What is the approach to a 90-year-old patient with a two-week history of diarrhea and a one-week history of nonproductive cough?

From the Guidelines

I would approach this 90-year-old patient with a thorough assessment focusing on both symptoms, as they could be related or separate issues requiring urgent attention, prioritizing their hydration status and potential for serious underlying conditions such as pneumonia or heart failure, as indicated by the guidelines for managing infectious diarrhea and cough 1.

Initial Assessment

First, I'd take a complete history including medication use, recent antibiotic exposure, travel, dietary changes, and contact with ill individuals. For the diarrhea, I would assess frequency, consistency, presence of blood or mucus, and associated symptoms like abdominal pain or fever. Laboratory tests should include complete blood count, comprehensive metabolic panel, C-reactive protein, and stool studies for infectious causes including Clostridioides difficile. For the cough, I would evaluate for fever, shortness of breath, chest pain, and perform a chest examination and possibly chest X-ray to rule out pneumonia or heart failure.

Management of Diarrhea

Given the patient's age and the potential for dehydration, initial management would include oral rehydration, possibly with electrolyte solutions, while avoiding anti-motility agents until infectious causes are ruled out, as suggested by guidelines for managing acute diarrhea 1. Empiric treatment might include loperamide 2mg after each loose stool (maximum 8mg/day) for non-infectious diarrhea.

Management of Cough

For the cough, considering the guidelines for the diagnosis and management of cough 1, symptomatic treatment with dextromethorphan 10-20mg every 4 hours could be appropriate if the cough is deemed to be postinfectious or of another nature not requiring specific antibiotic therapy. It's crucial to rule out other causes of cough such as upper airway cough syndrome, asthma, or gastroesophageal reflux disease.

Consideration of Underlying Conditions

In elderly patients, these symptoms could indicate serious conditions like inflammatory bowel disease, ischemic colitis, medication side effects, or respiratory infections. Therefore, a comprehensive approach considering the patient's overall health status, potential for dehydration, and the need for prompt diagnosis and treatment of underlying causes is essential, as highlighted by the guidelines for managing infectious diarrhea 1 and the approach to cough in elderly patients 1.

From the FDA Drug Label

Elderly No formal pharmacokinetic studies were conducted in elderly subjects However, there were no major differences reported in the drug disposition in elderly patients with diarrhea relative to young patients. No dose adjustment is required for the elderly.

In general, elderly patients may be more susceptible to drug-associated effects of the QT interval

Avoid loperamide hydrochloride capsules in elderly patients taking drugs that can result in prolongation of the QT interval (for example, Class IA or III antiarrhythmics) or in patients with risk factors for Torsades de Pointes (see WARNINGS).

The patient is a 90-year-old with diarrhea for two weeks and a cough for one week.

• The loperamide dosage for elderly patients does not require adjustment.
• However, caution is advised due to potential QT interval effects.
• Loperamide may be used to treat diarrhea, but the patient's cough is not addressed by this medication.
• The patient should receive appropriate fluid and electrolyte replacement as needed.
• It is recommended to follow the standard dosage for acute diarrhea in adults: an initial dose of 4 mg followed by 2 mg after each unformed stool, with a maximum daily dose of 16 mg.
• The patient's cough should be evaluated separately, as loperamide is not indicated for this symptom 2.

From the Research

Approach to a 90-year-old patient with diarrhea and cough

• The patient's symptoms of diarrhea for two weeks and a nonproductive cough for one week require a thorough evaluation to determine the underlying cause.
• According to 3, diarrhea in the elderly can have multiple causes, including infectious, osmotic, secretory, inflammatory, and malabsorptive mechanisms.
• The patient's age and symptoms suggest the need for a comprehensive approach, including clinical history, physical examination, and stool evaluation, as outlined in 4.
• Loperamide, an antidiarrheal medication, may be considered as a treatment option, as it has been shown to be effective in controlling diarrhea symptoms in various studies, including 5, 6, and 7.
• However, it is essential to address the root cause of the diarrhea, as stated in 3, to improve outcomes.
• The nonproductive cough may be related to the diarrhea or a separate condition, and further evaluation is necessary to determine the cause and appropriate treatment.
• The patient's advanced age and potential comorbidities should be taken into account when selecting a treatment plan, as elderly patients may be more susceptible to adverse effects and interactions with other medications, as noted in 6.