1. 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

2. 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

3. 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

4. Hand Grip Study Malnutrition Care Processes  Malnutrition management is part of EQuIP 5 accreditation – Nutrition Care Policy Directive PD2011_078 Bridget Thompson APD 2013

5. 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.

6. Hand Grip Study Malnutrition Screening Tool (MST) Ferguson, M. Capra, S Bauer, J. Banks, M. 1999 Nutrition, 15,458-64

7. 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

8. 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

9. 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

10. Hand Grip Study Hand 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 wasting Bridget Thompson APD 2013

11. Hand Grip Study

12. HGS Measurements  Three HGS for both the right and left hand– recording mean and maximum values Bridget Thompson APD 2013

13. Hand Grip Study HGS Measurements Bridget Thompson APD 2013

14. 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

15. 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

16. Hand Grip Study Results No significant association between HGS and the following:  Height, weight, PG-SGA  Mid upper arm muscle area – estimated  Medications 1, hand problems 1 associated with muscle loss Bridget Thompson APD 2013

17. Hand Grip Study Results Significant inverse association between HGS and the following:  Neurological problems Odds Ratio 3.8 (1.2, 12) (p=0.026)  Increased risk of malnutrition 1 Odds Ratio for dominant hand 3.4 (1.3, 19) (p=0.015) 1 PG-SGA B or C Bridget Thompson APD 2013

18. 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

19. Hand Grip Study Use of HGS increased the sensitivity of malnutrition screening Sensitivity of HGS as a screening tool for malnutrition MethodSensitivity Direct observation and MST69.2% 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%

20. Hand Grip Study Bridget Thompson APD 2013 HGS measurements in Males at risk of malnutrition 70yrs + (mean, dominant hand) N = 33kg (normative data) Normative Data Cut-offs 85% 65% 75%

21. Hand Grip Study Conclusion  HGS offers an objective measure of functionality to be used in conjunction with standard methods for malnutrition screening Bridget Thompson APD 2013

22. 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

23. Hand Grip Study Use of HGS enhances malnutrition screening Bridget Thompson APD 2013

24. Hand Grip Study Further 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

25. Hand Grip Study Implications 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

26. Hand Grip Study Need for further research  Establish usefulness of HGS to monitor management of malnutrition.  Establish precision of HGS measurements and magnitude of a significant change. Bridget Thompson APD 2013

27. Hand Grip Study Acknowledgements Team at Bega District Hospital Participants of the study HETI Mentor Statistician Bridget Thompson APD 2013

28. Hand Grip Study Thank you Any questions ? Bridget Thompson APD 2013