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Diagnostic and Therapeutic Aspects in Older Adults

Nicholas A. Smyrnios, MD; Richard S. Irwin, MD; Frederick J. Curley, MD; Cynthia L. French, MS, RN, CS, ANP

Arch Intern Med. 1998;158:1222-1228.

Background  Cough is the most common complaint for which adults see a physician in the ambulatory setting in the United States. An anatomical diagnostic protocol has been used since 1981 to evaluate patients with chronic cough. It has been shown to be effective in diagnosing the cause of cough and leading to specific treatment in a variety of adult populations but has never been evaluated specifically in a population of older adults.

Objectives  To question whether the spectrum and frequency of causes of chronic cough and the response to therapy would be different in older adults.

Methods  Thirty patients at least 64 years of age with a history of cough lasting at least 3 weeks were prospectively evaluated with a protocol designed to detect diseases that stimulate the afferent limb of the cough reflex. The final diagnosis of the cause of chronic cough required fulfillment of pretreatment criteria and having cough disappear with specific therapy. When more than one disease fulfilled pretreatment diagnostic criteria, therapy was instituted in the order that these were fulfilled. Probability statistics were used to describe the testing characteristics of individual components of the diagnostic protocol in terms of sensitivity, specificity, positive predictive value, and negative predictive value as they applied to chronic cough.

Results  Forty causes of chronic cough were identified in all 30 patients. Postnasal drip syndrome, gastroesophageal reflux disease, and asthma were the most common causes of chronic cough, accounting for 85% of all causes found. Among patients with normal chest radiograph findings who were not cigarette smokers and not taking an angiotensin-converting enzyme inhibitor, postnasal drip syndrome, gastroesophageal reflux disease, and asthma accounted for 100% of all causes found. Specific therapy was successful in eliminating chronic cough in 100% of the patients studied. Except for barium esophagography, all laboratory tests for which information was available had sensitivities and negative predictive values of 100%.

Conclusions  Postnasal drip syndrome, gastroesophageal reflux disease, and asthma accounted for 85% of all causes of chronic cough in older adults. Chronic cough caused substantial physical and emotional morbidity among older patients. The major value of performing objective testing in evaluating chronic cough is its ability to rule out specific diseases as a diagnostic possibility. The following clinical profile consistently predicts patients with cough attributable to gastroesophageal reflux disease: the patient has cough that has been persistently troublesome for at least 3 weeks; does not smoke cigarettes; does not take an angiotensin-converting enzyme inhibitor; does not have or has not responded to therapy for postnasal drip syndrome and asthma; and has normal or nearly normal findings and stable chest radiograph. The differences between what we observed regarding chronic cough in older adults and observations by ourselves and others regarding chronic cough in general are minor.

From the Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester.

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