What is the best management plan for an elderly female patient with a history of hypertension (high blood pressure), hyperlipidemia (elevated lipids), gastroesophageal reflux disease (GERD), and type 2 diabetes mellitus, who recently experienced a left middle cerebral artery (MCA) stroke, and is currently presenting with post-stroke spasticity, nutritional decline, mood and anxiety symptoms, electrolyte abnormalities, and abnormal liver enzymes?

Management of Post-Stroke Patient in Skilled Nursing Facility

Continue baclofen for post-stroke spasticity, maintain high-intensity atorvastatin and aspirin monotherapy for secondary prevention, aggressively manage hypertension and diabetes to target, reinforce fall precautions with supervised mobility, and continue mirtazapine with nutritional supplementation for malnutrition while monitoring for medication-related adverse effects.

Post-Stroke Spasticity Management

Your current baclofen regimen is appropriate and should be continued as oral baclofen is specifically recommended for spasticity-related symptoms in chronic stroke patients 1. Since the patient shows no sedation or weakness, maintain the current dose while monitoring tone and functional response during therapy sessions 1.

• Implement antispastic positioning, range of motion exercises, and stretching as foundational interventions alongside baclofen 1
• Consider botulinum toxin injections if focal spasticity worsens or causes pain, poor skin hygiene, or decreased function 1
• Avoid benzodiazepines (including the current PRN alprazolam for anxiety) during stroke recovery as they have deleterious effects on neurological recovery 1
• If spasticity becomes refractory to oral baclofen, consider intrathecal baclofen for severe cases 1

Secondary Stroke Prevention

Continue aspirin monotherapy indefinitely as it should be administered within 24-48 hours after stroke onset and maintained long-term 2. The discontinuation of clopidogrel per neurology was appropriate, as dual antiplatelet therapy beyond 2-3 years increases bleeding risk without additional benefit 3.

Maintain high-intensity atorvastatin regardless of baseline cholesterol levels 2, 4. The mild ALT elevation (specific value not provided) is acceptable and asymptomatic—continue statin therapy with periodic monitoring 5, 4. Statins demonstrate clear mortality and recurrence reduction benefits that outweigh the risk of new-onset diabetes or mild transaminase elevation 4.

Hypertension Management

Blood pressures appear within acceptable range based on your documentation, but specific targets matter. For this elderly post-stroke patient, target systolic blood pressure <130 mmHg 5. Treatment of hypertension with this goal is specifically recommended for noninstitutionalized ambulatory community-dwelling adults ≥65 years 5.

• Continue current antihypertensive regimen if achieving target <130/<80 mmHg 5
• Blood pressure lowering is more important than drug choice for stroke prevention 5
• Monitor for orthostatic hypotension given age and fall risk, though intensive BP control does not increase fall risk in community-dwelling elderly 5

Diabetes Management

Tighten glucose control to prevent recurrent stroke. Diabetes doubles stroke recurrence risk and requires aggressive management 6, 4.

• Target fasting glucose 80-130 mg/dL and A1C <7% 5
• Current dietary management alone may be insufficient—consider adding metformin or other agents if glucose values consistently exceed target 5
• Monitor for hypoglycemia given nutritional decline and mirtazapine use 5
• Maintain hypoglycemia protocol 5

Nutritional Decline Management

Continue mirtazapine for appetite stimulation and oral nutritional supplements 5. The low albumin despite stable weight indicates ongoing protein-calorie malnutrition requiring intervention.

• Target protein intake 1.2-1.5 g/kg/day with high-calorie supplements 5
• Weekly weights and intake monitoring 5
• Consider temporary nasogastric or PEG feeding if oral intake remains inadequate and weight declines 2
• Dietician involvement is appropriate and should continue 5

Hypomagnesemia

Continue magnesium replacement as hypomagnesemia can worsen cardiac arrhythmias and neuromuscular function 5. The improvement from initial level to current level demonstrates treatment effectiveness—repeat with routine labs and adjust supplementation to maintain normal levels 5.

Mood and Anxiety Management

Replace alprazolam with alternative anxiety management. Benzodiazepines should NOT be used during stroke recovery due to deleterious effects on neurological recovery and problematic sedation that increases fall risk 1.

• Continue sertraline for depression 5
• For anxiety, consider cognitive behavioral therapy, psychotherapy, or support groups rather than benzodiazepines 5
• If pharmacologic intervention required for severe anxiety, consider buspirone or low-dose SSRI augmentation instead of benzodiazepines 5
• Monitor for pseudobulbar affect (mood swings, pathological laughing/crying), which occurs in 10-48% of stroke patients 5

Fall Prevention Strategy

The recent non-injurious slide-to-floor event requires immediate intervention intensification. Falls most commonly occur during transfers and toileting, exactly as occurred here 5.

• Mandatory staff assistance for ALL transfers—no self-transfers permitted 5
• Bed/chair alarms and video monitoring 5
• Physiotherapy with postural training and task-oriented therapy 5
• Music therapy may reduce fall risk 5
• Ensure assistive devices are used consistently 5
• Risk factors present: anxiety, male sex (if applicable), NIHSS score likely ≥8 given hemiplegia 5

Rehabilitation Optimization

Continue skilled PT/OT/ST with early, short, frequent exercise sessions 5. Daily stretching of hemiplegic limbs prevents contractures 5.

• Position hemiplegic shoulder in maximum external rotation for 30 minutes daily in bed or chair 5
• Use supportive devices and slings to prevent shoulder subluxation 5
• Resting ankle splints at night and during assisted standing for ankle contracture prevention 5
• Train family members to assist with exercises 5

Monitoring Parameters

• Neurological examination for recurrent symptoms 5, 2
• Blood pressure at each visit targeting <130/80 mmHg 5
• Glucose monitoring with meals targeting 80-130 mg/dL fasting 5
• Temperature every 4 hours for first 48 hours after any acute change, treat if >37.5°C 2
• Weekly weights and nutritional intake 5
• Liver enzymes and lipid panel every 3-6 months on statin 4
• Magnesium with routine labs 5
• Skin assessment for pressure injuries using Braden scale 5
• Bowel and bladder function 5

Critical Pitfalls to Avoid

• Do not restart clopidogrel—dual antiplatelet therapy beyond 2-3 years increases bleeding without benefit 3
• Do not discontinue statin for mild transaminase elevation—benefits far outweigh risks 4
• Do not use benzodiazepines for anxiety—impairs stroke recovery 1
• Do not allow self-transfers—high fall risk patient requires supervision 5
• Do not use corticosteroids if cerebral edema develops—use osmotherapy instead 2