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ASCP is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
This home study web activity has been assigned 1.5 credit hours. ACPE UPN: 0203-0000-10-044-H01-P Release Date: 12-10-2010 Expiration Date: 12-10-2013
To receive continuing education credit for this course, participants must complete an on-line evaluation form and pass the online assessment with a score of 70% or better. If you do not receive a minimum score of 70% or better on the assessment, you are permitted 4 retakes. After passing the assessment, you can print and track your continuing education statements of credit online.
Geriatric Pharmacy Review courses have not yet been approved for Florida consultant pharmacy continuing education.
Content Experts
Current Content Expert: Nicole Brandt, PharmD, CGP, BCPP Assistant Professor, Geriatric Pharmacotherapy University of Maryland School of Pharmacy & Director Educational and Clinical Programs Lamy Center
Legacy Content Expert: Tom Snader, PharmD, FASCP President TCS Pharmacy Consultants & Clinical Associate Professor of Clinical Pharmacy USP - Philadelphia College of Pharmacy
Devra Dang, PharmD, BCPS, CDE Associate Clinical Professor University of Connecticut School of Pharmacy
Faculty Disclosure: Nicole Brandt, PharmD, CGP, BCPP has no relevant financial relationships to disclose. Devra Dang, PharmD, BCPS, CDE has no relevant financial relationships to disclose. Tom Snader, PharmD, FASCP has no relevant financial relationships to disclose.
Copyright 2011 American Society of Consultant Pharmacists
By the end of this Review Concept you should be able to: Define asthma and its prevalence in the elderly. Describe the pathogenesis of asthma. Describe the phases of asthma attacks and their corresponding symptoms in elderly patients. Specify diagnostic parameters for asthma. List the types of drugs used to treat asthma. Describe the pharmacology of each drug class and the major drugs within each class. Recommend specific clinical guidelines and pharmacotherapy for asthma management. Recognize major adverse effects of asthma drug therapies in the elderly. Discuss important age related factors and interactions with coexisting disease therapies.
Introduction to Asthma
Defining Characteristics: Airway inflammation, leading to bronchospasms, narrowing of airways and reduced airflow Recurrent episodes Airflow obstruction is usually reversible Increased airway responsiveness to a variety of stimuli Epidemiology: Affects 3-6% of adults > age 70 Asthma-related deaths are highest in elderly population May be overlooked when other conditions are present (e.g., COPD) Costs >$6 billion annually in the US
The aging of the respiratory system occurs at a constant rate and each individual has a unique threshold for experiencing pulmonary impairment. Once this threshold is reached, a variety of lung problems may appear. One of these problems is asthma. Asthma is a disease characterized by airway inflammation, leading to bronchospasms, narrowing of airways and reduced airflow. Episodes are recurrent, and airflow obstruction is usually reversible. Asthma may be overlooked in the elderly when other disorders such as chronic obstructive pulmonary disease are also present.
Pathogenesis of Asthma
Pathogenesis of Asthma Airway inflammation is caused by the overreaction to such triggering stimuli as exercise, infections, cold, betablockers, chemicals, allergens and emotions Mechanisms of this overreaction include release of histamine by mast cells, actions of leukotrienes, platelet activating factors, and other spasmogenic and chemotactic agents Histamine is released from mast cells when an allergen or other antigen bridges molecules of IgE attaches to the cell surface Asthmatics are extremely sensitive to histamine acting on the H1 receptors Incomplete reversibility of obstruction occurs in the elderly due to chronic, severe asthma and aging factors such as smooth muscle hypertrophy and fibrosis
The airway inflammation characteristic of asthma is caused by an overreaction to such triggering stimuli as exercise, infections, cold, beta-blockers, chemicals, allergens and emotions. A common trigger for acute attacks in the elderly is respiratory infection by rhinovirus. While sensitivity to some inhaled allergens is less prevalent in seniors, age-related changes in the lung may help to increase the severity of attacks. Understanding this age-related difference can help avoid over-diagnosis and the premature treatment of asthma-like conditions with inappropriate medications.
Phases of Asthma
Graphic Diagram Of Early And Late Phases Of Asthma (Including Some Medication Classes)
Phases of Asthma
Many asthmatics display two phases during their attacks: an early or initial onset phase and a delayed or late onset phase. The early phase symptoms include coughing, tightness in the chest, dyspnea and wheezing due to bronchospasms. Early phase symptoms can be reversed with beta agonists. The late phase symptoms include the early symptoms plus excessive mucous secretion, edema, fatigue and vasodilation effects. Late phase symptoms may be resolved with corticosteriods; however, bronchodilators do not work for late phase symptoms. Cromolyn sodium blocks both early and late phase symptoms.
Classification of Asthma
Step 1 Mild Intermittent Step 2 Mild Persistent Step 3 Moderate Persistent Step 4 Severe Persistent Pulmonary Function Tests Used to Classify Asthma: FEV1: Forced Expiratory Volume in 1 second (liters) PEF: AM/PM variation in Peak Expiratory Flow (liters per minute) FVC: Ratio of FEV1 to Forced Vital Capacity(FEV1: FVC)
While the signs and symptoms of asthma attacks may vary from one individual to the next, the four step classification scheme shown on your screen integrates pulmonary function tests to help match the severity of an attack to the suggested treatment guidelines. Parameters commonly used include the forced expiratory volume in one second or FE-V-1, and the variation between late afternoon and early morning measurements of the peak expiratory flow or P-E-F. The ratio of FEV1 to forced vital capacity or F-V-C also indicates an asthmatic condition if less than seventy percent. For older patients, the limit for this ratio is lower than for younger patients. While these pulmonary function tests are useful, the frailty of the elderly patient and limitations of the care setting may make such tests impractical to implement. The use of subjective and objective information on functional level, comfort level, exercise tolerance and Activities of Daily Living (ADLs) may provide the only guidance available.
Diagnostic parameters for each step are shown here. Many elderly asthmatics have reduced lung function and long histories of asthma. For those patients with other health problems, a correct diagnosis is important. Upon testing, if F-EV-1 improves more than twelve percent after proper use of an inhaled bronchodilator, asthma is a likely diagnosis. Even intermittent attacks can be life threatening and require a visit to the emergency room. A simple and easy-to-follow treatment plan must be developed for each patient in order to avoid possible emergency situations.
ASTHMA
COPD
Other allergic symptoms (rhini9s, conjunc9vi9s) Smoking Past history of asthma Family history of allergy
Source: Adapted from NAEPD Working Group Report (Considerations for diagnosing and managing asthma in the elderly: NAEPD Working Group Report. Washington, DC: Nation Institutes of Health/National Heart, Lung, and Blood Institute; 1996. US Department of Health and Human Services publication NIH 95-3675).
Copyright 2011 American Society of Consultant Pharmacists
ASTHMA
COPD
Source: Adapted from NAEPD Working Group Report (Considerations for diagnosing and managing asthma in the elderly: NAEPD Working Group Report. Washington, DC: Nation Institutes of Health/National Heart, Lung, and Blood Institute; 1996. US Department of Health and Human Services publication NIH 95-3675).
Copyright 2011 American Society of Consultant Pharmacists
Once a diagnosis of asthma has been confirmed, appropriatepharmacological treatment may be initiated. The main types of drugs used to treat asthma include bronchodilators, anti-inflammatory drugs, anti-allergy drugs and theleukotriene modifiers, the latter of which are also indicated as anti-allergy medications. These agents may be further differentiated based on whether they provide short-term or long-term therapeutic benefits. Because many older adults are being treated for concurrent health conditions, the risk of adverse drug interactions is increased for the elderly asthmatic. Close attention to drug dosing and control of symptoms is essential for the long-term management of asthma in the geriatric population. Because of their general frailty and health status, many elderly will require the use of a spacer with metered dose inhalants. The use of both M-D-Is and nebulizers by elderly patients should be closely monitored by health care personnel.
For most patients, short-acting beta 2 agonists are most effective in providing quick relief from the symptoms of asthma. In general, inhaled beta 2 agonists are preferred over oral forms because they produce fewer systemic side effects. Epinephrine works non-selectively to produce bronchodilation by increasing cyclic A-M-P production leading to smooth muscle relaxation in the airways. Epinephrine has a rapid onset and short duration of action after parenteral administration. It is not effective when given orally. Caution must be used since its non-selective actions include alpha and beta 1 effects. Like epinephrine, isoproterenol has the beta 1 effect of increasing heart rate, but with fewer adverse cardiovascular effects. It is still considered second line therapy.
Mechanism of Action (all): Increases cAMP but acts more selectively to produce bronchodilation effects Still has beta-1 activity, but not as much as non-selective agents Albuterol (Proventil): Inhaler:2 puffs (90 mcg/puff), q 15 minutes prior to exercise Nebulizer:1.25 5 mg (0.5%) in 2 3cc of saline q4 8h Syrup:2 mg/mL Duration:4 8 hours Bitolterol (Tornalate): Inhaler:2 puffs (370 mcg/puff), tid qid prn Nebulizer:0.5 3.5 mg (0.2%) in 2 3cc of saline q4 8h Duration:4 8 hours
Terbutaline (Brethaire): Inhaler:2 puffs (200 mcg/puff) tid qid prn Duration:4 8 hours Levalbuterol (Xopenex): (R)-isomer of the racemic albuterol Requires lower doses and has less cardiovascular and CNS adverse effects when compared to albuterol Currently only available in a nebulizer solution Nebulizer:0.63 mg tid, every 6 8 hours Inhaler: not available
Albuterol, bitolterol, and terbutaline also increase cyclic A-M-P but act more selectively to produce bronchodilation effects. Terbutaline may be given orally and subcutaneously while albuterol may also be given orally. These selective agents may cause muscle tremor, tachycardia and palpitations. Although rarely used in adults, albuterol is available in a syrup dosage form, typically as 2 mg/mL. However, you must be aware that albuterol syrup typically contains sorbitol or saccharin and should be used cautiously in patients with Diabetes. Levalbuterol is the R-isomer of albuterol and is available in a nebulizer solution. It has the advantage of having less systemic side effects when compared to other beta-agonists. Beta 2 agonists can be less effective with continuous use, due to down regulation of beta 2 receptors. If patients are using their beta agonists on a frequent basis then other therapies, depending on their level of asthma, should be added to their regimen since short acting beta 2 agonists are not indicated for long term control.
Cromolyn sodium(Crolom, Intal): Mechanism of Action: Inhibits release of chemical mediators by mast cells when stimulated Can also be used prior to exposure to prevent an attack Typical dose:2 4 puffs (1 mg/puff) TID QID Nedocromil (Tilade): Mechanism of Action: Works in a similar way Inhibits more mediators and is effective against more types of asthma Typical dose:2 4 puffs (1.75 mg/puff) TID QID Related Medications: Azelastine (Astelin) Nasal spray Antihistamine Typical dose:2 sprays in each nostril twice daily (137mcg/spray)
Guidelines for a stepwise approach to asthma treatment stress the use of anti-inflammatory agents as first line therapy and the development of an action plan. While the importance of avoiding asthma triggers cannot be overemphasized, the success of the treatment plan may ultimately depend upon patient education and the clinician-patient partnership. Once the basic facts about asthma, emergency procedures and medications are taught, specific inhaler techniques and self -management issues help elderly patients avoid major problems.
Management Priorities for the Elderly Patient with Asthma Balance treatments with quality of life and the ability to live independently Obtain proper dosage to avoid under medicating and triggering acute exacerbations Watchpotential for adverse effects or for interactions with other drugs Consider preventive measures such as getting influenza and pneumococcal vaccines
Traditionally, there have been two approaches to gaining control of asthma. The first is to start with high doses and step down to amounts needed. The second is to gradually step up doses to find optimum treatment levels. In elderly patients, higher initial dosages may be contraindicated and even life threatening. The step up approach can provide a safer plan while the initial choice of alternative medications may be the most important decision for older asthmatics. Examples include using cromolyn and nedocromil for long-term control regimens.
One of the most important management priorities for the elderly asthma patient is the limitation of adverse effects of asthma medications. Some of these effects can be avoided with simple precautions. For example, patients on steroid inhalers should rinse their mouth and expectorate following use. Other adverse effects can be a source of great concern, especially when used at higher and more frequent doses. Although rare, the leukotriene modifiers have been associated with Churg-Strauss syndrome. Some researchers believe it is caused by the reduction in inhaled steroid dose. However, a case has been reported in a patient who wasnt taking any steroids. While cromolyn and nedocromil have very minor adverse drug effects, many of the other long term treatments have unwanted and potentially dangerous effects.
Many elderly asthmatics are also being treated for other health problems and risk a variety of adverse drug interactions. A good example is the use of eye drops containing beta blockers. In asthmatics, these eye drops could lead to fatal bronchoconstriction. A complete assessment of all medications should be part of the individualized treatment plan.
Resources
For additional information, see: Anderson C. J. & Bardana E.J. Jr. Asthma in the elderly: the importance of patient education. Comprehensive Ther 1996:22(6): 375-83. Braman SS. Asthma in the Elderly.Clin Geriatr Med 2003: 19:57-75. Connolly, M. J.Aging, late-onset asthma and the beta-adrenoceptor. Pharmacology & Therapeutics 1993; 60(3): 389-404. Lackner, T. E. . Theophylline dose determinations in geriatric patients: pharmacokinetic considerations. Consult Pharm 1994; 9: 78-82. O'Brien-Ladner, A.Asthma: new insights in the management of older adults. Geriatrics 1994.; 49(11): 20-5, 30-2. Quadrelli SA, Roncoroni A. Features of Asthma in the Elderly. Journal of Asthma 2001;38(5):377-89. Renwick DS, Conolly MJ. Improving Outcomes in Elderly Patients with Asthma. Drugs & Aging 1999;14(1):1-9. Sherman, C. B. Late-onset asthma: making the diagnosis, choosing drug therapy. Geriatrics 1995; 50(12): 24-33. Tockman, M. S.Aging of the respiratory system, in Principles of Geriatric Medicine and Gerontology, Hazzard, W.R. et al. eds. Third edition. 1994, chapter 48: 555-64. Serevent FDA Prescribing Letter: http://www.fda.gov/medwatch/SAFETY/2003/serevent.htm
By the end of this Review Concept you should be able to: State the definition and risk factors for diseases comprising COPD. Describe the clinical features of COPD. Outline current therapy options. Discuss the recommended pharmacotherapy and specific drug usage. Evaluate medication dosages for expected outcomes. Recognize changes in therapy as COPD symptoms become more severe. Discuss therapy implications for the elderly.
Introduction to COPD
Defining Characteristics: Chronic, progressive airway obstruction Caused by chronic bronchitis, emphysema, or combination thereof Chronic bronchitis (blue bloater): cough and increased sputum present for at least 3 months of the year for 2 consecutive years Emphysema (pink puffer): permanent and abnormal enlargement of the airspace distal to terminal bronchioles and destructive changes of the alveolar walls without fibrosis Epidemiology: Affects more than 5 million adults > age 55 Accounts for 13% of hospitalizations Health care costs >$5 billion 4th leading cause of death in US Over 95% of deaths are in adults > age 55 Chronic obstructive pulmonary disease (C-O-P-D) is defined as persistent limitation in expiratory airflow that is not significantly reversible with the use of bronchodilators. This family of chronic obstructive pulomnary diseases includes emphysema and chronic bronchitis. Most patients have a combination of both of these conditions. C-O-P-D has long been associated with the elderly and the effects of smoking. Chronic obstructive pulmonary disease is the fourth leading cause of death in the United States, and ninety-five percent of C-O-P-D related deaths are in individuals over the age of fifty-five. The progressive nature of the disease can force many lifestyle changes on older adults, and the frequency of exacerbations can have a devastating effect on their quality of life.
Adapted from NAEPD Working Group Report (Considerations for diagnosing and managing asthma in the elderly: NAEPD Working Group Report. Washington, DC: Nation Institutes of Health/National Heart, Lung, and Blood Institute; 1996. US Department of Health and Human Services publication NIH 95-3675).
Copyright 2011 American Society of Consultant Pharmacists
CHARACTERISTIC Laboratory Findings Pulmonary func9on Chest X-ray Eosinophilia Posi9ve skin tests
ASTHMA
COPD
Similar to COPD OQen normal; may show hyperina9on More common More common
Similar to asthma Vessels, focal hyperaera9on (emphysema) Markings (chronic bronchi9s) Less common Less common
Response to Therapy FEV1 response to beta2- antagonist FEV1 with symptom relief LiZle/no change in FEV1 with poor symptom relief
Adapted from NAEPD Working Group Report (Considerations for diagnosing and managing asthma in the elderly: NAEPD Working Group Report. Washington, DC: Nation Institutes of Health/National Heart, Lung, and Blood Institute; 1996. US Department of Health and Human Services publication NIH 95-3675).
Risk factors for chronic obstructive pulmonary disease focus on the long-term smoking habits of the elderly as well as exposure to environmental pollution and workplace irritants. A typical medical history reveals a smoking pattern of twenty cigarettes each day for twenty years. Since 1968, there has been a progressive increase in the age-adjusted death rate for C-O-P-D, with the number of women being diagnosed with COPD increasing dramatically. While the disease itself has no cure, some respiratory parameters may be reversible to the extent of restoring a measure of lifestyle important to the patient. Many patients also relate their quality of life to the frequency of C-O-P-D episodes. It is in this area that the geriatric pharmacist can have the greatest impact.
Eliminate smoking and/or reduce exposure to pollutants, irritants Use preventive measures such as the pneumococcal and influenza vaccines Administer: Beta-2agonists with careful dosing Theophylline with careful dosing Anticholinergics such as ipratropium, tiotropium Corticosteroids in some cases Oxygen (18 hrs/day, < 3 liters/min) Antibiotics as needed
Treatment plans for chronic obstructive pulmonary disease are based upon the severity and frequency of symptoms, and must integrate oxygen use, physical therapies, and other adjunct therapy as necessary. Once the patient has stopped smoking and preventative measures are taken, individualized pharmacotherapy may be more effective. A stepwise approach to therapy is optimal. Although resting pulse oximetry may be over ninety percent, dramatic decreases may follow a minimal amount of exercise. For this reason, at least eighteen hours a day of continuous oxygen therapy at less than three liters per minute is standard for chronic C-O-P-D patients. Only smoking cessation and long term oxygen therapy have been shown to improve survival while drug therapy will only improve symptoms.
Treatment of Patients with Mild COPD and Variable Symptoms with Beta-2 agonists
Albuterol (Proventil): 1 2 puffs every 2 6 h, up to 8 12 puffs in 24 h Onset of action is 5 minutes Terbutaline (Brethaire): 1 2 puffs every 6 8 h Bitolteral (Tornalate): 2 puffs every 8 h, max of 2 puffs every 4 hours Pirbuterol (Maxair): 1 2 puffs every 6-8 h, max of 12 puffs in 24 hours
For mild chronic obstructive pulmonary disease with variable symptoms, short acting selective beta-2 agonists such as albuterol may be used. The dosage is one to two puffs every two to six hours up to a maximum of eight to twelve puffs in twenty-four hours. Beta agonists have been associated with muscle and nerve tremors, myocardial ischemia, and arrhythmias.
Ipratropium (Atrovent): 3 6 puffs qid; max 16 puffs/day Onset of action is 15 minutes Duration is 4 6 hours Tiotropium (Spiriva): Mechanism of Action: Quarternary ammonium compound that strongly binds to the muscarnic receptors in airway smooth muscle cells and mucus glands. Onset: Begins to work in about 30 minutes after inhalation and persists for 24 hours Reaches maximum effect by day 8 Inhaler:18mcg daily administered by Handihaler which is a breath activated, dry powder inhalation device AND If additional relief is needed after maximum doses are reached, an inhaled beta-2 agonist may be used for quick relief 1 4 puffs qid, but watch for ADEs OR Consider combination inhalers such as ipratropium + albuterol (Combivent)
If additional control of symptoms is needed, the use of oral corticosteroids may be considered. These agents have had limited use in the treatment of chronic obstructive pulmonary disease because they provide therapeutic benefits to only about ten to fifteen percent of patients, and their adverse effects can be very debilitating. Prednisone is a typical example of such an agent. It may be titrated up to forty milligrams per day for ten to fourteen days. If the patient shows no improvement, consider lowering the daily dose or alternating with lower daily doses. If the patient still does not improve, stop prednisone treatment immediately. Adverse drug effects to watch for include depression, peptic ulcers, and osteoporosis. It is important to remember that not all inhaled steroids are equally dosed or absorbed, and that systemic absorption can be significant with older agents.
Balance treatments with quality of life and the ability to live independently Obtain proper dosage through proper inhalation techniques to avoid undermedicating or overmedicating Watch for potential for adverse effects or for interactions with other drugs
In elderly patients being treated for chronic obstructive pulmonary disease, high doses are usually contraindicated. Medication should be gradually increased until optimum therapeutic effects are reached. The start low-go slow approach can provide a safer plan while the proper medication or combination of medications is being determined.
ADEs Associated with Corticosteroids: Depression PUD HTN Cataracts Osteoporosis Metabolic effects
One of the most important issues to consider when managing elderly patients with chronic obstructive pulmonary disease is the risk of adverse effects produced by the therapeutic agents discussed earlier. Adverse drug interactions should also be considered. For example, beta blockers and angiotensin-converting enzyme inhibitors can reduce the effectiveness of many of the medications discussed. Also, anticholinergic agents are not recommended for use in COPD patients with glaucoma, nor are beta agonists recommended for use in recent post-myocardial infarction patients.
Resources
For additional information, see: Alberts, W. M. & Rolfe, M. W.A step care approach to managing COPD. Hosp Formul1994: 29: 756-66. Chapman, K.M. & Winter, L. COPD: using nutrition to prevent respiratory function decline. Geriatrics1996: 57: 37-42. Kuhl, D. A, Agiri, O. A., & Mauro, L. S. Beta-agonists in the treatment of acute exacerbation of chronic obstructive pulmonary disease. Ann Pharmacother1998: 28(12): 1379-88. Pawels R, Sonia Buist A, Calverley P, Jenkins C, Hurd S. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD). Workshop summary. Am J Respir Crit Care Med 2001; 163: 1256-1276. Ramsdell, J. Use of theophylline in the treatment of COPD. Chest1995: 107(5 Suppl): 206S-209S. Rossi A., Ganassini A., Tantucci C., Grassi V. Aging and the respiratory system. Aging1996:8(3): 143-61.
Resources
For additional information, see: Seemungal, T.A.R., et al..Effect of Exacerbation on Quality of Life in Patients with Chronic Obstructive Pulmonary Disease. Am. J. Respir. Crit. Care. Med1998: 157(5): 1418-22. Senior, R. M., Anthonisen, N. R.Chronic Obstructive Pulmonary Disease (COPD). Am.J. Respir. Crit. Care Med 1998:157: S139-S147. Yohannes AM, Hardy CC. Treatment of Chronic Obstructive Pulmonary Disease in Older Patients. Drugs Aging 2003:20(3):209-228. Web Sites: American Thoracic Society at: http://www.thoracic.org
By the end of this Review Concept you should be able to: Define the types of coughs associated with respiratory disorders. Discuss the implications of chronic coughing in the elderly. Recognize medications that may produce or enhance coughing. Recommend alternative drugs and adjunct medications to reduce or eliminate coughing. Integrate cough management into a comprehensive treatment plan.
Introduction to Coughs
Defined as a forceful and sometimes violent expiration preceded by a preliminary inspiration May be acute or chronic May be referred to as wet or dry Caused by chemical, infectious, mechanical and thermal stimuli
A cough can be defined as a forceful and sometimes violent expiration preceded by a preliminary inspiration. In healthy individuals, coughing serves those suffering from an arrhythmia by helping to restore a normal heartbeat. However, coughing may become counterproductive when it becomes a chronic symptom of other diseases. It can be particularly stressful in elderly patients already experiencing other health problems
Coughs are mainly caused by chemical, infectious, mechanical, and thermal stimuli, especially extremely cold temperatures. The cough begins with an irriration of the nerves in the respiratory tract. The irritation may come from a plug of mucus in the airway, from post-nasal drip, or from exposure to a chemical aerosol, such as hair spray. As the glottis closes, expiratory muscles in the ribcage and abdomen generate intrathoracic pressures that are fifty to one hundred percent greater than are generated through other types of forced expiration.
Etiology of Cough
Acute (< 3 weeks): Chemical irritation Colds Pneumonia CHF Chronic (> 3 weeks): Smoking Asthma GERD Post-nasal drip syndrome
Coughs may be acute or chronic. An acute cough is one that lasts less than three weeks. Its most frequent cause is the common cold. Chronic cough lasts more than three weeks and is most often caused by smoking, asthma, and gastroesophageal reflux disease. A chronic persistent cough is one that is not associated with hemoptysis or prior history of chronic respiratory disease. Post-nasal drip syndrome can cause a chronic cough by a number of different factors, but is usually a symptom that indicates allergies or allergic rhinitis.
Respiratory Sources of Cough in the Elderly Asthmatic:combined with dyspnea Bronchial:source in airways Dry:no moisture involved Productive or effective:sputum, mucous, or other exudate is expectorated Hacking:repeated quick efforts Spasmodic or paroxysmal:deep airways Harsh:seen in laryngitis Pulmonary:severe due to major infection
While a cough in the elderly may be unrelated to any respiratory problems, it is often directly related to illnesses with a pulmonary component. Some types of coughssuch as productive, purulent coughs that the patient cannot clear well can lead to more serious reinfection, painful episodes of dyspnea, and insomnia. The use of cough medications can be both beneficial or harmful depending on the condition of the patient and interactions with other medications.
Diagnosis of cough relies on a combination of patient history, physical examination, and pulmonary tests. A drug history is also important. For example, patients who are taking ACE inhibitors because of the bradykinin-induced dry, nagging, cough that has been associated with ACE inhibitors. Others may have cough secondary to congestive heart failure or pneumonia. The history should document patient experiences with pain, hemoptysis, and sputum production. Day and evening coughing behavior and its relation to position, either sitting or standing, should also be noted. The physical exam should reveal any dyspnea, post-exercise wheezing, and hoarseness. Any changes in weight should be recorded. With respect to laboratory studies, chest x-ray, spirometry, and lung volumes are especially useful. Other diagnostic tools listed here may be used if the diagnosis is more elusive.
Copyright 2011 American Society of Consultant Pharmacists
Management of chronic cough in the elderly is based on treatment of the underlying causes. Conditions such as asthma, post-nasal drip, and chronic bronchitis should be treated along conventional lines. Although specific therapy is universally more successful than non-specific therapy, cough may be treated with non-specific medications such as dextromethorphan, codeine, and hydrocodone. Post-viral cough may be effectively treated with ipratropium.
Hydrocodone bitartrate is an opioid antitussive and analgesic used for the relief of cough and moderate to moderately severe pain. It is stronger than codeine, andis associated with greater risks of respiratory depression and dependence. Hydrocodone bitartrate is available in the United States only in fixed combinations with non-opiate drugs such as acetaminophen or aspirin. The usual adult dose is five to ten milligrams every four to six hours as needed not to exceed forty milligrams per day. The smallest effective dose should be administered as infrequently as possible to minimize the development of tolerance and physical dependence. Concurrent therapy with other narcotic analgesics, antipsychotics, antianxiety agents, sedatives, hypnotics and other CNS drugs such as tricyclic antidepressants may result in potentiation of CNS depression.
Cough management in the elderly is controversial when inflammation of the respiratory tract is involved. As a protective mechanism, coughs help to clear fluid buildup and prevent reinfection from occurring. It would be inadvisable to completely suppress this action and its related benefits. Conversely, a persistent or severe cough can disturb sleep, cause incontinence, rib fractures,general weakness, and reduce the effectiveness of certain medications. Once more serious and life-threatening causes for a cough has been ruled out, control of acute episodes and some chronic symptoms can proceed.
Medications themselves can be the source of coughing and interfere with other treatments for respiratory disorders. These include the angiotensin-converting enzyme inhibitors such as lisinopril. Fosinopril is supposed to have the least incidence of cough when compared to the other agents. Adding medications may eliminate the cough or reduce symptoms. For example, cromolyn sodium may be prescribed to suppress coughs caused by ACE inhibitors such as lisinopril. Angiotensin receptor blockers such as losartan provide some of the same benefits as ACE inhibitors without the cough, and may be used instead of ACE inhibitors if not contraindicated due to the diagnosed disease state. Once again, a review of all medications is an important step in treating the elderly.
Resources
For additional information, see: Fillit, H. M., Picariello G. Practical geriatric Assessment. 2nd edition, St. Louis: Mosby; 1997. Hargreaves M.(1993). On Cromolyn Sodium for ACE Inhibitor Cough Brit. J. Clin. Pract,47: 319-20 Bem J. L. & Peck, R. Dextromethorphan: an overview of safety issues. Drug Saff 1992: (7): 190-9 Hydrocodone Bitartrate Monograph. (1997). In: McEvoy, G. K., editor. AHFS Drug Information 1997. Bethesda: American Society of Health-System Pharmacists. Widdicombe J, Kamath S. Acute Cough in the Elderly. Drugs Aging 2004:21(4)243-258.