Hand Grip Strength As A Potential Nutritional Assessment Tool In Long-Term Care Homes

Loss of muscle mass and functionality leads to increased risk for falls and onset of frailty, especially residents of long term care (LTC) homes. Hand grip strength (HGS) is emerging as a promising tool to measure muscle strength and a proxy for functionality. Given its promise as a screening tool, several studies report cut-offs below which measured strength was predictive of risk of poor mobility in older subjects. A scoping review was conducted to examine whether HGS was currently being used in LTC, as studies demonstrate hand grip strength as positively correlated with activities of daily living, implying increased dependence on caregivers including mealtimes. Of 19 published studies in 2015, only two report HGS use. As there is an association of grip strength with nutrition-related outcomes, hand grip strength should be used as part of nutritional assessment by dietitians in LTC, as poor muscle strength adversely affects activities of daily living that may impact intake. DOI : 10.14302/issn.2474-7785.jarh-16-1177 Corresponding Author: Susan J. Whiting, College of Pharmacy & Nutrition, University of Saskatchewan, Saskatoon Canada, Email: susan.whiting@usask.ca, Phone no: 1-306-966-5837 Running Title: Hand grip strength as a nutrition tool.


Introduction
Aging is associated with loss of muscle mass and strength.Poor muscle strength, due to sarcopenia or frailty, results in deficits in physical activities of daily living (PADL) scores and possibly a poor quality of life. 1,2.As a risk factor, frailty has recently gained attention as an important reason for seniors' loss of independence. 3These factors may be accompanied by placement in long-term care homes and increased mortality and other comorbidities in older adults. 4Thus, efforts are made to provide appropriate interventions to preserve functionality and mobility by retaining muscle mass and strength in older adults. 5Nutritional interventions are key to maintenance or improvement in functionality.Nutritional assessments traditionally relied on biochemical markers to identify malnutrition.
Recently, nutritional assessment has undergone a paradigm shift in which functional assessment is used to determine malnutrition. 6One measure in this new protocol is hand grip strength. 7Thus, the purpose of this article is determine if hand grip strength is being used in long-term care and to consider whether hand grip strength is an appropriate assessment tool for older adults in long-term care homes.

Search Strategy
We used two methods for this review.In the first, we provide a critical examination of definitions for frailty, sarcopenia, with a focus on older adults and when possible, on adults living in long-term care (also called nursing homes).In the second method, we employ the scoping review methodology as defined by Grant and Booth 8 to "identify nature and extent" of the issue of using hand grip assessment in long-term care.
Searching the English language literature throughout 2015 (including epub), and using the search terms "nursing homes AND nutrition assessment" or "long term care AND nutrition assessment", we found, upon reading the title and abstract, 19 unique papers which concerned long term care and evaluation of nutritional status, eating behavior or functionality.Upon reading the full article, two were omitted: one study concerned only constipation assessment, and one study discussed staffing issues.Thus we examined, in detail, 19 articles on nutrition assessment to be discussed below.

Frailty and Sarcopenia
Measurement of the physical activities of daily living (PADL) is based on descriptive questions on how well one can manage day-to-day actions. 9Older adults may become less independent with increased frailty, which can be measured by the diminished abilities in activities of daily living. 1 Sarcopenia is the state of reduced muscle strength and muscle mass 10 which in turn increases functional limitations. 11Aging predisposes skeletal muscle to increased levels of oxidative stress, which might have a role in causing sarcopeniaassociated muscle loss. 12As sarcopenia leads to declined physical capacity with aging, it is the most important risk factor for functional status. 13Preserving physical capacity is crucial to maintaining autonomy, health and quality of life in older adults. 14ailty is prevalent in older adults and a significant contributor of fall incidence. 15,16The most commonly cited definition of frailty 15

Hand Grip Strength Measurement
The use of hand grip strength is recommended to evaluate an individual's muscle strength. 17 The generally accepted gold standard for hand grip strength measurement is the Jamar hand dynamometer with high test-retest reproducibility and inter-rater reliability. 26The test is performed in a seated position using with the subject's shoulders neutrally rotated and elbow flexed at 90° with forearm in neutral position.
Both arms are tested, alternately, in triplicate, with the highest value used.Some authors suggest a 5 second interval is sufficient time for the maximal value to be archived.The Jamal dynamometer automatically records the highest strength (kg).However, individuals who were abnormally weak may be unsuitable for this test as the device requires at least 1-2 kg to produce an accurate measurement. 26 healthy individuals (age 5-95+ y) measured across the life course using normative data from twelve British studies, 27

Hand Grip Strength and Functionality
Hand grip strength is closely related to PADL and functional limitations.Community-dwelling older adults with lower hand grip strength were 1.3-2.3times more likely to develop PADL dependence after a 5-year period. 29Specifically for males, weaker individuals were more likely to develop disability in dressing and bathing compared to men with greater hand grip strength [30].
Mobility limitations such as walking difficulties and inability to rise from a chair were also used as health outcomes for studies on hand grip strength in older adults.Individuals with weaker hand grip strength experienced more difficulties in walking 31,32 and lesser ability to rise from a chair 33

Nutrition and Hand Grip Strength
The criteria between defining frailty 15 and diagnosing malnutrition as proposed by AND/ASPEN overlap. 6The presence of two or more of the following six criteria is an indication of malnutrition: insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, fluid accumulation, and diminished hand grip strength. 6In one study, a reduction in hand grip strength correlated with protein loss in patients, and its return to more normal values in response to nutritional repletion was faster than changes in muscle mass. 28In another study, patients assessed using the Subjective Global Assessment (SGA) tool with grades B and C indicating moderate and severe malnutrition, respectively, had significantly lower percent of ideal grip strength compared to patients with SGA grade A (no malnutrition) as shown in Figure 1. 35 40 The other article with hand grip strength was an exercise training intervention and not involving dietitians. 53rrent best practice for nutrition assessment in Canada is described in working paper as including the following elements: current height and weight status, and historical weight data if available; current diet, food texture, fluid consistency needs; dietary history and current documented food and fluid intake; use of supplements; review of relevant conditions and diagnoses, including those known to be of particular risk to this population; review of physical and cognitive functioning; review of eating ability and need for assistance; examination for skin integrity; review of gastrointestinal/bowel function/issues; review of significant lab values; review of medications and potential food-drug interactions; review of intake of vitamins/minerals; dentition; allergies and/or food intolerances; daily nutritional requirements. 58While functional assessment is an important component, hand grip strength is not specifically mentioned, and it appears that "functional" assessment is not objectively measured.

Limitations of Measurement
In clinical practice the use of handgrip strength has important limitations.No study or guideline has published measurement protocols.
Clinical studies usually report the highest value achieved after triplicate measures 26 to allow for subjects to have one arm with an affliction due to arthritis or stroke.However, consistency in measuring hand grip strength appears to be important, with posture and handle position as important determinants of precision. 27In long-term care, frail individuals may have more difficulty in assuming proper positioning.The cognitive status of the subject may preclude accurate measurement as poor cognition may affect hand grip strength performance. 59,60This may be due to an inability of the subject to understand instructions to squeeze as hard as possible.Those with depression may also fail to perform optimally, although this has not been reported in studies.However, it must be noted that most studies have validated hand grip strength using crosssectional data of community-dwelling adults (Table 1).

Summary
The use of hand grip strength as a nutritional assessment tool remains novel to dietitians for use in practice but recent recommendations encourage its use.
,25  The wide application of hand grip strength has gained attention especially in the health care field as a proxy tool for functional assessment.The use of hand grip strength in the algorithms for screening frailty and sarcopenia stresses its increasing application as a functional assessment tool.However, its use remains fairly new to the field of dietetics.Functional impairment is now emphasized over biochemical assessment as the means to assess malnutrition, as put forward in a recent consensus statement through the Academy of Nutrition and Dietetics (AND) and the American Society of Parenteral and Enteral Nutrition (ASPEN).6

Figure 1
Figure 1 Mean predicted percent of ideal hand grip strength across different subjective global assessment (SGA) categories for hospitalized adults: category A = no malnutrition; category B = moderate malnutrition; category C = severe malnutrition (Diagram modified from [35]).There is a significant difference between means (P<0.001) of A vs B and A vs. C.

Table 2 .
Scoping review of articles (research studies or reviews) BMI, body mass index; GNRI, Geriatric Nutritional Risk Index; MNA, Mini-Nutritional Assessment; MNA-SF, mini-nutritional assessment -short form; MUST, malnutrition universal screening tool; NRS, nutritional risk screening; SNAQ, Short Nutritional Assessment Questionnaire Table 2 continuation... BMI, body mass index; GNRI, Geriatric Nutritional Risk Index; MNA, Mini-Nutritional Assessment; MNA-SF, mini-nutritional assessment -short form; MUST, malnutrition universal screening tool; NRS, nutritional risk screening; SNAQ, Short Nutritional Assessment Questionnaire Hand grip strength used as part of a nutritional assessment is recommended as a screening tool to Freely Available Online www.openaccesspub.org| JARH CC-license DOI : 10.14302/issn.2474-7785.jarh-16-1177Vol-1 Issue 2 Pg.no.-6 2. Kamp BJ, Wellman NS, Russell C. Position of the American Dietetic Association, American society for nutrition, and society for nutrition education: Food and nutrition programs for community-residing older adults.J Nutr Educ Behav.2010;42(2):72-82.M; Academy Malnutrition Work Group; A.S.P.E.N.Malnutrition Task Force; A.S.P.E.N.Board of Directors.Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics