What is the recommended treatment for hypertension (HTN) in a patient in a skilled nursing facility (SNF)?

Hypertension Management in Skilled Nursing Facilities

For patients with hypertension in skilled nursing facilities (SNFs), treatment should follow guideline-directed medical therapy with individualized medication selection based on comorbidities, while incorporating careful monitoring and lifestyle modifications appropriate for the SNF setting. 1, 2

Initial Assessment and Treatment Approach

• Medication Selection: Choose first-line agents based on patient-specific factors:

  • For patients with albuminuria: ACE inhibitor or ARB 2
  • For patients with heart failure: ACE inhibitor/ARB, beta-blocker, diuretic 1
  • For Black patients: ARB + dihydropyridine CCB or dihydropyridine CCB + thiazide-like diuretic 2
  • For non-Black patients: ACE inhibitor/ARB, with alternatives including dihydropyridine CCBs or thiazide-like diuretics 2

• Blood Pressure Targets:

  • For most SNF residents: <130/80 mmHg 2
  • For adults ≥65 years: <150 mmHg systolic (with consideration of <140 mmHg for those with high cardiovascular risk) 2

Medication Management in SNF Setting

1. First-line medications (based on comorbidities):

   • ACE inhibitors (e.g., lisinopril): Start at lower doses (5-10 mg daily) for elderly patients 3
   • ARBs (e.g., losartan): Alternative for those who develop cough with ACE inhibitors 4
   • Calcium channel blockers (dihydropyridine)
   • Thiazide or thiazide-like diuretics

2. Monitoring requirements:

   • Check serum creatinine/eGFR and potassium within 7-14 days after initiation of ACE inhibitors, ARBs, or diuretics 2
   • Monitor for orthostatic hypotension, especially in elderly patients 1
   • Regular weight measurements to assess fluid status 1
   • Daily assessment of symptoms (shortness of breath, edema) 1

3. Dosage adjustments:

   • Start with lower doses in elderly patients
   • Titrate medications slowly based on blood pressure response and tolerability
   • Consider reducing diuretic doses once euvolemia is achieved 1

SNF-Specific Considerations

1. Staff Education and Monitoring:

   • Train nursing staff to monitor for signs of volume overload 1
   • Implement structured assessment protocols for symptoms and vital signs 1
   • Establish clear parameters for when to notify providers about BP changes 1

2. Quality Improvement Measures:

   • Implement chart audit and feedback systems 1
   • Use clinical decision support tools for medication management 1
   • Establish reminder systems for medication reviews and laboratory monitoring 1

3. Lifestyle Modifications Appropriate for SNF Setting:

   • Dietary sodium restriction (ideally <100 mEq sodium/24 hours) 1
   • Supervised physical activity appropriate to functional status 1, 2
   • Weight management for overweight residents 1
   • Moderation of alcohol intake 1

Common Pitfalls and Caveats

• Avoid therapeutic inertia - regularly review medication efficacy and adjust as needed
• Don't combine ACE inhibitors with ARBs - increases risk of hyperkalemia and acute kidney injury without additional benefit 2
• Beware of orthostatic hypotension - particularly common in elderly SNF residents
• Monitor for medication adherence - SNF setting provides opportunity for supervised administration
• Consider drug interactions - elderly patients often take multiple medications
• Watch for worsening renal function - especially with ACE inhibitors, ARBs, and diuretics in elderly patients

Treatment Algorithm

1. Initial therapy:

   • Select agent based on comorbidities (see above)
   • Start with lower doses than typically used in younger adults
   • For significantly elevated BP (>20/10 mmHg above goal), consider two-drug combination therapy 2

2. If BP not controlled on initial therapy:

   • Ensure medication adherence
   • Increase dose of initial agent if tolerated
   • Add second agent from a different class
   • Consider three-drug combination if needed: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic 2

3. For resistant hypertension:

   • Add spironolactone as fourth-line agent if renal function permits 2
   • Review and address lifestyle factors 1
   • Consider secondary causes of hypertension 1

By implementing this comprehensive approach to hypertension management in SNF residents, providers can effectively control blood pressure while minimizing adverse effects and improving quality of life.