Tuberculosis Prevention and Control in Long-Term–Care Facilities for Older Adults

Abstract

In the United States, older adults comprise 22% of cases of tuberculous disease but only 12% of the population. Most cases of tuberculosis (TB) occur in community dwellers, but attack rates are highest among frail residents of long-term-care facilities. The detection and treatment of latent TB infection and TB disease can pose special challenges in older adults. Rapid recognition of possible disease, diagnosis, and implementation of airborne precautions are essential to prevent spread. It is the intent of this evidence-based guideline to assist healthcare providers in the prevention and control of TB, specifically in skilled nursing facilities for the elderly.

Tuberculosis: Pathophysiology, Clinical Features, and Diagnosis

“…8,19 Additionally, persons 65 years or older have a disproportionately higher rate of disease than any does other age group, 20 often because of diminishing immunity and reactivation of disease. 21 …”

“…The radiographs may show the characteristic findings of infiltrates with cavitation in the upper and middle lobes of the lungs 21 ( Figure 2 Although abnormal findings on a chest radiograph may suggest tuberculosis, they are not diagnostic for the disease. 19 Traditionally, the first laboratory test used to detect active tuberculosis in a patient with abnormal findings on chest radiographs is examination of a sputum smear for the presence of acid-fast bacilli (Table 2).…”

Health hazard evaluation report: evaluation of exposure to tuberculosis among employees at a long-term care facility (revised).

“…Nursing home residence had been reported to double the age-adjusted risk of developing active TB disease [CDC 1990;Yoshikawa 1992]. The elderly population residing in long-term care facilities is vulnerable not just because of reactivation from prior infection but also through acquisition of infection from other residents who develop disease [Thrupp et al 2004].…”

“…Many patients present clinically with changes in functional capacity, chronic fatigue, cognitive impairment, decreased appetite, or unexplained low-grade fever, symptoms which have a long differential diagnosis in the elderly [Nagami and Yoshikawa 1983;Yoshikawa 1992;Rajagopalan and Yoshikawa 2000]. Second, diagnosis in the elderly population in long-term care facilities is challenged by the occurrence of false negative TSTs, limited radiographic capabilities of these facilities, the difficulty in transporting residents to acute care centers for clinical evaluation, and the difficulty of obtaining expectorated sputum from cognitively impaired patients, as experienced by the facility in this evaluation [Thrupp et al 2004]. Diagnosis may be hampered by end of life care decisions, and few long-term care facility deaths lead to autopsies [Katz and Seidel 1990].…”

Challenges in assessing transmission of Mycobacterium tuberculosis in long-term-care facilities

“…13 Further, aging reduces the ability to mount a cell-mediated immune response, making atypical presentations of TB due to dissemination of TB disease or localization to other organs more common. 6,14 In elderly persons, classic presenting features of pulmonary TB disease such as weight loss, cough, hemoptysis, and night sweats may be either absent or attributable to alternative diagnoses. 6,14,15 Conditions such as dementia and strokes can be associated with dysphagia, increasing the possibility of chronic cough from recurrent aspiration.…”