Nutritional therapy in chronic wound management for older adults

Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].Purpose of reviewWe provided an updated overview of recent data on the value of nutritional therapy in the management of chronic wounds in older adults.In the last years, advances in this area were limited, but new data suggest considering nutritional care (screening and assessment of malnutrition and nutritional interventions) also in patients with chronic wounds other than pressure ulcers, namely venous leg and diabetic foot ulcers, as in these patients, nutritional derangements can be present despite overweight/obesity and their management is beneficial.Chronic wounds are wounds in which the process of repair does not progress normally due to a disruption in one or more of the healing phases. Nutritional therapy is aimed at recovering the process of repair. General principles of nutritional care in geriatrics apply to these patients but disease-specific recommendations are available, particularly for pressure ulcers. Interventions should address nutritional status, comorbidities, hydration and should provide key nutrients playing an active role in the healing process (arginine, zinc, and antioxidants) but always within the context of an individual care plan addressing patients requirements, particularly protein needs. Further evidence of efficacy in vascular and diabetic foot ulcers is warranted.Papers of particular interest, published within the annual period of review, have been highlighted as:Nowadays, the key role of nutritional domain in tissue viability is out of question (Fig. 1). An adequate blood flow in tissues is a prerequisite for promoting new synthesis but anabolism cannot occur without the provision of the appropriate building bricks. Protein-calorie deficit and the related catabolic background are important intrinsic factors responsible for skin breakdown. On the contrary, there is substantial evidence that inadequate nutritional care is associated with impaired tissue healing. Accordingly, in order to improve the healing process, wound care requires a multidisciplinary treatment, which must include an individualized nutritional care plan [1,2]. no caption availableFactors involved in the pathophysiology of skin breakdown and impaired wound healing, particularly pressure ulcers.Chronic wounds are wounds in which the process of repair - usually 8-week long - does not progress normally, orderly, and timely due to a disruption in one or more of the established healing phases: hemostasis, inflammation, proliferation, and remodeling. In this scenario, nutritional therapy is aimed at recovering the process of repair. Chronic wounds are a complex issue, particularly in older adults as in this age group reduced regenerative potential and altered healing processes may be further compromised by frequent and relevant overlapping comorbidities [e.g. diabetes, anemia, ischemia, organ dysfunction (namely heart, kidney, or lung) and malnutrition].Indeed, the proneness to nutritional risk in advanced age is well established due to multiple factors, which have been practically summarized in different ways - such as the acronym 'MEALS ON WHEELS' or the '9 Ds' [3] - but inadequate nutrient intake is a true modifiable factor through multiple treatment strategies.In the last three decades, substantial evidence has been collected on the efficacy of nutritional therapy in wound healing. However, although chronic wounds are a really heterogeneous entity, most data have been obtained in patients suffering from pressure ulcers. Pressure ulcers are currently considered a nutrition-related outcome to the point that a specific question is also included in the full version of the Mini Nutritional Assessment (MNA) screening tool. Thinking about the pathophysiologic role of extrinsic and intrinsic factors, it is worth considering that aging contributes to progressive dystrophy of the subcutaneous tissue - which is further worsened by poor nutritional status - but is also associated with chronic diseases, acute stress events, and physical and mental conditions responsible for the onset and maintenance pressure ulcers. Nonetheless, important chronic wounds frequently occurring in older adults are also vascular leg ulcers (venous or arterial) and diabetic foot ulcers.In the last 2 years, advances in the area of wound healing were limited and evidence-based recommendations rely almost exclusively on data collected in patients with pressure ulcers, reviewed for and summarized in the International guidelines released in 2019 by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) [1]. We believe that the SARS-Cov2 pandemic may have contributed to limited research in this area.Anyway, along with a summary of available recommendations, a focus on recent literature on any type of chronic wounds is reviewed herein.General principles of and recommendations for nutritional care in geriatrics [4] obviously apply to all older patients with chronic wounds but disease-specific recommendations could be also provided, at least for patients with pressure ulcers [1,2].The objectives of nutritional intervention are the optimization of nutrient intake (including water!), the maintenance or improvement of nutritional status and quality of life, and the disease-specific improvement of the clinical course, which translates in faster wound healing or the recovery of the healing process [1,2].Indeed, these patients - and particularly those with pressure ulcers - should be generally considered at risk of malnutrition, as they suffer from a chronic condition. Screening is, therefore, mandatory and referral to a nutrition specialist for a comprehensive assessment and the elaboration of an individualized nutrition care plan must be considered in case of positive screening. Interventions should also take into account the identification and potential elimination of any cause of malnutrition and altered hydration, including unnecessary dietary restrictions and eating dependency, which may limit high-quality nutrition. Normal oral diet must be implemented for texture and calorie content according to food preferences and estimated requirements, possibly in a pleasant and socially involving environment. Therefore, nutritional counseling is a first-line strategy but monitoring of food intake is also mandatory in order to review the therapy and determine if the use of fortified foods and/or oral nutritional supplements (ONS) should be early implemented. When spontaneous oral intake is inadequate, artificial nutrition - either enteral or parenteral according to achievable outcomes, gut function, and patient's willingness - must be considered as well [2,4].Most of the aforementioned recommendations clearly apply to patients unlikely to meet nutrients requirements. Pressure ulcers are usually associated with defect malnutrition, while the other types of chronic wounds (vascular and diabetic foot ulcers) are more closely related to obesity. However, absolute generalizations are deemed inappropriate. Decreased mobility and difficulty with self-repositioning could characterize obese patients and contribute to hypovascularity [4]. Nowadays, a major problem is the obesity epidemic, but a relevant overlapping disease is also sarcopenia [5]. Sarcopenic obesity is associated with altered protein metabolism [6] and this should be taken into account in caring for patients with chronic wounds. On the one hand, patients with vascular or diabetic foot ulcers could take advantage from body weight loss (improved circulation and glucose control), although no evidence is available on the related impact on wound healing. On the other hand, protein balance is crucial to wound healing [2] and nutritional therapy tailored to reduce body weight should be muscle-targeted as well, in order to sustain protein metabolism [7].Specific recommendations on nutritional requirements in patients with chronic wounds are available only for the setting of pressure ulcers (Table 1). In general, a guiding value for daily calorie and protein intake in older adults with reduced mobility has been proposed to be up to 27-30 kcal/kg and 1.0-1.2 g/kg, respectively. Then, adjustments on an individual basis should be considered according to nutritional status, physical activity level, disease status, comorbidities, and tolerance [2,4,8]. Particularly, in patients at one risk of malnutrition - as in the case of those with pressure ulcers - daily targets have been set to 30-35 kcal/kg and 1.25-1.5 g/kg for calories and protein, respectively [1,2,4,8]. The presence of a moderate-to-severe pressure ulcer (Stage III and IV) has been associated with increased energy expenditures (measured by indirect calorimetry), inflammation and the loss of nutrients, mainly proteins, through the wound [2,9]. Therefore, in the estimation of energy needs, an additional correction factor of +10% should be considered for pressure ulcers. Unfortunately, this disease condition is also associated with anorexia, reduced food intake and incapacity to meet estimated requirements [2,9]. For a 50-kg patient, a gap of about 400 kcal/day can be calculated. This is a clear, even indirect, indication to the systematic use of ONS with high protein content. The recommended minimum duration of the intervention with ONS is 8-12 weeks, but also up to complete healing [1,2]. Interestingly, recent guidelines for basic nutritional care in geriatrics have stated that ONS offered to older adults at risk shall provide at least 400 kcal/day and 30 g of proteins [4].Summary of main principles of nutritional therapyIn patients with reduced mobility: 27-30 kcal/kg; in patients malnourished/at risk of malnutrition or having a PU: 30-35 kcal/kg.In patients with reduced mobility: 1.0-1.2 g/kg; in patients malnourished/at risk of malnutrition or having a PU: 1.25-1.5 g/kg.Adequate fluid intake should be also encouraged and addressed. Water is a transport medium for nutrients and contributes mostly to the removal of waste products. Tissue perfusion is crucial to the healing process. In healthy adults, water content of foods usually accounts for 20-25% of the total fluid intake, which has been recommended to be about 30 ml/kg/day or 1 ml/kcal consumed. In other terms, this usually translates into a daily offer of at least 1.6 and 2.0 l of drinks for women and men, respectively, unless a different approach is required according to clinical conditions (e.g. heart failure, emesis, diarrhea, elevated temperature, increased perspiration or draining wounds, and so on) [1,2,4]. Indeed, in many patients with chronic diseases, it is not uncommon to find reduced plasma levels of one or more micronutrients. Correcting deficiencies is therefore mandatory and could be beneficial.In the last 20 years, further to calories and proteins, evidence of efficacy has been also collected on the combined extra provision of some nutrients involved in different pathways of the healing process: arginine, zinc, and antioxidants. However, although their value was demonstrated to be independent of other nutrients, their use has to be considered within the context of a high-quality nutrition care plan addressing the optimization of calorie and protein intake [1,2]. Most research on these nutrients has been conducted in patients with pressure ulcers. Nonetheless, the administration of ONS enriched with this blend of nutrients has been investigated also in a case series study showing a positive recovery of the healing process in other types of wounds (mixed arterial, venous, and diabetic foot ulcers) after these nutrients [10]. A large high-quality trial in the setting is warranted. Indeed, more limited is the evidence on interventions with specific nutrients in the other types of chronic wounds, as studies were small and heterogeneous and did not consider the combination with an individualized dietary therapy [11]. Topical use of vitamin A, and oral provision of vitamins B9, D, and E, and magnesium were found to reduce total diabetic ulcer surface area, while supplementations with vitamin B9 and zinc were demonstrated to reduce total surface area and/or time to complete closure of venous ulcer wounds.A brief rationale supporting the use of some nutrients is the following. Arginine is a conditionally essential amino acid in stress conditions and a mediator of immune response. It supports protein anabolism, it promotes cellular growth and, as donor of nitric oxide, improves blood flow to the wound area. Zinc actively participates in protein metabolism and DNA synthesis. It is an important cofactor for collagen formation, interacts with platelets in blood clotting, and sustains both immune function and cellular proliferation. Scavenging reactive oxygen species through the provision of antioxidants is also relevant to wound healing. Among these, we do remember vitamin C, which is also an important cofactor for collagen formation (improvement of tensile strength with the hydroxylation of lysine and proline), enhances leukocytes activation and contributes to the absorption of iron. Other important nutrients with antioxidant proprieties and contributing to other healing processes (collagen cross-linking, cell membrane stabilization, erythropoiesis, and so on) are also vitamin E, selenium, copper, and manganese. Vitamin E is also involved in the regulation of gene expression, cell signaling proliferation and differentiation, as well as in immune function. Vitamin A, acting as a hormone, actively stimulates the mitosis and growth of epithelial cells and fibroblasts, contributes to immune cell response and enhances multiple healing processes (e.g. granulation, angiogenesis, collagen synthesis, and extracellular matrix formation). Folate (vitamin B9) is a cofactor of enzymes involved in the synthesis of amino acids, DNA and RNA, which are critical for rapid cell division. Moreover, it sustains hematopoiesis. Finally, also anemia contributes to impaired wound healing. Therefore, if iron deficiency is present, supplementation must be considered although no specific evidence on its use has been collected. Moreover, iron is involved in collagen synthesis (activity of lysyl- and prolyl-hydroxylases) [12,13].