Handgrip strength as a screening tool for nutritional status in a rural hospital

1. Handgrip strength as a screening tool for nutritional status in a rural hospital Bridget Thompson, Greg Thompson, Liz Mathers, Dr PhillippaLyons-Wall, Danushka Fox

2. 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. 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. Malnutrition Care Processes • Malnutrition management is part of EQuIP 5 accreditation – Nutrition Care Policy Directive PD2011_078 Bridget Thompson APD 2013

5. Malnutrition Screening Tool (MST) MST is reported as being both sensitive and specific (Ferguson et al 1999) • unintentional weight loss • reduced appetite.

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

7. Literature search HGS had a significant association with muscle status (Windsor & Hill 1988 ) 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. 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 Bridget Thompson APD 2013

9. 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 Strength(HGS)Study 53 females and 43 males aged 60 years and over were screened for malnutrition : MSTand Direct observation- immediately obvious signs of wasting Bridget Thompson APD 2013

11. DYNAMOMETER

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

13. HGS Measurements Bridget Thompson APD 2013

14. 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. 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. Results No significant association between HGS and the following: Height, weight, PG-SGA Mid upper arm muscle area – estimated Medications1, hand problems 1associated with muscle loss Bridget Thompson APD 2013

17. Results Significant 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 C Bridget Thompson APD 2013

18. 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. Use of HGS increased the sensitivity of malnutrition screening 88.5%

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

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

22. 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. Use of HGS enhances malnutrition screening MST + HGS = more thorough screening • MST (subjective and reported): dietary Intake + unintentional weight loss 2. HGS (objective): measure of functionality Bridget Thompson APD 2013

24. 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. 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. 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. Acknowledgements Team at Bega District Hospital Participants of the study HETI Mentor Statistician Bridget Thompson APD 2013

28. Thank you Any questions ? Bridget Thompson APD 2013