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
HGS Measurements
Three HGS for both the right
and left hand– recording mean
and maximum values
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