What is the recommended treatment for a cold and cough in elderly patients?

Treatment of Cold and Cough in the Elderly

For elderly patients with cold and cough, use first-generation antihistamine/decongestant combinations as first-line therapy for nasal symptoms, and dextromethorphan 60 mg for bothersome cough, while avoiding these medications in patients with glaucoma, benign prostatic hypertrophy, or uncontrolled hypertension. 1, 2

Initial Assessment: Rule Out Serious Conditions

Before treating as a simple cold, exclude pneumonia by checking for:

• Tachycardia, tachypnea, or fever with systemic illness 2
• Abnormal chest findings: dullness to percussion, bronchial breathing, or crackles 1, 2
• Significant hemoptysis, progressive breathlessness, or voice changes requiring immediate referral 2

First-Line Pharmacological Treatment

For Nasal Congestion and Rhinorrhea

Use older-generation (first-generation) antihistamine plus decongestant combinations, such as dexbrompheniramine 6 mg twice daily plus pseudoephedrine 120 mg twice daily. 1 These work through anticholinergic properties rather than antihistamine effects and are effective within days to 2 weeks. 1

Critical contraindications in elderly patients include:

• Glaucoma (increased intraocular pressure risk) 1, 2
• Symptomatic benign prostatic hypertrophy (urinary retention risk) 1, 2
• Uncontrolled hypertension 1, 2
• Renal failure or congestive heart failure 2

Do NOT use newer nonsedating antihistamines (loratadine, terfenadine) as they are ineffective for cold-related cough. 1

For Bothersome Cough

Dextromethorphan 60 mg is the preferred antitussive with maximum cough suppression and superior safety profile compared to codeine. 1, 2, 3, 4 Lower doses are subtherapeutic; the dose-response relationship shows optimal effect at 60 mg. 1, 3

Avoid codeine or pholcodine as they have no greater efficacy than dextromethorphan but significantly more adverse effects, particularly problematic in elderly patients. 1, 3

For Nighttime Cough Disrupting Sleep

First-generation sedating antihistamines suppress cough while aiding sleep, making them suitable for nocturnal symptoms in elderly patients without contraindications. 1, 2, 3

Alternative and Adjunctive Options

Non-Pharmacological First

Simple home remedies like honey and lemon are recommended as initial cost-effective approaches without adverse effects, particularly important in elderly patients with multiple comorbidities. 1, 2, 3

Additional Symptomatic Relief

• Menthol inhalation provides acute but short-lived cough suppression and can be used as needed 1, 2, 3
• Ipratropium bromide nasal spray is the only inhaled anticholinergic recommended for cough suppression in upper respiratory infections 1, 3
• Naproxen as monotherapy is an alternative for cold symptoms, though monitor for gastrointestinal bleeding risk in elderly 2

Critical Pitfalls to Avoid in Elderly Patients

Medication-related errors:

• Do NOT prescribe antibiotics for uncomplicated viral cold—they provide no benefit 2, 5
• Avoid combination products containing excessive paracetamol when using higher-dose dextromethorphan 1, 2
• Do NOT use albuterol for cough not due to asthma 1, 6
• Avoid over-the-counter combination products unless they contain older antihistamine/decongestant ingredients 1, 2

Elderly-specific concerns:

• Start antihistamines once daily at bedtime for several days before advancing to twice-daily dosing to minimize sedation 1
• Monitor carefully for urinary retention in older men, even without known prostatic hypertrophy 1
• Watch for insomnia, jitteriness, tachycardia, or worsening hypertension from decongestants 1

Expected Timeline and When to Reassess

Cough from uncomplicated viral infection should gradually improve over 1-2 weeks. 2, 5 Reassess if:

• Symptoms worsen after initial improvement (biphasic worsening suggests bacterial sinusitis) 2
• No improvement after one week 2
• Symptoms persist beyond 2-3 weeks without steady improvement 2
• Green or yellow sputum develops, suggesting bacterial superinfection 7

Practical Dosing Algorithm for Elderly

1. If nasal congestion predominates without contraindications: First-generation antihistamine/decongestant combination 1, 2
2. If dry cough predominates: Dextromethorphan 60 mg 1, 2, 3
3. If nighttime cough disrupts sleep: First-generation sedating antihistamine 1, 2
4. If multiple contraindications exist: Start with honey/lemon and menthol inhalation, consider ipratropium nasal spray 1, 2, 3