingthat many malnourished stroke patients are undergoingrehabilitation. In stroke patients, malnutrition has beenreported to be a negative predictor of FIM score atdischarge and discharge outcome [2], and associatedwith high mortality, high rate of complications such as
infectious diseases, and furthermore difficulty ofmaintaining independence in activities of daily living(ADL) [3-5]. The above findings thus indicate that instroke patients, malnutrition is an impeding factor thatcannot be neglected for efficient rehabilitation.
Furthermore, sarcopenia is attracting attention asa malnutrition-related problem. The prevalence ofsarcopenia has been reported to vary depending on theage in community-dwelling elderly people in Japan[6]. Compared with approximately 10% in the 65-74
age group, the prevalence increases in correlation withage to approximately 25% in the 75-79 age group,
Jpn J Compr Rehabil Sci Vol 8, 2017

Fujitaka Y et al.: Nutritional status and age-related differences in FIM improvement in rehabilitation ward stroke patients99

40% in the 80-84 age group, and 60% in the 85 andabove age group. These data imply that among patients
admitted to KRW, the proportion with poor nutritional
status may become higher in older patients. Sinceolder age correlates with poorer ADL outcome instroke patients [7, 8], it may be necessary to consider
age during nutrition management of stroke patients.
However, research on the relationship between
nutrition management and improvement of ADL
capability in KRW [9] grouped all the elderly subjects
aged 65 years or older into one large age group.
Therefore, the effect of the status of malnutrition andthe effect of age stratified into finer age groups on the
FIM improvement rate in KRW remain unknown.
The purpose of this study was to investigate thedifferences in FIM improvement rate stratified bynutritional status and age in stroke patients admitted toa KRW.
Methods
1. Subjects
Stroke patients aged 60 years or older admitted to
the KRW in our hospital between May 2013 andFebruary 2015 were studied. Exclusion criteria weretransfer to other facilities including acute care hospitals

due to complications including pneumonia and heart
failure or concurrent diseases during the course of
hospitalization, hospital stay not more than 30 days,
and presence of missing data. The KRW of our hospitalmeets the facility criteria for rehabilitation ward
admission fee 1. The rehabilitation volume provided
during the study period averaged across the hospital
was 8.5 to 8.6 units per day per patient.
2. Stratification by nutritional status and age
Nutritional status was measured at admission using
the Mini Nutritional Assessment-Short Form (MNASF). The Mini Nutritional Assessment (MNA) is anutritional assessment method developed by Guigoz etal. [10], and the validity of this tool has also been
established in Japan [11]. The MNA-SF is a simplified
version of the MNA and has been validated to be aneffective screening tool [12]. MNA-SF scores of 0 to 7
points are assessed as malnourished, 8 to 11 points as at
risk of malnutrition, and 12 to 14 points as normal
nutritional status. In the present study, patients with
MNA-SF scores of 7 or lower at admission wereclassified in the malnutrition group, and those withscores of 8 or higher in the normal nutrition group. In
addition, each group was stratified by age into 60s, 70s,
and 80 and older, with a total of 6 groups (Figure 1).

Figure 1. Flowchart of subject selection and classification.
MNA-SF, Mini Nutritional Assessment-Short Form.
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Fujitaka Y et al.: Nutritional status and age-related differences in FIM improvement in rehabilitation ward stroke patients

3. Assessment items
As basic attribute data of the subjects, we examinedage, gender, disease type, comorbidity, length of
hospital stay, FIM score at admission, FIM score atdischarge, and body mass index (BMI). For theevaluation of nutritional status, we measured MNASF at admission and at discharge, and calculated theratio of MNA-SF score at admission to that atdischarge. For the evaluation of ADL improvement
rate, we measured FIM scores at admission and atdischarge, and calculated FIM effectiveness [FIM
score at discharge−FIM score at admission / (126−FIM
score at admission)] according to the method of Shahet al. [13].

analyzed using Kruskal-Wallis test, followed by posthoc Steel-Dwass test for multiple comparison.
Statistical analyses were performed using Statcel 3. A
p value less than 0.05 was considered to indicate asignificant difference.
Results
A total of 333 stroke patients (190 males, 143
females) were analyzed. The basic attribute data areshown in Table 1.
From the MNA-SF scores at admission, 252 patientswere assessed as malnourished, 80 patients as at riskof malnutrition, and 1 patient as normal nutritional
status. Since MNA-SF scores of 7 and below were
defined as malnutrition in the present study, 252patients (75.7%) were classified in the malnutritiongroup and 81 patients (24.3%) in the normal nutritiongroup. At discharge, 91 patients were assessed as
malnourished, 206 patients as at risk of malnutrition,and 36 patients as normal nutritional status according
to MNA-SF scores. Ninety-one patients (27.3%) wereclassified in the malnutrition group and 242 patients(72.7%) in the normal nutrition group (Figure 2).

4. Ethical consideration
This study was planned in compliance with the
Declaration of Helsinki, and was conducted after
obtaining approval from the ethics review committeeof our hospital.
5. Statistical analysis
The data of FIM effectiveness was tested for normal
distribution by Shapiro-Wilk test. Then, the data wereTable 1. Basic attribute data of the subjects.
All
NumberAge, years
Mean (standard deviation)
Gender, no. (%)
Male
FemaleDisease, no. (%)
Cerebral infarction
Cerebral hemorrhage
Subarachnoid hemorrhage
Comorbidity, no. (%)
Diabetes
Dyslipidemia
Hypertension
Cardiac disease
Renal disease

333
75.3
(8.8)
190
(57.1)
143(43.0)
198(59.5)
116(34.8)
19(5.7)
95(28.5)
80(24.0)
205(61.6)
67(20.1)
13
(3.9)

126.0
Hospital stay, days
Median (interquartile range) (88.0-147.0)
58.0
FIM at admission, score
Median (interquartile range) (36.0-82.0)
95.0
FIM at discharge, score
Median (interquartile range) (64.0-112.0)
21.9
BMI, kg/m2(3.4)
Mean (standard deviation)

Aged 60s

Aged 70s

Aged ≥ 80

NormalMalnutrition
nutrition group
group

Malnutrition
Normalgroup
nutrition group

Malnutrition
Normalgroup
nutrition group

71
64.8
(2.5)
50
(70.4)
21(29.6)
28(39.4)
39(54.9)
4(5.6)
20(28.2)
14(19.7)
49(69.0)
11(15.5)
5
(7.0)

25
65.0
(2.7)
15
(60.0)
10(40.0)
15(60.0)
10(40.0)
0(0.0)
7(28.0)
10(40.0)
18(72.0)
1
(4.0)
0
(0.0)

140.0
110.0
(113.5-147.0) (68.0-147.3)

35
74.0
(2.8)
25
(71.4)
10(28.6)
25(71.4)
8(22.9)
2(5.7)
10(28.6)
9(25.7)
24(68.6)
5(14.3)
5(14.3)

138.0
88.0(102.0-147.0) (50.5-127.0)

90
85.5
(4.0)
38
(42.2)
52(57.8)
64(71.1)
25(27.8)
1(0.1)
21(23.3)
21(23.3)
43(47.8)
27(30.0)
0
(0.0)

21
84.8
(5.7)
13
(61.9)
8(38.1)
16(76.2)
3(14.3)
2(9.5)
5(23.8)
7(33.3)
17(81.0)
6(28.6)
0
(0.0)

128.0
(90.0-146.0)

103.0(94.0-115.0)

48.0(32.5-78.8)

90.0(66.0-102.0)

53.0(34-71.5)

86.0(59.0-95.0)

46.5(29-68)79.0(58.0-94.0)

100.0(65-117.8)

119.0(103-123)

87.0(61.5-105)

115.0(100.5-120.0)

68.0(44-98)105.0(100.0-114.0)

21.1
(3.5)

24.8
(3.4)

21.1
(3.1)

25.1
(2.6)

20.9
(2.7)

24.0
(1.9)

FIM, Functional Independence Measure; BMI, Body Mass Index.

Jpn J Compr Rehabil Sci Vol 8, 2017

91
74.6
(3.1)
49
(53.8)
42(46.2)
50(54.9)
31(34.1)
10(11.0)
32(35.2)
19(20.9)
54(59.3)
17(18.7)
3(3.3)

Fujitaka Y et al.: Nutritional status and age-related differences in FIM improvement in rehabilitation ward stroke patients
101

Figure 2. Nutritional status assessed by MNA-SF at admission and at discharge.

Table 2. FIM effectiveness (%).
Malnutrition group
Normal nutrition group

Aged 60s

Aged 70s

Aged ≥ 80

60.4 (28.6-78.7)
n.s.
73.3 (52.8-88.3)

45.5 (21.8-64.8)*
74.2 (41.8-83.0)

28.6 (10.1-46.8)**
58.8 (40.6-74.5)

¶,‡

n.s.

Median (interquartile range), FIM, Functional Independence Measure; n.s., not significant.
*, malnutrition group vs. normal nutrition group, p < 0.05; **, malnutrition group vs. normal
nutrition group, p < 0.01.
¶, 60s vs. ≥ 80, p < 0.01; ‡, 70s vs. ≥ 80, p < 0.05.
First, FIM effectiveness was compared between two
nutritional status groups. FIM effectiveness did not
differ between two groups in patients aged 60s(malnutrition group: median 60.4%, normal nutritiongroup: median 73.3%), but was significantly lower inthe malnutrition group in those aged 70s (malnutritiongroup: median 45.5%, normal nutrition group: median
74.2%) and 80 and older (malnutrition group: median
28.6%, normal nutrition group: median 58.8%). Next,
FIM effectiveness was compared among three agegroups within each nutritional status group. In thenormal nutrition group, FIM effectiveness did not
differ significantly among those aged 60s, 70s, and80 and older (60s: median 73.3%, 70s: median 74.2%,≥ 80: median 58.8%). In the malnutrition group,
however, FIM effectiveness was significantly lower inthose aged 80 and older compared to the other two age
groups (60s: median 60.4%, 70s: median 45.5%, ≥ 80:
median 28.6%) (Table 2).
Discussion
In the present study, we investigated the presence orabsence of malnutrition in stroke patients admitted toa KRW, and the difference in FIM improvement rateby age stratification.
Among the subjects in the present study, 75.7%
were assessed as malnourished at admission, and therate was higher than that (43.5%) reported by Nishioka
et al. [2]. A possible reason for this difference is thedifference in method of assessment. Nishioka et al.
used the Geriatric Nutritional Risk Index (GNRI)
obtained from height, body weight, and serum albumin
level, while we used the MNA-SF based on aquestionnaire. In a previous study using the MNA-SF
as the nutritional indicator, 87.6% of patients withdisuse syndrome in an acute care ward were classified
as malnourished [14]. In another study including
patients with stroke and other diseases in the KRW,
82.0% were reported as malnourished [9], a rate that
was as high as the result of our study. Among the six
items in the MNA-SF, three items have a time frame of“in the past 3 months”. In the present study, the MNASF was administered at admission to the KRW, and“the past 3 months” before admission includes theperiod after onset of stroke. This may contribute to thehigh prevalence of malnutrition as assessed by the
MNA-SF at the time of admission to the KRW.
In this study, FIM effectiveness was used as anindicator of the FIM improvement rate. Although FIM
gain (FIM at admission ‒ FIM at discharge) has been
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102

Fujitaka Y et al.: Nutritional status and age-related differences in FIM improvement in rehabilitation ward stroke patientsused as another index for FIM improvement, FIM gainin mild cases with high FIM at admission is low due tothe ceiling effect, whereas the gain is often high inindividuals who require moderate-level support [15].
FIM effectiveness is expected to correct thisshortcoming of FIM gain.
Multiple comparison of FIM effectiveness revealed
two features. First, in the intergroup comparison
between the malnutrition and normal nutrition groups,
FIM effectiveness was not different between two
groups in patients aged 60s, but was significantly
lower in the malnutrition group in those aged 70s and
80 and older. Second, in the intragroup comparison
within each nutritional status group, FIM effectivenesswas significantly lower in patients aged 80 and older
compared to those aged 60s and 70s in the malnutritiongroup, but did not differ depending on age in thenormal nutrition group.
First, regarding the intergroup comparison in which
FIM effectiveness was significantly lower in themalnutrition group in patients aged 70s and 80 andolder, these findings will be discussed with reference
to previous studies on the relationship of ADL withnutritional status and age. In previous studies on therelationship between nutritional status and ADL,
nutritional status at admission in stroke patients [2],pneumonia patients [16] and heart failure patients [17]affected the ADL outcome, and FIM gain was lower in
KRW patients with malnutrition than patients withnormal nutritional status [9]. Moreover, in previous
studies on the association between age and ADL, ADL
outcome became poorer in older stroke patients [7, 8],
and FIM gain and FIM effectiveness decreased
significantly as age increased in stroke patients in the
KRW [18, 19]. In the present study, among patientswith malnutrition, FIM effectiveness was significantly
lower in those aged 70s and 80 and older, and theseresults support previous reports on the relationship of
ADL with nutritional status and age. However, in one
previous study on ADL and nutritional status in rehab
ward [9], the subjects were not limited to stroke
patients and the age group had a wide range (65 years
and older), suggesting a possibility that wide variationin functional capability may have existed. In addition,
two other previous studies on ADL and age in KRW[18, 19] reported the importance of stratification by
age and by FIM at admission in the prediction of FIM
gain, as well as the association of FIM at discharge
with trunk function and walking ability, but nutritional
status was not mentioned. Taken together, the noveltyof the present study is the finding suggesting thatthe nutritional status may affect the rate of ADL
improvement in stroke patients aged over 70 years.
Next, the intragroup comparison in which FIM
effectiveness was significantly lower in patients aged
80 and older compared to those aged 60s and 70s in
the malnutrition group, but did not differ depending on
age in the normal nutrition group will be discussed.
Jpn J Compr Rehabil Sci Vol 8, 2017

Elderly people show large individual differences in
the rate of progression of aging, and often manifest
atypical symptoms and abnormal findings [20-22]. In
the malnutrition group, apart from nutritional status
and comorbid diseases examined in this study, thephysiological function of the body likely also declined.
Age-related decline in physiological function includes
impaired chewing and swallowing abilities, disturbed
gastrointestinal function including diarrhea andconstipation, olfactory disorder, taste disorder, andloss of appetite, which have been reported to affect thenutritional status of the elderly [23]. In addition,elderly people lack reserve capacity of physiological
function compared to younger people, and once
functional capability of daily living has deteriorated,complete recovery may be difficult [24, 25]. This may
explain why elderly people who were malnourished atadmission had low FIM improvement rate. As anotherfactor, the prognosis of rehabilitation has been reported
to worsen in patients with chronic obstructive
pulmonary disease or dysphagia complicated bymalnutrition [26, 27]. It is possible that concurrent
respiratory diseases and dysphagia, which were notinvestigated in the present study, may have caused adecrease in FIM improvement rate.
The present findings suggest that in order to conduct
rehabilitation efficiently for stroke patients admitted
to the KRW, the nutritional status should be taken
into consideration when planning the rehabilitation
program, especially in patients of advanced age.
This study has several limitations. Because of thestrict inclusion and exclusion criteria, we were notable to investigate the subjects’ functional deficit
including paralysis or the status of comorbidities suchas respiratory diseases and dysphagia. In addition,
there were variations in ADL capability and otherdata, and we were not able to exclude factors otherthan malnutrition and age. In addition, due to theretrospective design of the research, the causal
relationship between ADL capability and nutritional
status cannot be clarified. To address these limitations,a prospective study with new subject selection criteriausing multivariate analysis to analyze the causal
relationship between ADL capability and nutritional
status is needed.

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