Despite an alarming TB burden among the older people, programmatic response to address it is far from optimal, said Dr Vijay Kumar Arora, Chairperson of TB Association of India, as well as of Southeast Asia region of the International Union Against TB and Lung Disease (The Union). He was addressing the media at Thrissur Press Club, Kerala Union of Working Journalists, alongside 78th National Conference of Tuberculosis and Chest Diseases (NATCON).
In India, one in four of those who were notified to have active TB disease in 2022 were over 55 years of age as per the WHO Global TB Report 2023 (over 650,000 people).
“The population of the elderly persons in India has increased exponentially from 77 million at the beginning of the last century to around 100 million now, forming 9% of the total population of the country. At the same time the number of elderly persons suffering from TB has also remained alarmingly high,” said Dr VK Arora.
TB rate is double among those above 55 years of age
“The prevalence of TB is 16% among the elderly in India. In fact, the TB rate in those above 55 years of age is 588 per 100,000 population, as compared to the national average of 316 per 100000 population of all ages. There is also a large number of elderly TB patients who remain undiagnosed. Such a high rate of TB necessitates concentrated efforts to control the condition effectively. Increased life expectancy, changes in the demographic profile and atypical presentation of the clinical features of TB pose many challenges in the management of TB in the elderly,” said Dr VK Arora.
Diagnosing TB in elderly is challenging
The diagnosis poses difficulties as they exhibit many atypical features, and symptoms are often similar to other age-related diseases. Many elderly patients present with nonspecific symptoms and the condition is missed for a long period of time, causing delay in correct diagnosis.
TB treatment challenges among the elderly
The treatment of elderly patients with TB is similar to that given to younger patients. However, adverse reactions, such as hepatotoxicity, are more common in the elderly. “Drug interactions are more frequent in them. It has been seen that 63% of the elderly patients exhibit poor tolerance to anti-TB drugs, as compared to 54% in younger patients,” added Dr VK Arora, who was among the Guest Editors of a special issue of Indian Journal of Tuberculosis last year.
Financial issues often become a hindrance in continuing treatment. Many are not able to take care of themselves. This results in poor adherence to treatment and failure to complete the prescribed course. Loss to follow-up is also quite high. So the response to treatment is also less and there is an increased rate of treatment failure with advancing age.
“The susceptibility of elderly to TB is increased due to the presence of co-morbid conditions, such as type-2 diabetes mellitus, hypertension, cardiovascular diseases, chronic kidney diseases, chronic obstructive pulmonary disease, and malignancy. A strong connection has been established between diabetes and TB among the elderly,” said Dr Arora.
“Moreover, immunity declines with old age. As immunity wanes, many cases appear to have links to the reactivation of lesions that had remained dormant over many years. The susceptibility to the disease is also increased in the background of malnutrition, chronic alcoholism, pollution, unhygienic living conditions and smoking. Also, drug-resistant TB strains put great hurdles to achieve successful treatment outcomes,” he added.
Pneumonia, invasive pneumococcal disease and other lung diseases
Community acquired pneumonia in winters and invasive pneumococcal disease in unimmunised people pose a challenge. Opportunistic bacterial, fungal, viral, and parasitic infections in the elderly are not only difficult to diagnose but also difficult to treat. Further, there are many potential interactions between anti-TB drugs and other additional medications used by the elderly for the management of co-existing diseases.
According to a study, an all-inclusive management that includes geriatricians and infectious disease specialists, is required in these vulnerable patients, said Dr Arora. Health systems equipped with integrated services will have to address the challenge of an ageing population. Early screening and initiation of treatment along with nutritional management are essential to tackle TB in the elderly. Partnerships between organizations are essential for better management of cases.
Dr VK Arora said that “India is progressing towards delivering on the promise to end TB in the next 21 months (by 2025). It is evident that every person with TB needs to be reached with a full spectrum of TB services, including TB prevention, diagnostics, treatment, care and support. We cannot leave behind the elderly – or other TB vulnerable groups.”
“The prevalence of TB is 16% among the elderly in India. In fact, the TB rate in those above 55 years of age is 588 per 100,000 population, as compared to the national average of 316 per 100000 population of all ages. There is also a large number of elderly TB patients who remain undiagnosed. Such a high rate of TB necessitates concentrated efforts to control the condition effectively. Increased life expectancy, changes in the demographic profile and atypical presentation of the clinical features of TB pose many challenges in the management of TB in the elderly,” said Dr VK Arora.
Diagnosing TB in elderly is challenging
The diagnosis poses difficulties as they exhibit many atypical features, and symptoms are often similar to other age-related diseases. Many elderly patients present with nonspecific symptoms and the condition is missed for a long period of time, causing delay in correct diagnosis.
TB treatment challenges among the elderly
The treatment of elderly patients with TB is similar to that given to younger patients. However, adverse reactions, such as hepatotoxicity, are more common in the elderly. “Drug interactions are more frequent in them. It has been seen that 63% of the elderly patients exhibit poor tolerance to anti-TB drugs, as compared to 54% in younger patients,” added Dr VK Arora, who was among the Guest Editors of a special issue of Indian Journal of Tuberculosis last year.
Financial issues often become a hindrance in continuing treatment. Many are not able to take care of themselves. This results in poor adherence to treatment and failure to complete the prescribed course. Loss to follow-up is also quite high. So the response to treatment is also less and there is an increased rate of treatment failure with advancing age.
“The susceptibility of elderly to TB is increased due to the presence of co-morbid conditions, such as type-2 diabetes mellitus, hypertension, cardiovascular diseases, chronic kidney diseases, chronic obstructive pulmonary disease, and malignancy. A strong connection has been established between diabetes and TB among the elderly,” said Dr Arora.
“Moreover, immunity declines with old age. As immunity wanes, many cases appear to have links to the reactivation of lesions that had remained dormant over many years. The susceptibility to the disease is also increased in the background of malnutrition, chronic alcoholism, pollution, unhygienic living conditions and smoking. Also, drug-resistant TB strains put great hurdles to achieve successful treatment outcomes,” he added.
Pneumonia, invasive pneumococcal disease and other lung diseases
Community acquired pneumonia in winters and invasive pneumococcal disease in unimmunised people pose a challenge. Opportunistic bacterial, fungal, viral, and parasitic infections in the elderly are not only difficult to diagnose but also difficult to treat. Further, there are many potential interactions between anti-TB drugs and other additional medications used by the elderly for the management of co-existing diseases.
According to a study, an all-inclusive management that includes geriatricians and infectious disease specialists, is required in these vulnerable patients, said Dr Arora. Health systems equipped with integrated services will have to address the challenge of an ageing population. Early screening and initiation of treatment along with nutritional management are essential to tackle TB in the elderly. Partnerships between organizations are essential for better management of cases.
Dr VK Arora said that “India is progressing towards delivering on the promise to end TB in the next 21 months (by 2025). It is evident that every person with TB needs to be reached with a full spectrum of TB services, including TB prevention, diagnostics, treatment, care and support. We cannot leave behind the elderly – or other TB vulnerable groups.”
(Citizen News Service)
3 March 2024
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