Nutritional status as a predictor of comprehensive activities of daily living function and quality of life in patients with stroke

Abstract

BACKGROUND:

Nutritional status could affect functional capacity and reduce quality of life in patients with stroke. Although the associations between nutritional status, basic activities of daily living (BADL)/Instrumental ADL, and quality of life (QOL) in older people have been identified, the relationships have not yet been examined in patients with stroke, using the full Mini Nutritional Assessment (MNA) or MNA-short form (MNA-SF).

OBJECTIVE:

This study aimed to examine the relationship between nutritional status (using full MNA and MNA-SF), comprehensive ADL function, and QOL in patients with stroke.

METHODS:

Eighty-two patients with ischemic stroke participated in this cross-sectional design study. Each participant was assessed with the full MNA, MNA-SF, comprehensive ADL function (including Barthel Index and Frenchay Activities Index), and WHO Quality of Life Questionnaire (WHOQOL-BREF) once.

RESULTS:

The MNA-SF was only significantly correlated with the comprehensive ADL function (rho = 0.27, p = 0.013), whereas, the full MNA was found to be significantly correlated with the comprehensive ADL function and WHOQOL-BREF (rho = 0.24, p = 0.029 and rho = 0.30, p = 0.005, respectively). The MNA-SF was a significant predictor of comprehensive ADL function, accounting for 44% of the variance. The full MNA was the only significant predictor of the WHOQOL-BREF, explaining 17% of the variance.

CONCLUSIONS:

This study has revealed a relationship between nutritional status, comprehensive ADL function, and QOL among patients with stroke. Patients with stroke with better nutritional status had higher ADL function as well as better QOL. The MNA-SF was useful in predicting comprehensive ADL, whereas, the full MNA could be used to predict QOL. Knowledge and evidence of the association and predictive power of the MNA-SF and full MNA could guide clinicians to choose tools for assessing the nutritional status of patients with stroke more effectively.

Keywords

Nutritional status activities of daily living quality of life stroke

1 Introduction

Nutritional status is an important determinant of functional capacity, independence, and quality of life for the elderly (Posner, Jette, Smith, & Miller, 1993; Sugiura et al., 2016). However, nutritional status can easily be affected by diseases such as stroke (Keller, Ostbye, & Goy, 2004). Stroke has been linked to malnutrition and reduced intake of food due to the difficulty in swallowing, and which contribute to longer hospital stay, and a tendency to be dependent on other for activities of daily living (ADL).

Comprehensive ADL function refers to an individual’s ability to perform activities independently whether in the home or community, and consists of basic ADL (BADL) and instrumental ADL (IADL) (Hsieh & Hsueh, 1999). A systematic review identified different studies that found an association between nutritional status and BADL in older people (Phillips, Foley, Barnard, Isenring, & Miller, 2010). Individuals with poor nutrition status are more likely to experience imbalance in energy, protein, vitamins, and minerals intake, leading to deleterious consequences such as loss of comprehensive ADL function (Farouk Mahmoud & Gaber Sheha, 2018). Loss of comprehensive ADL function might have a great impact on life expectancy (Sato, Demura, Kobayashi, & Nagasawa, 2002). Although many studies have reported the association between nutritional status, BADL, and/or IADL among older people (Kanwal, Qidwai, & Nanji, 2018; Salminen et al., 2019; Sugiura et al., 2016), the relationship in patients with stroke remains unknown. It is important to gain insights into how the two (i.e., nutritional status and comprehensive ADL function) interact in patients with stroke, which in turn could assist in the planning of interventions to prevent further functional decline.

It has been reported that individual with poor nutrition status are also more likely to experience poor quality of life (QOL) (Salminen et al., 2019). Today, QOL is one of the most important factors considered in the treatment of patients with stroke. Despite the extensive research related to QOL in patients with stroke (Yeoh et al., 2019), there is limited evidence regarding the relationship between malnutrition and QOL. Knowledge of the relationship between nutritional status and QOL could guide clinicians to improve QOL in patients with stroke more effectively.

Among the different methods and tools that may be used to assess nutritional status, one of the most popular is the Mini Nutritional Assessment (MNA). The MNA is a simple, inexpensive, and noninvasive assessment that can be completed within 10–15 minutes. A short form of the MNA (MNA-SF), using some of the items in the MNA, has been developed to reduce the administration time (Secher, Soto, Villars, van Kan, & Vellas, 2007). With the addition of this short form, nutritional assessment occurs in two stages. The first stage, in order to identify people at risk of malnutrition, the MNA-SF is used as a screening scale. The complete full version of the MNA is assessed in the second stage after the subject has been identified as at risk of malnutrition in the first stage (Montejano Lozoya, Martínez-Alzamora, Clemente Marín, Guirao-Goris, & Ferrer-Diego, 2017; Secher et al., 2007). In clinical settings, it is important to use a quick assessment to enhance the efficiency of administration and reduce the assessment burden on patients with stroke. As it has been reported that the MNA-SF has been found to be as equally effective as the full version of the MNA (Soysal et al., 2019), it seems that the MNA-SF is promising for use in clinical practice. To our knowledge, although the associations between nutritional status, BADL/IADL, and QOL in older people have been identified, the relationships have not yet been examined in patients with stroke, using the full MNA or MNA-SF. Therefore, the objective of this study was to examine the relationship between nutritional status (using full MNA and MNA-SF), comprehensive ADL function, and QOL in patients with stroke.

2 Method

2.1 Participants

A cross-sectional design was conducted to examine the relationships between nutritional status and activities of daily living functions and quality of life between May 2017 and October 2018. Patients with chronic stroke were recruited from the Department of Neurology at one hospital in northern Taiwan. Participants were included if they: (1) had a diagnosis of cerebral hemorrhage or cerebral infraction and (2) had the ability to follow verbal instructions to complete the assessments. The exclusion criteria were (1) having unstable medical conditions that may result in re-admission during the study period and (2) receiving nasogastric tube feeding. Moreover, the sample size was determined to be at least 50 participants to allow for more accurate interpretations of the associations between the MNA (including full MNA and MNA-SF) and the comprehensive ADL (measured by Barthel Index [BI] and Frenchay Activities Index [FAI]), and the WHO Quality of Life Questionnaire (WHOQOL-BREF), as recommended in the literature (Hopkins, 2000; Delice, 2010; Faber & Fonseca, 2014).

This study was approved by the Research Ethics Committee of Taiwan Adventist Hospital (Files #105-E-22 and 106-E-29). Written informed consent was obtained from each participant.

2.2 Procedure

Each participant was assessed with the full MNA, MNA-SF, BI, FAI, and WHOQOL-BREF once by a trained rater (a dietitian) in an assessment room. All assessments were administered to the participants via face-to-face interview. Prior to the study, the rater familiarized herself with all assessments. The rater studied the user manual of the full MNA, MNA-SF, BI, FAI, and WHOQOL-BREF and received 2 hours of training on the administration of assessments. At the end of the training, the rater individually administered all assessments to two patients while the corresponding author observed and scored the patients at the same time. The rater’s scoring results were checked by the corresponding author. Any discrepancies in the results were discussed to ensure that the rater was thoroughly familiar with the standardized procedure of administration and scoring.

2.3 Measures

2.3.1 Nutritional status

Full MNA. The full MNA was initially developed for the frail elderly, but it has been validated in other older populations (Guigoz, 2005). The importance of the full MNA is that it may provide additional information about the causes of malnutrition in individuals identified as malnourished or at risk of malnutrition (Secher et al., 2007). The full MNA consists of 18 items and the total score ranges from 0 to 30. The full MNA takes approximately 10 to 15 minutes to complete (Secher et al., 2007). A cut-off of≥24 points is regarded as an indication of being well-nourished, 17–23.5 points indicate a risk of malnutrition, and < 17 points indicates the person is malnourished (Vellas et al., 2006). The full MNA is reported to have good test-retest reliability (ICC = 0.91) in patients with stroke (Lin et al., 2019).

MNA-SF. The MNA-SF was designed to be a quick nutritional screening tool for older adults (Guigoz, 2005). The MNA-SF comprises six items that assess decline in food intake, weight loss, mobility, psychological stress, neuropsychological problems and the Body Mass Index (Vellas et al., 2006). The MNA-SF takes approximately five minutes to complete and the maximum possible score is 14 points. Scores of 12–14 indicate a normal nutritional status, 8–11 indicate at risk of malnutrition, and 0–7 represent malnourished (Secher et al., 2007). The MNA-SF has been reported to have high sensitivity (about 97.9%) and specificity (100%) (Cohendy, Rubenstein, & Eledjam, 2001).

2.3.2 Comprehensive ADL function

The BI was used to indicate the BADL function in our participants (Mahoney & Barthel, 1965). The BI consists of 10 items, including feeding, grooming, bathing, dressing, bowel and bladder care toilet use, ambulation, transfer, and stair climbing. The total score of the BI ranges from 0 to 20, with higher scores indicating more independence in BADL (Collin, Wade, Davies, & Horne, 1988). The BI has been shown to be a reliable, valid, and responsive measure of disability in patients with stroke (Hsueh, Lin, Jeng, & Hsieh, 2002).

The FAI is a measure of IADL which is associated with everyday life (Holbrook & Skilbeck, 1983). The FAI includes 15 items that assess the frequency of a patient participating in an activity. The total score of the FAI ranges from 0 to 45. The FAI has been shown to be a reliable and valid measure of IADL in patients with stroke (Chern et al., 2014; Schuling, de Haan, Limburg, & Groenier, 1993).

Previous studies found that the BI and FAI scores could be combined to represent comprehensive ADL function representing the entire continuum of disability (Hsieh & Hsueh, 1999; Hsieh, Sheu, Hsueh, & Wang, 2002). The standardized scores of the BI and FAI (Z score of BI plus Z score of FAI) can be combined to measure comprehensive ADL (Hsieh et al., 2002). The combined Z scores were used in this study (Hsieh & Hsueh, 1999).

2.3.3 Quality of life

WHOQOL-BREF. The WHOQOL-BREF Taiwan version was used in the present study to evaluate patients’ QOL. The design of the Taiwanese version added 2 additional items to account for Taiwanese cultural adaptations, which resulted in a total of 28 items (Lin et al., 2019; Yao, Chung, Yu, & Wang, 2002). Each item of the WHOQOL-BREF Taiwan version is scored from 1 to 5, with higher scores indicative of better QOL (score range: 28–140) and is assessed by self-administration (Yao et al., 2002). The reliability and validity of the WHOQOL-BREF Taiwan version have been widely confirmed (Lin et al., 2019).

2.4 Statistical analysis

Descriptive statistics were used to describe the characteristics of each participant. Spearman’s rho correlation coefficients were used to first examine the correlations between the MNA (including full MNA and MNA-SF) and comprehensive ADL (measured by BI and FAI), and the WHOQOL-BREF. A rho value > 0.75 indicates high correlation; values of 0.50 to 0.75 represent moderate correlation; values of 0.25 to 0.50 indicate small correlation; and values of≤0.25 indicate weak correlation (Portney & Watkins, 2009).

Multiple regression analyses were conducted to further investigate the relationships between nutritional status, comprehensive ADL function, and QOL adjusted for age, as ADL function tends to decline with age (Sato et al., 2002). The scores of comprehensive ADL and WHOQOL-BREF were used as dependent variables. In all, two regression models were conducted individually and each model was predicted by variables of nutritional status (scores of the MNA-SF and full MNA). The stepwise approach was used for model selection. Data were analyzed with the SPSS 17.0 for Windows Statistical Program.

3 Results

A total of 82 patients with ischemic stroke participated in the study. The mean age was 74 years, and 63.4% of the participants were male (Table 1). The mean score of the full MNA was 25.3, indicating that on average, our participants were well-nourished.

Table 1
Characteristics of the participants (N = 82)

Characteristic

Gender, n (%)

Male 52 (63.4%)

Female 30 (36.6%)

Age, years, mean (SD) 74.0 (11.3)

Side of hemiplegia, n (%)

Right 27 (32.9%)

Left 37 (45.1%)

Bilateral 18 (22.0%)

Time since onset, months median (minimum ∼ maximum) 38.5 (5.0∼342.0)

Full MNA, mean (SD) 25.3 (2.6)

Barthel Index, mean (SD) 18.5 (3.5)

Frenchay Activities Index, mean (SD) 21.0 (11.0)

Total WHOQOL-BREF score, mean (SD) 97.2 (13.2)

Characteristic
Gender, n (%)
Male	52 (63.4%)
Female	30 (36.6%)
Age, years, mean (SD)	74.0 (11.3)
Side of hemiplegia, n (%)
Right	27 (32.9%)
Left	37 (45.1%)
Bilateral	18 (22.0%)
Time since onset, months median (minimum ∼ maximum)	38.5 (5.0∼342.0)
Full MNA, mean (SD)	25.3 (2.6)
Barthel Index, mean (SD)	18.5 (3.5)
Frenchay Activities Index, mean (SD)	21.0 (11.0)
Total WHOQOL-BREF score, mean (SD)	97.2 (13.2)

SD = standard deviation; MNA = Mini Nutritional Assessment; WHOQOL-BREF =WHO Quality of Life-BREF.

The results of the correlation analyses of the MNA-SF, full MNA, comprehensive ADL function, and WHOQOL-BREF revealed a number of significant correlations. The MNA-SF was significantly correlated with the comprehensive ADL function (rho = 0.27, p = 0.013). However, no significant relationship was found between the MNA-SF and the WHOQOL-BREF (rho = 2.0, p = 0.74). The full MNA was found to be significantly correlated with the comprehensive ADL function and the WHOQOL-BREF (rho = 0.24, p = 0.029 and rho = 0.30, p = 0.005, respectively).

Table 2 shows the results of the final stepwise regression analysis adjusted by age. The MNA-SF was a significant predictor of comprehensive ADL function, accounting for 44% of the variance. The full MNA was the only significant predictor of the WHOQOL-BREF, explaining 17% of the variance.

Table 2

Summary of the results of multiple regressions on measurements of interest in patients with stroke (N = 82)

Regression model	Predictors	Estimate	t-value	p-value	R²
Comprehensive ADL function	(constant)	–8.614	–5.278	0.000^*	0.44
	MNA-SF	0.677	5.308	0.000^*
WHOQOL-BREF	(constant)	43.842	3.410	0.001^*	0.17
	Full MNA	–0.048	4.175	0.000^*

ADL= activities of daily living; WHOQOL-BREF =WHO Quality of Life-BREF; MNA-SF = Mini Nutritional Assessment-short form; MNA= Mini Nutritional Assessment. ^*p < 0.01.

4 Discussion

The objective of this study was to examine the relationship between nutritional status, comprehensive ADL function and QOL, and whether nutritional status could predict comprehensive ADL function and QOL in patients with stroke. The results showed that the scores of comprehensive ADL and WHOQOL-BREF were weak to small but significantly associated with that of the MNA-SF and full MNA. Additionally, the MNA-SF was an important predictor of comprehensive ADL function, whereas, the full MNA was the only predictor of the WHOQOL-BREF. These results further support the value of the MNA-SF, showing that it not only can be used as a screening tool, but also as a useful tool for predicting comprehensive ADL function.

The present study findings revealed a significant positive relationship between the scores of the MNA (either the full MNA or MNA-SF) and comprehensive ADL in patients with stroke. Our results were consistent with the previous studies that showed nutritional intake is associated with ADL (Nishioka, Wakabayashi, Nishioka, Yoshida, Mori, & Watanabe, 2016; Kokura, Wakabayashi, Nishioka, & Maeda, 2018; Nishiyama, Wakabayashi, Nishioka, Nagano, & Momosaki, 2019). These findings indicate that patients with stroke who are well-nourished, have higher comprehensive ADL function. This is quite plausible given the positive effect of good nutrition on the ability to engage in ADL independently (Kanwal et al., 2018). Thus, clinicians could help patients with stroke improve their nutritional status in order to promote independence in ADL (Nishioka, Wakabayashi, Nishioka, Yoshida, Mori, & Watanabe, 2016).

It is worth noting that the MNA-SF, not the full MNA, was the predictor of comprehensive ADL. The MNA-SF consists of items that, although not related specifically to nutrition, such as mobility, psychological stress, and neuropsychological problems, could have impact on the ADL status of the patients (Soysal, Veronese, Arik, Kalan, Smith, & Isik, 2019). Our finding suggests that the predictive power of the MNA-SF for comprehensive ADL in patients with stroke is supported. It is beneficial, particularly in busy clinical settings, to use a short and simple measure such as the MNA-SF to obtain information regarding the nutritional status of a patient. Based on our findings, it is recommended that the MNA-SF should be used to assess the nutritional status of patients with stroke while providing ADL interventions.

We found that either the full MNA or MNA-SF was positively associated with the WHOQOL-BREF. The findings imply that better nutritional status is associated with better QOL in patients with stroke which is in concordance with previous studies (Lin, Lin, Lee, Peng, & Chiu, 2019; Sheard, Ash, Mellick, Silburn, & Kerr, 2014). However, contrary to other studies that reported the MNA-SF had predictive power of QOL (Maseda et al., 2018; Rasheed & Woods, 2014), our regression result showed that only the full MNA had the power to predict WHOQOL-BREF. The discrepancy might be due to first, the multiple factors of QOL. The QOL of a stroke patient usually depends on multiple factors (e.g., physical, psychological, social relationships, environmental factors). The full MNA includes the tasks (e.g., residential status, psychological problems, self-perception of health and nutrition) that are related to multiple factors of QOL. Second, the discrepancy may be due to the characteristics of patients we recruited. Most of our participants were in chronic phase of stroke (median 38.5 months after onset), a short, simple assessment (i.e., the MNA-SF) may not be able to catch their total nutritional status. Although it might have to spend more time on administer, it was a trade-off for using a more comprehensive assessment (i.e., the full MNA) to gain more precise results. Our findings suggest that the full MNA was more suitable than the MNA-SF for identifying the risk of deteriorating QOL, in addition to identifying the risk of malnutrition, in patients with chronic stroke.

Three limitations of the present study should be acknowledged. First, the cross-sectional design of our study does not permit drawing causal relationships so it is hoped that these findings prove that future longitudinal studies are needed. Second, the patients included in this study were a convenience sample with chronic and ischemic stroke. Thus, the results of this study may not be generalizable to patients in other stages and types of stroke (e.g., acute stage and hemorrhagic stroke). Third, a large number of the participants in this study were well-nourished. To further validate our findings, future studies that recruit stroke patients with a diverse range of nutritional status are needed.

5 Conclusion

This study has shown a relationship between nutritional status, comprehensive ADL function, and QOL among patients with stroke. Patients with stroke with better nutritional status had higher ADL function as well as better QOL. The MNA-SF was useful in predicting comprehensive ADL, whereas, the full MNA could be used to predict QOL. Knowledge and evidence of the association and predictive power of the MNA-SF and full MNA could guide clinicians to choose tools for assessing the nutritional status of patients with stroke more effectively.

Footnotes

Acknowledgments

The authors would like to thank the participants for their work during data collection.

Conflict of interest

The authors declare no conflict of interest.

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