Clinical spectrum of tuberculosis in older patients

Clinical spectrum of TB in elderly in a TB & respiratory institution

Tuberculosis has maximum burden among young population in developing countries like India. However, children and elderly form a special group where TB may have atypical presentation. This presents with epidemiological, diagnostic and treatment challenges in these groups which may need special attention in the national programmes for TB. Due to atypical presentation, elderly population is vulnerable to frequent misdiagnosis and disease may already be in advanced stage when correct diagnosis is made. Not only this, adjustment of drug dosages and high chances of adverse drug reaction make the management of TB more complicated in elderly. Mortality due to TB is also higher in this group as compared to young patients of TB. This view point briefly highlights the epidemiological, clinical and disease outcome aspects of TB disease in elderly patients.

Time to diagnosis of tuberculosis is greater in older patients: a retrospective cohort review

Introduction

Age-related immunosenescence influences the presentation of tuberculosis (TB) in older patients. Here, we explore the clinical and radiological presentation of TB in the elderly and the factors associated with time to treatment for TB.

Methods

This is a retrospective cohort study comparing the clinical, radiological and demographic characteristics of TB patients aged ≥65 years with TB patients aged 18–64 years in a large cohort of TB patients in the UK. Factors associated with the time to presentation and time to treatment were identified using a multivariable analysis model.

Results

1023 patients were included in the analyses: 679 patients aged 18–64 years and 344 patients aged ≥65 years. “Classical” symptoms of TB (cough, haemoptysis, fever, nights sweats and weight loss) were less common among older patients with pulmonary TB (PTB) (p<0.05), but dyspnoea was more common among older patients (p=0.001). Time from presenting in secondary care to starting treatment was shorter in younger compared with older patients: 3 versus 15 days (p=0.001). When adjusted for age, factors associated with shorter time to treatment from symptom onset include sex (male versus female) (hazard ratio (HR) 1.23 (95% CI 1.05–1.46)), UK born (HR 1.23 (95% CI 1.05–1.46)) and HIV (HR 2.07 (95% CI 1.30–3.29)). Only age remained an independent predictor of time to treatment in a multivariable model (HR 0.98 (95% CI 0.98–0.99)). For those with PTB, chest radiography findings showed that cavitation and lymphadenopathy were more common among younger patients (p=0.001).

Conclusions

Older patients aged ≥65 years with TB had fewer “classical” clinical and radiological presentations of TB, which may explain longer times to starting treatment from symptom onset compared with younger patients aged <65 years.

A retrospective UK study in patients with TB shows only age remains an independent predictor of time to treatment in a multivariable model. Older patients have fewer of the “classical” clinical and radiological features of TB compared with younger patients.http://bit.ly/2yHc0OL

Epidemiological, clinical and mechanistic perspectives of tuberculosis in older people

With the ageing population globally, tuberculosis (TB) in older people becomes a major clinical and public health challenge. In many Asian countries, especially those located in the eastern and southeastern parts of the continent, geriatric TB is a significant problem. TB in the older patients is more difficult to diagnose in the early course of disease, and has poorer treatment outcomes, largely as increased failure and death. More drug-induced adverse reactions are also experienced by this population during TB therapy. Oxidative stress and mitochondrial dysfunction are now well recognized to be associated with the ageing process, and it is likely that the cellular and molecular perturbations interact inextricably with the immunological dysfunction biophysiologically inherent to ageing. These underlying mechanistic bases putatively contribute to the development of TB in the geriatric population and worsen the disease outcomes, especially when the TB is compounded by co-morbid conditions such as smoking and diabetes mellitus. Unravelling these mechanisms further would yield knowledge that might potentially help to prevent reactivated TB in older people, and also to better manage the established disease with drug regimens and other new therapeutic strategies. In addition, addressing the social elements associated with geriatric TB is also imperative in the relief of individual patient suffering and improvement of overall disease control.

Treatment delay and fatal outcomes of pulmonary tuberculosis in advanced age: a retrospective nationwide cohort study

BACKGROUND AND OBJECTIVE

Studies focusing on pulmonary tuberculosis in advanced age (≥80 years) are lacking. This study aimed to explore treatment delay, outcomes and their predictors in this group.

METHODS

Adult (≥20 years) patients with pulmonary tuberculosis were identified from the National Health Insurance Research Database of Taiwan from 2004 to 2009. Treatment completion and mortality rates were noted at one year after treatment.

RESULTS

Among the 81,081 patients with pulmonary tuberculosis identified, 13,923 (17.2%) were aged ≥80 years, and 26,897 (33.2%) were aged 65-79 years. The treatment completion, mortality rates and treatment delay were 54.8%, 34.7% and 61 (12-128) [median, (1st-3rd quartiles)] days in patients aged ≥80 years, 68.3%, 18.5% and 53 (8-122) days in patients aged 65-79 years, and 78.9%, 6.5% and 21 (1-84) days in patients aged <65 years, respectively. The elder patients were more likely to receive second-line anti-tuberculosis agents. The treatment completion rate decreased with older age, female sex, comorbidities, low income, requiring second-line anti-tuberculosis agents, severity of pulmonary tuberculosis and longer treatment delay. Older age, female sex, comorbidities, low income, and not undergoing rapid molecular diagnostic tests were independently associated with longer treatment delays.

CONCLUSIONS

Pulmonary tuberculosis in advanced age has a longer treatment delay and a higher mortality rate. Applying rapid molecular diagnostic tools may reduce treatment delay and should be integrated into the diagnostic algorithm for pulmonary tuberculosis, particularly in elderly patients.

The imaging spectrum of pulmonary tuberculosis

Tuberculosis has still an important impact on public health because it is an important cause of death, particularly in developing countries. On the other hand recent studies have shown that tuberculosis is again becoming concentrated in big cities of Western Europe, especially among immigrants, drug addicts, poor people, and the homeless, despite progress in reducing national rates of the disease. Diagnostic imaging is challenging for radiologists because signs of tuberculosis may easily mimic other diseases such as neoplasms or sarcoidosis. Clinical signs and symptoms in affected adults can be non-specific and a high level of pre-test clinical suspicion based on history is fundamental in the diagnostic work-up. Impact of tuberculosis in the world is extremely important considering the high incidence estimated during 2011 that was 8.7 million cases. This article gives a review of imaging patterns of chest tuberculosis as may be detected on conventional radiography and computerized tomography (CT). The main aim is to improve radiologist's familiarity with the spectrum of imaging features of this disease and facilitate timely diagnosis. Furthermore, we consider the emerging role of alternative methods of imaging, such as magnetic resonance imaging (MRI), that can be helpful and highly accurate for a better definition of some signs of tuberculosis.

Tuberculosis at extremes of age

ABSTRACT Although tuberculosis (TB) has its highest burden among young adults, especially since the advent of HIV infection, two other groups with low immunity, the very young (<1 year) with immature immunity and the elderly (>65 years) with waning immunity, are vulnerable groups not to be forgotten. This review describes the epidemiology, clinical aspects, public health aspects and outcome of TB in patients at the extremes of age. The epidemiology differs therein that TB in infants occurs in developing countries with high incidences of TB and HIV, while TB in the elderly occurs in developed countries with ageing populations. The clinical presentation may be non-specific, history of contact with TB is often not known and TB is often not considered at these age extremes, and when the diagnosis is considered, disease progression may already be advanced. Anti-TB treatment regimens are the same as in other age groups, but drug dosages may need adjustment according to weight, renal function, liver function and other potentially complicating factors. Adverse events are more difficult to observe and both the young and the elderly are reliant on others for adherence to treatment. Mortality at both age extremes is higher than in the general TB population. For all the above reasons, public health measures to: prevent transmission of infection; identify those infected and providing preventive therapy; high index of suspicion in order to make an early diagnosis; and timely initiation of treatment are important in both the very young and the elderly.

Mortality of tuberculosis in very old people

OBJECTIVES

To describe the clinical characteristics and outcomes of tuberculosis (TB) in elderly people.

DESIGN

Observational analysis of a prospective cohort of adults with TB (1995-2004). A case-control study to determine attributable mortality to TB in very old people was done.

RESULTS

Of 319 patients with TB, 109 (34.2%) were aged 65 and older. The older group was more likely to have comorbidities (1.4% vs 0.4%; P<.001), extrapulmonary and disseminated TB (50.4% vs 26.1%; P<.001), toxicity (22% vs 9.8%; P=.006), and 30-day mortality (18.3% vs 1.6%; P<.001). When patients aged 65 to 79 were compared with those aged 80 and older, only differences in TB-related mortality were detected (9.8% vs 44.4%; P=.01). In the attributable mortality analysis, 30-day and 6-month mortality were higher in very old patients with TB than in controls without TB (41.7% vs 11.1%, P=.005; 45.8% and 19.4%, P=.01, respectively). No differences in mortality were shown when excluding patients with postmortem TB diagnosis or those who died within the first 72 hours of diagnosis.

CONCLUSION

Older people with TB had a higher frequency of atypical features, more adverse drug reactions, and greater TB-related mortality than younger people. Data suggest that very old patients with TB have higher mortality, but if diagnosed early and adequately treated, very old patients with TB do not have greater mortality than those without.

Delayed diagnosis of active pulmonary tuberculosis in emergency department

BACKGROUND AND PURPOSE

Tuberculosis (TB) is a worldwide health challenge. Emergency department (ED) is the major public access to the health care system. Delayed diagnosis of active pulmonary TB was believed to precipitate mortality and morbidity. The study was designed to investigate clinical characteristics and factors in patients with delayed diagnosis of active TB in ED.

METHODS

We used a retrospective chart review.

PATIENTS

A total of 103 patients were enrolled between December 2003 and March 2006.

RESULTS

Typical chest radiographic findings were noted in 79.8% of nondelayed TB group and 31.6% of delayed TB group (P < .001). Diagnosis of pneumonia was made at ED in 22.6% of nondelayed TB group and 68.4% of delayed TB group (P < .001). Length of initiation of TB treatment intervention was 0 days (0-1 days) and 9 days (6-16 days), respectively (P < .001). In-hospital mortality rate was 15.5% and 47.4%, respectively (P < .01). Age (odds ratio, 1.07; 95% confidence interval, 1.01-1.1) and intensive care unit admission (odds ratio, 5.01; 95% confidence interval, 1.18-21.3) were associated with lower in-hospital survival. Delayed ED diagnosis of TB was associated with mortality in results of univariate analysis (P = .002), but no statistical significance was noted in the final result of stepwise logistic regression analysis.

CONCLUSION

Intensive care unit admission and age are associated with mortality. Awareness of varying features of pulmonary TB by physicians is important.

Male-female differences in the risk of tuberculosis in dialysis patients

AIM

To define any gender-related differences in the prevalence and risk for tuberculosis (TB) in hemodialysis (HD) patients.

METHODS

All active TB cases were recorded during a 36-month follow-up of 272 (193 male and 79 female) HD patients. Entering the study, HD patients were tested with tuberculin and 2,4-dinitrochlorobenzene, and a cell-mediated immunity (CMI) index was estimated. Relative risks (RR) for TB were calculated considering subjects from the background general population as a reference group. The independent effect of age, BMI and tuberculin sensitivity was determined using Cox's proportional hazard model.

RESULTS

Female HD patients presented significantly lower CMI indices and rates of positive Mantoux tests, but higher rates of DM, as compared to males. The male:female ratio in TB for the general and HD patients population was 1.8 and 0.6, respectively. There was a significantly lower TB prevalence in male as compared to female HD patients (7.7% vs. 11.3%), and a subsequent female predominance in risk for TB in those HD patients aged <49 and 50-69 years (M:F adjusted relative risk 0.67 and 0.53) was recorded.

CONCLUSIONS

In contrast to the general population, there is a female predominance among dialysis TB patients younger than 70 years associated with the coexistence of DM. Female gender should always be considered as a risk factor when evaluating diabetic HD patients for active TB.

[Analysis of the treatment of pulmonary tuberculosis in elderly patients at a university hospital in Rio de Janeiro, Brazil]

OBJECTIVE

To describe the clinical and therapeutic aspects of pulmonary tuberculosis and compare the adverse effects of the treatment and its outcome in elderly and nonelderly patients.

METHODS

This was a case-control study of 117 elderly individuals (over the age of 60 years) and 464 nonelderly individuals (aged 15-49 years). All subjects presented pulmonary tuberculosis that had been diagnosed and treated at the Thoracic Diseases Institute of the Federal University of Rio de Janeiro between 1980 and 1996.

RESULTS

In the elderly group, pulmonary tuberculosis was found to be correlated with diabetes (OR = 3.98; 95% CI = 2.07-7.65; p = 0.001), lung disease (OR = 7.24; 95% CI = 3.64-14.46; p = 0.001) and heart disease (OR = 5.86; 95% CI = 2.88-11.95; p = 0.001). Smoking (OR = 2.07; 95% CI = 1.26-3.42; p = 0.002) and alcohol abuse (OR = 1.63; 95% CI = 1.01-2.68; p = 0.041) were also more common in the elderly group. In the elderly group, the treatment more frequently resulted in adverse reactions (OR = 1.62; 95% CI = 1.04-2.54; p = 0.024), especially gastrointestinal reactions (OR = 1.64; 95% CI = 1.01-2.77; p = 0.047), and treatment efficacy was lower: cure rate, 51%; mortality rate, 24%. Treatment adherence was low (approximately 77%) in both groups.

CONCLUSIONS

In the elderly group, adverse reactions were more common, treatment outcomes were less favorable, there was a greater frequency of clinical complications and deaths related to drug toxicity, and the prevalence of concomitant diseases was higher.

Aspectos clínicos da tuberculose pulmonar em idosos atendidos em hospital universitário do Rio de Janeiro, RJ, Brasil

OBJETIVOS: Avaliar as características clínicas e diagnósticas da tuberculose pulmonar (TP) em idosos. MÉTODOS: Foram comparados 117 pacientes com 60 anos de idade ou mais (idosos) e 464 pacientes entre 15 e 49 anos (não idosos), acompanhados no Instituto de Doenças do Tórax da Universidade Federal do Rio de Janeiro, de 1980 a 1996. RESULTADOS: Nos idosos, predominou história prévia de TP (OR = 2,09; IC95% = 1,26-3,45; p = 0,002) enquanto o contato intradomiciliar de TP predominou nos não idosos (OR = 0,26; IC95% = 0,10-0,66; p = 0,002). O tempo mediano para diagnóstico alcançou 90 dias nos idosos e 60 dias nos não idosos. No grupo idoso, prevaleceu a dispnéia (OR = 1,64; IC95% = 1,06-2,53; p = 0,018) e o emagrecimento (OR = 1,66; IC95% = 1,01-2,82; p = 0,047). Nos não idosos, prevaleceu a hemoptise (OR = 0,51; IC95% = 0,32-0,81; p = 0,002), a dor torácica (OR = 0,62; IC95% = 0,40-0,97; p = 0,027) e a febre (OR = 0,55; IC95% = 0,35-0,86; p = 0,006). No padrão radiológico, predominaram as infiltrações e as cavitações; porém, o acometimento bilateral foi mais freqüente nos idosos (OR = 1,76; IC95% = 1,12-2,78; p = 0.009). Não houve diferenças nas positividades do teste tuberculínico, baciloscopia e cultura de Mycobacterium tuberculosis. CONCLUSÕES: Há poucas diferenças clínicas e laboratoriais entre os grupos etários e o maior tempo de diagnóstico nos idosos deve-se à menor suspeição médica nestes pacientes.

Prevalence of tuberculous infection and active tuberculosis in old age homes in Hong Kong

OBJECTIVES

To assess the prevalence of tuberculous infection and active tuberculosis (TB) in old age homes in Hong Kong and to determine whether there is institutional transmission in these homes.

DESIGN

Cross-sectional.

SETTING

Old age homes.

PARTICIPANTS

Total of 2,243 residents, representing 84.6% of all residents in 15 old age homes; 1,698 were women, and 545 were men, with an average age of 82.

MEASUREMENTS

All residents had a questionnaire-based interview, medical record review, two-stage tuberculin testing using two units purified protein derivative-RT23, and a chest x-ray. Those with radiological abnormalities had sputum examined for acid-fast bacilli.

RESULTS

The estimated prevalence rate of active TB in this population was 669 per 100,000, significantly higher in men than in women (1,101 per 100,000 vs 530 per 100,000). The proportion with positive tuberculin reactivity (> or =10 mm induration) after two-stage testing was 68.6%, significantly higher in men than in women. There was no evidence of active transmission of disease in these old age homes, with restriction fragment length polymorphism (RFLP) analysis performed on five cases of active pulmonary TB in the home with the highest rate of TB showing unique RFLP patterns.

CONCLUSION

The rate of active TB and TB infection in old age homes in Hong Kong is still high. Because treatment for latent TB carries a high risk for liver dysfunction in this population, clinicians and other healthcare workers need a high index of suspicion and to diagnose and treat this disease as early as possible to prevent transmission.

Mycobacterium tuberculosis in Taiwan

OBJECTIVE

The resurgence of tuberculosis (TB) and the emergence of drug resistance of Mycobacterium tuberculosis (MTB) isolates are of great impact on public health.

METHODS

Taiwanese data on disease burden of TB and anti-microbial resistance of MTB identified from Annual Reports of Centre for Disease Control, Department of Health, Taiwan and from peer-reviewed publications from MEDLINE (1995-2004).

RESULTS

In Taiwan in 2002, the incidence (per 100,000 population) of tuberculosis was 74.6 and it was higher in aborigines (289.8) and in people living in mountainous regions (256.0). The mortality rate of tuberculosis in Taiwan in 2002 was 5.68 per 100,000 population. Susceptibility data summarized from 1990 to 2002 reports showed primary resistance ranged from 4.7 to 12% for isoniazid, 0.7 to 5.9% for rifampin, 1 to 6% for ethambutol, and 4 to 11% for streptomycin. The overall rates of multidrug-resistant tuberculosis (MDRTB) among new cases and previously treated cases were 1 to 3% and 15 to 46%, respectively. The increasing burden of patients with MDRTB infection, the persistent high rate of mortality, the lack of nationwide surveillance system using the standard methodology to determine the trends and current status of resistance, and the inadequate current TB control infrastructure and training to accomplish the tasks required to implement the directly observed treatment short-course (DOTS) strategy are having a great impact on public health in Taiwan.

CONCLUSIONS

High disease burden of TB and high resistance rates in MTB as well as inappropriateness of the current control infrastructure for TB services illustrate increasingly serious health problems from TB in Taiwan.

Age Transition of Tuberculosis Patients in Taiwan, 1957-2001

BACKGROUND

The incidence of tuberculosis (TB) has been falling in many developed countries; however, there is a trend of an increasing proportion of TB among the elderly. The aim of this study was to evaluate the age transition of patients with TB in Taiwan from 1957 to 2001.

METHODS

Data on the number of TB cases and patient age were collected from the National Tuberculosis Registry for three different 5-year periods: 1957-1961, 1977-1981, and 1997-2001. The distribution of TB cases in these three different periods was analyzed.

RESULTS

The age distributions of TB patients were different among the 1957-61 (n = 26,000), 1977-81 (n = 31,363) and 1997-2001 (n = 71,447) groups. During the 1957-61 period, the most common age group was 25-44 years (50.9%). During 1977-81, the most common age group was 45-64 years (44.9%). In 1997-2001, the most common age group had shifted to people aged 65 years or older (43.7%). For the whole period from 1957 to 2001, after adjusting for age shifts in the general population, the proportion of TB patients had significantly increased in persons 65 years or older, slightly increased in persons aged 0-14 years, and decreased in the 15-24, 25-44, and 45-64-year-old age groups. For the period 1977-2001, age-specific registered case rates increased with age.

CONCLUSION

The age of TB patients in Taiwan showed a rising trend from 1957 to 2001. A high index of suspicion and prompt investigation of elderly patients with signs and symptoms characteristic of TB may allow earlier diagnosis and treatment.

Diagnostic and therapeutic problems of pulmonary tuberculosis in elderly patients

To identify differences in the clinical, radiologic, and microbiologic features of pulmonary tuberculosis (TB) in the young (<64 yr) and elderly (> or =65 yr), we performed a retrospective analysis of the medical charts and chest radiographs of 207 young and 119 elderly pulmonary TB patients. Hemoptysis and a febrile sense were more frequent in the young, whereas weakness, dyspnea, anorexia, and mental change were more frequent in the elderly. Elderly patients showed higher frequencies of cardiovascular and chronic lung diseases, whereas the young showed a higher proportion of underlying liver disease. In addition, chest radiography showed a significantly higher frequency of mid or lower lung involvement by TB lesions in the elderly (10.6% vs. 22.7%, p<0.05). Lesions were frequently misdiagnosed as pneumonia or lung cancer in the elderly. However, there was no difference between these two groups in terms of sputum acid-fast bacilli positivity. The elderly showed a higher frequency of adverse drug reactions (18.5% vs. 40.7%, p<0.05), and higher TB-related mortality (1.3% vs. 11.1%, p<0.05). In conclusion this study showed that young and elderly pulmonary TB patients have similar microbiologic features; however, the elderly showed higher frequencies of atypical clinical and radiologic presentations, adverse drug reactions, and higher TB-related mortality.

Quality of life in tuberculosis: a review of the English language literature

INTRODUCTION

Tuberculosis (TB) studies have concentrated on clinical outcomes; few studies have examined the impact of TB on patients' quality of life (QOL).

METHODS

A systematic review of published medical literature using specific MESH terms: [Tuberculosis] and 1-[Outcome], 2-[Outcome Assessment], 3-[Quality of Life], 4-[Mood Disorder], 5-[Cost and Cost Analysis], 6-[Religion], 7-[Perception], 8-[Social Support], 9-[Optimism], 10-[Stress], 11-[Signs and Symptoms], and 12-[Cost of Illness]. This yielded 1972 articles; 60 articles met inclusion criteria and were reviewed.

RESULTS

TB somatic symptoms have been well studied, but there were no studies of effects on physical functioning or general health perceptions. Patients tend to be worried, frustrated, or disappointed by their diagnosis, but it is unknown how emotional health changes with treatment. Diagnosed patients are less likely to find work, and less able to work and care for their families. TB creates the greatest financial burden on the poor. In developing, countries, patients and their families are ostracized by society, and families sometimes ostracize patients; the extent of TB's social stigma in the developed countries is unknown.

CONCLUSION

There has been relatively little research on TB QOL and even less in developed countries. A better understanding may help improve treatment regimens, adherence to treatment, and functioning and well-being of people with TB.

Aging and infectious diseases in the developing world

Although demographic aging does not remain restricted to industrialized countries, the medical challenge arising from the aging population will be distinct in the developing world. This is particularly true with respect to infectious diseases, which have a distinct spectrum in the elderly population, as well as a greater overall relevance in the developing world. Tropical diseases have a specific presentation and epidemiology in elderly patients. Infectious diseases with a worldwide distribution impact elderly patients in the developing world in a specific manner, which is most obvious with respect to human immunodeficiency virus and tuberculosis but is also true with respect to "trivial" manifestations of infection, such as diarrhea and pneumonia. Malnutrition contributes in a major way to the immunodeficiency of elderly patients in the developing world. Poorly controlled use of antimicrobial drugs leads to multidrug-resistant microorganisms, which, together with the limited resources available for drug treatment, makes appropriate treatment of infections in elderly patients in developing countries very difficult. Infections in elderly patients will have an increasing impact on the public health and economy of developing countries.

Tuberculosis in the elderly

As the result of the strengthening of TB-control programs nationwide, a decline in the overall number of reported TB cases in the United States has been observed within the last 10 years. Despite these declines in absolute numbers, the elderly continue to account for a disproportionate share of the cases. The high number of cases diagnosed at autopsy among the elderly suggests that this condition often remains unrecognized, possibly due to the subtle clinical manifestations in this age group. Evidence suggests that, compared with their community-dwelling counterparts, the institutionalized elderly are at a greater risk for re-activation of latent TB and for the acquisition of new TB infection. More studies are needed to make final conclusions. New guidelines for the treatment of LTBI emphasize targeted TST among persons at high risk for development of active TB and no longer use age as an exclusionary condition. All nursing home residents must therefore be regularly screened for LTBI and treated if necessary. Even though elderly persons are at greater risk for hepatic toxicity from TB treatment, the poor outcome of untreated TB in this age group warrants more aggressive treatment of this condition.

Impact of age and radiographic presentation on the presumptive diagnosis of pulmonary tuberculosis

We compared delay in presumptive diagnosing pulmonary tuberculosis (PTB) in elderly and younger patents, yield of diagnosis and whether the yield is influenced by the radiographic presentation, even when PTB was suspected. Time from first complaints to first consideration of PTB was determined as suspicion interval (SI) and from first consideration to diagnosis as recognition interval (RI). Presumptive diagnosis was defined as positive staining for acid-fast bacilli or presence of granulomatous lesions in pulmonary specimens. Inthe elderly and in the younger patients, the mean SI was 111.1 and 878 days respectively (P = NS), and the mean RI was 5.9 and 8.3 days, respectively (P = NS). The mean RI was longer in uncharacteristic than in characteristic radiographic findings in both elderly (8.2 and 4.6 days; P = 0.007) and younger patients (10.6 and 3.9 days; P=0.0001). A diagnosis was obtained in 89/113 elderly (79%) and in 109/138 younger (79%) patients (P=NS) and also in 59/80 (73%) patients with uncharacteristic findings and in 139/170 (82%) patients with characteristic findings (P = NS). In the latter, sputum contributed for 66% ofdiagnosis, whereas it was only 31% in patients with uncharacteristic findings (P < 0.005). In elderly patients with uncharacteristic radiographic findings, diagnosis was obtained from sputum in 41% and from other specimens in 35% (P = NS); in the younger group diagnosis was obtained from sputum in 23% and from other specimens in 48% (P < 0.05). In conclusion, there was no difference in SI and RI in elderly patients in comparison with younger patients. Uncharacteristic radiographic findings increased RI in both age groups. Age or radiographic presentation did not influence diagnosing PTB. In patients with characteristic radiographic findings, diagnosis was especially made from examination of sputum, whereas in those with uncharacteristic findings, diagnosis was more often obtained from the complementary investigation of other specimens.

Tuberculosis in older people: a retrospective and comparative study from Hong Kong

OBJECTIVES

To compare tuberculosis (TB) in older and younger patients.

DESIGN

A retrospective and comparative observational study.

SETTING

Four chest clinics and two chest hospitals in Hong Kong.

PARTICIPANTS

All notifications from the participating hospitals and clinics in 1996 were extracted from the TB notification registry. The characteristics of patients aged 65 and older were compared with a one-in-three random sampling of those aged 16 to 64.

MEASUREMENTS

Demographic, clinical, radiological, and laboratory data of the two groups were compared alongside treatment and outcomes.

RESULTS

Older people with TB were more likely to be male, to smoke, to have had TB previously, to have coexisting medical diseases, to be socioeconomically disadvantaged, and to weigh less than younger people with TB. Dyspnea, weight loss, and malaise were more common, whereas extrathoracic lymph node enlargement was less common. Chest radiograph showed more extensive disease and lower zone involvement. Positive tuberculin test was present in only 61.9%. Sputum bacteriology was more likely to be positive. There was a longer delay in presentation and commencement of treatment, and 77.2% required at least one admission. Adverse effects of treatment, notably hepatic dysfunction, occurred more commonly. Fluoroquinolones appeared well tolerated. Only 72.5% of the older people were cured or completed their treatment. Mortality was 16%. Age of 65 and older, comorbidity, socioeconomic disadvantage, moderate-extensive disease, positive sputum smear, and poor adherence were factors independently associated with unfavorable outcomes (P <.001 to P = .01; odds ratios = 1.61-27.02).

CONCLUSION

Substantial differences were found between older and younger TB patients. Many of these were associated with unfavorable outcome. Increased awareness in disease recognition and better medical and social support are therefore needed in addressing the growing problem of TB in older people.

Delay in diagnosis among hospitalized patients with active tuberculosis--predictors and outcomes

Delayed diagnosis of active pulmonary tuberculosis (TB) among hospitalized patients is common and believed to contribute significantly to nosocomial transmission. This study was conducted to define the occurrence, associated patient risk factors, and outcomes among patients and exposed workers of delayed diagnosis of active pulmonary TB. Among 429 patients newly diagnosed to have active pulmonary TB between June 1992 and June 1995 in 17 acute-care hospitals in four Canadian cities, initiation of appropriate treatment was delayed 1 week or more in 127 (30%). This was associated with atypical clinical and demographic patient characteristics, and after adjustment for these characteristics, with admission to hospitals with low TB admission rate of 0.2-3.3 per 10,000 admissions (odds ratio [OR]: 7.4; 95% confidence interval [CI]: 3.2,17.5) or intermediate TB admissions of 3.4-9.9/10,000 (OR: 2.3; CI: 1.6,3.2) as well as potentially preventable (late) intensive care unit admission (OR: 16.8; CI: 2.0,144) and death (OR: 3.3; CI: 1.7,6.5]). In hospitals with low TB admission rates, initially missed diagnosis, smear-positive patients undergoing bronchoscopy, late intensive care unit admission (OR: 2.3; CI: 0.1,56), and death (OR: 3.8; CI: 1.2,12.1) were more common than in hospitals with high TB admissions (> 10/ 10,000); a similar trend was seen in hospitals with intermediate TB admissions. Even after adjustment for workers' characteristics and ventilation in patients' rooms tuberculin conversions were disproportionately high in hospitals with low and intermediate TB admission rates and significantly higher in hospitals with overall TB mortality rate above 10% (OR: 2.5; CI: 1.6,3.7). In the hospitals studied, as the rate of TB admissions decreased, the likelihood of poor outcomes and risk of transmission of TB infection per hospitalized patient with TB increased. Institutional risk of TB transmission was poorly correlated with number of patients with TB and better correlated with indicators of patient care such as delayed diagnosis and treatment and overall TB-related patient mortality.

Does aging modify pulmonary tuberculosis?: A meta-analytical review

STUDY OBJECTIVES

To evaluate the differences in the clinical, radiologic, and laboratory features of pulmonary tuberculosis (TB) in older patients, as compared to younger patients.

DESIGN

A meta-analysis (the Schmidt-Hunter method) of published works found in MEDLINE and other sources was performed. A total of 12 studies were collected, and each variable was submitted to meta-analysis.

RESULTS

No differences were found between older (>/= 60 years old) and younger TB patients with respect to male predominance, evolution time before diagnosis, prevalence of cough, sputum production, weight loss, fatigue/malaise, radiographic upper lobes lesions, positive acid-fast bacilli in sputum, anemia or hemoglobin level, and serum aminotransferases. A lower prevalence of fever, sweating, hemoptysis, cavitary disease, and positive purified protein derivative, as well as lower levels of serum albumin and blood leukocytes were noticed among older patients. In addition, the older population had a greater prevalence of dyspnea and some concomitant conditions, such as cardiovascular disorders, COPD, diabetes, gastrectomy history, and malignancies.

CONCLUSIONS

This meta-analytical review identified the main differences of older TB patients, as compared to younger TB patients, that should be considered during the diagnostic evaluation. Most of these differences are explained by the already known physiologic changes that occur during aging.

[Distinctive features of tuberculosis in the aged]

INTRODUCTION

Current recrudescence of human tuberculosis is ascribed to HIV. Nevertheless, other at-risk individuals, particularly the elderly, have been reported.

METHODS

A retrospective study aimed at defining distinctive features of tuberculosis in the elderly was conducted. Eighty-two records of patients aged 18 to 64 years were compared to those of 58 patients of 65 years of age and over.

RESULTS

In the French area considered in this study, the elderly represent the most at-risk group. Institutionalization is a significant risk factor for tuberculosis (RR = 4). Despite a past history of tuberculosis and public awareness campaigns, first-intent diagnosis was evoked in only 22% of the older patients. The mean number of infectious localizations was higher in the elderly (1.3/patient) than in younger patients (1.1/patient). Results of tuberculin skin tests are unreliable. Prognosis is poor in the elderly. In the present study, 14 of the 18 encountered deaths occurred in the elderly, of which eight were due to tuberculosis.

CONCLUSION

To decrease the current incidence of tuberculosis, evaluations of preventive measures in the elderly should be validated and implemented, especially in institutionalized patients.

Tuberculosis in the elderly. Epidemiology and optimal management

The problem with the emergence of HIV-associated tuberculosis (which usually occurs in young adults) is that attention has been diverted away from the fact that, in the developed world, the elderly represent the biggest pool of tubercular disease and therefore the greatest pool of infection within the community. Although the incidence rate of tuberculosis continues to decline in most countries, there is evidence from parts of the developing world that rates may be beginning to increase. The presentation of the disease in the elderly is often uncharacteristic, e.g. disease tending to be more insidious in onset, pyrexia often absent and haemoptysis less common. Chest x-ray changes may also mislead the clinician in that disease is frequently present in the mid or lower zones. The elderly are probably at greater risk of extrapulmonary tuberculosis, which also presents in uncharacteristic ways. The diagnosis remains based on clinical presentation and the presence of smear and culture positivity, although some patients may be treated in the absence of microbiological proof. Standard treatment is with a combination of isoniazid, rifampicin and pyrazinamide, with or without a fourth drug such as ethambutol. The incidence of adverse effects in the elderly is much greater than that in younger patients, often resulting in the need to change the medication to drugs which are better tolerated. This may require changing to regimens which are less effective and therefore have to be taken for a longer period of time. The presence of concomitant disease such as liver or renal failure may also necessitate the administration of a suboptimal regimen. Mortality in elderly patients with tuberculosis is considerably higher than that in younger patients, even when treatment appears to have been started on time; even in the developed world mortality exceeds 30% in those patients over 70 years of age.