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l REVIEW Coughing in the Elderly Fae Farrer, BPharm Amayeza Info Centre Abstract Coughing is a normal reflex reaction due to stimulation of the cough receptors in the brain. Generally, elderly patients have an increased incidence of illnesses and take more medications compared to younger patients.1 This potentially increases risks of drug interactions and side effects. Because coughing can be a symptom of another underlying disease, a careful evaluation of signs, symptoms and other factors must be undertaken when an elderly patient presents with a cough. Introduction Coughing is one of the most common symptoms for which treatment is sought in the community pharmacy.3 The cough reflex is a vital part of the body’s defence mechanisms.4 Along with other mechanisms, coughing helps to protect the lungs from particles that have been inhaled. The expulsion of air during a cough will force the particles out of the airways. Elderly patients tend to have an increased incidence of illnesses, including those affecting the lungs. Although a cough may be a trivial symptom, it can also point to a more serious underlying disease. Therefore, it is important to identify the cause of the cough and if this is not possible, to refer the elderly patient for further medical attention. Who is elderly? The increase in illnesses, symptoms and pathologies becomes most apparent after the age of 65 years.1 However, the elderly are not a uniform group. The ‘old’ elderly (those over 75 years) show greater age-related changes in drug disposition and response than the ‘young’ elderly. The sick elderly patient may tolerate and respond differently to medications than the well elderly person.1 What is a cough? A cough is a natural reflex reaction to an irritation in the air passages and lungs. Air is drawn into the air passages with the glottis open. The inhaled air is blown out against the closed glottis, which, as the pressure builds, suddenly opens, expelling the air at speeds of up to 960 kilometres per hour. This expels harmful substances from the respiratory tract.2 Coughing helps the body to rid itself of excess mucus and other irritants. The physical efforts of persistent coughing can increase irritation of the air passages and cause distress to the patient.2 Each cough occurs through the irritation of cough receptors. These receptors may be found not only in the upper and lower respiratory tracts, but also in the pericardium, oesophagus, diaphragm and stomach. Chemical receptors are sensitive to acid, heat and 20 SAPJMay10pp20-24.indd 20 capsaicin-like compounds.3 Triggers such as touch or displacement can stimulate mechanical receptors.3 Some receptors such as those found in the larynx and trachea, respond to both chemical and mechanical stimuli.3 Impulses from stimulated receptors are transmitted to a “cough centre” in the brain. A signal is generated to the expiratory muscles to cause the cough.3 Causes of cough Cough may be classified by duration of the cough. Acute cough lasts for less than three weeks and is commonly due to an acute respiratory infection. Coughing that has lasted for more than 3 weeks, but less than eight weeks, is classed as sub-acute, while a cough that has been present for more than eight weeks is known as a chronic cough.3 The causes of cough are summarised in Table I. Acute cough: • Choking – sucking or inhaling liquid or solid particles into the airways leads to intense coughing. This coughing bout may cause discomfort but generally does not require medical attention once the foreign matter is expelled, unless some of the material is aspirated. Aspiration requires medical treatment to prevent infection and lung damage. If the foreign body is not expelled and occludes the airway, coughing may cease, followed by cyanosis and unconsciousness. This is a medical emergency. • Acute respiratory tract infection – Bacterial or viral infections of the respiratory tract such as acute bronchitis, sinusitis, laryngitis, pharyngitis or pneumonia may produce increased mucus and inflammation, which causes coughing. These conditions should clear within two to three weeks with appropriate treatment. The cough may continue after the acute symptoms of the infection have disappeared due to irritability of the airways.3,5 Chronic cough: • Postnasal drip – cough due to postnasal drip may also be referred to as upper airway cough syndrome.3 This is one of the most common causes of sub-acute and chronic cough. The main reasons for a postnasal drip include allergic rhinitis, perennial non-allergic rhinitis, vasomotor rhinitis, acute naso-pharyngitis and sinusitis.3 Increased secretions in the upper airway stimu- SA Pharmaceutical Journal – May 2010 5/14/2010 10:43:18 AM 19896 B l REVIEW late cough receptors in the laryngeal mucosa. Symptoms may include nasal discharge, a sensation of fluid dripping in the back of the throat and frequent throat clearing. A “silent” postnasal drip causes no symptoms other than a cough. Symptoms and signs of postnasal drip are non-specific, and it is the response to treatment that confirms the diagnosis.3 When patients have no other obvious cause for a cough, treatment for postnasal drip should be considered. Allergy-related coughs may be non-productive and worse at night. However, other symptoms such as nasal congestion, itching of the eyes, nose or mouth are usually present.7 •Asthma – is considered to be one of the leading causes of persistent cough in adults and the most common cause of chronic cough in children.3 Asthma is commonly characterised by coughing, wheezing, shortness of breath (dyspnoea) and chest tightness.7 However, asthma may present solely as a non-productive cough. This is known as cough-variant asthma, and can progress to include wheezing and shortness of breath.3 Asthma-related cough may be seasonal, may follow a respiratory infection, or may worsen with exposure to cold, dry air or certain allergens.3 •Gastro-oesophageal reflux disease (GORD) – is one of the most common causes of chronic cough.3 Many patients with cough due to acid reflux complain of heartburn or a sour taste in the mouth, but these symptoms are not present in all patients for whom cough is related to acid reflux.3,5 Cough associated with GORD is potentially due to the following: stimulation of receptors in the larynx, aspiration of stomach contents, leading to irritation of receptors in the lower respiratory tract, or reflux of acid into the oesophagus.3 Table I: Causes of cough Choking Respiratory tract infections: • Acute bronchitis • Laryngitis • Pharyngitis • Tonsillitis • Sinusitis • Pneumonia Postnasal drip: • Allergic • Perennial non-allergic • Vasomotor rhinitis • Sinusitis Asthma Gastro-oesophageal Reflux Disease (GORD) Chronic bronchitis Lung cancer Smoking Eosinophilic bronchitis ACE inhibitors# Bronchiectasis Tuberculosis (TB) Heart Failure The side effect profiles of many other medications also list cough as a possible adverse effect, for example non-steroidal anti-inflammatories (NSAIDs) and beta-blockers.7 However, these are not often associated with chronic cough. # Note: Cough can also be caused by other factors such as pertussis, croup (in children) and vocal cord paralysis. In the elderly, swallowing dysfunction may lead to chronic cough.3 22 SAPJMay10pp20-24.indd 22 Cough due to acid reflux may be exacerbated when lying down.7 •Chronic bronchitis – is defined as the presence of a cough and the production of sputum on most days over a three-month period for at least two consecutive years.3 Almost all patients are smokers, although a few have airway inflammation due to chronic exposure to other fumes and dusts.3 The cough is usually productive, producing a clear or white sputum.3 The term COPD (chronic obstructive pulmonary disease) is often used interchangeably with the terms chronic bronchitis and/or emphysema because chronic bronchitis and emphysema are the most common forms of COPD.6 •Lung cancer – should be considered as a possible cause of a new cough or a change in chronic “smoker’s cough”.3 The cough may produce blood-streaked sputum.7 •Smoking – many long-term smokers develop a chronic cough. This is typically a loud hacking cough, often resulting in the expiration of phlegm.7 Most smokers accept cough as a side effect of smoking and do not seek medical attention.3 A change in the nature of the cough, or in the colour of the sputum produced may indicate increased damage to the lungs or possible malignancy.7 •Eosinophilic bronchitis – presents as a non-productive cough caused by inflammation in the airways. Patients demonstrate atopic tendencies (a tendency to produce large amounts of antibodies), with elevated sputum eosinophils and active airway inflammation.3 Patients with eosinophilic bronchitis may be at increased risk of asthma, and most asthmatics have this condition.3 •Angiotensin converting enzyme (ACE) inhibitors – are commonly used to treat hypertension. A dry, hacking non-productive cough is a well-recognised side effect of these medications.3 Onset of cough may occur within a few hours of the initial dose, or may develop after several months of therapy.3 If a cough is suspected to be due to an ACE inhibitor, does not resolve within four weeks, then a change in antihypertensive therapy may be indicated.7 ACE-inhibitor induced cough tends to resolve one to four days after discontinuing treatment, but may take up to four weeks to disappear completely.3 •Bronchiectasis – results from severe, repeated, or persistent airway inflammation leading to progressive airway damage.3 Bronchi become dilated as a result of obstruction, poor mucus clearance, pooling of secretions, and chronic lower respiratory tract infections.3 Some patients may have non-productive cough, but most produce chronic mucopurulent sputum.3,7 Lung examination often reveals abnormal lung sounds.3 •Tuberculosis (TB) – is characterised by its slow onset and initially mild symptoms. The cough becomes chronic and sputum production varies from mild to severe. Sputum is often blood- streaked.7 •Heart failure – is characterised by its slow progression. The initial symptoms are shortness of breath and dyspnoea at night. Later the patient may develop a productive, frothy cough, which may be pink-tinged, indicative of ventricular failure.7 Types of cough Coughs are often described as wet or dry. A wet or productive cough is one in which sputum or mucus is produced. The mucus may be loose so that it can be swallowed or spat out, or may be described as ‘chesty’, in that it is retained in the lungs. SA Pharmaceutical Journal – May 2010 5/14/2010 10:43:25 AM l REVIEW When mucus is coughed up it may be examined in order to help in the differential diagnosis of cough: •• Clear or white sputum is often present in chronic bronchitis.3 •• A greenish or yellow appearance to the mucus is often indicative of an infection such as acute bronchitis or pneumonia.3 •• Blood-stained sputum - the patient should always be referred to a doctor if blood is present in the mucus or sputum as this may be indicative of tuberculosis or cancer.7 A dry or non-productive cough is often described as tight, tickly or irritating. A dry cough may be caused by air pollution, dust or a change in temperature, as well as by various medical conditions, including asthma.7 See Table II. Table II: Types of cough Wet Cough Respiratory tract infections: • Laryngitis • Sinusitis • Pharyngitis • Tonsillitis • Pneumonia Postnasal drip Chronic bronchitis Lung cancer Smoking Bronchiectasis TB Heart failure Dry Cough Asthma GORD ACE inhibitors Allergic rhinitis Acute bronchitis Eosinophilic bronchitis Considerations in the elderly Different causes for the cough As many elderly patients may present with pre-existing conditions, it is important to enquire about their medical history. Many of the common causes of cough are associated with medical conditions affecting older people e.g. chronic bronchitis, hypertension treated with ACE inhibitors, and heart failure. Higher risk for drug interactions and adverse effects Due to the increased incidence of illnesses, the associated increased use of medicines, both prescribed and over-thecounter, increases the potential for drug-drug interactions, drug-disease interactions and medication adverse effects.1 Symptom presentation The presentation of illness may change with age. Adverse effects caused by medications may not be recognised e.g. ACE-inhibitor cough.1 Aging-related alterations Aging is associated with an increase in body fat, a reduction in body water, changes in gastric acidity and changes in hepatic and renal clearance. These changes may require changes in doses of medications or the use of a different medication.1 In the elderly, persistent coughing may more easily lead to exhaustion, insomnia, dizziness and musculoskeletal pain. A bout of coughing may result in urinary incontinence, especially in women.3 24 SAPJMay10pp20-24.indd 24 Another potentially serious complication of chronic cough in an elderly patient is cough-induced rib fractures. Women with decreased bone density are at the greatest risk of this complication.3 Treatment of cough Various questions must be asked of all patients seeking treatment for cough: •• Who is the patient? Adult or child? •• What type of cough is it? Wet or dry? •• When did the cough start? •• Is there any mucus? What colour is it? •• Are there any other medical conditions present? •• Is the patient on any medication? •• Does the patient smoke? Once the various signs and symptoms have been evaluated, medication use and other medical conditions taken into consideration, a treatment course may be decided. A doctor must be consulted if any ‘red flag’ symptoms are present (See Table III). Table III: Red flag symptoms of cough4 Discoloured mucus – yellow, green, rusty brown, blood-stained or pink Foul smelling mucus Chest pain Heartburn Shortness of breath or wheezing Recurrent night-time cough Whooping cough or croup Worsening smoker’s cough Sudden weight loss Fever Cough lasting more than 3 weeks Conclusion Elderly people are a unique group with unique treatment problems as they frequently have pre-existing conditions that are being treated. No medication need be withheld on the grounds of age alone, providing that the indications exist and that all other factors have been considered.1 When a patient presents with a cough a thorough history should be taken to determine whether the problem can be dealt with over-the-counter, or whether further examination is necessary. A doctor must evaluate any cough that has been present for more than two to three weeks or that produces discoloured mucus.r References 1.Gibbon CJ. (ed) South African Medicines Formulary (SAMF) 8TH ed. Health and Medical Publishing Group of the South African Medical Association. 2.Macpherson G (ed). Black’s Student Medical Dictionary. A&C Black Publishers Limited. 3.Silvestri RC. Weinberger SE. Evaluation of sub acute and chronic cough in adults. UpToDate.com. (Accessed 25 February 2010). 4.Pillinger J. Coughing. www.netdoctor.co.uk (Accessed 25 February 2010). 5.Silvestri RC. Weinberger SE. Patient Information: Chronic cough in adults. September 2009. http://www.utdol.com/patients/ . (Accessed 2 March 2010). 6.Rennard SI. Patient information: Chronic obstructive pulmonary disease (COPD). June 2009. http://www.utdol.com/patients/ (Accessed 2 March 2010). 7.Truter I. 2007. Cough. SA Pharmaceutical Journal. 74 (4 May):20-27. SA Pharmaceutical Journal – May 2010 5/14/2010 10:43:26 AM