Table 2.

Features of Included Studies

Authors	Title	Study Aim	Findings/Conclusion	Limitations/New Research
Oates and Price (2017)	Clinical assessments and care interventions to promote oral hydration among older patients: a narrative systematic review	Describe clinical assessment tools which identify patients at risk of insufficient oral fluid intake and the impact of simple interventions to promote drinking, in hospital and care home settings	Nine formal hydration assessments were identified, five of which had an accompanying intervention/ care protocol. Interventions to provide extra opportunities to drink such as prompts, preference elicitation and routine beverage carts appeared to support hydration maintenance. Despite a lack of knowledge of fluid requirements and dehydration risk factors among staff, there was no strong evidence that increasing awareness alone would be beneficial for patients.	Further research is required in interventions to provide extra opportunities to drink. Insufficient evidence to recommend a specific clinical assessment to identify older persons at risk of poor oral fluid intake.
Abdallah et al. (2009)	Dehydration reduction in community-dwelling older adults	Investigate dehydration problems among community-dwelling older adults and to identify strategies perceived to be helpful in preventing dehydration in this population.	89% of participants identify dehydration as a problem affecting older adults, and 94% noted the need for a public campaign on dehydration awareness and reduction. Strategies identified to promote hydration in community-dwelling older adults included community partnerships, community education, community engagement, and interdisciplinary approaches.	For future research, four major themes emerged: Intentional Avoidance and Caution, Lack of Awareness/Education/Understanding, Poor Access to Fluids, and Social and Environmental Influences.
McCarthy and Manning D (2012)	Water for wellbeing: promoting oral hydration in the elderly	Raising awareness of the importance of drinking adequate fluids for good health and the prevention and treatment of bladder and bowel control problems among frail older people. An education kit was promoted and disseminated to residential and community care providers	Individual resources were rated as excellent 16/25 (64%) or good 9/25 (37%). All respondents agreed that the resources provided adequate information to both advise older people on adequate fluid intake and educate staff so they can promote adequate fluid intake to older people. The majority of respondents 20/25 (80%) had used the kit information in a range of ways including staff, client, and carer education. Feedback from users was positive.	One constraint of the project was the limited number of the printed resource kits available, sufficient only sufficient to provide one kit per organization. Further follow-up is needed with organizations and programs to determine to what extent they have integrated the materials into their practice.
Chen et al. (2017)	Effects of a dietary self-management program for community-dwelling older adults: a quasi-experimental design	To examine the effectiveness of a 12-week dietary self-management program for salt-, fluid-, fat-, and cholesterol-intake behaviors of community-dwelling older adults and to compare these effects in rural- and urban-dwelling older adults.	After 12 weeks, the intervention group had significantly better nutritional status and higher internal health locus of control than the control group. Moreover, older rural participants who received the intervention tended toward higher nutritional self-efficacy and internal health locus of control than their urban counterparts.	The knowledge gained from this study can help stakeholders to recognize the need for healthcare policy to establish effective strategies and sustainable intervention programs for this population, especially those living in rural areas.
Gomez et al. (2013)	A water intervention program to improve fluid intake among French women	Assessing the impact of a water intervention program on fluid intake over a 12-month period in free-living conditions.	Water intake and total fluid intake increased by 151% and 84% respectively after 4 weeks. The habit of drinking water was also strengthened. The results show a significant progression in the water intake of the LOW group participants: an increase of 67% between phases 1 and 2 and 154% compared with the baseline. After 12 months, on average, water intake increased significantly compared with the baseline. The same trend is observed for total fluid intake. Ultimately, the LOW group participants reached the intake levels of the HIGH group participants. However, habit strength remained significantly higher in the latter group after 12 months (high group, 33.97; low group, 28.00; P G .05).	Limitations such as sample representativeness, difficulty to disentangle the impacts of water affordance from those of the educational program. Very encouraging results and should drive researchers and practitioners to extend similar programs at a larger scale or to other populations, combining access to water and education.
Herke et al. (2018)	Environmental and behavioral modifications for improving food and fluid intake in people with dementia	To assess the effects of environmental or behavioral modifications on food and fluid intake and nutritional status in people with dementia. To assess the adverse consequences or effects of the included interventions.	Due to the quantity and quality of the evidence currently available, we cannot identify any specific environmental or behavioral modifications for improving food and fluid intake in people with dementia.	More and good quality research in the field is needed
Konings et al. (2014)	Prevention of dehydration in independently living elderly people at risk: a study protocol of a randomized controlled trial	To compare two interventions to prevent dehydration in elderly people at risk: an educational intervention alone and an educational intervention in combination with a drink reminder device.	The drinker reminder service (Obli) will constantly remind the elderly to drink sufficiently; so, it is believed to be much more effective than education alone, given only at one single instance. This study will improve the knowledge of the effectiveness of interventions designed to prevent dehydration in elderly people.	Limits: the study does not include patients with kidney or bladder disease or elderly patients living in nursing homes. This includes not using a control group without any intervention, the risk of excessive fluid intake, and the influence of alcohol and coffee intake; it excludes patients with kidney/bladder disease and nursing home residents.
Archibald (2006)	Promoting hydration in patients with dementia in healthcare settings	It aims to enhance nurses’ understanding of dehydration in patients with dementia.	Patients with dementia are at a higher risk of morbidity, mortality, and dehydration compared with other older people. Dehydration can be prevented by increasing the patient’s fluid intake by two glasses of fluid per day, which can lead to fewer falls, less frequent urinary infections and laxative prescriptions.	Not enough information provided
Chua et al. (2016)	A systematic review to determine the most effective interventions to increase water intake	To undertake a systematic review to determine the most effective interventions to increase water intake.	The quality of the studies was mostly neutral (63%), with no studies of high quality. Interventions ranged from instruction alone to self-monitoring tools, providing water bottles, and counselling and education. Most interventions successfully increased water intake, with 13 studies reporting an increase of at least 500 mL. The most effective strategies were instruction and self- monitoring using a urine dipstick or 24 h urine volume.	More high-quality long-term intervention studies are required to further validate findings
Benleam & Wyness (2010)	Hydration and health: a review	Increase the Knowledge of hydration and the role of water in our body	Water is essential for life, and maintaining optimum hydration is important for the body to function efficiently	Not enough information provided
Journal of Community Nursing (2014)	The provision of adequate hydration in community patients	Prevent dehydration in the community setting	Hydration is such a basic requirement of good health, but it can be easily overlooked. It is important to monitor patients’ hydration status.	Not enough information provided
Feliciano et al. (2010)	Assessment and management of barriers to fluid intake in community-dwelling older adults	To assess factors that are barriers to hydration for two elders using a functional assessment interview	The highest endorsed categories included Knowledge and Skills at 83.3% of items endorsed, Functional Barriers: Mobility at 70% of items endorsed and Preference and Access at 40% of items endorsed. Large increase in consumption of healthy fluids (M = 73.1 oz) and a decrease in consumption of unhealthy fluids (M = 5.6 oz) with the administration of the package intervention when compared to baseline (M = 46.7 oz, M = 19.4 oz, respectively)	Future researchers should consider expanding this model to include greater numbers of elders to increase our knowledge base regarding barriers to hydration. Future research should also include larger numbers of minority elders to assess whether the barriers to hydration are robust or if specific cultural variables may also need to be included in the model.
Bak (2017)	Improving hydration of care home residents by addressing institutional barriers to fluid consumption – an improvement project	To assess current hydration care in nursing homes, identify barriers to drinking adequate amounts and develop strategies to optimize fluid intake in the older care home residents.	Observations revealed that most residents consumed less than the recommended minimum of 1500mL of fluids. Hydration not seen as a priority resulted in several barriers that hindered staff ability to serve adequate amounts of fluids, and residents’ enjoyment and ability to consume them. During the testing, most interventions resulted in the residents consuming more fluids, but sustaining these interventions was difficult. Barriers to sustainability included poor leadership and task-oriented work culture.	Limitations: One of the issues identified was the impact of escalating these interventions across the home. Due to time limitations of the project, it was not possible to determine the extent of this problem. Another limitation was the small number of PDSA cycles to ensure successful implementation of the interventions on the new unit. Setting may be considered the greatest limitation of this study. The work was conducted in one large nursing home in London. Future research needs to be done to test different designs of drinking vessels suitable for this population. There is a need for future research to identify appropriate methodologies and describe barriers and facilitators for improving care in this setting and assessing hydration in a wider setting
Steven et al. (2019)	The implementation of an innovative hydration monitoring app in care home settings: a qualitative study	The aim of this study was to examine the implementation of Hydr8 in a sample of care homes in one area in England.	Findings suggest that Hydr8 benefits practice and improves staff communication. However, due to technical glitches, the enthusiasm for long-term use was dependent on the resolution of issues. In addition, Hydr8 heightened perceptions of personal accountability, and while managers viewed this as positive, some staff members were apprehensive.	Limitations: The sample was small and restricted to a specific geographical area; therefore, it is not representative of the wider population. The technical issues negatively impacted the use and effectiveness of the Hydr8 app, and technical functionality is necessary before further implementing the app in care homes. Staff interviewed were those who volunteered to participate on the day, and this was the deciding factor in the numbers involved. In addition, some sites (n=2) only implemented the use of the Hydr8 app in specific parts of the care home, and the researchers were not aware of it until data collection took place. The focus of further study needs to encompass multiple aspects of use, including normalization into a daily routine, technical issues experienced, information needed on implementation, residents’ perceptions, and participants’ content and design suggestions.
Godfrey et al. (2012)	An exploration of the hydration care of older people: a qualitative study	To understand the complexity of issues associated with the hydration and hydration care of older people.	Health professionals employed several strategies to promote drinking, including verbal prompting, offering choice, placing drinks in older people’s hands, and assisting with drinking. Older people revealed their experience of drinking was diminished by a variety of factors including a limited aesthetic experience and a focus on fluid consumption rather than on drinking as a pleasurable and social experience. Hydration practice, which supports the individual needs of older people, is complex and goes beyond simply ensuring the consumption of adequate fluids.	The different contexts and cultures of the two settings may not have been sufficiently considered in developing the theoretical interpretations. Direct observation may have altered hydration practice during the data collection. The observation of practice was limited to communal areas and did not extend to times when patients were away from the ward or residents were in their own rooms. While the role of nurses and HCAs in hydration care has been explored, the study did not attempt to delineate distinctions in hydration practice relating to type and level of professional qualification.
Bhanu et al. (2019)	“I’ve never drunk very much water and I still don’t, and I see no reason to do so”: a qualitative study of the views of community-dwelling older people and carers on hydration in later life	To understand community-dwelling older people and informal carers’ views on hydration in later life and how older people can be supported to drink well.	Concerns about urinary incontinence and knowledge gaps were significant barriers. Consideration of individual taste preference and functional capacity acted as facilitators. Distinct habitual drinking patterns with medications and meals exist among individuals. Many relied on thirst. Older people could be supported to drink well by building upon existing habitual drinking patterns. Individual barriers, facilitators, and tailored education should be considered.	The study recruited a limited number of carers, further research may be needed to fully understand the experience of informal caregivers. Exploring both hydration and nutrition may have affected how participants expressed their views around drinking, and some findings could have been taken out of context. Future research is needed to explore educational models of intervention in public health and primary care to promote healthy drinking for older people. This could include exploring the role of the community’s allied health professionals and understanding older peoples’ perceptions of public health information in the media.