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 Study

Problem of Malnutrition

Malnutrition 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 search

1. 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 Study

DYNAMOMETER

Hand Grip Study

HGS Measurements

Three 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

Hand Grip Study

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

Hand Grip Study

Results

No 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 malnutrition1

Odds 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 Sensitivity

Direct 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 2013

70 75 80 85 90 955

7.5

10

12.5

15

17.5

20

22.5

25

27.5

30

32.5

35

37.5

40

42.5

45

HGS (kg) mean Males 70yrs +

Age (yrs)

HG

S (k

g)

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

Normative Data

Cut-offs

85%

65%

75%

Hand Grip Study

Conclusion

HGS offers an objective

measure of functionality to be

used in conjunction with

standard methods for

malnutrition screeningBridget Thompson APD

2013

Hand Grip Study

Conclusion

HGS 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 screening

MST + HGS = more thorough

screening

1. MST (subjective and reported): dietary

Intake + unintentional weight loss

2. HGS (objective): measure of

functionalityBridget 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

Hand Grip Study

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

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

Bridget Thompson APD 2013

Hand Grip Study

Acknowledgements

Team at Bega District Hospital

Participants of the study

HETI

Mentor

StatisticianBridget Thompson APD

2013

Hand Grip Study

Thank you

Any questions ?

Bridget Thompson APD 2013