What is the acute management of cough in the elderly?

From the Guidelines

The acute management of cough in elderly patients should prioritize identifying and treating the underlying cause, while providing symptomatic relief with caution against overuse of antibiotics and careful consideration of potential drug interactions. For immediate symptom management, consider short-term use of dextromethorphan 15-30mg every 4-6 hours (maximum 120mg daily) for dry, non-productive coughs, as suggested by guidelines for managing adult lower respiratory tract infections 1.

When considering the use of antibiotics, it's crucial to note that they are rarely effective for acute cough and are not indicated for acute cough from the common cold, acute bronchitis, asthma, mild exacerbations of chronic bronchitis related to smoking, or environmental irritants, according to guidelines for treating adults with acute cough 1. However, antibiotics may be effective for conditions such as pneumonia, upper airway cough syndrome from bacterial sinusitis, and Bordetella pertussis infection in the lower respiratory tract (whooping cough) if given early in the illness, as well as for exacerbations of bronchiectasis and severe chronic bronchitis in current or previous smokers with severe airflow obstruction 1.

Key considerations in the management of cough in elderly patients include:

• Avoiding codeine-based cough suppressants due to increased risk of confusion, constipation, and falls
• Using antihistamines like diphenhydramine cautiously due to anticholinergic side effects
• Considering intranasal corticosteroids like fluticasone (1-2 sprays per nostril daily) for coughs due to post-nasal drip
• Ensuring adequate hydration with 6-8 glasses of water daily to thin secretions
• Using a humidifier to moisten dry air, which can aggravate cough
• Positioning the patient with head elevated to reduce nocturnal cough
• Always checking for drug interactions before starting any cough medication, given the high likelihood of multiple comorbidities and concurrent medications in elderly patients

If cough persists beyond 2 weeks, worsens, or is accompanied by fever, shortness of breath, or chest pain, prompt medical evaluation is necessary to rule out serious conditions like pneumonia, heart failure, or medication side effects. This approach prioritizes the reduction of morbidity, mortality, and improvement of quality of life for elderly patients with acute cough.

From the FDA Drug Label

USES Helps loosen phlegm (mucus) and thin bronchial secretions to make coughs more productive. The FDA drug label does not answer the question.

From the Research

Acute Management of Cough in Elderly

• The German Respiratory Society guidelines for diagnosis and treatment of adults suffering from acute, subacute, and chronic cough provide recommendations for the management of cough, including acute cough 2.
• The guidelines emphasize the importance of understanding the physiology of cough and the introduction of new drugs, as well as detailed treatment for cough triggered by affectations of the upper respiratory tract or gastroesophageal reflux.
• Gastroesophageal reflux disease (GERD) is a common cause of chronic cough, and the management of GERD is crucial in the treatment of cough 3, 4, 5.
• Proton pump inhibitors (PPIs) are the first-choice therapy in the treatment of GERD, but a consistent proportion of patients continue to experience symptoms despite their intake 4, 5.
• Lifestyle changes, such as weight loss and smoking cessation, are often useful in the management of GERD 5.
• Antidepressant medications can also contribute to the development of GERD, and the emergence of GERD symptoms should be evaluated when initiating antidepressant therapy 6.

Treatment Options

• Medication with a PPI is the most common treatment for GERD, and after initial full-dose therapy, the aim is to use the lowest effective dose 5.
• Surgery with laparoscopic fundoplication is an invasive treatment alternative in select patients after thorough and objective assessments 5.
• New endoscopic and less invasive surgical procedures are evolving, which may reduce the use of long-term PPI and fundoplication 5.

Considerations

• The clinical management of GERD influences the lives of many individuals and is responsible for substantial consumption of health care and societal resources 5.
• Long-term PPI therapy requires follow-up and reevaluation for potential adverse effects 5.
• The emergence of GERD symptoms should be evaluated when initiating antidepressant therapy, and the anticholinergic profile of medications should be considered 6.