Understanding Acute Cough in Adults and Elderly – Causes & Care

Introduction

A cough is one of the most frequent symptoms prompting adults, including the elderly, to seek medical advice. While often benign and self-resolving, an acute cough (typically defined as lasting less than three weeks) may also signal an underlying infection or other pathology. Differentiating between harmless causes and those that require prompt intervention is critical, particularly in older adults who are more vulnerable to complications.

In this essay, I examine the epidemiology, physiology, causes, clinical assessment, red flags, management, and prevention of acute cough in adult and elderly populations, emphasizing a balanced, practical approach guided by evidence and clinical guidelines.

1. What Is an Acute Cough?

According to medical literature, an acute cough is defined as a cough lasting under 3 weeks. NCBI+2mayoclinic.org+2
In contrast, a subacute cough (3–8 weeks) and chronic cough (more than 8 weeks) reflect different underlying processes. NCBI+1
In older adults, cough reflex sensitivity may be altered due to age-related changes, comorbidities, or medications, so even an “acute” cough warrants careful evaluation.

2. Physiology: Why We Cough

Cough reflex: A protective reflex involving afferent sensory nerves (in the airways), the cough center in the brainstem, and efferent signals to the respiratory muscles. NCBI
It helps clear pathogens, irritants, mucus, and foreign particles from the airway.
However, in acute illness, infection or inflammation stimulates sensory nerves, causing an exaggerated cough. Over time, the cough may persist even after the original trigger has resolved, due to lingering airway hyperresponsiveness.

3. Epidemiology / Clinical Significance in Adults & Elderly

In a large real-world Indian study, acute cough was very common in adults (18–65) and elderly (>65), with respiratory tract infection being the most frequently associated condition. PubMed
Despite its frequency, up to 90% of chronic coughs in adults are not due to malignancy but common non-malignant etiologies. PubMed
While many acute coughs are viral and self-limiting, older adults are at higher risk of complications (e.g., pneumonia, decompensation of chronic lung or heart disease).

4. Common Causes of Acute Cough in Adults & Elderly

Based on clinical reviews and epidemiological data, the major causes include:

A. Infectious Causes

Viral upper respiratory tract infection: The most common cause. NCBI+1
Acute bronchitis: Often viral, but sometimes bacterial (≈10% cases). NCBI
Acute sinusitis / rhinosinusitis: Postnasal drip stimulating cough. mayoclinic.org
Pneumonia: Lower respiratory tract infection – bacterial or viral. mayoclinic.org
Pertussis (whooping cough): Though less common in vaccinated populations, can cause prolonged cough. mayoclinic.org
Other infections: Influenza, RSV, laryngitis.

B. Non-Infectious Causes

Acute exacerbation of chronic airway disease: In people with COPD, asthma, or bronchiectasis.
Post-viral cough: Even after infection has cleared, airway hyperreactivity may persist. PubMed
Environmental irritants: Smoke, dust, pollutants.
Gastroesophageal reflux disease (GERD): Acid irritation may trigger cough. mayoclinic.org
Medications: ACE inhibitors often cause cough. mayoclinic.org
Other serious causes (less common in acute phase but must be considered): Pulmonary embolism, aspiration, heart failure.

5. Clinical Assessment: History & Examination

5.1 History

When evaluating an adult or elderly patient with acute cough, key questions include:

Onset, pattern, and duration of cough
Quality: dry (non-productive) vs. productive (sputum)
Associated symptoms: fever, shortness of breath, chest pain, wheezing, sore throat, rhinorrhoea
Systemic signs: weight loss, night sweats
Exposures: smoking, pollutants, allergens
Medical history: COPD, asthma, heart disease, GERD
Medications: ACE inhibitors, etc.
Risk factors: recent travel, immobilization (PE), aspiration risk

5.2 Physical Examination

Vital signs: temperature, respiratory rate, oxygen saturation
Lung auscultation: wheeze, crackles, diminished breath sounds
Heart exam: signs of heart failure
ENT: nasal congestion, postnasal drip
General exam: signs of systemic illness, lymphadenopathy

6. Red Flags (“When to Worry”)

Referral or further evaluation is warranted if the patient:

Has hemoptysis (coughing blood) northyorkshireccg.nhs.uk
Exhibits persistent high fever, or systemic toxicity
Reports unintentional weight loss or night sweats
Has dyspnoea, chest pain, or signs of respiratory distress
Is immunocompromised or has significant comorbidities
Has risk factors for pulmonary embolism (sudden onset, leg swelling, immobility)
Doesn’t improve or cough persists beyond 3–4 weeks, per guidelines Nice
Is elderly (>65) with comorbidities like heart failure, who may decompensate

7. Diagnostic Work-Up

Based on initial assessment and red flags, investigations may include:

No investigation: For typical viral URTI presentation, self-care is often sufficient (especially if no red flags). NICE guidelines emphasize avoiding unnecessary antimicrobial use. Nice+1
Chest X-ray: If pneumonia is suspected or if cough persists beyond expected duration.
Sputum culture: For productive cough, especially if purulent or in patients with chronic lung disease.
Pulse oximetry: For oxygen saturation measurement.
Blood work: CBC, CRP may help, but often not required in simple acute cough.
Pulmonary function testing: If recurrent episodes or suspicion of asthma/COPD.
D-Dimer / CT pulmonary angiogram: Only if pulmonary embolism is suspected.
Referral to specialist: If cough persists beyond guideline durations, or if uncommon etiology is suspected.

8. Management of Acute Cough

8.1 Self-care and Symptomatic Treatment

Rest and hydration: Encourage fluids, rest, and nutrition.
Humidification: Use humidifiers or take steamy showers to loosen secretions.
Over-the-counter remedies: Simple cough suppressants, expectorants, or throat lozenges may help, though the evidence is limited.
Avoid irritants: Smoking cessation, avoidance of pollutants.
Safety netting: Provide advice on when to return for worsening symptoms (e.g., red flags above). NICE recommends giving patients clear advice on when to re-consult. Nice

8.2 When to Use Antibiotics

According to NICE Guideline NG120, antibiotics are generally not recommended for acute cough due to upper respiratory tract infection or acute bronchitis in otherwise healthy adults. Nice+1
If antibiotics are used (e.g., for suspected bacterial bronchitis, or high-risk patients), doxycycline is often first-line in adults: 200 mg on day 1, then 100 mg daily for 4 more days. Nice
Provide safety netting and explain when symptoms should prompt re-evaluation (worsening, no improvement in 3–4 weeks).

8.3 Additional Therapies

If asthma/COPD exacerbation is identified: bronchodilators, inhaled corticosteroids.
In special cases (e.g., pertussis), macrolide antibiotics may be needed.
Supportive oxygen therapy if hypoxia.

9. Specific Considerations in the Elderly

Elderly patients may not mount a robust immune response, so infection may present without fever, but with cough or confusion.
They often have comorbidities (CHF, COPD, immunosuppression) increasing risk of complications.
Drug interactions: careful when prescribing antibiotics (renal function, polypharmacy).
Hydration may be more difficult due to reduced thirst drive, kidney function.
Consider aspiration: in older adults, impaired swallowing or neurological issues may lead to aspiration cough.

10. Prognosis

Most cases of acute cough due to viral infection resolve within 1–3 weeks. Nice
Residual cough can persist (post-viral) but gradually improve.
With appropriate management, complications such as pneumonia or exacerbation of chronic disease can be minimized.

11. Prevention

Key preventive strategies include:

Vaccination
- Influenza vaccine (annual)
- COVID-19 vaccine / booster
- Pneumococcal vaccination (for older adults)
Lifestyle modifications
- Smoking cessation
- Avoiding secondhand smoke and pollutants
- Hand hygiene to prevent viral infections
Manage chronic conditions
- Control asthma, COPD, heart failure, GERD, etc.

12. Summary and Clinical Principles

Acute cough (<3 weeks) in adults and the elderly is very common, often viral, and most often self-limited.
A careful history and examination help distinguish benign from serious causes.
Red-flag features (e.g., hemoptysis, systemic toxicity, hypoxia) demand urgent evaluation.
Routine antibiotics are not indicated for uncomplicated acute cough; overuse may cause resistance.
Treatment emphasizes symptomatic care, hydration, rest, and explanation to patients about expected course.
In elderly patients, higher vigilance is needed due to comorbidity, atypical presentation, and risk of decompensation.
Preventive measures (vaccination, lifestyle, chronic disease control) reduce the risk of recurrent or complicated cough.

Relevant Website Links

Mayo Clinic – Cough in adults: causes & when to see a doctor mayoclinic.org+1
NICE Guideline NG120: Acute cough – antimicrobial prescribing Nice
StatPearls – Cough: etiology, evaluation, and management NCBI
nidirect (UK) – Advice on cough nidirect
North Yorkshire Clinical Commissioning Group – suggested management of cough northyorkshireccg.nhs.uk

References

StatPearls. Cough. NCBI Bookshelf. NCBI
Mayo Clinic Staff. Cough causes (acute & chronic). Mayo Clinic. mayoclinic.org
NICE. Cough (acute): antimicrobial prescribing, NG120. Nice
NICE. Recommendations – Acute Cough, NG120. Nice
PubMed / medical study: From acute cough to chronic cough in adults PubMed
AAFP / American Family Physician. Evaluation of the Patient with Chronic Cough (includes acute cough section). AAFP
Countess of Chester Hospital NHS Foundation Trust. Managing Common Infections in Adults – Acute Cough Protocol. cheshireformulary.nhs.uk

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