Undernutrition is reported to occur in a large

66 Dependence and Nutritional Status After Acute Stroke Mitra Unosson, RN, DMSc; Anna-Christina Ek, RN, DMSc; Per Bjurulf, MD, PhD; Henning von Schenck, MD, PhD; Jorgen Larsson, MD, PhD Background and Purpose We assessed the nutritional status of patients with acute stroke and evaluated it in relation to the patients' dependence on assistance with feeding. Methods Fifty patients aged 7 years or older, admitted from their homes, were included. Weight index, triceps skinfold thickness, arm muscle circumference, serum proteins, delayed hypersensitivity, body composition measured by bioelectric impedance, and functional condition were determined on admission and 2 and 9 weeks after admission. Food and fluid consumption were also recorded. Results On admission, four patients were regarded as protein-energy malnourished. Those who required assistance with feeding after admission (n=, 6%) had lower serum albumin (P<.), lower body cell mass (P<.), and were more anergic than the independent patients (P<.) on admission. The mean food consumption was 72% of the food served without significant difference between dependent and independent patients. Nine weeks after the onset of stroke symptoms, the patients who were dependent on assisted feeding showed a decrease in body cell mass. The loss of body cell mass was related to their activity and feeding dependence. Conclusions Low serum albumin and anergy commonly occur in elderly patients with acute stroke, and they occur more prevalently among those with a severely impaired functional condition. During the recovery period, the patients use body fat to compensate for energy needs, and immobility leads to loss of body cell mass. (Stroke. 994^:66-7.) Key Words diet elderly stroke Downloaded from http://ahajournals.org by on November, 2 Undernutrition is reported to occur in a large number of elderly patients on admission to a hospital. Among patients with acute stroke, undernutrition is reported at a frequency of 6%/ but how the acute stroke affects the nutritional status during the recovery period, regardless of the patients' residence after discharge, has not been determined. Stroke may affect the individual's physical and mental capacity and may also cause disability in cognitive function, perception, communication, and motor function. 6 Disturbances in eating behavior among patients with acute stroke are common and may cause a decline in food and fluid intake, leading to further decreases in nutritional status. 7 A correlation between changes in body weight and calculated energy from food intake during hospital stay has been reported. 2 Patients requiring help with feeding are reported to have a reduced nutrient intake. Because many patients with acute stroke are unable to perform self-care activities, undernutrition may result and then accelerate. The side effects of undernutrition are associated with decreased immune competence, 9 increased rate of pressure sores, higher morbidity and mortality, and prolonged hospital stay. The aim of the present study was to describe the nutritional status in elderly patients with acute stroke on admission and after 2 and 9 weeks and to evaluate the patients' nutritional state in relation to food intake and dependence on assisted feeding. Received May 2, 99; final revision received September 27, 99; accepted October 2, 99. From the Departments of Caring Sciences, Community Medicine, Clinical Chemistry and Surgery, Faculty of Health Sciences, University of LinkOping, Sweden. Correspondence to Mitra Unosson, Faculty of Health Sciences, Department of Caring Sciences, S- LinkOping, Sweden. Subjects and Methods All patients aged 7 years or older, living at home, who were admitted to a neurological unit from April to October 99 with a clinically diagnosed stroke were included. Patients suffering from renal, hepatic, or malignant diseases were excluded. Informed consent was obtained from either the patients or their next of kin after written and oral information about the investigation. The study was approved by the Research Ethical Committee of the Faculty of Health Science, Linkdping University, Sweden. Of 6 consecutive patients, refused. Of the patients included in the study, 27 were female and 2 male, the mean age being.2±4. years and 77.7±4.4 years, respectively. During the interval of observation, (6%) patients died (2 men and 6 women; mean age,.6±. years), and 4 refused to participate further. On the basis of their medical records, patients were diagnosed as having cerebral infarction, 4 intracerebral hemorrhage, unspecified stroke, and transient ischemic attack, of whom 29 had hemiparesis and 2 hemianopsia. Nutritional status was assessed within 4 hours after admission and after 2 and 9 weeks. The patient's height was measured in the supine position on a flat bed. The measuring equipment had a fixed head and foot part, adjustable in the middle. Weight was measured with an electronic bed scale (Viola-scale, KEBO Care, Sweden) and a portable bathroom scale for the ambulatory patients. The two scales were checked for accuracy by a precise set of weights. Weight index was calculated according to the following equation: actual weight/ reference weight for women=.6xheight-4.4, and for men=".xheight-62., taken from a population of middleaged and elderly men and women in Sweden. Midarm circumference (MAC) was measured with a tape measure, and triceps skinfold thickness (TSF) was measured with a Harpenden skinfold caliper. MAC and TSF were taken from the left arm, except when the left arm was paralyzed. The arm muscle circumference (AMC) was calculated as AMC=MAC. (irxtsf), and the reference values used were related to age and sex from a Swedish reference population. 4 All

Unosson et al Nutritional Status After Stroke 67 Downloaded from http://ahajournals.org by on November, 2 anthropometric measurements were performed by the same investigator. Serum protein analysis included serum albumin, transthyretin, and a,-antitrypsin. The assays were performed applying the Behring Nephelometer Analyzer with standards and antisera from Behringswerke (Svenska Hoechst, Stockholm, Sweden). The interassay coefficients of variation were.%,.4%, and 4.%, respectively. Delayed hypersensitivity skin testing was performed on admission and at 9 weeks, using three antigens: purified protein derivative, Candida, and mumps. The patients were regarded as reactive if the sum of two perpendicular diameters, read at 4 hours, in at least one of the tests was > mm; they were regarded as anergic if the reaction was < mm. The patients were classified as proteinenergy malnourished if at least three nutritional variables were lower than the following values, including one of each of the anthropometric, serum protein, and skin test measurements. The cutoff values for men and women, respectively, were as follows: weight index, <% and <%; TSF, s6 mm and <.\2 mm; AMC, s2 cm and 9 cm in those aged 79 years and s2 cm and s cm in those aged >79 years; transthyretin, <.2 g/l and <. g/l; albumin, <6 g/l and <6 g/l; and skin test, < mm and < mm. Body fat mass, body lean mass, total body water, and body cell mass were assessed by a bioelectric impedance analyzer (model BIA-, RJL Systems, Detroit, Mich) on admission and after 2 and 9 weeks. Bioelectric impedance was measured between the hand and the foot of the left side with the patient in the supine position, with the arms and the legs abducted. 6 Formulas provided by the manufacturer of the instrument were used. Eleven patients were not assessed because of technical problems, edema, or the presence of a pacemaker. The patients were divided into two groups according to feeding dependence in the first week after admission: independent (2 of 2 with hemiparesis), those who fed themselves without assistance; and dependent (7 of with hemiparesis), those who received assistance such as cutting the food or spoon feeding or those who were fed partly through intravenous fluids. 7 To assess the patients' mental condition, activity, mobility, incontinence, and general physical condition, the Norton scale was used, modified by including food and fluid intake." Each variable was scored through 4, with representing lack of function and 4 representing full or almost full function. When the patients were in the hospital the ratings were performed by the research nurse and the practical nurses responsible for the patients' care. When the patients were at home the ratings were performed by two research nurses. The patients' voluntary food and fluid intake was recorded for 26 patients ( dependent and 6 independent) on 2 consecutive days and 2 weeks after admission for those patients who remained at the neurological ward and consumed solid foods. The amount of food eaten was calculated by weighing the food before and after the consumption of three main meals (breakfast, lunch, and dinner) using an electronic scale (EKS International AB, Sweden) accurate to ± g. All fluids were registered. The patients were given ordinary hospital food and were offered the same menu during the first and second week when the food was recorded. The amount of food served was calculated by weighing 2 portions, excluding the packing. The mean was 22 g/d, containing 62 kj and 7 g of proteins, drinks excluded. The amount of food consumed was estimated as a mean of the 4 recorded days. The occurrence of complications during the stay at the neurological unit was collected from the patients' medical records. The statistical analyses were performed with Student's t test for dependent and independent groups, Fisher's exact test, Mann-Whitney U test, and multiple regression analysis. For regression analysis, the dependent variable was the change of body cell mass between admission and 9 weeks after admission. The independent variables were the values of activity (, TABLE. Anthropometry, Serum Proteins, Anergy, and Body Composition In Men and Women on Admission Transthyretin, g/l Antitrypsln, g/l Anergy, No. of patients Men (n=2) 72.+. 92.6±.2.±2. 2.±2..±..24±.6.2±.2 /2 Women (n=27) 6.9±2.2 99.±. 9.±6. 24.±. 4.4±.2.2 ±..2±.26 /26 (n=9) 9.4±6..±6..±.4.4±.2 (n=2) 2.±6. 4.4±6.6 29.±.9.±.6 Values are mean±sd. TSF indicates triceps skinfold thickness; AMC, arm muscle circumference. ambulant;, walks with help or worse), food intake (, normal;, insufficient or parenteral), and feeding capacity (, feeds self;, needs assistance) on week 2. The independent variables were tested all together, in pairs, and singly. Results The patients' nutritional status and body composition on admission are described in Table. Initially serum albumin and transthyretin values below the cutoff limits used were noted in (62%) and 9 (%) patients, respectively. Four of the patients met criteria for protein-energy malnutrition (2 women and 2 men), and these were also judged to be malnourished with the skin tests excluded. One week after admission, (6%) of the patients required assistance with feeding, while 2 (64%) were independent. Of those who were dependent, three patients were fed partly with intravenous fluids. The patients who required assistance were older (mean age,.2±4. years [range, 7 to 9 years]) than those who were independent (mean age, 77. ±4. years [range, 7 to 7 years]) (P<.). More women than men were dependent (P<.) (Table 2), but there were no differences in coexisting diseases. During the course of the study patients (6%) were discharged to their homes, and 7 were transferred to geriatric clinics. The proportion of the patients who required transferral to geriatric clinics was higher in the dependent than in the independent group (P<.) (Table 2). All those who died before leaving the neurological ward (n=) or the geriatric hospital (n=) belonged to the dependent group. The mean inpatient stay in the neurological ward for the dependent patients was ±.9 days, compared with 9.±4 days for the independent patients (P<.). On admission the serum albumin concentration and body cell mass were lower in the dependent group than in the independent (Table ). Thirteen (72%) of the dependent patients were anergic on admission, com-

6 Stroke Vol 2, No 2 February 994 Downloaded from http://ahajournals.org by on November, 2 TABLE 2. Sex, Residence, Social Condition, and Clinical Outcome Among and Patients Sex Men Women Residence Own house/apartment Service apartment Sodal condition Alone Cohabitant Clinical outcome Discharged to home Transferred to geriatric clinic Died in neurological ward (n=) 4 4 2 (n=2) 4 2 9 27 Transthyretln, g/l Antitrypsin, g/l (n=) 64.±.2 94.2±2.6 4.±7.9 2.7±. 2.±4..2±..67±.47 (n=2) 2.2±.2 44.6±.6 2.4±6..±.2 (n=29) 6.6±.7 9.9±2..7±4.7 2.±2.4 4.7±.t.2±.7*.29±.2t (n=24) 2.2±6. 49.±. 6.4±6. v " 9.±.9+ Values are mean±sd. TSF indicates triceps skinfold thickpared with (2%) of the independent patients CP<.). Two weeks after admission the dependent patients had lower concentrations of serum albumin and transthyretin, a higher concentration of a,-antitrypsin, and lower body cell mass compared with the independent patients (Table 4). Paired t tests between admission and the 2-week follow-up showed that both TSF (P<.) and serum albumin concentration decreased (P<.) in the patients who were dependent, whereas the patients who were independent showed a decline in TSF and body fat (P<.). TABLE. Anthropometry, Serum Proteins, and Body Composition on Admission In and Patients (n=) (n=2) Transthyretin, g/l Antitrypsin, g/l Anergy, No. of patients 6.±4.7 97.±2. 6.2±7.6 24.7±. 2.±.9.2 ±..±.27 / (n=) 2.±7. 4.7±7.2.±. 4.±. 6.±. 9.4±.7 4.±.7 2.±2.6. ±4.4*.2±..26±.2 / (n=24) 2.±. 4. ±..±.*.4±.t Values are mean±sd. TSF indicates triceps skinfold thickness; AMC, arm muscle circumference. *P<., tp<. by Student's t test. TABLE 4. Anthropometry, Serum Proteins, and Body Composition 2 Weeks After Admission In and Patients *P<.O, tp<.ooi by Student's Mest. At the 9-week follow-up the dependent patients had lower concentrations of serum albumin and lower body cell mass compared with the independent patients (Table ). The change of body cell mass between admission and 9 weeks later was significantly greater in the dependent group (Table 6). Multiple regression analysis showed a varying pattern of significant relations between the change of body cell mass and the patients' activity and feeding dependence. This latter related significantly to the change of body cell mass both in combination and singly (R between 4.% and 44.%, TABLE. Anthropometry, Serum Proteins, Anergy, and Body Composition 9 Weeks After Admission In and Patients (n=) (n=2) Transthyretin, g/l Antitrypsin, g/l Anergy, No. of patients.7±4.9 7.±22. 2.±.7 2.2±.4.6±4.6.2±.4.4±.27 / (n-).±9. 4.6±.9 2.2±..2±. 6.±.* 96.±.2 4.±.6 24.6±2.6.±2.9t.27±.7.24±.4 /27 (n-2) 9.4±. 4.6±9.9.±6.4 9.±4.9t Values are mean±sd. TSF Indicates triceps skinfold thickness; AMC, arm muscle circumference. *P<., tp<. by Student's t test.

Unosson et al Nutritional Status After Stroke 69 TABLE 6. Changes of Anthropometry. Serum Proteins, and Body Composition Between Admission and After 9 Weeks In and Patients Transthyretln, g/l (n=) -.47±.9 -.69±2.2.6±.9 -.±..±. (n=) -.6±2.6 (n=2) -.42±2.7 -.4±. -.4±.*.2±.2.±.4* (n=2) -2.±2.42t P (mean change between the two groups).97.9.26.4.22.±.6.±2.4-2.±4.46.7±4.7.9 ±2.9.2±...49. Values are mean±sd change. TSF Indicates triceps sklnfold thickness; AMC, arm musde drcumference. *P<., tp<., *P<. by paired Student's nest..2 Downloaded from http://ahajournals.org by on November, 2 / > <.2). Three patients reverted to malnutrition at the end of the study, all of whom belonged to the dependent group. The patients' mean food intake was 9±29 g/d, which is equal to 72% of the food served. The mean fluid intake was 7±2 ml/d. The dependent group consumed 79 ±2 g/d of the food served (64%) and 2±29 ml/d of the fluids compared with 92± g/d of food (7%) and 99 ±22 ml/d of fluids in the independent group (P>.). Before admission there were no significant differences between the dependent and independent patients on the modified Norton scale (Table 7). The numbers of patients in the dependent and independent groups with impaired functional condition at 2 and 9 weeks are shown in Table 7. While at the neurological care unit, 6 patients (2%) experienced at least one complication, of those in the dependent group (Table ). Discussion The major findings of the present investigation were that a high proportion of acute stroke patients admitted from their own home had a low concentration of serum proteins on admission, % were considered to be protein-energy malnourished, and approximately one third were dependent on assisted feeding. The dependent group had a lower serum albumin concentration and lower body cell mass on admission and after 2 and 9 weeks compared with the independent group. The loss of body fat during the observation period was not related to the patients' dependence, in contrast to the loss of body cell mass, which was greater in those who were dependent. According to the 976 study of Katz and Akpom, 7 patients who need help to prepare food should be classified as independent. However, we chose to place those patients in the dependent group for the statistical analysis, because stroke patients who need help to prepare food usually do so because of paresis in the upper extremity. Although there are many methods available to estimate body composition, there are also several limitations. 2 Anthropometric measurements and bioelectric impedance analysis were the methods used in this study. The reference values for our anthropometric measurements were obtained from a Swedish population and are adjusted for age and sex. ' 4 There is no ideal method for assessing nutritional status in elderly patients. We used a combination of anthropometric measurements, serum proteins, and skin tests to define protein-energy malnutrition. TABLE 7. Number of Patients With Low Modified Norton Score (<;) Before the Onset of Stroke Symptoms and After 2 and 9 Weeks Comparing and Patients Low Modified Norton Score (s) Mental condition Activity Mobility Food intake Fluid intake Incontinence Before (n=6) 2 2 General physical condition *P<., tp<. by Mann-Whitney U test. Week 2 (n=) 4 4 Week 9 (n=) 6 7 6 Before (n=2) 4 9 Week 2 (n=29) * 6t t t Ot 9t t Week 9 (n=2) 4* t t t 4*

Downloaded from http://ahajournals.org by on November, 2 7 Stroke Vol 2, No 2 February 994 TABLE. Incidence of Complications During Stay at Neurological Care Unit In and Patients Complication Pressure sore Vein thrombosis Cardiac failure Gastrointestinal problems Pneumonia Urinary tract Infection Other At least one complication (n=) 4 7 (n=2) * Total (n=) 2(4) (2) 2(4) (2) (2) 4() (6) 6(2) Values are number of patients, with percentage in parentheses. *P<. by Fisher's exact test. Although bioelectric impedance analysis is supposed to be an appropriate method of assessing body composition, 2 good validity and reliability have been reported by some 222 but not all. 2 ' 24 Reliable assessment of different compartments of body composition in the elderly seems to require population-specific prediction formulas validated in different health situations. 24 Therefore, until such formulas are available, the results in the present study should be interpreted with some caution because the formulas used were estimated from younger adults. Eating dependence followed the alterations of the patients' condition as assessed by the modified Norton scale (Table 7). patients require both time and the commitment of the nursing staff to provide for their food and fluid intake, 2 despite the amount of food intake being only a little less than that of the independent patients. Food records with regard to amount were kept only for those patients who consumed solid foods. The nutritional content could not be measured because the records did not show whether the patients had selective reduction of foodstuffs. The difference in serum albumin concentration between the dependent and independent groups on admission (Table ) is probably due to significant problems before the onset of the stroke. A gradual fall in albumin concentration develops when the consumption of protein is insufficient despite adequate energy consumption over a long time. 26 We did not investigate food habits before admission. In addition to lower serum albumin on admission, the dependent patients were also significantly more anergic and had lower body cell mass than the independent patients, while there were no significant differences in the anthropometric variables. Those differences might be related to the patients' lifestyle before admission. Low physical activity and high caloric intakes may have affected the body composition in the dependent group. However, the dependent patients were older than those who were independent, and there were more women. Longitudinal studies of body composition in the elderly have shown that body cell mass decreases with age and is lower in women than in men. 27 It is difficult to ascertain the actual influence of age on body cell mass in this study because the age difference between the two groups is not very large. At the follow-up, the high concentration of antitrypsin and the low concentration of serum albumin and transthyretin indicate acute phase reaction, ie, an active disease process. Nine weeks after admission there was a decline in body fat in both the dependent and independent groups, indicating consumption of energy stores. In contrast, the change of body cell mass between admission and after 9 weeks was significantly greater in the dependent patients compared with the independent (Table 6). Malnutrition is characterized by loss of body cell mass, while lean body mass changes minimally. 2 Immobilized individuals lose muscle mass irrespective of nutritional intake because of reduced synthesis of proteins, while the rate of breakdown of proteins is unchanged. 2 The dependent patients in this study were more immobilized (Table 7). Keeping this in mind, we used regression analysis to test the hypothesis of whether the change of body cell mass was more related to the patients' functional condition than to food intake. Our results showed significant relations between patients' activity and feeding dependence. According to Katz and Akpom, 7 there is a pattern of cumulative order among personal activities of daily living. If the patient loses the ability to feed, he or she has also lost all other abilities in the activities of daily living scale. Therefore, early rehabilitation is important not only to help the patient gain independence and function but also preserve body cell mass. Even in severely impaired patients after stroke, mobility improves continuously for up to months afterward. 29 The sample size in our study was small, however, and there is need for further studies. In summary, hypoalbuminemia and anergy were common on admission in elderly patients with acute stroke, and this seemed to be more obvious in the dependent group. During the recovery period the stroke patients seemed to break down body fat to compensate for energy needs, independent of their functional condition. However, change of body cell mass appeared to relate to the patients' functional condition after stroke. These are relevant data that draw attention to the need for both nutritional intake and intensive rehabilitation measures during the recovery period. There is also a need for more prospective controlled studies. Acknowledgments This study was supported by grants from the Swedish Medical Research Council and the research fund of the County of Ostergotland. The nursing staff of the Department of Neurology care units is also gratefully acknowledged. References. Albiin N, Asplund K, Bjermer L. Nutritional status of medical patients on emergency admission to hospital. Acta Med Scand. 92;22:-6. 2. Sandstrom B, Alhaug J, Einarsdottir K, Simpura E-M, Isaksson B. Nutritional status, energy and protein intake in general medical patients in three Nordic hospitals. Hum Nulr Appl Nutr. 9;9A: 7-94.. Cederholm T, Hellstrom K. Nutritional status in recently hospitalized and free-living elderly subjects. Gerontology. 992;: -. 4. Axelsson K, Asplund K, Norberg A, Alafuzoff I. Nutritional status in patients with acute stroke. Acta Med Scand. 9;224:27-224.

Unosson et al Nutritional Status After Stroke 7. Hamrin EKE, IJndmark B. The effect of systematic care planning after acute stroke in general hospital medical wards. J Adv Nun. 99;:46-. 6. Bernspring B, Fugel-Meyer AR, Viitanen M. Perceptual function in the elderly and after stroke. ScandJ Caring Set. 9;2:7-79. 7. Axelsson K, Norberg A, Asplund K. Eating after a stroke: towards an integrated view, lnt J Nun Stud. 94^2:9-99.. MacLennan WJ, Martin P, Mason BJ. Causes for reduced dietary intake in a long-stay hospital. Age Ageing. 97;4:7-. 9. Ek A-C, Larsson J, von Schenck H, Thorslund S, Unosson M, Bjurulf P. The correlation between anergy, malnutrition and clinical outcome in an elderly hospital population. Clin Nutr. 99; 9:-9.. Ek A-C, Unosson M, Larsson J, von Schenck H, Bjurulf P. The development and healing of pressure sores related to the nutritional state. Clin Nutr. 99;:24-2.. Larsson J, Unosson M, Ek A-C, Nilsson L, Thorslund S, Bjurulf P. Effect of dietary supplement on nutritional status and clinical outcome in geriatric patients: a randomised study. Clin Nutr. 99;9:79-4. 2. Sullivan DH, Patch GA, WaUs RC, Lipschitz DA. Impact of nutrition status on morbidity and mortality in a select population of geriatric rehabilitation patients. Am J Clin Nutr. 99;: 749-7.. Warnold I, Lundholm K. Clinical significance of preoperative nutritional status in 2 noncancer patients. Ann Surg. 94;99: 299-. 4. Symreng T. Arm anthropometry in a large reference population and in surgical patients. Clin Nutr. 92;:2-29.. Symreng T, Groth O, Norr A, Schildt B, Zetterqvist H. Delayed hypersensitivity: a critical evaluation of five recall antigens in a large reference population. Clin Nutr. 9;l:26-27. 6. Lukaslri HC, Johnson PE, Bolonchuk WW, Lykken GI. Assessment of fat-free mass using bioelectrical impedance measurements of the human body. Am J din Nutr. 9;4:-7. 7. Katz S, Akpom CA. A measure of primary sociobiological functions, lnt J Health Serv. 976;6:49-7.. Hulter Asberg K, Sonn U. The cumulative structure of personal and instrumental ADL. Scand Rchabil Med. 9;2:7-77. 9. Ek A-C, Bjurulf P. Interrater variability in a modified Norton scale. Scand J Caring Sci. 97;l:99-2. 2. Lukaski HC. Methods for the assessment of human body composition: traditional and new. Am J Clin Nutr. 97;46:7-6. 2. Shizgal HM. Validation of the measurement of body composition from whole body bioelectric impedance. Infusionstherapie. 99; 7(suppl ):67-74. 22. Steen B, Bosaeus I, Elmsthal S, Garvard H, Isaksson B, Robertsson E. in the elderly estimated with an electrical impedance method. Compr GerontolA. 97;l:2-. 2. Deurenberg P, van der Kooij K, Evers P, Hushof T. Assessment of body composition by bioelectrical impedance in a population aged >6 y. Am J Clin Nutr. 99^:-6. 24. Svendsen OL, Haarbo J, Heitmann BL, Gotfredsen A, Christiansen C. Measurement of body fat in elderly subjects by dualenergy x-ray absorptiometry, bioelectrical impedance, and anthropometry. Am J Clin Nutr. 99^:7-2. 2. Athlin E, Norberg A, Asplund K. Caregivers' perceptions and interpretations of severely demented patients during feeding in a task assignment system. Scand J Caring Sci. 99;4:47-. 26. Haider M, Haider SQ. Assessment of protein-calorie malnutrition. Clin Chan. 94;:26-299. 27. Steen B, Lundgren BK, Isaksson B. at age 7, 7, 79, and years: a longitudinal population study. In: Chandra RK, ed. Nutrition, Immunity and Illness in the Elderly. New York, NY: Pergamon Press, Inc; 9:49-2. 2. Schonheyder F, Heilskov NCS, Olesen K. Isotopic studies on the mechanism of negative nitrogen balance produced by immobilization. Scand Clin Lab Invest. 94;6:7-. 29. Lindmark B. The improvement of different motor functions after stroke. Clin Rehabil. 9;2:27-2. Downloaded from http://ahajournals.org by on November, 2