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Nutrition and the Lifecycle

Malnutrition and Frailty Screening in Older Adults

Challenges and Opportunities for Dietetic Professionals

Weiler, Mary PhD, RDN, LDN; Arensberg, Mary Beth PhD, RDN, LDN, FAND; Paul, Marika H. PhD, MS; Gahche, Jaime J. PhD, MPH; Comee, Laura MS, RDN, LDN; Krok-Schoen, Jessica L. PhD; Dwyer, Johanna T. DSc, RDN

Author Information
doi: 10.1097/NT.0000000000000435
  • Open

Abstract

Good nutrition is fundamental to healthy aging. Yet, for many older Americans, malnutrition and frailty remain important concerns.1,2 Registered dietitian nutritionists (RDNs) are well suited to screen for undernutrition (often called malnutrition or protein energy malnutrition3) and, with additional cross-training, to screen for frailty.4 Frailty has been defined as “a medical syndrome characterized by diminished strength, endurance, and reduced physiologic function that increases an individual's vulnerability for developing increased dependency and/or death.”5 It is critical to better understand RDNs' knowledge, skills, and practices about screening of both conditions, although they are rarely measured together to guide professional development and education.6

An estimated 15% of community-dwelling older adults and 23% to 62% of hospitalized older patients experience undernutrition.1 Among older adults presenting to the emergency department, 16% were malnourished and 60% were either malnourished or at risk of it.7 The prevalence of frailty among community-dwelling older adults is also considerable, with approximately 45% prefrail and 15% frail.2

Both undernutrition and frailty can be identified and treated early in older Americans, and so systematic screening and intervention programs for undernutrition and frailty for them are important.8 Unfortunately, neither has been widely adopted, despite that both conditions have many of the same characteristics and both contribute significantly to adverse health outcomes.4,6 With broader and greater involvement by RDNs, progress might be more rapid. Here, we present the results of a Web-based survey on malnutrition and frailty screening, based on a national sample of RDNs who worked with older adults (≥65 years old).

METHODS

Survey

An online descriptive, pilot survey was developed to gather information on current malnutrition and frailty screening and intervention policies, prevalence estimates, knowledge and use of screening tools, contributing risk factors, available measures, and dietetic professionals' beliefs about potential roles in frailty screening and intervention for adults 65 years or older. Survey questions used the term malnutrition but specifically referred to the form of malnutrition defined as undernutrition or protein energy malnutrition.3 Survey response options included dichotomous, multiple-choice with an open-ended “Other,” and precategorized responses. Respondents could select more than 1 option for some questions. Demographic information and dietetic practice characteristics were also collected. The survey questionnaire is available from the corresponding author.

The survey was piloted by 3 dietetic professionals working in different practice areas: academia, long-term care, and clinical outpatient oncology. Their feedback was incorporated to finalize the survey instrument. An online, self-service, closed survey platform (Survey Monkey) was used to host the survey, collect responses, and eliminate duplicates from the same Internet protocol address. The Ohio State University Institutional Review Board approved the study protocol via expedited review, and respondents provided electronic informed consent before survey initiation.

Sample

Two randomly sampled lists of 5000 dietetic professionals' email addresses were requested from and provided by the Commission on Dietetic Registration. Duplicates were eliminated, resulting in 9279 unique email addresses. An email linking to the survey was sent in March 2018, followed by 3 email reminders for the next 5 weeks, after which the survey was closed. There was no incentive offered for completing the survey.

Statistical Analysis

The Statistical Product and Service Solutions (version 23; Chicago, Illinois) and SAS software (version 9.4; Cary, North Carolina) were used for statistical analysis, and P ≤ .05 indicated statistically significant findings. Descriptive statistics were used for continuous and categorical data, and χ2 or Fisher exact tests were used to determine significance of categorical data where appropriate. Items with greater than or equal to 95% of responses in 1 category were not statistically analyzed.

FINDINGS

A total of 903 surveys were returned (10% response rate), and of those, 576 respondents reported working with an older adult population (≥65 years) and they constituted the survey sample. All of them were RDNs, 61% had practiced for more than 15 years, and 53% had worked with an older adult population for more than 15 years. Fully 70% of respondents reported that at least half of the population they currently served were older adults. Most of the respondents (57%) practiced in hospital settings, 19% practiced in long-term care settings, 9% practiced in community settings, and the remaining 14% practiced in other care settings, which were primarily dialysis, diabetes care, oncology, and psychiatric-related facilities. Of the respondents, 27% did not specify membership in an Academy of Nutrition and Dietetics dietetic practice group (DPG), whereas 19% reported membership in the Nutrition Support DPG, and 15% reported membership in the Diabetes Care and Education DPG.

Familiarity With and Use of Screening Tools and Risk Characteristics

Tables 1 and 2 compare respondents' overall reported familiarity with and use of common malnutrition and frailty screening tools (further information about these tools is provided in Tables 3 and 4).

TABLE 1 - Familiarity With and Use of Malnutrition Screening Tools by Dietetic Professional Survey Respondents
n (%)
BMI CNAQ DETERMINE Checklist MST MUST MNA MNA-SF SCALES a SCREEN b I and II SGA c
Reported familiarity with toold
 Years in practice as an RDN (n = 576)
  ≤5 79 (100) 13 (16) 26 (33) 57 (72) 34 (43) 55 (70) 46 (58) 16 (20) 16 (20) 63 (80)
  6–15 145 (99) 32 (22) 34 (23) 119 (82) 74 (51) 94 (64) 87 (60) 25 (17) 27 (18) 132 (90)
  >15 346 (99) 73 (21) 87 (25) 255 (73) 168 (48) 228 (65) 176 (50) 82 (23) 56 (16) 262 (75)
   P NA .61 .25 .10 .55 .70 .11 .29 .59 <.01
 Current practice settinge (n = 545)
 Inpatient 379 (99) 80 (21) 93 (24) 306 (80) 194 (51) 256 (67) 214 (56) 73 (19) 67 (18) 305 (80)
  Outpatient 113 (98) 20 (17) 20 (17) 73 (63) 42 (37) 64 (56) 52 (45) 28 (24) 15 (13) 91 (79)
  Community 48 (100) 13 (27) 20 (42) 30 (63) 22 (46) 36 (75) 26 (54) 13 (27) 7 (15) 34 (71)
   P NA .37 <.01 <.01 .03 .03 .13 .26 .49 .35
 Current employerf (n = 497)
 Hospital 330 (99) 72 (22) 79 (24) 295 (88) 196 (59) 228 (68) 192 (57) 60 (18) 54 (16) 287 (86)
 Long-term care 111 (100) 24 (22) 35 (32) 62 (56) 37 (33) 79 (71) 63 (57) 23 (21) 25 (23) 72 (65)
  Community 51 (98) 11 (21) 14 (27) 31 (60) 20 (38) 30 (58) 26 (50) 17 (33) 11 (21) 33 (64)
   P NA .99 .25 <.01 <.01 .22 .60 .05 .27 <.01
Reported use of toold
 Years in practice as an RDN (n = 576)
  ≤5 70 (89) 2 (3) 2 (3) 30 (38) 6 (8) 15 (19) 9 (11) 8 (10) 2 (3) 15 (19)
  6–15 124 (85) 5 (3) 4 (3) 71 (49) 6 (4) 9 (6) 6 (4) 16 (11) 3 (2) 41 (28)
  >15 300 (85) 11 (3) 16 (5) 142 (40) 17 (5) 44 (13) 22 (6) 57 (16) 5 (1) 93 (27)
   P .73 NA NA .17 .50 .01 .10 .17 NA .30
 Current practice settinge (n = 545)
 Inpatient 326 (85) 13 (3) 9 (2) 196 (51) 18 (5) 42 (11) 17 (4) 46 (12) 7 (2) 86 (23)
  Outpatient 104 (90) 2 (2) 5 (4) 27 (23) 7 (6) 13 (11) 10 (9) 23 (20) 1 (1) 45 (39)
  Community 40 (83) 2 (4) 8 (17) 11 (23) 4 (8) 10 (21) 5 (10) 7 (15) 1 (2) 9 (19)
   P .32 NA NA <.01 .53 .14 .09 .10 NA <.01
 Current employerf (n = 497)
 Hospital 274 (82) 11 (3) 9 (3) 204 (61) 20 (6) 29 (9) 11 (3) 32 (10) 4 (1) 94 (28)
 Long-term care 104 (94) 5 (5) 3 (3) 16 (14) 2 (2) 24 (22) 11 (10) 17 (15) 3 (3) 17 (15)
  Community 47 (90) 1 (2) 8 (15) 9 (17) 4 (8) 10 (19) 5 (10) 14 (27) 2 (4) 12 (23)
   P .01 NA NA <.01 .16 <.01 .01 <.01 NA .02
Abbreviations: BMI, body mass index; CNAQ, Council on Nutrition Appetite Questionnaire; DETERMINE Checklist, Nutrition Screening Initiative DETERMINE (Disease, Eating Poorly, Tooth loss/Mouth pain, Economic Hardship, Reduced social contact, Multiple medicines, Involuntary weight loss/gain, Needs Assistance in self-care, Elder years above age 80) Checklist; MNA, Mini Nutritional Assessment; MNA-SF, Mini Nutritional Assessment-Short Form; MST, Malnutrition Screening Tool; MUST, Malnutrition Universal Screening Tool; NA, not statistically analyzed; RDN, registered dietitian nutritionist.
aThe SCALES (Sadness, Cholesterol, Albumin, Loss Of Weight, Eating, and Shopping) protocol for evaluating risk of malnutrition in the older adults.
bThe SCREEN (Seniors in the Community: Risk Evaluation for Eating) I and II protocols for evaluating risk of malnutrition in the older adults.
cSubjective Global Assessment: an assessment tool to evaluate nutritional status.
dThe survey question associated with this table allowed for 1 or more responses.
eThe 3 categories of interest used for analysis represent 545 of the 576 respondents (95%).
fThe 3 categories of interest used for analysis represent 497 of the 576 respondents (86%).

TABLE 2 - Familiarity With and Use of Frailty Screening Tools by Dietetic Professional Survey Respondents
n (%)
The Bright Tool Frailty Index Fried Phenotype The Gerontopole Frailty Groningen Frailty Index PRISMA-7 Simple Frail Questionnaire Strawbridge Questionnaire Tilburg Frailty Indicator
Reported familiarity with toola
 Years in practice as an RDN (n = 576)
  ≤5 2 (3) 3 (4) 3 (4) 1 (1) 0 0 2 (3) 0 0
  6–15 4 (3) 11 (8) 0 1 (1) 1 (1) 2 (1) 8 (5) 2 (1) 1 (1)
  >15 6 (2) 38 (11) 3 (1) 2 (1) 2 (1) 4 (1) 26 (7) 2 (1) 5 (1)
   P NA .11 NA NA NA NA .24 NA NA
 Current practice settingb (n = 545)
 Inpatient 7 (2) 35 (9) 5 (1) 2 (1) 1 (<1) 5 (1) 22 (6) 1 (<1) 3 (1)
 Outpatient 3 (3) 10 (9) 1 (1) 1 (1) 1 (1) 0 9 (8) 2 (2) 2 (2)
  Community 1 (2) 3 (6) 0 0 0 0 1 (2) 0 1 (2)
   P NA .80 NA NA NA NA .36 NA NA
 Current employerc (n = 497)
 Hospital 5 (2) 30 (9) 4 (1) 1 (1) 2 (1) 5 (2) 21 (6) 2 (1) 2 (1)
 Long-term care 4 (4) 7 (6) 2 (2) 2 (2) 0 0 5 (5) 0 1 (1)
  Community 1 (2) 6 (12) 0 1 (2) 1 (2) 0 6 (12) 1 (2) 3 (6)
P NA .50 NA NA NA NA .23 NA NA
Reported use of toola
 Years in practice as an RDN (n = 576)
  ≤5 1 (1) 2 (3) 0 0 0 1 (1) 0 0 1 (1)
  6–15 0 2 (1) 0 0 0 2 (1) 5 (3) 0 1 (1)
  >15 0 8 (2) 0 0 2 (1) 0 9 (3) 0 3 (1)
   P NA NA NA NA NA NA NA NA NA
 Current practice settingb (n = 545)
 Inpatient 1 (<1) 7 (2) 0 0 1 (<1) 2 (1) 7 (2) 0 4 (1)
  Outpatient 0 3 (3) 0 0 1 (1) 0 4 (3) 0 0
  Community 0 0 0 0 0 1 (2) 1 (2) 0 1 (2)
   P NA NA NA NA NA NA NA NA NA
 Current employerc (n = 487)
  Hospital 0 6 (2) 0 0 1 (1) 2 (1) 8 (2) 0 3 (1)
 Long-term care 1 (1) 2 (2) 0 0 0 1 (1) 2 (2) 0 2 (2)
  Community 0 2 (4) 0 0 1 (2) 0 2 (4) 0 0
   P NA NA NA NA NA NA NA NA NA
Abbreviations: NA, not statistically analyzed; RDN, registered dietitian nutritionist.
aThe survey question associated with this table allowed for 1 or more responses.
bThe 3 categories of interest used for analysis represent 545 of the 576 respondents (95%).
cThe 3 categories of interest used for analysis represent 497 of the 576 respondents (86%).

TABLE 3 - Malnutrition Screening Tools
Screening Tool Measures
Body mass index (BMI) Objective calculation derived from recorded height and weight
The Council on Nutrition Appetite Questionnairea Self-reported, scored questionnaire on appetite, food intake, and happiness level
DETERMINE Checklistb Self-reported, scored questionnaire including questions on appetite, food intake, food security, weight loss, and factors that may influence nutrition status
Malnutrition Screening Toolc Self-reported, scored 2-item questionnaire on appetite and weight loss
Malnutrition Universal Screening Toold Subjective, scored measures including BMI, weight loss, and acute disease
Mini Nutritional Assessmente Subjective, scored measures including appetite, food intake, weight loss, mobility, anthropometric measures, and factors that may influence nutrition status
Mini Nutritional Assessment-Short Formf Subjective, scored measures including food intake, weight loss, mobility, and BMI
SCALES (Sadness, Cholesterol, Albumin, Loss of Weight, Eating, Shopping) protocolg Subjective questions including weight loss, mobility/self-feeding, and food insecurity
SCREEN I and II (Seniors in the Community: Risk Evaluation for Eating) protocolsh Self-reported questionnaires including appetite, food intake, weight loss, and mobility
Subjective Global Assessmenti Subjective, objective measurements, including nutrient intake, weight, symptoms, functionality, and physical examination
aWilson MM, Thomas DR, Rubenstein LZ, et al. Appetite assessment: simple appetite questionnaire predicts weight loss in community-dwelling adults and nursing home residents. Am J Clin Nutr. 2005;82(5):1074–1081.
bDeGroot LC, Beck, AM, Schroll, M, Staveren, WA. Evaluating the DETERMINE your nutritional health checklist and the mini nutritional assessment as tools to identify nutritional problems in elderly Europeans. Eur J Clin Nutr. 1998;52(12):877.
cFerguson M, Capra S, Bauer J, Banks M. Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutr. 1999;15(6):458–464.
dElia M. The ‘MUST’ report, Nutritional screening of adults: a multidisciplinary responsibility. Development and use of the ‘Malnutrition Universal Screening Tool’ (‘MUST’) for adults. London, England: British Alliance for Enteral and Parenteral Nutrition (BAPEN); 2003. https://eprints.soton.ac.uk/362499/
eGuigoz Y, Vellas B, Garry PJ. Assessing the nutritional status of the elderly: the mini nutritional assessment as part of the geriatric evaluation. Nutr Rev. 1996;54:S59–S65.
fMurphy MC, Brooks CN, New SA, Lumbers ML. The use of the Mini-Nutritional Assessment (MNA) tool in elderly orthopaedic patients. Eur J Clin Nutr. 2000;54:555–562.
gMorley JE. Why do physicians fail to recognize and treat malnutrition in older persons? J Am Ger Soc. 1991;39:1139–1140.
hKeller HH, Goy R, Kane SL. Validity and reliability of SCREEN II (Seniors in the Community: Risk Evaluation for Eating and Nutrition, Version II). Eur J Clin Nutr. 2005;59(10):1149–1157.
iDetsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr. 1987;11(1):8–13.

TABLE 4 - Frailty Screening Tools
Screening Tool Measures
The Bright Tool (Brief Risk Identification of Geriatric Health Tool)a Self-reported 11-item questionnaire: independence, social status, walking, falls, cognition, executive function, depression, perceived health status, frailty
Frailty Indexb Calculated percentage of 40 health deficits: symptoms, morbidities, labs, sensory, disabilities
Fried Phenotypec Self-reported questionnaire: exhaustion and depression; functional measures: weight loss, timed walking test, grip strength
The Gerontopole Frailty Screening Toold MD interview (social status, weight loss, activity level, disability, psychological status, gait speed, and MD clinical judgment of frailty)
Groningen Frailty Indexe Self-reported 15-item questionnaire: mobility, physical activity, vision, hearing, nutrition, morbidities, cognition, psychological and social status
PRISMA-7f Self-reported 7-item questionnaire: age, gender, morbidities, independence, social status, mobility
Simple Frail Questionnaireg Self-reported 5-item questionnaire: fatigue, independent mobility, walking endurance, morbidities, weight loss
Strawbridge Questionnaireh Self-reported questionnaire: problems in ≥2 of the 4 domains: physical health (balance, weakness), nutritional (loss of appetite, unintentional weight loss), cognitive (attention, verbal communication, memory), sensory (visual and hearing problems)
Tilburg Frailty Indicatori Self-reported questionnaire: gender, age, marital status, education, income, health status, morbidities, physical capabilities, psychological and social status
aKerse N, Boyd M, McLean C, Koziol-McLain J, Robb G. The BRIGHT tool. Age Aging. 2008;37(5):553–588.
bMitnitski AB, Mogilner AJ, Macknight C, Rockwood K. The mortality rate as a function of accumulated deficits in a frailty index. Mech Aging Dev. 2002;123(11):1457–1460.
cFried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146–M156.
dVellas B, Balardy L, Gillette-Guyonnet S, et al. Looking for frailty in community-dwelling older persons: the Gerontopole Frailty Screening Tool (GFST). J Nutr Health Aging. 2013;17(7):629–631.
e Bielderman A, van der Schans CP, van Lieshout M-RJ, et al. Multidimensional structure of the Groningen Frailty Indicator in community-dwelling older people. BMC Geriatrics. 2013;13:86.
fRaîche M, Hébert R, Dubois M-F. PRISMA-7: a case-finding tool to identify older adults with moderate to severe disabilities. Arch Geron Ger. 2008;47(1):9–18.
gMorley JE, Malmstrom TK, Miller DK. A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans. J Nutr Health Aging. 2012;16(7):601–608.
hStrawbridge WJ, Wallhagen MI. Self-rated health and mortality over three decades. Res Aging. 1999;21(3):402–416.
I Gobbens RJJ, van Assen MALM, Luijkx KG, Wijnen-Sponselee MT, Schols JMGA. The Tilburg Frailty Indicator: psychometric properties. J Am Med Dir Assoc. 2010;11(5):344–355.

Malnutrition

Respondents' familiarity with/use of malnutrition screening tools varied significantly by their current practice setting and current employer, but only slightly by years of dietetic experience (Table 1).

Frailty

Registered dietitian nutritionists reported greater familiarity with screening tools for malnutrition than for frailty. Less than 10% of respondents were familiar with individual frailty screening tools (Table 2).

Risk Characteristics

When respondents were asked which risk factors they consider during screening to establish a diagnosis of malnutrition, they reported most commonly weight loss (99%), appetite loss (95%), food history (90%), chewing and swallowing ability (84%), clinical history (78%), physical examination (74%), body mass index (BMI) (71%), and impaired wound healing (71%). They reported the most common contributing factors for frailty risk were related to weight loss (87%), appetite loss (84%), chewing and swallowing ability (77%), BMI (76%), malnutrition (76%), food history (74%), physical examination (71%), and impaired wound healing (66%).

Availability of Frailty Screening Measures and Beliefs About Screening Roles and Barriers

Respondents reported use of subjective measures for frailty risk, including those related to appetite loss and weight loss (53%), mental health screening (39%), functional screening (38%), polypharmacy (28%), and sarcopenia (21%). Fewer had access to physical function measures for frailty risk, with only 17% having access to hand grip strength measures and 14% having access to gait speed measures.

The majority (68%) agreed that dietetic professionals should play a role in frailty screening, including assessing (97%), implementing interventions (97%), referring to other healthcare professionals/organizations (94%), and advocating for those at frailty risk (93%). The most frequently listed barrier to frailty risk screening was lack of an organizational policy to do so (39%).

Most RDNs agreed that dietetic professionals should play a role in frailty screening.

Other Findings

Organizational Screening Policies and Practices

Most respondents (70%) reported that their organizations had policies for malnutrition screening, whereas only a few (6%) reported policies for frailty screening. Differences existed by care settings. More inpatient RDNs (78%) reported a malnutrition screening policy than RDNs working with outpatient (50%) or community-based (52%) organizations (P < .001).

Most reported policies to screen for malnutrition, but not frailty, with the most identified barrier being lack of institutional policy.

Screening Practices

Most RDNs (66%) reported at least half of the older adult populations they served were screened for malnutrition risk. Most respondents (70%) estimated the prevalence of malnutrition risk in their populations served was 26% to 75%. Many RDNs (47%) were unsure whether any of the patients they served were screened for frailty, and 42% estimated that only 0% to 25% were screened. Many (47%) were also unsure of the prevalence of frailty risk in their older adult populations.

PRACTICE IMPLICATIONS

Our survey of RDNs who worked with older adults revealed that they were familiar with and used several common malnutrition screening tools, but most RDNs were neither familiar with nor used common frailty screening tools. Thus, the survey identified several challenges and opportunities for the profession.

First, dietetic professionals have been called on to “lead the charge” in the fight against malnutrition,9 and indeed, RDNs reported they were using malnutrition screening tools, particularly the BMI, Malnutrition Screening Tool, and Subjective Global Assessment. However, standardized malnutrition screening across the continuum of care is still lacking in the United States,10 although it does exist elsewhere, such as in the United Kingdom.11

Overall, the BMI was reported as the most commonly used malnutrition screening tool. It is quick and easy to calculate, but it has poor sensitivity and specificity for screening older adults due to issues such as changes in body composition (more fat, less lean, bone, and body water) and difficulties in obtaining valid measures of stature due to scoliosis.12 The RDNs reported using the Malnutrition Screening Tool most frequently in inpatient and community settings and used the Subjective Global Assessment (generally considered an assessment, not a screening tool)13 most frequently in outpatient settings. In contrast, RDNs were unfamiliar with and did not use the Seniors in the Community: Risk Evaluation for Eating and Nutrition questionnaire, which was developed in Canada and was recently identified to have the greatest validity in the community, through a review completed by the Malnutrition in the Elderly European project group.14

The need for standardization in frailty screening and intervention is clear; more than a dozen frailty instruments exist. Consensus has been called for on the methods of measuring frailty,15 as well as standardized procedures and interventions,16 to be implemented in different healthcare settings. Only approximately 10% of the RDN respondents were familiar with and/or used frailty screening tools, although most respondents reported no barriers to their organizations adopting frailty screening policies. This is not surprising, given frailty is not a focus for dietetic education or practice.4

In other countries such as China and Finland, the combined screening of malnutrition and frailty is being used as a powerful clinical tool in hospital and community settings, because incidence of a condition is associated with an increased likelihood of the other.17,18 Dual diagnoses of malnutrition and frailty increase mortality risk,19 and in some populations, such as hip fracture patients, they are positive predictors of postoperative complications and increased likelihood for all-cause mortality.20 Registered dietitian nutritionists recognized the overlap in risk factors (such as weight loss and appetite loss) for these conditions.6 This is a challenge that can be leveraged into an opportunity for RDNs. However, RDNs' understanding of the accuracy of these risk factors was not identified in our survey and is an area for further exploration, particularly as physical factors were not as commonly reported by RDNs as were nutrition risk factors, yet awareness of the entire range of factors impacting frailty may be useful for developing interventions.21 Education specific to the operational indicators defining physical frailty and use of validated frailty screening tools could help dietetic professionals take leadership in filling the gap in frailty screening, as Wilkinson et al4 and Laur et al6 have emphasized. Most of the RDNs in our survey agreed they could play an important role in screening and treating frailty.

Registered dietitian nutritionists identified advocating for those at frailty risk as an important responsibility. Roberts et al22 recommended advocating for individuals at frailty risk as well as advocating for management of undernutrition in older people with frailty; developing care pathways; conducting studies on the impact of nutritional interventions on functional, clinical, and patient-centered outcomes; and training key staff.

Dietetic professionals can and should play a primary role in filling the gap in frailty and malnutrition screening. The need for a multidisciplinary approach to screening and intervention for malnutrition and frailty was recognized by RDN respondents. In clinical settings, RDNs may have the opportunity to partner with physical therapists and other medical providers to address frailty. However, in other care settings, RDNs may need to be more proactive in identifying the primary care providers who are implementing multimodal therapies for frailty. One opportunity to consider is how malnutrition and frailty screening and intervention may help improve value-based care. Frailty fits well into risk stratification23; adding a frailty index to the current Centers for Medicare & Medicaid Services model used to predict patients' annualized Medicare costs in value-based payment programs improved Medicare cost predictions.24 Registered dietitian nutritionists' adoption of new and expanded roles in geriatric care specialties, such as in frailty screening and intervention, which is an identified change driver,25 would have a positive impact on RDN clinical practice and the health of the older adult population they serve. Identification of frailty and use of screening instruments by those without training are challenging. However, frailty could become an opportunity for advanced practice training, such as development of a certificate of training as part of the RDN scope of practice's26 management and advancement component. Completion of such a certificate of training would enable RDNs to demonstrate expertise and enhance their collaboration with the interprofessional team, thus supporting the Competence and Professional Development in Practice standard of the profession's Code of Ethics.27

Our study provides preliminary data subject to general survey limitations, such as coverage, sampling, measurement, and nonresponse bias.28 The overall survey response rate was low, although health professional surveys typically have low response rates and these rates have been decreasing in recent years.29 The low survey response rate was compounded by the reported lack of knowledge about frailty and frailty screening tools, which limited our ability to identify any differences based on survey respondent characteristics. In addition, the survey did not measure other healthcare professionals' perceptions, such as those of nutrition and dietetics technicians, registered, or registered nurses, who may have critical roles in screening patients in various healthcare settings. Finally, the RDNs responding to our survey likely work in settings with screening policies already in place, versus the settings dietetic practitioners as a whole experience, and thus the results may not be representative of the broader profession.

CONCLUSION

Because malnutrition and frailty are partially reversible, screening to identify those at risk is critical to promote healthy aging, especially among our oldest citizens. Most of the RDNs working with older adults whom we surveyed reported that their facilities had a malnutrition screening and intervention policy in place and that they screened for malnutrition risk. However, very few of them reported policies to screen and intervene for frailty or that they were familiar with or used frailty screening tools. To move forward and take a leading role in frailty screening and intervention, RDNs working with older adults need skills-based competency, education, and training regarding frailty. These additional roles will improve the health and well-being of older adults in our country and also help expand dietetic practice in ways that will champion frailty screening and intervention policies within organizations and the larger community.

Acknowledgments

Thank you to Deborah Hustead, PhD, for the very important contribution of organizing survey data sets and the significant help in the statistical analysis.

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