Identifying and Managing Malnutrition, Frailty and Sarcopenia in the Community: A Narrative Review

Malnutrition, frailty and sarcopenia are becoming increasingly prevalent among community-dwelling older adults; yet are often unidentified and untreated in community settings. There is an urgent need for community-based healthcare professionals (HCPs) from all disciplines, including medicine, nursing and allied health, to be aware of, and to be able to recognise and appropriately manage these conditions. This paper provides a comprehensive overview of malnutrition, frailty and sarcopenia in the community, including their definitions, prevalence, impacts and causes/risk factors; and guidance on how these conditions may be identified and managed by HCPs in the community. A detailed description of the care process, including screening and referral, assessment and diagnosis, intervention, and monitoring and evaluation, relevant to the community context, is also provided. Further research exploring the barriers/enablers to delivering high-quality nutrition care to older community-dwelling adults who are malnourished, frail or sarcopenic is recommended, to inform the development of specific guidance for HCPs in identifying and managing these conditions in the community.


Introduction
Australia and New Zealand (ANZ) have ageing populations, with the number of people aged ≥ 80 years expected to increase by >200% by 2050, totalling > 510,000 New Zealanders and 2.8 million Australians in this age group within the next 30 years [1,2]. This is likely to result in an increased prevalence of age-associated conditions such as protein-energy malnutrition, frailty and sarcopenia; common and overlapping problems impacting the functional and health outcomes of older adults that are often left unidentified and untreated in community settings [3]. Consequently, these conditions lead to increased healthcare costs, with malnourished, frail and/or sarcopenic individuals requiring more health care professional (HCP) consultations, hospitalization, health care monitoring and treatments [4,5]. While these conditions are traditionally recognised and treated in hospital, not all community-dwelling adults are hospitalised; and being a short period in a person's life, hospitalisation is usually insufficient to correct malnutrition or associated conditions. As patients are acutely unwell while hospitalised, it may also be difficult for them to engage in care discussions or implement nutrition advice. Therefore, there is an urgent need for HCPs from all disciplines, including medicine, nursing and allied health, to understand, recognise and act on suspected malnutrition, frailty and sarcopenia among communitydwelling older adults. This review will focus on malnutrition, frailty and sarcopenia in the ANZ community, covering their prevalence, impacts and risk factors; as well as the steps for identifying and managing these conditions in this setting.

Prevalence of Malnutrition, Frailty and Sarcopenia
The prevalence of malnutrition among ANZ community-dwelling older adults ranges between 1% and 17%; and between 4% and 63% are at risk for developing malnutrition [26][27][28][29][30][31][32][33][34][35][36][37] (refer to Table S1 in Supplementary Files). Several tools were used to assess malnutrition in studies, with the modified Seniors in the Community: Risk Evaluation for Eating and Nutrition questionnaire (SCREEN© II) among the most common. The use of different tools, coupled with the population studied, may explain the differences in malnutrition prevalence reported across studies. Indeed, a recent study that used secondary data analyses from 11 European and one New Zealand study encompassing over 5000 older adults demonstrated higher malnutrition rates in adults > 80 years, in women, and in those with one or multiple morbidities; and prevalence differed by geographic location and tool employed [38]. The criteria used to identify malnutrition appear to strongly affect prevalence, highlighting the importance of considering each criterion separately, as each may indicate a nutritional problem.
Prevalence of frailty and pre-frailty among ANZ community-dwelling older adults is estimated to be between 2-29% and 41-54%, respectively [16,[39][40][41][42][43][44] (Table S1). Frailty rates appear higher among Australian women (18-29%) than men (6-21%). While the Modified Fried Frailty Phenotype (FFP) appears to be the most common approach, a number of tools were used to assess frailty. This, in conjunction with the population screened (e.g., men to women ratio), may help explain differences in findings between studies. In fact, one study reported minimal agreement between four different frailty measures; 35% of participants were identified as frail by only one measure, 9% by two measures, 3% by three measures, and <1% by all four measures [43], illustrating how the criteria or tools used to identify frailty can greatly impact its diagnosis.

Impact and Effects of Malnutrition, Frailty and Sarcopenia
Malnutrition, frailty and sarcopenia have serious consequences at an individual and societal level. Malnutrition adversely impacts the body's healing process and increases a person's risk of functional decline [54], infections [55], falls [56,57], pressure injuries [58], hospitalisation [35,54], institutionalization [54] and mortality [35]. In turn, these adverse events negatively influence an individual's quality of life, especially in elderly persons, and that of their families, and substantially contribute to acute and long-term healthcare costs [59]. Similarly, the consequences of frailty and sarcopenia include increased risk of falls and fractures [60], disability [45,60,61], poor quality of life [62,63], and mortality [44,45,64]. Importantly, a recent study reported that frailty and sarcopenia in combination are over three times more predictive of mortality than either condition alone in older communitydwelling adults [44]. At a societal level, frailty and sarcopenia lead to higher costs [4,5] and increased use of health care resources, such as HCP consultation/monitoring [5], emergency department visits hospitalization [65], and institutionalisation [45]. Although cost estimates for the Australian population are not available, increasing life expectancy indicates that frailty, sarcopenia and malnutrition are a growing economic burden.

Causes/Risk Factors of Malnutrition, Frailty and Sarcopenia
Causes of PEM, frailty and sarcopenia in older community-dwelling adults are multifactorial and interrelated (Table 1). While many factors have been correlated with PEM in community-dwelling older adults, and are thus suspected to be determinants of malnutrition, much of this evidence has been generated from studies with limited ability to make causal inferences. As a result, contradictory findings have been reported. For example, a recent review of 35 studies reported conflicting evidence for dental status, swallowing, cognitive function, depression, polypharmacy, constipation and periodontal disease being determinants of PEM in older adults [12]. Despite this, moderate to strong evidence for an association with PEM have consistently been reported for several modifiable and non-modifiable determinates, including poor appetite [12,66,67], hospitalization [12,31,67], poor self-reported health [12,66,67] and increasing age [31,36,66]. Further, moderate quality evidence suggests chewing difficulties, mouth pain, gum issues, visual and hearing impairments, smoking status, alcohol consumption and physical activity levels, complaints about taste of food and specific nutrient intake are not determinants of malnutrition [12].
Similarly, several modifiable and non-modifiable determinates are consistently associated with the development of frailty and sarcopenia. Nutrition is acknowledged as a major modifiable risk factor in the context of frailty and sarcopenia. Five previous systematic reviews have been conducted on the association between nutrition and frailty [68][69][70][71] or sarcopenia [73]. Further, international studies have reported that malnutrition is associated with a fourfold and fivefold higher risk of developing sarcopenia [78] and frailty [79], respectively. Several factors might be responsible for this close relationship, including oral health [71], nutritional status [68], diet quality [68,73], the antioxidant capacity of the diet [68,70] and protein intake [68,69]. Of interest, the psychological and social factors impacting frailty and sarcopenia have been studied to a limited extent. Lastly, non-modifiable determinants such as increasing age is associated with the development all these conditions [15,16,31,36,44,47,66,80], while evidence for the role of gender remains contradictory. Table 1. Risk factors for malnutrition, frailty and sarcopenia in older community-dwelling adults.

Addressing Malnutrition, Frailty and Sarcopenia Using the Nutrition Care Process
The Nutrition Care Process (NCP) is a standardised model used to guide HCPs in providing consistent and high-quality nutrition care [81]. It involves four main steps: (1) nutrition assessment and re-assessment, (2) nutrition diagnosis, (3) nutrition intervention, (4) nutrition monitoring and evaluation, as well as (a) precursor (screening and referral) and (b) follow-up (outcomes management) steps [81]. While this process is specific to nutrition care, frailty and sarcopenia are closely related to and intertwined with malnutrition; hence, we propose that the NCP steps can be applied to all three conditions, using tools and approaches appropriate to each. This section will outline the process for identifying and managing malnutrition, frailty and sarcopenia in the community.

Screening and Referral
The importance of identifying malnutrition, frailty and sarcopenia in the community is clear when considering their impacts on patients and health services. Screening is a preceding step to the NCP that allows HCPs to recognise and prioritise at-risk patients so they can be formally assessed and managed or referred to other HCPs. It involves using a validated screening tool to determine a patient's risk of having one or more of these conditions. There are several valid and reliable tools available for use in clinical and community settings (see Table 2). Screening tools can be used by any HCP and should be selected based on their practicability and reliability in the intended setting [3]. Screening tools are readily available online; however, if a practice setting does not use formal screening tools routinely, HCPs can use informal methods (such as recognising risk factors; Table 1) to identify and prioritise at-risk patients for referral to appropriate HCPs. specificity; however few studies used appropriate reference standards [83].
Designed to assess nutritional status among community-dwelling older adults [82]; however predictive validity in community setting is poor (unable to predict mortality, hospitalisation, or weight loss of >5%).

Malnutrition Universal Screening Tool (MUST)
Considers BMI, weight loss and acute disease effect.
Has been validated in hospital, residential aged care and community settings [84]; but more validation studies are needed in community.
Mini Nutritional Assessment-short form (MNA-SF) Six items on dietary intake, weight loss, mobility, disease/stress, neurological problems and BMI [85].
Recommended for use with older adults and validated in hospital, residential aged care and community settings.

Malnutrition Screening Tool (MST)
Two questions on appetite and unintentional weight loss [86].
Was developed to assess general nutrition status in community-dwelling older adults, but is also validated as a malnutrition screening tool [88].
Determine your Health Checklist (DETERMINE) Self-completed, 10-question survey assessing dietary intake, nutrition impact symptoms, health conditions, medications, social/economic factors, weight changes and functional status [82].
Designed to assess nutritional status among community-dwelling older adults [82]; however predictive validity in community setting is poor (unable to predict mortality, hospitalisation, or weight loss of >5%).
Acceptable performance for predicting disability only, and not related to mortality or institutionalization; therefore, not recommended as first choice for screening.

FRAIL scale
Self-administered survey on ambulation, fatigue, illness, resistance and weight.
Using Fried frailty phenotype as a reference standard, sensitivity was 87-96% and specificity 64-86%, with a FRAIL scale score of 2 being the optimal cut-off point, among community-dwelling Australians [91] and Chinese [92].
Good validity in community setting. A strength is that it does not require measurements nor administration by healthcare professionals [17,93]. Considered gold standard for frailty screening due to high validity and ability to predict cause-specific mortality; however can be complex and time consuming to complete due to its mathematical nature, reducing its popularity clinically [17].
Fried's Frailty Phenotype (also known as Fried Scale) Underpinned by biological causative theory and considers weight loss, exhaustion, grip strength, gait speed and physical activity [13].
Can identify frailty and predict adverse clinical outcomes; hence is widely used in clinical and research settings.
Requires measurement of handgrip strength and gait speed, which are not always practical/feasible in community settings.

Gérontopôle Frailty Screening Tool
Involves two steps: questionnaire evaluating weight, exhaustion, slowness, cognition, dependence; and clinician judgement of frailty.
Good sensitivity (88%) and specificity (84%) when assessed against Cardiovascular Health Study criteria definition of frailty as reference standard [95]. Considered one of the most appropriate frailty screening tools for use in community-dwelling adults.
Designed for early frailty recognition in community-dwelling older people [96]; however, its lack of specific guidance for clinicians to identify frailty is a limitation [97].
Can determine the level of frailty.

Name Description Validity in Community Setting Recommendation/Comment
Tilburg Frailty Indicator Self-administered 15-item questionnaire considering health, weight, walking difficulty, balance, hearing, sight, grip strength, fatigue, memory, sensory, anxiety, coping capacity, solitude and social support [99,100].
Developed for identifying frail community-dwelling older people, and is validated in this setting with high diagnostic accuracy (95% sensitivity; 86% specificity) for frailty [105]. A limitation is that it takes 14 mins to complete.

Vulnerable Elders Survey
Contains 13 questions on age, self-rated health, physical fitness and independence [106].
Developed to identify community-dwelling vulnerable elderly at risk for functional decline. Relatively short and easy to complete.

Vulnerable Elders Survey
Contains 13 questions on age, self-rated health, physical fitness and independence [106].
Developed to identify community-dwelling vulnerable elderly at risk for functional decline. Relatively short and easy to complete.

Sarcopenia screening tools
European Working Group on Sarcopenia in Older People (EWGSOP) Two-step algorithm assessing gait speed and handgrip strength to identify people 'at risk' of sarcopenia who should then proceed to a full assessment [22].
Reported sensitivity is between 33-71% and specificity 89-91% when validated against multiple criteria for diagnosing sarcopenia [107]. * Highly specific, relatively simple tool (however requires measurement of gait speed and handgrip strength). Cut-off thresholds for skeletal muscle mass indexes are 9.2 kg/m 2 and 7.4 kg/m 2 and for hand grip-strength are 32 kg and 22 kg, for males and females, respectively [108]. Considers age, hospitalisation in past year, activity level, number of meals/day, daily dairy intake, daily calorie intake, and weight loss in past year [111].
The Strength, Assistance with walking, Rise from a chair, Climb stairs, and Falls (SARC-F) Questionnaire on ability to carry a heavy load, walking, rising from a chair, climbing stairs, and frequency of falls [113].
Initially validated in community-dwelling Chinese adults with low sensitivity but good specificity [113]. Other studies report sensitivities between 36-56% and specificity between 85-87% when validated against multiple criteria for diagnosing sarcopenia [107]. * Relatively simple to complete and score; but requires assessment on stairs and of lifting a 4.5 kg load. Two versions; SARC-F-5 and SARC-F-3, comprising five and three questions, respectively. SARC-F-5 is recommended due to better diagnostic performance. Score of ≥4 (out of 10) on SARC-F-5 indicates sarcopenia risk.

Yu et al.'s prediction equation.
Uses weight, BMI, age and sex to identify people 'at risk' of sarcopenia [114].
Reported sensitivity is between 16-83% and specificity 60-87% when validated against multiple criteria for diagnosing sarcopenia [107]. * Recommended as a 'rule-out' screening test for sarcopenia (i.e., to reduce the number of costly DXA assessments undertaken). Cut-off values are dependent on the importance of DXA assessment cost vs. risk of missing sarcopenia cases [114].
DXA: Dual-energy X-ray absorptiometryˆThere is limited to no distinction between frailty screening and assessment tools; rather, tools are used interchangeably for both screening and assessment/diagnosis. * Sarcopenia screening tools were validated against multiple criteria for diagnosing sarcopenia: European Working Group on Sarcopenia in Older People (EWGSOP) [22], International Working Group on Sarcopenia (IWGS) [115], Asian Working Group for Sarcopenia (AWGS) [116], and Society for Sarcopenia, Cachexia and Wasting Disorders (SCWD) [117].
While risk screening is typically conducted in clinical settings (for example, most Australian and New Zealand hospitals mandate nutrition risk screening using a validated tool), screening in the community is equally important, as not all people will be admitted to hospital. General practitioners (GPs), practice nurses and community-based allied health clinicians are all well-placed to screen for malnutrition, frailty and sarcopenia. Screening should be prioritised for those at increased risk, such as patients with acute or chronic disease, reduced BMI or recent unintentional weight loss, older age or other risk factors (per Table 1). Patients identified as at risk should be referred to accredited HCP/s for formal assessment (i.e., dietitian for malnutrition risk; physiotherapist/exercise physiologist for frailty/sarcopenia risk).
Patients themselves can and should be involved in the screening process. Literature suggests that patients desire to be involved in their nutrition care [118,119], and several screening tools have been validated for use by patients and/or family members. A Dutch study found that online self-screening for malnutrition may be an easy, useful, accessible and contemporary way to identify older adults at nutritional risk in the community [120]. Consistent with a patient-centred care approach, patients should be adequately informed about the purpose and outcome of risk screening. A 2020 systematic review found that while most patients were accepting of nutrition screening, many did not understand its purpose or its results, which caused some to disbelieve or disregard their risk and was a barrier to patients enacting dietary advice [121]. This highlights the importance of engaging patients in the care process and keeping them informed to make health care decisions.
Community-based HCPs can provide better quality and more holistic care by using validated screening tools or identifying risk factors among community-dwelling adults who may have or be at risk of malnutrition, frailty and sarcopenia; so appropriate interventions or referral to other HCPs (such as dietitians) can be enacted [3]. Table 2 provides an overview of screening tools used in the community setting to identify patients at risk of malnutrition, frailty and sarcopenia.

Assessment and Diagnosis
Nutrition assessment involves systematically collecting and evaluating relevant information to diagnose nutrition-related problems and understand their causes [81]. This is typically done by a dietitian and involves evaluating a patient's nutrition intake, anthropometry, biochemistry, clinical signs/symptoms, and nutrition-focused physical findings (Table 3). Dietitians use this information, along with formal nutrition assessment tools, to make a nutrition diagnosis and to inform nutrition interventions. Several nutrition assessment tools exist and are commonly used in clinical and community settings. For example, the Subjective Global Assessment (SGA) can reliably identify malnutrition-related muscle dysfunction and impaired functional status among hospital patients [122]. The Mini Nutritional Assessment (MNA) is designed for and validated in elderly patients (including in community) [123][124][125] and assesses food intake, weight loss, mobility, disease/stress, BMI and neuropsychological problems. It has also been proposed as a useful tool to identify frail patients [93]. While such tools are commonly used in community, there is limited evidence for their diagnostic accuracy in this setting. In fact, one review found that no nutrition assessment tool had undergone sufficient validity testing in community-living adults, and authors were unable to recommend any one tool for diagnosing malnutrition in this group [125]. The best evidence shows moderate confidence in the ability of the MNA to predict death and limited confidence in its ability to predict physical dysfunction [125]. Despite this, it is suggested that nutrition assessment should be undertaken to ensure malnourished patients are adequately managed; and that more diagnostic accuracy studies are needed for all nutrition assessment tools in community settings [125]. Given this, community-based HCPs should refer patients at-risk of, or with suspected malnutrition, to a dietitian for formal assessment (where resources allow); or alternatively, use the domains in Table 3 to make an informal assessment to guide care. Frailty assessment is still evolving, likely due to the lack of consensus on a universal definition of frailty and how to identify it. There are two models by which frailty is recognised; the Fried Frailty Phenotype defines it as a set of physical characteristics (weakness, exhaustion, weight loss slowness, poor endurance) that are independent of disability and comorbidities [13], while the accumulation of deficits model considers summative physical, mental and social deficits, rather than a specific set of criteria [17]. Further, there seems to be poor distinction between frailty screening and assessment tools in the literature, with tools often used interchangeably. There are also fewer validity, consensus and systematic review papers published on frailty tools (compared to malnutrition tools), making it difficult to compare different tools' performance in various settings [3]. Systematic reviews have been unable to recommend specific tools for frailty assessment in community-dwelling adults, stating more research is needed [3,126,127]. One author suggests a two-step approach to frailty assessment; (1) a simple self-report screening questionnaire to identify those who would benefit from (2) a further complex assessment [127]. This may help to prioritise patients who are most at-risk and inform care planning. Frailty measures can include HCP judgment-based assessments, physical performance tests (e.g., gait speed, grip strength), physical frailty measures (e.g., frailty phenotype), multi-dimensional instruments (that include other dimensions such as cognition), and frailty indices [128]. Frailty tools should cover one or more of the assessment domains listed in Table 3.
Similar to frailty, the assessment and diagnosis of sarcopenia is an evolving area. However, multiple criteria exist for diagnosing sarcopenia, including the European Working Group on Sarcopenia in Older People (EWGSOP) [22], the International Working Group on Sarcopenia (IWGS) [115], the Asian Working Group for Sarcopenia (AWGS) [116], and the Society for Sarcopenia, Cachexia and Wasting Disorders (SCWD) [117]. The Australia and New Zealand Society for Sarcopenia and Frailty Research encourages the adoption of EWGSOP2 definition of sarcopenia in practice [129].
Assessment should occur upon initial referral of patients suspected to be malnourished, frail or sarcopenic; and should be repeated as appropriate to evaluate the effects of interventions (refer to Monitoring and Evaluation section) [81].

Intervention
As nutrition intake is a major modifiable risk factor in the development and progression of malnutrition, frailty and sarcopenia, interventions targeting these conditions frequently use nutrition-based strategies that aim to improve an individual's nutritional status. Table 4 illustrates the use of such interventions among community-dwelling older adults in Australia and New Zealand. These broadly fall within two categories: strategies to influence patient knowledge/behaviour; and strategies to improve dietary intake. While limited intervention studies using nutrition-based strategies among frail or sarcopenic individuals have been conducted in the ANZ context, international work supports the role of nutrition used alone [130,131] or in combination with exercise to aid in the management of these conditions [130][131][132][133]. Further, the same strategies can be applied to treat frailty and sarcopenia as the principle remains the same -to improve an individual's nutritional status. Importantly, while a combination of nutrition and exercise strategies are recommended to manage/treat malnutrition, frailty and/or sarcopenia, given the interplay of these three conditions, the focus and type of strategies used may vary depending on the primary condition being treated. For example, if the condition being treated is malnutrition, the HCP's primary focus may be on improving the individual's nutrition status through the use of nutrition-based strategies, whereas exercise-based strategies may be the focus of interventions for someone being treated for sarcopenia, considering sarcopenia is thought to occur regardless of energy balance [134]. Prior to delivering any nutrition-or exercisebased intervention(s), appropriately trained HCPs should be consulted first (dietitians for nutrition interventions; physiotherapists for exercise interventions) to ensure patient safety and the delivery of high-quality care.  Quality adjusted life years. * Exercise is commonly used and is effectives in treating and managing frailty and/or sarcopenia in older adults; however, given the focus of this review, only interventions using nutrition-related strategies alone or in combination with exercise are included here. a Kit included: leaflet on high-energy/-protein foods, 'Eating Well' booklet, local council directory of nutrition/support services for older persons in their area. b Strategies included: personalised dietetic advice, prescription of ONS, referral to a MOW service and/or referral to various community services. c Intervention included: community dietitian and/or speech therapist consults, needs assessment and service coordination, day care and/or home delivered meals. d Nutrition program included: dietitian evaluation, home-delivered meals, ONS prescribed. e Nutriton program included: Dietary counselling focusing on timing, size, and frequency of meals, recommendations of nutrient-rich foods and recipes, referral to community meal programmes, and provision of commercial oral nutritional supplements or commercial protein powders as deemed appropriate.

Strategies to Influence Knowledge and Behaviour
Delivery of one-on-one counselling [135,137,140] and resource kits [136] are common educational strategies used in interventions to improve an individual's malnutrition or frailty status (Table 4). These strategies align with Australian and European guideline recommendations suggesting that patients and caregivers should be offered knowledge about their nutritional problems and treatment options to promote appropriate nutritional care [141,142]. A large Australian study (n = 1145) reported that 82% of at-risk and malnourished community dwelling older adults who received one-on-one individualized counselling had improved PG-SGA scores after six months of intervention [135]. Similarly, a smaller Australian study (n = 68) provided older adults with tailored individual dietary advice two weeks post-hospital discharge, and reported that the proportion of at-risk and malnourished adults reduced from 62% to 24% three months after the intervention [137]. For both interventions, education was tailored to the individual's needs and delivered frequently, at home, by trained dietitians; factors which have been shown to contribute to high adherence to dietary advice among elderly individuals [143]. Despite these positive findings, 55% of at-risk or malnourished patients who were offered free dietetic counselling in the aforementioned study declined to partake [135].
This emphasises the difficulty in engaging this high-risk group and suggests the need for nutrition education to be given at opportune times (e.g., by nurses or GPs when elderly adults visit healthcare services). Indeed, there is evidence that nutrition advice delivered by nurses can positively influence the functional outcomes and diets of older people living at home [144]. Further, there is moderate evidence to support the role of domiciliary carers in implementing malnutrition risk screening, education and referral pathways, which may be effective and cost-efficient strategies to manage malnutrition in community-dwelling older adults [145,146]. This suggests strategies to improve nutrition knowledge should not only be limited to dietitians, but also include carers, nurses and GPs in the community. Further, geographically relevant resource kits (which include educational material) have been shown to be effective at improving nutritional status among community-dwelling ANZ adults [136] and should therefore be considered when individual dietary counselling from trained HCPs is not immediately available.

Strategies to Influence Intake
The use of ONS is a common strategy used to improve nutrition intake among adults [137,139,140]. These are nutritionally complete drinks that contain a mix of macroand micro-nutrients. Randomised Control Trials (RCTs) have shown a positive effect of daily ONS consumption on energy/ protein intakes and nutritional status among malnourished older patients after discharge from hospital [147,148]. Yet, the success of such interventions relies on patient adherence. One systematic review reported high compliance to ONS among community-living adults [149]; however others have reported lower [150] or variable adherence [151]. Other influencing factors commonly cited include duration of usage [152], if the patient is aware of reason for ingestion [153], variety of supplements prescribed [149] and how the supplement is taken [149]. As such, education should be provided on the potential benefits of ONS ingestion considering dietary counselling combined with ONS is the most effective intervention to improve energy intake and body weight among older adults [154]. However, other strategies to influence intake should be prioritised where barriers to using ONS have been identified.
Food-based fortification (also called dietary enrichment) is an alternative strategy to improve energy and protein intake [136,138]. This involves increasing the energy and protein of a meal without increasing volume, by adding extra-high-energy/-protein ingredients such as oils, butter, cream, or powdered milk; and/or powdered modules such as casein, whey protein, or maltodextrin. Indeed, a recent systematic review demonstrated that energy-and protein-based fortification can be employed as an effective and welltolerated intervention to improve dietary intake amongst older adults [155]. This strategy may be particularly useful for patients who do not tolerate or cannot afford ONS and has the advantage of better catering to individual dietary habits and preferences. Low dairy intake has also been identified as a frequently occurring risk factor among at-risk and malnourished community-living older adults [32,137], highlighting another avenue for low-cost dietary intervention.
Home delivery meal services, such as Meals on Wheels (MOW), which deliver healthy meals to clients' homes, may also be used as a convenient strategy to improve intakes among individuals who are unable to prepare meals or shop for themselves [137,138]. A recent systematic review reported a beneficial effect of home-delivered meals on intakes of energy, protein and/or micronutrients (e.g., calcium, vitamin A, B complex vitamins, vitamin D, zinc, magnesium and others) in older community-dwelling adults [156]. While evidence shows that meals delivered by this service provide an important contribution to an individual's overall intake [157], the inclusion of other foods (e.g., snacks) is still necessary for older individuals to meet their nutrition needs; something that is not always acknowledged among these clients [138]. Strategies therefore still need to be tailored amongst MOW clients, given their potentially limited ability to access, cook and/or prepare food.

Monitoring and Evaluation (Including Documentation)
Thorough monitoring and evaluation are helpful to track patients' progress and improve their outcomes by identifying any personal and/or environmental factors that may hinder compliance to nutrition intervention [158]. Evidence-based practice and patient preferences should be used to guide the selection of appropriate outcome measures/indicators to assess nutrition care [158]. Unfortunately, an internationally standardized set of outcomes for nutrition care is unavailable [158]; but outcomes to monitor/evaluate nutrition interventions can be classified into the four categories outlined in Table 5 [159,160]. Recent studies on the outcomes used in usual dietetic practice in Australia are lacking, however a 2008 Australian study found dietitians used a range of outcome measures in practice and these aligned with three of the four categories described in Table 5 (healthcare utilisation/cost savings were not routinely assessed, consistent with other studies) [159]. Table 5. Outcome/indictor categories to assess nutrition intervention.

Category
Outcome/Indicator Patients should be involved in selecting the outcomes most important to them. An Australian study identified 11 quality indicators of dietetic services from the perspec-tives of malnourished older patients, spanning three domains: structure (healthcare systems/environments), processes (dietitian-patient interaction) and outcomes (desired measurable outcomes of nutrition care) [163]. Outcome measures most important to patients were: (1) improvement in health status; (2) improvement or maintenance of independence; and (3) weight gain. Further, a qualitative study examining patients' experiences with dietetic consultations in the United Kingdom found that patients preferred dietitians who adopted a patient-centred approach and considered what patients wanted from the consultation [162]. As such, HCPs should monitor/evaluate nutrition interventions using a combination of indicators from the four categories outlined in Table 5, factoring in indicators most important to patients, to provide evidence-based, patient-centred care. This requires high level critical reasoning and should be planned thoroughly, also taking into account available data collection tools/methods and feedback strategies to other HCPs.
The frequency of measurement and strategy for data collection/reporting are important aspects of monitoring and evaluation. Data should be collected during the first consultation, halfway through the intervention or when significant changes occur (in adherence, clients' status or situation) and at the end of the process. However, it is often up to the judgement of the HCP, based on predictions of expected effects and available resources (i.e., time and costs) [158]. Available measurement options and equipment need to be taken into consideration; and a mix of qualitative (collected through asking questions in the consultation) and quantitative data (collected from self-monitoring, computer programs/apps, telephone or electronic follow-up) is recommended [158]. Lastly, monitoring and evaluation outcomes should be fed back and shared with all HCPs treating the patient to raise the success rate in achieving the patient's desired health outcomes and to justify the importance of adequate nutrition and the dietitian's role in health care.

Hospital-to-Community Transition
Transitioning home from hospital is a critical step in the management of malnutrition, frailty and sarcopenia in community-dwelling adults. Rehospitalization rates for older adults are high and up to a third of readmissions are considered preventable [161]. Providing quality nutrition care upon and/or after discharge has been shown to reduce avoidable readmissions by 28% [161], due to the effect that nutrition intervention (predominately, prescription of ONS) has on oral intake and nutritional status [147,148,[164][165][166]. Despite this, many older adults who are in need of quality nutrition care in this transition period do not receive it [167]. Communication problems between HCPs and across healthcare services, insufficient knowledge/attention to nutritional needs/problems by HCPs, and limited access to services have been described as barriers to delivering continuity of care [168][169][170]. Further complicating the problem is low compliance among those patients who do receive this care [153,164]. Qualitative and observational work has shown that gastrointestinal symptoms, lack of knowledge of ONS purpose, lack of ONS prescription and receiving nutrition care that lacked a person-centred approach are common reasons for low compliance among patients [153,171]. These findings demonstrate that the nutrition care of older adults during hospital to home transition periods needs improvement.

Conclusions
While the different populations, definitions and diagnostic criteria used by individual studies may explain the large variance in prevalence rates reported for these conditions, it is clear that malnutrition, frailty and sarcopenia affect a large proportion (~25%) of community dwelling adults. Given our ageing population, it is important for health professionals to be proficient in recognising and treating malnutrition, frailty and sarcopenia in the community. The NCP should be used to guide HCPs in providing consistent and high-quality nutrition care for these conditions, using tools and approaches appropriate for each step: (i) screening and referral, (ii) assessment and diagnosis, (iii) intervention and (iv) monitoring and evaluation. Further, the transition of patients from hospital to home, or between care settings, should be considered in any care plan for community-dwelling adults. While this paper provides broad evidence-based recommendations (Table 6), next steps in this area should include: (i) exploration of the barriers limiting the delivery of highquality care to older adults in the community who are malnourished, frail or sarcopenic (or are at risk of these conditions), from the perspectives of consumers and HCPs; and (ii) development of specific guidance for HCPs to manage and treat these conditions in the community, considering this is currently non-existent. Table 6. Recommendations for the nutritional management of malnutrition, frailty and sarcopenia.

Screening and Referral
Use a validated screening tool to identify patients at risk of malnutrition, frailty or sarcopenia. Tools that perform best in the community setting include: • Malnutrition: SCREEN-14 (with MNA-SF and MUST also performing well) • Frailty: Vulnerable Elders Survey (FRAIL scale, Fried's Phenotype also perform well) • Sarcopenia: MSRA-5 or SARC-F Tool selection should be based on performance in the intended setting (see Table 2) and with consideration of the time, resources and staffing/skill level required to complete.
Screening should be completed upon: • Initial contact with a new patient • Changes in a patient's health status (e.g., new diagnosis or recent hospitalisation) • Suspected malnutrition, frailty or sarcopenia (e.g., presence of risk factors) If it is not possible to screen using a validated tool, HCPs should consider the patient's risk factors (see Table 1) to determine if they are at risk / would benefit from a full assessment (e.g., by a dietitian or exercise physiologist).
Screening should be prioritised for patients who are older, have multiple comorbidities, have recently lost weight/are underweight, or who appear malnourished/frail/sarcopenic.

Assessment and diagnosis
Patients identified as 'at-risk' of malnutrition, frailty or sarcopenia should be referred to an appropriate health professional (e.g., dietitian, physiotherapist/exercise physiologist) for a full assessment and diagnosis, to inform nutrition and/or exercise interventions.
These health professionals should use appropriate assessment tools or criteria to diagnose malnutrition, frailty or sarcopenia; and document the level/stage (if applicable). For example *: If it is not possible to refer patients to appropriate allied health professionals, clinicians should use the domains in Table 3 to make an informal assessment, in order to guide care.

Intervention
A combination of nutrition-and exercise-based strategies should be adopted to manage malnutrition, frailty and sarcopenia. Common nutrition-based strategies used in combination include: • Nutrition education and high energy, high protein / dietary fortification • Nutrition education and oral nutrition supplements • Nutrition education and home delivery meal services Strategies should be tailored to the individual, factoring in their preferences, needs and context/geographical area.
Further work with consumers and HCPs should be undertaken to determine feasible and effective ways of improving nutrition among community-dwelling older adults in ANZ.

Monitoring and evaluating
HCPs should monitor/evaluate nutrition interventions using a combination of the indicators listed in Table 5, in conjunction with factoring in the indicators most important to patients to provide evidence-based, patient-centred care. This may include evaluating the following: Qualitative and quantitative measures should be used to collect data, and, where available, validated tools.
Findings should be communicated to all HCPs caring for the individual, as well as to the patient themselves.
* Note: There is limited evidence for the diagnostic accuracy of malnutrition, frailty and sarcopenia assessment tools in the community setting. The authors have suggested these tools based on the evidence available at the time this review was undertaken; however more diagnostic accuracy studies are needed in the community setting for all three conditions and their respective assessment tools.
Author Contributions: Conceptualization, S.R., M.R. and P.C.; investigation, S.R. and M.R.; writingoriginal draft preparation, S.R. and M.R.; writing-review and editing, S.R., M.R. and P.C.; funding acquisition, P.C. All authors have read and agreed to the published version of the manuscript.
Funding: This research was funded by Danone Nutricia.
Data Availability Statement: N/A-this study did not report on any data (narrative review).

Conflicts of Interest:
The authors declare no conflict of interest. The funders had no role in the study design or conduct, or in the writing of the manuscript.