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Nutrition and the Life Cycle

Are You Prepared for the Decade of Healthy Aging 2020-2030?

A Panel Summary From the Academy of Nutrition and Dietetics 2020 Food & Nutrition Conference & Expo Virtual Event

Chao, Shirley PhD, RDN, LDN, FAND; Corish, Clare A. PhD, RD, FINDI; Keller, Heather PhD, RD, FDC, FCAHS; Rasmussen, Helen PhD, RDN, FAND; Arensberg, Mary Beth PhD, RDN, FAND; Dwyer, Johanna T. DSc, RDN

Author Information
doi: 10.1097/NT.0000000000000492
  • Open

Abstract

The year 2020 initiated the World Health Organization's (WHO's) Decade of Healthy Aging.1 This declaration was the culmination of the WHO's work to define the importance of aging and health and develop a global strategy and action plan on integrating healthy aging into health and social care. Early research requested by the WHO and the International Institute for Society & Health at University College London collated findings on social determinants of health, which helped to build this global effort.2

In October 2020, during the Academy of Nutrition and Dietetics Food & Nutrition Conference & Expo Virtual Event, Dr Helen Rasmussen moderated a panel on the Decade of Healthy Aging that featured examples of older adult nutrition programs in Canada, the European Union (EU), and the United States. Multiple areas important to aging—stress, social support, food, and social exclusion—were addressed and can help guide registered dietitian nutritionists (RDNs) in “Identifying the trajectories of important health measures central to forecasting health care needs and generating policies for older persons.”3 The session showcased how nutrition professionals can apply the “best the world has to offer” by building on evidence-based practices to develop local approaches that integrate screening/intervention strategies for frailty and malnutrition in older adults into clinical and community practice settings. This article summarizes the panel presentations of the featured speakers whose clinical research and practice has demonstrated the important role of nutrition in promoting healthy aging. It explains the foundation for and how nutrition is incorporated into the WHO Decade of Healthy Aging. It then outlines ways to apply the Malnutrition in the Elderly (MaNuEL) Knowledge Hub results to develop a common/shared definition of malnutrition, preferred screening tools, and effective interventions across different healthcare settings. Finally, it identifies how to apply evidence-based research to develop effective frailty/malnutrition screening and nutrition/lifestyle interventions for community-living older adults.

The session showcased how nutrition professionals can apply the “best the world has to offer” by building on evidence-based practices to develop local approaches that integrate screening/intervention strategies for frailty and malnutrition in older adults into clinical and community practice settings.

CANADIAN PERSPECTIVE

Dr Heather Keller presented “Nutrition's Starring Role on the Global Stage, Promoting Healthy Aging Across Sectors of Care,” drawing on her work in Canada. Over the last 5 years, the WHO has released a series of reports focused on aging and health.4–6 The goal of the WHO has been to help countries support their citizens in maintaining function and well-being to age as healthfully as possible. The WHO strategies are driven by growth in the size of older adult populations and the increased rates of chronic disease and disabilities, which are leading to greater healthcare utilization and costs. Addressing nutrition and malnutrition is an important part of WHO's recommended proactive strategies and are included in their Integrated Care for Older People guidelines. The Integrated Care for Older People guidelines specifically identify “oral supplemental nutrition with dietary advice should be recommended for older people affected by undernutrition” based on an evidence review.7

Canada's Healthy Aging Strategy was developed more than a decade ago.8 It also identified healthy eating as a focus area and highlighted the need for improved nutrition screening and diet quality in institutional settings. Since that time, the Canadian Malnutrition Task Force has taken the lead in identifying malnutrition-related care gaps for acute, postacute, and community care settings and in developing tools and best practices for malnutrition screening and intervention.9 In the acute care setting, the malnutrition care gaps included the following:

  • 75% of malnourished hospital patients were not referred to a dietitian.
  • 30% of hospital patients did not eat half of the food on their trays.
  • Many hospital patients experienced organizational, mealtime, and eating environmental barriers, such as not being able to reach their tray, no snacks/alternatives offered when meals were missed for tests, and difficulty with opening packages.
  • Most patients were discharged from the hospital with the same or worse nutritional status and 25% experienced weight loss after discharge.
  • Only 11% of hospital patients had a consultation with a dietitian after discharge.10–13

Figure 1 shows an example of a “best practice” nutrition pathway for acute care called the Integrated Nutrition Pathway for Acute Care (INPAC). It was developed in response to the acute care malnutrition gap findings. In 2 implementation studies, it was shown to increase rates of nutrition screening for hospital patients.14,15 Furthermore, a malnutrition prevention, detection, and treatment standard is being finalized by the Canadian Health Standards Organization16; it is based on the INPAC pathway and evidence on best practices for improving malnutrition in the hospital.

F1
FIGURE 1.:
Canadian INPAC adult patients.14,15

Malnutrition care gaps have also been delineated in the long-term and postacute care setting, where older adults had multifactorial determinants of poor food intake. Thus, the strategies developed to support improved nutrition were also multifactorial. The Making the Most of Mealtimes (M3) conceptual framework is shown in Figure 2. This framework demonstrates the diverse determinants of food intake in residential care categorized into the areas of meal quality, meal access, and mealtime experience.17 This conceptual framework was the basis for the M3 prevalence study, which identified the status of food and fluid intake in 32 long-term care homes and more than 600 residents. Key areas for improvement included quality of meals and specifically key micronutrients and protein; improved taste, appearance, and nutritional profile of modified texture foods; promoting fluid intake; and improving the mealtime experience to promote quality of life as well as food intake.18 Interventions are being developed and evaluated based on these care gaps. “Nutrition in Disguise” is a menu planning knowledge translation program in long-term care that addresses the issue of inadequate micronutrient and protein intake in residential care.19 “CHOICE+” is an intervention program for staff and volunteers that has been extensively evaluated and shown to improve the mealtime experience.20,21 This program is being translated to a virtual platform to promote scale and spread.

F2
FIGURE 2.:
Canadian M3 program targeting malnutrition care gaps for older adults in the long-term/postacute care setting. Figure reproduced with permission.17

Care transitions from the hospital were found to be a particularly vulnerable time for patients. Another key group that needs to be targeted for nutrition care is older adults living in the community. Consensus and evidence-based, best practice pathways for the community setting and for care transitions have been developed to help resolve this (Figures 3–4).

F3
FIGURE 3.:
Canadian consensus and evidence-based best practice pathway for malnutrition care during care transitions. Figure from Canadian Malnutrition Task Force.22
F4
FIGURE 4.:
Canadian consensus and evidence-based best practice pathway for malnutrition care of older adults in the community. Figure from Canadian Malnutrition Task Force.22

Care transitions from the hospital were found to be a particularly vulnerable time for patients.

The pathways are supported by multiple, recently published guidance documents that target key areas for intervention.22 With RDNs leading the implementation of these recommended nutrition pathways in community and acute care settings and using novel interventions to improve long-term care resident food intake, there is an opportunity to strengthen the base for promoting healthful aging into the next decade and beyond.

EU PERSPECTIVE

Dr Clare Corish provided an overview of “The European Malnutrition in the Elderly (MaNuEL) Knowledge Hub.” The MaNuEL Knowledge Hub was a project of the EU's Joint Programming Initiative, Healthy Diet for a Healthy Life,23 and brought together 22 research groups from 6 European countries and New Zealand. Through 6 work projects (Figure 5) and multiple publications,24–37 it features many of the best practices for evaluating the literature to:

F5
FIGURE 5.:
The MaNuEL Knowledge Hub organization under 6 work projects (WPs). Figure reproduced with permission.24
  • Summarize and extend current knowledge about malnutrition in older people
  • Strengthen evidence-based practice across the EU
  • Build better research capacity on the topic of malnutrition in older people
  • Harmonize malnutrition screening and assessment practices.

There are many different forms of malnutrition. However, protein-energy malnutrition (PEM) or undernutrition is the type of malnutrition that is most often associated with functional impairments and worsened clinical outcomes in older adults. Emerging evidence suggests that those at high risk of undernutrition have greater disease severity and poorer outcomes from COVID-19.38 The diagnosis of undernutrition is complicated by the variety of criteria used to define it. Malnutrition in the Elderly defined malnutrition as striking unintended weight loss or markedly low body mass index.35 These criteria are similar to those of the Global Leadership Initiative on Malnutrition39 and also include criteria that are part of the Nutrition Focused Physical Examination, which is evolving to become a gold standard for nutrition assessment across care settings. One important consideration when interpreting prevalence rates for undernutrition is to examine the diagnostic criteria used. Each single criterion indicates at least a risk of malnutrition, so it is important to look at each criterion separately and try to identify underlying causes. In addition, standardization of the diagnostic criteria is strongly recommended.35

Malnutrition in the Elderly also calculated the prevalence of high PEM risk from 196 studies, representing 223 study samples from 24 European countries and 583 972 older adults. Pooled prevalence rates of high PEM risk across all countries and malnutrition screening tools (MSTs) were 28.0% (n = 127 study samples), 17.5% (n = 30), and 8.5% (n = 32), for the hospital, residential care, and community settings, respectively.30

Malnutrition in the Elderly found that, worldwide, 48 MSTs are used in older adults. Of the MSTs identified, 34 had evidence of validity in populations with a mean age of 65 years or older in a total of 119 studies.26 Most of the studies on MSTs were conducted in community or hospital settings. One important take-away is to always use an MST that has been validated in older persons and in the care setting of interest (ie, hospital, long-term care, rehabilitation, or community setting).32

One important take-away is to always use an MST that has been validated in older persons and in the care setting of interest (ie, hospital, long-term care, rehabilitation, or community setting).

Based on existing evidence, MaNuEL developed a framework of all potential determinants of malnutrition in older adults, the Model on Determinants of Malnutrition in Aged Persons,34 as shown in Figure 6. The 3 central mechanisms underpinning the development of malnutrition were identified as low intake, reduced nutrient bioavailability, and high requirements. MaNuEL recommends assessing the determinants of malnutrition as comprehensively as possible because malnutrition is a multifactorial problem and, thus, the analysis of single factors is of limited benefit. Furthermore, practitioners should be particularly cognizant of functional impairments and recent hospitalization and focus on those determinants that can be removed or mitigated.27,36

F6
FIGURE 6.:
The MaNuEL Knowledge Hub determinants of protein-energy malnutrition (PEM) in aged persons (Model on Determinants of Malnutrition in Aged Persons). Figure reproduced with permission.34

Researchers of MaNuEL performed a literature study on the effects of nonpharmacological interventions in older patients with well-defined malnutrition using relevant outcomes agreed to by a broad panel of experts29 as well as statistical analysis of pooled individual participant data (from 9 randomized controlled trials on the effects of nutritional interventions in older persons at risk of malnutrition).33 The evidence suggested that a combination of individualized dietary counseling plus oral nutritional supplements improves energy intake and body weight in older malnourished individuals or those at high risk of malnutrition.

All of the MaNuEL project information and results are available in the MaNuEL Toolbox.40 The Toolbox is being used to effectively disseminate MaNuEL results and recommendations to support researchers, healthcare professionals, policymakers, educational institutions, and other stakeholders as they work together to promote healthy aging by tackling the increasing problem of PEM in older adult populations around the globe.

US COMMONWEALTH OF MASSACHUSETTS PERSPECTIVE

Dr Shirley Chao spoke on “Integrating Frailty and Malnutrition Screening into Community Care: Strategies to Engage Older Adults and Their Caregivers.” The presentation provided examples of creative programs being developed in the United States and how Massachusetts community-based programs are addressing 4 key challenges—food insecurity, socialization, family caregiver support, and communication—with social media during the COVID-19 pandemic.

In Massachusetts, as in many states in the United States, the population is rapidly aging and thus will continue to drive demand for community-based services. Figure 7 shows that by 2030, more than 70 million Americans will be 65 years and older and represent 21% of the US population.41 Most older adults have many chronic conditions, which can impact their quality of life and ability to perform activities of daily living as well as increase their risk for malnutrition and frailty.42

F7
FIGURE 7.:
Population growth projections for US adults 65 years and older, 2016-2060. Figure reproduced with permission.41

Frailty is defined as the accumulation of health deficits that cause functional decline or loss of physiologic reserves and increase susceptibility to illness and injury. It is considered a clinical syndrome separate from malnutrition or disability and an estimated 15% of older Americans are frail.43 Malnutrition and frailty diagnoses often overlap and share multiple common screening measures, including appetite loss, unintentional weight loss, poor mobility/functionality, recent hospitalizations, polypharmacy, comorbidities, and food insecurity. Both conditions are serious issues for older adults but can be addressed proactively in the community setting to reduce risk.44

The Massachusetts Executive Office of Elder Affairs (EOEA) has developed several best practices to address both conditions, based on community research to determine older adults' needs and more specific requirements that have evolved during the COVID-19 pandemic. These initiatives and programs are explained in greater detail later in this article. The initial community research was fielded by the Massachusetts Commission on Malnutrition Prevention Among Older Adults. The research included the following:

  • A baseline survey of clinicians in 280 targeted long-term care facilities across the Commonwealth. Most respondents (>60%) were unaware if a screening tool for malnutrition was used in their facility and most commented that they believed questions on weight loss and appetite were asked, but not as part of the scored MST.
  • In-depth interviews with aging-specific organizations and focus groups of older adults to determine the best methods for raising awareness about malnutrition and frailty. Key findings were caregivers/families should be the primary audience for awareness efforts and malnutrition messaging should be person centered and connected to major life changes. Information was best delivered by a trusted source using word-of-mouth and printed materials. The in-depth interviews also identified the need for screening.45

The EOEA conducted nutrition clinics and malnutrition and frailty screenings throughout the Commonwealth in 2019, to help determine the scope of risk for malnutrition (using the MST46) and frailty (using the FRAIL scale47). More than 800 older adults were screened. An additional more than 200 homebound older adults were screened as part of the Commonwealth's American Society for Parenteral and Enteral Nutrition Malnutrition Awareness Week activities. Not surprisingly, homebound older adults in the community were at higher risk of malnutrition and frailty than the community-living older adults who were physically able to attend the nutrition clinics (Figure 8).48

F8
FIGURE 8.:
Results of Massachusetts malnutrition and frailty screenings of older adults in the community.47 MST score >2, at risk; FRAIL scale score 1–2, prefrail, and 3-5, frail.

The EOEA identified multiple challenges during the COVID-19 pandemic that were related to increased risk for malnutrition and frailty. These challenges included many community-living older adults who suddenly became homebound because of COVID-19 and increased rates of isolation and depression. In addition, increased numbers of older adults faced more limited access to healthy and therapeutic foods because of stay-at-home orders, limited financial resources, and food insecurity.

In response, Massachusetts community-based programs were refocused to address the following issues:

Food security

  • o Home meal delivery increased by 50% to 40 000 meals daily. Congregate meal programs shifted to grab-and-go offerings (averaging 2000 daily) and mobile markets with “Senior on the Go” buses provided these offerings.
  • o The Commonwealth used federal Families First Coronavirus Response Act funds to distribute 7 days of frozen or shelf-stable meals to 85 000 older adults. Massachusetts also participated in the US Department of Agriculture Farmers to Families Food Box program, completing 2 rounds of deliveries to more than 34 000 community-living older adults in need by September 2020.

Socialization

  • o The biggest challenge during the pandemic was staying connected with community-living older adults and also staying connected with their caregivers. The local nutrition programs implemented daily wellness checks with high-risk older adults. They also conducted video conference calls (using Zoom or other video call technology) and recorded videos to post on YouTube and broadcast via local media stations and cable access TV channels. Outreach program subjects included cooking and nutrition education; some platforms also had the capacity for interactive sessions and polling. Many activities were transferred to virtual platforms. For example, the Boston Chinese Golden Age Center hosted live broadcasts via Zoom that enabled home-bound older adults to participate. Medical nutrition therapy provided by RDNs also shifted to virtual platforms, using the Academy of Nutrition and Dietetics information on providing and billing for remote medical nutrition therapy.49

Family caregiver support

  • o As recommended by the Governor's Council to Address Aging in Massachusetts, EOEA is engaging with partners to increase workplace supports for family caregivers.50 During COVID-19, the Commonwealth's caregiver specialists ramped up services to meet increased demand. Many caregivers who needed minimum help before the pandemic were requiring weekly support and new caregivers were reaching out for support too.

Social media

  • o The EOEA launched new social media campaigns to promote food access programs and emphasize the need to check on the nutrition health of older neighbors. Figure 9 provides media excerpts from these campaigns. The #BeaNutritionNeighbor had 113 campaign placements across Facebook, Twitter, and LinkedIn, and 108 000 followers were reached via social media during Malnutrition Awareness Week 2020.
F9
FIGURE 9.:
Massachusetts social media campaigns focused on increasing awareness about malnutrition and availability of food resources for older adults in the community.

There are many different physical, emotional, cognitive, and economic changes that can impact healthy aging and increase risk for malnutrition and frailty. The experiences of Massachusetts community nutrition programs provide a model of how providers can be flexible to address these risks and meet the needs of older adults in the community, even during a pandemic.

There are many different physical, emotional, cognitive, and economic changes that can impact healthy aging and increase risk for malnutrition and frailty.

CONCLUSIONS

The realities of our aging world underscore the need to support healthy aging, and nutrition plays a fundamental role in this. Nutrition professionals around the globe are finding ways to make a difference and provide a foundation for healthy aging, and they can continue to learn from each other. Global best practices range all the way from care setting–specific nutrition pathways and intervention programs, to strengthened evidence-based practices and research capacity, to creative community programs that pivot to address real-time needs of older adults and their families.

REFERENCES

1. World Health Organization. Decade of healthy aging: 2020-2030. https://www.who.int/docs/default-source/decade-of-healthy-ageing/final-decade-proposal/decade-proposal-final-apr2020-en.pdf?sfvrsn=b4b75ebc_5. Accessed December 15, 2020.
2. Wilkinson RG, Marmot M. World Health Organization Regional Office for Europe, WHO Centre for Urban Health (Europe) & International Centre for Health and Society. Social Determinants of Health: The Solid Facts. WHO Regional Office for Europe: Copenhagen; 1998: https://apps.who.int/iris/handle/10665/108082.
3. National Research Council (US) Panel on a Research Agenda and New Data for an Aging World. Preparing for an Aging World: The Case for Cross-National Research. The Health of Aging Populations. Washington, DC: National Academies Press; 2001. https://www.ncbi.nlm.nih.gov/books/NBK98373/.
4. World Health Organization. World Report on Ageing and Health. 2015. https://www.who.int/ageing/events/world-report-2015-launch/en/. Accessed December 15, 2020.
5. World Health Organization. Global strategy and action plan on ageing and health. 2017. https://www.who.int/ageing/WHO-GSAP-2017.pdf. Accessed December 15, 2020.
6. World Health Organization. 10 priorities for a decade of action on healthy ageing. 2017. https://www.who.int/ageing/WHO-ALC-10-priorities.pdf?ua=1. Accessed December 15, 2020.
7. World Health Organization. Integrated Care for Older People (ICOPE) guidelines on community-level interventions to manage declines in intrinsic capacity, evidence profile: malnutrition. 2017. https://www.who.int/ageing/health-systems/icope/evidence-centre/ICOPE-evidence-profile-malnutrition.pdf?ua=1. Accessed December 15, 2020.
8. Healthy aging in Canada: a new vision, a vital investment. A discussion brief prepared for the Federal, Provincial and Territorial Committee of Officials (Seniors). 2006. https://www.health.gov.bc.ca/library/publications/year/2006/Healthy_Aging_A_Vital_latest_copy_October_2006.pdf. Accessed December 15, 2020.
9. Canadian Malnutrition Task Force. Malnutrition Action Center. https://www.nutritioncareincanada.ca. Accessed December 15, 2020.
10. Keller H, Laporte M, Payette H, et al. Prevalence and predictors of weight change post-discharge from hospital: a study of the Canadian Malnutrition Task Force. Eur J Clin Nutr. 2017;71(6):766–772. doi:10.1038/ejcn.2016.277.
11. Allard JP, Keller H, Jeejeebhoy KN, et al. Decline in nutritional status is associated with prolonged length of stay in hospitalized patients admitted for 7 days or more: a prospective cohort study. Clin Nutr. 2016;35(1):144–152. doi:10.106/j.clnu.2015.01.009.
12. Keller H, Allard JP, Laporte M, et al. Predictors of dietitian consult on medical and surgical wards. Clin Nutr. 2015;34(6):1141–1145. doi:10.1016/j.clnu.2014.11.011.
13. Keller H, Allard J, Vesnaver E, et al. Barriers to food intake in acute care hospitals: a report of the Canadian Malnutrition Task Force. J Hum Nutr Diet. 2015;28(6):546–557. doi:10.1111/jhn.12314.
14. Keller H, McCullough J, Davidson B, et al. Integrated Nutrition Pathway for Acute Care (INPAC): building consensus with a modified Delphi. Nutr J. 2015;14:63. doi:10.1186/s12937-015-0051-y.
15. Keller H, Laur C, Atkins M, et al. Update on the Integrated Nutrition Pathway for Acute Care (INPAC): post implementation tailoring and toolkit to support practice improvements. Nutr J. 2018;17:2. doi:10.1186/s12937-017-0310-1.
16. Health Standards Organization. Public notice of intent, malnutrition safety intervention standard. https://healthstandards.org/standards/notices-of-intent/malnutrition-safety-intervention/. Accessed December 15, 2020.
17. Keller H, Carrier N, Duizer L, et al. Making the Most of Mealtimes (M3): grounding mealtime interventions with a conceptual model. J Am Med Dir Assoc. 2014;15(3):158–161. doi:10.1016/j.jamda.2013.12.001.
18. Keller H, Carrier N, Slaughter S, et al. Prevalence and determinants of poor food intake of residents living in long term care. J Am Med Dir Assoc. 2017;18(11):941–947. doi:10.1016/j.jamda.2017.05.003.
19. Keller H, Lucio Pereira de Paula F, Wei C, et al. Nutrition in disguise: development, testing and cost-analysis of nutrient-enhanced food for residential care. J Clin Nutr Food Science. 2019;2(1):36–45.
20. Keller H, Wu S, Iraniparast M, et al. Relationship-centered mealtime training program demonstrates efficacy to improve the dining environment in long-term care [published online ahead of print December 9, 2020]. J Am Med Dir Assoc.
21. Wu S, Morrison J, Dunn H, et al. Developmental evaluation of the CHOICE program: a relationship-centred mealtime intervention for long-term care. BMC Geriatr. 2018;18:277. doi:https://doi.org/10.1186/s12877-018-0964-3.
22. Canadian Malnutrition Task Force. Nutrition Care pathways. https://www.nutritioncareincanada.ca/resources-and-tools/primary-community-care/nutrition-care-pathways. Accessed December 15, 2020.
23. Malnutrition in the Elderly (MaNuEL) Knowledge Hub. http://www.healthydietforhealthylife.eu/index.php/news/232-manuel-the-knowledge-hub-on-malnutrition-in-the-elderly. Accessed December 15, 2020.
24. Visser M, Volkert D, Corish C, et al. Tackling the increasing problem of malnutrition in older persons: the Malnutrition in the Elderly (MaNuEL) Knowledge Hub. Nutr Bull. 2017;42(2):178–186. doi:10.1111/nbu.12268.
25. Correa-Pérez A, Lozano-Montoya I, Volkert D, et al. Relevant outcomes for nutrition interventions to treat and prevent malnutrition in older people: a collaborative SENATOR-ONTOP and MaNuEL Delphi study. Eur Geriatr Med. 2018;9(2):243–248. doi:10.1007/s41999-018-0024-8.
26. Power L, Mullally D, Gibney ER, et al. A review of the validity of malnutrition screening tools used in older adults in community and healthcare settings—a MaNuEL study. Clin Nutr ESPEN. 2018;24:1–13. doi:10.1016/j.clnesp.2018.02.005.
27. Streicher M, van Zwienen-Pot J, Bardon L, et al. Determinants of incident malnutrition in community-dwelling older adults: a MaNuEL multicohort meta-analysis. J Am Geriatr Soc. 2018;66(12):2335–2343. doi:10.1111/jgs.1553.
28. Corish CA, Bardon LA. Malnutrition in older adults: screening and determinants. Proc Nutr Soc. 2019;78(3):372–379. doi:10.1017/S0029665118002628.
29. Correa-Pérez A, Abraha I, Cherubini A, et al. Efficacy of non-pharmacological interventions to treat malnutrition in older persons: a systematic review and meta-analysis. The SENATOR project ONTOP series and MaNuEL Knowledge Hub project. Ageing Res Rev. 2019;49:27–48. doi:10.1016/j.arr.2018.10.011.
30. Leij-Halfwerk S, Verwijs MH, van Houdt S, et al. Prevalence of protein-energy malnutrition risk in European older adults in community, residential and hospital settings, according to 22 malnutrition screening tools validated for use in adults ≥65 years: a systematic review and meta-analysis. Maturitas. 2019;126:80–89. doi:10.1016/j.maturitas.2019.05.006.
31. O'Keeffe M, Kelly M, O'Herlihy E, et al. Potentially modifiable determinants of malnutrition in older adults: a systematic review. Clin Nutr. 2019;38(6):2477–2498. doi:10.1016/j.clnu.2018.12.007.
32. Power L, de van der Schueren MAE, Leij-Halfwerk S, et al. Development and application of a scoring system to rate malnutrition screening tools used in older adults in community and healthcare settings—a MaNuEL study. Clin Nutr. 2019;38(4):1807–1819. doi:10.1016/j.clnu.2018.07.022.
33. Reinders I, Volkert D, de Groot LCPGM, et al. Effectiveness of nutritional interventions in older adults at risk of malnutrition across different health care settings: pooled analyses of individual participant data from nine randomized controlled trials. Clin Nutr. 2019;38(4):1797–1806. doi:10.1016/j.clnu.2018.07.023.
34. Volkert D, Kiesswetter E, Cederholm T, et al. Development of a model on determinants of malnutrition in aged persons: a MaNuEL project. Gerontol Geriatr Med. 2019;5:2333721419858438. doi:10.1177/2333721419858438.
35. Wolters M, Volkert D, Streicher M, et al. Prevalence of malnutrition using harmonized definitions in older adults from different settings—a MaNuEL study. Clin Nutr. 2019;38(5):2389–2398. doi:10.1016/j.clnu.2018.10.020.
36. Bardon LA, Streicher M, Corish CA, et al. Predictors of incident malnutrition in older Irish adults from the Irish longitudinal study on ageing cohort—a MaNuEL study. J Gerontol A Biol Sci Med Sci. 2020;75(2):249–256. doi:10.1093/gerona/gly225.
37. Volkert D, Visser M, Corish CA, et al. Joint action Malnutrition in the Elderly (MaNuEL) Knowledge Hub: summary of project findings. Eur Geriatr Med. 2020;11(1):169–177. doi:10.1007/s41999-019-00264-3.
38. Li T, Zhang Y, Gong C, et al. Prevalence of malnutrition and analysis of related factors in elderly patients with COVID-19 in Wuhan, China. Eur J Clin Nutr. 2020;74(6):871–875. doi:10.1038/s41430-020-0642-3.
39. Jensen GL, Cederholm T, Correia MITD, et al. GLIM criteria for the diagnosis of malnutrition: a consensus report from the global clinical nutrition community. JPEN J Parenter Enteral Nutr. 2019;43(1):32–40. doi:10.1002/jpen.1440.
40. Malnutrition in the Elderly (MaNuEL) Knowledge Hub. MaNuEL toolbox, clinical practice and policy recommendations from the MaNuEL Knowledge Hub. https://www.stuurgroepondervoeding.nl/wp-content/uploads/2018/11/MaNuEL-Toolbox_Oct2018_final.pdf. Accessed December 15, 2020.
41. US Government Accountability Office. Report to congressional requesters, nutrition assistance programs: agencies could do more to help address the nutritional needs of older adults. November 2019. https://www.gao.gov/assets/710/702788.pdf. Accessed December 15, 2020.
42. Dwyer JT, Gahche JJ, Weiler M, et al. Screening community-living older adults for protein energy malnutrition and frailty: update and next steps. J Community Health. 2020;45:640–660. doi:10.1007/s10900-019-00739-1.
43. Bandeen-Roche K, Seplaki CL, Huang J, et al. Frailty in older adults: a nationally representative profile in the United States. J Gerontol A Biol Sci Med Sci. 2015;70(11):1427–1434. doi:10.1093/gerona/glv133.
44. Dwyer JT, Gahche JJ, Arensberg MB. Malnutrition & frailty screening tools and interventions, what's common, what's not, what's needed. Presented at: Aging in America Conference; April 16, 2019; New Orleans, LA.
45. Massachusetts Executive Office of Elder Affairs. 2018 Commission on Malnutrition Prevention Among Older Adults annual report. https://defeatmalnutrition.today/sites/default/files/documents/2018%20Malnutrition%20Prevention%20Commission%20Annual%20Report_11292018_1.pdf. Accessed December 15, 2020.
46. Marshall S, Young A, Isenring E. The Malnutrition Screening Tool in geriatric rehabilitation: a comparison of validity when completed by health professionals with and without malnutrition screening training has implications for practice. J Acad Nutr Diet. 2018;118(1):118–124. doi:10.1016/j.jand.2017.03.019.
47. Susanto M, Hubbard RE, Gardiner PA. Validity and responsiveness of the FRAIL scale in middle-aged women. J Am Med Dir Assoc. 2018;19:65–69. doi:10.1016/j.jamda.2017.08.003.
48. Massachusetts Executive Office of Elder Affairs. 2019 Commission on Malnutrition Prevention Among Older Adults annual report. https://defeatmalnutrition.today/sites/default/files/documents/Malnutrition%20annual%20report_12.27.19.pdf. Accessed December 15, 2020.
49. Academy of Nutrition and Dietetics. Telehealth quick guide for RDNs. https://www.eatrightpro.org/practice/practice-resources/telehealth. Accessed December 15, 2020.
50. Massachusetts Executive Office of Elder Affairs, Massachusetts Business Roundtable, Massachusetts eHealth Institute. Massachusetts employer toolkit to support working caregivers. http://maroundtable.com/caregiving/MAEmployersToolkit.pdf. Accessed December 15, 2020.
Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc.