Elham Souferzadeh

By Elham Souferzadeh, MS /RDN Introduction As a Registered Dietitian working with older adults in long-term care, I have seen firsthand how quickly inadequate nutrition can affect an older person's strength, function, wound healing, and overall quality of life. One of the most important—and sometimes overlooked—aspects of geriatric nutrition is adequate protein intake. When an older resident begins eating less, loses weight, becomes weaker, develops a wound, or experiences an acute illness, protein intake should be one of the important components of the nutrition assessment. Protein is not simply another nutrient on the menu. For many older adults, it is an important part of maintaining muscle, strength, function, recovery, and independence. Research and geriatric nutrition guidelines recognize that older adults generally require more protein than the minimum recommendation traditionally used for younger adults. ESPEN recommends that older adults receive at least 1.0 g/kg/day, with the amount individualized according to nutritional status, physical activity, disease status, and tolerance. Healthy older adults are often estimated at approximately 1.0–1.2 g/kg/day, while older adults with illness or nutritional risk may require approximately 1.2–1.5 g/kg/day. Aging Changes the Way the Body Uses Protein As we age, the body becomes less responsive to dietary protein. This reduced response is commonly described as anabolic resistance. In simple terms, an older adult may consume the same amount of protein as a younger person, but the body may not use that protein as efficiently for maintaining and building muscle. At the same time, older adults are more likely to experience conditions that increase muscle breakdown, including: • Acute illness • Infection • Inflammation • Surgery • Wounds • Hospitalization • Prolonged bed rest • Reduced physical activity • Poor appetite • Unintentional weight loss The combination of reduced muscle-building response and increased muscle breakdown makes adequate protein intake particularly important in the geriatric population. Protein and Muscle: Protecting More Than Body Weight One of the most important concerns in long-term care is loss of lean body mass. When a resident loses weight, it is important to ask: What exactly is being lost? Weight loss can involve fat, fluid, and lean tissue. Loss of muscle can be particularly concerning because muscle is directly related to physical function. A resident who loses muscle may gradually have more difficulty: • Standing • Walking • Transferring • Dressing • Bathing • Feeding themselves • Participating in activities • Maintaining independence Loss of physical function can ultimately have a greater impact on a person's quality of life than the number on the scale alone. Research supports the importance of adequate protein, particularly in combination with appropriate physical activity, for maintaining muscle function as people age. The Long-Term-Care Resident Is Particularly Vulnerable In long-term care, adequate protein intake can be challenging. Many residents have multiple barriers to eating enough protein. A resident may have a calculated protein requirement but still consume inadequate amounts because of: Poor appetite Some residents simply do not feel hungry enough to finish meals. Early satiety A resident may feel full after eating only a small amount of food. Dysphagia Swallowing difficulties can significantly restrict food choices and intake. Dental problems Poor dentition, ill-fitting dentures, or oral pain can make protein-rich foods such as meats difficult to consume. Cognitive impairment Residents with dementia may forget to eat, lose interest in meals, or require significant assistance. Feeding dependence A resident may have the appetite to eat but lack the physical ability to feed themselves. Acute illness An infection or other acute medical condition may dramatically decrease appetite while increasing nutritional demands. Food preferences Even nutritionally appropriate meals will not be effective if the resident does not like or recognize the food being offered. These challenges demonstrate why nutrition care in long-term care must be individualized. Protein and Unintentional Weight Loss Unintentional weight loss is one of the most common nutrition concerns encountered in long-term care. When a resident begins losing weight, the nutrition assessment should go beyond simply documenting the percentage of weight loss. The RD should ask: • How much is the resident actually eating? • How much protein is the resident receiving? • Is the resident able to feed themselves? • Is chewing difficult? • Is swallowing difficult? • Is there a recent infection? • Has the resident been hospitalized? • Are medications affecting appetite? • Is the resident experiencing depression? • Does the resident dislike the current diet? • Are cultural or religious preferences being addressed? • Is the resident receiving appropriate assistance at meals? • Is the resident accepting supplements? Most importantly, we need to identify why the resident is not meeting nutritional needs. Simply adding a supplement without identifying the underlying problem may not solve the issue. Protein Is More Than a Number As dietitians, we often calculate protein requirements using grams per kilogram of body weight. For example, a resident weighing 60 kg might have a protein target of approximately 60–72 grams per day at 1.0–1.2 g/kg/day. But achieving that number in practice is another matter. A resident may require 70 grams of protein but consume only 25–30 grams from meals. This is where clinical nutrition intervention becomes important. The RD may need to modify the food, timing, texture, portion size, meal pattern, snacks, supplements, and feeding assistance rather than simply increasing the amount of food placed on the plate. Protein Throughout the Day Protein intake should ideally be incorporated throughout the day rather than relying exclusively on one meal. Potential strategies include: Breakfast • Eggs • Greek yogurt • Cottage cheese • Fortified milk • High-protein oatmeal Lunch and Dinner • Chicken • Turkey • Fish • Lean meat • Beans • Lentils • Tofu Snacks • Greek yogurt • Cheese • Cottage cheese • Fortified pudding • Protein-fortified beverages • Oral nutrition supplements when indicated Recent literature suggests that distributing protein across meals may help older adults reach adequate daily protein intake and support muscle protein synthesis. When Food Alone Is Not Enough In long-term care, there are residents for whom meals alone simply cannot provide enough protein and energy. For these residents, nutrition interventions may include: • Fortifying foods • High-protein snacks • Fortified beverages • Oral nutritional supplements • Increased meal frequency • Smaller, more nutrient-dense portions • Assistance with feeding • Texture modification when clinically indicated • Enteral nutrition when appropriate • Parenteral nutrition in carefully selected clinical situations The goal is not to automatically give every resident a supplement. The goal is to determine what intervention is most appropriate for that individual resident. Protein and Wound Healing Protein is particularly important when an older adult has increased nutritional demands associated with tissue repair. Residents with pressure injuries or other wounds may require careful assessment of their energy and protein intake. In these situations, the RD should work closely with nursing, wound-care professionals, physicians, speech-language pathology, and other members of the interdisciplinary team. Nutrition is only one component of wound management, but inadequate nutrition can make it more difficult for the body to meet the demands of healing. Protein During Illness Illness can place additional stress on an older adult. Infection, inflammation, surgery, wounds, and other acute or chronic conditions can increase nutritional requirements and contribute to muscle breakdown. The PROT-AGE group recommends approximately 1.2–1.5 g/kg/day for many older adults with acute or chronic disease, although individual needs must be determined clinically. This is especially relevant in long-term care, where residents frequently have multiple chronic diseases in addition to episodes of acute illness. The Importance of the Interdisciplinary Team Protein nutrition cannot be managed by the dietitian alone. Successful nutrition care requires communication among: Dietitian → Nursing → CNAs → Physician/NP → Speech-Language Pathologist → Wound Care → Food Service → Family/Caregivers For example, the dietitian may recommend increased protein intake, but if the resident requires feeding assistance and that assistance is not provided consistently, the nutrition intervention may fail. Similarly, a resident may require a modified texture because of dysphagia. Without coordination with speech-language pathology and nursing, the resident may continue to have difficulty consuming adequate protein. Nutrition recommendations need to become actions at the bedside. Renal Disease: One Size Does Not Fit All Higher protein recommendations cannot simply be applied to every older adult. Renal function must be considered when developing a protein prescription. For example, older adults with severe kidney disease who are not receiving dialysis may require protein restriction rather than the higher protein intake recommended for many other older adults. This is an important reason why protein recommendations should be individualized rather than based solely on age. The RD must consider renal function, nutritional status, disease severity, dialysis status when applicable, weight trends, intake, and overall goals of care. What I Have Learned in Long-Term Care Working with older adults has reinforced an important lesson: Meeting nutritional needs is not just about calculating requirements. It is about understanding the person. A nutrition prescription can be perfectly calculated and still fail if the resident: • Does not like the food • Cannot chew it • Cannot swallow it • Cannot feed themselves • Is too fatigued to eat • Has no appetite • Does not recognize the food • Is experiencing pain • Is depressed • Is acutely ill • Has cultural or religious food preferences that are not being respected This is why individualized nutrition care is so important in geriatrics. Sometimes the most effective intervention is not another supplement. It may be a preferred food, assistance during meals, a different texture, a smaller portion, an additional snack, or simply taking the time to understand why the resident is not eating. Preserving Independence Should Be the Goal The ultimate goal of geriatric nutrition should not be simply to achieve a laboratory value or a calculated number of grams of protein. The goal should be to help the older adult maintain strength, function, dignity, and quality of life for as long as possible. Adequate protein is one important component of that effort. For a resident who can maintain enough strength to transfer independently, walk to the dining room, participate in activities, or feed themselves, the benefits extend far beyond nutrition. They affect independence and quality of life. Conclusion Protein is an essential component of nutrition care for older adults, and its importance becomes particularly evident in long-term care. Older adults experience physiological changes that can reduce the body's response to dietary protein, while illness, inflammation, inactivity, wounds, and poor intake can further increase the risk of muscle loss. Current geriatric nutrition guidance recommends at least 1.0 g/kg/day, with approximately 1.0–1.2 g/kg/day for many healthy older adults and 1.2–1.5 g/kg/day for many older adults with acute or chronic illness, with individualized adjustment based on clinical circumstances. But the real challenge in long-term care is not knowing the number. The real challenge is helping the resident achieve it. As Registered Dietitians, our role is to turn nutrition science into practical, individualized care—one resident, one meal, and one intervention at a time. References • Volkert D, Beck AM, Cederholm T, et al. ESPEN practical guideline: Clinical nutrition and hydration in geriatrics. Clinical Nutrition. 2022. • Bauer J, Biolo G, Cederholm T, et al. Evidence-based recommendations for optimal dietary protein intake in older people: A position paper from the PROT-AGE Study Group. J Am Med Dir Assoc. 2013. • Deutz NEP, Bauer JM, Barazzoni R, et al. Protein intake and exercise for optimal muscle function with aging: Recommendations from the ESPEN Expert Group. Clinical Nutrition. 2014. • Bauer J, Diekmann R. Protein and Older Persons. Clinics in Geriatric Medicine. 2015. • Protein and Aging: Practicalities and Practice. 2025.