Introduction:
Aging which is accompanied by major changes in body composition that can negatively affect functional status (1) has a deteriorating effect on hand function (2) and this decline could be as a result of weakness of muscle mass, strength, co-ordination, grip strength and dexterity in the geriatric population (3). The effects of sedentary lifestyle are very evident due to decreased physical activity; leading to a reduced ability of the hands to manipulate objects (4). A decline in spatial acuity at finger tips may yield difficulties with tasks involving fine manipulations (5). Physical function tests are strong predictors of key clinical outcomes and adverse health events in the geriatric population.
Hand grip strength (HGS) which is an important function of upper extremities for older adults (6) has been generally used as an important indicator of whole body strength (7). Good hand grip strength is essential in the performance of daily activities, such as carrying out domestic tasks, and self-care activities (8). Presentation of a weak hand grip strength is often associated with premature mortality (9) and also a determinant of cardio- metabolic diseases (10). Hand grip strength is a significant predictor of pulmonary function in healthy young adults living in low-resource country (11). Age-related functional changes in the respiratory system result from decrease in compliance of the chest wall, strength of the respiratory muscles and elastic recoil of the lung (12). Cardiorespiratory fitness measured as maximal oxygen uptake (VO2max) refers to the overall capacity of an individual to carry out prolonged exercise (13, 14). Decrease in physical activity (PA) contributes to decline of VO2max (15, 16), the contribution of PA in the decline of VO2max has been found to be relatively less for the geriatric population (16, 17).
To our knowledge, there is paucity of published studies on the relationship between grip strength, cardiorespiratory fitness and functional decline in the geriatric population of Sub-Saharan Africa especially in Nigeria. Assessing the relationship between these variables and identifying the predictors of cardiorespiratory fitness and functional decline in the geriatric population will help initiate evidence-based primary prevention among individuals at elevated risk of cardiorespiratory impairments. This study sought to ascertain hand grip strength, dexterity and hand function and its relationship with selected cardiorespiratory fitness parameters and functional decline in the geriatric population.
Therefore, the research questions for this study were:
- What is the inter-relationship among hand grip strength, hand function, dexterity, functional decline and cardiorespiratory fitness parameters (FEV1, FVC, FEV1/FVC, PEFR, aerobic capacity (VO2max) in a geriatric population?
- Which of the variables are predictors of the selected cardiorespiratory fitness parameters and functional decline in a geriatric population?
Method
This study was conducted in three different centres which include: Little sisters of the poor old people’s home in Agbani Road, Security and Works Department, University of Nigeria, Enugu Campus and Holy Ghost cathedral Ogui New layout Enugu, Enugu State, South-Eastern Nigeria.
Study Design: This study employed a cross-sectional research design. This study was approved by the University of Nigeria Medical Research and Ethics committee (NHREC/05/01/2008B-FWA 00002458-1RB00002323). Participants gave written informed consents prior to participation in the study.
Participants: One hundred and fifteen geriatrics (forty six males and sixty nine females) who were 65 years and above participated in the study. They were recruited into the study through a convenience sampling method following weeks of announcements and information through the respective heads of their units. Inclusion criteria were: Individuals who were = 65 years with no significant record of alcohol and drug abuse. The exclusion criteria included the presence of neurological or psychiatric disorders, smokers, ambulatory challenges, presence of cardiac pacemakers, Individuals with diseases that could impair fine motor skills or functional abilities e.g. carpal tunnel syndrome, arthritis.
Procedure for Data Collection
Aerobic Capacity (VO2max): this was indirectly calculated using the formula by Uth et al., (18).
VO2 max = 15x (HRmax/HRrest)
HRmax = maximum heart rate = 220- age of subject
HRrest = Baseline heart rate of subject.
Spirometry: Height and weight of each participant was measured. Participants’ smoking history was considered. Pulmonary functions were measured by the electronic spirometer, model-RMS Helios-702 in accordance with the standards of lung function testing of the American Thoracic Society/European Respiratory Society (ATS/ERS) (19). Pulmonary function report included patient’s gender, height, weight, age and smoking status. Standard spirometric measures included, forced vital capacity (FVC), forced expiratory volume in one second FEV1, the ratio of forced expiratory volume in one second to forced vital capacity (FEV1/FVC), and peak expiratory flow rate (PEFR). Pulmonary function variables were recorded as a percentage of the normal value predicted on reported height and age (20).
Demographic variables
Body Mass Index (BMI): The researcher measured the heights of the participants to the nearest centimeter using the stadiometer (Secca, England). Doing this, the researcher ensured that the participants stood erect and barefoot, with their backs touching the stadiometer, their arms held laterally by their sides and with the two feet closely apposed. Also, the weight of each participant was measured using a weighing scale (Beurer, Germany), while the participant was putting on light clothing to avoid errors. The Body Mass Index (BMI) was calculated from the weight (kg) and height (m2) (weight/height2).
Waist-Hip Ratio: Waist and hip circumferences were measured using a tape measure (butterfly brand, China) and duplicate measurements were taken at each site and were obtained in a rotational order. The waist-hip ratio was calculated by dividing the waist circumference (cm) by the hip (cm).
Assessment of Functional Decline in the Geriatric Population: Competence in daily functioning was assessed with Groningen activity restriction scale (GARS) (21). The GARS is a non-disease specific instrument for measuring disabilities. GARS has a sound psychometric property and measures both ADL and IADL simultaneously with a reliability coefficient of 0.94 (22). A sum score was calculated separately for ADL and IADL. Hence, each sum score ranged from nine (competent in all activities) to thirty six (unable to perform any activity without help). The scale was researcher administered.
Assessment of Hand Grip Strength using a Hand held Manual Dynamometer: Hand grip strength measurement was performed with both hands using a manual handgrip calibrated dynamometer (W-L-B, 1213 scientific instrument, china). The dynamometer was calibrated at the onset of the study. Grip strength was measured with the participants facing the examiner while sitting comfortably in a seat or in some cases wheelchair. The examiner ensured that the arm to be tested was held by their side and their elbow was at 90 degrees angle. The handle positioned with the rest on first metacarpal and the handle rested on the middle of the four fingers prior to testing. The participants were asked to squeeze the hand as hard as possible for few seconds. Hand grip strength was expressed in kilograms (Kg). For further analysis, the grip strength of the dominant hand was used (23). The dominant hand was determined using Edinburgh handedness inventory (24, 25).
Assessment of Dexterity: To evaluate motor dexterity of the dominant hand, Coin Rotation Task (CRT) was employed (26). The CRT was developed as a quick and convenient measure for assessing subtle residual lateralized motor dexterity or impairments. It demonstrated good convergent validity and divergent validity when compared with other standardized motor measures. The levels of sensitivity and specificity of CRT were comparable with or better than other standardized tests of manual dexterity (26). Here the participants was instructed to hold the nickel coin (diameter=18.20mm, thickness=1.25mm, weight=2.2g) between their thumb, index and middle fingers in their dominant hand and rotate the coin as quickly as possible through 180o turns for 20 rotations. They were timed and three trials were given and the examiner measured the time of completion. The participants were also instructed to pick up the coin as quickly as possible when it dropped during the assessment and complete the procedure. The average duration of the three trials was obtained and used for the study.
Assessment of Hand Function using Michigan Hand Outcome Questionnaire : This is a reliable and valid instrument for measuring hand outcome of an individual (4). Test-retest reliability using spearman’s correlation demonstrated substantial agreement, ranging from 0.81 for aesthetics scale to 0.97 for the ADL scale (27). It has 6 scales and they are overall hand function, activities of daily living (ADL), work performance, pain, aesthetics, and satisfaction with hand function. An overall MHQ score was obtained by summing the scores for all the six scales and divide by six. This questionnaire was researcher administered.
Method of Data Analysis
The descriptive statistics was used to calculate the frequency, mean, standard deviation and percentile. Pearson moment correlation was used to show the relationship between the dependent and independent variables while multiple regression analysis was used to provide the p-value and r2 value for the prediction of cardiorespiratory parameters from handgrip strength, dexterity and hand function. The significance level was set at 0.05. SPSS for windows version 21.0 was used for the data analysis.
Results
This study involved One hundred and fifteen (46 males and 79 females). Forty six 46 participants (40%) had weak hand grip strength, 33 (28.7%) had normal hand grip strength, while 36 (31.3%) had strong hand grip strength. Nine (7.8%) were underweight, 48 (41.7%) had normal weight; 43 (37.4%) were overweight, 12 (10.4%) were in class I obesity, 2 (1.7%) were in class II obesity while 1 (0.9%) was in class III obesity.
| Table 1: Descriptive Statistics of Demographic, Independent and Dependent Variables of the participants. N=115 |
| Variable |
Minimum |
Maximum |
Mean ± SD |
Age |
65 |
88 |
72.11±6.24 |
Waist- hip ratio |
0.73 |
1.33 |
0.92±0.06 |
Waist-height ratio |
0.44 |
0.8 |
0.58±0.07 |
Body mass index |
16.4 |
45.33 |
25.4±4.73 |
Hand grip strength |
3 |
87 |
24.39±17.04 |
Dexterity |
10 |
120 |
34.98±22.97 |
Overall Hand function |
25 |
125 |
60.91±20.15 |
Overall ADL |
25 |
125 |
51.62±23.78 |
Work |
25 |
125 |
83.26±26.33 |
Pain |
0.00 |
105 |
62.26±28.15 |
Aesthetics |
43.75 |
100 |
70.73±13.28 |
Satisfaction |
25 |
125 |
63.61±23.49 |
MHQ score |
38.79 |
97.08 |
65.34±11.98 |
FEV1 |
0.19 |
1.82 |
0.73±0.36 |
FVC |
0.23 |
2.08 |
0.77±0.39 |
PEFR |
20 |
244 |
119.73±48.18 |
FEV1/FVC |
0.21 |
1.20 |
0.96±0.11 |
VO2max |
23.13 |
42.60 |
31.98±3.93 |
ADL |
5.5 |
21 |
9.47±3.69 |
IADL |
3.5 |
14 |
8.24±3.69 |
Total GARS |
9 |
35 |
17.71±6.94 |
| Key: ADL- Activities of daily living, MHQ- Michigan Hand outcome Questionnaire, FEV1- Forced expiratory volume in 1 second, FVC- Forced vital capacity, PEFR- Peak expiratory flow rate, FEV1/FVC- The ratio of forced expiratory volume in 1 second and forced vital capacity, VO2max- Maximum oxygen consumption, IADL- Instrumental activities of daily living, GARS- Groningen Activity Restriction Scale. |
Table 1 shows the descriptive statistics; minimum and maximum values, mean and standard deviation of the demographic variables of the participants, independent variables (hand grip strength, dexterity and the six domains of Michigan Hand Outcome Questionnaire which was used to assess hand function; overall hand function, overall ADL, work, pain, Aesthetics and satisfaction) and dependent variables (FEV1, FVC, PEFR, VO2max and functional decline which was assessed using Groningen Activity Restriction Scale (GARS) with the scores of the two domains of GARS which is ADL and IADL). Pearson Moment Correlation among Dexterity, Hand Grip Strength, Hand Function, Cardiorespiratory Fitness Parameters and Functional Decline of the geriatric population was shown in Table 2.
| Table 2: Pearson Moment Correlation between Hand Grip Strength, Dexterity, MHQ Cardiorespiratory Fitness Parameters and Functional Decline |
| Variable (n=115) |
r-value |
p-value |
HGS vs. FEV1 |
0.326 |
0.001* |
HGS vs. FVC |
0.295 |
0.001* |
HGS vs. PEFR |
0.479 |
0.001* |
HGS vs. FEV1/FVC |
0.51 |
0.586 |
HGS vs. VO2max |
-0.02 |
0.983 |
HGS vs. GARS |
-0.581 |
0.001* |
Dexterity vs. FEV1 |
-0.318 |
0.001* |
Dexterity vs. FVC |
-0.295 |
0.001* |
Dexterity vs. PEFR |
-0.448 |
0.001* |
Dexterity vs. FEV1/FVC |
-0.089 |
0.345 |
Dexterity vs. VO2max |
0.094 |
0.317 |
Dexterity vs. GARS |
0.514 |
0.001* |
MHQ vs. FEV1 |
-0.185 |
0.048* |
MHQ vs. FVC |
-0.159 |
0.090 |
MHQ vs. PEFR |
-0.227 |
0.015* |
MHQ vs. FEV1/FVC |
-0.78 |
0.409 |
MHQ vs. VO2 max |
0.87 |
0.353 |
MHQ vs. GARS |
0.674 |
0.001* |
| Key: * means statistically significant, HGS- Hand grip strength, FEV1- forced expiratory volume in 1 seconds, FVC- forced vital capacity, PEFR- peak expiratory flow rate, VO2max- Maximum oxygen consumption, GARS- Groningen activity restriction scale. MHQ- Michigan hand outcome questionnaire |
Table 3 shows HGS and dexterity statistically predict FEV1, F (3, 114) =5.991, P<0.05, r2=0.139. The unstandardized coefficient for HGS is 0.005 and significance (p=0.037) and for dexterity is -0.003 and significance (p=0.045); this result shows that an increase in hand grip strength and dexterity result in 13.9% increase in FEV1.
| Table 3: Multiple Regression Analysis to Predict the FEV1 from the independent variables (Hand Grip Strength, Dexterity and Hand Function) n=115 |
| Variable |
Df |
F-ratio |
r2 |
p-value |
B |
Overall Significance |
3 |
5.991 |
0.139 |
0.002 |
|
|
114 |
|
|
|
|
Independent Significance |
|
|
|
|
|
Hand grip strength |
|
|
|
0.037* |
0.005 |
Dexterity |
|
|
|
0.045* |
-0.003 |
MHQ |
|
|
|
0.931 |
0.000 |
Table 4 shows the independent variables HGS (p=0.062), Dexterity (p= 0.056) and hand function (p= 0.0834) statistically did not predict FVC.
| Table 4: Multiple Regression Analysis to Predict the FVC from the independent variables (Hand Grip Strength, Dexterity and Hand Function) n=115 |
| Variable |
Df |
F-ratio |
r2 |
p-value |
B |
Overall Significance |
3 |
4.909 |
0.117 |
0.003 |
|
|
114 |
|
|
|
|
Independent Significance |
|
|
|
|
|
Hand grip strength |
|
|
|
0.062 |
0.005 |
Dexterity |
|
|
|
0.056 |
-0.003 |
MHQ |
|
|
|
0.834 |
0.001 |
Table 5 shows the independent variable HGS and Dexterity statistically predict PEFR, F (3,114) =15.293, p<0.05, r2=0.292. Unstandardized coefficient for HGS is 1.036 and significance (p=0.001) and for dexterity is 0.0621 and significance (p=0.002). This result shows that an increase in handgrip strength and dexterity results in 29.2% increase in PEFR.
| Table 5: Multiple Regression Analysis to Predict the PEFR from the independent variables (Hand Grip Strength, Dexterity and Hand Function) n=115 |
| Variable |
Df |
F-ratio |
r2 |
p-value |
B |
Overall Significance |
3 |
15.293 |
0.292 |
0.001 |
|
|
114 |
|
|
|
|
Independent Significance |
|
|
|
|
|
Hand grip strength |
|
|
|
0.001* |
1.036 |
Dexterity |
|
|
|
0.002* |
-0.062 |
MHQ |
|
|
|
0.464 |
0.276 |
Table 6 shows the independent variables (HGS, Dexterity, and hand function), statistically predict functional abilities (GARS), F (3,114) =48.922, p<0.05, r2=0.569. The unstandardized coefficient for HGS is -0.212 and significant (p=0.001), for dexterity is 0.118 and significant (p=0.009), for hand function (MHQ), 0.545 and significant (p=0.001). This result shows that an increase in hand grip strength, dexterity and hand function result in 56.9% reduction in functional decline.
| Table 6: Multiple Regression Analysis to Predict GARS from Hand Grip Strength, Dexterity and Hand Function n=115 |
| Variable |
Df |
F-ratio |
r2 |
p-value |
B |
Overall Significance |
3 |
48.922 |
0.569 |
0.000 |
|
|
114 |
|
|
|
|
Independent Significance |
|
|
|
|
|
Hand grip strength |
|
|
|
0.001* |
-0.212 |
Dexterity |
|
|
|
0.009* |
0.118 |
MHQ |
|
|
|
0.001* |
0.545 |
Discussion
This study evaluated hand grip strength, dexterity, hand function and its relationship with cardiorespiratory parameters and functional decline in a selected geriatric population. The findings showed that hand grip strength correlated positively and significantly with FEV1, FVC, and PEFR but not significant with FEV1/FVC and VO2max. The finding of this study is in agreement with the previous studies by (11, 28), but not in line with the study by Masamitsu et al, (29) which demonstrated peak VO2 is an independent determinant of handgrip strength in community dwelling elderly outpatients. This dissimilarity could be attributed to 6-month exercise training given to their elderly participants, which could have increased their aerobic capacity (VO2max) and other indices such as stroke volume and heart rate. A multiple regression analysis done also showed that hand grip strength was a significant predictor of FEV1 and PEFR in the geriatric population and could be explained by a strong relationship between skeletal and respiratory muscle strength, particularly the Maximal inspiratory pressure (MIP) of the diaphragm (30)
The results of this study also revealed a significant moderate negative correlation between hand grip strength and functional decline in the elderly. Individuals with higher hand grip strength have less activity restriction and those with poor hand grip strength have more activity restriction and therefore a greater functional decline. A multiple regression analysis showed that weak hand grip strength is a significant predictor of functional decline in the elderly. The findings of this study is in line with that of the previous studies by Taekema et al., (21), that showed that weak hand grip strength is a predictor of decline in functional, psychological and social health in the oldest old and Ishizaki et al., (31), that showed that weak hand grip strength is a predictor of functional decline in community dwelling non-disabled older Japanese. Weak hand grip strength is associated with poor functional performance capacity and frailty among older adults (8). Hand grip strength assessment may be used in geriatric clinical practice to identify the elderly patients at elevated risk of functional decline.
The finding of this study showed a significant weak negative correlation between dexterity and FEV1, FVC, PEFR but not for FEV1/FVC and VO2max. The ability of an individual to perform movements or manipulate object in a coordinated manner with their hands may depend on the individual’s cardiorespiratory state, that is to say the higher the dexterity in these elderly population, the better the cardiorespiratory fitness. Although there is paucity of literature on these findings on the apparently healthy elderly, Mateos-Toset et al, (32), in their study showed that a single hand session exercise showed an improvement in manual dexterity and strength in elderly persons with Parkinson’s disease and Soyupek, et al., (33), in their study showed that aerobic exercise of 30 minutes duration had an immediate effect on hand dexterity of patients with coronary heart diseases. Aerobic exercise improving both cardiorespiratory fitness and dexterity suggests a positive relationship between the two components of physical fitness. Therefore assessing the dexterity of the elderly ones may be an important indicator of their cardiorespiratory state.
The result of this study showed a significant moderate positive correlation between dexterity and functional decline in the elderly. Multiple regression analysis revealed that poor dexterity is a significant predictor of functional decline in the elderly. This result is in tandem with the study by Estela et al, (34), which showed that hand dexterity strongly associates with executive function in Japanese community dwelling older adults and that by Choi, et al., (35), which showed that manual dexterity is an important factor for predicting physical performance in daily living in elderly patients with Parkinson disease. The rationale of this relationship resides in that hand dexterity through the sensorimotor coordination of hands, fingers, eyes and the complex cognitive processes play a significant role in the successful performance of both activities of daily living and instrumental activities of daily living (34); therefore a decline in spatial acuity in finger tips and visual acuity in old age which result in subsequent reduction in dexterity in the elderly may yield difficulties with tasks involving fine manipulation and precision grip movements (36), thereby resulting in functional decline in the elderly population.
Furthermore, study findings revealed a significant weak negative correlation between hand function, FEV1 and PEFR but not for FVC, FEV1/FVC and VO2max. This means that as FEV1 and PEFR increases, MHQ score decreases which signify better hand outcome or performance in the elderly. Haugen et al, (37) showed a relationship between a hand pathology like hand osteoarthritis and increased risk of coronary heart disease in older adults, stating that this could have been due to the sedentary lifestyle observed in individuals with hand osteoarthritis which is often a marker of generalized osteoarthritis. Sedentary lifestyle could lead to obesity, hyperlipidemia, diabetes and hypertension which are well known risk factors for cardiorespiratory morbidity and mortality.
The finding of this study showed that there was a significant strong positive correlation between hand function and functional decline in the elderly. This means that a higher MHQ score (lower hand function) denotes a greater functional decline (lower GARS score). A multiple regression analysis also showed that hand function was a significant predictor of functional decline in the elderly population. The finding of this study is in tandem with the study by Incel et al. (2), which showed that hand function correlates with functional dependency in the elderly. This could be due to the degenerative effect of age on hand function especially after age of 65 and Carmeli et al, (38) which stated that elderly presents difficulties with hand functioning which can affect every day activities of daily living. Deterioration in hand function occurs as a result of both normal aging and established disorders frequently encountered in older people such as osteoporosis, osteoarthritis and rheumatoid arthritis (38); therefore hand assessment may identify the specific prehension patterns needed for specific tasks and should be incorporated in the health management policy of the elderly patients.
Conclusion
The results of our study indicate a relationship between HGS and FEV1, FVC, PEFR and functional decline (GARS), dexterity and FEV1, FVC, PEFR and functional decline (GARS), hand function and FEV1, PEFR and functional decline (GARS). HGS and dexterity statistically predicted FEV1, PEFR and functional decline (GARS) while hand function only predicted functional decline in the elderly. Age-related decline in spirometric values shows restrictive ventilation, hence, there’s a need for regular breathing exercise. Consistent monitoring and assessment of hand grip strength, dexterity and hand function should be included in the cardiorespiratory health management policy for geriatrics.
Funding: This study was solely funded by the authors.
Conflict of Interest: The authors declare no conflict of interest.
Acknowledgement: The authors appreciate all the participants who took part in this study and the University of Nigeria Enugu Campus, where this study was carried out.
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