Tuberculosis (TB) is an ancient disease present in Egypt around 3700 BC (Morse, Brothwell, & Ucko, 1964) and was described by Hippocrates (1939) in his writing around 460-377 BC. Koch's discovery of the bacteria, Mycobacterium tuberculosis in 1882 convinced physicians that the disease was communicable and stimulated concerted efforts to fight the disease (Snider, 1994). Prior to 1944, when streptomycin was discovered, the treatment of TB consisted of bed rest, fresh air in dry climates, and surgical interventions in sanitariums, often in rural areas. The disease was viewed as a stigma because of fears of ostracism, job loss, and decreased marriage eligibility. With the discovery of several effective antibiotics in the 1940s and 1950s, TB began to be treated on an outpatient basis without the need for hospitalization or bed rest (Dubos & Dubos, 1994).
A TB infection is caused by the aerobic, acid-fast bacillus, M. tuberculosisy which is carried on airborne droplet nuclei when an infectious TB client sings, sneezes, laughs, or speaks. The small droplet nuclei (1 to 5 microns) are carried on air currents, and those that are inhaled and reach the alveoli can cause infection. People who are infected for the first time are usually protected by a well -functioning immune system, which walls off the bacillus in the lungs, and may remain asymptomatic for years (Hopkins & Schoener, 1996). Of those active infections which do occur, the majority are in the lungs, but the disease can spread to all parts of the body in elderly people who are especially susceptible to extrapulmonary infections (Yoshikawa, 1992).
Many elderly clients were exposed to M. tuberculosis as children and young adults. Once exposed, an individual may remain infected for years. Symptomatic TB disease may develop within a few weeks, or the person may remain asymptomatic for years if not for life. In those people, the only symptom of the disease is the positive tuberculin skin test. Infected people are more likely to develop the disease if they are under physical or emotional stress, are immunocompromised such as with an HIV infection, or experience a decline in immune system function because of the aging process (Snider, 1994).
TUBERCULOSIS IN THE UNITED STATES
During the first third of the 1900s, by the age of 30, 80% of people had been infected by M tuberculosis. Many of these people outlived their infection and are no longer at risk for developing TB, but some survived the initial infection and still harbor the bacteria in dormant caseous and even calcified lesions (Dutt & Stead, 1992). In approximately 15 % to 30% of these individuals, the infection persists and accounts for approximately 90% of the cases of TB in the elderly today (Stead, 1991).
Tuberculosis rates increase with age for all racial and ethnic groups and for both sexes. Among nursing home residents, the incidence of TB disease is two to seven times higher in some areas than among demographically similar people living in other settings (Centers for Disease Control and Prevention [CDC], 1995). In a 1984-1985 study sponsored by the CDC of 15,379 cases of TB in 29 states, the nursing home residents were at approximately twice the risk of developing TB than older adults in the community. In approximately 84% of these cases, other pulmonary diseases coexisted (CDC, 1990). Tuberculosis continues to be a health problem today.
In 1944, when the United States Public Health Service began its TB program, there were 126,000 reported cases of TB. When antibiotic treatment was introduced, the numbers began to decline with the hope of TB eradication. From 1953 to 1984, the number of cases declined by approximately 5.6% per year from 84,000 cases in 1953 to 22,255 cases in 1984, and this goal looked attainable. However, in 1984 through 1993 the figures began to climb again by 14% per year (United States Department of Health and Human Services [USDHHS], 1994). This increased number of cases were attributed to these factors: "the association of TB with the HIV epidemic, the immigration from countries where TB is common, the transmission of TB in congregate settings (e.g., health care facilities, correctional facilities, and homeless shelters), and a deterioration of the health care infrastructure" (USDHHS, 1994, p. 11).
In 1995, for the third year in a row, there was once again a decline, with the total number of cases at 22,813, (8.7 cases per 100,000 population). This represents a decline in the number of TB cases among United States-born people but an increase among foreign-born people. In the elderly age 65 and older, the number of people with reported cases declined by 3.9% from 5,546 cases in 1994 to 5,332 cases in 1995 (CDC, 1996). It is anticipated that this decline will continue.
GROUPS AT RISK
The high-risk groups for TB as listed by the Advisory Council for the Elimination of Tuberculosis (CDC, 1995) include:
* People infected with the HIV virus.
* Those with close contact to cases of active TB.
* People with certain medical conditions such as HIV infection, diabetes mellitus, conditions requiring prolonged high-dose corticosteroid therapy and other immunosuppressive therapy, chronic renal failure, some hematologic disorders (e.g., leukemia, lymphomas), other specific malignancies (e.g., carcinoma of the head or neck), weight of greater than 10% below ideal body weight, silicosis, gastrectomy, and jejunoileal bypass.
* Health care workers who serve high-risk clients.
* Foreign-born people from areas of the world where TB is common.
* Medically underserved, lowincome populations.
* Residents and employees of high-risk congregate facilities (e.g., nursing homes).
* High-risk racial or ethnic minority populations, as defined locally.
* People who inject illicit drugs or other locally identified high-risk substance users.
* Infants, children, and adolescents exposed to adults in high-risk categories.
Many of these high risk groups are found in the United States and within the elderly population.
TUBERCULOSIS IN THE ELDERLY
Susceptibility in the Elderly
The elderly have a higher incidence of TB because of several factors. As mentioned above, many elderly people were exposed as children and young adults to M. tuberculosis and are continuing to harbor the dormant bacteria. As individuals age, the immune system declines and T-cell activity decreases. As the body becomes less able to ward off infection, there is increasing potential for the dormant TB bacteria to become active (Eliopoulos, 1993). The elderly also suffer from many chronic conditions which cause greater susceptibility to infection. Many elderly people have at least one, if not several, of the medical conditions which place them in the high-risk groups for TB (Hopkins & Schoener, 1996).
The environmental conditions in many long-term care facilities also lead to increasing incidence of TB. The recirculation of air with few open windows and doors can allow circulation of air containing the droplet nuclei with the bacillus. When there is M. tuberculosis present and limited exchange of air, higher concentrations of bacteria can be present (Hopkins & Schoener, 1996).
The diagnosis of TB is often overlooked in elderly clients. Because of misinterpretation of radiographic patterns as well as atypical patterns in the elderly, they are often thought to have bronchitis, bronchopneumonia, or cancer rather than TB (Couser & Glassroth, 1993). Because the clinical signs of TB, such as fatigue and weight loss, are not uncommon in elderly clients, they can be easily overlooked and assigned to other ailments. The cognitive abilities of older adults may also be impaired, and it may be very difficult to get an accurate history of past exposures, skin testing results, vaccine history with bacillus CalmetteGuérin, and family history.
CLINICAL MANIFESTATION OF ACTIVE TB IN THE ELDERLY
Symptoms of TB are:
* Chronic productive cough.
* Chest pain.
* Night sweats.
* Becoming easily fatigued.
* Loss of appetite.
* Weight loss (USDHHS, 1994).
These symptoms may be seen in the elderly, but often the primary symptoms may only be anorexia and weakness. Night sweats may not be present because of reduced diaphoresis in the elderly. Likewise, fever may not be present because oí changes in the body's ability to regulate its temperature (Eliopoulos, 1993). Older clients are more likely to be immunocompromised and to have chronic cardiac and pulmonary diseases, which tend to mask the symptoms of TB. The chest radiograph may be atypical for TB and easily misinterpreted for other conditions (Couser & Glassroth, 1993).
Extrapulmonary TB is more common in the elderly than in younger people. If present, the elderly client may present with nonspecific symptoms of anorexia, weakness, and failure to thrive (Couser & Glassroth, 1993). These symptoms easily can be associated with many other conditions in the elderly.
Because of the difficulties in diagnosing TB, health care providers need to keep a high level of suspicion for TB in elderly clients exhibiting a wide variety of complaints and functional disturbances. The status of the Mantoux skin test should be prominently displayed on the medical chart for TB to be considered when an elderly client becomes ill.
TESTING FOR TB IN THE ELDERLY
Periodic testing with the Mantoux test is the best way to screen for and contain TB. The screening is performed to detect people who have been infected with M. tuberculosis and have inactive or active TB. The principle value of the tuberculin skin test is to detect infected people before the disease has developed (Dutt & Stead, 1993). If the person has a history of a positive skin test, the test is not repeated, and a chest x-ray is needed.
The Mantoux test is performed by injecting intradermally 5 tuberculin units of purified protein derivative (PPD) and is read by measuring in millimeters the induration, not the area of redness, 48 to 72 hours later (Pettit, 1996). This is then measured against a standard for the degree of risk for TB. Because of the unreliability of the puncture test (Tine test), it is not recommended for diagnosis (Dutt & Stead, 1992). If the PPD is positive, a chest x-ray is performed (Dutt & Stead, 1993). Any client also exhibiting signs and symptoms of TB should have sputum smears and cultures done (American Thoracic Society, 1993).
The Mantoux test may need to be repeated in the elderly population. The test relies on a person's ability to mount a delayed-type hypersensitivity response to infections in the past. This response may be impaired in the elderly. If the first test is negative, the Mantoux test should be repeated in 1 to 3 weeks. The stimulus of the first test may boost or increase the size of the reaction to the second test, which is then considered positive (CDC, 1995). Any client with a positive Mantoux should have a chest x-ray to assess for active disease. If the x-ray is negative, the positive results of the Mantoux should be posted on the front of the chart to remind medical and nursing staff to consider TB if the client develops symptoms such as a prolonged cough, night sweats, weight loss, or general decline (Dutt & Stead, 1993).
The recommendations of the Advisory Council for the Elimination of Tuberculosis (CDC, 1995) for residents and employees of nursing homes for the elderly are to screen all residents for TB on admission by use of the two-step method. This method gives a baseline for interpretation of later tests. Screening only by chest x-ray is insufficient. Testing should then be repeated if there is an exposure.
TREATMENT FOR ACTIVE TB IN THE ELDERLY
Treatment for TB is the same for the elderly as for any age group. With appropriate and timely treatment, individuals can be expected to have complete recovery. Recommended drug therapy is isoniazid (INH), rifampin (RIF) and pyrazinamide (PZA) for the first 2 months and isoniazid and rifampin for the next 4 months. Ethambutol hydrochloride (EMB) is added to the drug regimen until the drug sensitivity reports are returned if drug resistance is suspected (American Thoracic Society, 1994). Because older adults were generally infected many years prior to activation of the disease or became infected by such a person, drug resistance is very rare (Dutt & Stead, 1993). Pyridoxine (vitamin B6) is given with the medication to prevent side effects.
Usually the drugs for TB are well tolerated, and few side effects occur. Before treatment begins, baseline studies should be performed, including a complete blood count, as well as hepatic and renal functions. Once therapy has begun, hepatic functions do not need to be repeated unless anorexia, nausea, or vomiting occur because asymptomatic elevation is common and can cause confusion. If nausea, vomiting, or anorexia do occur, drug therapy should be stopped immediately and can be reintroduced depending on the results of the test. Response to drug therapy is measured by submitting sputum for bacteriological examination each month during treatment and then for 6 months after therapy (Dutt & Stead, 1993).
The TB drugs do have side effects and can interfere with other medications. The elderly are especially vulnerable because they generally have chronic conditions and take other medications. It is important for nurses to be familiar with these drug interactions and side effects and to monitor the client closely (Table).
PREVENTION OF TB IN THE ELDERLY
When the Mantoux test is positive, the chest x-ray is negative, and the client is asymptomatic, preventive therapy can reduce the risk that the TB infection will progress to the active disease. This therapy is not generally recommended for elderly clients because there is a much greater risk of hepatic toxicity. The strongest indication for therapy in the elderly is a recent converter of the Mantoux test because older adults are at much greater risk (8% to 12%) for contracting TB. For prevention, 300 mg of INH is given for 6 to 9 months (Dutt & Stead, 1993 ).
GERONTOLOGICAL NURSING IMPLICATIONS
A careful history can assist nurses in assessing clients' past exposure to and present symptoms of TB. Because this often can be difficult to obtain from elderly clients, it is important to include their families. Tuberculosis can be very frightening to older adults, and it is important to allay their fears and correct their misconceptions to get accurate information. The language needs to be kept very simple and in terms the client can understand. Often it is not possible to get an accurate history, and exposure can only be assessed by the purified protein derivative.
Education is extremely important for not only the elderly TB client but also their family. Many of the current older adults grew up at a time when TB carried a stigma, and many people were sent away to sanitariums for long periods. They may fear they can infect their family and friends and thus will avoid contact with people. These misconceptions need to be corrected and the client reassured (Eliopoulos, 1993). Some restrictions may be necessary, but these can done in the home. The client must also be taught the proper use of a tissue when sneezing and coughing, as well as proper disposal of the tissue.
Education is also important for proper administration of medication. The clients' cognitive and physical abilities to take the medication must be assessed carefully. Nurses can devise ways to help the client remember to take the medication. The medication could be placed by the toothbrush or in multiday pill boxes by a family member. The client and the family must be taught the side effects of the medication and be constantly on the alert for them. They must be told what to do if these side effects occur. It is also important to be consistent and to monitor medication administration.
The safe administration of the medication should be of prime concern for nurses. Liver and renal function tests and blood counts should be performed before the medication is begun and at regular intervals as prescribed. Drug interactions and side effects should be monitored carefully on a continuing basis by talking to clients and their families.
Nurses must be on the alert for the symptoms of TB in the elderly and consider it as a diagnosis when elderly clients complain of night sweats, cough, anorexia, weight loss, or fever. Histories from clients and their families should be recorded to assess for past exposure to TB, and proper testing for TB should be initiated.
In long-term care facilities, nurses are critical to identifying and controlling TB. Through careful monitoring of all residents for TB, it can be contained before it spreads in the facility. Nurses can monitor for universal precautions and teach both residents and staff the proper use and disposal of tissues for sneezing and coughing, as well as proper hand washing. When residents are isolated, nurses can teach them about the reasons for isolation, check that the rooms are properly ventilated for use with TB clients, and stress the importance of compliance to residents and their families (Hopkins & Schoener, 1996).
Tuberculosis is still with us today. There was an increase in the number of TB cases from 1985 to 1992, but currently the numbers are decreasing. Nurses working with the elderly can be instrumental in ensuring this downward trend continues. Because many of elderly clients were exposed as children and young adults, they can be reservoirs of the bacillus. Health care providers must be alert to recognize the symptoms of TB in these clients and consider TB as a possibility. Nurses can also be instrumental in ensuring compliance with a long medical treatment regimen by continuous teaching, supportive understanding, and constant alertness to possible problems.
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