What is the best approach for managing cough in elderly patients?

Cough Management in the Elderly

Elderly patients with chronic cough require a systematic diagnostic approach targeting the most common causes—upper airway cough syndrome (UACS), gastroesophageal reflux disease (GERD), and asthma/eosinophilic bronchitis—while recognizing that elderly-specific considerations include multiple comorbidities, polypharmacy, and the potential for both hypersensitive and hyposensitive cough reflexes. 1, 2

Initial Assessment and Mandatory Baseline Investigations

Obtain chest radiograph and spirometry as mandatory baseline investigations to exclude structural lung disease and assess airway function. 3 The elderly frequently present with more clinical heterogeneity due to multiple comorbidities, making thorough initial evaluation critical. 1

Critical Medication Review

• Immediately discontinue ACE inhibitors if present—no patient with troublesome cough should continue these medications. 3 ACE inhibitor-induced cough occurs in elderly patients, though incidence may decrease with advancing age. 4
• Review all medications for potential cough-inducing agents beyond ACE inhibitors. 3

Duration-Based Classification

• Acute cough (<3 weeks): Most commonly viral upper respiratory infection requiring symptomatic management only. 3, 5
• Chronic cough (>8 weeks): Requires systematic evaluation for underlying causes. 3, 6

Systematic Diagnostic and Treatment Algorithm

Step 1: Evaluate and Treat Upper Airway Cough Syndrome (UACS)

UACS is the most common cause of chronic cough in adults and should be addressed first, even in the absence of obvious postnasal drip symptoms. 7, 8 Approximately 20% of patients have "silent" UACS with no obvious nasal symptoms yet still respond to treatment. 7, 8

Clinical Features to Assess

• Look for cobblestoning of posterior pharyngeal wall, throat clearing, sensation of postnasal drainage. 7, 8
• Recognize that poor correlation exists between symptom severity and cough presence—absence of prominent upper airway symptoms does not exclude UACS. 8
• Perform ear, nose, and throat examination in preference to sinus imaging initially. 3, 8

Treatment Protocol for UACS

For elderly patients without cardiovascular contraindications:

• Initiate first-generation antihistamine/decongestant combination (e.g., dexbrompheniramine plus sustained-release pseudoephedrine) as first-line therapy. 7 This is the most effective evidence-based treatment with improvement expected within days to 2 weeks. 7
• To minimize sedation, start with once-daily dosing at bedtime for a few days before increasing to twice-daily therapy. 7
• Monitor blood pressure closely after initiating decongestant therapy, as decongestants can worsen hypertension and cause tachycardia. 7, 8

For elderly patients with cardiovascular contraindications (hypertension, heart disease):

• Start with intranasal corticosteroids (fluticasone 100-200 mcg daily) as first-line therapy for a minimum 1-month trial. 7, 8 These are effective for both allergic and non-allergic rhinitis-related cough without systemic cardiovascular effects. 7, 8
• Add ipratropium bromide nasal spray (42 mcg per spray, 2 sprays per nostril 4 times daily) for anticholinergic drying effects without systemic cardiovascular side effects. 7, 8
• Consider adding high-volume saline nasal irrigation (150 mL) to mechanically remove secretions and improve mucociliary function. 7

Common Pitfalls with UACS Treatment

• Never use topical nasal decongestants (oxymetazoline, xylometazoline) for more than 3-5 consecutive days due to risk of rhinitis medicamentosa. 7
• Allow adequate treatment duration—topical corticosteroids require a full month trial before declaring treatment failure. 8

Step 2: Evaluate and Treat Gastroesophageal Reflux Disease (GERD)

Failure to consider GERD as a cause for cough is a common reason for treatment failure, and reflux-associated cough may occur in the absence of gastrointestinal symptoms. 3 This is particularly important in elderly patients who may have atypical presentations. 1

Treatment Protocol for GERD

• Initiate intensive acid suppression with proton pump inhibitors (omeprazole 20-40 mg twice daily before meals) plus alginates for a minimum of 3 months. 3, 8
• Include dietary modifications: low-fat diet, avoid coffee, tea, chocolate, citrus, and alcohol. 8
• Improvement in cough from GERD treatment may take up to 3 months—never undertreat with shorter durations. 7, 8
• Empirical treatment should be offered before oesophageal testing, as no current test of oesophageal function predicts treatment response. 3

Step 3: Evaluate for Asthma/Eosinophilic Bronchitis

Cough may be the only manifestation of asthma or eosinophilic bronchitis, and no currently available tests of airway function can reliably exclude a corticosteroid-responsive cough. 3

Diagnostic Approach

• Perform bronchial provocation testing in patients without clinically obvious etiology who have chronic cough and normal spirometry. 3 A negative test excludes asthma but does not rule out steroid-responsive cough. 3
• If sputum eosinophilia is demonstrated, this has important treatment implications and should guide therapy. 3 Induced sputum should be requested after exclusion of other common causes. 3

Treatment Trial

• Cough is unlikely to be due to eosinophilic airway inflammation if there is no response to a two-week oral steroid trial. 3

Step 4: Sequential Evaluation if Initial Treatments Fail

If symptoms persist despite adequate treatment of UACS for 2 weeks, proceed with sequential evaluation for other causes rather than discontinuing partially effective treatments. 3, 7, 8 UACS, asthma, and GERD together account for approximately 90% of chronic cough cases. 7

• Maintain all partially effective treatments rather than discontinuing them prematurely, as multiple causes frequently coexist. 7, 8
• A combination of selected diagnostic testing and empirical trials of treatment is likely to be most cost-effective. 3

Special Considerations for Elderly Patients

Cough Reflex Sensitivity

The elderly present unique challenges with cough reflex that can be hypersensitive, normosensitive, or hyposensitive. 1, 2

• Hypersensitive cough reflex is mostly due to gastroesophageal reflux in nursing home patients. 9
• Hyposensitive cough reflex may result from central nervous system illnesses and poses risk for aspiration pneumonia. 9, 2 Marked depression of cough reflex sensitivity is reported in elderly patients with aspiration pneumonia. 9

Polypharmacy and Comorbidities

• Elderly patients frequently suffer from multiple comorbidities leading to more clinical heterogeneity in chronic cough. 1
• Exercise caution with first-generation antihistamines due to potential side effects including dry mouth, transient dizziness, insomnia, urinary retention, jitteriness, and increased intraocular pressure in glaucoma patients. 7
• Monitor for drug interactions given typical polypharmacy in elderly populations. 1

Acute Cough Management in the Elderly

For acute viral upper respiratory infections (cough <3 weeks), first-line pharmacologic therapy is a first-generation antihistamine combined with a decongestant to decrease cough severity. 5

• Over-the-counter analgesics (acetaminophen, ibuprofen, or naproxen) for symptomatic relief of associated sore throat. 5
• Antibiotics should not be used in patients with less severe presentations, as they have no role in viral upper respiratory infections. 5
• Dextromethorphan may be considered as an over-the-counter cough suppressant. 3, 10
• Reassess if cough persists beyond 3 weeks, which transitions to subacute/chronic cough requiring different evaluation. 5

When Cough Suppression May Be Contraindicated

Suppression may be relatively contraindicated especially when cough clearance is important for secretion management. 3, 8 This is particularly relevant in elderly patients with impaired cough reflex who are at risk for aspiration pneumonia. 9, 2

Referral to Specialist Cough Clinic

Referral to a specialist cough clinic should be encouraged for chronic cough that remains unexplained after thorough evaluation and adequate treatment trials. 3, 8

• Chronic cough should only be considered idiopathic following thorough assessment at a specialist cough clinic. 3, 8
• Specialist cough clinics provide improved patient outcomes, avoid inappropriate prescribing, and offer access to advanced diagnostic testing. 3

Key Pitfalls to Avoid

• Never diagnose idiopathic cough prematurely—ensure adequate treatment duration and thorough evaluation first. 8
• Never undertreat GERD—requires full 3-month trial of intensive acid suppression. 8
• Never continue ACE inhibitors in patients with troublesome cough. 3
• Never rely solely on physical examination findings—absence of typical UACS findings doesn't rule out the diagnosis. 7, 8
• Never use topical nasal decongestants for more than 3-5 days consecutively. 7
• Recognize that smoking cessation should be encouraged as it is accompanied by significant remission in cough symptoms. 3