What is the appropriate workup for an 85-year-old male presenting with cough and fatigue to the office?

Workup for Cough and Fatigue in 85-Year-Old Male

The appropriate workup for an 85-year-old male presenting with cough and fatigue should begin with a chest radiograph and spirometry, followed by targeted investigations based on the duration of cough and associated symptoms. 1, 2

Initial Assessment

Determine Duration of Cough

• Acute cough (<3 weeks): Likely viral and self-limiting if no concerning features
• Chronic cough (>8 weeks): Requires comprehensive evaluation

Essential History Elements

• Duration and character of cough (productive vs. non-productive)
• Associated symptoms (hemoptysis, weight loss, fever, dyspnea)
• Medication review (particularly ACE inhibitors)
• Smoking history (dose-related association with persistent cough)
• Occupational exposures and environmental triggers
• Past medical history (focus on respiratory, cardiac, and malignant conditions)

Mandatory Initial Investigations

1. Chest radiograph - To evaluate for pneumonia, malignancy, heart failure, tuberculosis 1, 2
2. Spirometry with bronchodilator response - To assess for obstructive or restrictive lung disease 1, 2
3. Basic laboratory tests - Complete blood count, basic metabolic panel, and inflammatory markers

Further Investigations Based on Initial Findings

If Initial Tests Are Normal

• Consider empiric treatment trials based on most common causes:
  • Upper airway cough syndrome/post-nasal drip
  • Cough-variant asthma
  • Gastroesophageal reflux disease
  • ACE inhibitor-induced cough (if applicable)

Red Flags Requiring Immediate Further Investigation

• Hemoptysis
• Significant weight loss
• Persistent fever
• Severe dyspnea or hypoxemia
• Abnormal chest radiograph findings 2

Additional Targeted Testing

• High-resolution CT scan - If initial investigations are normal but cough persists 2
• Bronchoscopy - If suspicion of foreign body, endobronchial lesion, or lung cancer 1, 2
• COVID-19 testing - Particularly important in elderly patients with cough and fatigue 2
• Pertussis testing - Consider in persistent cough (paired acute and convalescent sera) 1

Special Considerations for Elderly Patients

• Medication review is critical - No patient with troublesome cough should continue on ACE inhibitors 1
• Consider atypical presentations - Elderly patients may not present with classic symptoms
• Evaluate for aspiration risk - Oral-pharyngeal dysphagia is common in elderly and can cause chronic cough 1
• Consider cancer-related fatigue - Particularly in those with history of malignancy 2

Management Approach

1. Treat identified underlying causes
2. For suspected asthma or eosinophilic bronchitis with normal spirometry, consider a 2-week oral steroid trial 1
3. If pertussis is confirmed, prescribe macrolide antibiotics 1
4. For smokers, strongly encourage smoking cessation 1

Pitfalls to Avoid

• Failing to obtain a chest radiograph in elderly patients with cough
• Missing ACE inhibitor-induced cough (can take up to 4 weeks to resolve after discontinuation)
• Overlooking occupational and environmental triggers
• Neglecting to consider multiple concurrent causes of cough in elderly patients
• Assuming all chronic cough in elderly is due to common causes without appropriate investigation

The British Thoracic Society guidelines emphasize that no patient with troublesome cough should continue on ACE inhibitors, and smoking cessation should be strongly encouraged as it is accompanied by significant remission in cough symptoms 1.