Muscle strength as a predictor of loss of functional status in hospitalized patients

Feasibility and inter-rater reliability of physical performance measures in acutely admitted older medical patients

Objective

Physical performance measures can be used to predict functional decline and increased dependency in older persons. However, few studies have assessed the feasibility or reliability of such measures in hospitalized older patients. Here we assessed the feasibility and inter-rater reliability of four simple measures of physical performance in acutely admitted older medical patients.

Design

During the first 24 hours of hospitalization, the following were assessed twice by different raters in 52 (≥ 65 years) patients admitted for acute medical illness: isometric hand grip strength, 4-meter gait speed, 30-s chair stand and Cumulated Ambulation Score. Relative reliability was expressed as weighted kappa for the Cumulated Ambulation Score or as intra-class correlation coefficient (ICC_1,1) and lower limit of the 95%-confidence interval (LL_95%) for grip strength, gait speed, and 30-s chair stand. Absolute reliability was expressed as the standard error of measurement and the smallest real difference as a percentage of their respective means (SEM% and SRD%).

Results

The primary reasons for admission of the 52 included patients were infectious disease and cardiovascular illness. The mean± SD age was 78±8.3 years, and 73.1% were women. All patients performed grip strength and Cumulated Ambulation Score testing, 81% performed the gait speed test, and 54% completed the 30-s chair stand test (46% were unable to rise without using the armrests). No systematic bias was found between first and second tests or between raters. The weighted kappa for the Cumulated Ambulation Score was 0.76 (0.60–0.92). The ICC1,1 values were as follows: grip strength, 0.95 (LL_95% 0.92); gait speed, 0.92 (LL_95% 0.73), and 30-s chair stand, 0.82 (LL_95% 0.67). The SEM% values for grip strength, gait speed, and 30-s chair stand were 8%, 7%, and 18%, and the SRD_95% values were 22%, 17%, and 49%.

Conclusion

In acutely admitted older medical patients, grip strength, gait speed, and the Cumulated Ambulation Score measurements were feasible and showed high inter-rater reliability when administered by different raters. The feasibility and inter-rater reliability of the 30-s chair stand were moderate, complicating the use of the 30-s chair stand in acutely admitted older medical patients. However, the predefined modified version of the chair stand test was both feasible and with high inter-rater reliability in this population.

Selected nutrients and their implications for health and disease across the lifespan: a roadmap

Worldwide approximately two billion people have a diet insufficient in micronutrients. Even in the developed world, an increasing number of people consume nutrient-poor food on a regular basis. Recent surveys in Western countries consistently indicate inadequate intake of nutrients such as vitamins and minerals, compared to recommendations. The International Osteoporosis Foundation’s (IOF) latest figures show that globally about 88% of the population does not have an optimal vitamin D status. The Lancet’s “Global Burden of Disease Study 2010” demonstrates a continued growth in life expectancy for populations around the world; however, the last decade of life is often disabled by the burden of partly preventable health issues. Compelling evidence suggests that improving nutrition protects health, prevents disability, boosts economic productivity and saves lives. Investments to improve nutrition make a positive contribution to long-term national and global health, economic productivity and stability, and societal resilience.

[Measuring the handgrip strength of geriatric patients]

The handgrip strength of geriatric patients can be measured when the patient is hospitalized. This article elaborates on the intrinsic and extrinsic factors which have a direct or indirect influence on handgrip strength. For the best results the tests need to be taken in the best circumstances with attention to individual differences and the age of the patient. Handgrip strength as determination of biological vitality is a key concept. Besides the physical characteristics there are many psychological factors (cognition, psyching-up, test attitude…) influencing the results. These are barely mentioned or not mentioned at all in the usual procedures. Research of handgrip strength testing theories is mostly focused on young, healthy adults and less on elderly patients. The main goal of this article is stimulating experimental research on the measurement of handgrip strength with elderly people and involving them more actively with the procedure. It is not enough to acquire insight in function and predicting characteristics of handgrip strength. Next to the aiming for the best test performance is 'working interactively with elderly patients' a goal on itself in the modern vision of health care.

Handgrip strength predicts functional decline at discharge in hospitalized male elderly: a hospital cohort study

Functional decline after hospitalization is a common adverse outcome in elderly. An easy to use, reproducible and accurate tool to identify those at risk would aid focusing interventions in those at higher risk. Handgrip strength has been shown to predict adverse outcomes in other settings. The aim of this study was to determine if handgrip strength measured upon admission to an acute care facility would predict functional decline (either incident or worsening of preexisting) at discharge among older Mexican, stratified by gender. In addition, cutoff points as a function of specificity would be determined. A cohort study was conducted in two hospitals in Mexico City. The primary endpoint was functional decline on discharge, defined as a 30-point reduction in the Barthel Index score from that of the baseline score. Handgrip strength along with other variables was measured at initial assessment, including: instrumental activities of daily living, cognition, depressive symptoms, delirium, hospitalization length and quality of life. All analyses were stratified by gender. Logistic regression to test independent association between handgrip strength and functional decline was performed, along with estimation of handgrip strength test values (specificity, sensitivity, area under the curve, etc.). A total of 223 patients admitted to an acute care facility between 2007 and 2009 were recruited. A total of 55 patients (24.7%) had functional decline, 23.46% in male and 25.6% in women. Multivariate analysis showed that only males with low handgrip strength had an increased risk of functional decline at discharge (OR 0.88, 95% CI 0.79–0.98, p = 0.01), with a specificity of 91.3% and a cutoff point of 20.65 kg for handgrip strength. Females had not a significant association between handgrip strength and functional decline. Measurement of handgrip strength on admission to acute care facilities may identify male elderly patients at risk of having functional decline, and intervene consequently.

Comparison of nutritional status assessment parameters in predicting length of hospital stay in cancer patients

BACKGROUND & AIMS

Undernutrition has been associated with an increased length of hospital stay which may reflect the patient prognosis. The aim of this study was to quantify and compare the association between nutritional status and handgrip strength at hospital admission with time to discharge in cancer patients.

METHODS

An observational prospective study was conducted in an oncology center. Patient-Generated Subjective Global Assessment, Nutritional Risk Screening 2002 and handgrip strength were conducted in a probabilistic sample of 130 cancer patients. The association between baseline nutritional status, handgrip strength and time to discharge was evaluated using survival analysis with discharge alive as the outcome.

RESULTS

Nutritional risk ranged from 42.3 to 53.1% depending on the tool used. According to Patient-Generated Subjective Global Assessment severe undernutrition was present in 22.3% of the sample. The association between baseline data and time to discharge was stronger in patients with low handgrip strength (adjusted hazard ratio, low handgrip strength: 0.33; 95% confidence interval: 0.19-0.55), compared to undernourished patients evaluated by the other tools; Patient-Generated Subjective Global Assessment: (adjusted hazard ratio, severe undernutrition: 0.45; 95% confidence interval: 0.27-0.75) and Nutritional Risk Screening 2002: (adjusted hazard ratio, with nutritional risk: 0.55; 95% confidence interval: 0.37-0.80).

CONCLUSIONS

An approximate 3-fold decrease in probability of discharge alive was observed in patients with low handgrip strength. Decreasing handgrip strength tertiles allowed to discriminate between patients who will have longer hospital stay, as well as undernutrition and nutritional risk assessed by Patient-Generated Subjective Global Assessment and Nutritional Risk Screening 2002.

Motor assessment using the NIH Toolbox

Motor function involves complex physiologic processes and requires the integration of multiple systems, including neuromuscular, musculoskeletal, and cardiopulmonary, and neural motor and sensory-perceptual systems. Motor-functional status is indicative of current physical health status, burden of disease, and long-term health outcomes, and is integrally related to daily functioning and quality of life. Given its importance to overall neurologic health and function, motor function was identified as a key domain for inclusion in the NIH Toolbox for Assessment of Neurological and Behavioral Function (NIH Toolbox). We engaged in a 3-stage developmental process to: 1) identify key subdomains and candidate measures for inclusion in the NIH Toolbox, 2) pretest candidate measures for feasibility across the age span of people aged 3 to 85 years, and 3) validate candidate measures against criterion measures in a sample of healthy individuals aged 3 to 85 years (n = 340). Based on extensive literature review and input from content experts, the 5 subdomains of dexterity, strength, balance, locomotion, and endurance were recommended for inclusion in the NIH Toolbox motor battery. Based on our validation testing, valid and reliable measures that are simultaneously low-cost and portable have been recommended to assess each subdomain, including the 9-hole peg board for dexterity, grip dynamometry for upper-extremity strength, standing balance test, 4-m walk test for gait speed, and a 2-minute walk test for endurance.

Handgrip strength at admission and time to discharge in medical and surgical inpatients

BACKGROUND AND OBJECTIVE

Handgrip strength is a relevant marker of functional status and is also a component of nutrition assessment. The simplicity of this measurement supports its usefulness as a tool to predict who will likely take longer to hospital discharge. The aim of this study was to quantify the association between sex-specific handgrip strength at hospital admission and time to discharge alive. We intended to include a group of diverse diagnoses and to compare medical and surgical wards, taking into account the potential confounders' effect of patients' characteristics and severity of disease.

SUBJECTS AND METHODS

Prospective study in 2 public acute-care general hospitals in Porto, Portugal, in 2004. Handgrip strength was evaluated using a handgrip dynamometer in a probability sample of 425 patients from medical and surgical wards. The association between baseline handgrip strength and time to discharge was evaluated using survival analysis with discharge alive as the outcome and deaths and transfers being censored.

RESULTS

In medical wards, women with high admission handgrip strength had a very short hospital stay (all had been discharged by the sixth day), and among men, patients with low handgrip strength had a particularly longer stay (approximately 50% were discharged after 15 days of hospitalization). In surgical wards, an increasing length of stay with decreasing handgrip strength quartiles was also observed in both sexes.

CONCLUSIONS

Lower handgrip strength at hospital admission was associated with a longer time in the hospital, in patients of both sexes, in medical and surgical wards. Although this association was explained in part by age, height, education level, cognitive status, and disease severity, its direction remained unchanged regardless of the aforementioned factors.

Reference values for handgrip strength in young people of both sexes

The handgrip strength is considered an excellent predictor of morbidity and mortality for acute and long term outcomes. In fact, several studies showed that the reduced handgrip strength is correlated to all-cause mortality in both middle aged and elderly subjects. Nevertheless, defined reference values of handgrip strength are not available, especially from young and healthy populations. The aim of this study was to determine the reference values for handgrip strength from a healthy population of young volunteers. A secondary objective was to derivate a muscle function T score useful for adults and elderly individuals. We enrolled 335 healthy university students (157 men and 178 females) aged 19-25 years. The handgrip strength was measured using a hydraulic hand dynamometer by trained dietitians. The mean handgrip strength value was 27.70 ± 4.3 kg for female and 44.77 ± 6.6 kg for male. We showed statistical difference between sexes. We also found the lower T score in community-dwelling elderly individuals in comparison to the young people. The muscle strength loss is a multi-factorial process influenced by age and hormonal factors. The availability of the reference values in both sexes might open the way to the diffusion of the handgrip strength assessment for more clinical use, and it might be useful to identify people who could benefit from early nutritional or pharmacological programs.

Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions

Lack of a uniform definition is responsible for underrecognition of the prevalence of malnutrition and its impact on outcomes in children. A pediatric malnutrition definitions workgroup reviewed existing pediatric age group English-language literature from 1955 to 2011, for relevant references related to 5 domains of the definition of malnutrition that were a priori identified: anthropometric parameters, growth, chronicity of malnutrition, etiology and pathogenesis, and developmental/ functional outcomes. Based on available evidence and an iterative process to arrive at multidisciplinary consensus in the group, these domains were included in the overall construct of a new definition. Pediatric malnutrition (undernutrition) is defined as an imbalance between nutrient requirements and intake that results in cumulative deficits of energy, protein, or micronutrients that may negatively affect growth, development, and other relevant outcomes. A summary of the literature is presented and a new classification scheme is proposed that incorporates chronicity, etiology, mechanisms of nutrient imbalance, severity of malnutrition, and its impact on outcomes. Based on its etiology, malnutrition is either illness related (secondary to 1 or more diseases/injury) or non-illness related, (caused by environmental/behavioral factors), or both. Future research must focus on the relationship between inflammation and illness-related malnutrition. We anticipate that the definition of malnutrition will continue to evolve with improved understanding of the processes that lead to and complicate the treatment of this condition. A uniform definition should permit future research to focus on the impact of pediatric malnutrition on functional outcomes and help solidify the scientific basis for evidence-based nutrition practices.

Relationship between hand grip strength and nutritional assessment methods used of hospitalized patients

OBJECTIVE: This study verified the association between hand grip strength and body mass index, subjective global assessment and nutritional risk screening 2002. METHODS: This cross-sectional study calculated the body mass index, measured hand grip strength and administered the subjective global assessment and nutritional risk screening 2002 to 118 patients hospitalized at the University Hospital of the Universidade Federal de Santa Catarina, Florianópolis, Brazil. Hand grip strength was compared with the reference values for the Brazilian population according to gender and age. The statistical analyses included the Student's t-test or Mann-Whitney test and multiple linear regression. The results were considered significant when p<0.05. RESULTS: The prevalences of nutritional risk or malnutrition according to body mass index, global subjective assessment, nutritional risk screening 2002 and hand grip strength were 3.5%, 50.9%, 33.9% and 35.6%, respectively. Malnourished individuals according to body mass index had, on average, 11.0kg less hand grip strength than the nourished individuals (p=0.008). There was no association between hand grip strength and the subjective global assessment (malnourished individuals had -2.8kg; p=0.078) and nutritional risk screening 2002 (malnourished individuals had -1.5kg; p=0.352). CONCLUSION: Hand grip strength was associated with body mass index but not with the subjective global assessment or nutritional risk screening 2002.

Is grip strength associated with length of stay in hospitalised older patients admitted for rehabilitation? Findings from the Southampton grip strength study

BACKGROUND

identification of patients at risk of prolonged hospital stay allows staff to target interventions, provide informed prognosis and manage healthcare resources. Admission grip strength is associated with discharge outcomes in acute hospital settings.

OBJECTIVE

to explore the relationship between grip strength and length of stay in older rehabilitation in-patients.

DESIGN

single-centre prospective cohort study.

SETTING

community hospital rehabilitation ward.

SUBJECTS

one hundred and ten patients aged 70 years and over.

METHODS

data on age, height, weight, body mass index (BMI), co-morbidities, medication, residence, grip strength, physical function, cognitive function, frailty, falls, discharge destination and length of stay were recorded.

RESULTS

higher grip strength was associated with reduced length of stay, characterised by an increased likelihood of discharge to usual residence among male rehabilitation in-patients (hazard ratio 1.09 (95% confidence interval 1.01, 1.17) per kilo increase in grip strength, P = 0.02) after adjustment for age and size.

CONCLUSIONS

this is the first prospective study to show that stronger grip strength, particularly among male in-patients, is associated with a shorter length of stay in a rehabilitation ward. This is important because it demonstrates that grip strength can be discriminatory among frailer people. Further research into the clinical applications of grip strength measurement in rehabilitation settings is needed.

Muscle function, physical performance and body composition changes in men with prostate cancer undergoing androgen deprivation therapy

Prostate cancer (PCa) is the most common visceral malignancy in men with androgen deprivation therapy (ADT) the preferred therapy to suppress testosterone production and hence tumor growth. Despite its effectiveness in lowering testosterone, ADT is associated with side effects including loss of muscle mass, diminished muscle strength, decrements in physical performance, earlier fatigue and declining quality of life. This review reports a survey of the literature with a focus on changes in muscle strength, physical function and body composition, due to short-term and long-term ADT. Studies in these areas are sparse, especially well-controlled, prospective randomized trials. Cross-sectional and longitudinal data (up to 2 years) for men with PCa treated with ADT as well as patients with PCa not receiving ADT and age-matched healthy men are presented when available. Based on limited longitudinal data, the adverse effects of ADT on muscle function, physical performance and body composition occur shortly after the onset of ADT and tend to persist and worsen over time. Exercise training is a safe and effective intervention for mitigating these changes and initial guidelines for exercise program design for men with PCa have been published by the American College of Sports Medicine. Disparities in study duration, types of studies and other patient-specific variables such as time since diagnosis, cancer stage and comorbidities may all affect an understanding of the influence of ADT on health, physical performance and mortality.

A systematic review of dynamometry and its role in hand trauma assessment

The dynamometer was developed by American neurologists and came into general use in the late 19th century. It is still used in various ways as a diagnostic and prognostic tool in clinical settings. In this systematic review we assessed in detail the different uses of dynamometry, its reliability, different dynamometers used and the influence of rater experience by bringing together and evaluating all published literature in this field. It was found that dynamometry is applied in a wide range of medical conditions. Furthermore, the great majority of studies reported acceptable to high reliability of dynamometry. Jamar mechanical dynamometer was used most often in the studies reviewed. There were mixed results concerning the effect of rater experience. The factors influencing the results of dynamometry were identified as age, gender, body weight, grip strength, BMI, non/dominant hand, assessing upper/lower limbs, rater and patient’s strength and the distance from the joint where the dynamometer is placed. This review provides an understanding of the relevance and significance of dynamometry which should serve as a starting point to guide its use in hand trauma assessment. On the basis of our findings, we suggest that hand dynamometry has a great potential, and could be used more often in clinical practice.

Grip strength and functional balance in community-dwelling older women

Background: Effective detection and treatment of balance impairment in older people is a matter of clinical urgency. 4 screening tool for impaired balance is required, as is clarity regarding the role of muscle strength in balance control.

Methods: This observational study examined the relationship between grip strength and balance in 40 community-dwelling women aged 65-95 years. Measures included grip strength, Functional Reach test, Single Leg Stance Test, Timed Up and Go test and the Berg Balance Scale. Correlation analyses were used to investigate relationships between the variables.

Findings: Significant correlations were found between grip strength and each of the balance measures. The strongest correlation (r=0.55, P<0.001) was found between right grip strength and the Berg Balance Scale. The weakest correlation (r=-0.36, P=0.012) was between left grip strength and the Timed Up and Go test. Grip strength accounted for only 14%-31% of the variance in balance test scores

Conclusions: The association between grip strength and balance was not sufficiently robust for grip strength to be recommended as a screening tool for balance impairment in older people.

Nutritional status and associations with falls, balance, mobility and functionality during hospital admission

OBJECTIVES

To explore associations between nutritional status, falls and selected falls risk factors amongst older hospitalized people. Lengths of stay amongst fallers and the malnourished were assessed.

DESIGN

An observational longitudinal cohort study.

SETTING

Geriatric Assessment and Rehabilitation Unit (GARU) of a tertiary teaching hospital.

PARTICIPANTS

Admissions to the GARU during a six-month period were included.

MEASUREMENTS

Associations between nutritional status and falls during hospitalization, reported preadmission history of falls, functional status, balance and mobility during GARU admission were analysed. Associations between nutritional status or experiencing a hospital fall and length of stay were also examined.

RESULTS

Malnutrition prevalence was 39% (75/194, 95% CI 32-46%) with odds of falling during admission being 1.49 (95%CI: 0.81, 2.75), p< 0.20). Patients assessed as malnourished were older (p<0.001) and more likely to have a poorer score on both the admission (p<0.05) and discharge (p<0.009) timed "Up and Go" test. Malnutrition was associated with reduced mobility (p<0.05). Those who fell during admission had statistically greater lengths of stay compared with non-fallers [median (range): 57.0 (7-127) vs 35.0 (5-227) days; p<0.002].

CONCLUSION

Evidence of reduced mobility was evident during GARU admission amongst older people assessed as malnourished. Considering the results, a larger study concerning nutritional status, functionality and falls in the hospitalized population is warranted. The influence of nutritional status upon a person's physical functioning should be considered more broadly in falls research.

Hand grip strength: outcome predictor and marker of nutritional status

BACKGROUND & AIMS

Among all muscle function tests, measurement of hand grip strength has gained attention as a simple, non-invasive marker of muscle strength of upper extremities, well suitable for clinical use. This review outlines the prognostic relevance of grip strength in various clinical and epidemiologic settings and investigates its suitability as marker of nutritional status in cross-sectional as well as intervention studies.

METHODS

Studies investigating grip strength as prognostic marker or nutritional parameter in cross-sectional or intervention studies were summarized.

RESULTS AND CONCLUSIONS

Numerous clinical and epidemiological studies have shown the predictive potential of hand grip strength regarding short and long-term mortality and morbidity. In patients, impaired grip strength is an indicator of increased postoperative complications, increased length of hospitalization, higher rehospitalisation rate and decreased physical status. In elderly in particular, loss of grip strength implies loss of independence. Epidemiological studies have moreover demonstrated that low grip strength in healthy adults predicts increased risk of functional limitations and disability in higher age as well as all-cause mortality. As muscle function reacts early to nutritional deprivation, hand grip strength has also become a popular marker of nutritional status and is increasingly being employed as outcome variable in nutritional intervention studies.

[Adductor pollicis muscle thickness: a fast and reliable method for nutritional assessment in surgical patients]

OBJECTIVE

Investigate whether the right adductor pollicis muscle thickness is a reliable method to evaluate the nutritional status of surgical patients and whether it correlates or not correlate to other anthropometric, biochemical, and clinical parameters.

METHODS

Cross-sectional study evaluating 87 patients candidates to major operations of the gastrointestinal tract. All were submitted to global subjective evaluation, traditional anthropometry (arm circumpherence ; triceps skin fold; and arm muscle circumpherence, serum albumin, lymphocytes and measurement of in both hands.

RESULTS

The mean right adductor pollicis muscle thickness in dominant hand was 12,64 +/- 3,19 mm and in non-dominant hand (EMAPND) 12,23 +/- 2,9 mm. Sensitivity was 72,37% for left adductor pollicis muscle and 77,33% for left adductor pollicis muscle thickness being the cut-offs given by the ROC curve (13,4 and 13,1mm respectively). Specificity was 100% for both hands. There was a significantly correlation (P<0.01) for right adductor pollicis muscle thickness with all anthropometric parameters. The mean value for normal individuals was significantly greater (P<0.001) than for mild malnourished which was greater (p<0.05) when compared to patients with severe malnutrition.

CONCLUSION

right adductor pollicis muscle thickness is a low-cost, reliable, and trustworthy method to assess nutritional status that can be easily and safety used in clinical practice for surgical patients.

Prevalence of undernutrition in Dutch hospital outpatients

BACKGROUND

The prevalence of undernutrition in hospital inpatients is high. Earlier detection and treatment in the hospital outpatient clinic may help to reduce these numbers. The purpose of this study was to assess the prevalence of undernutrition in hospital outpatients in the Netherlands, to determine high risk departments, and to determine the percentage of patients receiving dietetic treatment.

METHODS

This cross-sectional multicenter study was conducted in nine hospitals. Patients who visited the outpatient clinic on one of the screening days in the period March-May 2008 received a short questionnaire and were weighed. Patients were classified as severely undernourished, moderately undernourished or not undernourished.

RESULTS

2288 patients were included in the study, of which 5% were severely undernourished and 2% were moderately undernourished. The prevalence of severe undernutrition was highest in the outpatient departments of oral maxillofacial surgery (17%), oncology (10%), rehabilitation (8%), gastroenterology (7%) and pulmonology (7%). Only 17% of all severely undernourished and 4% of all moderately undernourished patients reported to receive dietetic treatment.

CONCLUSION

The prevalence of undernutrition in hospital outpatients is generally low but largely undertreated. Future screening should focus on high risk departments.

Bioimpedance vector analysis as a measure of muscle function

INTRODUCTION

The impedance vector produced by an alternating current in the bioimpedance analysis can be seen as a standardised test of cellular mass and function since reactance is believed to reflect the mass and integrity of cell membranes. This study investigated the association between resistance and reactance normalised for height (R/H and Xc/H), and muscle function as assessed by hand grip strength.

METHODS

363 patients (172 male, 191 female) from Berlin and Copenhagen were included in the analysis. Whole body impedance was determined by BIA 2000M (Berlin) or EFG2.0 (Copenhagen). Hand grip strength was measured with Digimax electronic hand dynamometer (Berlin) or Jamar dynamometer (Copenhagen). The general linear model was used to assess the association between R/H, Xc/H and hand grip strength.

RESULTS

We observed a significant association between the impedance parameters R/H and Xc/H and hand grip strength after adjusting for confounding variables (hand grip strength= -36.9 - 0.063 x R/H + 0.573 x Xc/H + 40.7 x Height + 0.115 x Weight - 0.09 x Age + 3.41 (gender=male) + 1.87 (Centre Berlin); Weight: P=0.04, all other coefficients: P<0.0005. r(2)=0.708).

CONCLUSIONS

The impedance parameters R/H and Xc/H are related to hand grip strength and might therefore be used as a cooperation-independent method to reproducibly assess muscle function.

Acute effects of high-dose methylprednisolone on diaphragm muscle function

The time- and dose-dependent effects of acute high-dose corticosteroids on the diaphragm muscle are poorly defined. This study aimed to examine in rabbits the temporal relationships and dose-response effects of acute high-dose methylprednisolone succinate on diaphragmatic contractile and structural properties. Animals were assigned to groups receiving: (1) 80 mg/kg/day methylprednisolone (MP80) intramuscularly for 1, 2, and 3 days; (2) 10 mg/kg/day methylprednisolone (MP10, pulse-dose) for 3 days; or (3) saline (placebo) for 3 days; and (4) a control group. Diaphragmatic in vitro force-frequency and force-velocity relationships, myosin heavy chain (MyHC) isoform protein and mRNA, insulin-like growth factor-1 (IGF-1), muscle atrophy F-box (MAF-box) mRNA, and volume density of abnormal myofibrils were measured at each time-point. MP80 did not affect animal nutritional state or fiber cross-sectional area as assessed in separate pair-fed groups receiving methylprednisolone or saline for 3 days. Compared with control values, MP80 decreased diaphragmatic maximum tetanic tension (Po) by 19%, 24%, and 34% after 1, 2, and 3 days (P < 0.05), respectively, whereas MP10 decreased Po modestly (12%; P > 0.05). Vmax and MyHC protein proportions were unchanged in both the MP80 and MP10 groups. Maximum power output decreased after 2 and 3 days of MP80. Suppression of IGF-1 and overexpression of MAF-box mRNA occurred in both MP groups. Significant myofibrillar disarray was also observed in both MP groups. The decline in Po was significantly associated with the increased volume density of abnormal myofibrils. Thus, very high-dose methylprednisolone (MP80) can produce rapid reductions in diaphragmatic function, whereas pulse-dose methylprednisolone (MP10) produces only modest functional loss.

Reference values of handgrip dynamometry of healthy adults: a population-based study

BACKGROUND & AIMS

Although maximal voluntary handgrip strength (HGS) is considered a reliable tool in nutritional assessment there are few reference data available. This paper presents reference values for handgrip strength of healthy adults (age > or = 20 years) from a household survey.

METHODS

Data were obtained from a representative sample of adults (1122 males and 1928 females) living in Niterói, Rio de Janeiro, Brazil. HGS was measured three times with a Jamar mechanical dynamometer in both hands and the highest value used in the analysis. The percentile distribution of HGS was calculated according to sex and age categories.

RESULTS

Mean values of right and left HGS were 42.8 and 40.9 kg for males, and 25.3 and 24.0 kg for females, respectively. HGS increased with age and significantly decreased after 40 and 50 year-olds for women and men, respectively. Body mass index (BMI) was associated with HGS in both sexes but only underweight male subjects had significantly lower HGS values.

CONCLUSIONS

The highest HGS values are observed at the 4th decade of life with significant declines thereafter. HGS is significantly associated with BMI. The reference values of HGS may be useful in assessing the nutritional status of similar adult urban population.

Subjective and objective nutritional assessment methods: what do they really assess?

PURPOSE OF REVIEW

Objective and subjective methods are used to assess nutritional status. They are used as diagnostic, prognostic and response tools. It is still controversial which of them is more suitable for each situation and what they are really assessing. The most recent findings about these methods will be discussed in this review.

RECENT FINDINGS

Malnutrition still has a high prevalence all over the world. Anthropometric measurements are best useful to assess chronic malnutrition, and albumin and other visceral protein should no longer be considered as nutritional markers, but inflammatory response markers. Subjective global assessment enables comparison among different populations, and its scored version may be useful in other clinical situations besides cancer. Functional methods and bioelectrical impedance analysis may become possible to identify malnutrition in an early stage. Nitrogen balance seems to be the only way to assess the response to nutritional interventions.

SUMMARY

Malnutrition should be understood as a continuum. Nutritional assessment should not be an expensive and time-consuming process, and simple methods such as subjective global assessment may be enough to identify those patients who need nutritional intervention. Future studies may show which method is more suitable to evaluate the response to this treatment.

Bioelectrical impedance and strength measurements in patients with heart failure: comparison with functional class

OBJECTIVE

Patients with chronic heart failure (HF) develop important changes in body composition. Nevertheless, the usual methods of body composition assessment can be misleading in patients with HF because tissue hydration is altered. Bioelectrical impedance vector analysis (BIVA) works without making any assumption about constant soft tissue hydration. In this study, patients with HF and systolic dysfunction (HFS) and preserved systolic function (HFPSF) underwent a body composition evaluation by the BIVA method; the comparison was done between New York Heart Association (NYHA) functional classes I-II and III-IV.

METHODS

We studied 243 patients with HF, 140 (101 in NYHA I-II and 39 in III-IV) with HFS and 103 (67 in NYHA I-II and 36 in II-IV) with HFPSF. Whole-body bioelectrical impedance was measured using BodyStat QuadScan 4000, which is tetrapolar and multiple-frequency equipment.

RESULTS

In both HF categories, reactance and phase angle were significantly lower, the impedance ratio of 200 kHz to that at 5 kHz was higher, and had significantly shorter and downsloping impedance vector in the NYHA III-IV group compared with the NYHA I-II group by gender.

CONCLUSION

Bioelectrical impedance analysis allows an easier evaluation of body composition and this might be particularly useful to stratify the severity of HF.

Grip strength predicts cause-specific mortality in middle-aged and elderly persons

PURPOSE

Handgrip strength is a simple measurement used to estimate overall muscle strength but might also serve as a predictor of health-related prognosis. We investigated grip strength-mortality association in a longitudinal study.

METHODS

A total of 4912 persons (1695 men and 3217 women), 35 to 74 years old at baseline, were the subjects of this study. Members of the Adult Health Study (AHS) cohort in Hiroshima, Japan, these individuals underwent a battery of physiological tests, including handgrip-strength testing, between July 1970 and June 1972. Mortality was followed until the end of 1999. Estimates of relative risk (RR) of mortality associated with grip strength were adjusted for potentially confounding factors by Cox proportional hazard analysis.

RESULTS

Multivariate-adjusted RR of all causes of death, except for external causes, for the highest quintile of grip strength in men was 0.52 (95% confidence interval [CI], 0.33-0.80) for the age group 35-54 years, 0.72 (95% CI, 0.53-0.98) for the ages 55-64 years, and 0.67 (95% CI, 0.49-0.91) for the ages 65-74 years. These figures were significantly lower than the RR for the reference group (the third quintile). Similar trends were observed in women. Multivariate-adjusted RR of all causes of death except external causes for each 5-kg increment of grip strength was significantly low (RR: 0.89, 95% CI, 0.86-0.92 for men, RR: 0.87, 95% CI, 0.83-0.92 for women). Multivariate-adjusted RR for heart disease, stroke, and pneumonia in men was 0.85 (95% CI, 0.79-0.93), 0.90 (95% CI, 0.83-0.99), and 0.85 (95% CI, 0.75-0.98), respectively. RR for each 5-kg increment of grip strength remained 0.92 (95% CI, 0.87-0.96), even after more than 20 years of follow-up.

CONCLUSION

Grip strength is an accurate and consistent predictor of all causes of mortality in middle-aged and elderly persons.

Physiological functions should be considered as true end points of nutritional intervention studies

With the beginning of this millennium it has become fashionable to only follow ‘evidence-based’ practices. This generally-accepted approach cruelly negates experience or intelligent interpretation of pathophysiology. Another problem is that the great ‘meta-analysts’ of the present era only accept end points that they consider ‘hard’. In the metabolic and nutritional field these end points are infection-related morbidity and mortality, and all other end points are considered ‘surrogate’. The aim of this presentation is to prove that this claim greatly negates the contribution of more-fundamentally-oriented research, the fact that mortality has multifactorial causes, and that infection is a crude measure of immune function. The following problems should be considered: many populations undergoing intervention have low mortality, requiring studies with thousands of patients to demonstrate effects of intervention on mortality; nutrition is only in rare cases primary treatment, and in many populations is a prerequisite for survival rather than a therapeutic modality; once the effect of nutritional support is achieved, the extra benefit of modulation of the nutritional support regimen can only be modest; cost–benefit is not a valid end point, because the better it is done the more it will cost; morbidity and mortality are crude end points for the effect of nutritional intervention, and are influenced by many factors. In fact, it is a yes or no factor. In the literature the most important contributions include new insights into the pathogenesis of disease, the diminution of disease-related adverse events and/or functional improvement after therapy. In nutrition research the negligence of these end points has precluded the development and validation of functional end points, such as muscle, immune and cognitive functions. Disability, quality of life, morbidity and mortality are directly related to these functional variables. It is, therefore, of paramount importance to validate functional end points and to consider them as primary rather than surrogate end points.

The new Geriatric Nutritional Risk Index is a good predictor of muscle dysfunction in institutionalized older patients

BACKGROUND & AIMS

The validity of Geriatric Nutritional Risk Index (GNRI), in predicting nutrition-related risk of complications in the elderly, has been recently underscored. Malnutrition may results also in muscle function impairment. Thus, the present study aims to investigate if GNRI might be a reliable detector of muscle dysfunction in institutionalized older people.

METHODS

In total, 153 institutionalized elderly (71 males, 82 females; mean age+/-SD: 75.2+/-8.4; range: 65-96) were studied in anthropometric parameters, serum albumin concentration and total score on GNRI. Muscle function was assessed by handgrip strength (HG).

RESULTS

Women were significantly older than men and presented lower values of HG and arm muscle area (AMA). In overall population, GNRI was significantly correlated with AMA, HG and strength for centimeter of muscle area (HG/AMA); however, in gender-separated analysis, men presented higher degrees of correlation. After dividing patients in four categories according to GNRI, a more significant difference was detected in HG and HG/AMA rather than the other clinical and anthropometric parameters. Moreover, ANOVA analysis between HG quartiles was highly significant for GNRI, AMA and HG/AMA.

CONCLUSIONS

GNRI is a good predictor of muscle dysfunction, particularly in men, and useful in identifying patients suitable for nutritional support and physical activity.

Handgrip strength as a hospital admission nutritional risk screening method

OBJECTIVE

To investigate if handgrip strength (HGS) could be used as a single screening procedure in identifying patients who are classified as being undernourished or nutritionally-at-risk at hospital admission.

DESIGN

Cross-sectional study. In the second day of hospital admission, HGS was evaluated and results were compared with Nutritional Risk Screening (NRS-2002).

SETTING

Two public hospitals in Porto, Portugal, a university and a district one.

SUBJECTS

A probabilistic sample of 50% in-patients from each hospital of 314 patients (age range of 18-96) was studied. Patients were considered eligible if they were >or=18 years old and able to give informed consent. Hand pain, upper limb deformities, incapacity to perform muscle strength measurements and pregnancy were considered further exclusion criteria.

RESULTS

Patients identified as undernourished by NRS-2002 (37.9%) were older, shorter and lighter, with a lower functional capacity, a longer length of stay and a lower HGS (P<0.001). When comparing patients with lower HGS (first quartile) with those with the highest HGS (fourth quartile), this parameter revealed good sensitivity (86.7%) and specificity (70.2%) and a k=0.56. Multivariate analysis showed that patients with higher HGS had an independent decreased risk of being at nutritional risk (P for trend <0.001) odds ratio=0.19 (95% confidence interval=0.08-0.48). Our entire sample of hospitalized patients was -1.96 Z-score below the HGS cutoff of distribution data for healthy individuals.

CONCLUSIONS

HGS identifies a high proportion of nutritionally-at-risk patients and can be a reliable first screening tool for nutritional risk in hospitals.

Socio-demographic, behavioral and functional characteristics of groups of community and institutionalized elderly Quechua Indians of Peru, and their association with nutritional status

Socio-demographic, behavioral, functional and anthropometric data for groups of elderly Quechua Indians of Peru were used to investigate the effects of gender and lifestyle patterns on nutritional status. Two community-dwelling samples were selected for study, representative of divergent lifestyles in terms of their combination of socio-economic, demographic and cultural contexts, plus an ad-hoc sample of institutionalized individuals with controlled food intake and reduced physical activity. Results suggest that differences in socio-demographic, behavioral and functional characteristics exist between the sexes and across settings (low- vs. highland) and lifestyles (institutionalized vs. community-dwelling; semi-urban vs. rural). These factors are likely to be related to diverging dietary and physical activity patterns, and have considerable effects on the nutritional status of the respondents.

Indications and limitations of the use of subjective global assessment in clinical practice: an update

PURPOSE OF REVIEW

Subjective global assessment is a clinical tool for assessing nutritional status that merges alterations in body composition and physiological function. Although it was first described almost two decades ago, many studies using this method have been published during the past few years. This review describes recent findings from such studies.

RECENT FINDINGS

Subjective global assessment has proved to be a good nutritional assessment and prognostic indicator in several clinical situations. Agreement between subjective global assessment and newer screening methods is not always acceptable, and it has not been validated with respect to clinical outcome. Some modifications have been suggested that may increase the sensitivity of subjective global assessment as a screening tool. A scored version of subjective global assessment for cancer patients is now being validated for use in other patient groups. This could increase its utility in nutritional intervention studies if it can be demonstrated that subtle changes in nutritional status are reflected by numerical scores in patient-generated subjective global assessment.

SUMMARY

Subjective global assessment represents a good option for assessing nutritional status in various clinical situations. As a screening tool, it better identifies established malnutrition than nutritional risk but its sensitivity is suboptimal. The scored version of subjective global assessment may have advantages and extend the usefulness of this tool even further.

Are malnourished patients complex patients? Health status and care complexity of malnourished patients detected by the Short Nutritional Assessment Questionnaire (SNAQ)

BACKGROUND

This article describes the characteristics of patients identified as malnourished using the Short Nutritional Assessment Questionnaire (SNAQ) in terms of health status (quality of life, functional capacity, and body composition) and care complexity. We expected that by using the quick and easy SNAQ method of screening on malnutrition, inferences could be made about general health status and care complexity. This information can be used for optimal multi-disciplinary treatment of the malnourished patient.

METHODS

The research population consisted of a group of 588 patients admitted to internal medicine and surgery wards of the VU university medical center. Patients with a SNAQ score of at least 3 points were considered malnourished. The SNAQ score was compared to the health status, which was determined by serum albumin, hand grip strength, quality of life, body composition, and estimated care complexity.

RESULTS

At admission, 172 patients (29%) had a SNAQ score of at least 3 points. These patients had a significantly poorer quality of life, poorer physical functioning, a lower fat free mass index, and higher care complexity.

CONCLUSION

These findings confirm our assumption that a considerable proportion of malnourished patients should be considered as complex patients and that malnutrition is an important aspect and indicator of overall health status of the patients. The SNAQ is a simple malnutrition screening tool, applicable in the current complex hospital situation, to identify these complex, malnourished patients.

Serum Albumin and Muscle Strength: A Longitudinal Study in Older Men and Women

OBJECTIVES

To examine whether low serum albumin is associated with low muscle strength and future decline in muscle strength in community-dwelling older men and women.

DESIGN

Population-based cohort study.

SETTING

The Longitudinal Aging Study Amsterdam.

PARTICIPANTS

Six hundred seventy-six women and 644 men aged 65 to 88.

MEASUREMENTS

Serum albumin was determined at baseline. Muscle strength was assessed using grip strength at baseline, after 3 (n=1,009), and 6 (n=741) years. The outcomes were continuous baseline muscle strength, 3- and 6-year change in muscle strength, and a dichotomous indicator for substantial decline (a decrease if > or =1 standard deviations for women=11 kg, for men=12 kg) in muscle strength.

RESULTS

Mean serum albumin concentration+/-standard deviation was 45.0+/-3.3 g/L for women and 45.2+/-3.2 g/L for men. At baseline, adjusting for age, lifestyle factors, and chronic conditions, lower serum albumin was cross-sectionally associated with weaker muscle strength (P<.001) in women and men. After 3 years of follow-up, mean decline in muscle strength was -5.6+/-10.9 kg in women and -9.6+/-11.9 kg in men. After adjustment for potential confounders, lower serum albumin was associated with muscle strength decline over 3 years (P<.01) in women and men (beta=0.57, standard error (SE)=0.18; beta=0.37, SE=0.16, respectively). Lower serum albumin was also associated with substantial decline in muscle strength in women (per unit albumin (g/L) adjusted odds ratio (OR)=1.14, one-sided 95% confidence limit (CL)=1.07) and men (per unit albumin (g/L) adjusted OR=1.14, 95% CL=1.08). Similar but slightly weaker associations were found between serum albumin and 6-year change in muscle strength (P<.05).

CONCLUSION

These results suggest that low serum albumin, even within the normal range, is independently associated with weaker muscle strength and future decline in muscle strength in older women and men.

Nutrition education for care staff and possible effects on nutritional status in residents of sheltered accomodation

OBJECTIVE

We investigated the nutritional, cognitive and functional status in residents of two service-flat (SF) complexes and the effects of a nutrition education programme for care staff.

DESIGN

Controlled nonrandomised study.

SETTING

Two SF complexes, that is community-assisted accommodation.

SUBJECTS

Of 115 eligible SF residents, 80 subjects participated (age 83+/-7 y, 70% women).

INTERVENTION

The nutritional status was assessed using body mass index (BMI, kg/m(2)), subjective global assessment (SGA), serum concentrations of albumin, insulin-like growth factor-I (IGF-I) and vitamin B(12). Cognitive and functional status were evaluated using the Mini Mental State Examination (MMSE, 0-30 points, <24 points indicates impaired cognition) and the Katz activities of daily living (ADL) index, respectively. Two assessments were made with a 5-month interval. At the start, a 12-h education programme was given to the staff at one of the SF complexes.

RESULTS

At baseline, the means of BMI and the biochemical nutritional indices were normal, whereas one-third had BMI <22 kg/m(2) and one-fourth had lost > or =10% of previous weight. According to SGA, 30% demonstrated possible or serious malnutrition. The median MMSE was 23 points (19.5-26.5, 25-75th percentile). Nearly 70% were ADL-independent. At the 5-month follow-up there were no differences in the nutritional and cognitive status of the residents. The nutritional knowledge of the staff improved slightly (P<0.05) at both SF complexes (NS between groups).

CONCLUSIONS

Around one-third of SF residents appeared to be at nutritional risk. Five months after a 12-h staff nutrition education programme, no objective changes were seen in the nutritional status of the SF residents.

Relationships between structural and functional measures of nutritional status in a normally nourished population

BACKGROUND AND AIMS

Both anthropometric and functional measurements have been used in nutritional assessment and monitoring. Hand dynamometry is a predictor of surgical outcome and peak expiratory flow rate has been used as an index of respiratory muscle function. This study aims to measure in normal subjects the relationship between anthropometric measurements, voluntary muscle strength by hand grip dynamometry and respiratory muscle function by peak expiratory flow rate.

METHODS

Ninety-eight subjects (46 male, 52 female) with a mean age of 45.9 years were studied. Hand grip strength was measured in the dominant and non-dominant hands with a portable strain-gauge dynamometer. Peak expiratory flow rate was measured using a mini-Wright peak flow meter. Three readings were taken, each 1 min apart, and the average recorded. Midarm muscle circumference (MAMC) was derived from triceps skin fold thickness and midarm circumference (MAC) using standard anthropometric techniques. Statistical relationships were measured with Pearson's coefficient of correlation.

RESULTS

In both sexes there was significant correlation between hand grip strength in the dominant and non-dominant hands and peak expiratory flow rate (P<0.001). In men, there was a positive correlation between MAMC, hand grip strength (P<0.001) and peak expiratory flow rate (P<0.001). In women muscle function correlated with height (P<0.001) but not MAMC (P>0.05).

CONCLUSIONS

In normal subjects bedside tests of skeletal and respiratory muscle function correlated with each other in both sexes, and with muscle mass in men but not in women.

The Subjective Global Assessment reliably identifies malnutrition-related muscle dysfunction

BACKGROUND

Muscle dysfunction is a common finding in malnourished patients and is associated with poor outcome. We investigated whether the Subjective Global Assessment (SGA) is a valuable tool for identifying malnutrition-related muscle dysfunction.

METHODS

Two hundred eighty seven consecutive patients were assessed on admission to hospital according to the SGA, anthropometric measurements, and to the results of bioelectrical impedance analysis. The SGA was used as the main criterion for the classification of malnutrition. Muscle function was assessed by handgrip strength.

RESULTS

Maximal voluntary handgrip strength was significantly lower in malnourished than in well-nourished male and female patients (45.22 (13.51-67.7)kg versus 30.82(11-48) kg in men; 23.81 (5.60-56.5) kg versus 18.5 (5.90-48.8) kg in women). Handgrip strength tended to decline with age. Handgrip strength was positively correlated to body cell mass (BCM) (r=0.72, P<0.001 in men and: r=0.56, P<0.001 in women) and to body mass index (r=0.271, P=0.03 in men and r=0.183, P=0.02 in women). BCM was identified as a powerful contributor to the variation in handgrip strength (delta r2=0.645, P<0.001).

CONCLUSION

The SGA appears to be a reliable bedside assessment tool for malnutrition and malnutrition-related dysfunction. Patients classified malnourished according to the SGA have an impaired functional status. Every effort should be made to provide both nutritional and physical therapy in order to improve the patients' outcome.

Nutritional status of cancer patients and its relationship to function in an inpatient rehabilitation setting

BACKGROUND

Malnutrition is associated with prolonged hospitalization, lower survival rate, and various medical complications. However, little is known about malnutrition and its relationship with the functional status. We undertook this retrospective study to examine whether or not malnutrition affects rehabilitation outcome in patients who had undergone cancer rehabilitation.

METHODS

We conducted a review of the charts of 30 consecutive cancer patients who had been admitted to the inpatient rehabilitation unit in a tertiary cancer center, from the beginning of March 2001 to the end of April 2001.

RESULTS

The patients' mean rehabilitation stay was 9 days and their mean age was 58 years (range 22-86 years). On rehabilitation admission, 15 of the patients (50%) had a below normal prealbumin (<18 mg/dl) level (95% confidence interval 31-69%), and on discharge 10 of the patients (33%) had a below normal prealbumin level (95% CI 17-54%). The serum prealbumin concentration level correlated with motor functional independence measure scores on admission. After inpatient rehabilitation, statistically significant gains in functional independence measure scores (P<0.0001) were obtained in patients with below normal admission prealbumin, as well as in those whose prealbumin levels were within the normal range; no statistically significant difference was found in functional gain between these two groups.

CONCLUSION

Our study showed that a large number of cancer rehabilitation patients had malnutrition. Nevertheless, functional gain was achieved in all patients after rehabilitation, whether or not malnutrition was present. We conclude that malnourished patients should still be considered candidates for rehabilitation.

Short-term outcomes and their predictors for patients hospitalized with community-acquired pneumonia

PURPOSE

This study of patients who were hospitalized with pneumonia describes 4 short-term outcomes and the relative value of 4 variables for predicting the outcomes.

METHOD

We prospectively documented 4 short-term outcomes (hospital length of stay, discharge location, death, 30-day readmission) among 213 adults (mean age = 72.5 years) with pneumonia who were admitted to the hospital. Relationships between the Pneumonia Severity Index (PSI), preadmission walking, malnutrition, grip strength, and outcomes were examined with correlations and multiple logistic regression.

RESULTS

The mean (SD) hospital stay was 8.8 (10.4) days. Many patients (51.6%) were not discharged to their homes; 13.6% died during admission or within 30 days of discharge. Of 205 patients discharged alive, 23.9% were readmitted within 30 days. All predictor variables correlated significantly with length of stay, discharge, and death. Except for grip strength, all predictor variables correlated significantly with readmission. Regression showed that the PSI contributed significantly to the prediction of all outcomes but that other variables also contributed (R(2) =.099 [readmitted] to.484 [discharged to home]).

CONCLUSIONS

Because malnutrition and physical performance measures independently predicted or added to the PSI's prediction of untoward outcomes, the measures merit inclusion when assessing patients with pneumonia.