Handgrip strength as a health screening tool. Dr Kinda Ibrahim, Research Fellow in Geriatric Medicine.

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1 Handgrip strength as a health screening tool Dr Kinda Ibrahim, Research Fellow in Geriatric Medicine. K.Ibrahim@soton.ac.uk

2 Background Nearly two thirds of people admitted to hospital in the UK are aged over 65 years old. It is estimated that % of hospitalised older patients are frail and up to 25% have sarcopenia (Loss of skeletal muscle mass and function associated with increasing age). Grip strength is a marker of frailty (Fried Frailty Score) and sarcopenia (the EWGSOP)

3 Increased morbidities such as coronary heart disease and stroke Increased all-cause mortality Increased falls Reduced health related QoL Low GS Increased risk of osteoporosis and fracture Risk of malnutrition Longer LOS Higher hospitalization costs Grip strength is a stronger predictor of all-cause and cardiovascular mortality than systolic blood pressure.

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5 Management of low Grip Strength Exercise - progressive resistance training. Dietary supplementation: higher protein intake, oral nutritional supplementation (ONS) + Vitamin D.

6 Aim of the study The aim was to assess the feasibility and acceptability of routine measurement of grip strength among older inpatients admitted to Medicine for Older People (MOP) wards. This was a mixed method study It was conducted in five MOP wards at Southampton General Hospital. Patients aged 80 years and over. Training Implementation

7 Educational leaflet Practical demonstration Competency check Feedback

8 155 staff were trained First block of training occurred in 3 weeks period. (n=98)

9 Maximum grip strength is <27 kg for men or <16 kg for women Follow the ONS care pathway Refer the patient to physiotherapy Report at handover and use the grip strength magnet

10 Implementation strategies Study Steering Group/ Grip strength ward champion. Regular timely audit and feedback to ward staff and managers about coverage. Regular formal and informal meetings with ward managers MOP monthly newsletter/the employee of the month Include the grip strength test in the routine admission documentation and handover list.

11 Review of patients nursing and medical notes at regular intervals (weekly / or every other week) All patients on the ward were eligible with the exception of palliative patients (end of life) or those who had been on the ward for less than 3 days. The mean weekly coverage of grip strength measurement varied across the wards and ranged between 25% and 80%

12 Weekly coverage of grip strength measurment 120% 100% 80% 60% 40% 20% 0% ward 1 ward 2 ward 3 ward 4 ward 5 Monthly coverage of grip strength measurment 100% 80% 60% 40% 20% 0% february march april may june july august september october ward 1 ward 2 ward 3 ward 4 ward 5

13 811 patients had grip strength care plan completed and filed 655 (81%) performed the grip test 156 (19%) were unable to do the test (severe dementia, confused, patient refused, aggressive patients, patients unable to follow instructions, severe arthritis, and patients who did not speak English). Among those who had performed the test: 81% of female patients had low grip strength (<16 kg), Median=11kg 75% of male patients had low grip strength (<27 kg), Median= 20kg

14 Facilitators and barriers of implementation With 8 patients and 15 healthcare staff across the study wards including: 7 nurses, 4 therapy staff, 2 dieticians, 2 consultants Facilitators Buy-in and support. Keen and highly motivated ward champions. Shared commitment by staff members. Understanding the rationale of the test Engagement strategies. Simplicity of the test Self-monitoring of implementation Barriers Lack of buy-in and support. Less keen and enthusiastic champions Lack of shared commitment and support from other staff members. Inability to see the end results High staff turnover. Lack of perceived responsibility

15 Acceptability of implementation Well providing it provides long term information to help find out how strong people are normally and if they can manage on their own then it seems a good idea. (P8, M, GS=20) I think it s an interesting screening tool. It s a really simple easy thing to do. So if we were to show that was a really good marker of frailty which is the thing about, it would be a really cheap simple thing to do (yeah) which would be fantastic. (consultant 1)

16 Costs of implementation The total cost of 5 dynamometers and training 155 staff across 5 wards over 1 year = 2,257 The implementation provisional costs per patient (Mean = 5.80).

17 Conclusions It was feasible, cheap and acceptable to train a large number of staff and to routinely measuring grip strength of older patients on admission. A high percentage of patients were found to be frail and at high risk of poor healthcare outcomes and sarcopenia. Staff across MOP have recognised the urgent need to offer high-protein oral nutritional supplements and encourage mobility and exercises to their patients. We have decided that routine use of grip strength among this group of patients (over 80 years old) is not necessary. Instead, routine use of fortisips compact and exercises will be adopted. Grip strength measurement could be used in younger populations (65 years and above) or with specific patients such as those with fragility fractures.

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19 Acknowledgment All staff and ward managers across MOP for their hard work and support of the study. MOP departmental education team. All patients and staff participants who took part in the interviews/focus groups. Rosanna Orlando and Tom Monks