What is the best management strategy for an 87-year-old female patient with hypertension, impaired renal function, and currently taking amlodipine 10mg once daily?

Management of Hypertension in an 87-Year-Old Female with Renal Impairment

For an 87-year-old female with hypertension (146/88 mmHg), impaired renal function (Cr 1.72), and currently on amlodipine 10mg daily, the optimal approach is to add an angiotensin receptor blocker (ARB) while maintaining a more lenient blood pressure target of <140/90 mmHg appropriate for her advanced age. 1

Assessment of Current Situation

• Current BP: 146/88 mmHg - slightly above target for elderly patients
• Age: 87 years - falls into the very elderly category (≥85 years)
• Renal function: Impaired (Cr 1.72) - indicates moderate renal dysfunction
• Current medication: Amlodipine 10mg daily (maximum recommended dose)

Blood Pressure Targets for Elderly Patients

• For patients ≥85 years old, the European Society of Cardiology recommends a more lenient target of <140/90 mmHg 1
• Aggressive BP lowering in elderly patients increases risks of:
  • Orthostatic hypotension
  • Falls
  • Adverse medication effects

Medication Management Recommendations

1. Maintain amlodipine 10mg daily

   • Amlodipine is effective and safe in patients with renal dysfunction 2, 3
   • No dosage adjustment is necessary for amlodipine in renal impairment 3

2. Add an ARB as second-line agent

   • The American College of Cardiology suggests using ARBs in combination with calcium channel blockers for patients with chronic kidney disease 1
   • Start with a low dose and titrate based on BP response and renal function

3. Avoid certain medications

   • Avoid non-dihydropyridine CCBs (diltiazem, verapamil) due to negative inotropic properties 1
   • Use mineralocorticoid receptor antagonists with caution due to risk of hyperkalemia, especially with creatinine >2.5 mg/dL 4
   • Avoid thiazide diuretics if CrCl <30 mL/min 4

Monitoring Recommendations

1. Regular BP monitoring

   • Check for orthostatic hypotension by measuring BP supine and after standing for 1 and 3 minutes 1
   • Monitor for symptoms of hypotension (dizziness, falls)

2. Renal function monitoring

   • Check renal function and electrolytes within 1-2 weeks of adding a new antihypertensive agent
   • Monitor potassium levels, especially if adding an ARB 4

3. Medication review

   • Assess for polypharmacy and potential drug interactions
   • Consider starting with the lowest effective dose of any new medication due to age-related changes in pharmacokinetics 5

Special Considerations for This Patient

• Frailty assessment: Evaluate for frailty as it may warrant even less aggressive BP targets 1
• Renal protection: ARBs provide additional renal protection beyond BP control in patients with kidney disease
• Loop diuretics: Consider a loop diuretic instead of thiazide if estimated GFR is severely reduced 1

Common Pitfalls to Avoid

• Overly aggressive BP lowering: Can lead to orthostatic hypotension, falls, and cognitive impairment in elderly patients
• Rapid medication changes: Make one change at a time and allow adequate time for assessment (7-14 days between titration steps) 5
• Ignoring orthostatic BP changes: Always check for postural drops in BP in elderly patients
• Neglecting renal function: Close monitoring is essential when adding medications that affect the renin-angiotensin system

By following this approach, you can achieve better BP control while minimizing risks in this elderly patient with renal impairment.