General Medicine 2015, vol. 16, no. 2, p. 68–75.

Original Articles

Factors Associated with Recovery of Activities of Daily Living

in Elderly Pneumonia Patients

Ryohei Goto, PT, MS,1,2 Hiroki Watanabe, PT, MS,1,2

Naoki Tanaka, PT, PhD,2 Takeshige Kanamori, PT,2
and Hisako Yanagi, MD, PhD3

1
Department of Medical Science and Welfare, Graduate School of Comprehensive Human Sciences,
University of Tsukuba, Tsukuba, Japan
2
Department of Rehabilitation, Tsukuba Memorial Hospital, Tsukuba, Japan
3
Department of Medical Science and Welfare, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan

Background: The current study aimed to investigate factors associated with the prognosis of activities of daily living
(ADL) in elderly patients with pneumonia who had undergone rehabilitation during their hospitalization.

Methods: The study included patients of age ²65 years who were hospitalized due to pneumonia and had undergone
rehabilitation for disuse syndrome at Tsukuba Memorial Hospital. The main outcome was measured using the
functional independence measure (FIM) scores to assess ADL. The participants were divided into a high-recovery
group (²80%) and a low-recovery group (<80%) based on the FIM recovery rate score. Further, factors associated with
the prognosis of ADL were evaluated using multivariate logistic regression analysis. Basic characteristics,
consciousness, usual mode of transportation, FIM score, grip strength, range of motion, orthostatic hypotension,
exercise tolerance (6-minutes walking distance), respiratory disorder (Hugh–Jones classification), constipation,
malnutrition (mini-nutritional assessment), cognitive (mini-mental state examination), depression (geriatric depression
scale), balance (functional balance scale), urinary incontinence, and pressure ulcers were included as the evaluation
items.

Results: Among the 51 elderly patients with pneumonia (average age « SD; 82.0 « 11.3), 34 patients were classified in
the high-recovery group and 17 in the low-recovery group. In multivariate logistic regression analysis, it was revealed
that the number of days from the onset until the initiation of rehabilitation (days of inactivity) and nutritional status were
factors associated with a high-recovery FIM score.

Corresponding author: Hisako Yanagi, MD, PhD

Department of Medical Science and Welfare, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba,
Ibaraki 305-8577, Japan
E-Mail: hyanagi@md.tsukuba.ac.jp
Received for publication 22 July 2014 and accepted in revised form 14 January 2015
© 2015 The Japan Primary Care Association

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 Factors Associated with Recovery of Activities of Daily Living in Elderly Pneumonia Patients
Conclusions: The study results suggest that days of inactivity and early management of nutritional status after
hospitalization are important for elderly patients with pneumonia to return to their ADL.
Introduction
Hospitalization for acute illness is a stressful and
potentially hazardous event for elderly patients.1–4
Acute illness and prolonged bed rest are associated
with a significant decline in functional ability called
disuse syndrome. Disuse syndrome includes symptoms
that are a) musculoskeletal, b) cardiovascular and
pulmonary, c) genitourinary and gastrointestinal, d)
metabolic and endocrine, and e) cognitive and behav-
ioral caused by inactivity, immobility, and prolonged
bed rest.5 The effectiveness and feasibility of early
physical rehabilitation programs for hospitalized eld-
erly patients in preventing a decline in functional
ability due to disuse syndrome have been reported in a
previous study,6 which indicated that early physical
rehabilitation care for acutely hospitalized elderly
patients could lead to functional benefits and be safely
done.
Pneumonia is the third most common cause of death
and is one of the most frequent reasons for the initiat-
ing the Long-Term Care Insurance (LTCI) system in
Japan.7 Guy et al. reported that the extent and mobility
outcomes of acute inpatient rehabilitation for hospital-
associated deconditioning in the elderly were associ-
ated with mobility from admission to rehabilitation
and indicated the importance of rehabilitation in
elderly patients including those with pneumonia.8
Early physical rehabilitation programs seem to be
important for the elderly patient to reduce required care
after pneumonia. However, it is unclear whether the
prognosis of activities of daily living (ADL) for elderly
patients with pneumonia is affected by the initiation
time of rehabilitation. Furthermore, factors associated
with the prognosis of ADL, including disuse symp-
toms, in elderly patients with pneumonia have not yet
been clarified.
The purpose of the current study was to investigate
factors associated with the prognosis of ADL in elderly
patients with disuse syndrome due to pneumonia who
had undergone rehabilitation during hospitalization.
— 69 —
Methods
Participants
The study included patients of age ²65 years who were
hospitalized at the Tsukuba Memorial Hospital from
August 2012 to July 2013 and had undergone a
rehabilitation program for disuse syndrome due to
pneumonia diagnosed by a physician. Patients who
were discharged within one week, died during hospi-
talization (because it is impossible to evaluate at
discharge), or did not consent were excluded from the
study.
All patients and their families read and signed the
informed written consent. This study was conducted in
accordance with the guidelines proposed in the
Declaration of Helsinki, and the study protocol was
reviewed and approved by the Ethics Committee of
Tsukuba Memorial Hospital and the University of
Tsukuba, Japan.
Measures
Each subject’s main characteristics [age, sex (male or
female), living place before hospitalization (home or
facility), use of the LTCI system (independent, support
level, or care level), usual mode of transportation
before onset (gait, wheelchair, or other), functional
independence measure (FIM) score9 before onset (total,
motor, and cognitive), number of days from onset until
initiation of rehabilitation (days of inactivity), duration
of stay, number of days from hospitalization until
initiation of rehabilitation, and the A-DROP system10]
were collected from medical records.
The Japanese LTCI system consists of seven eligibility
levels, including two support levels and five care
levels. For support levels, the service is basically used
to prevent the care level from worsening. Alternatively,
care level 1 or higher means some help is required for
ADL, and care level 3 or higher means total care for
ambulation or clothing is required.11 The A-DROP
system is severity stratification of pneumonia modified
CURB-65,12 and it comprises five items (Table 1). It
classifies the case as severe pneumonia if more than
 General Medicine 2015, vol. 16, no. 2

Table 1. A-DROP system indicates a low level of functioning, and the maximum
Age male: 70 years or older score is 126, which indicates a very high level of
female: 75 years or older functioning.19
Dehydration BUN: 21 mg/mL or more, dehydration
Respiration SpO2: 90% or less Analysis
(PaO2: 60 Torr or less) The participants were classified into two groups
Orientation disturbance of consciousness according to their FIM recovery rates [FIM score at
Pressure SBP*: 90 mmHg or less discharge/FIM score before onset © 100 (%)]. The
*SBP, systolic blood pressure participants with a FIM recovery rate ²80% were
defined as the high recovery group (high group),
three items pertain. whereas those with a FIM recovery rate <80% were
An evaluation was performed for each subject within defined as the low recovery group (low group).
three days of the initiation of rehabilitation and no Student’s t-test was used for quantitative variables
more than three days before discharge. The initiation of when comparing the means of the two groups. A »2 test
rehabilitation was defined as the day when instruction was used to test the significance of the association
regarding rehabilitation was given by a physician. For between the two qualitative variables. Variables were
evaluation, basic characteristics, consciousness, usual removed if collinearity diagnostics found correlation
mode of transportation (gait, wheelchair, or other), FIM coefficients between variables of ²0.7.20 Multivariate
score (total, motor, and cognitive), and the following logistic regression analysis (forced entry) was used to
twelve items were included. determine the factors associated with a high FIM
1) Muscle strength: grip strength (kg) recovery rate. The level of statistical significance was
2) Range of motion: cervical spine, shoulder, elbow, set at p < 0.05. All statistical analyses were performed
hip, knee, and ankle on SPSS 21.0 for Windows.
3) Orthostatic hypotension (Yes/No)
4) Exercise tolerance: 6-minute walking distance (6- Results
MWD) test (m)13 A total of 167 elderly patients with pneumonia were
5) Respiratory disorder: Hugh–Jones classification hospitalized during the study period, and of these, 72
ranging from 1–514 patients underwent rehabilitation for disuse syndrome
6) Constipation (Yes/No) due to pneumonia. Further, of the 72 patients who
7) Malnutrition: Mini Nutritional Assessment underwent rehabilitation, 21 of them were excluded. A
(MNA) ranging from 0–3015 total of 51 patients were included in the study
8) Cognitive: Mini-Mental State Examination (Figure 1). The average age (« SD) of the subjects
(MMSE) ranging from 0–30 16
was 82.0 « 11.3 years (high group: 83.2 « 7.6 years,
9) Depression: Geriatric Depression Scale 15 low group: 79.6 « 16.0 years) and 56.9% were female
17
(GDS15) ranging from 0–15 (high group: 58.8%, low group: 52.9%). Analysis of
10) Balance: Functional Balance Scale (FBS) ranging living place before hospitalization revealed that 68.6%
from 0–5618 of the patients were at home and 31.4% of the patients
11) Urinary incontinence (Yes/No) were in a facility. Evaluation of their LTCI system
12) Pressure ulcers (Yes/No) levels revealed that 29.4% of subjects were inde-
Functional disability was assessed using the FIM score, pendent and 70.6% were at the care level. No subjects
which can measure both physical and cognitive ability. were at the support level. A total of 23 patients (45.1%)
The FIM comprises thirteen motor items and five had been able to move on their feet and 26 patients
cognitive items. The items are scored on a seven-point (51%) used a wheelchair before onset. The total FIM
ordinal scale based on the amount of assistance score was 61.2 « 35.6, motor FIM score was
required. The minimum score for the FIM is 18, which 43.8 « 27.8, and cognitive FIM score was 17.3 « 9.7

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 Factors Associated with Recovery of Activities of Daily Living in Elderly Pneumonia Patients

Figure 1. Flow diagram of the sample before onset. Days of inactivity was 4.6 « 4.5 days,
Hospitalized elderly patients
duration of hospital stay was 22.7 « 14.4 days, and
of pneumonia during study duration of hospitalization before initiating rehabilita-
period (n=167)
tion was 2.7 « 1.7 days.
As shown in Table 2, days of inactivity was signifi-
Undergone rehabilitation for cantly different in the comparison between the high
disuse syndrome group and low group (high group: 3.5 « 3.4 days, low
(n=72)
group: 5.6 « 5.2 days, p = 0.048). According to the A-
Exclude (n=21) DROP pneumonia severity index, five patients (14.7%)
discharged within one week (n=6)
had severe pneumonia in the high group and five
died during hospitalization (n=8)
did not consent (n=7) patients (29.4%) had severe pneumonia in the low
group.
Participants in the study
(n=51) The variables significantly different at the initiation of
rehabilitation in comparison between the two groups

Table 2. Demographic and clinical characteristics of elderly pneumonia patients

participants high group low group P value
n = 51 n = 34 n = 17 (high vs low)
Age
(Mean « SD) 82.0 « 11.3 83.2 « 7.6 79.6 « 16.0 0.285
Sex
Male n (%) 22 (43.1) 14 (41.2) 8 (47.1) 0.769
female 29 (56.9) 20 (58.8) 9 (52.9)
Living place before hospitalization
home n (%) 35 (68.6) 25 (73.5) 10 (58.8) 0.345
facility 16 (31.4) 9 (26.5) 7 (41.2)
LTCI system
independent n (%) 15 (29.4) 9 (26.5) 6 (35.3) 0.532
support level 0 (0.0) 0 (0.0) 0 (0.0)
care level 36 (70.6) 25 (73.5) 11 (64.7)
Transportation before onset
gait n (%) 23 (45.1) 18 (52.9) 5 (29.4) 0.275
wheelchair 26 (51.0) 15 (44.1) 11 (64.7)
other 2 (3.9) 1 (2.9) 1 (5.9)
FIM before onset
Total (Mean « SD) 61.2 « 35.6 64.9 « 36.4 54.6 « 29.5 0.366
Motor 43.8 « 27.8 46.1 « 28.2 40.4 « 23.3 0.516
Cognitive 17.3 « 9.7 18.7 « 9.3 14.2 « 9.5 0.142
Number of days
days of inactivity (Mean « SD) 4.6 « 4.5 3.5 « 3.4 5.6 « 5.2 0.048
duration of stay 22.7 « 14.4 22.5 « 16.1 23.1 « 8.7 0.908
before rehabilitation 2.7 « 1.7 2.4 « 1.4 3.0 « 1.7 0.189
Rehabilitation intervation
amount (minutes per day) (Mean « SD) 51.8 « 21.5 53.7 « 14.7 49.8 « 15.9 0.679
A-DROP
mild case n (%) 41 (80.4) 29 (85.3) 12 (70.6) 0.270
severe 10 (19.6) 5 (14.7) 5 (29.4)
LTCI, Long-Term Care Insurance; FIM, functional independence measure. days of inactivity, number of
days from onset until initiation of rehabilitation; before rehabilitation: number of days from
hospitalization until initiation of rehabilitation

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 General Medicine 2015, vol. 16, no. 2

Table 3. Comparison of patients between high recovery group and low recovery group
participants (n = 51) high group (n = 34) low group (n = 17) P value
starting discharge starting discharge starting discharge (high vs low*1)
Consciousness n (%)
clear 13 (23.5) 16 (31.4) 11 (32.4) 13 (38.2) 2 (11.8) 3 (17.6)
0.175
no clear 38 (74.5) 35 (68.6) 23 (67.6) 21 (61.8) 15 (88.2) 14 (82.4)
Transportation n (%)
gait 4 (7.8) 15 (29.4) 4 (11.8) 14 (41.2) 0 (0.0) 1 (5.9)
wheelchair 27 (52.9) 33 (64.7) 18 (52.9) 18 (52.9) 9 (52.9) 15 (88.2) 0.301
other 20 (39.2) 3 (5.9) 12 (35.3) 2 (5.9) 8 (47.1) 1 (5.9)
FIM (Mean « SD)
Total 41.7 « 26.1 52.3 « 31.5 47.1 « 28.0 59.5 « 32.6 28.3 « 13.3 33.9 « 16.8 0.023
Motor 26.2 « 18.7 36.1 « 24.2 30.0 « 20.2 41.6 « 24.9 17.0 « 9.3 21.4 « 12.2 0.029
Cognitive 15.4 « 9.2 16.6 « 9.4 17.1 « 9.3 17.8 « 9.2 11.3 « 7.6 12.4 « 7.7 0.046
Muscle strength (Mean « SD)
grip strength (kg) 10.9 « 8.2 12.3 « 8.5 12.4 « 8.6 14.1 « 8.8 8.6 « 4.9 9.7 « 5.7 0.344
Range of motion (Mean « SD)
cervical spines flexion 32.7 « 13.3 33.6 « 13.3 34.2 « 12.4 34.6 « 12.3 28.9 « 14.7 30.0 « 14.1 0.324
extension 30.9 « 16.4 31.4 « 16.3 32.5 « 15.9 33.1 « 16.2 26.7 « 17.2 26.7 « 15.6 0.380
shoulder flexion 126.3 « 35.0 127.3 « 34.8 131.5 « 33.9 132.5 « 33.1 115.8 « 34.6 116.9 « 35.8 0.194
extension 21.5 « 16.9 21.5 « 16.6 23.1 « 18.6 23.1 « 18.2 17.2 « 10.0 17.2 « 10.2 0.387
abduction 124.5 « 36.8 125.7 « 36.4 129.8 « 34.7 131.3 « 34.2 112.9 « 38.4 113.3 « 38.0 0.198
elbow flexion 131.5 « 12.3 132.1 « 11.2 132.6 « 11.2 133.0 « 11.2 129.2 « 14.3 130.0 « 10.8 0.436
extension ¹3.7 « 7.0 ¹3.5 « 6.6 ¹3.0 « 6.8 ¹2.6 « 6.1 ¹5.4 « 7.2 ¹5.4 « 7.0 0.328
hip flexion 111.9 « 13.3 112.4 « 13.1 113.0 « 12.1 113.0 « 12.3 109.7 « 15.2 111.3 « 14.4 0.442
extension ¹5.1 « 14.1 ¹4.9 « 14.1 ¹2.0 « 12.2 ¹1.7 « 12.2 ¹7.3 « 8.1 ¹7.3 « 8.4 0.149
knee flexion 125.2 « 16.5 125.0 « 15.7 127.8 « 15.2 127.2 « 14.9 120.3 « 17.7 120.7 « 16.4 0.164
extension ¹10.8 « 18.0 ¹11.0 « 18.2 ¹5.9 « 12.8 ¹6.2 « 13.3 ¹14.4 « 13.2 ¹14.2 « 13.4 0.040
ankle flexion 34.4 « 14.2 34.3 « 14.1 36.3 « 13.4 36.3 « 13.4 33.1 « 14.1 33.1 « 14.2 0.499
extension 4.8 « 10.9 5.6 « 11.4 5.5 « 8.8 6.1 « 9.2 1.9 « 9.7 2.8 « 9.5 0.218
Orthostatic hypotension n (%)
Yes 8 (15.7) 8 (15.7) 5 (14.7) 5 (14.7) 3 (17.6) 3 (17.6)
No 41 (80.4) 43 (84.3) 28 (82.4) 29 (85.3) 13 (76.5) 14 (82.4) 0.835
impossibility 2 (3.9) 0 (0.0) 1 (2.9) 0 (0.0) 1 (5.9) 0 (0.0)
Exercise tolerance (Mean « SD)
6MD (m) 5.6 « 15.0 15.6 « 39.7 6.8 « 16.9 19.3 « 45.5 2.3 « 7.2 5.7 « 11.5 0.253
Respiratory disorder n (%)
HJ 1 1 (2.0) 1 (2.0) 1 (2.9) 1 (2.9) 0 (0.0) 0 (0.0)
HJ 2–3 5 (9.8) 7 (13.7) 4 (11.8) 6 (17.7) 1 (5.9) 1 (5.9) 0.659
HJ 4–5 42 (82.4) 40 (78.4) 28 (82.4) 26 (76.5) 14 (82.4) 14 (82.4)
impossibility 3 (5.9) 3 (5.9) 1 (2.9) 1 (2.9) 2 (11.8) 2 (11.8)
Constipation n (%)
Yes 16 (31.4) 14 (27.5) 8 (23.5) 6 (17.6) 8 (47.1) 8 (47.1)
0.115
No 35 (68.6) 37 (72.5) 26 (76.5) 28 (82.4) 9 (52.9) 9 (52.9)
Nutrition (Mean « SD)
MNA 9.9 « 5.6 11.8 « 6.1 11.5 « 5.4 13.9 « 6.0 7.7 « 4.4 8.1 « 4.1 0.028
Cognitive (Mean « SD)
MMSE 16.3 « 8.5 17.3 « 8.5 17.3 « 7.9 17.8 « 8.0 13.5 « 9.4 15.9 « 9.7 0.291
Depression (Mean « SD)
GDS15 5.5 « 3.0 5.5 « 3.1 4.6 « 2.8 5.0 « 3.1 8.3 « 1.7 7.3 « 1.9 0.068
Balance (Mean « SD)
FBS 9.7 « 14.2 13.9 « 16.9 12.4 « 15.7 17.6 « 17.9 3.5 « 6.9 5.7 « 10.4 0.029
Urinary incontinence n (%)
Yes 10 (19.6) 5 (9.8) 4 (11.8) 1 (2.9) 6 (35.3) 4 (23.5)
0.065
No 41 (80.4) 46 (90.2) 30 (88.2) 33 (97.1) 11 (64.7) 13 (76.5)
Pressure ulcers n (%)
Yes 3 (5.9) 1 (2.0) 2 (5.9) 0 (0.0) 1 (5.9) 1 (5.9)
1.000
No 48 (94.1) 50 (98.0) 32 (94.1) 34 (100) 16 (94.1) 16 (94.1)

*1 high group vs low group at starting rehabilitation. FIM, functional independence measure; 6MD, 6-minutes walking
distance; HJ, Hugh–Jones classification; MNA, mini nutritional assessment; MMSE, mini-mental state examination;
GDS, geriatric depression scale; FBS, functional balance scale.

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 Factors Associated with Recovery of Activities of Daily Living in Elderly Pneumonia Patients
Table 4. Multivariate logistic regression analysis for recovery of ADL
B SE
Independent variables
days of inactivity ¹0.33 0.15
motor FIM score 0.06 0.04
MNA 0.32 0.15
Constant ¹2.66 3.02
Adjusted variables include age and sex. days of inactivity, number of days from onset until initiation
of rehabilitation; FIM, functional independence measure; MNA, mini nutritional assessment
were as follows: the total FIM score (high group:
47.1 « 28.0, low group: 28.3 « 13.3, p = 0.023),
motor FIM score (high group: 30.0 « 20.2, low group:
17.0 « 9.3, p = 0.029), cognitive FIM score (high
group: 17.1 « 9.3, low group: 11.3 « 7.6, p = 0.046),
knee extension range of motion (high group: ¹5.9 «
12.8, low group: ¹14.4 « 13.2, p = 0.040), MNA
(high group: 11.5 « 5.4, low group: 7.7 « 4.4, p =
0.028), and FBS (high group: 12.4 « 15.7, low group:
3.5 « 6.9, p = 0.029) (Table 3).
In multivariate logistic regression analysis, the total
FIM score and the cognitive FIM score at the initiation
of rehabilitation, knee extension range of motion, and
FBS were removed due to collinearity with the motor
FIM score at the initiation t of rehabilitation. Therefore,
the motor FIM score at the initiation t of rehabilitation,
days of inactivity, and MNA were established as
independent variables and FIM recovery rate (²80%,
<80%) was established as a dependent variable.
According to the results of logistic regression analysis,
days of inactivity (odds ratio: 0.72, 95% CI: 0.54–0.96)
and MNA (odds ratio: 1.37, 95% CI: 1.02–1.85) were
shown to be significantly associated with a high FIM
recovery rate (Table 4).
Discussion
In the present study, we aimed to investigate factors
associated with the prognosis of ADL (FIM score) in
elderly patients with disuse syndrome due to pneumo-
nia. To investigate the factors associated with good
recovery, we compared a high group (FIM recovery
rate ²80%) and low group. The total FIM score, motor
FIM score, cognitive FIM score, knee extension range
of motion, nutritional status (MNA), and balance
ability (FBS) were significantly different between the
— 73 —
Odds Ratio 95% CI P
0.72 0.54–0.96 0.024
1.06 0.99–1.15 0.094
1.37 1.02–1.85 0.036
0.07
two groups. Furthermore, multivariate logistic regres-
sion analysis revealed that days of inactivity and
nutritional status were associated with a high FIM
recovery rate.
Generally, prolonged bed rest results in disuse
syndrome which includes muscle weakness, joint
contractures, and orthostatic hypotension. However,
the effectiveness and feasibility of early physical
rehabilitation have been investigated in a previous
study and the importance of early rehabilitation has
been reported among patients with stroke, cardiopul-
monary disease, and other conditions.6,21,22 The current
study also showed that initiating rehabilitation early
was an important factor associated with a high
probability of recovery of ADL in elderly patients
with pneumonia. A previous study showed that func-
tional decline two weeks before hospitalization in
elderly patients influences hospital discharge and
functional outcomes.23 In the current study it is
interesting to note that no significant difference was
observed in the FIM score before onset between the
high group and low group. In addition, severity of
pneumonia at admission was not different between the
two groups. These findings may support the importance
of early rehabilitation.
Nutrition status was reported to be important for
recovery of ADL. In a previous study, low serum
albumin was associated with weaker muscle strength
and future decline in muscle strength in older women
and men.24 It has been considered that weaker muscle
strength causes a reduction in activity which may lead
to severe disuse syndrome. In the another study using
the MNA as an assessment of nutrition it was reported
that the prevalence of malnutrition was considerably
different between settings (hospital: 38.7%, rehabili-
 General Medicine
tation: 50.5%, nursing home: 13.8%, community:
5.8%).25 The prognosis of ADL in rehabilitation was
reported to be poor when there was malnutrition in the
previous study.26–29 In the present study, nutritional
status was already significantly different at the
initiation of rehabilitation between two the groups.
Therefore, it is believed that early management of
nutrition may be important for elderly patients with
pneumonia who have undergone rehabilitation.
It has been suggested that pneumonia itself has little
effect on ADL; however, ADL in elderly patients
with pneumonia is reduced due to disuse syndrome.
Therefore, we believe it is important to utilize early
rehabilitation to prevent or treat disuse syndrome.
Limitations
The current study contains significant content suggest-
ing the importance of early rehabilitation in elderly
patients with pneumonia. Nevertheless, there are three
limitations. (1) The sample size of the study was small,
so the variables that were included as independent
variables in multivariate analysis were limited. There-
fore, we excluded the variables that showed collinear-
ity, and included minimum variables. (2) There are
no unifying criteria among physician regarding the
optimal time of initiating rehabilitation after admission.
Therefore, we cannot deny the possibility that patients
who were expected to have a high recovery of ADL
were given the instruction of rehabilitation early by a
physician although there was no significant difference
in the duration of hospitalization before initiating
rehabilitation between the high group and low group.
Therefore, we considered that this limitation had a
small effect on the results. (3) Only limited conclusions
can be drawn because the study was a single-center
design. A multi-center study with a larger sample size
is required to confirm our results.
Conclusions
The study results suggest that days of inactivity and
early management of nutritional status after hospital-
ization are important for elderly patients with pneumo-
nia to return to their ADL by treatment including
rehabilitation.
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2015, vol. 16, no. 2
Acknowledgments
We are grateful to the rehabilitation staff and patients at
Tsukuba Memorial Hospital, Tsukuba, Japan, for their
support of this study. We thank Brian K. Purdue of the
Medical English Communications Center, University
of Tsukuba for his native English speaker revision.
Conflict of interest
There is no conflict of interest with regard to this study.
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