Improving Refusal to Eat Behavior in Elderly Patients: Research Plan

This research plan focuses on an intervention to improve the refusal to eat behavior in elderly patients in a clinical setting. It discusses the background, study design and methodology, data collection and analysis, anticipated problems, and ethical considerations.

Running head: NURSING
Research plan
Name of the Student
Name of the University
Author Note

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Introduction
Geriatric nurses have the primary responsibility of assisting older patients, recovering
from injury or illness, by providing them practical care. This domain of nursing also
encompasses creating provisions for check-ups, and rehabilitation for the elderly patients,
within hospice or skilled care facilities (Tabloski, 2014). Caring for the elderly population is
a global issue to all clinical practitioners and educators. Challenges are also encountered
during the determination of a plethora of service delivery models that are in relation to the
aged population. Nurturing care and compassion have been recognized as typical personality
characteristics for all individuals who care for geriatric patients (American Geriatrics Society
Ethics Committee and Clinical Practice and Models of Care Committee, 2014). While
providing nursing care, refusal to eat is a common challenge that is exhibited by the elderly
patients, which deteriorates their health and impedes the process of caregiving. There is
mounting evidence on the fact that older adults often refuse to intake adequate food or
beverages, which leads to the onset of malnutrition (Pouyet et al., 2014). In other words,
refusal to drink and eat is a distressing and common precursor to the onset of malnutrition
among the elderly patients, residing in institutional settings (Bauer, Halfens & Lohrmann,
2015). This research plan will focus on an intervention to improve the refusal to eat
behaviour in the target population, at a clinical setting.
Background
A case report by Meier and Ong (2015) has highlighted the fact that competent
patients often have the right and authority to refuse intake of food, and any form of artificial
hydration and nutrition. The researchers also stated that owing to the fact that patients have
all rights to forgo any life-sustaining treatment, those patients who are competent can
willingly stop eating and drinking (VSED). In addition, they stated that the physicians do not
have the authority to overrule the decision of such patient for refusing eating and drinking. It

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has been affirmed by Schwartz et al. (2018) that old age is a crucial period, in relation to
selection of food and eating behaviour among humans and repeated exposure to an
assortment of food products acts in the form of a crucial determinants for selecting or
refusing food and drink consumption. In addition, it has also been established that
development of a food bolus that the elderly people can safety swallow involves a
multifaceted procedure, which often makes them refuse foods (Khan, Carmona & Traube,
2014). According to Abizanda et al. (2016) malnutrition has been found to enormously
increase the healthcare costs for older adults, by increasing their likelihood of suffering from
morbidity. Therefore, intake of dairy and meat food products that are rich in proteins
considerably lowers the risks of malnutrition (Iuliano et al., 2017).
Cerri et al. (2015) have also provided evidence for the prevalence of malnutrition and
sarcopenia among 22.3% (n=23) older hospitalised patients, of whom 10.3% died within
three months of being discharged from the healthcare setting. This enabled them to draw the
conclusion that malnutrition due to food refusal is highly prevalent amid the elderly patients,
which in turn creates a major impact on their overall health status. The association between
malnutrition and food pickiness amid elderly patients was investigated by Maitre et al. (2014)
who suggested that as much as 23% older patients (n=559) generally are picky eaters and an
elevation in food selectivity is associated with an increase in risks of suffering from
malnutrition. Additionally, the researches were also able to demonstrate an increase in food
selectivity, with an upregulation in dependency. Douglas and Lawrence (2015) also opined
that with a progress in dementia, a decline is observed in the nutritional intake of the patients
that needs to be addressed by making necessary changes in the meal pattern and
environmental setting.

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Study design and methodology
The PICO process has been used to frame a question that is pertinent to the clinical
phenomenon being investigated. This framework proved beneficial in organizing the research
question in the form of a searchable query (Scells et al., 2017). The table provided below
demonstrates the different components of the PICO framework:
P/population Older patients in nursing home and/or
community
I/intervention Flavour enhanced food
C/comparison Normal food
O/outcome Improved dietary intake
Table 1- PICO framework for the research plan
The research question is given below:
Can flavour enhanced foods improve dietary intake among older adults residing in
hospital and community settings?
The research will be based on a case-control study design, which is a type of
observational study where two different older patient groups, having varied outcomes will be
compared and contrasted, based on the intervention implemented. Selection of this research
design can be attributed to the fact that the research will be comparatively expensive and can
be accomplished within a shorter duration (Rothman, 2014). In addition, conducting a case-
control study will also facilitate demonstration of the association between applied
intervention (flavour enhanced food) and enhanced dietary intake among the patients. The
study will be conducted in the geriatric ward of a nursing home, whereby the participations
will be selected based on certain inclusion criteria such as, (i) aged above 65 years, (ii) no
cognitive dysfunction and/or dementia, (iii) no hypersensitivity to monosodium glutamate

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(MSG), and (iv) consuming the meal provided by nurses at lunch and dinner, for at least 4-5
days/week. It is estimated that the research will involve at least 20-25 elderly patients as
participants.
Following recruitment of the participants, they will be non-randomised into case and
control group. Meals provided to those in the intervention group will be enhanced with
chicken flavour, turkey flavour, and fish flavour, prior to delivering them to the patients,
owing to the fact that multisensory mechanisms are involved in flavour perception (Prescott,
2015). An estimated 1gm of flavour will be added to each dish. In contrast, those in the
control group will be provided the same food, without added flavours.
Data collection and analysis
Several anthropometric measurements shall be recorded at baseline and after
completion of the study. The body weight of all recruited patients will be measured in the
form of an index of their direct nutritional status, which in turn will help in assessing the
presence of malnutrition among the elderly patients (Heale & Twycross, 2015). This
measurement will be carried out prior to breakfast, and following voiding, while the patients
are dressed in light clothes and without shoes and/or slippers. Body height measurement will
also be imperative for determining their BMI. The patterns of dietary intake will be recorded
twice during lunch and dinner, before and after the intervention has been applied. In addition,
the patterns of beverage consumption will also be recorded. This data collection will be
conducted by the patients themselves in individual food diaries provided to all of them. The
records will be confirmed and evaluated by nurses as well, who will maintain a separate diary
for each patient.
Details regarding the discrete menus and food recipes will be obtained from the
trained dietician of the nursing home. In addition, the impacts of adding flavours to food, on

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the potential food intake behaviour of the elderly patients will be determined by usage of a
questionnaire that will assess the feelings of patients recruited in both the groups, in relation
to their hunger, feelings, appetite, smell perception, and taste. The questionnaire will also be
presented to them prior to the intervention, with the aim of drawing a comparison between
the intervention implemented and the normal food that is typically prepared for elderly
patients in the setting. Questionnaire ratings will help in establishing the presence of positive
feelings related to the consumed food, increased appetite, and increased hunger. Quantitative
analysis of the responses will be conducted by calculating the mean and standard deviation at
baseline and at the end of intervention. A student-t test will also be carried out for comparing
the variation between the two groups. SPSS 21.0 software package will be used for the
purpose (Green & Salkind, 2016).
Anticipated problems
One major problem associated with conduction of this case-control study is the
generation of selection bias. According to Certo et al. (2016) this kind of bias often gets
introduced during recruitment of participants, in a manner that prevents proper
randomisation. Taking into consideration the fact that convenience sampling will be used for
recruiting the elderly patients, they might not be representative of the wider population
(Etikan, Musa & Alkassim, 2016). In addition, the information on exposure of participants to
the intervention might also be subject to observation bias. This might be governed by the
tendency of what is expected to be observed among the participants, after providing flavour
enhanced food to them. It is also expected that the elderly patients might display resentment
in keeping a record of the food and beverages that they consume.
Ethical considerations
Prior to conduction of the research, the research plan needs to be approved by the
ethical committee of the university. It is imperative to show adherence to ethical principles

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while conducting research that involves human research, as in this case. Obtaining informed
consent form the participants is crucial prior to research conduction. It will demonstrate that
the patients have voluntarily agreed to participate in the study, after gaining a sound
understanding of the purpose, potential benefits, and risks of the research (Haahr, Norlyk &
Hall, 2014). An informed consent is an important legal and ethical requirement for any kind
of investigation that involves human participants. Taking into consideration their old age, the
family members of the old patients will also be asked for approval. Maintaining
confidentiality and anonymity are central to any kind of ethical research practice (Hardicre,
2014).
Efforts will be taken to safeguard personal and health related information of the
participants in a manner that they cannot be accessed by any third party members. In
addition, pseudonyms will be used for the patients, while referring to their baseline or other
characteristics during and after the investigation. It will also be ensured that the elderly
patients are subjected to not subject to any kind of intervention that causes potential harm.

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