Cough is an important reflex to keep the airways clear and often becomes operative by an irritant entering the upper part of the airway. Cough is a common symptom following viral infections where it is self- limiting. Any cough which persists for more than 8 weeks is called chronic cough.
Chronic cough is a common symptom affecting around 10% of population but more often seen in the elderly population, where it can disrupt the daily routine and lead to negativity.
This is because it can be exhausting and preventing good sleep. It can lead to muscles becoming hurt and sometimes even fracturing the ribs especially in the elderly frail people.
It can also lead to loss of urinary control. With the global burden of the elderly population increasing the problem of chronic cough is expected to become a major health care issue for the practising physicians.
Common Causes and Associated Illnesses:
The three most common causes of chronic cough are upper respiratory disease especially in chronic smokers, asthma and gastro-oesophageal reflux (GERD). This reflux which is a common cause because of secretions getting into the respiratory tract is often overlooked as the cause. In addition, persons with sinusitis because of the post nasal drip getting into the breathing passages especially during sleep is an important cause. Poorly controlled diabetes is a frequent association and could be acting by affecting the nerves (neuropathy) and leading to GERD. Air pollution a common problem in our cities always compounds it.
X-Ray chest a commonly ordered investigation usually does not help in these subjects. Often an old healed in-active tuberculosis shadow can be seen in the elderly subjects and is just a bystander which is not contributing. However if accompanied by fever and weight loss etc needs to be taken seriously and investigated further by microbiological assay and computed tomography (CT) of the chest.
A frequently missed cause is the medications. Angiotensin converting enzyme inhibitors ( enalapril, ramipril etc ) can frequently lead to very irritating cough ( 10-30% ). These drugs are very frequently used to treat high BP and heart failure. Although angiotensin receptor blockers (ARB’s), [losartan. telmisartan , Olmesartan etc] is the best alternative with much less chance of cough but there are persons who get it with it also. Besides these some anti-seizure drugs like topiramates, drugs to treat rheumatoid arthritis like methotrexate and drugs used after organ transplant like mycophenolate can also be causing cough.
Safety of drugs often used for chronic cough :
Various classes of ant-histaminic agents are used (cetirizine, fexofenadine). They may be temporarily effective but the elderly population are especially prone to their side effects like injurious falls or fractures which are highly morbid agents. These especially the first generation agents should be avoided. Short term use of oral cortico- steroids (Prednisolone) can bring rapid symptom relief but are potentially harmful and increase the chance of sepsis, clots in leg veins and even fractures.
Inhaled corticosteroids which are generally considered safe if used for long term can result in weakening bones, fractures, cataracts with higher risk of pneumonias.
Proton pump inhibitors (PPI) like pantoprazole etc have become a household remedy in our country. These are used to treat GERD for long periods by many patients. Recently a number of concerns with their prolonged like iron deficiency anaemia, low blood magnesium levels, osteoporosis, dementia, pneumonia which are mostly elderly prone conditions.
Cough suppressant drugs also can have safety issues in the elderly population. As these aim at controlling the cough these can potentially lead to aspiration pneumonias especially with the use of opioid containing syrups besides producing drowsiness and constipation.
Thus, the agents listed above should not be used indiscriminately and never as self-medications for long periods for managing chronic cough.
Home remedies to get relief:
There are a number of them especially advocated by the grand mothers. These are Honey, garlic, turmeric, ginger, cloves, steam inhalation, pineapple, mint, eucalyptus oil etc. These are harmless if taken in small amounts in any form which is palatable. Besides having a placebo effect these could be worth a trial for these very symptomatic persons, although none of them have been studied in detail scientifically.
Take Home Message:
Chronic cough is a well-known problem in our population. The elderly is more prone to it. With the increasing longevity it is rapidly becoming a major healthcare issue. Many subjects with this problem very often have multiple co-morbidities which makes the assessment and management a challenge. Often, they have old lung problems, acid reflux issues like GERD. Drug induced cough should always be kept in mind as a cause. While managing these patients , safety concerns of treatment need to be considered and poly pharmacy should be avoided. “The Cure should not become worse than the disease”.
Prof Upendra Kaul Founder Director Gauri Kaul Foundation
Disclaimer: The views and opinions expressed in this article are the personal opinions of the author.
The facts, analysis, assumptions and perspective appearing in the article do not reflect the views of GK.