Harnessing Stakeholder Perspectives and Experience to Address Nutrition Risk in Community-Dwelling Older Adults

Community-dwelling, older adults have a high prevalence of nutrition risk but strategies to mitigate this risk are not routinely implemented. Our objective was to identify opportunities for the healthcare system and community organizations to combat nutrition risk in this population in the jurisdiction of Alberta, Canada. An intersectoral stakeholder group that included patient representatives was convened to share perspectives and experiences and to identify problems in need of solutions using a design thinking approach. Results: Two main themes emerged from the workshop: (1) lack of awareness and poor communication of the importance of nutrition risk between healthcare providers and from healthcare providers to patients and (2) the necessity to work in partnerships comprised of patients, community organizations, healthcare providers and the health system. Conclusion: Improving awareness, prevention and treatment of malnutrition in community-dwelling older adults requires intersectoral cooperation between patients, healthcare providers and community-based organizations.


Introduction
A high rate of malnutrition in hospitalized patients is a long recognized clinical issue. Recently the Canadian Malnutrition Task Force (CMTF) reported that 45% of patients who stayed in hospital more than two days were malnourished at admission [1] and most remained in this condition when discharged [2]. Moreover, older adults (≥65 years) represent approximately 40% of the hospital population, thus malnutrition may be disproportionately impacting this population [3]. This high level of malnutrition is also seen on admission to hospital, which suggests that the cause may not be related to hospital care but rather due to a lack of awareness and resources in the community [2].
Using standardized methodology and cut-points, a tri-country study (Canada, New Zealand, The Netherlands) found a uniformly high prevalence of high nutrition risk (61. .1%) in community-dwelling adults ≥65 years of age [4]. The validated screening tool (SCREEN II) is considered useful for identifying upstream factors (e.g., determinants of food intake such as grocery shopping difficulty) that may predict future as well as The focus of this iKT event was to facilitate brainstorming and developing solutions for malnutrition in older adults that align with the knowledge users' knowledge and experiences; however, the diverse range of stakeholders was first apprised of the current state from multiple expert viewpoints in order to break down siloed thinking and create empathy. This report highlights how the iKT process resulted in identification of new directions for preventing and treating nutrition risk and malnutrition in communitydwelling older adults. Figure 1. Constituencies of knowledge users and their connections to community-dwelling older adults (green box), the healthcare system and other organizations. Solid dark blue arrows denote direct interaction of older adults with the healthcare system, government and community organizations. Stippled arrows show potential progression of older adults to requirement for home care support or long-term care. Thick striped arrows indicate the relationship between acute and primary care with community organizations, which was identified by symposium participants. It was also identified that these connections could be strengthened, for example through transitions pathways from acute to primary care. Community organizations identified that many of their services could be better utilized by augmenting connectivity between themselves and primary care. Thin arrows indicate organizations that provide policy and other leadership support for implementation of best practices; Alberta Health provides operating budgets to the primary care system and AHS. Involvement of other government organizations not directly providing healthcare was not explored in depth. Letters in parentheses reference Table 1.

Materials and Methods
The Research Ethics Board at the University of Alberta approved this study entitled "Malnutrition Symposium and Workshop" (Pro00097622). Prior to attending, participants were provided with an information letter indicating that the symposium and workshop were part of a research project. The information letter was reviewed at the beginning of the symposium and participants were given the opportunity to opt out by communicating with the organizers at any time up to one month following the event. The research took place in three phases following a design thinking protocol.

Overall Structure of the Integrated Knowledge Translation Activities
Integrated knowledge translation, as defined by the Canadian Institutes of Health Research, is "an approach to doing research that applies the principles of knowledge translation to the entire research process" [23]. By involving stakeholders in research as collaborators, it was anticipated that the research outcomes would be more applicable to knowledge users. Thus, a symposium (Day 1) and workshop (Day 2) was convened to involve stakeholders in a design thinking process to articulate why the problem of malnutrition in older adults exists as well as potential solutions. The stakeholders included patients, healthcare professionals and administrative leadership, community organization representatives and researchers. This methodology was preferred over other techniques that were considered, such as modified Delphi processes using questionnaires as was used by CMTF to develop an in-hospital nutrition pathway [24], because the face-to-face format offered better opportunity for building new connections between people and organizations.

Participants
Targeted invitations were sent to more than 70 individuals (Table 1). Invitations were sent by email approximately two months prior to the Symposium and Workshop, with additional follow-up reminders. If invitees were unavailable, they could suggest another knowledge user from their organization. Registration was free but limited by the available budget; therefore, efforts were made to ensure attendance from the various constituents. On arrival at the venue, participants signed in to log attendance and were given their group assignment for Phase 2 activities described in Section 2.3.2. Patient representatives were provided an honorarium in recognition of their contribution. Attendance from geographic regions was encouraged by providing transportation and hotel accommodation. * Many invitees represented more than one constituency but were only counted once. Letters in parentheses refer to constituencies represented in Figure 1.

Design Thinking
AHS supports innovation via several embedded processes, including learning collaboratives and design thinking. Design thinking was selected as a framework for tackling the problem of malnutrition in older adults because of its focus on the people impacted by the condition and their needs [25] and it allowed for multiple approaches to solve problems, whereas the learning collaborative model is focused specifically on pathwaydriven quality improvement. This problem-based research approach meets criteria for iKT, which is an approach that engages knowledge users at multiple phases of the research and implementation of potential solutions. Participating in co-design with knowledge users in the research process can help disseminate findings that are applicable and meaningful because of the unique insights brought to the findings. The process also facilitates the movement of research results into health practices or programs and/or policy [26]. The overall structure of the Malnutrition Symposium and Workshop was developed with input from AHS' Design Lab personnel.

Phase 1-Evaluating Current State (Empathize)
In order to understand the current state of caring for older adults with malnutrition in Alberta, on Day 1 the symposium organizing committee enlisted presenters from a variety of constituencies as shown in Table 2. Podium presentations were delivered to cover background information about malnutrition in older adults in Canada, the expertise and capacity present in community organization, the activities of the CMTF and the transitions in care pathway work of the PHCIN™. Those on the panel discussion provided brief explanations of the role of their constituency in responding to nutrition risk in older adults, followed by a question-and-answer session. Panel member presentations and discussions were audio-recorded and transcribed verbatim. During a world café formatted session, presenters spoke briefly on ongoing initiatives with small groups of participants. Attendees also had the opportunity to learn more about PHCIN™ and CMTF work on transition pathways. These discussions were recorded on paper by note-takers.

Presentation Content Constituency Represented by the Presenter Length Format
Inspiring initiatives as exemplars: A website of resources directed at older adults ("Seniors Community Hub") and frailty screening in primary care; AHS-facilitated Enhancing Care in the Community initiative to enable Albertans to be as healthy, well and independent as possible in their homes and communities; a seniors organization with a health clinic run by a nurse practitioner In groups of 6-8 representing the different constituencies and individuals not usually working together, symposium attendees were charged with developing two problem statements regarding malnutrition in older adults in Alberta, building on their own experience in addition to the information provided in Phase 1 and alignment with the research priorities of the day. For each problem statement, the groups then brainstormed and prioritized co-created potential solutions. Discussions were recorded on paper by note-takers. At the end of Day 1, the symposium organizing committee and the Design Lab facilitators used the notes to discuss impressions of the day and to develop six problem statements to use for the Workshop in Phase 3.

Phase 3-Developing a Framework for Intervention Development (Ideate, Prototype)
The activities on Day 2 were facilitated by Alberta Health Services Design Lab personnel (https://www.d4ahs.com, accessed on 23 March 2021) according to their protocol. In small groups, workshop participants selected a problem statement and, over six hours, developed an intervention that addressed the stated problem. These interventions form the framework for future development and refinement of interventions for older adult nutrition risk and malnutrition.

Analysis
Recordings from Phase 1 presentations, discussions and question and answer periods were transcribed verbatim and organized in Excel as strengths and gaps in nutrition care for older adults. Themes were developed inductively by iterative categorization of the concepts and ideas presented by the speakers, during the world café and question periods as recommended for thematic analysis following the steps of familiarization, coding, generating initial themes, reviewing themes, defining/naming themes [27]. This was carried out by C.B.C. and checked for accuracy and consistency by N.P. Any disagreements were resolved by discussion and consensus. Quotations were sorted by themes, e.g., (Potential) Role of Government/AHS, Primary Healthcare, Community Organizations; User/Patient Perspective; Relationship of Malnutrition to Socioeconomic Determinants of Health; Strategies. Reports from Phase 2 brainstorming were also transcribed and synthesized. The transcripts were examined for mention of linkages and strategies used by different constituencies that already existed and/or could be strengthened to enable continuity of care for older adults with nutrition risk, such as better transitions and community support.

Participants
Attendance for the symposium and workshop is reported in Table 1.

Current State
The purpose of Phase 1 was to provide an understanding of the problem of nutrition risk in community-dwelling older adults in Alberta, so that participants realized the scope of the problem, developed empathy for those at risk and were focused on identifying solutions. Speakers in Phase 1 were charged with describing the current state of identifying and caring for seniors in Alberta who are malnourished or at nutrition risk, and perspectives on gaps in the system that needed to be addressed. Presenters were representatives of several constituencies in order to capture multiple points of view (Table 2 and Figure 1). Speakers identified a number of existing initiatives; however, these were largely occurring independently without formalized cooperation or partnership between constituents. Overall, a key message emerged related to lack of knowledge and communication of malnutrition, not only to older adults but also to healthcare professionals who are not dietitians. Secondly, malnutrition and nutrition risk are closely related to social isolation and other social determinants of health as well as clinically relevant conditions such as frailty. Scrutiny of the transcripts identified strengths and gaps in addressing nutrition risk in older adults-summarized in Table 3.  I really worry that her diabetes is overtreated, her hypertension is overtreated, she's having falls, she's going to end up with a broken hip and require a nursing home and if there isn't a general assessment of her whole condition, and part of that is that what we call harmonizing the therapy and the palliative care. . . . care focused on her quality of life, and her comfort and avoiding acute issues, will enlarge. The therapy, the therapeutic focus part will reduce . . . we know a single focus on a problem leads to problems. If all you worry about is somebody's blood pressure, they'll be on blood pressure pills til the end of their life. If all you worry about is malnutrition, there will be people that want to have people dying of dementia on heart healthy diets.
Community organizations provide programs including food provision, transportation, social engagement Lack of consensus on best practices in malnutrition/nutrition risk treatment; lack of validated models for partnerships between healthcare system and community organizations CP: Another program that I've used and have been involved in is community dining, or wheels to meals program. And they can be held in churches, community centres, I came from-[name of town] and we used to run them in our neighborhood associations, which are your community leagues (great places to have community dieting programs) . . . and I have seen a lot of good things come out of that because a lot of the times people that are coming are socially isolated. They're not eating properly so we get together we eat socially because we're all social people. We like to eat with people and a lot of the times if people have lost somebody that that they've been cooking for or they're eating partner well then we know what happens and they don't eat like they used to.

Strengths Gaps Quotes
Evidence of cost to system of malnutrition on length of stay and readmission to acute care in Canada Communicating nutrition's importance in healthy aging Pt: I also learned the importance of eating and food in health and recovery and think that's very profound information that I want to disseminate to the world and say, "We have to make food far more important in healthcare and in living than it is right now and I think you'll find that's really supported by our data." Compared with medical interventions, an individual receiving assistance from a community organization programs can be less stigmatizing Pt: So then we also . . . found people feeling shamed and embarrassed by realizing that they were malnourished, but this was their own perception because they hadn't been told. "So by not taking care of myself the way I used to do it, I'm making things worse. I'm inducing the deficiencies that I know I have. And guilt-pretending to my family that everything is all right. The last thing I need is my family to know is that I am potentially in trouble." Primary care via PCNs provides team-based, interdisciplinary care including dietitians, physio-and occupational therapists; includes majority of general practice and family medicine MDs throughout Alberta Older adults' lack of knowledge of or access to community supports, particularly in rural settings and by immigrants CP: Rural Alberta is underserviced, especially when it comes to outreach services and I think that's a problem because we know that our older adults in rural Alberta do not want to move into the urban. They want to stay in their farmhouse; so how are we going to help mitigate that?

Use of technology for mass education, program delivery versus older adults' utilization of such technology
Res: So I think we need to figure out those connection points and what will be feasible and realistic depending on who that senior is, as well as the community provider, too, right, in terms of their technology. I don't have the answers, but that's a key part of it is figuring that piece out. And tech's gotta be at our side; we have to use it better than we have been.
In addition to identifying general strengths and gaps in the current state, additional presentations focused on initiatives already underway in AHS, primary care settings, academic and community organizations (Figure 2). Within Alberta, ongoing efforts to support the malnutrition strategy and recent roll-out of a provincial electronic medical record that will facilitate charting of malnutrition and its identification as a discharge planning and care transition issue were identified by Nutrition Services as critical to advancing continuity of care for patients with malnutrition risk. In addition, initiatives outside of Nutrition Services that could be enhanced further by "adding on" nutritional assessment and treatment were identified. These included the PHCIN™ guidance on home to hospital to home transitions, CMTF-led development of a pathway for addressing screening and support for patients with nutrition risk in the community, a focus on frailty prevention by the Senior's Health Strategic Clinical Network™. Community organizations identified a number of ongoing food provision initiatives as well as related services such as transportation and mitigating loneliness. Community organizations emphasized that while they have some capacity to assist with the problem of malnutrition, they find themselves competing for limited resources rather than presenting a unified, coordinated approach. Discussion focused on how these activities could be leveraged to enhance nutrition-related care for older adults. Identification of initiatives that could be leveraged to address nutrition risk in community-dwelling older adults. These ideas were derived from the transcripts of the Symposium's presentations and discussions. The figure depicts a patient-centred approach to anchor initiatives and programs. A need for intersectoral cooperation was identified, for example in facilitating transitions from hospital (acute care) to home (primary health care and community organizations) as was the existence of already present supports such as the AHS Malnutrition strategy and the CMTF pathways for transitions and primary care. Research areas to support evidence-based practice were identified. Abbreviations: EMR, electronic medical record; HCP, healthcare professionals.

Prioritizing the Most Important Gaps, Solutions, Barriers and Facilitators to Solutions
Following the presentations outlined in Table 2 along with ample opportunity for question-and-answer and general discussion, participants were organized into six groups from diverse constituencies for Phase 2-Brainstorming Solutions. Each group was charged with identifying two of the most important gaps or problems based on their own knowledge and the information provided during the presentations. The key problems arising were:

•
Lack of awareness and importance of (mal)nutrition among older adults. This problem was related to physical function (" . . . patients don't connect nutrition with function . . . and so therefore it's not really a priority in maintaining their health").

•
Ineffective communication of malnutrition between HCP-HCP and between HCP and patients. This was exemplified during open discussion by this quote, "I have a hard time making a diagnosis about malnutrition or telling the patient that they have malnutrition . . . . maybe we have to change our language but I can't believe that we cannot help patients . . . like if you had cancer you would say 'Oh my God that's going to make them feel bad. I better not tell them that.'" One of the groups stated, "Then our last problem statement is: there's no standardized assessment or communication or treatment plans across health care providers. And so, we talked about having the importance of kind of common . . . language and more research to continue on the patient's perspective and how they view this . . . . We all felt that would . . . help bring these things forward." • Lack of health system recognition of and education in the importance of nutrition and nutrition risk in older adults (" . . . care providers don't view malnutrition as some of those asymptomatic problems that they need to address or act on.") • Diagnosing physical changes with aging (chewing, swallowing, dentition) that affect nutrition as exemplified by this quote: "We talked a lot about the chewing and swallowing issues, people don't want to admit that they have them and that they're doing fine. They think needing modified texture is a failure. And that those people are often readmitted for malnutrition and aspiration; so again, just catching those readmissions and identifying that and working with the patients." • Lack of assessment of nutrition risk and continuity of care in the health system (" . . . there's no standardized assessment or communication or treatment plans across health care providers.") • Social isolation among older adults as a driver of nutrition risk, represented by the quote: " . . . people who are lonely are more likely to be malnourished . . . " Once the problems had been articulated, the same groups were asked to propose solutions. The most common solution was education and awareness campaigns aimed at older adults and their families, volunteers and organizations who work with older adults, the general public and HCP to address the gap in knowledge of nutrition, malnutrition and its link to maintaining function and independence in older adults. The importance of ensuring that older adults participate in the development of such a campaign was emphasized. A second solution was aimed at addressing the communication gap, in particular reconciling the stigma of malnutrition might confer patients versus their need to understand the importance of proper nutrition to maintaining their health and independence. A third solution was ensuring that malnutrition was assessed for, diagnosed and charted for the purposes of discharge planning, transitions and continuity of care, and appropriate treatment. Finally, the important roles that community organizations already play in safeguarding the health of older adults was acknowledged and ideas advanced for extending those roles and for creating better connections between government, health, community and academic sectors.
The last activity of Phase 2 was identification of problem statements that would be used in Phase 3-Developing a Framework for Intervention Development. This task was facilitated by the AHS Design Lab team. The symposium and workshop organizing committee (i.e., the authors) reviewed the gaps and problems and selected six, which the facilitators further refined to address the patient-centered approach that would be taken in Phase 3.

Developing a Framework for Interventions
On Day 2, the participants were organized into groups representing multiple constituencies and led through a process of identifying a problem from Day 1 for which they would develop a prototype solution. The facilitators had purposely worded the problem statements to emphasize the centrality of the patient with nutrition risk. The AHS Design Lab facilitators challenged participants to develop a prototype intervention within a 6-h window of time via interactive small group activities and large group discussions. The interventions and the problems they address are listed in Table 4. Notably all of the six solutions involved partnerships of the health system with community-based organizations and some also included increased connectivity between acute and primary care as well as other government departments. Although there were only three patient representatives present, they had input into all of the interventions through a process in which members of each group learned about the innovation of each other group and offered feedback and suggestions for strengthening the proposed solution.

Problem Definition Prototype Solution New Connections Proposed
There is a lack of communication and continuity of management of malnutrition between different supports in the community and in the health system; People don't connect nutrition with phyical and cognitive function FUNction app-a personalized nutrition, fitness, wellness and sleep plan with information and prompts provided on an app. Supported by a clinician/coach Acute care-primary care adaptation and uptake of CMTF transition pathway; primary care-community organizations providing services to support the health plan, as well as health coaches

Discussion
Approximately two-thirds of older adults in Canada are identified as having nutrition risk [4]. It is recognized that better screening as well as identifying opportunities for prevention could help older adults retain their independence and improve their quality of life as well reduce hospital length of stay and associated costs. Leveraging the initiatives of several stakeholders, an iKT event was undertaken using a design thinking process to increase empathy for older adults with nutrition risk and malnutrition amongst multiple stakeholders, brainstorm solutions and develop ideas for future intervention development.
A high-functioning health system puts patients and patient-centered care at the center of all activities, including innovation. Our Symposium and Workshop included three patient representatives, one of whom was a speaker on the panel discussion. In addition, these individuals are part of AHS' Patient and Community Engagement Researcher (PaCER) team, and have been trained to conduct qualitative, patient-oriented research to support innovation in healthcare. They had previously conducted a project with the DON SCN™ to interview people recently discharged from hospital with a diagnosis of malnutrition. Thus, they had an excellent perspective as exemplified by the panel discussion presenter ( Table 2). The patient representatives brought three important themes from their research, patient unawareness of malnutrition risk, barriers to eating well as well as personal facilitators such as trying new recipes, consulting dietitians, sharing meals with friends. Our findings are consistent with the priorities identified in a citizen panel comprised of older adults and specifically the need to improve malnutrition through accessing knowledge about food and nutrition, identification of nutrition risk in older adults and coordinated services delivery [28]. The United States National Blueprint: Achieving Quality Malnutrition Care for Older Adults, 2020 Update also targets educating older adults and their caregivers on nutrition-related topics and services [29].
Lack of awareness of the importance of good nutrition in maintaining physical and cognitive function and independence, not only by patients but also by the healthcare system was identified as a key problem. Health system priorities such as optimizing hospitalto-home transitions, a provincial surgery initiative and implementing care pathways for nutrition risk in primary care settings were recognized as opportunities to leverage initiatives such as enhanced screening for and follow-up of nutrition risk in community settings. Conversely, community organizations identified opportunities for partnership to capitalize on initiatives and services they were already providing to their constituents. Thus, partnerships between community organizations and the health system became a focus of the Workshop on Day 2, when prototype solutions were developed.
The importance of nutrition to overall health and function in older adults was a fundamental knowledge gap identified by multiple stakeholders. Moreover, communicating malnutrition from both conceptual and diagnostic perspectives was determined to be problematic. The proposed communication solution between HCP and patients was a smartphone app that the HCP could program with a specific plan to improve nutrition risk and other health behaviors. The app could also link to community resources and was envisaged as an aid to transitioning from hospital to home. While many currently available apps track nutrition and fitness, mainly to aid weight loss, few seem designed to provide holistic support. An app called WittyFit combining behavioral data with health outcomes is currently in clinical trials [30]; such apps may become more available in future and may be feasible to use in older adult populations as they gain more familiarity and expertise with smartphone technology, but their current use is limited by low uptake by older adults [31].
Capacity within the nongovernmental, community organization sector was identified as a strength on Day 1, as was the opportunity to leverage ongoing initiatives in primary healthcare, AHS-led partnership called Enhancing Care in the Community, the CMTF, and hospital-based programs such as Enhanced Recovery After Surgery [32]. Creation or formalization of intersectoral partnerships could address persistent gaps in nutrition care for older adults because the health concerns of the rapidly growing older adult population in Canada and elsewhere are challenging for traditional healthcare delivery models to provide quality care. Indeed, the World Health Organization's Active Ageing: A Policy Framework identified the need to "develop a continuum of affordable, accessible, highquality and age-friendly health and social services that address the needs and rights of people as they age" but the follow-up Report on Ageing and Health noted that little progress had been made over the subsequent decade [33].
Participants addressed how nutrition-related services could be provided in partnership with the healthcare system to provide older adults with more seamless care. Four of the proposed solutions involved enhanced access to food, or reducing social isolation at mealtimes either through group activities or videoconferencing. Community-based supports have been acknowledged as potential strategies for improving nutrition status of older adults living independently [34]. Many of these are informal, involving family, friends and neighbors, while community services providing congregate dining or meal delivery are also recognized to reduce nutrition risk [34]. Two recommended strategies to mitigate nutrition risk in older adults are delivered meals and congregate dining [35]. Post-hospitalization meal delivery has the potential to reduce emergency department visits and re-hospitalization [36]. Congregate dining may concomitantly reduce social isolation and increase nutrient intake [37]. The community organizations present at the Symposium emphasized that many programs already available could specifically target older adults with nutrition risk, including social supports, a variety of meal provision options, transportation and shopping. However, the small volume of published evidence in this area makes it difficult to be guided by best practice. The prototype solutions devised using the Design Lab process used the knowledge gained at the Symposium to suggest practical outreach activities that could be implemented in a variety of settings or use technology to overcome access challenges, particularly in rural areas.
The final solution addressed the problem of lack of knowledge of the importance of nutrition to avoiding conditions such as frailty. Importantly, the older adult voice was considered essential to developing an awareness campaign that would resonate with that audience. We note that none of the solutions focused on communications between healthcare professionals, despite this being an important issue identified at the Symposium. This may have been due to the Design Lab's focus on patient-centered solutions as well as the interests of individuals attending the Workshop.
The literature is sparse on formalized community-healthcare partnerships. Despite recommendations to improve access [29], models of partnerships still need to be developed. Lim et al. [38] proposed new models not centered around doctors and illness are required; rather, the reforms should focus on integration, patient-centeredness, health-centered, emphasizing team-based care that evolves with the patient from being well-healthy, to wellunhealthy, unwell-unhealthy (frail) and end-of-life care. A specific model developed in Singapore involving the public, businesses, community as well as healthcare organizations was described [38]. Such case studies are extremely useful, but each environment needs to develop strategies and partnership agreements that reflect the local culture and needs. However, an interesting component of the Singapore model was the development of wellness community collectives, which serviced residents by offering programming and courses in physical activity, nutrition, social engagement activities and health related activities-including screening and interventions [38].
With the impetus engendered by this iKT activity, AHS and its partners have started on a path towards intersectoral support for older adult's nutrition risk or malnourished living in the community. One year post-event, the organizing committee is aware of at least three research projects initiated or proposed that involve academic-health system-community organization partnerships. In addition, plans to adapt and adopt the CMTF-developed pathway for screening for nutrition risk in primary care, with community organization and AHS partnership, are well underway.

Conclusions
A design thinking protocol was used to identify potential interventions that could be used to create awareness of, prevent or treat malnutrition in community-dwelling older adults. Partnerships between stakeholders, including the voice of patients, were deemed essential and included in this iKT. Our findings indicate that leveraging existing initiatives could reduce barriers to innovation and the new intersectoral partnerships can support a way forward for addressing nutrition risk and malnutrition in older adults in Alberta.

Informed Consent Statement:
All participants involved in the study were informed that the proceedings would be recorded and provided consent by inaction/non-objection were given the opportunity to opt out up to one month following the event.
Data Availability Statement: Data are available upon reasonable request to the corresponding author.