A STUDY

ON TUBERCULOSIS
MRCP (lre.) FCCP

IN ELDERLY

PATIENTS

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

Dr. Victor K. K. Chan MBChB(CUHK) Medical Officer Dr. Antony C. T. Leung, MBBS (HK) FRCP (Glasg)
Hospital Deportment Chief Executive and Extended Care of Aged

Heaven of Hope Hospital. TseungKwan O, Hong Kong The aim of the present study is to compare the features of tuberculosis between the younger (aged below 65 years) and older (aged 65 years or above) patients. Patients and Method From 1st to 14th September 1993, patients receiving antituberculous treatment in tno tuberculosis male wards of our hospital were recruited into the study. An age cut-off of 65 years was used to divide the patients into young and old groups. The following data were recorded for these two age groups of patients: 1. 2. 3. 4. 5. 6. Clinical characteristics of tuberculosis Comorbid medical conditions Biochemical parameters of nutrition Social factors Functional status Drug therapy

Summary

Introduction The overall incidence of tuberculosis in Hong Kong is falling but age specific notification rate for patients aged 65 years and above has not decreased as rapidly as the younger age groups (1990 versus 1980). Also, an absolute increase in new cases in the older group is seen while a decrease occurs in the younger group. The proportion of tuberculosis patients aged 65 and above rises from 12.5% (1980) to 21.2% (1990), while the percentage of population aged 65 and over has risen only from 6.6% (1980) to 8.6% (1990). Although the mortality from tuberculosis has dropped in all age groups (mortality rate per 100,000 was 7.0 in 1989 as against 6.6 in 1990), more deaths occur in the older age group (50% in 1980 as against 63% in 1990). Also the average age at death from tuberculosis in 1990 was 69 years. Tuberculosis still ranks ninth position among the ten leading causes of death in Hong Kong. An ageing population, immunosenescence, comorbid medical conditions. nutrition and socioeconomic factors interact to result in the rising incidence of tuberculosis in the older person.

Results 33 male patients were recruited into the study, 16 were aged below 65 years and 17 aged 65 and above. representing nearly equal numbers for both age groups. 1. Clinical characteristics (Tables 1 and 2) The mean ages of the younger and older groups were 54.6 years and 72 years respectively. All the patients were being treated for pulmonary tuberculosis except one old patient who was treated for extra-pulmonary tuberculosis, with negative chest radiograph. All pulmonary tuberculosis patients showed radiological activity. A positive sputum in direct smear or culture was found in 12/16 (75%) and 15/16 (93.8%) in the young and aged groups respectively. 2/16 was multiresistant tuberculosis in the younger patients as against 1/7 of the aged patients. No atypical mycobacteria were identified in all the patients. The chest X-ray zones were involved in 35/96 (36.5%) and 49/96 (51%) of the young and aged groups respectively. More radiological zones at all levels were involved in the older patient: the percentages increase in the older patient when compared to the young for the apical, middle and lower

40

Table 1. Clinical characteristics

of tuberculosis

More comorbid conditions existed in the older group averaging 2.05 conditions per patient. while 1.1 condition per patient occurred in the young. 31.3 - 35.3% of patients had a past history of pulmonary tuberculosis. Aged patients had more coexisting conditions of dementia. diabetes mellitus. luns cancer and chronic obstructive pulmonary disease. Table 2. Chest X-ray appearance tuberculosis in pulmonary The older patients were lighter in hody weight at on average. and by 18.3kg than the younger patients. Haemoglobin levels were simiar. A higher MCV and ESR were apparent in the older patient. The absolute lymphocyte count. albumin level, uric acid and creatinine levels were lower in the older patient. Phosphate. urea, sodium. potassium were comparable in either groups. The older patient showed a higher fasting sugar of 7.9 mmol/l. Spot sugars were comparable in either groups.

Proportion inwlvecl in young Ir~=l(i) l&&L.& m 12.10 10 16 22 j2 t 10 i 16 9 32 1 10 j 16 t j 1- ts 18 -tx js 96 x 16 716 7 16

Proportion in\.olvrcl in old fr1=f6/ f&&tLcft 15 10 It 10 7 16 t. 16 0 16 3 16 2s is 2 1 4s 7 16 9 16 016 Totlll 29 32 11 32 9 32 to )(I

40.6kg

Zonrs:

Apt3 &lid LO\\ Total

Apex only hlore than 2 levels Pleural efwiion

Table 4. Biochemical

parameters
.klfl bdws

of nutrition
in yxmg
hkan values

in old

Table 3. Comorbid Conditions No.in young patients Past tuberculosis Liver disease Renal disease Chronic obstructive pulmonary disease Silicosis Cardiovascular disease Eye disorder Joint disorder Skin disorder Neurological disorders Diabetes mellitus Pneumonia Lung cancer Gastrointestinal disorders Prostate disease Drug addict B12/ folate deficiency Total: 5 No.in old patients Botl>- \x.eight (kg) HMgj .LICV (fl) 5lCHC (g/ dl) ESR (mmhr) Lymphocyte count (xlO,,l) Albumin (g/l) Globulin (mmol; 1) Calcium (mmol, I) Phosphate (mmol: I) Cric acid Cmmol: 1) Urea Cmmol; II Creatinine (mmol. I) Sodium (mmol;l) Potassium (mmol. I) Glucose: fasting (mmol, 1) spot

Patients (range) 58.9 12.9 (33.57.4) (11.3-15.8)

Patients (range) 40.6 (33-57.5) 12.7 (9.1-16.3) 92.2 (8j.l-108.6) 31.9 (28.7-34.X 70.4 (10-200) 1.25 (0.14-1.91) 30.2 (20.4-38.1) 36 (27-53.1) 2.35 (2.1-2.8) 1.29 (1.1-1.55) 0.32 (0.11-0.6) 6.2 (3.6-10.8) 97.7 (67-154) 13j.8 (127-143) 3.9 (2.9-5.1) 7.9 9.1

1 2
2
I

6 5
1 4

88.9 (74.7-121.9) 32.8 (31.0-34.2)

65.4 1.7 37,7 2.36 0.4 (j-150) (0.91-3.36) (X3.7-42.7) (1.9528)

2 1 2 (catsract, glaucoma) 1 (gout) 1 (psoriasis) 1 3 (dementia) (mentally retarded, epilepsy) 7 1 2 2 1 1

1.26 (0.83-1.6) 6.1

4 5.7 9.8 (0.16-0.84) (2.8-13.4) 111.3 (8j-240) (3.3-4.7)

137.4 (133-l-a

18

35

41

4. Social factors (TAble 5) Although in either groups the majority live with the family or children, 2 older patients came from old age homes. 47% of older patients espressed inadequate family, support. 6.25% of younger and 41.2% of older patients requiretl public assistance.
Table 5. Social factors

Table 6. Functional status

(11=171

12 2 1 2 2 1 (moderate)

1 (mild)
1, 2 1 2

adequate inadequate prixlte public assistance

It

2 15
1

11 6

10

6.25% of younger patients showed abnormality in cognition as against 29.4% of the older person, of which 60% of the latter were of at least moderate severity. All younger patients were ambulant, the majority requiring no walking aids. About 18% of the older patient were either chair-bound or bed-bound. All younger patients were urinary continent with a normal bowel habit. 35.3% of the older were incontinent in urine and 23.5% in faeces; 29.4% were constipated. Nearly all younger patients were independent in activities of daily living (ADL) while 17.6%-47% of older patients were dependent, particularly for bathing. dressing and toileting. Although independent in ADL. younger patients become dependent in instrumental ADL from 6.25% to 12.5%, especially for shopping, cooking and handling finance. About 60% of older patients were independent in all areas of instrumental ADL. 11.8% of the older patient were suspected to have depression. Only a small proportion of patients had significant visual or hearing deficit in either groups.

9 11 1-t 10 li

7 7 6

* XDL (activities ofdaily living) and IADL (instrumental ADL) classified as either independent or dependent of older patients. The older patient took on average 18.3 drugs per day. Discussion Tuberculosis is still prevalent in Hong Kong. The increase in incidence in the elderly patients is out of proportion to the expanded total aged population, Mortality from tuberculosis has also shifted to the older age group. Fattors leading to this phenomenon include (i) reactivation of tuberculosis in the growing aged population who had been infected remotely in the past when tuberculosis was rampant in Hong Kong, (ii) recently acquired infection, and (iii) reduced rate of transmission in the younger age group. Powell and Farrer2 ontended that the age shifts demonstrated the past successes with tuberculosis control, in the event of decreasing transmission of Mycobacterium tuberculosis.

6.25% of young and 23.5% of older patients esperienced drug intolerance. Drug hypersensitivity occurred in 6.25% of young and 47% in the older group, most frequently liver impairment, followed by renal and skin rash. Compliance was comparable in both groups. The drug regimes were similar in either groups. Streptomycin was used in 58.8% of older patients. 31.3% of young and 35.3% older patients were receiving treatment for the second time. A defaulter history was noted in 11.8%

42

Dai DLK. Tang AWC, Chan VKK, Leung ACT

Tuberculosis

Study

Table 7. Drug therapy

Morris described pulmonary tuberculosis in elderly patients as a different disease entity, by virtue of distinct clinical and diagnostic characteristics. Radiologically, our elderly patients showed more extensive involvement and there was a tendency for the lower and mid zones to be more affected in the older patients than the younger. though it did not reach statistical significance in this study (20/32 in old compared with 13/32 in young. p=0.133 by the Yates corrected chi-square). Mid and lower lobe involvement were reported as varying from 26% to 83%) in three series4. Pulmonary tuberculosis involving the lower and middle lobes usually arise from the upper lobe through endohronchial spread. The occurrence of lesions in lower lung field or anterior segment of upper lobe should lead one to look for factors such as diabetes mellitus, advanced age, steroid treatment, renal or hepatic disorder. malignancy and alcoholism5,6. The radiological changes can also conform to classical post-primary tuberculosis with apical fibrosis, cavitation and pleural thickening. Disseminated tuberculosis can present in the reactive miliary or "areactive cryptic fashions. The overall radiological pattern in the elderly patient differs from those of pure primary or post-primary tuberculosis, and are similar to those seen in patients with decreased or absent cell-mediated immunity2. A high positive bacteriology rate by direct smear or culture was found in our older patients probably by virtue of more extensive parenchymal disease and heavier bacterial load. A further increase in positive yield can be achieved through culture of bronchoscopic washing, bronchial brushing and transbronchial biopsy7. Tuberculosis should

not pose a diagnostic prohlem in the elderly patient given adequate index Of suspicion and diligent investigations, The classical symptoms of night sweats, fever. haemopvsis and chest pain tend to be mild in the older age group, However. these were not examined in our study. One feature of tuberculosis in the elderly patient demonstrated in our study is the frequent association of comorbid conditions. In particular, concurrent occurrence of tuberculosis and malignancy is not uncommon8. Our elderly patients are malnourished, as evidenced by a low, body weight. higher MCV, lower lymphocyte count. low albumin and uric acid levels. Other abnormal parameters reported in other series. but not in our study include hyponatraemia and hypokslaemia. The higher incidence of hcpatic dysfunction in our group may reflect dissemination or reactivation of disease in the liver of an older person3. The fasting sugar is higher in the older age group indicating a higher prevalence of abnormal glucose tolerance. Age related immunosenescence plays a role in the increased frequency of tuberculosis in the elderly population4. Malignancy. diabetes mellitus. chronic renal failure, immunosuppressive drugs and poor nutrition may act through similar pathways. Our older patients belonged to a lower socio-economic class with inadequate family support. More patients came from home than an aged institution. American authors reported 80% of all tuberculosis cases in the elderly patient to arise among those at home. largely from recrudescence of remote infection. About 20% of cases arise among those who live in nursing homes as a mixture of old and recently acquired infection. Chronic institutionalised elderly persons in Hong Kong are prone to tuberculoof (i) frailty and comorbid conditions, (ii) malsis because nutrition, and (iii) increased transmission from a crowded environment. The authors believe that tuberculosis in private care and attention homes may be under-detected and ma)- potentially form a sizeable reservoir of untreated infection. Most papers on geriatric tuberculosis cover the atypical clinical features10,11. Our present paper, in addition. describes the more prevalent dysfunction of the elderly patient in physical, and in particular, the instrumental activities of daily. living. This is to be expected from a group of frail. socioeconomically deprived, and chronically ill patients of older age. Depression is a recognised association with tuberculosis and may be more prevalent in the elderly. The side effects of antituberculous drugs are more frequent and more severe in elderly patients, presenting as intolerance or hypersensitivity. The figures are comparable to a recent study by Teale et al10.Our high incidence of liver impairment is similar to other studies. With regard to this, ethambutol has been recommended in elderly patients. Streptomycin in the authors opinion, can be used in the elderly patient, provided caution is taken in monian

43

1.

2.

3. 4.

5. 6. 7.

Effective surveillance and eradication of disease in the younger population. Enhancing immunocompetence of the elderly person through adequate nutrition. Avoid unnecessary use of immunosuppressive drugs such as steroids. Prevention of transmission particularly in institutions by improving environment: such as reducing overcrowdedness and better ventilation. Early detection. and appropriate nutrition and drug therapy. Optimal treatment of comorbid conditions. Rehabilitation and community support for the functionally incapacitated.

References 1. Annual Report 1990, Chest Service of the Hong Kong Government Department of Health. 2 Powell KE. Farrer IS. The rising age of the tuberculo-. sis patient: a sign of success and failure. J Infec Dis 1990:142(6):946-8. Morris CDW. Pulmonary Tuberculosis in the elderly: 3. a different disease? Thorax 1990;45:912-3. 4. Yoshikawa IT Tuberculosis in ageing adults. J Am Geriatr Soc 1992:40:178-187. Chang SS, Lee PY, Perng RI? Lower lung field tuber5. culosis. Chest 1987;91:230-2. 6. Spencer D. Anterior segment upper lobe tuberculosis in the adult. Chest 1990:97:384-8. Pate1 YR Flexible bronchoscopy as a diagnostic tool 7. in the evaluation of pulmonary tuberculosis in an elderly population. J Am Geriatr Soc 1993;41:629-632. 8. Alvarez S, Shell C, Berk S. Pulmonary tuberculosis in elderly men. Am J Med 1987;82:602-6. Stead WW. Tuberculosis in elderly persons. Annu Rev 9. Med 1991,42:267-276. 10. Teale C, Goldman JM, Pearson SB. The Association of age with the presentation and outcome of tuberculosis. Age Ageing 1993;22:289-293. 11. Brande PMV. Clinical spectrum of endobronchial tuberculosis in elderly patients. Arch Intern Med 1990;150:2105-8.