From the Guidelines
Costochondritis in an 88-year-old patient should be managed with caution, prioritizing pain relief while minimizing the risk of adverse effects, particularly gastrointestinal and cardiovascular complications. The management of costochondritis in elderly patients requires a careful balance between effective pain control and the potential risks associated with certain medications. Given the patient's age, it is essential to start with the safest options for pain relief. According to the guidelines for the appropriate use of non-steroidal anti-inflammatory drugs, cyclo-oxygenase-2-specific inhibitors, and proton pump inhibitors in patients requiring chronic anti-inflammatory therapy 1, the use of NSAIDs in patients aged ≥ 65 years, especially those with previous complicated gastrointestinal events or on medications like aspirin, steroids, or warfarin, should be approached with caution. Key considerations include:
- Starting with acetaminophen (Tylenol) at 500-650mg every 6 hours as needed, not exceeding 3000mg daily, due to its relatively safer profile in elderly patients.
- Considering topical NSAIDs like diclofenac gel 1% applied to the affected area 3-4 times daily if acetaminophen provides insufficient relief, to minimize systemic exposure.
- Avoiding oral NSAIDs unless absolutely necessary due to their increased risk of gastrointestinal bleeding, kidney problems, and cardiovascular events in this age group.
- Physical therapy focusing on gentle stretching and posture improvement, and avoiding activities that worsen chest pain, can be beneficial.
- A supportive brace might provide comfort during daily activities. It is crucial to rule out serious conditions like heart attack, pulmonary embolism, or pneumonia before confirming a costochondritis diagnosis, especially in elderly patients where these conditions can present atypically 1. The condition typically resolves within weeks to months but may recur, emphasizing the need for ongoing monitoring and adjustment of the treatment plan as necessary.
From the Research
Clinical Implications of Costochondritis
The clinical implications of costochondritis in an 88-year-old patient can be significant, with potential impacts on daily activities and quality of life.
- Costochondritis can last from several weeks to several months, limiting the patient's ability to perform tasks at work and home 2.
- The condition can cause significant chest pain and decline in ability of daily activities, particularly in cases of Tietze syndrome, a rare form of chest wall costochondritis with joint swelling 3.
Treatment Options
Various treatment options are available for costochondritis, including:
- Physical therapy (PT) utilizing an impairment-based examination and treatment approach, including manual therapy and therapeutic exercise, which may facilitate the resolution of costochondritis 2.
- Oral corticosteroids, which have been shown to be effective in improving pain and quality of life in patients with Tietze syndrome 3.
- Stretching exercises, which can provide a significant amelioration in pain for patients with costochondritis 4.
- Traditional practice of treating with acetaminophen or anti-inflammatory medications, advising patients to avoid activities that produce chest muscle overuse, and providing reassurance 5.
Diagnostic Considerations
It is essential to distinguish costochondritis from other, more serious causes of chest pain, particularly in older adults or those with a history or risk of coronary artery disease 5.
- Patients older than 35 years, those with a history or risk of coronary artery disease, and any patient with cardiopulmonary symptoms should have an electrocardiograph and possibly a chest radiograph 5.
- Further testing may be necessary to rule out cardiac causes if clinically indicated by age or cardiac risk status 5.