Diagnostic and therapeutic problems of pulmonary tuberculosis in elderly patients

Monocytes predict prognosis and successful treatment in older patients with miliary tuberculosis

Background

The increasing number of patients with miliary tuberculosis (MTB) is a concern in an aging society because of its high mortality rate. Several prognostic biomarkers for MTB have been identified; however, the predictive ability of monocytes as biomarkers remains unknown. This study demonstrates the usefulness of monocytes as prognostic biomarkers for MTB.

Materials and methods

We retrospectively compared the clinical findings of 52 patients with MTB hospitalized between April 2013 and October 2021. The predictive ability of biomarkers for 3-month prognosis and their cutoff values were calculated. Survival times and longitudinal changes in monocytes after initiating treatment were compared.

Results

A smaller number of monocytes (#M), higher lymphocyte-monocyte ratio (LMR), higher neutrophil-monocyte ratio, and poorer performance status were associated with death within 3 months. #M was an independent prognostic factor. #M and LMR exhibited the highest predictive performance compared to others using receiver operating characteristic curve analysis (area under the curve = 0.86 and 0.85, respectively). Survival time was shorter in patients with #M ≤ 200 cells/μL and LMR > 2.5. Rapidly increasing #M after treatment was related to better prognosis in patients with #M ≤ 200 cells/μL at diagnosis.

Conclusions

#M at diagnosis and longitudinal changes in monocytes are related to MTB prognosis.

Tuberculosis in older adults: challenges and best practices in the Western Pacific Region

The Western Pacific has one of the fastest-growing older adult populations globally, and tuberculosis (TB) remains one of the foremost infectious causes of disease and death in the region. Older adults are at higher risk of TB due to immunosenescence, comorbidities, and increased institutionalisation. Atypical symptoms and reduced access to health services may delay care-seeking and TB diagnosis, while co-morbidity and increased risk of adverse drug reactions complicate TB treatment. Post-TB sequelae and socioeconomic challenges may decrease the quality of life after TB treatment completion. Despite their high disease burden and special challenges, there is a lack of regionally coordinated policies and guidelines to manage TB among older adults. Routine TB screening at aged-care facilities, age-friendly infrastructure and services, awareness of atypical TB features, integration of TB and non-communicable diseases services, and person-centred approaches to treatment support could improve TB management among older adults. Addressing these challenges and adopting the best practices identified should inform policy formulation and implementation.

Funding

This project was funded by 1) the World Health Organization Regional Office for the Western Pacific, with financial contributions from the Government of the Republic of Korea through the Korean Disease Control and Prevention Agency and the Government of Japan through the Ministry of Health, Labour and Welfare, and 2) NUS Start-up Grant. The funders had no role in the paper design, collection, analysis, and interpretation of data and in writing of the paper.

Tuberculosis in elderly population: A cross-sectional comparative study

Background

Tuberculosis (TB) is a common but neglected infectious disease of global significance. It has a varied presentation in the elderly compared to adults. The present study was conceived to study the resemblances and differences shared in terms of clinical profile, comorbidities, and laboratory investigations by TB in adults and the elderly population.

Methods

In this cross-sectional study, 68 adults and 72 elderly patients of both genders were enrolled. We collected information on demographics, comorbidities, clinical presentations, and laboratory investigations. The comparison of data between groups was done using the unpaired t-test for continuous variables and the Chi-square test for frequency distribution analysis.

Results

The mean age of the adults and elderly population was 42.13 ± 10.7 years and 68.78 ± 7.62 years, respectively. The elderly TB group demonstrated loss of weight, appetite, the prevalence of comorbid conditions (coronary artery disease, hypertension, and malnutrition), bilateral, predominantly lower lobe, and diffuse involvement of lungs.

Conclusion

As the elderly population increases, nonspecific clinical manifestations or laboratory results in this population mandate awareness of these atypical features for effective management of TB in this group.

MDR tuberculosis in elderly

Tuberculosis is very common in young population, but it has emerged in a significant number in geriatric/elderly population (>60 Yrs. of age) as the population is ageing. Most cases of TB in the elderly are linked to the reactivation of lesions that have remained dormant. The awakening of these lesions is attributable to changes in the immune system related to senescence. Mortality rate from tuberculosis remains higher in elderly patients. Diagnosis is difficult as symptoms of active TB are nonspecific and less pronounced in the elderly. MDR TB is known to occur in poorly compliant patients (non-adherence) and this can be a major issue in elderly due to loss of independence and frailty resulting in treatment failure. Multidisciplinary management, involving geriatricians and infectious disease specialists is essential throughout care to optimize a favourable outcome in these vulnerable patients.

Challenges in treating tuberculosis in the elderly population in tertiary institute

Tuberculosis (TB) epidemic is most prevalent in the India with increase in mortality and morbidity. Ongoing elderly population as a result of increase in health care facilities are at high risk of TB. Elderly people are four-fold more prone to TB. Most cases of TB in the elderly result from reactivation of latent TB due to immunosenescence. Major challenge in dealing with therapeutic aspects of elderly patients is recognising frailty to prevent loss of independence. Challenges facing with elderly TB are difficult to reach out to hospital because of poor health seeking behaviour especially elderly female either due to ignorance or neglected by the family members, atypical presentation mimicking other disorders leading to diagnostic delay, if at all diagnosed impoverished tolerance and adherence to treatment due to various factors like associated comorbidities leading to pill load, impaired renal and hepatic functions with aging and stigma. Emerging resistance with usage of non-standard treatment regimens lead to unpropitious outcomes and increases mortality. The mortality rate is six times higher in elderly compared to younger individuals. Hence elderly people need tertiary level health care facilities for enhancing the diagnosis and appropriate management of tuberculosis and its complications. New set of guidelines to be made for elderly to increase adherence and tolerance thereby decreasing drug interactions and adverse drug reactions. With the increased prevalence of TB in the elderly, it is the need of the hour for India, to focus on this vulnerable population as they are a potential source of infection in the community. Awareness to be created among the elderly community regarding this deadly disease and its outcomes to increase their health consciousness and medical attention. Priming the special focus on females coterie as they are the most neglected population in our society.

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.

Drug resistant tuberculosis among elderly: Challenges

The article deals with challenges faced by the geriatric populations while on MDR treatment. Risk factors like tobacco use, low socio-economic status, previous disease, longer delays in seeking treatment and reduced mobility are some of the challenges while initiating MDR treatment. Other issues like drug-related adverse events and increased co-morbidity pose a major challenge while treating patients. Susceptibility among the geriatric age group includes various anatomical and physiological changes including nutritional deficiencies and co morbidities.

Challenges in diagnosis and treatment of tuberculosis in elderly

Tuberculosis (TB) is a major infectious disease worldwide. Early diagnosis and prompt treatment reduces the transmission, morbidity and mortality in tuberculosis. Elderly (age >65 years) have many risk factors to develop tuberculosis. Recent survey in India showed incidence of TB higher in elderly. They may not have classical symptoms, clinical and radiological signs of TB which can lead to delayed diagnosis or misdiagnosis. In addition, elderly have many comorbid and coexisting diseases which make diagnosis and treatment of TB challenging. Comorbidities, poor general health status and other medications may lead to increased drug adverse reactions and poor adherence to treatment in elderly. Hence special emphasis should be given to elderly for early diagnosis and treatment. Elderly with multiple comorbidities require individualized approach for better outcome.

Tuberculosis in an Aging World

Tuberculosis (TB) is one of the leading causes of death due to its being an infectious disease, caused by the airborne pathogen Mycobacterium tuberculosis (M.tb). Approximately one-fourth of the world’s population is infected with latent M.tb, and TB is considered a global threat killing over 4000 people every day. The risk of TB susceptibility and mortality is significantly increased in individuals aged 65 and older, confirming that the elderly represent one of the largest reservoirs for M.tb infection. The elderly population faces many challenges that increase their risk of developing respiratory diseases, including TB. The challenges the elderly face in this regard include the following: decreased lung function, immuno-senescence, inflammaging, adverse drug effects, low tolerance to anti-TB drugs, lack of suitable diagnoses/interventions, and age-associated comorbidities. In order to find new therapeutic strategies to maintain lung homeostasis and resistance to respiratory infections as we age, it is necessary to understand the molecular and cellular mechanisms behind natural lung aging. This review focuses primarily on why the elderly are more susceptible to TB disease and death, with a focus on pulmonary function and comorbidities.

A narrative review of tuberculosis in the United States among persons aged 65 years and older

Tuberculosis (TB) is a preventable infectious disease that confers significant morbidity, mortality, and psychosocial challenges. As TB incidence in the United States (U.S.) decreased from 9.7/100,000 to 2.2/100,000 from 1993 to 2020, the proportion of cases occurring among adults aged 65 and older increased. We conducted a review of published literature in the U.S. and other similar low-TB-burden settings to characterize the epidemiology and unique diagnostic challenges of TB in older adults. This narrative review also provides an overview of treatment characteristics, outcomes, and research gaps in this patient population. Older adults had a 30% higher likelihood of delayed TB diagnosis, with contributing factors such as acid-fast bacilli sputum smear-negative disease (56%) and non-classical clinical presentation. At least 90% of TB cases among older adults resulted from reactivation of latent TB infection (LTBI), but guidance around when to screen and treat LTBI in these patients is lacking. In addition, routine TB testing methods such as interferon-gamma release assays were two times more likely to have false-negative results among older adults. Advanced age was also often accompanied by complex comorbidities and impaired drug metabolism, increasing the risk of treatment failure (23%) and death (19%). A greater understanding of the unique factors of TB among older adults will inform clinical and public health efforts to improve outcomes in this complex patient population and TB control in the U.S.

Multidrug-resistant and extensively drug-resistant Mycobacterium tuberculosis strains in geriatrics: An analysis and its implications in tuberculosis control

Objective

This study aimed to analyze the trends of tuberculosis (TB) disease, drugs susceptibility patterns in geriatric TB over a period of three years (from 2010 to 2012).

Materials & methods

In this study, laboratory data on diagnosis of geriatric tuberculosis suspected patients (age ≥60 years) was analyzed retrospectively at National Reference Laboratory (NRL).

Results

Among 12,140 geriatric TB suspects, 1621 (13%) were acid-fast bacillus (AFB) smear-positive and 10,519 (87%) were smear-negative. Analysis of 915 culture results showed 470 (51%) as positive for Mycobacterium tuberculosis complex (MTBC), 63 (7%) contaminated and 36 (4%) identified as mycobacteria other than tuberculosis (MOTT). A total 210/470 (45%) were multidrug-resistant TB (MDR-TB) strains. Among the mono-resistant strains, isoniazid mono-resistant was found more frequently (134/470, 28%) whereas, it was least among rifampicin mono-resistant 5/470 (1%). The second-line drug susceptibility testing (DST) results showed 7% (17/240) extensively drug-resistant TB (XDR-TB) strains. Most common second line mono-resistant strain was observed with ofloxacin, 16% (38/240).

Conclusion

This study shows high number of MDR/XDR geriatric TB patients at tertiary care TB hospital. The study highlighted the need of separate line of early identification, diagnosis and treatment of geriatric TB patients. However, further study with improved sample size may needed to confirm the findings.

Tuberculosis Screening via Chest X-Ray is Financially Burdensome in Previously Independently Living Elective Total Knee Arthroplasty Patients

BACKGROUND

In 1995, to reduce the transmission of Tuberculosis (TB) the Centers for Disease Control and Prevention recommended that all patients discharged from hospitals be required to have chest x-rays (i.e., radiography) performed before admission to long term care facilities (LTCFs). Previously independently living patients (PILPs) who undergo elective total knee replacement (TKA) surgery are a population at higher risk to end up in LTCFs for rehabilitation. By 2017, the incidence of TB was 9,105 cases compared to 22,762 in 1995. However, the recommendations that hospitals be required to perform a chest x-ray in all patients (including PILPs) being transferred to LTCF's have remained in place. The purposes of this study were to: a) determine the incidence of TB-positive chest x-rays in PILPS discharged to LTCFs after undergoing elective TKA surgery, and b) assess the cost (i.e., both financial and possible exposure to unnecessary radiation) of mandated chest x-rays before hospital discharge to LTCF for PILPs.

METHODS

Retrospective 2012-2017 patient chart data were collected from the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) to identify all elective TKAs for PILPs performed at two Ascension participating centers. Study data included sex, age, body mass index (BMI), length of stay, comorbidities, and chest x-ray results before discharge. Patients who underwent surgery for fracture, infection, trauma, or malignancy were excluded from the study. Categorical data were analyzed using Fisher's exact test and Student's t-test were used for continuous data.

RESULTS

The authors identified 4,041 total elective TKA's, from which 500 PILPs were discharged to a LTCF due to functional, medical and/or social concerns. Chest x-rays were associated with 500 (100%) negative findings for TB. Overall hospital costs for chest x-rays for patient's being discharged to an extended care facility totaled $90,848.

CONCLUSIONS

The mandated use of chest x-rays for TB screening of PILPs undergoing elective surgery TKA prior to discharge to LTCFs appear to place an unnecessary financial burden on the healthcare system. The mandatory use of x-rays for assessment of possible TB infection before transfer to LTCFs appears to also expose PILPs unnecessarily to radiation. Although further studies are needed to verify these results, the authors recommend that perhaps instead chest x-rays should be reserved for patients with specific comorbidities (e.g., patients on immunosuppressive therapy, with HIV, etc.) or for those patients residing in LTCFs prior to surgery.

Tuberculosis in the Elderly

The tuberculosis (TB) epidemic is most prevalent in the elderly, and there is a progressive increase in the notification rate with age. Most cases of TB in the elderly are linked to the reactivation of lesions that have remained dormant. The awakening of these lesions is attributable to changes in the immune system related to senescence. The mortality rate from tuberculosis remains higher in elderly patients. Symptoms of active TB are nonspecific and less pronounced in the elderly. Diagnostic difficulties in the elderly are common in many diseases but it is important to use all possible techniques to make a microbiological diagnosis. Recognising frailty to prevent loss of independence is a major challenge in dealing with the therapeutic aspects of elderly patients. Several studies report contrasting data about poorer tolerance of TB drugs in this population. Adherence to antituberculosis treatment is a fundamental issue for the outcome of treatment. Decreased completeness of treatment was shown in older people as well as a higher risk of treatment failure.

Unexpected slowdown in the decline of tuberculosis mortality rates in Brazil from 1997 to 2017: an ecological study

BACKGROUND

Brazil is a signatory to the World Health Organization End TB Strategy and the United Nations Sustainable Development Goals. This study aims to characterize tuberculosis (TB) deaths and TB mortality rates in Brazil for the period 1997-2017.

METHODS

We performed an ecological study based on information for TB deaths between 1997 and 2017 extracted from the Mortality Information System of the Brazilian Ministry of Health. Data included gender, age group and geographic regions. The trends in mortality rates were estimated using Joinpoint regression analysis, which identifies years in which there is a change in slope of the time series by the Monte Carlo permutation.

RESULTS

Between 1997 and 2017 there were 104 172 recorded TB deaths in Brazil and the mortality rates were higher for men and the elderly. The age-adjusted mortality rate decreased from 4.2 per 100 000 in 1997 to 3.0 per 100 000 in 2003 to 2.0 per 100 000 in 2017. The average percentage reduction from 1997 to 2003 was 6.2% (95% confidence interval [CI] -7.7 to -4.7) per year, while from 2003 to 2017 it was 3.0% (95% CI -3.4 to -2.5) per year, representing a slowdown in the rate of decline.

CONCLUSION

The high number of deaths and the slowdown in the decline of mortality rates from TB in Brazil maintain the disease as an important public health concern and an obstacle to reaching goals set by international commitments.

Estimating the burden of nosocomial exposure to tuberculosis in South Korea, a nationwide population based cross-sectional study

BACKGROUND/AIMS

The aim of the study was to investigate the current nationwide burden of nosocomial exposure to tuberculosis (TB) using national health insurance claims data.

METHODS

All patients who had claims for drug susceptibility testing for TB from 2012 to 2016, which indicated culture-proven TB, were included. The first day of the infectious period was defined as 3 months before a doctor's suspicion of TB in patients with respiratory symptoms and 1 month before in patients without symptoms. The last day of the infectious period was defined as one day before the prescription of anti-TB medications. Patients hospitalized during infectious periods were investigated and their hospitalization days were calculated. Records of medical procedures which increased the risk of nosocomial transmission by generating aerosols were also investigated.

RESULTS

A total of 7,186 cases with 94,636 person-days of hospitalization with unrecognized active TB were found. Patients above 60 years of age accounted for 63.99% of the total number and 69.70% of the total duration of hospitalization. TB patients in the older age group showed a trend toward higher risks for hospitalization with unrecognized active TB. Patients in their 80s showed the highest risk (12.65%). Bronchoscopy (28.86%), nebulizer therapy (28.48%), and endotracheal intubation (13.02%) were common procedures performed in these patients during hospitalization.

CONCLUSION

The burden of nosocomial exposure to TB in South Korea is still substantial. Hospitalization with unrecognized active TB, especially among the elderly TB patients could be a serious public health issue in South Korea.

Tuberculosis in Older Adults: Seattle and King County, Washington

BACKGROUND

In the United States, tuberculosis (TB) incidence rates are highest among adults aged ≥65 years. We performed this study to evaluate outcomes of older patients undergoing treatment for TB disease, including the frequency of adverse events related to TB treatment.

METHODS

This study evaluated adult patients who were diagnosed with pulmonary TB from 2009 to 2014 in King County, Washington. Patient characteristics, manifestation of TB, and treatment outcomes in different age groups were compared. Frequency and type of adverse events that resulted in treatment interruption were evaluated and patients aged ≥65 years were compared with selected younger patients.

RESULTS

There were 403 patients who met the study criteria, 111 of whom were aged ≥65 years. Older patients were significantly less likely to have cavitation on chest radiographs. Patients aged ≥65 years were less likely to complete TB treatment (76.6% vs 94.9%, P < .0001) and were more likely to die during treatment (18.9% vs 2.1%, P < .0001). The difference in these outcomes was heightened for those aged ≥75 years compared with those aged <75 years. Those aged ≥75 years were also more likely to have an adverse event attributable to TB medication and were more likely to have an adverse event later in therapy. Regardless of age, pyrazinamide was responsible for the majority of adverse reactions.

CONCLUSIONS

Adults aged ≥65 years with pulmonary TB had less-advanced disease but a higher risk of complications during treatment such as death or adverse events. This effect was most pronounced among those aged ≥75 years.

Comparison of Clinical, Radiological and Laboratory Parameters Between Elderly and Young Patient With Newly Diagnosed Smear Positive Pulmonary Tuberculosis: A Hospital-Based Cross Sectional Study

Introduction To compare clinical, radiological and haematological manifestations among newly diagnosed smear positive tuberculosis patients between Group I (Elderly >60 yrs) and Group II (Younger age between 13 and 60 years). Methodology This was a hospital-based cross-sectional study conducted at the out-patient department of pulmonary medicine, between March 2014 and December 2017. There were 61 patients in Group I (Elderly > 60 yrs) and 110 patients in Group II (Younger age between 13 and 60 years). Continuous variables were compared using student's t-test and Mann-Whitney test. Chi square test and Fischer test was used for analysing categorical variables. All statistics were two-tailed, and a p-value of 0.05 was considered to be statistically significant. Results The mean age for Group I (Elderly >60 yrs) was 65 ± 2 years and for the Group II (Younger age between 13 and 60 years) was 40 ± 1 years. There was a statistically significant association of cavitation with infiltrates (p = 0.007) in younger age group. Bilateral multiple zone (48, 64.86%) involvements were commonly observed in both the age groups. There was no significant difference between two groups with regard to haematological and clinical parameters. Conclusion We did not find any difference in the presentation of tuberculosis in both the groups. Radiologically, there was more of cavitating lesion in younger age group. So, they should be isolated and followed up at regular intervals.

Delayed Isolation of Active Pulmonary Tuberculosis in Hospitalized Patients: A Pivotal Role of Radiologic Evaluation

OBJECTIVE. The purpose of this study was to determine factors related to delayed isolation of patients hospitalized with active pulmonary tuberculosis (TB). MATERIALS AND METHODS. A total of 130 immunocompetent hospitalized patients with active pulmonary TB who had positive sputum culture results from January 2015 to December 2017 were reviewed. Delayed isolation of pulmonary TB was defined as failure to initiate airborne isolation within the first 3 days of hospitalization. Clinical and microbiologic characteristics of the patients and radiologic features on chest radiography (n = 130) and chest CT (n = 118) were retrospectively reviewed. Findings were compared between patients with early isolation and those with delayed isolation. Univariate and multivariate analyses were performed to determine independent predictors of delayed isolation. RESULTS. Forty-four patients (34%) had delayed isolation after initial hospitalization. On univariate and multivariate analyses, atypical presentation of active pulmonary TB on CT (odds ratio, 7.203; 95% CI, 2.203-23.551; p = 0.001) and concurrent lung parenchymal diseases on CT (odds ratio, 14.605; 95% CI, 3.274-65.155; p < 0.001) were significant predictors of delayed isolation of patients with active pulmonary TB. CONCLUSION. Awareness of the factors related to delayed diagnosis of active pulmonary TB is important to avoid an unexpected in-hospital outbreak of TB and control the disease. Atypical presentation of active pulmonary TB and concurrent lung parenchymal diseases on CT are significant factors related to delayed isolation of hospitalized patients with active pulmonary TB.

Radiological significance of high-resolution computed tomography for elderly pulmonary tuberculosis patients - an analysis with culture test

Purpose

Pulmonary tuberculosis (PTB) is one of the major health problems in the elderly population, causing significant morbidity and mortality. The aim of this study is to evaluate the significance of the high-resolution computed tomography (HRCT) modality for the diagnosis of PTB, in comparison to culture test.

Material and methods

Thoracic HRCT images of the study population, comprising 124 patients clinically suspected for PTB with smear and culture reports, were analysed for sensitivity and specificity of the HRCT test. Features of active PTB were centrilobular nodules, ‘tree-in-bud’ pattern densities, macro-nodules, consolidations, cavitary lesions, ground-glass opacities, and miliary nodules.

Results

Among the study population, 108 cases presented HRCT features of active PTB and the remaining cases were negative but had presented a few features mimicking PTB. As inferred from positive culture test results, 106 cases had active PTB, the remaining cases were culture negative for PTB. False-positive (FP) or ‘type I error’ cases, and false-negative (FN) or ‘type II error’ cases were ascertained by Bayes’ theorem. Sensitivity (true positive rate) and specificity (true negative rate) of HRCT test were 0.8125 and 0.8571, respectively.

Conclusions

For proper diagnosis the predictive capability, as two values of ‘a posteriori probability’, was computed; the mean value of ‘a posteriori probability’ for HRCT was 0.6358. When its culture test was positive, the HRCT test was 69.56-92.85% efficient in ascertaining positive results with a sample; on the other hand, when its culture test was negative it was 66.66-100% efficient for a negative result. Thus, the HRCT test is considerably dependable.

Central nervous system tuberculoma with miliary tuberculosis in the elderly

The aging phenomenon of tuberculosis (TB) patients is recognized all over the world, but no country is as prominent as Japan. Central nervous system (CNS) TB includes clinical entities: tuberculous meningitis, intracranial tuberculoma, and clinical features of CNS TB in the elderly may be atypical, non-specific, and confused with concomitant age-related diseases. Atypical clinical manifestations of TB in older persons can result in delay in diagnosis and initiation of treatment. A 91-year-old woman was brought to our emergency department after her family noted her altered mental status. Chest computed tomography confirmed miliary opacities. The cerebrospinal fluid (CSF) analysis showed elevated protein level, low glucose level, and a lymphocytic pleocytosis. Brain magnetic resonance imaging (MRI) showed multiple well‑defined enhancing lesions in the cerebral and cerebellar hemispheres and the pons, suggestive of tuberculomas. Smear, culture, and polymerase chain reaction (PCR) tests confirmed Mycobacterium tuberculosis in the sputum and aspirate. Based on the CSF and brain MRI findings and the sputum microbiology results indicating the presence of M. tuberculosis in the sputum and gastric aspirate, the patient was diagnosed with CNS tuberculoma. The onset of TB is mainly associated with decreased immunity; however, several other factors such as comorbidities, decreased activity, dysphagia, and malnutrition, which influence one another, also influence the development of TB in the elderly. Because the mortality rate of TB increases rapidly with age, reaching approximately 30 % among the elderly, early diagnosis is critical.

Clinical characteristics of elderly pulmonary tuberculosis in an acute-care general hospital in Tokyo, Japan: A 12-year retrospective study

OBJECTIVE

A significant feature of tuberculosis (TB) in Japan is the fact that a high proportion of cases belong to the elderly population. Furthermore, previous reports have pointed out the delayed diagnosis of pulmonary TB in acute-care settings. We aimed to examine the clinical characteristics of pulmonary TB patients in an acute-care general hospital, particularly focusing on the elderly population.

METHODS

We retrospectively reviewed the medical records of patients with pulmonary TB who presented at our institution between May 2005 and December 2016. We described the overall clinical characteristics of these patients and compared them according to age.

RESULTS

Overall, 289 patients were eligible for the analysis, with a median age of 58 [42-73] years, and 29.4% being older than 70 years. Among the elderly patients, 42.4% were characterized by atypical presentation.

CONCLUSION

Our findings suggest that the elderly population tends to present as atypical cases lacking respiratory complaints, thereby being at a risk of misdiagnosis.

Treatment outcomes for elderly patients in Thailand with pulmonary tuberculosis

Background

Elderly patients with pulmonary tuberculosis are less likely to achieve treatment success than younger patients, and patients aged ≥60 years have a substantial increase in mortality.

Objectives

To compare treatment outcomes over 2 periods during the transition of Thai national tuberculosis (TB) reporting systems and determine treatment success rates and mortality for elderly patients in TB treatment-care settings in Thailand.

Methods

Retrospective cohort study of all records of elderly patients extracted from 2 national TB databases in Thailand: the TB Case Management (TBCM) database of the National TB Program (2014–2015) and the database of the National Health Security Office (NHSO; 2010–2011).

Results

There were 8,301 elderly patients with TB in the TBCM cohort and 11,869 in the NHSO cohort. Overall treatment success rates were 78.5% for patients in the TBCM cohort and 87.5% for patients in the NHSO cohort. High success rates for treatment were found for those aged 60–69 years: 91.1% in 2010–2011 and 85.0% in 2014–2015. High mortality was reported for patients aged ≥90 years: 34.6% in 2010–2011 and 50.0% in 2014–2015.

Conclusions

Compared with the NHSO historical cohort, success rates for treatment were lower and death rates were higher in the TBCM cohort. Because NHSO enforced intensive case monitoring and follow-up while TBCM has no such mechanism, the estimates from the TBCM database may be less accurate for TB circumstances in Thailand. Frequent routine home visits may ensure more complete treatment-care information and support, and increase the treatment success rate in the elderly.

Response to anti-tuberculosis treatment by people over age 60 in Kampala, Uganda

While old age is a known risk factor for developing active tuberculosis (TB), studies on TB in the population aged 60 years and older (considered elderly in this study) are few, especially in the developing world. Results of the TB prevalence survey in Uganda found high TB prevalence (570/100,000) in people over 65. We focused on treatment outcomes in the elderly to understand this epidemic better. We conducted a retrospective analysis of data from TB facility registers in Kampala City for the period 2014-2015. We analyzed the 2014-15 cohort with respect to age, sex, disease class, patients' human immunodeficiency virus (HIV) and directly observed therapy (DOT) status, type of facility, and treatment outcomes and compared findings in the elderly (≥60) and younger (<60) age groups. Of 15,429 records, 3.3% (514/15,429) were for elderly patients. The treatment success rate (TSR) among elderly TB patients (68.3%) was lower than that of the non-elderly (80.9%) and the overall TSR 80.5%, (12,417/15,429) in Kampala. Although the elderly were less likely to test positive for HIV than the young (AOR 0.39; 95% CI 0.33-0.48, p<0.001), they had a two-fold higher risk of unfavorable treatment outcomes (AOR 2.14; CI 1.84-2.72, p<0.001) and were more likely to die while on treatment (AOR 1.86; CI 1.27-2.73; p = 0.001). However, there was no statistically significantly difference between treatment outcomes among HIV-positive and HIV-negative elderly TB patients. Compared to the younger TB patients, elderly TB patients have markedly poorer treatment outcomes, although TB/HIV co-infection rates in this age group are lower.

[Tuberculosis in older persons in African setting: Epidemiological, diagnostic and evolutive features]

OBJECTIVE

To determine the epidemiological, diagnostic and evolutives features of tuberculosis (TB) in older subjects in Benin.

PATIENTS AND METHODS

This was a retrospective cohort study of adults TB patients (age≥15 years) who were notified at all the Basic Management Units (BMU) in Benin from January 1st, 2013 to December 31st. Older subjects (age≥60 years) were compared to those less than 60 years named young subjects. The threshold of significance was set at 5%.

RESULTS

The analysis was carried out on 6531 cases adults cases notified during the period. 601 (9.2%) were 60 years old or above. The case notification rate (CNR) in elders was more than twice the CNR in young people (68 cases vs. 31 cases per 100,000 population). Older subjects were less often infected with HIV (9.3%) than young's (16.7%), P<0.0001. In new bacteriologically confirmed pulmonary TB negative for HIV, unfavorable treatment outcomes were more frequent in older subjects than in young subjects with more deaths (7.5% vs. 3.0%). On the other hand, in bacteriological confirmed TB seropositive for HIV and all the other cases, treatment outcomes were comparable between the two groups.

CONCLUSION

The high CNR and the high death rate in older subjects should plead for a specific care for an adapted management of TB case in this group.

Determinants of excessive daytime sleepiness in two First Nation communities

Background

Excessive daytime sleepiness may be determined by a number of factors including personal characteristics, co-morbidities and socio-economic conditions. In this study we identified factors associated with excessive daytime sleepiness in 2 First Nation communities in rural Saskatchewan.

Methods

Data for this study were from a 2012–13 baseline assessment of the First Nations Lung Health Project, in collaboration between two Cree First Nation reserve communities in Saskatchewan and researchers at the University of Saskatchewan. Community research assistants conducted the assessments in two stages. In the first stage, brochures describing the purpose and nature of the project were distributed on a house by house basis. In the second stage, all individuals age 17 years and older not attending school in the participating communities were invited to the local health care center to participate in interviewer-administered questionnaires and clinical assessments. Excessive daytime sleepiness was defined as Epworth Sleepiness Scale score > 10.

Results

Of 874 persons studied, 829 had valid Epworth Sleepiness Scale scores. Of these, 91(11.0%) had excessive daytime sleepiness; 12.4% in women and 9.6% in men. Multivariate logistic regression analysis indicated that respiratory comorbidities, environmental exposures and loud snoring were significantly associated with excessive daytime sleepiness.

Conclusions

Excessive daytime sleepiness in First Nations peoples living on reserves in rural Saskatchewan is associated with factors related to respiratory co-morbidities, conditions of poverty, and loud snoring.

Clinical and epidemiological characteristics associated with unfavorable tuberculosis treatment outcomes in TB-HIV co-infected patients in Brazil: a hierarchical polytomous analysis

Background

TB patients co-infected with HIV have worse treatment outcomes than non-coinfected patients. How clinical characteristics of TB and socioeconomic characteristics influence these outcomes is poorly understood. Here, we use polytomous regression analysis to identify clinical and epidemiological characteristics associated with unfavorable treatment outcomes among TB-HIV co-infected patients in Brazil.

Methods

TB-HIV cases reported in the Brazilian information system (SINAN) between January 1, 2001 and December 31, 2011 were identified and categorized by TB treatment outcome (cure, default, death, and development of MDR TB). We modeled treatment outcome as a function of clinical characteristics of TB and patient socioeconomic characteristics by polytomous regression analysis. For each treatment outcome, we used cure as the reference outcome.

Results

Between 2001 and 2011, 990,017 cases of TB were reported in SINAN, of which 93,147 (9.4%) were HIV co-infected. Patients aged 15–19 (OR = 2.86; 95% CI: 2.09–3.91) and 20–39 years old (OR = 2.30; 95% CI: 1.81–2.92) were more likely to default on TB treatment than those aged 0–14 years old. In contrast, patients aged ≥60 years were more likely to die from TB (OR = 2.22; 95% CI: 1.43–3.44) or other causes (OR = 2.86; 95% CI: 2.14–3.83). Black patients were more likely to default on TB treatment (OR = 1.33; 95% CI: 1.22–1.44) and die from TB (OR = 1.50; 95% CI: 1.29–1.74). Finally, alcoholism was associated with all unfavorable outcomes: default (OR = 1.94; 95% CI: 1.73–2.17), death due to TB (OR = 1.46; 95% CI: 1.25–1.71), death due to other causes (OR = 1.38; 95% CI: 1.21–1.57) and MDR-TB (OR = 2.29; 95% CI: 1.46–3.58).

Conclusions

Socio-economic vulnerability has a significant effect on treatment outcomes among TB-HIV co-infected patients in Brazil. Enhancing social support, incorporation of alcohol abuse screening and counseling into current TB surveillance programs and targeting interventions to specific age groups are interventions that could improve treatment outcomes.

Does tuberculosis threaten our ageing populations?

Background

The global population is ageing quickly and our understanding of age-related changes in the immune system suggest that the elderly will have less immunological protection from active tuberculosis (TB).

Discussion

Ongoing global surveillance of TB notifications shows increasing age of patients with active TB. This effect of age is compounded by changes to clinical manifestations of disease, confounding of diagnostic tests and increased rates of adverse reactions to antimicrobial treatment of TB. Future epidemiological surveillance, development of diagnostic tests and trials of treatment shortening should all include a focus on ageing people.

Summary

More detailed surveillance of TB notifications in elderly people should be undertaken and carefully evaluated. Risk stratification will help target care for those in greatest need, particularly those with comorbidities or on immunosuppressive therapies. Novel diagnostics and treatment regimes should be designed specifically to be used in this cohort.

The clinical outcomes of oldest old patients with tuberculosis treated by regimens containing rifampicin, isoniazid, and pyrazinamide

Objectives

To investigate the clinical characteristics, adverse drug reactions, and outcomes of the oldest old patients (aged ≥80 years) with tuberculosis (TB) treated with rifampicin, isoniazid, and pyrazinamide (RIP)-containing regimens.

Design

A retrospective chart review study.

Setting

A 1,200-bed tertiary teaching hospital in southwest Taiwan.

Participants

We conducted a retrospective observational study between January 1, 2005 and December 31, 2011. Seven hundred adult patients (aged ≥18 years) with TB treated with RIP-containing anti-TB regimens were reviewed, including 161 oldest old patients.

Outcome measures

Clinical outcomes included clinical responsiveness and microbiological eradication. Adverse outcomes included drug-induced hepatitis, and other symptoms included gastrointestinal upset (eg, abdominal pain, vomiting, diarrhea, or dyspepsia), skin rash, joint pain, and hyperuricemia.

Results

Compared with the non-oldest old adult patients, the oldest old patients more frequently had hepatitis (P=0.014), gastrointestinal upset (P=0.029), and unfavorable outcomes (P<0.001). In a multivariate analysis, hepatitis during treatment (adjusted odds ratio: 3.482, 95% confidence interval: 1.537–7.885; P<0.003) and oldest old age (adjusted odds ratio: 5.161, 95% confidence interval: 2.294–11.613; P<0.010) were independent risk factors for unfavorable outcomes. In the oldest old patients with hepatitis, rifampicin use was more common in the favorable outcome group than in the unfavorable outcome group (100% vs 37.5%; P=0.001).

Conclusion

The oldest old age and hepatitis during RIP treatment were associated with unfavorable outcomes. For the oldest old patients with TB having hepatitis during treatment, rifampicin rechallenge and use might benefit the treatment outcome.

Tuberculosis among older adults--time to take notice

Knowledge that older people are vulnerable to develop tuberculosis is rarely considered in developing country settings. According to 2010 Global Burden of Disease estimates, the majority of tuberculosis-related deaths occurred among people older than 50; most in those aged 65 and above. Older people also contribute a large proportion of Disability-Adjusted Life Years (DALYs); 51% of tuberculosis DALYs occurred in patients aged 50 years and older in East Asia. Tuberculosis age distributions in Africa have been severely skewed by the human immunodeficiency virus (HIV) epidemic, but emerging data suggest increasing disease burdens among older people. Older adults are more likely to develop extra-pulmonary and atypical forms of disease that are often harder to diagnose than conventional sputum smear-positive pulmonary tuberculosis. Their care is complicated by more frequent drug-related adverse events and increased co-morbidity, which may prove difficult to manage in regions where health resources are already constrained. Health systems will have to confront the challenge of an ageing global population and the integrated services required to address their health needs.

Hepatotoxicity from antituberculous therapy in the elderly: a systematic review

BACKGROUND

Elderly persons have the highest rates of tuberculosis (TB) in the United States compared to all other age groups. A systematic literature review was conducted to determine if older age was a risk factor for hepatotoxicity resulting from treatment with first-line drugs used to treat active (TB) and latent tuberculosis (LTBI).

METHODS

A systematic review of MEDLINE, Cochrane Controlled Trial Registry, CINAHL(®), and Science Citation Index Expanded (from 1970 to 2011) was performed to determine the risk of hepatotoxicity, comparing those over 60 with those under 60. A meta-analysis was performed using a random effects model along with log odds ratios and the chi-square test.

FINDINGS

Thirty-eight studies (40,034 participants; 1208 cases of hepatotoxicity) met the selection criteria. For active TB, an overall mean effect of 0.277 (p = 0.024, 95% CI: 0.037-0.517) was observed, which is equivalent to an odds ratio of 1.32 (95% CI: 1.04-1.68). For LTBI, an overall mean effect of 1.42 (p < 0.001, 95% CI: 0.794-2.05) was observed, which translates to an odds ratio of 4.14 (95% CI: 2.21-7.74).

INTERPRETATION

Our analysis revealed that patients older than 60 had significantly more risk of hepatotoxicity. These studies suggest that a gentler regimen of treatment for older individuals could benefit health outcomes in this population of TB patients and minimize risks to the public's health.

A high-resolution computed tomography-based scoring system to differentiate the most infectious active pulmonary tuberculosis from community-acquired pneumonia in elderly and non-elderly patients

OBJECTIVE

The objective of this study was to use high-resolution computed tomography (HRCT) imaging to predict the presence of smear-positive active pulmonary tuberculosis (PTB) in elderly (at least 65 years of age) and non-elderly patients (18-65 years of age).

METHODS

Patients with active pulmonary infections seen from November 2010 through December 2011 received HRCT chest imaging, sputum smears for acid-fast bacilli and sputum cultures for Mycobacterium tuberculosis. Smear-positive PTB was defined as at least one positive sputum smear and a positive culture for M. tuberculosis. Multivariate logistic regression analyses were performed to determine the HRCT predictors of smear-positive active PTB, and a prediction score was developed on the basis of receiver operating characteristic curve analysis.

RESULTS

Of 1,255 patients included, 139 were diagnosed with smear-positive active PTB. According to ROC curve analysis, the sensitivity, specificity, positive predictive value, negative predictive value, false positive rates and false negative rates were 98.6 %, 95.8 %, 78.5 %, 99.8 %, 4.2 % and 1.4 %, respectively, for diagnosing smear-positive active PTB in elderly patients, and 100.0 %, 96.9 %, 76.5 %, 100.0 %, 3.1 % and 0.0 %, respectively, for non-elderly patients.

CONCLUSIONS

HRCT can assist in the early diagnosis of the most infectious active PTB, thereby preventing transmission and minimizing unnecessary immediate respiratory isolation.

KEY POINTS

• HRCT can assist in the early diagnosis of the infectious active PTB • HRCT imaging is useful to predict the presence of smear-positive active PTB • Predictions from the HRCT imaging are valid even before sputum smear or culture results.

Profile and response to anti-tuberculosis treatment among elderly tuberculosis patients treated under the TB Control programme in South India

INTRODUCTION

The demographic transition in India has resulted in an increase in the elderly population. There is limited data on the profile of elderly tuberculosis (TB) patients and their treatment outcomes in India.

OBJECTIVE

To compare the clinical profile, presentation and response to anti-TB treatment among elderly (≥ 60 yrs) and younger (15-59 yrs) TB patients treated under the Revised National TB Control programme.

METHODOLOGY

Retrospective cohort analysis of TB patients treated from May 1999 to December 2004 in one Tuberculosis Unit of Tiruvallur district, South India.

RESULTS

Records of 865 elderly and 4343 younger TB patients were examined: elderly were more likely to be male (84% vs. 71%), smokers (46% vs.37%), illiterate (63% vs. 45%), identified by active case finding through survey (19% vs. 11%), have pulmonary TB (96% vs. 91%) and initial smear negative disease (46% vs. 36%) compared to younger (for all p<0.001). Among a total of 352 elderly and 1933 younger new smear positive pulmonary TB, the elderly had higher loss to follow-up (15% vs. 11%; p = 0.03) and death rates (9% vs. 4%; p<0.001). Mycobacterium tuberculosis susceptibility to first line anti-TB drugs did not differ (elderly 87% vs. younger 84%) (p = 0.20). Side effects related to anti-TB drugs were reported by a higher proportion of elderly patients (63% vs. 54%) (p = 0.005). Previously treated patients had similar treatment outcomes in both the groups.

CONCLUSION

Elderly TB patients are less likely to have smear positive disease. Newly diagnosed elderly TB patients are more likely to be lost to follow-up or die and report drug side effects. Suitable interventions need to be developed for effective management and better treatment outcomes of TB in the elderly.

Treatment response and adverse reactions in older tuberculosis patients with immunocompromising comorbidities

PURPOSE

The aim of this study was to elucidate the effects of immunocompromising comorbidities on treatment response and adverse reactions in older tuberculosis (TB) patients.

MATERIALS AND METHODS

The medical records of 182 patients older than 65 years with proven TB by positive culture of Mycobacterium tuberculosis and with available drug susceptibility tests were reviewed retrospectively. These patients were subsequently assigned to either the comorbidity group (n=78) or non-comorbidity group (n=104) depending on whether they had immunocompromising comorbidities.

RESULTS

The mean durations of treatment were 9.9 ± 3.3 months in the comorbidity group and 9.3 ± 3.2 months in the non-comorbidity group (p=0.21). M. tuberculosis culture results converted to negative in most patients with available follow-up cultures at two months after treatment. The successful treatment rates were 94.9% and 98.9% in the comorbidity and non-comorbidity groups, respectively (p=0.30). The most common side effects of anti-TB treatment were skin rash/pruritus (13% in the comorbidity group vs. 11% in the non-comorbidity group, p=0.79), gastro-intestinal problems (14% vs. 9%, p=0.25) and hepatotoxicity (14% vs. 7%, p=0.09).

CONCLUSION

The present study shows that the successful treatment rate for TB is high and that immunocompromising comorbidities have no effect on the response to treatment and adverse effects in older TB patients.

Increased tuberculosis burden due to demographic transition in Korea from 2001 to 2010

Background

Notified tuberculosis (TB) cases in Korea have not decreased over the last decade (2001-2010).

Methods

To clarify the reasons, we analyzed an annual report on notified tuberculosis patients and age-specific population drift in Korea.

Results

Compared to the age-specific notified TB cases between 2001 and 2010, distinctive features in notified TB cases and new cases increased markedly in people aged 45-54 years and in patients over 65 years old, whereas those between 15-34 years in 2010 decreased drastically. In particular, notified TB individuals over 65 years old occupied 29.6% of the cases in 2010, which was 1.5 times higher than that in 2001. The main reason not to decrease in notified TB patients for the last decade (2001-2010) was due to the increasing elderly population as well as the aging of baby boomers, which have a higher risk of TB development.

Conclusion

Korea needs to pay attention to the older population in order to successfully decrease the burden of TB in the future.

The impact of monitoring tuberculosis reporting delays in New York City

Public health departments rely on the timely receipt of tuberculosis (TB) reports to promptly initiate patient management and contact investigations. In 2003, 43% of persons in New York City with confirmed or suspected TB were reported 4 or more days late. An intervention to increase the timeliness of TB reporting was initiated in 2004. A list of patients who were reported late and had a smear positive for acid-fast bacilli, a pathology finding consistent with TB, or who initiated 2 or more anti-TB medications was generated quarterly. Health care providers and laboratories were contacted to determine the reasons for reporting late and were educated on TB reporting requirements. To assess the effectiveness of the intervention, we evaluated the trend in delayed reports between 2003 and 2006, using the Jonckheere-Terpstra test for trend. The proportion of patients who were reported late decreased from 43% (942/2183) in 2003 to 20% (386/1930) in 2006 (Ptrend < .0001). There were improvements in reporting timeliness for all 3 reporting criteria included in the evaluation and all provider types (all Ptrend < .0001); however, private providers consistently had a higher proportion of delayed reporting (22% reported late in 2006). This relatively simple intervention was very effective in improving the timeliness of TB reporting and could be utilized for other reportable diseases where prompt reporting is critical.

Relationship between computed tomography findings and nutritional status in elderly patients with pulmonary tuberculosis

OBJECTIVE

This study was aimed to identify the relationship between radiographic features of elderly pulmonary TB patients and nutritional deficiency.

METHODS

Ninety-two patients older than 70 years of age with pulmonary TB were retrospectively enrolled. The influence of nutritional parameters, such as serum albumin concentration and peripheral blood total lymphocyte count on CT findings was examined. CT findings of pulmonary TB patients were classified as those including atypical findings (segmental or lobar consolidation in an unusual location, miliary nodules, and hilar and mediastinal lymphadenopathy) or not. The number of segments involved by TB was also counted.

RESULTS

Age- and gender-adjusted analyses for the nutritional parameters and confounders revealed that hypoalbuminemia, lymphocytopenia, and steroid therapy were significantly related to the presence of atypical CT findings. Furthermore, hypoalbuminemia, lymphocytopenia, and the amount of acid-fast bacilli in sputum smears were significantly related to an increased number of involved segments. In multivariate analysis, only hypoalbuminemia was significantly related to the presence of atypical CT findings (OR: 0.335, 95% CI: 0.142-0.794, p = 0.013) and an increased number of involved segments (OR: 0.145, 95% CI: 0.047-0.453, p = 0.0009). Among the CT findings, the tree-in-bud pattern was the most common in all patients (79.3%). However, the presence of the tree-in-bud pattern was not significantly related to any nutritional parameter.

CONCLUSION

Elderly TB patients of poor nutritional status, in particular those with hypoalbuminemia, tended to show atypical CT findings and widespread lesions. The tree-in-bud pulmonary pattern could be observed in TB patients in any nutritional state.

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.