Clinical Geriatrics

Case Presentation
Mr. D is a 67-year-old married male who comes to the Emergency Department (ED) with complaints of chest pain and shortness of breath. He is accompanied by his wife, who reports that Mr. D has been having episodes of coughing and shortness of breath for several months but has refused to see his doctor. Earlier that day he developed chest pain in addition to coughing and shortness of breath, so Mrs. D called 911.

Mr. D is evaluated in the ED. He is very ill-appearing and requires oxygen by face mask. He is febrile, with a temperature of 39.2 degrees C (102.6 degrees F); tachycardic, with an irregular heart rate of 115-120 beats per minute; and hypotensive, with a blood pressure of 100/58 mm Hg. The patient is placed on a cardiac monitor and is found to be in atrial fibrillation. A chest x-ray reveals a large infiltrate in his left lung. He has an elevated white blood cell count of 15,500/µL, consistent with a clinical diagnosis of pneumonia. Mr. D is given intravenous hydration, blood is drawn for cultures, and he is admitted to the Cardiac Telemetry Unit for monitoring of his arrhythmia. Intravenous ceftriaxone 1 g daily is started for pneumonia, and metoprolol 50 mg by mouth twice daily is given for tachycardia.

Mr. D spends a quiet night following admission, and the next day he is no longer short of breath. He remains febrile, but his heart rate and blood pressure are now in the normal range. The patient tells the nursing staff that he wants to go outside for a few minutes to smoke a cigarette. The nurse spends time with Mr. D in his hospital room asking about his smoking history and finds out that he has been smoking two packs of cigarettes per day since the age of 17. Mr. D reports that he has tried to quit smoking more than 20 times, often at the urging of his wife. He reports that he never received any formal advice or assistance from his doctor but was told many times that he should stop smoking. He tried using nicotine gum and patches in the past but was never able to stop smoking for more than seven days. His wife stopped allowing him to smoke in their house five years ago, so Mr. D goes outside and smokes with his neighbors. The patient becomes more insistent about leaving the Telemetry Unit to smoke. His nurse tells him that she will ask the doctor to prescribe some nicotine replacement therapy for him and asks if she can call his wife. Mr. D agrees to wait for his wife and the doctor but appears restless and reports that he knows he will feel better if he can have “just one cigarette.”

The nurse pages the doctor on call and explains the situation. She asks the physician to speak with Mr. D, given his lengthy smoking history. While she is on the telephone, Mrs. D arrives. She begs the nurse for help, stating that her husband was told more than ten years ago that he suffers from smoking-related lung disease and that his coughing has been chronic for more than five years. Mrs. D is hoping that, while her husband is in the hospital, something can be prescribed to help with his cravings for cigarettes.

Discussion
The Centers for Disease Control and Prevention (CDC) recently estimated that approximately one in ten older adults is a current smoker, accounting for more than 40% of adults who smoke.¹ Of those who are over the age of 65 years, 4.5 million smoke cigarettes daily. Older men are five times more likely to be active smokers in late life as compared to women.¹ Quitting smoking at an older age can still yield substantial health benefits.^1,2 Older smokers can still benefit from a reduction in coronary artery disease, lung cancer, chronic obstructive pulmonary disease, and improvement in osteoporosis if they stop smoking.³ Those who suffer from chronic illnesses such as cardiac and lung disease will have fewer exacerbations related to smoking and will recover at a faster rate following smoking cessation.