What is the best course of action for an elderly female long-term skilled nursing facility (SNF) resident with a history of severe protein-calorie malnutrition, chronic pain syndrome, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), anemia, and electrolyte abnormalities, who presents with acute onset of decreased coordination, trunk control, and generalized spasticity?

Acute Spasticity with Electrolyte Disturbances in a Frail SNF Resident

The acute spasticity episode is most likely multifactorial, driven primarily by severe hypokalemia (3.0 mEq/L) and hypomagnesemia (1.5 mg/dL) in the context of severe protein-calorie malnutrition, and requires immediate aggressive electrolyte repletion with close neurologic monitoring while continuing nutritional optimization. 1

Immediate Priority Actions

Electrolyte Correction Protocol

Hypokalemia must be corrected aggressively to 4.0-5.0 mEq/L, particularly given the concurrent cardiac risk factors and potential for arrhythmia. 2

• Administer oral potassium chloride 40-60 mEq/day in divided doses (20 mEq three times daily) 2
• Check serum magnesium immediately and replicate aggressively, as hypomagnesemia (current level 1.5 mg/dL) makes hypokalemia refractory to correction 2
• Magnesium supplementation is critical as it directly contributes to neuromuscular irritability and spasticity risk 1
• Monitor electrolytes every 4 hours initially, then daily until stable, then weekly 2

The combination of hypokalemia and hypomagnesemia is a known precipitant of neuromuscular irritability and can manifest as the generalized spasticity observed. 1

Refeeding Syndrome Risk Assessment

This patient meets multiple high-risk criteria for refeeding syndrome: severe protein-calorie malnutrition (albumin 3.0, total protein 4.6), significant electrolyte abnormalities pre-feeding, and chronic poor nutritional intake. 1

• The acute spasticity episode may represent early manifestations of refeeding syndrome, which includes muscle weakness, neuromuscular irritability, and electrolyte shifts 1
• Monitor phosphate levels closely (current 3.7 is acceptable but requires surveillance) as hypophosphatemia is the hallmark of refeeding syndrome 1
• Continue nutritional support but ensure gradual advancement over 72 hours with close monitoring of phosphate, potassium, magnesium, and thiamine 1
• Supplement thiamine even with mild deficiency given the risk profile 1

Medication Review for CNS-Active Agents

Pregabalin (current chronic pain medication) carries significant risk for neuromuscular adverse effects including ataxia, incoordination, tremor, and myoclonus, particularly in elderly patients with renal impairment. 3

• With GFR 67 mL/min, pregabalin dosing requires adjustment and close monitoring 3
• Pregabalin causes dose-related ataxia (15% at therapeutic doses), incoordination (4%), tremor (8%), and myoclonus (2%) 3
• The combination of pregabalin with electrolyte abnormalities and malnutrition significantly increases risk of neuromuscular adverse effects 3
• Consider temporary dose reduction or holding pregabalin during acute episode, then reintroducing at lower dose once electrolytes stabilized 3
• Monitor closely for CNS side effects including somnolence (22%), dizziness (32%), and confusion (4%) which could contribute to falls risk 3

Hydrocodone-acetaminophen PRN adds additional CNS depression risk and should be used cautiously during this acute period. 3

Nutritional Optimization Strategy

Severe protein-calorie malnutrition (E43) with albumin 3.0 and total protein 4.6 requires aggressive nutritional intervention with target of 30 kcal/kg/day and minimum 1.0-1.2 g/kg/day protein. 1

• Continue Pro-Stat supplementation but verify actual intake and absorption 1
• Target energy provision of approximately 30 kcal/kg/day based on current weight 1
• Protein requirements are minimum 1.0 g/kg/day, preferably 1.2 g/kg/day given multiple comorbidities and healing requirements 1
• Daily weights to monitor for fluid shifts versus true weight gain 1
• Weekly nutrition labs including albumin, prealbumin, total protein 1

In elderly patients with severe malnutrition, nutritional support has been shown to correct immune dysfunction, reduce confusion, and improve functional capacity within 21-42 days. 4, 5

Heart Failure Monitoring in SNF Setting

The most common reasons for rehospitalization in elderly Medicare beneficiaries with heart failure include electrolyte imbalances, altered mental status, and infections—all requiring priority surveillance. 1

• Daily weights and clinical assessment for volume overload 1
• The current electrolyte disturbances (hypokalemia, hypomagnesemia) are established precipitants of heart failure exacerbation 1
• Continue carvedilol, losartan, and furosemide but recognize that diuretic therapy is likely contributing to electrolyte losses 1
• Monitor for signs of congestion while aggressively repleting electrolytes 1

Leukocytosis Evaluation

WBC 19.4 with neutrophilic predominance (79%, absolute 15.3) requires close surveillance for occult infection, particularly pneumonia, urinary tract infection, or wound infection. 1

• No fever or localizing symptoms currently, but elderly patients often have blunted fever response 1
• Examine right shin wound carefully for signs of infection despite intact dressing 1
• Monitor for respiratory symptoms given COPD history 1
• Repeat CBC in 48-72 hours to assess trend 1
• Consider urinalysis if leukocytosis persists without clear source 1

Neurologic Monitoring Protocol

Close nursing neurologic monitoring is essential given the transient nature of symptoms and risk of recurrence. 6

• Assess coordination, trunk control, and extremity tone every 4 hours for next 24 hours, then every 8 hours for 48 hours 6
• Document ability to hold objects, perform ADLs, and maintain sitting balance 6
• Notify provider immediately if symptoms recur or worsen 6
• Falls precautions given impaired coordination and trunk control 6
• Consider physical therapy evaluation once acute episode resolves to assess baseline function and safety 6

Physical Activity Considerations

Despite acute episode, encourage physical activity and exercise as tolerated once symptoms resolve to maintain muscle mass and function. 1

• Older muscle remains responsive to anabolic stimuli of exercise even in severe malnutrition 1
• Range-of-motion exercises and positioning to prevent contracture development 6
• Avoid pharmacological sedation or physical restraints as these counteract nutritional goals and lead to muscle loss 1

Common Pitfalls to Avoid

• Do not correct potassium without simultaneously correcting magnesium—hypokalemia will be refractory 2
• Do not advance nutritional support too rapidly—risk of precipitating full refeeding syndrome with cardiac complications 1
• Do not overlook pregabalin as contributor—neuromuscular side effects are common and dose-related, particularly with renal impairment 3
• Do not assume leukocytosis is stress response—elderly patients with multiple comorbidities require thorough infection evaluation 1
• Do not restrict fluids excessively—maintain minimum 1.6 L/day for elderly female unless treating confirmed SIADH 1, 2

48-72 Hour Reassessment Points

• Repeat electrolytes to confirm correction trajectory 2
• Repeat CBC to assess leukocytosis trend 1
• Assess neurologic status for recurrence or new deficits 6
• Evaluate nutritional intake and tolerance 1
• Review medication regimen and consider pregabalin dose adjustment 3