Example of barriers for nurses in providing patients with nutrition and hydration literature review

Critical Analysis

In a qualitative study, Bryon, Gastmans & de Casterle (2012) explored the experiences of nurses with nurse-physician communication that occurred during decision-making for artificial nutrition or hydration (ANH) among hospitalised dementia patients. Twenty-one nurses in nine hospitals in Belgium were selected for semi-structured interviews as they reflected a wide range of personal characteristics and practice experiences. Successful advocacy for the dying patient and his family, a nurse’s ethical responsibility, depends on the quality of interdisciplinary communication. From data analysis which used a grounded theory framework emerged three factors influencing the nurse-physician communication: the attitudes of physicians toward nurses, the attitude of nurses toward physicians and the forms of communication utilised by RNs. The findings imply that to achieve optimal patient care and increase RN job satisfaction, nurse-physician communication must be transformed into an open dialogue founded on mutual respect.
Meanwhile, Kim et al. (2012) addressed underfeeding, a common problem among adult medical intensive-care unit patients in a Korean hospital, which contributes to increased rates of complications and patient deaths. Using a prospective cohort design, the research aimed to determine if protein and energy intake was sufficient, meaning that 90% or more of body requirement was met, within the four days post enteral feeding initiation in a sample of 34 patients. Factors that influence whether patients received adequate intake were also studied. Prescriptions, records of energy and protein intake, methods of feeding used and feeding interruptions were obtained and analysed. Results of the study showed that 62% of patients did not receive enough energy while 56% failed to receive enough protein. Underfeeding was associated with under-prescription, early initiation and prolonged interruption. Therefore, there is a need to generate evidence for preventive interventions.
In another qualitative study, Martinsen & Norlyk (2011) aimed to describe assisted feeding as a phenomenon in the care of adult patients with communication impairments. Forty-two assisted feeding encounters with neurology patients were observed and recorded simultaneously through field notes. Caregivers and patients were asked questions as necessary and answers and field notes were analysed using a phenomenological framework. Results revealed that assisted feeding was regarded as a transaction governed by efficiency and shaped by the institution. With a fixed schedule and duration of meals, various techniques were used to quickly administer food and fluids with nutrition and medication as goals. Feeding interruptions and delays occurred as caregivers fulfilled other responsibilities deemed more important. Findings highlight the necessity of also meeting patients’ social and emotional needs, such as conventions, aesthetics and preferences, during assisted feeding through changes in institutional structures.
A qualitative descriptive study by Ross et al. (2010) was done to explore awareness, knowledge and perceptions of patient malnutrition in the acute care setting to identify barriers to the implementation of nutrition care. Tape-recorded focus group discussions were held with 22 medical ward staff representing six disciplines including nursing. The transcribed discussions were subjected to framework analysis. Patient-related barriers included noncompliance with nutrition plans. Institution-related barriers identified were: inadequate knowledge of the processes involved in nutrition care, suboptimal interdisciplinary communication, absence of clear roles and interdisciplinary sharing of responsibilities, priorities taking precedence over nutrition care, powerlessness to change the order of priorities, and RN shortage. Though there is consensus that more nursing staff and education are solutions, it is clear that organisational change to promote a team-based model of care founded on accountability and staff empowerment needs to be implemented.

Discussion of Interventions and Findings

The studies were conducted in hospital (medical ICU, medical ward, neurology ward, unspecified hospital wards) and aged care settings in different countries and dealt with the provision of assisted feeding, general nutrition care, hydration as well as artificial nutrition and hydration (ANH). Data was obtained from the perspective of patients, their friends and families, nurses and other health care professionals. Majority of the studies used a qualitative phenomenological design as a single method or in conjunction with other methods. Thus, they were descriptive in nature. Majority also studied patient populations that were highly vulnerable to malnutrition and dehydration including ICU patients, older adults and patients with dementia and language deficits.
The studies focused on different issues. One study elucidated on how nurse-physician communication affects nurses’ performance of their ethical role as patient advocates during the decision-making process regarding ANH. Another study reported on the extent of and the contributory factors to malnutrition when ANH is administered. One study explored the barriers to providing nutrition care based on staff awareness, knowledge and perceptions. While one focused on describing the phenomenon of assisted feeding, the other explored the promotive factors and barriers to sufficient hydration.
Overall, the studies contribute to a deeper understanding of nutrition and hydration. Whatever methods are used to deliver these interventions, nurses have a duty to adhere to ethical standards, primarily by upholding patient autonomy (Stiles 2012). When the decision-making process is dominated by the medical profession, this presents a barrier to providing ethical nutrition and hydration care (Bryon, Gastmans & de Casterle 2012). Another finding is that though contributory factors to malnutrition are identified, the lack of evidence-based practices is a barrier to the formulation of effective guidelines aimed at prevention (Kim et al. 2012). Fulfilling nutrition and hydration needs also entails looking beyond physiologic goals to more holistic interventions that incorporate individual preferences, social interaction, conventions in eating, enjoyment and aesthetics (Martinsen & Norlyk 2011; Godfrey et al. 2012). Lastly, there are patient-related, nurse-related and organisational barriers to providing adequate nutrition and hydration care, the latter related to fragmented processes and structures (Ross et al. 2010).
A general agreement in views is evident when the need for change at the level of the organisation was identified by majority of the studies. Being able to provide ethical, evidence-based, individualized and holistic care requires modifying current models of care to allow for the prioritization of nutrition and hydration. It also requires instituting an organisational culture that is open to change. At the same time, interdisciplinary communication and collaboration, staff education and training, role delineation, staffing levels and staff empowerment are more apt to be the focus of quality improvement initiatives (Sables-Baus & Zuk 2012).
Despite the wealth of information, gaps in knowledge and practice remain. The range of interventions that address poor nutrition and hydration care and their evidence base needs to be known (Begum & Johnson 2010). Institutional standards or guidelines for nutrition and hydration care must also be evaluated for adherence to evidence. Further, models of care promoting optimal nutrition and hydration and their applications to different practice settings have to be explored. For example, individualized nutrition interventions are being advocated today and how these can be translated into practice provide guidance to their adoption (Dorner, Friedrich & Posthauer 2010).

Critical Analysis of the Research Problem

Based on the literature review, a research question on the barriers to providing patient nutrition and hydration is not highly relevant anymore. One exception is when the aim of research is to do a case study on a specific care setting or institution for the purpose of instituting changes. Another exception is when assessing the barriers in Australia’s health care organisations with the objective of generating national standards of nutrition and hydration care (Agarwal et al. 2012). Answering the said research question is necessary since the studies were conducted in different countries which have different health care systems. The findings may not fully reflect the reality in hospitals here in the country.
Otherwise, the review has outlined comprehensively the barriers at all levels, the general course of action to address these barriers, and the necessary improvements to the practice of nutrition and hydration care. Standards or guidelines, evidence-based practices and models of care are more relevant research problems to work on as findings will lead to specific actions that will improve the quality of care.

Development of a Research Question

The American Dietetics Association is advocating an individual approach to nutrition in aged care including hospice care and rehabilitation settings (Dorner, Friedrich & Posthauer 2010). The rationale is that traditional therapeutic diets, which are used as treatment to achieve and maintain the physiologic goals of adequate nutrition and hydration, are often unappealing to patients leading to poor food and fluid intake. Thus, the diet itself contributes to the problem of malnutrition and dehydration it seeks to correct. On the other hand, least-restrictive or liberal diets promote appetite and the pleasure of eating as they take into consideration both the patient’s condition and personal preferences (Dorner, Friedrich & Posthauer 2010). Thus, the following is a relevant research question: “ What are the patient, staff and organizational outcomes associated with individualised nutrition and hydration interventions among older adults?”

Bibliography

Agarwal, E, Ferguson, M, Banks, M, Batterham, B, Bauer, J, Capra, S & Isenring, E 2012, ‘ Nutrition care practices in hospital wards: Results from the Nutrition Care Day Survey 2010’, Clinical Nutrition, vol. 31, no. 6, pp. 995-1001.
Begum, MN & Johnson, CS 2010, ‘ A review of the literature on dehydration in the institutionalized elderly’, European e-Journal of Clinical Nutrition and Metabolism, vol. 5, no. 1, e47-e53.
Bryon, E, Gastmans, C & de Casterle, BD 2012, ‘ Nurse-physician communication concerning artificial nutrition or hydration (ANH) in patients with dementia: A qualitative study’, Journal of Clinical Nursing, vol. 21, no. 19-20, pp. 2975-84.
Dorner, B, Friedrich, EK, Posthauer, ME 2010, ‘ Practice paper of the American Dietetic Association: Individualized nutrition approaches for older adults in health care communities’, Journal of the American Dietetic Association, vol. 110, no. 10, pp. 1554-63.
Godfrey, H, Cloete, J, Dymond, E & Long, A 2012, ‘ An exploration of the hydration care of older people: A qualitative study’, International Journal of Nursing Studies, vol. 49, no. 10, pp. 1200-11.
Kim, H, Stotts, NA, Froelicher, ES, Engler, MM, Porter, C & Kwak, H 2012, ‘ Adequacy of early enteral nutrition in adult patients in the intensive care unit’, Journal of Clinical Nutrition, vol. 21, no. 19-20, pp. 2860-69.
Martisen, B & Norlyk, A 2012, ‘ Observations of assisted feeding among people with language impairment’, Journal of Clinical Nursing, vol. 21, no. 19-20, pp. 2949-57.
Ross, LJ, Mudge, AM, Young, AM & Banks, M 2011, ‘ Everyone’s problem but nobody’s job: Staff perceptions and explanations for poor nutritional intake in older medical patients’, Nutrition & Dietetics, vol. 68, no. 41-6.
Sables-Baus, S & Zuk, J 2012, ‘ An exemplar for evidence-based nursing practice using the Magnet Model as the framework for change: Oral feeding practice in the neonatal intensive care unit’, Journal of Pediatric Nursing, vol. 27, no. 5, pp. 557-82.
Stiles, E 2013, ‘ Providing artificial nutrition and hydration in palliative care’, Nursing Standard, vol. 27, no. 20, pp. 35-42.
Appendix
Abstracts
1. J Clin Nurs. 2012 Oct; 21(19-20): 2860-9. doi: 10. 1111/j. 1365-2702. 2012. 04218. x.
Epub 2012 Jul 30.
Adequacy of early enteral nutrition in adult patients in the intensive care unit.
Kim H, Stotts NA, Froelicher ES, Engler MM, Porter C, Kwak H.
Division of Nursing, Hallym University, Chuncheon, Korea.
AIMS AND OBJECTIVES: To evaluate the adequacy of energy and protein intake of
patients in a Korean intensive care unit in the first four days after initiation
of enteral feeding and to investigate the factors that had impact on adequate
intake.
BACKGROUND: Underfeeding is a common problem for patients hospitalised in the
intensive care unit and is associated with severe negative consequences,
including increased morbidity and mortality.
DESIGN: A prospective, cohort study was conducted in a medical intensive care
METHODS: A total of 34 adult patients who had a primary medical diagnosis and who
had received bolus enteral nutrition for the first four days after initiation of
enteral nutrition were enrolled in this study. The data on prescription and
intake of energy and protein, feeding method and feeding interruption were
recorded during the first four days after enteral feeding initiation.
Underfeeding was defined as the intake <90% of required energy and protein. RESULTS: Most patients (62%) received insufficient energy, although some (29%)received adequate energy. More than half of patients (56%) had insufficientprotein intake during the first four days after enteral feeding was initiated. Logistic regression analysis showed that the factors associated with underfeedingof energy were early initiation of enteral nutrition, under-prescription ofenergy and prolonged interruption of prescribed enteral nutrition. CONCLUSION: Underfeeding is frequent in Korean critically ill patients owing toearly initiation, under-prescription and prolonged interruption of enteralfeeding. RELEVANCE TO CLINICAL PRACTICE:   Interventions need to be developed and testedthat address early initiation, under-prescription and prolonged interruption ofenteral nutrition. Findings from this study are important as they form thefoundation for the development of evidence-based care that is badly needed toeliminate underfeeding in this large vulnerable Korean intensive care unitpopulation.© 2012 Blackwell Publishing Ltd. PMID: 22845617 [PubMed - indexed for MEDLINE]2. J Pediatr Nurs. 2012 Oct; 27(5): 577-82. doi: 10. 1016/j. pedn. 2011. 10. 008. Epub 2012Jan 5. An exemplar for evidence-based nursing practice using the Magnet(®) model as theframework for change: oral feeding practice in the neonatal intensive care unit. Sables-Baus S, Zuk J. Children's Hospital Colorado, Aurora, CO, USA. Implementation of research evidence into practice can be challenging in areassuch as the neonatal intensive care unit (NICU), where the environment is complexand rapidly changing and caregiving goals have shifted from simply infantsurvival to supporting positive long-term neurodevelopmental outcomes. Clinicalnurse specialists (CNS) are ideally positioned to use research to obtain newknowledge, innovations, and improvements in care as part of an interdisciplinaryteam. The authors describe the role of the CNS in changing NICU culture aroundfeeding infants, an important and frequent nursing activity, with the Magnet(®)model as the framework for change. PMID: 22154660 [PubMed - indexed for MEDLINE]3. Everyone's problem but nobody's job: Staff perceptions and explanations for poor nutritional intake in older medical patientsLynda J. ROSS1,*, Alison M. MUDGE2, Adrienne M. YOUNG1, Merrilyn BANKS1Article first published online: 24 FEB 2011DOI: 10. 1111/j. 1747-0080. 2010. 01495. x© 2011 The Authors. Nutrition & Dietetics © 2011 Dietitians Association of AustraliaKeywords: attitude of health personnel; elderly; focus group; malnutrition; patient care; qualitative researchAbstractAim:  Up to 60% of older medical patients are malnourished with further decline during hospital stay. There is limited evidence for effective nutrition intervention. Staff focus groups were conducted to improve understanding of potential contextual and cultural barriers to feeding older adults in hospital. Methods:  Three focus groups involved 22 staff working on the acute medical wards of a large tertiary teaching hospital. Staff disciplines were nursing, dietetics, speech pathology, occupational therapy, physiotherapy, pharmacy. A semistructured topic guide was used by the same facilitator to prompt discussions on hospital nutrition care including barriers. Focus groups were tape-recorded, transcribed and analysed thematically. Results:  All staff recognised malnutrition to be an important problem in older patients during hospital stay and identified patient-level barriers to nutrition care such as non-compliance to feeding plans and hospital-level barriers including nursing staff shortages. Differences between disciplines revealed a lack of a coordinated approach, including poor knowledge of nutrition care processes, poor interdisciplinary communication, and a lack of a sense of shared responsibility/coordinated approach to nutrition care. All staff talked about competing activities at meal times and felt disempowered to prioritise nutrition in the acute medical setting. Staff agreed education and ‘ extra hands’ would address most barriers but did not consider organisational change. Conclusions:  Redesigning the model of care to reprioritise meal-time activities and redefine multidisciplinary roles and responsibilities would support coordinated nutrition care. However, effectiveness may also depend on hospital-wide leadership and support to empower staff and increase accountability within a team-led approach. 4. Int J Nurs Stud. 2012 Oct; 49(10): 1200-11. doi: 10. 1016/j. ijnurstu. 2012. 04. 009. Epub 2012 May 9. An exploration of the hydration care of older people: a qualitative study. Godfrey H, Cloete J, Dymond E, Long A. BS16 1DD, United Kingdom. BACKGROUND: Older adults are more susceptible to water imbalance and ensuringthey drink sufficiently is a complex and challenging issue for nurses. Thefactors that promote adequate hydration and the barriers which prevent olderpeople from drinking are not well understood. OBJECTIVE: This study aimed to understand the complexity of issues associatedwith the hydration and hydration care of older people. DESIGN: A qualitative study using multiple methods. SETTINGS: Two healthcare sites providing care for older people in the South Westof England: a hospital ward in a major hospital and a care home providingpersonal and nursing care. PARTICIPANTS: Twenty-one older people aged 68-96 years, were recruited to thestudy from the hospital ward and care home. The inclusion criteria for olderpeople to participate were men or women aged 65 years and over and the exclusioncriteria were being unable to provide informed consent, or being too ill ordistressed to take part in the study. The staff participants of nurses and healthcare assistants totalled 21. The inclusion criterion for staff was any nurse orhealth care assistant providing hydration care. Seven friends or relativesparticipated by making anonymous comments via a suggestion box available to allfriends and relatives. METHODS: Data were collected via interviews with older people, focus groupdiscussions involving staff, suggestion box comments made by friends andrelatives and twelve hours observation of hydration practice. The data wereanalysed using thematic analysis. RESULTS: Health professionals successfully employed several strategies to promotedrinking including verbal prompting, offering choice, placing drinks in olderpeople's hands and assisting with drinking. Older people revealed theirexperience of drinking was diminished by a variety of factors including a limitedaesthetic experience and a focus on fluid consumption rather than on drinking asa pleasurable and social experience. CONCLUSION: The rich and varied dimensions usually associated with drinking werelacking and the role of drinking beverages to promote social interaction wasunderplayed in both settings. Hydration practice which supports the individualneeds of older people is complex and goes beyond simply ensuring the consumptionof adequate fluids. PMID: 22575619 [PubMed - indexed for MEDLINE]5. J Am Diet Assoc. 2010 Oct; 110(10): 1549-53. Position of the American Dietetic Association: individualized nutritionapproaches for older adults in health care communities. Dorner B, Friedrich EK, Posthauer ME; American Dietetic Association. Nutrition Consulting Services, Becky Dorner & Associates, Inc., Akron, OH, USA. Erratum inJ Am Diet Assoc. 2010 Dec; 110(12): 1941. It is the position of the American Dietetic Association that the quality of lifeand nutritional status of older adults residing in health care communities can beenhanced by individualization to less-restrictive diets. The American DieteticAssociation advocates for registered dietitians to assess and evaluate the needfor nutrition interventions tailored to each person's medical condition, needs, desires, and rights. Dietetic technicians, registered, assist registereddietitians in the assessment and implementation of individualized nutrition care. Health care practitioners must assess risks vs benefits of therapeutic diets, especially for older adults. Food is an essential component of quality of life; an unpalatable or unacceptable diet can lead to poor food and fluid intake, resulting in undernutrition and related negative health effects. Including olderindividuals in decisions about food can increase the desire to eat and improvequality of life. The Practice Paper of the American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health Care Communitiesprovides guidance to practitioners on implementation of individualized diets andnutrition care. PMID: 20882714 [PubMed - indexed for MEDLINE]6. J Clin Nurs. 2012 Oct; 21(19-20): 2975-84. doi: 10. 1111/j. 1365-2702. 2011. 04029. x. Epub 2012 May 30. Nurse-physician communication concerning artificial nutrition or hydration (ANH)in patients with dementia: a qualitative study. Bryon E, Gastmans C, de Casterlé BD. Centre for Health Services and Nursing Research, Catholic University of Leuven, Leuven, Belgium. AIMS AND OBJECTIVES: To explore nurses' experiences with nurse-physiciancommunication during artificial nutrition or hydration (ANH) decision-making inhospitalised patients with dementia. BACKGROUND: Artificial nutrition or hydration decision-making often occurs inpatients with dementia. Effective communication between professionals isextremely challenging in this population, because these patients are unable tocommunicate their treatment wishes. DESIGN: Qualitative interview design. METHODS: Between April 2008 and June 2009, we conducted 21 interviews with nurses(Belgium). Interviews were audiotaped and later transcribed. Data processinginvolved (1) simultaneous and systematic data collection and analysis, (2)constant forwards-backwards wave, (3) continuous dialogue with the data and (4)interactive team processes. RESULTS: The interviews showed that communication with physicians is the centralinstrument the nurses used in their attempts to realise their perception of 'thebest possible care'. From the nurses' perspective, we distinguished threemutually connected factors that affected the effectiveness of nurse-physiciancommunication during artificial nutrition or hydration decision-making: thephysicians' attitude towards the nurses, the nurses' attitude towards thephysicians and the forms of communication used by the nurses. The complexinteraction between these three factors resulted in a range of nurses'perceptions, varying from positive to negative. The direction of theirperceptions depended on the extent to which they succeeded or failed to usenurse-physician communication as an instrument to realise the 'best care'. CONCLUSION: Nurse-physician communication was the most important instrumentdetermining whether nurses succeeded or failed to actively act as a patient'srepresentative and whether nurses achieved the best possible care in co-operationwith physicians. RELEVANCE TO CLINICAL PRACTICE: To reach optimal care and nurse job satisfaction, nurse-physician communication during artificial nutrition or hydrationdecision-making should be an open dialogue characterised by mutual respect andunderstanding.© 2012 Blackwell Publishing Ltd. PMID: 22642618 [PubMed - indexed for MEDLINE]7. Clin Nutr. 2012 Dec; 31(6): 995-1001. doi: 10. 1016/j. clnu. 2012. 05. 014. Epub 2012Jun 18. Nutrition care practices in hospital wards: results from the Nutrition Care DaySurvey 2010. Agarwal E, Ferguson M, Banks M, Batterham M, Bauer J, Capra S, Isenring E. The University of Queensland, School of Human Movement Studies, St Lucia, Brisbane, QLD 4072, Australia. BACKGROUND & AIM: This paper describes nutrition care practices in acute carehospitals across Australia and New Zealand. METHODS: A survey on nutrition care practices in Australian and New Zealandhospitals was completed by Directors of dietetics departments of 56 hospitalsthat participated in the Australasian Nutrition Care Day Survey 2010. RESULTS: Overall 370 wards representing various specialities participated in thestudy. Nutrition risk screening was conducted in 64% (n = 234) of the wards. Seventy nine percent (n = 185) of these wards reported using the MalnutritionScreening Tool, 16% using the Malnutrition Universal Screening Tool (n = 37), and5% using local tools (n = 12). Nutrition risk rescreening was conducted in 14%(n = 53) of the wards. More than half the wards referred patients at nutritionrisk to dietitians and commenced a nutrition intervention protocol. Feedingassistance was provided in 89% of the wards. " Protected" meal times wereimplemented in 5% of the wards. CONCLUSION: A large number of acute care hospital wards in Australia and NewZealand do not comply with evidence-based practice guidelines for nutritionalmanagement of malnourished patients. This study also provides recommendations forpractice. Metabolism. All rights reserved. PMID: 22717261 [PubMed - in process]8. J Clin Nurs. 2012 Oct; 21(19-20): 2949-57. doi: 10. 1111/j. 1365-2702. 2011. 04011. x. Epub 2012 May 25. Observations of assisted feeding among people with language impairment. Martinsen B, Norlyk A. Annelise Norlyk, Denmark. AIMS AND OBJECTIVES: This study examines the phenomenon of assisted feeding amongpeople with language impairment. BACKGROUND: Patients' experience of assisted feeding is influenced by thecaregivers' availability and their other responsibilities. Also, caregivers andpatients may have different values with respect to assisted feeding. METHODS: Instances of assisted feeding (n= 42) were observed among people withlanguage impairment admitted to a neurological ward. Field notes were takensimultaneously and in some cases a few simple questions were posed to thecaregivers or the patients. All notes and answers were analysed using thephenomenological guidelines of Dahlberg and colleagues (2008, StudentlitteraturAB, Stockholm). RESULT: The essence of assisted feeding among people living with languageimpairment was identified to be a transaction characterised by efficiency. Theconstituents of the essence were in the shadow of institutional structures, accidental relationships with potential humiliation, meal-related conventionsversus respect for the individual's wishes, sense of joy threatened bygoal-related determination' time being significant for the course of the meal. CONCLUSION: This study shows that assisted feeding is not important enough topostpone other activities in a neurological ward. Although assisted feeding is anopportunity to enjoy mutual contact and exchange information between the patientand the caregiver, it is a situation where the nutritional aspect of the mealtends to take precedence. We recommend that the focus of recent years on thepatients' nutritional status is now supplemented by improvement in the relationaland affective aspects of meals, especially for people who require assistance toeat. RELEVANCE TO CLINICAL PRACTICE: The findings indicate that the institutionalconditions for meals need to be reconsidered. For instance caregivers could beexempted from other responsibilities during mealtimes. More flexible time-limitsfor meals depending on the number of patients with extensive assistance needs isanother possibility.© 2012 Blackwell Publishing Ltd. PMID: 22624775 [PubMed - indexed for MEDLINE]9. Nurs Stand. 2013 Jan 16-22; 27(20): 35-42. Providing artificial nutrition and hydration in palliative care. Stiles E. Cardiac Care Unit, Hillingdon Hospital, Hillingdon. This literature review investigates nurses' attitudes towards providingartificial nutrition and hydration (ANH) in the palliative care setting. Variousfactors that influence nurses' attitudes are examined. While some of the findingshave limited generalisability because of the dearth of evidence originating fromthe UK, United States and western Europe, the issues should still be considered. It is recommended that more research is carried out examining nurses' attitudestowards providing ANH in palliative care in the UK, to gain a betterunderstanding of the factors that may influence decision making. PMID: 23431937 [PubMed - indexed for MEDLINE]10. e-SPEN, The European e-Journal of Clinical Nutrition and MetabolismVolume 5, Issue 1 , Pages e47-e53, February 2010A review of the literature on dehydration in the institutionalized elderlyMonirun Nessa BegumC. Shanthi JohnsonBottom of FormReceived 23 December 2006; accepted 23 October 2009. published online 19 November 2009. Summary Background & aimsDehydration is the most common fluid and electrolyte problem among the elderly. The purpose of this review is to summarize the literature on dehydration in the institutionalized elderly. MethodsResultsDehydration is conceptualized and operationalized in many different ways in the literature. Yet, dehydration is reported to be widely prevalent and costly to individuals and to the health care system. It affects large numbers, contributes to or exacerbates other severe medical conditions, may cause acute confusion and disorientation, and severely impairs the elderly individual's quality of life. Various strategies to detect and address dehydration are reported in the literature and these are primarily based on practice, or small scale research projects. ConclusionsDetection and prevention of dehydration is critically important among the frail, institutionalized elderly. In the future, the efficacy, effectiveness and economics of these strategies need to be further evaluated through research. Keywords: Dehydration, Elderly, Hypernatremia, Hyponatremia, Confusion, DisorientationPII: S1751-4991(09)00093-6doi: 10. 1016/j. eclnm. 2009. 10. 007© 2009 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Inc. All rights reserved.