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A STUDY ON TUBERCULOSIS IN ELDERLY PATIENTS Dr. David L. K. Dai, MBBS (HK) MRCP(UK)

A STUDY

ON TUBERCULOSIS

IN ELDERLY

PATIENTS

Dr. David L. K. Dai, MBBS (HK) MRCP(UK) MRCP (lre.) FCCP Consultant Dr. Anthony W. C. Tang, MBBS(NSW)

Medical

Officer

Dr. Victor K. K. Chan MBChB(CUHK) Medical Officer Dr. Antony C. T. Leung, MBBS (HK) FRCP (Glasg)

Hospital

Chief

Executive

 

Deportment

of

Aged

and

Extended

Care

Heaven of Hope Hospital. TseungKwan O, Hong Kong

Summary

Introduction The overall incidence of tuberculosis in Hong Kong is

falling but age specific notification rate for patients aged 65

years and above has not decreased as rapidly as the

age groups (1990 versus 1980). Also, an absolute increase

in new cases in the older group is seen

occurs in the younger group. The proportion of tuberculo- sis patients aged 65 and above rises from 12.5% (1980) to 21.2% (1990), while the percentage of population aged 65 and over has risen only from 6.6% (1980) to 8.6% (1990). Although the mortality from tuberculosis has dropped in

all age groups

(mortality rate per 100,000 was 7.0 in 1989 as

younger

while a decrease

against 6.6 in 1990), more deaths occur in the older age

Also the aver-

age age at death from tuberculosis in 1990 was 69 years. Tuberculosis still ranks ninth position among the ten lead- ing causes of death in Hong Kong’. An ageing population, immunosenescence, comorbid medical conditions. nutri- tion and socioeconomic factors interact to result in the ris- ing incidence of tuberculosis in the older person.

40

group (50% in 1980 as against 63% in 1990).

the fea-

tures of tuberculosis between the younger (aged below 65

years) and older (aged 65 years or above) patients.

The aim of the present study

is to compare

Patients and Method From 1st to 14th September 1993, patients receiving

antituberculous treatment in tno tuberculosis male wards

were recruited into the study. An age cut-off divide the patients into young and

of 65 years was used

of our hospital

to

old groups. The following data were recorded for these two age groups of patients:

1.

Clinical characteristics of tuberculosis

2.

Comorbid medical conditions

3.

Biochemical parameters of nutrition

4.

Social factors

5.

Functional status

6.

Drug therapy

Results

33

male patients were recruited into the study, 16 were

aged below 65 years and 17 aged 65 and above. represent-

ing nearly equal numbers for both age groups.

1. Clinical

characteristics

(Tables 1 and

2)

and older groups were

54.6 years and 72 years respectively. All the patients were being treated for pulmonary tuberculosis except one old

patient who was treated for extra-pulmonary tuberculosis, with negative chest radiograph. All pulmonary tuberculo- sis patients showed radiological activity. A positive spu- tum in direct smear or culture was found in 12/16 (75%) and 15/16 (93.8%) in the young and aged groups respec- tively. 2/16 was multiresistant tuberculosis in the younger patients as against 1/7 of the aged patients. No atypical mycobacteria were identified in all the patients. The chest X-ray zones were involved in 35/96 (36.5%) and 49/96 (51%) of the young and aged groups respectively. More radio- logical zones at all levels were involved in the older pa- tient: the percentages increase in the older patient when compared to the young for the apical, middle and lower

The mean ages of the younger

Table 1. Clinical characteristics of tuberculosis Table 2. Chest X-ray appearance tuberculosis in pulmonary

Table 1. Clinical

characteristics

of tuberculosis

Table 2. Chest X-ray appearance tuberculosis

in pulmonary

 

Proportion

inwlvecl

Proportion

in\.olvrcl

 

in young

Ir~=l(i)

 

in old fr1=f6/

l&&L.&

 

m

f&&tLcft

 

Totlll

Zonrs:

Apt3

12.10

10 16

22 j2

15 10 It

10

29 32

&lid

t

10

i

16

9 32

7

16

t.

16

11 32

LO\\

1 10

j

16

t

j’

0

16

3 16

9 32

Total

1-

ts

18 -tx

js

96

2s is

2 1 4s

to

‘)(I

 

More comorbid

conditions

existed

in the older

group

averaging

2.05 conditions

per

patient.

while

1.1 condition

per patient

occurred

in the young.

31.3 - 35.3% of

patients

had

a past

history

of

pulmonary

tuberculosis.

Aged

pa-

tients

had

more

coexisting

conditions

of dementia.

diabe-

tes mellitus.

luns

cancer

and

chronic

obstructive

pulmo-

nary

disease.

 

The

older

patients

were

lighter

in hody

weight

at

40.6kg on

average.

and by 18.3kg than the younger

patients.

Haemoglobin

levels

were

simiar.

A higher

MCV and ESR

were

apparent

in

the

older

patient.

The

absolute

lymphocyte

count.

albumin

level,

uric

acid

and creatinine

levels

were

lower

in

the

older

patient.

Phosphate. urea,

sodium.

potassium

were

comparable

in either

groups.

The

older

patient

showed

a higher

fasting

sugar of

7.9 mmol/l.

Spot sugars

were

comparable

in either

groups.

Apex

x

16

7

16

hlore

only than 2 levels

7’16

 

9

16

Pleural efwiion

7

16

016

Table 4. Biochemical

parameters

of nutrition

 

.klfl

bdws

in yxmg

hkan

values

in old

Table 3. Comorbid

Conditions

 

Patients (range)

Patients (range)

 

No.in young

 

patients

No.in old patients

Botl>- \x.eight (kg)

58.9

(33.57.4)

40.6

(33-57.5)

 

HMgj

12.9

(11.3-15.8)

12.7

(9.1-16.3)

Past tuberculosis

 

5

6

.LICV (fl)

88.9

(74.7-121.9)

92.2 (8j.l-108.6)

Liver disease

1

5

5lCHC (g/ dl)

32.8

(31.0-34.2)

31.9

(28.7-34.X

Renal disease

2

1

ESR(mm’hr)

65.4

(j-150)

70.4

(10-200)

Chronic obstructive

2

4

Lymphocyte

count

 

pulmonary

disease

 

(xlO”,,l)

1.7

(0.91-3.36)

1.25

(0.14-1.91)

Silicosis

 

I

Albumin

(g/l)

37,7

(X3.7-42.7)

30.2

(20.4-38.1)

Cardiovascular

disease

2

1

Globulin

(mmol; 1)

-

36

(27-53.1)

Eye disorder

2

(catsract, glaucoma)

 

Calcium (mmol, I)

2.36

(1.9528)

2.35

(2.1-2.8)

Joint disorder

1

(gout)

Phosphate (mmol: I)

1.26

(0.83-1.6)

1.29

(1.1-1.55)

Skin disorder

1

(psoriasis)

 

Cric acid Cmmol: 1)

0.4

(0.16-0.84)

0.32

(0.11-0.6)

Neurological

disorders

1

3 (dementia)

Urea Cmmol; II

6.1

(2.8-13.4)

6.2

(3.6-10.8)

 

(mentally

retarded,

epilepsy)

Creatinine

(mmol. I)

111.3 (8j-240)

97.7 (67-154)

Diabetes mellitus

 

7

Sodium (mmol;l)

137.4 (133-l-a

13j.8 (127-143)

Pneumonia

1

Potassium (mmol. I)

4

(3.3-4.7)

3.9

(2.9-5.1)

Lung cancer

2

Glucose: fasting

5.7

7.9

Gastrointestinal disorders

2

(mmol, 1) spot

9.8

9.1

Prostate disease

1

Drug addict B12/ folate deficiency

1

Total:

18

 

35

 

41

9.1 Prostate disease 1 Drug addict B12/ folate deficiency 1 Total: 18   3 5  
4. Social factors (TAble 5) majority live with the family or children, 2 older patients
4. Social factors (TAble 5) majority live with the family or children, 2 older patients

4. Social factors

(TAble

5)

majority live with the

family or children, 2 older patients came from old age

homes.

support. 6.25% of younger quiretl public assistance.

47% of older patients espressed inadequate family,

of older patients re-

Although

in either groups

and

the

41.2%

Table 5. Social

factors

Table 6. Functional

status

(11=171

12

2

1

2

2

1 (moderate)

1 (mild)

adequate

It

9

inadequate

2

8

prixlte

15

10

public assistance

1

1,

2

1

2

11

6

prixlte 15 10 public assistance 1 1, 2 1 2 11 6 6.25% of younger patients

6.25% of younger patients showed abnormality in cognition as against 29.4% of the older person, of which 60% of the latter were of at least moderate severity. All younger patients were ambulant, the majority requiring no walking aids. About 18% of the older patient were either chair-bound or bed-bound. All younger patients were uri- nary continent with a normal bowel habit. 35.3% of the older were incontinent in urine and 23.5% in faeces; 29.4% were constipated. Nearly all younger patients were inde- pendent in activities of daily living (ADL) while 17.6%-47%

of older patients were dependent, particularly for bathing. dressing and toileting. Although independent in ADL. younger patients become dependent in instrumental ADL from 6.25% to 12.5%, especially for shopping, cooking and handling finance. About 60% of older patients were inde-

pendent in all areas of instrumental ADL. 11.8% of the

patient were suspected to have depression. Only a small proportion of patients had significant visual or hearing defi- cit in either groups.

older

6.25% of young and 23.5% of older patients esperi- enced drug intolerance. Drug hypersensitivity occurred in

6.25% of young and 47% in the older group, most frequently

liver impairment, followed

by renal and skin rash. Compli-

ance was comparable in both groups. The drug regimes were similar in either groups. Streptomycin was used in 58.8% of older patients. 31.3% of young and 35.3% older patients were receiving treatment for the second time. A defaulter history was noted in 11.8%

42

9

11

1-t

10

l‘i

7

7

6

* XDL (activities ofdaily living) and IADL (instrumental sified as either independent or dependent

of older patients. The older patient took on average 18.3 drugs per day.

ADL) clas-

Discussion Tuberculosis is still prevalent in Hong Kong. The in-

crease in incidence in the elderly patients is out of propor- tion to the expanded total aged population, Mortality from tuberculosis has also shifted to the older age group’. Fat- tors leading to this phenomenon include (i) reactivation of tuberculosis in the growing aged population who had been infected remotely in the past when tuberculosis was ram- pant in Hong Kong, (ii) recently acquired infection, and

(iii) reduced rate of transmission in the younger age group.

Powell and Farrer2 ontended that the age shifts demon- strated the past successes with tuberculosis control, in the event of decreasing transmission of Mycobacterium tuber-

culosis.

Dai

DLK.

Tang AWC, Chan

VKK,

Leung ACT

l Tuberculosis

Study

Table 7. Drug therapy

not pose a diagnostic prohlem

an adequate index Of suspicion and diligent investigations,

in the elderly patient given

Morris’ described pulmonary tuberculosis in elderly patients as a different disease entity, by virtue of distinct clinical and diagnostic characteristics. Radiologically, our elderly patients showed more extensive involvement and there was a tendency for the lower and mid zones to be more affected in the older patients than the younger. though it did not reach statistical significance in this study (20/32 in old compared with 13/32 in young. p=0.133 by the Yates’ corrected chi-square). Mid and lower lobe involvement were reported as varying from 26% to 83%)in three series4. Pul- monary tuberculosis involving the lower and middle lobes usually arise from the upper lobe through endohronchial spread. The occurrence of lesions in lower lung field or anterior segment of upper lobe should lead one to look for factors such as diabetes mellitus, advanced age, steroid treat- ment, renal or hepatic disorder. malignancy and alcohol- ism5,6.The radiological changes can also conform to classi- cal post-primary tuberculosis with apical fibrosis, cavitation and pleural thickening. Disseminated tuberculosis can present in the “reactive” miliary or "areactive” cryptic fash- ions. The overall radiological pattern in the elderly patient differs from those of pure primary or post-primary tubercu- losis, and are similar to those seen in patients with decreased or absent cell-mediated immunity2. A high positive bacteriology rate by direct smear or culture was found in our older patients probably by virtue of more extensive parenchymal disease and heavier bacte- rial load. A further increase in positive yield can be achieved through culture of bronchoscopic washing, bronchial brushing and transbronchial biopsy7. Tuberculosis should

The classical symptoms of night sweats, fever. haemopvsis and chest pain tend to be mild in the older age group, How- ever. these were not examined in our study. One feature of tuberculosis in the elderly patient demonstrated in our study is the frequent association of comorbid conditions. In particular, concurrent occurrence of tuberculosis and malignancy is not uncommon8. Our elderly patients are malnourished, as evidenced by a low, body weight. higher MCV, lower lymphocyte count. low albumin and uric acid levels. Other abnormal parameters reported in other series. but not in our study include hyponatraemia and hypokslaemia. The higher in- cidence of hcpatic dysfunction in our group may reflect dissemination or reactivation of disease in the liver of an older person3. The fasting sugar is higher in the older age group indicating a higher prevalence of abnormal glucose tolerance. Age related immunosenescence plays a role in the increased frequency of tuberculosis in the elderly popula-

tion4. Malignancy. diabetes mellitus. chronic renal failure, immunosuppressive drugs and poor nutrition may act through similar pathways. Our older patients belonged to a lower socio-eco- nomic class with inadequate family support. More patients came from home than an aged institution. American au- thors reported 80% of all tuberculosis cases in the elderly patient to arise among those at home. largely from recru- descence of remote infection. About 20% of cases arise among those who live in nursing homes as a mixture of old and recently acquired infection”. Chronic institutional- ised elderly persons in Hong Kong are prone to tuberculo-

(i) frailty and comorbid conditions, (ii) mal-

nutrition, and (iii) increased transmission from a crowded environment. The authors believe that tuberculosis in pri- vate care and attention homes may be under-detected and ma)- potentially form a sizeable reservoir of untreated in- fection. Most papers on geriatric tuberculosis cover the atypical clinical features10,11.Our present paper, in addi- tion. describes the more prevalent dysfunction of the eld- erly patient in physical, and in particular, the instrumental activities of daily. living. This is to be expected from a group of frail. socioeconomically deprived, and chronically ill patients of older age. Depression is a recognised associa- tion with tuberculosis and may be more prevalent in the

elderly.

The side effects of antituberculous drugs are more frequent and more severe in elderly patients, presenting as intolerance or hypersensitivity. The figures are compa- rable to a recent study by Teale et al10.Our high incidence

of liver impairment to this, ethambutol

is similar to other studies. With regard has been recommended in elderly pa-

tients. Streptomycin in the authors’ opinion, can be used in the elderly patient, provided caution is taken in moni-

sis because

of

in the authors’ opinion, can be used in the elderly patient, provided caution is taken in

43

in the authors’ opinion, can be used in the elderly patient, provided caution is taken in
1 . Effective surveillance and eradication of’ disease in the younger population. 2 . Enhancing
1 . Effective surveillance and eradication of’ disease in the younger population. 2 . Enhancing
1 . Effective surveillance and eradication of’ disease in the younger population. 2 . Enhancing
1 . Effective surveillance and eradication of’ disease in the younger population. 2 . Enhancing
1 . Effective surveillance and eradication of’ disease in the younger population. 2 . Enhancing
1 . Effective surveillance and eradication of’ disease in the younger population. 2 . Enhancing

1. Effective surveillance

and eradication

of’ disease in

the younger

population.

2. Enhancing immunocompetence of the elderly person through adequate nutrition.

3. Avoid unnecessary use of immunosuppressive drugs such as steroids.

4. Prevention of transmission particularly in institutions by improving environment: such as reducing overcrowdedness and better ventilation.

5. Early detection. and appropriate nutrition and drug therapy.

6. Optimal treatment of comorbid conditions.

7. Rehabilitation and community support for the func- tionally incapacitated.

References

1. Annual Report 1990, Chest Service of the Hong Kong Government Department of Health.

-. 2

Powell KE. Farrer IS. The rising age of the tuberculo- sis patient: a sign of success and failure. J Infec Dis

1990:142(6):946-8.

3. Morris CDW. Pulmonary Tuberculosis in the elderly:

a different disease? Thorax 1990;45:912-3.

4. Yoshikawa ‘IT Tuberculosis in ageing adults. J Am Geriatr Soc 1992:40:178-187.

5. Chang SS, Lee PY, Perng RI? Lower lung field tuber- culosis. Chest 1987;91:230-2.

6. Spencer D. Anterior segment upper lobe tuberculosis in the adult. Chest 1990:97:384-8.

7. Pate1 YR Flexible bronchoscopy as a diagnostic tool in the evaluation of pulmonary tuberculosis in an eld- erly population. J Am Geriatr Soc 1993;41:629-632.

8. Alvarez S, Shell C, Berk S. Pulmonary tuberculosis in elderly men. Am J Med 1987;82:602-6.

9. Stead WW. Tuberculosis in elderly persons. Annu Rev Med 1991,42:267-276.

10. Teale C, Goldman JM, Pearson SB. The Association of age with the presentation and outcome of tuberculo- sis. Age Ageing 1993;22:289-293.

11. Brande PMV. Clinical spectrum of endobronchial tu- berculosis in elderly patients. Arch Intern Med

1990;150:2105-8.

11. Brande PMV. Clinical spectrum of endobronchial tu- berculosis in elderly patients. Arch Intern Med 1990;150:2105-8.
11. Brande PMV. Clinical spectrum of endobronchial tu- berculosis in elderly patients. Arch Intern Med 1990;150:2105-8.
11. Brande PMV. Clinical spectrum of endobronchial tu- berculosis in elderly patients. Arch Intern Med 1990;150:2105-8.