The double-sidedness of cough in the elderly

Chronic cough in adults: recommendations from an Italian intersociety consensus

BACKGROUND

Chronic cough (CC) is a burdensome health problem in adult and older people, with a major impact on quality of life. Its management is often troublesome, and many guidelines have been released. Notwithstanding, a proportion of cases still do not reach a definite diagnosis and resolutive treatment. A coordinated approach between different specialists would be highly recommended, but its implementation in clinical practice suffers from the lack of shared protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues.

AIMS

To develop evidence-based recommendations for the management of adults with CC.

METHODS

A 12-member expert task force of general practitioners, geriatricians, pneumologists, allergologists, otorhynolaringologists and gastroenterologists was established to develop evidence-based recommendations for the diagnostic and therapeutic approach to subjects with CC. A modified Delphi approach was used to achieve consensus, and the US Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence.

RESULTS

A total of 56 recommendations were proposed, covering 28 topics and concerning definitions and epidemiology, pathogenesis and etiology, diagnostic and therapeutic approach along with the consideration of specific care settings.

CONCLUSION

These recommendations should ease the management of subjects with CC by coordinating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.

Cough in the Elderly During the COVID-19 Pandemic

INTRODUCTION

The prevalence of chronic cough increases with age. However, data on the prevalence and background disorders of cough subtypes in the elderly are scarce. The objective of this study was to identify the point prevalence and risk factors of acute, subacute, and chronic cough in an elderly community-based population.

METHODS

This was a cross-sectional email survey amongst 26,205 members of the Finnish Pensioners' Federation during the COVID-19 pandemic in spring 2021.

RESULTS

The response rate was 23.6% (6189). 5983 subjects aged at least 64 years were included in the analyses (mean 72.6 years, 66.3% female). The point prevalence of daily acute, subacute, and chronic cough were 1.4%, 0.7%, and 9.6%, respectively. Only 0.4% of the subjects had a COVID-19 infection. In the multivariate analyses, chronic rhinosinusitis, and obstructive sleep apnoea were common risk factors for all cough subtypes. Chronic cough had several risk factors; Bronchiectasis (OR 5.79 (CI95% 2.70-12.41)), current asthma (2.67 (2.02-3.54)), chronic rhinosinusitis (2.51 (1.94-3.24)), somatic symptom score (1.13 per symptom (1.07-1.19)), family history of chronic cough (1.88 (1.54-2.30)), gastro-oesophageal reflux disease (1.86 (1.50-2.32)), advanced age (1.20 per decade (1.02-1.40)), chronic obstructive pulmonary disease (1.74 (0.99-3.05)), dog ownership (1.42 (1.07-1.89)), and obstructive sleep apnoea (1.41 (1.16-1.73)).

CONCLUSION

Acute and subacute cough, as well as previous COVID-19 infection, were uncommon in this Finnish elderly population. The prevalence of chronic cough was higher than that previously found in younger adults. Chronic cough is a multifactorial disorder in the elderly.

Ischemic Stroke and Asymptomatic Pulmonary Opacities

PURPOSE

Pulmonary opacities are described in many chest radiograph reports in stroke patients and are often asymptomatic. The aim of this study is to investigate the clinical features associated with asymptomatic pulmonary opacities (APO) and evaluate APO prognostic value in ischemic stroke.

METHODS

We prospectively analyzed patients with acute ischemic stroke without pneumonia symptoms referred to our stroke center. All patients underwent a chest x-ray within 48 hours after admission. We divided patients with APO (defined as asymptomatic area of increased pulmonary attenuation) and patients without APO. Firstly, we compared clinical, laboratory, and echocardiographic parameters between groups; secondly, APO were evaluated as a possible predictor of the neurological severity at discharge and functional outcome at 90 days.

RESULTS

We included 162 patients, 78 of whom had APO. On univariate analysis, we observed a significant difference between patients with APO and patients without APO in terms of neutrophils (73,56±10,10 vs 69,72±12,29; p=0,031), atrial fibrillation (AF, paroxysmal 27,4% vs 25,6%; permanent 19% vs 2,6%; p<0,002), cardioembolic etiology (37,2% vs 22,7%, p <0,033), thrombectomy (58,3% vs 42,9%, p <0,05), dysphagia/vomit (34,5% vs 14,10%, p<0,005), admission NIHSS (14,20±5,98 vs 10,29±5,82, p=0,001), discharge NIHSS (8,68±6,73 vs 5,64±6,20; p=0,003), and 90 days mRS (3,47±2,12 vs 2,31±1,93; p=0,001). On multivariate analysis, APO were significantly associated with admission NIHSS and AF. APO were a predictor of outcome on univariate analysis, but not on multivariate.

CONCLUSION

APO in acute ischemic stroke are associated with AF. APO were not a predictor of neurological and functional outcome.

The Cough Reflex: The Janus of Respiratory Medicine

In clinical practice, we commonly face adversity when encountering dysfunction of the cough reflex. Similar to ancient Roman deity Janus, it often presents with one of two opposing "faces". Continual aberrant activation of the cough reflex, also known as chronic cough, can cause great detriment to quality of life and many of these patients are left misdiagnosed and undertreated. In contrast, loss of normal functioning of the cough reflex is the cause of a significant proportion of mortality in the elderly, primarily through the development of aspiration pneumonia. In this review we discuss both hyper- and hypo-activation of the cough reflex and how airway reflux and chronic aspiration may be involved in the aetiology and sequalae of both disease states. We detail the physiological and pharmacological mechanisms involved in cough, and how the recent development of P2X3 receptor antagonists may lead to the first pharmaceutical agent licensed for chronic cough. The treatment and prevention of loss of the cough reflex, which has been largely neglected, is also discussed as novel low-cost interventions could help prevent a number of hospital and domiciliary deaths from both acute and chronic aspiration.

Impact and disease burden of chronic cough

Cough is an important physiological mechanism to protect the lower airways, but it is also one of the most common symptoms that lead patients to seek medical consultations. Chronic cough, usually defined by cough duration longer than 8 weeks in adults, is prevalent in the community and impairs quality of life in individual patients. There are several characteristics that may differentiate pathologic coughs from protective cough responses, including cough duration, frequency, hypersensitivity, impaired cough suppressibility, or treatment refractoriness. However, the impact of cough, or its perceived severity, is a sum of the patient's experience of coughing and is a factor that may finally define cough as a disease. Social isolation is a major impact of chronic cough, which is now worse due to the coronavirus disease 2019 pandemic and a widespread fear of cough as a source of contagion. Emotional impact and economic impact (medical cost, reduced work productivity, and job loss) are also important complications of chronic cough, and they interact in a vicious cycle, aggravated by social isolation and treatment failures. This paper is a narrative review that aims to address the impact and disease burden of chronic cough in adult patients. We review the literature, but also introduce the findings from recent qualitative interviews and the patients' experiences of the impact and burden of chronic cough and discuss unmet needs in these patients.

Longitudinal Speech Biomarkers for Automated Alzheimer's Detection

We introduce a novel audio processing architecture, the Open Voice Brain Model (OVBM), improving detection accuracy for Alzheimer's (AD) longitudinal discrimination from spontaneous speech. We also outline the OVBM design methodology leading us to such architecture, which in general can incorporate multimodal biomarkers and target simultaneously several diseases and other AI tasks. Key in our methodology is the use of multiple biomarkers complementing each other, and when two of them uniquely identify different subjects in a target disease we say they are orthogonal. We illustrate the OBVM design methodology by introducing sixteen biomarkers, three of which are orthogonal, demonstrating simultaneous above state-of-the-art discrimination for two apparently unrelated diseases such as AD and COVID-19. Depending on the context, throughout the paper we use OVBM indistinctly to refer to the specific architecture or to the broader design methodology. Inspired by research conducted at the MIT Center for Brain Minds and Machines (CBMM), OVBM combines biomarker implementations of the four modules of intelligence: The brain OS chunks and overlaps audio samples and aggregates biomarker features from the sensory stream and cognitive core creating a multi-modal graph neural network of symbolic compositional models for the target task. In this paper we apply the OVBM design methodology to the automated diagnostic of Alzheimer's Dementia (AD) patients, achieving above state-of-the-art accuracy of 93.8% using only raw audio, while extracting a personalized subject saliency map designed to longitudinally track relative disease progression using multiple biomarkers, 16 in the reported AD task. The ultimate aim is to help medical practice by detecting onset and treatment impact so that intervention options can be longitudinally tested. Using the OBVM design methodology, we introduce a novel lung and respiratory tract biomarker created using 200,000+ cough samples to pre-train a model discriminating cough cultural origin. Transfer Learning is subsequently used to incorporate features from this model into various other biomarker-based OVBM architectures. This biomarker yields consistent improvements in AD detection in all the starting OBVM biomarker architecture combinations we tried. This cough dataset sets a new benchmark as the largest audio health dataset with 30,000+ subjects participating in April 2020, demonstrating for the first time cough cultural bias.

Management of Very Old Patients in Intensive Care Units

The global population is aging and the demand for critical care wards increasing. Aging is associated not only with physiological and cognitive vulnerability, but also with a decline in organ function. A new topic in geriatric care is how to appropriately use critical care resources and provide the best treatment plan for very old patients (VOPs). Our special geriatric intensive care unit has admitted nearly 500 VOPs. In this review, we share our VOP treatment strategy and summarize the key points as “ABCCDEFGHI bundles.” The aim is to help intensivists to provide more comprehensive therapy for VOPs in intensive care units.

Cut-off Values of the Respiratory Muscle Power and Peak Cough Flow in Post-Stroke Dysphagia

Background and objectives: This study aimed to determine the cut-off values of the following three respiratory pressure meters; the voluntary peak cough flow (PCF), maximal expiratory pressure (MEP) and maximal inspiratory pressure (MIP); associated with post-stroke dysphagia and assess which of these parameters show good diagnostic properties associated with post-stroke dysphagia. Materials and Methods: Retrospective analysis of a prospectively maintained database. Records of patients with first-ever diagnosed dysphagia attributable to cerebrovascular disease, who had performed spirometry measurements for the PCF, MIP and MEP. Results: From a total of 237 stroke patients, 163 patients were diagnosed with dysphagia. Those with dysphagia had significantly lower PCF values than those without dysphagia (116.3 ± 75.3 vs. 219.4 ± 91.8 L/min, p < 0.001). In addition, the former group also had lower MIP (30.5 ± 24.7 vs. 41.6 ± 25.7 cmH₂O, p = 0.0002) and MEP (41.0 ± 27.9 vs. 62.8 ± 32.3 cmH₂O, p < 0.001) values than the latter group. The receiver operating characteristic curve analysis showed that the PCF cut-off value of 151 L/min (area under the receiver operating characteristic curve [AUC] 0.81; sensitivity 72%; specificity 78.8%) was associated with post-stroke dysphagia. The optimum MEP and MIP cut-off were 38 cmH₂O (AUC 0.70, sensitivity 58%; specificity 77.7%) and 20 cmH₂O (AUC 0.65, sensitivity 49%; specificity 84%). PCF showed the highest AUC results. Results from the univariate analysis indicated that PCF values of ≤151 L/min increased risk of dysphagia by 9.51-fold (4.96–18.23). Multivariable analysis showed that after controlling of other clinical factor, the PCFs at this cut-off value still showed increased risk of by 4.19 (2.02–83.69) but this was not observed with the MIPs or MEPs. Conclusions: Our study has provided cut-off values that are associated with increased risk of dysphagia. Among the three parameters, PCF showed increased association with post-stroke dysphagia.

Perspectives on chronic cough in Korea

Chronic cough is a common condition, and generally affects about 3% of Korean adults with a significant influence on quality of life (QoL). Despite continued clinical and academic efforts, there are unmet needs for chronic cough prevention and management in Korea. Epidemiologically, there are two major challenges: an aging population and air pollution. Korea is one of the most rapidly aging countries, and the relative proportion of elderly to younger people is expected to double within the next two decades. Air pollution is a major concern, but there is very limited evidence on the effects of air pollutant on cough in Korean patients. Clinically, upper and lower airway diseases, such as rhinitis/rhinosinusitis and cough variant asthma/eosinophilic bronchitis, are reported to account for about 75% of chronic cough in Korean adults, which formed the basis in formulating clinical practice guidelines. However, further studies are warranted to resolve clinical uncertainty, particularly for the evaluation and treatment of upper airway conditions in chronic cough. The prevalence of gastroesophageal reflux disease (GERD) is increasing, thus its relevance to cough among Koreans may warrant re-evaluation. Infection-associated chronic cough, such as tuberculosis, is another continuing concern. The proportion of chronic refractory or unexplained cough is assumed to be 10–20% among patients visiting referral clinics for chronic cough. This review presents our perspectives on current epidemiological and clinical issues of chronic cough in Korea, and addresses major knowledge gaps and future research priorities.

Chronic cough in the elderly

Chronic cough is a multi-factorial syndrome commonly presenting as cough hypersensitivity in adult patients. It is a common medical condition in the communities but is more prevalent in older adults. Elderly patients (≥65 years) frequently suffer from multiple comorbidities, which may lead to more clinical heterogeneity in chronic cough and pose diagnostic and therapeutic challenges. Hyposensitivity in cough reflex, probably resulting from central nervous system illnesses, is another potential concern. Despite these complexities and challenges, elderly-specific issues have rarely been addressed in current clinical practice guidelines for chronic cough. Considering recent trends in global population aging, the burden of elderly chronic cough is expected to increase into the near future. This review aimed to respond to following clinical questions: (1) is chronic cough a more heterogeneous condition in the elderly compared to younger adults; and (2) are there additional considerations when choosing the diagnostic and therapeutic approaches to this condition in the elderly?