Hand Grip Study

Bridget Thompson, Greg Thompson, Liz Mathers, Dr Phillippa Lyons-Wall, Danushka Fox

Handgrip strength as a screening tool for

nutritional status in a rural hospital

Hand Grip Study

Malnutrition Protein Energy Malnutrition (PEM)- or Under nutrition. Can occur in underweight and overweight

patients 30-60% hospitalized patients are at risk Prevalence malnutrition 39% (Seldon 2009)

inpatients (over 60yrs) in rural hospitals HNE district Bridget Thompson APD

2013

Hand Grip StudyProblem of MalnutritionMalnutrition is associated with poor outcomes, such as: Frequent hospital readmissions Pressure ulcers Infectious complications Frailty and falls

Bridget Thompson APD 2013

Hand Grip Study

Malnutrition Care Processes Malnutrition management is

part of EQuIP 5 accreditation – Nutrition Care Policy Directive PD2011_078

Bridget Thompson APD 2013

Hand Grip Study

Malnutrition Screening Tool (MST) MST is reported as being both sensitive and specific (Ferguson et al 1999)

unintentional weight loss reduced appetite.

Hand Grip StudyMalnutrition Screening Tool (MST)

Ferguson, M. Capra, S Bauer, J. Banks, M. 1999 Nutrition, 15,458-64

Hand Grip Study

Literature search1. HGS had a significant association with

muscle status (Windsor & Hill 1988 )

2. HGS has been used to assess the nutritional status in groups of inpatients (Norman et al 2006, 2010 etc )

Indicative of health outcomes. Monitor the re-feeding process

Bridget Thompson APD 2013

Hand Grip Study

Bridget Thompson APD 2013

Gaps identified• Lack of consensus on measuring HGS

• Some patients may not be good candidates for HGS – certain medication, motivation, hand pain, neurological problems

• There was a lack of research performed on HGS in the mixed hospital wards

Hand Grip Study

HETI research project Aimed to determine how useful HGS

could be for patients seen in Bega District Hospital when assessing their risk for malnutrition

Inform practice for conducting HGS.

Bridget Thompson APD 2013

Hand Grip StudyHand Grip Strength(HGS)

Study 53 females and 43 males aged 60 years

and over were screened for malnutrition :

MST and Direct observation- immediately

obvious signs of wastingBridget Thompson APD

2013

Hand Grip StudyDYNAMOMETER

Hand Grip Study

HGS MeasurementsThree HGS for both the right

and left hand– recording mean and maximum values

Bridget Thompson APD 2013

Hand Grip Study

HGS Measurements

Bridget Thompson APD 2013

Hand Grip Study

Other data collected: Anthropometric – MUAMA, BMI Medications – total and those

associated with muscle weakness Hand problems – pain or injury Neurological problems Activity levels- low, moderate to high

Bridget Thompson APD 2013

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Results 33 participants were at risk of

malnutrition (7 were transferred and lost to the study)

26 participants confirmed as malnourished by Patient Generated-Subjective Global Assessment (PG-SGA)

Bridget Thompson APD 2013

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ResultsNo significant association between HGS

and the following: Height, weight, PG-SGA Mid upper arm muscle area – estimated Medications1, hand problems1associated with muscle loss

Bridget Thompson APD 2013

Hand Grip Study

ResultsSignificant inverse association between

HGS and the following:Neurological problems

Odds Ratio 3.8 (1.2, 12) (p=0.026)

Increased risk of malnutrition1Odds Ratio for dominant hand 3.4 (1.3, 19) (p=0.015)

1PG-SGA B or CBridget Thompson APD

2013

Hand Grip Study

Weakened HGS associated with increased risk of malnutrition

Mean of 3 measurements for the dominant hand (p = 0.017 , Odds Ratio = 3.1)

(Left hand p= 0.029, Right hand p= 0.017)

Bridget Thompson APD 2013

Hand Grip Study

Use of HGS increased the sensitivity of malnutrition screening

Sensitivity of HGS as a screening tool for malnutrition

Method SensitivityDirect observation and MST 69.2%Direct observation, MST and

HGS 65% normative value 76.9%

Direct observation, MST and HGS 75% normative value 76.9%

Direct observation, MST and HGS 85% normative value

88.5%

Hand Grip Study

Bridget Thompson APD 201370 75 80 85 90 95

57.510

12.515

17.520

22.525

27.530

32.535

37.540

42.545

HGS (kg) mean Males 70yrs +

Age (yrs)

HG

S (

kg)

HGS measurements in Males at risk of malnutrition 70yrs + (mean, dominant hand) N = 33kg (normative data)

Normative Data

Cut-offs

85%

65%

75%

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Conclusion HGS offers an objective

measure of functionality to be used in conjunction with standard methods for malnutrition screening

Bridget Thompson APD 2013

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ConclusionHGS did not provide a direct association with malnutrition diagnosed by PG-SGA in this group of patients. Possible limitation: low prevalence of malnutrition 26/96 with 6 severely malnourished.

Bridget Thompson APD 2013

Hand Grip StudyUse of HGS enhances malnutrition screeningMST + HGS = more thorough screening1. MST (subjective and reported): dietary

Intake + unintentional weight loss 2. HGS (objective): measure of functionality

Bridget Thompson APD 2013

Hand Grip StudyFurther support for use of HGS in nutritional assessment and diagnosis Jensen et al (2012)– HGS promoted for

functional assessment (JPEN 2012 36:267)

White et al (2012) –diagnosis of adult malnutrition 2 or more out of 6 characteristics (including diminished functional status by HGS)(JAND 2012 112:730)

Limitations: no criteria provided to assist practitioner to interpret HGS eg no reference standards or practice guidelines

Hand Grip StudyImplications for practice Include HGS in the nutrition screening process in combination with MST and direct observation Use standard practice and focus on

dominant hand if available – use mean of 3 measurements

Also record maximum to monitor serial measurements

Compare mean with normative data and use cut off point of 85% of mean for age and sex

Clinical judgement required eg neurological problems, hand pain, usual level of activity, impact of medications Bridget Thompson APD 2013

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Need for further researchEstablish usefulness of HGS to monitor management of malnutrition.

Establish precision of HGS measurements and magnitude of a significant change.

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Acknowledgements

Team at Bega District HospitalParticipants of the studyHETI MentorStatistician

Bridget Thompson APD 2013

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Thank you

Any questions ?

Bridget Thompson APD 2013