GERIATRIC NUTRITION

What is Geriatric Nutrition?

Geriatrics is the study of the chronic diseases frequently

associated with aging, including their diagnosis and treatment.
Medical nutrition therapy for older adults is often called
geriatric nutrition.
 THEORY OF AGEING
 Ageing is a biological process, which begins at conception and ends only with
death.
 Most gerontologists (people who study aging) feel that aging is due to the
interaction of many lifelong influences.
 These influences include heredity, environment, culture, diet, exercise and
leisure, past illnesses, and many other factors.
 Some theories claim that aging is caused by injuries from ultraviolet light over
time, wear and tear on the body or by products of metabolism.
 Other theories view aging as a predetermined process controlled by genes.
 No single theory can fully explain the complex processes of aging.
 One prominent theory of ageing is the “Free Radical Theory”.
 It is the formation of free radicals as a result of exposure to oxygen and
harmful exposure to environmental factors, which lead to damage and
alteration in the structure of proteins, lipids, carbohydrates and chromosomal
materials in cell which leads to changes associated with ageing.
 Accumulated, random damage caused by oxygen radicals slowly cause cells,
tissues, and organs to stop functioning.
 Wear and tear theory -Years of damage to cells, tissues, and organs eventually
take their toll, wearing them out and ultimately causing death.
Biological aspects of ageing
 CELLULAR LEVEL CHANGES
 It is not exactly known how the ageing process takes place ,but changes are
observed first in the cell.
 The rate of division slows as the cell nears the ends of its normal life span and
eventually stops.
 Although the older person will always have some cells that are rapidly
dividing, they will be fewer in number and total cell count will be reduced.
 Cells are the basic building blocks of tissues. All cells experience changes with
aging. They become larger and are less able to divide and multiply.
 Among other changes, there is an increase in pigments and fatty substances
inside the cell (lipids). Many cells lose their ability to function, or they begin
to function abnormally.
 Waste products build up in tissue with aging. A fatty brown pigment
called lipofusion collects in many tissues, as do other fatty substances.
  ORGAN LEVEL CHANGES-
 Highly differentiated cells including brain, kidney and muscles do not
continue to divide throughout life but do under go functional changes with
time and some cells die.
 As a result the organ system become less efficient as few cells remain to
carry on normal body function.
 The ageing cell is less able to synthesize important molecules required for
hormonal or neural control.
 Consequently specialized organs and tissues are less able to respond to
environment stimuli and there is breakdown in the coordination of body
systems that works together to carry out physiological functions.
 PHYSIOLOGICAL CHANGES
 Body Composition Changes
 Body composition changes with aging. Fat mass and visceral fat increase,
whereas lean muscle mass decreases.
 Sarcopenia, the age-related loss of muscle mass, strength, and function, can
significantly impact an older adult's quality of life by decreasing mobiliary
increasing risk for falls, and altering metabolic rates. It accelerates with a
decrease in physical activity.
 Sarcopenic obesity is the loss of lean muscle mass in older persons with excess
adipose tissue. Together the excess weight and decreased muscle mass leads to
further decrease physical activity, which in turn accelerates sarcopenia.
 Taste and smell
 Age-related alterations to the sense of taste, smell, and touch can lead to poor
appetite, inappropriate food choices, and lower nutrient intake.
 Although some degrees of dysgeusia (altered taste) and hyposmia (decreased
sense of smell) are attributable to aging, many changes are due to medications.
 A risk when these senses are impaired is the temptation to overseason foods,
especially to add more salt. Since taste and smell stimulate metabolic changes
such as salivary gastric acid, and pancreatic secretions and increases in plasma
levels of insulin; decreased sensory stimulation may impair these metabolic
processes.
 Oral Health
 Diet and nutrition can be compromised by poor oral health.
 Tooth loss, use of dentures, and xerostomia (dry mouth) can lead to difficulties
chewing and swallowing.
 Decrease in salivary secretion causes feeling of dry mouth (xerostomia).
 Missing, loose, or rotten teeth or poor-fitting painful dentures make it difficult to
eat some foods.
 Gastrointestinal functions
 The digestive system undergoes considerable change with age.
 The amount of acid and digestive enzymes secreted by gastric glands decreases.
Thus the digestion and absorption of nutrients is decreased.
 About 10 per cent of the elderly suffer from reduced secretion of hydrochloric
acid or gastric acid. This takes away the first line of defence of the body, since
gastric acid acts as an antiseptic also.
 As a result, you hear about frequent diarrhea and upsets due to increased
infections in this age group.
 The movement of the alimentary tract becomes sluggish with age.
 Food stagnates, bowels do not move regularly and constipation is a common
problem. It may have been habitually ' with drugs, further reducing its activity.
 Dysphagia due to weakened tongue or cheek muscles can make chewing and
swallowing both difficult and dangerous. Dysphagia increases the risk for
aspiration pneumonia, an infection caused by food or fluids entering the lungs.
 Decreased gastric mucosa leads to an inability to resist damage such as
cancer, ulcers, and infections.
 Gastritis causes inflammation and pain; delayed gastric emptying, discomfort.
These all affect the bioavailability of nutrients and increase the risk of
developing a chronic deficiency disease such as osteoporosis.
 Achlorhydria is the insufficient production of stomach acid. The decline in
acid can be due to age as well as atrophic gastritis.
 Sufficient stomach acid and intrinsic factor are required for the absorption of
vitamin B12.
 The incidence of diverticulosis increases with age. The most common
problems with diverticular disease are lower abdominal pain and diarrhea.
 Constipation is defined as having fewer bowel movements than usual, having
difficulty or excessive straining at stool, painful bowel movements, hard
stool, or incomplete emptying of the bowel.
 Primary causes include insufficient fluids, lack of physical activity, and low
intake of dietary fiber. Constipation is also caused by delayed transit time in
the gut and medication
 Cardiovascular
 Changes include decreased arterial wall compliance, decreased maximum
heart rate; decreased responsiveness to B-adrenergic stimuli, increased
left ventricle muscle mass, and slowed ventricular relaxation.
 Blood vessels become less elastic and total peripheral resistance
increases.

 Renal function
 On average, glomerular filtration rate, measured in creatinine clearance
rates, declines by about 8 to 10 ml/min/1.73m2/decade after ages 30 to
35.
 The progressive decline in renal function can lead to an inability to
excrete concentrated or dilute urine, a delayed response to sodium
deprivation or a sodium load, and delayed response to an acid load. Renal
function is also impacted by dehydration, diuretic use, and medications,
especially antibiotics.
 Changes in acid base balance.
 Neurologic Function
 There can be significant age-related declines in neurologic processes.
 Functions including cognition, steadiness, reactions, coordination, gait,
sensations, and daily living tasks can decline as much as 90% or as little as 10%.
 Other changes in brain physiology include widening of surface grooves, decrease
in surface area, increase in number of plaques, and neurofibrillary tangles (i.e.,
the microscopic filaments that run through the neuron body and extend into the
axon and dendrites).
 Immunocompetence
 As immunocompetence declines with age, immune response is slower and less
efficient.
 Changes occur at all levels of the immune system, from chemical alterations
within the cells to differences in the kinds of proteins found on the cell surface
and even to mutations to entire organs.
 The progressive decline in T-lymphocyte function and cell-mediated immunity is a
major contributor to the increased infection and cancer rates seen in aging
populations.
 PSYCHOLOGICAL CHANGES
 Depression can cause mental impairment that is both transient and treatable,
but it is not an inevitable consequence of aging.
 Among older persons it is often caused by other conditions such as heart disease,
stroke, diabetes, cancer and grief and stress.
 Depression in older people is frequently undiagnosed or misdiagnosed because
symptoms are confused with other medical illnesses.
 Untreated depression can have serious side effects for older adults. It diminishes
the pleasures of living, including eating; it can exacerbate other medical
conditions; it can compromise immune function.
 It is associated with decreased appetite, weight loss, and fatigue.
 Nutritional care plays an important role in addressing this condition by providing
nutrient- and calorie-dense foods, additional beverages, texture-modified foods,
and favorite foods at optimal times when people are most likely to eat the
greatest quantity.
 SOCIO-ECONOMIC CHANGES
 As you realize, this is the stage of life when those who were working, retire.
 Due to retirement, there is generally a reduction in income and decreased
physical activity.
 Most of the elderly people in India have restricted income and hence limited
money for food.
 There is a change in the household set-up, as the younger generation takes
charge and the former head has to play a secondary role.
 Inadequate nutrient intake, both excess and insufficiency, may induce or
hasten decline as a result of loss of muscle mass and strength, which can have
a negative effect on performing ADLs.
 DIETARY GUIDELINES
 Empty calories foods should be taken in minimum amount, and calorie dense
foods should be avoided.
 Foods rich in protein, Vitamins and minerals should be included.
 Fats should be restricted especially saturated fats, inclusion of PUFA is
preferred.
 Vegetables and fruits should be added more to the diet as they are good
source of antioxidants and fibre.
 Foods with soft in consistency, easily chewable and digestible should be
preferred.
 Fried and fatty foods should be avoided.
 Gas forming foods should be avoided.
 Caffeinated drinks should be avoided.
 Include small and frequent meals instead of 3 heavy meals.
 Plenty of fluid intake has to be made sure.
 Food should be less spicy and salty.
 NUTRITIONAL NEEDS OF ELDERLY
 ENERGY
 Basal metabolic rates decrease linearly with age; this change is the result
of the body composition change.
 Healthy elderly individuals ,thus, need only two third of the energy
requirement by healthy younger individuals.
 Energy needs decrease approximately 3% per decade.
 Low-kilocalorie diets are often deficient in most essential nutrients.
 Encourage older adults to select nutrient-dense foods that provide
substantial amounts of micronutrients for the calories supplied.
 PROTEINS
 Protein needs do not usually change with age.
 Protein intake in excess of the recommended dietary allowance for older
adults is associated with increased bone mineral density when calcium intake
is adequate, and does not appear to compromise renal health in older
individuals with normal renal function.
 Protein absorption may decrease with aging as the body may make less
protein.
 However, this does not mean that protein intake should be routinely increased.
Because of the general decline in kidney function, excess protein could
unnecessarily stress kidneys.
 Increasing the RDA for older individuals to 1.0 to 1.2 g/kg per day would
maintain normal calcium metabolism and nitrogen balance without affecting
renal.
 Of total caloric intake 20-25% should be from protein.
 Emphasis should be given on bioavailable protein.
 CARBOHYDRATES
 An impaired glucose tolerance in the elderly can lead to hypoglycemia,
hyperglycemia and type 2 DM.
 Insulin sensitivity can be enhanced by balanced energy intake, weight
management and regular physical activity.
 Since caloric requirement are reduced, carbohydrates intake is also
reduced.
 Current dietary guidelines recommend that approximately 45% to 60% of
the total daily calories should come from carbohydrates.
 Emphasis is on increasing intake of complex carbohydrate sources such as
legumes, vegetables, whole grains, and fruits to provide fiber and
essential vitamins and minerals.
 LIPIDS
 Of the total caloric intake 20 to 30% should be from fats, with most from
polyunsaturated and monounsaturated sources.
 Consuming less than 10% of calories from saturated fats, less than 300
mg/day of cholesterol, and eating trans-fats as little as possible.
 Lower intakes of fat, less than 7% saturated fat and less than 200 mg/day
cholesterol may be recommended for older adults with elevated low-density
lipoprotein cholesterol (LDL).
 Severe restriction of fats alter the taste, texture, and enjoyment of food and
can negatively impact the overall diet, weight, and quality of life.
 Emphasis should be placed on reducing saturated fats and choosing
monounsaturated or polyunsaturated fats.
 Fat intake should be limited to 2-3 tsp/day.
 VITAMINS
 Oxidative processes affect aging,
reinforcing the central role
antioxidants play in maintaining
health throughout life.

 Vitamin A-
 Advancing age does not increase the
requirement for vitamin A or hinder
its resorption.
 In fact vitamin A may be more easily
absorbed by elderly people
 When deficient serum level are
detected ,they usually rate to low
intake and respond to dietary
improvement .
 VITAMIN D
 People over age 50 may be at increased
risk of vitamin D deficiency.
 As there is decreased exposure to
sunlight skin does not synthesize
vitamin D as efficiently.
 The kidneys are less able to convert
vitamin D to its active hormone form.
 The dietary supplementation of vitamin
D and calcium improves bone density.
 Those at high risk, including older
adults and dark-skinned individuals,
should consume substantially higher
levels of vitamin D to maintain serum
25-hydroxy-vitamin D levels at 80
nmol/L. To attain these levels,
supplementation may be necessary.
 Vitamin E
 It is an antioxidant vitamin and
have promoted as agent that
enhance the health of elderly.
 Vitamin E has also been found
to be potential nutrient for
reducing the decline in cellular
immunity that occur in elderly.
 Changes in immune system can
be overcome by taking 200mg
vitamin E.
 Protection from DNA damage
enhances the body’s self
defence mechanism.
 VITAMIN K
 Vitamin K consumption will
reduce the risk of
Alzheimer’s.
 Emphases should be given
on consumption of leafy
vegetables.
 VITAMIN C
 It is an antioxidant vitamin
and have promoted as agent
that enhance the health of
elderly.
 Vitamin C protects against
cataract with an intake level
of 150mg to 250mg per day,
which can be achieved from
dietary sources.
 The deficiency is seen due to
loss of teeth and wearing
dentures, hence the intake of
fruits and vegetables will be
less.
 Vitamin B6
 Requirement is increased in
elderly owing to atrophic
gastritis, which interfere with
absorption.
 Alcohol and liver dysfunction are
other factors leading to vitamin
B6 deficiency.
 Increased serum B6 can provide
protection against elevated
homocysteine levels, which is a
risk factor for CVD.
 Folate (Vitamin B9)
 Folate is important in lowering
homocysteine levels, a possible risk
marker for atherothrombosis,
Alzheimer's disease and Parkinson's
disease.
 Folate fortification of grain products
has greatly improved folate status,
when supplementing with folate, it is
important to monitor B12 levels.
 Alcoholism is a risk factor for folate
deficiency.
 Severe deficiency in elderly may
result in megaloblastic anaemia and
elevated serum homocysteine levels.
 Vitamin B12
 Older adults are at risk for
deficiency because of low intakes of
vitamin B12-rich sources and the
decline in gastric acid, which aids in
releasing vitamin B12 from protein.
 It is recommended that those over
age 50 eat foods fortified with the
crystalline form of vitamin B12 such
as in fortified cereals or
supplements.
 If not corrected, vitamin B12 can
lead to pernicious anemia.
 Increased serum B12 can provide
protection against elevated
homocysteine levels, which is a risk
factor for CVD
MINERALS
 Calcium
 The older adult's dietary calcium
requirement may be increased due
to decreased absorption that
occurs with aging.
 Only 4% of women and 10% of men
over age 60 reach the daily calcium
recommendation.
 Women over 50yrs who are not
receiving estrogen requires more
calcium as there is increased loss
due to demineralization of bone
and osteoporosis.
 Not only women but also men
require more calcium as calcium
absorption efficiency decreases and
vitamin D levels decreases in
ageing.
 Chromium
 Chromium is an important nutrient for
maintaining normal glucose metabolism
since it facilitate the interaction of
insulin with its receptor site on the cell
membrane.
 Zinc
 Low zinc intake is associated with
impaired immune function, anorexia,
loss of sense of taste, delayed wound
healing, and pressure ulcer
development.
 Zinc deficiency is generally seen in older
individuals who are vegetarian.
 RDA for zinc is 15 micro gram/day.
 Sodium
 Older adults are at risk of both hypernatremia and hyponatremia.
 Hypernatremia can be a consequence of dietary excess and dehydration.
 Hyponatremia can result from fluid retention.
 The older adults are recommended to consume no more than 1500 mg/day
of sodium.
 Moderate amount of salt helps improve the palatability.

 Potassium
 A potassium-rich diet can blunt the effect of sodium on blood pressure.
 Older adults are encouraged to meet the potassium recommendation of
4700 mg/ day with food, especially fruits and vegetables.
 Renal function has to be monitored.
 IRON
 The iron deficiency seen in elderly is
due to inadequate iron intake.
 Other causes can be blood loss due to
chronic diseases, reduced non- heame
iron absorption secondary to
achlorhydria of atrophic gastritis.
 HCl is required to reduce iron from
ferric form to iron in ferrous form
necessary for absorption.
 Decrease HCl and antacids which
raises the pH causes reduced
absorption of iron from GI tract.
 Vitamin C deficiency can also impair
iron absorption.
 Mild anaemia can affect elderly due
to poor circulation of blood.
 Requirement is same as adult man,
i.e, 30mg, if anaemia is seen then
supplements can also be given.
 WATER
 Maintenance of fluid balance is essential for normal physiologic functions at
all ages.
 Hydration status of older adults is often tenuous.
 The lean body mass decrease with age impacts the percentage of water in
the body. It can diminish from 60% to 50%" total body weight.
 Dehydration in older adults can be caused by decreased fluid intake,
decreased kidney function, or increased losses due to increased urine
output from medications, including laxatives or diuretics.
 Fluid intake of at least 1500 ml/day ensures proper hydration.
 Symptoms of dehydration are electrolyte imbalance, altered drug effects,
headache, constipation, blood pressure change, dizziness, confusion, and
dry mouth and nose.
 Older adults are at increased risk of dehydration because of their impaired
sense of thirst, fear of incontinence, and dependence on others to get
beverages.
 Dehydration in older adults is often unrecognized because it can present as
falls, confusion, change in level of consciousness, weakness or change in
functional status or fatigue.
 Fibre
 A low intake of dietary fiber has been shown to be related to many
conditions common to elderly people such as constipation ,colon cancer
and diabetes.
 Fibre stimulates peristalsis.
 Fibers can absorb up to three times their weight of water, thus increasing
the bulk and weight of the stool.
 This increases transit time and facilitates evacuation of the stool, thereby
preventing constipation.
 Fibre intake should be encouraged but gradually to avoid bowel discomfort,
distension and flatulence.
 Rough fibre, bran and mature vegetables should be avoided in elderly
instead tender vegetable, fruits should be included.
 Fibre helps in reducing cholesterol, weight loss, diabetes etc.
 NUTRITIONAL RELATED PROBLEMS IN OLD AGE
 OBESITY
 Obesity rates are greater among those ages 65 to 74 than among those age 75 and
over.
 Obesity is associated with increased mortality and contributes to many chronic
diseases: type 2 diabetes, heart disease, hypertension, arthritis, dyslipidemia, and
cancer.
 Obesity causes a progressive decline in physical function, which may lead to
increased frailty. Overweight and obesity can lead to a decline in IADLs.
 Obesity causes a progressive decline in physical function, which may lead to
increased frailty. Overweight and obesity can lead to a decline in ADLs.
 Dietary changes include an energy deficit of 500 to 1000 kcal/day. Usual caloric
goals range from 1200 to 1800 kcal/day but should not be less than 800 kcal/day. It
is critical for the older adult on a calorie restricted diet to meet nutrient
requirements. This may necessitate the use of a multivitamin/mineral supplement
as well as nutrition education.
 Accordingly weight loss therapies that maintain muscle and bone mass are
recommended for obese older adults.
 Lifestyle changes that include diet, physical activity, and behavior
modification techniques are the effective.
 The goals of weight loss and management for adults are the same for the
general population. They should include prevention of further weight gain, or
reduction of body weight, and maintenance of long-term weight loss.
 UNDERNUTRITION
 The prevalence of underweight among older adults is quite low.
 It is common among older people who are institutionalized.
 With increasing age there is decreased intake of food and nutrients.
 Some causes of undernutrition include medications, depression,
decreased sense of taste or smell, poor oral health, chronic diseases,
dysphagia, and other physical problems that make eating difficult.
 Social causes may include living alone, inadequate income, lack of
transportation and limitations in shopping for and preparing food.
 The physiologic changes of aging, as well as changes in living conditions
and income, all contribute to the problem.
 Older adults with low incomes, who have difficulty chewing and
swallowing meat, who smoke, or engage in little or no physical activity
are at increased risk of developing PEU.
 Most contributing factors are modifiable through diet and physical
activity.
 Strategies to decrease PEU include increased caloric and protein intake.
In a clinical setting nutritional oral supplements and enteral feedings may
be used.
 In a community setting older adults should be encouraged to eat energy-
dense and high-protein foods. Diet restrictions should be liberalized to
offer more choices. Adding gravies and creams can increase calories and
soften foods for easier chewing.
 ANAEMIA
 Anemia in old age is an independent risk factor for decline in physical
performance.
 It is characterized by feeling of fatigue, anxiety, lack of energy and
sleeplessness.
 It can also decrease myocardial function and can lead to heart failure.
 It can be caused by low dietary iron intake, impaired absorption resulting
from lack of haem iron or lack of Vitamin C or blood loss.
 In elderly it can also be caused due to the underlying diseases such as
cancer, infections and malnutrition.
 Iron deficiency anaemia can be rectified using iron supplements and iron
rich diet together with Vitamin C to enhance absorption.
 Older adults are at risk pernicious anaemia because of low intakes of
vitamin B12-rich sources and the decline in gastric acid, which aids in
releasing vitamin B12 from protein.
 It can be overcome by including animal foods and vitamin supplement of
1000mcg.
OSTEOPOROSIS
 It is condition where there is loss of bone mineral density.
 Which is due to increase in osteoclast bone resorption activity and
concomitant decrease in osteoblast mediated bone formation.
 The early indication of osteoporosis are an increased incidence of bone pain
and back pain in women.
 The major symptom of osteoporosis is increased vulnerability to bone
fractures.
 In elderly or as people age, resorption begins to predominate over the bone
formation which eventually results in osteoporosis.
 Due to decreased cells, there is decreased thickness of cortex and increased
porosity of bone.
 Decreased intestinal absorption of calcium and production of vitamin D,
reduced physical activity and increased parathyroid hormone secretion also
causes osteoporosis.
 The most effective preventive measure are ensuring additional calcium
intake. Adequate protein along with calcium also helps in bone formation.
OSTEOARTHRITIS
 Inflammatory diseases include periodontal disease, osteoarthritis, rheumatoid
arthritis, celiac disease (gluten intolerance), irritable bowel disease,
diverticulitis (an infection in the large intestine), atrophic gastritis (typically
due to Helicobacter pylori infection), and asthma. Of these conditions,
arthritis affects the greatest number of older individuals.
 Prevalence of osteoarthritis at the knee is twice as common as at the hip; the
knee and hip are the two most common sites for persons aged 30 and older.
 Prevalence increases with age and peaks between 70 and 79 years. More men
than women have osteoarthritis before age 50; after age 50, women are more
often affected.
 Cartilage loss, bone hypertrophy, changes in the synovial membrane,
hardening of soft tissues, and inflammation leading to tissue damage
constitutes osteoarthritis.
 In contrast to osteoarthritis, rheumatoid arthritis is an autoimmune collagen
disease characterized by inflammation and increased protein turnover.
 Osteoarthritis is a degenerative joint disease. Joint movement brings on pain
because cartilage that cushions the bone ends has eroded.
 Osteoarthritis is among the most disabling conditions of older adults.
 Treatment goals are to control pain, improve joint function, maintain a
normal body weight, and achieve a healthy lifestyle.
 Obesity, continuous overexposure to oxidants, and possibly low vitamin D
levels are risk factors for developing osteoarthritis.
 Obesity may have two detrimental effects. One is the weight stressing the
joint, and the other is due to secretion of cytokines in adipose tissue.
 Fat is a metabolically active tissue that secretes signaling molecules that can
trigger inflammation.
 Low intakes of vitamins C and D are risk factors for osteoarthritis
progression.
 Nutritional Remedies
 Antioxidants : Individuals with the highest levels of vitamin C intake had
significantly slower (threefold) disease progression and less knee pain
than individuals with the lowest intakes.
 Vitamin D : Progression at higher intakes and serum levels is roughly one-
third slower than at the lowest levels. The DRI for older adults is 400 to
600 IU, with a tolerable upper intake level of 2000 IU.
 Flavonoids : This is a large group of phytochemicals with antioxidant and
anti-inflammatory properties that act to maintain cell membranes. Higher
levels of antioxidants are required to scavenge oxidized metabolites and
free radicals in inflammatory diseases
 Vegetarian Diets : Plants are rich in antioxidants that may play a role in
managing inflammatory diseases in general.
 Other Treatments: Fatty acids and oils are other anti inflammatory
therapies with potential to lessen signs and symptoms in a variety of
conditions, including osteo- and rheumatic arthritis
DIABETES
 Individuals with diabetes are at greater risk for heart disease and its
complications; diabetes itself is an independent risk factor for
atherosclerosis.
 Four of five older people have diabetes as one of several comorbid conditions,
and these complicate diabetes management.
 Diabetes leads to a tenfold greater risk of amputations, macular
degeneration, visual loss, cataracts, glaucoma, and neuropathies (nerve
damage, pain, or tingling) of the hands and feet.
 Hyperglycaemia may lead to sodium depletion and dehydration, trace mineral
depletion (zinc, chromium, magnesium), insomnia, nocturia, blurred vision,
increased platelet adhesiveness related to atherosclerosis, increased
infection and decreased wound healing, and aggravated peripheral vascular
disease.
 Hypoglycemia in older adults may lead to weakness, confusion, and possible
falls and fractures.
 Diabetes self-management training, to the extent that the individual is able
to manage his or her own regimen, works in tandem with medical nutrition
therapy to achieve glycemic control.