NIHR DC Discover

Elderly man exercising and testing his grip strength.

NIHR Signal Routine measurement of grip strength can help assess frailty in hospital

Published on 2 October 2018

doi: 10.3310/signal-000650

Training clinical staff to routinely measure grip strength can help identify frail older hospital inpatients. This could help tailor their care.

This NIHR-funded study was conducted across five acute medical wards in one hospital in England over a nine-month period. Nursing staff were trained to measure grip strength of people aged over 80 years. They were instructed to assess if those with low grip required nutritional supplements and to refer them to physiotherapy for consideration of strength exercises.

Successful implementation and acceptance of grip strength measurement into routine practice was variable across the wards and heavily dependent on the interest and commitment of staff. Ward champions were important for successful implementation. Grip strength was measured in 40% of those eligible. Though over three-quarters of them had low grip strength, referral for supplements or physiotherapy was inconsistent. The study did not assess if these measures improved outcomes or how it compared with other ways of assessing frailty. 

For those considering a similar scheme, this study shows it is feasible, acceptable and inexpensive but requires team commitment. 

Share your views on the research.

Why was this study needed?

In the UK, older people account for almost two thirds (65%) of people admitted to hospital. Frail older people make up 30% of acute medical unit inpatients. Frailty and sarcopenia (loss of skeletal muscle mass and strength) are ageing syndromes which can lead to longer lengths of hospital stay and increased hospitalisation costs. Poor health outcomes are also common, for instance with frailty related falls costing the NHS an estimated £4.6 million per day.

Low grip strength is a common indicator of frailty but is not usually assessed in hospital inpatient settings. The routine measurement of grip strength using a relatively low-cost piece of equipment, a dynamometer, could help identify at-risk older inpatients. It could also support the implementation of appropriate early health care interventions to prevent poor health outcomes and speed up the discharge process.

This study assessed the feasibility and acceptability of a strategy to implement grip strength measurement into routine clinical practice in inpatient settings for older people.

What did this study do?

This mixed-methods study was conducted within one hospital in England across five acute medical wards. Grip strength training on using a Jamar dynamometer was provided to 155 staff, mainly nurses. Training and ward visits were provided by the research team throughout the nine-month implementation period.

Staff were instructed to use the grip strength test on all patients over 80 years. If they had low-grip strength, staff were directed to set up a dietary assessment and refer them to physiotherapy to consider resistance training exercises.

Semi-structured interviews and focus groups were carried out with 15 clinical staff members and eight patients on the acceptability of the test.

As a feasibility study, this is early research designed to understand the practical issues with using the grip test and to uncover any limitations to implementing it in other settings with different organisational cultures or structures.

What did it find?

  • Grip strength was measured in 811/2,043 (40%) eligible people. Looking at a sample of 86 people with low grip strength, nutritional supplements were prescribed to 60% of them and strength exercises to 20%. High levels of acceptance were found in the eight patients interviewed. Most found no difficulty in doing the grip strength test.
  • Training sessions lasted around 20 minutes and were not considered disruptive to daily working practices. High levels of confidence in measuring grip strength and using the care plan were reported by staff in a post-training evaluation.
  • Acceptance of the intervention by staff was variable across wards. Supportive ward managers and keen ward champions achieved better implementation and staff acceptance. Regular changes in ward managers, lack of interest, and lack of support for the intervention were barriers to acceptance and implementation.
  • Dieticians thought that it could be useful for early identification of people who could benefit from supplements, but also expressed some reservations about inappropriate prescribing.
  • The costs reported for delivering training across all five wards were between £2,218 and £2,302 per year and between £5.78 and £10 per patient depending on the seniority of staff. Dietician and physiotherapy costs were not included.

What does current guidance say on this issue?

Guidelines focussing on frailty related problems in older people have a common focus on falls. NICE guidelines on falls risk assessment highlight that interventions to improve strength should be identified for at-risk older people.  

Whilst grip strength measurement can aid the identification of frailty in older people, routine assessment of grip strength is not currently recommended in any relevant UK guidance. A range of tests for assessing frailty are available, including gait speed and the timed up and go test.

What are the implications?

Incorporating grip strength measurement into routine assessment has potential to be a more consistent approach in identifying patients at risk of frailty.

This study indicates mostly positive attitudes amongst staff and patients towards routine measurement of grip strength in an acute hospital inpatient setting. Routine implementation is feasible; however, success would be dependent on a strong investment of time, willingness to engage, and commitment from all staff involved. The use of ward champions seemed important for success. This might be difficult in wards with high staff turnover. This study was based on one hospital only, so results may not be generalisable to all other sites. 

Routine implementation appears low cost, but any workload implications for physiotherapists and dieticians could be considered further before this test becomes widespread. 

Citation and Funding

Ibrahim K, May C, Patel H, et al. Implementation of grip strength measurement in medicine for older people wards as part of routine admission assessment: identifying facilitators and barriers using a theory-led intervention. BMC Geriatrics. 2018;18(1):79.

This study was funded by the NIHR Collaboration for Leadership in Applied Health Research and Care Wessex.

Bibliography

BGS. Fit for frailty part 1: consensus best practice guidance for the care of older people living in community and outpatient settings. London: British Geriatrics Society; 2014.

Cornwell J, Levenson R, Sonola L, et al. Continuity of care for older hospital patients: a call for action. The King’s Fund; 2012.

Cruz-Jenfoft A, Baeyens J P, Bauer J M, et al. Sarcopenia: European consensus on definition and diagnosis: report of the European working group on sarcopenia in older people. Age Ageing. 2010; 39(4):412.

Imison C, Poteliakhoff E, Thompson J. Older people and emergency bed use: exploring variation. London: The King’s Fund; 2012.

NHS Improvement. Rapid improvement guide to: identifying and managing frailty at the front door. London: NHS Improvement; 2016.

NICE. Falls in older people: assessing risk and prevention. CG161. London: National Institute for Health and Care Excellence; 2013.

Why was this study needed?

In the UK, older people account for almost two thirds (65%) of people admitted to hospital. Frail older people make up 30% of acute medical unit inpatients. Frailty and sarcopenia (loss of skeletal muscle mass and strength) are ageing syndromes which can lead to longer lengths of hospital stay and increased hospitalisation costs. Poor health outcomes are also common, for instance with frailty related falls costing the NHS an estimated £4.6 million per day.

Low grip strength is a common indicator of frailty but is not usually assessed in hospital inpatient settings. The routine measurement of grip strength using a relatively low-cost piece of equipment, a dynamometer, could help identify at-risk older inpatients. It could also support the implementation of appropriate early health care interventions to prevent poor health outcomes and speed up the discharge process.

This study assessed the feasibility and acceptability of a strategy to implement grip strength measurement into routine clinical practice in inpatient settings for older people.

What did this study do?

This mixed-methods study was conducted within one hospital in England across five acute medical wards. Grip strength training on using a Jamar dynamometer was provided to 155 staff, mainly nurses. Training and ward visits were provided by the research team throughout the nine-month implementation period.

Staff were instructed to use the grip strength test on all patients over 80 years. If they had low-grip strength, staff were directed to set up a dietary assessment and refer them to physiotherapy to consider resistance training exercises.

Semi-structured interviews and focus groups were carried out with 15 clinical staff members and eight patients on the acceptability of the test.

As a feasibility study, this is early research designed to understand the practical issues with using the grip test and to uncover any limitations to implementing it in other settings with different organisational cultures or structures.

What did it find?

  • Grip strength was measured in 811/2,043 (40%) eligible people. Looking at a sample of 86 people with low grip strength, nutritional supplements were prescribed to 60% of them and strength exercises to 20%. High levels of acceptance were found in the eight patients interviewed. Most found no difficulty in doing the grip strength test.
  • Training sessions lasted around 20 minutes and were not considered disruptive to daily working practices. High levels of confidence in measuring grip strength and using the care plan were reported by staff in a post-training evaluation.
  • Acceptance of the intervention by staff was variable across wards. Supportive ward managers and keen ward champions achieved better implementation and staff acceptance. Regular changes in ward managers, lack of interest, and lack of support for the intervention were barriers to acceptance and implementation.
  • Dieticians thought that it could be useful for early identification of people who could benefit from supplements, but also expressed some reservations about inappropriate prescribing.
  • The costs reported for delivering training across all five wards were between £2,218 and £2,302 per year and between £5.78 and £10 per patient depending on the seniority of staff. Dietician and physiotherapy costs were not included.

What does current guidance say on this issue?

Guidelines focussing on frailty related problems in older people have a common focus on falls. NICE guidelines on falls risk assessment highlight that interventions to improve strength should be identified for at-risk older people.  

Whilst grip strength measurement can aid the identification of frailty in older people, routine assessment of grip strength is not currently recommended in any relevant UK guidance. A range of tests for assessing frailty are available, including gait speed and the timed up and go test.

What are the implications?

Incorporating grip strength measurement into routine assessment has potential to be a more consistent approach in identifying patients at risk of frailty.

This study indicates mostly positive attitudes amongst staff and patients towards routine measurement of grip strength in an acute hospital inpatient setting. Routine implementation is feasible; however, success would be dependent on a strong investment of time, willingness to engage, and commitment from all staff involved. The use of ward champions seemed important for success. This might be difficult in wards with high staff turnover. This study was based on one hospital only, so results may not be generalisable to all other sites. 

Routine implementation appears low cost, but any workload implications for physiotherapists and dieticians could be considered further before this test becomes widespread. 

Citation and Funding

Ibrahim K, May C, Patel H, et al. Implementation of grip strength measurement in medicine for older people wards as part of routine admission assessment: identifying facilitators and barriers using a theory-led intervention. BMC Geriatrics. 2018;18(1):79.

This study was funded by the NIHR Collaboration for Leadership in Applied Health Research and Care Wessex.

Bibliography

BGS. Fit for frailty part 1: consensus best practice guidance for the care of older people living in community and outpatient settings. London: British Geriatrics Society; 2014.

Cornwell J, Levenson R, Sonola L, et al. Continuity of care for older hospital patients: a call for action. The King’s Fund; 2012.

Cruz-Jenfoft A, Baeyens J P, Bauer J M, et al. Sarcopenia: European consensus on definition and diagnosis: report of the European working group on sarcopenia in older people. Age Ageing. 2010; 39(4):412.

Imison C, Poteliakhoff E, Thompson J. Older people and emergency bed use: exploring variation. London: The King’s Fund; 2012.

NHS Improvement. Rapid improvement guide to: identifying and managing frailty at the front door. London: NHS Improvement; 2016.

NICE. Falls in older people: assessing risk and prevention. CG161. London: National Institute for Health and Care Excellence; 2013.

Implementation of grip strength measurement in medicine for older people wards as part of routine admission assessment: identifying facilitators and barriers using a theory-led intervention

Published on 22 March 2018

Ibrahim K, May CR, Patel HP, Baxter M, Sayer AA and Roberts HC

BMC Geriatrics , 2018

Background Low grip strength in older inpatients is associated with poor healthcare outcomes including longer length of stay and mortality. Measuring grip strength is simple and inexpensive. However, it is not routinely used in clinical practice. We aimed to evaluate the implementation of grip strength measurement into routine clinical practice. Methods This implementation study was a mixed methods study based in five acute medical wards for older people in one UK hospital. Intervention design and implementation evaluation were based on Normalization Process Theory (NPT). A training program was developed and delivered to enable staff to measure grip strength and use a care plan for patients with low grip strength. Routine implementation and monitoring was assessed using the “implementation outcome variables” proposed by WHO: adoption, coverage, acceptability, fidelity, and costs analysis. Enablers and barriers of implementation were identified. Results One hundred fifty-five nursing staff were trained, 63% in just 3 weeks. Adoption and monthly coverage of grip strength measurement varied between 25 and 80% patients across wards. 81% of female patients and 75% of male patients assessed had low grip strength (< 27 kg for men and < 16 kg for women). Staff and patients found grip measurement easy, cheap and potentially beneficial in identifying high-risk patients. The total cost of implementation across five wards over 12 months was less than £2302. Using NPT, interviews identified enablers and barriers. Enablers included: highly motivated ward champions, managerial support, engagement strategies, shared commitment, and integration into staff and ward daily routines. Barriers included lack of managerial and staff support, and high turnover of staff, managers and champions. Conclusions Training a large number of nurses to routinely implement grip strength measurement of older patients was feasible, acceptable and inexpensive. Champions’ motivation, managerial support, and shared staff commitment were important for the uptake and normalisation of grip strength measurement. A high percentage of older patients were identified to be at risk of poor healthcare outcomes and would benefit from nutritional and exercise interventions. Measuring grip strength in these patients could provide an opportunity to identify those with normal grip strength for fast tracking through admission to discharge thereby reducing length of stay.

Expert commentary

It is believed that knowing the frailty status of patients will enable clinical outcomes to be improved. Clinicians normally use simple but subjective clinical frailty rating scales.

This study looked at the implementation of the routine objective clinical measurement of frailty in hospital wards, handgrip strength (a good indicator of frailty). Unsurprisingly, with effort and leadership, it is possible to implement this.

So far, so good – but research is still needed to show how this information can be used to improve outcomes.

JRF Gladman, Professor of the Medicine of Older People, University of Nottingham