What is the best initial approach for an elderly patient presenting with headache, runny nose, and cough without fever?

Management of Elderly Patient with Headache, Runny Nose, and Cough Without Fever

This presentation is most consistent with a viral upper respiratory infection (common cold), and should be managed with symptomatic treatment only—antibiotics are not indicated. 1

Initial Diagnostic Approach

The absence of fever in this elderly patient is reassuring but not definitive, as elderly patients may lack typical fever response even with serious bacterial infections 2, 3. However, the constellation of runny nose, cough, and headache starting a few days ago strongly suggests a viral URI rather than bacterial infection. 1

Key Clinical Assessment Points

Rule out pneumonia by assessing for:

• Tachypnea (respiratory rate >20/min) 4
• Tachycardia (heart rate >100 bpm) 4
• Dyspnea or abnormal lung findings on auscultation 5
• Absence of runny nose (its presence argues against pneumonia) 1

The presence of nasal symptoms (runny nose) is a critical distinguishing feature—it strongly suggests common cold rather than acute bronchitis or pneumonia. 1 In fact, acute bronchitis should not be diagnosed unless the common cold has been ruled out, as their definitions overlap and bronchitis diagnosis leads to unnecessary antibiotic prescriptions 65-80% of the time. 1

When to Consider Chest Radiography

Chest radiography is NOT indicated for this patient unless specific high-risk features develop 1:

• Fever ≥38°C (100.4°F) 4
• Tachycardia or tachypnea 4
• Dyspnea or abnormal lung examination 5
• Dementia (elderly patients with dementia have >75% prevalence of pneumonia when presenting with respiratory complaints) 1

Recommended Symptomatic Treatment

First-line therapy should include a first-generation antihistamine/decongestant combination, which has been shown in double-blind placebo-controlled studies to decrease cough severity and hasten resolution. 1, 5, 4 Examples include diphenhydramine with pseudoephedrine or phenylephrine. 6

Additional symptomatic measures:

• Acetaminophen (paracetamol) for headache and general achiness 5, 4
• Naproxen (NSAID) as an alternative, which favorably affects cough in common cold 1, 4
• Adequate fluid intake to avoid dehydration (no more than 2 liters per day) 5, 4
• Honey for cough suppression if culturally acceptable 5, 4

Important Contraindications in Elderly Patients

Exercise caution with first-generation antihistamine/decongestants in patients with: 1

• Glaucoma
• Benign prostatic hypertrophy
• Uncontrolled hypertension
• Congestive heart failure

Avoid NSAIDs (naproxen) in patients with: 1

• Renal failure
• Gastrointestinal bleeding history
• Congestive heart failure

Do NOT use newer-generation nonsedating antihistamines—they are ineffective for acute cough from common cold. 1, 4

When Antibiotics Would Be Indicated

Antibiotics should be reserved ONLY for specific bacterial complications, not for the common cold itself. 1 Consider antibiotics if the patient develops:

Acute Bacterial Rhinosinusitis Criteria 1:

• Symptoms persisting >10 days without improvement, OR
• Severe symptoms: fever >39°C with purulent nasal discharge or facial pain for ≥3 consecutive days, OR
• "Double sickening": worsening symptoms after initial improvement (new fever, headache, or increased nasal discharge after 5 days of typical viral URI)

Pneumonia Indicators 1, 4:

• Fever ≥38°C with tachycardia and dyspnea
• Abnormal lung examination findings
• Radiographic confirmation

Critical Pitfalls to Avoid

Do not prescribe antibiotics for uncomplicated viral URI—the number needed to harm (8) exceeds the number needed to treat (18) for acute rhinosinusitis. 1

Do not dismiss the headache without considering secondary causes in elderly patients, particularly if it is new-onset, severe, or associated with neurologic symptoms. 7, 8, 9 However, in the context of concurrent runny nose and cough, the headache is most likely sinus congestion or viral URI-related. 1

Do not overlook functional decline as a sign of serious infection in elderly patients—unexplained change in mental status, weakness, or falls may be the only manifestation of pneumonia or other serious bacterial infection. 2, 3

Follow-Up Instructions

Advise the patient to return immediately if: 4

• High fever develops (>38.5°C)
• Worsening dyspnea or chest pain
• Signs of respiratory distress
• Symptoms persist beyond 3 weeks (reclassify as subacute cough and reassess) 4

Reassess within 48-72 hours to ensure clinical improvement and that no bacterial complications have developed. 4