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Chest Surveys of the Aged
Chest Surveys of the Aged EDMUND G. BEACHAM, M.D., F.C.C.P.- and STANLEY H. MACHT, M.D.t Baltimore, Maryland Few reports appear in the literature concerning tuberculosis case finding in "Old Folks" homes. Myers 4 calls attention to the reservoir of contagious tuberculosis in the aged. Medlar 2 •3 reported an increasing incidence of tuberculosis in the "over 50 year" group that came to autopsy during 1940-1945 as compared to a similar group autopsied in 1916-1920 in New York City. In 1942, in 1945 and again in 1949, The Baltimore City Hospitals, Baltimore, Maryland, has held mass chest surveys of its Infirmary patients. The purpose of this paper is to present information gained from these surveys as they offer material that would probably be characteristic of data obtained through a survey of any public home for the elderly. Material and Methods
In the 1942 survey 670 persons had 35 mm . film inspections of their chests. All films were interpreted by a physician from the United States Public Health Service National Institute of Health, Division of Tuberculosis. In 1945 the survey was repeated. This time 636 persons were photofluorographed on 70 mm. film. All films were interpreted by a phthisiologist. In 1949, 581 inmates of the same group were surveyed on 70 mm. film, but this time the films were interpreted by a radiologist. The findings are summarized and compared in Table 1. There have been several recent papers illustrating variations in the interpretations of survey films depending on the ability, experience and degree of fatigue of the reader. The present report is also of interest because the same group of patients was surveyed three times, the films of each survey being read by a different type of specialist. The films of the first survey were read by an epidemiologist whose basic outlook was that of a clinician in the research field . The films of the second survey were read by a specialist in chest diseases who was interested primarily in tuberculosis, and who had probably had more experience with that disease than either of the two other readers. The films of the third survey were read by a radiologist who was not influenced from -Assistant Chief, Tuberculosis Division, Baltimore City Hospitals. tFormer Chief of Radiology, Baltimore City Hospitals. Now Chief of Radiology, Washington County Hospital, Hagerstown, Maryland. 102
Table I : Note "over-readin g" of films by clinician, "un der - reading" of films by phthisiologist and "mean-betw een -the- tw o" by ra diologist. 1942 U.S.P.H .S . M .D .
1945 Phthisiologist
1949 Rad iologis t
1942 U.S.P.H .S. M .D .
Number of C a s es
Total No. Chests Examined Healthy Ches ts Tuberculosis Abnormalities of Heart and Aorta Other Diseases
1945 Phth isiologist
x ~
Perce n t a ges
670
636
581
554
469
71.1
87.1
80.7
88
49
85
13.1
7.7
14.6
24
25
14
3.6
3.9
2.4
82
8
13
12.2
1.2
2.2
1949 Rad iolo gis t
M .D .
1942 U .S .P .H .B.
::I:
..,UJ I:'il
UJ
~<:
I:'il
><
0
1945 Pht hlslolog ist
1949 Rad iologis t
M .D .
Nu mb er of Ca s es
0
UJ
Table II : Sho wing break-down and comparison of findin gs no ted in posi tive cases in all three surveys. 1945 P h t his iologist
!2.
1949 R ad iologis t
476
1942 U .S .P .H .B.
<
"'.l
~
I:'il
>
P erc e n t a ges
0
Total Ches ts Examined Total No. Cases Thought to be Tuberculosis Minimal Tuberculosis Moderately Advanced Far Advanced Suspicious Lesion
670
636
581
88
49
85
22
16
18
17
2 46
I:'il
tl
13.0
7.7
14.6
38
3.2
2.5
6.5
24
2.7
2.7
4.1
3
5
0.3
0.5
0.8
13
18
6.8
2.0
3.1
0
c.>
BEACHAM AND MACHT
104
Jan., 1952
either the clinical standpoint or from the phthisiologist's viewpoint, but who initiated the survey with two objectives in mind: (1) To find active tuberculosis. (2) To compare the results of his survey with the others that had been performed previously. This description of the readers is given because many intangible factors are thus brought into the picture. It is interesting to note that the results show the epidemiologist "over-read" the films (71 per cent negative) , the phthisiologist "under-read" the films (87 per cent negative) and the radiologist hit a middle path (80.7 per cent negative) . Apparently the phthisiologist's more varied experience with tuberculosis enabled him to consider inactive or insignificant many lesions which the other two readers considered positive. The clinician found a significant percentage of other diseases (12.2 per cent cardiac enlargement, etc.) which the phthisiologist tended to ignore. However, again the radiologist took the "middle path" averaging 2.2 per cent positive cases. Those cases showing any type of inflammatory change in the lungs, regardless of apparent age of the lesion, were listed as being suspicious for tuberculosis of undetermined activity. They were further subdivided into four groups. Table II illustrates the breakdown of these findings. Cases having positive findings in the 1949 survey were referred to the medical service of the general hospital for careful study. Many had been seen there previously and already had undergone sufficient study to establish a final diagnosis. Table III: Final classification of cases of 1949 survey after extensive clinical , laboratory and radiological follow-up. Per cent of 85 Positive Cases
Fibroid Infiltration Minimal Mod. Adv. . Far Adv. Fibrocalcific Changes Minimal Mod. Adv. Exudative Lesions Minimal Mod. Adv. . Other Diseases
. . 28 . 16 5· 8 1 2 7**
Per cent or Total Survey Cases (581 cases)
49
57.7
8.4
9
10.5
1.5
9
10.5
1.5
18
21.2
3.0
·1 active case of pulmonary tuberculosis in this group. ··2 active cases of pulmonary tuberculosis in this group. 0.5 per cent of 581 cases had active tuberculosis.
"
Vol. XXI
CHEST SURVEYS
OF THE
105
AGED
There were six patients known to have had active pulmonary tuberculosis at one time, but who had eventually been considered as arrested cases. Of these, two had undergone thoracoplasties and a third one had been re-admitted to the tuberculosis division as an active case. There remained 79 patients with chest lesions suspicious for pulmonary tuberculosis. All of these cases had serial 14 x 17 inch films repeated at six week intervals until activity was noted or until the lesion was considered static. History, physical examination and sputum studies were carried out in all but 17 cases. It was not possible to obtain sputa or gastric cultures on these cases because of their age, mental and physical conditions.
Results Of this entire group only three had positive cultures. Following complete evaluation over a 10 month period on the total group of 85 patients who had roentgen evidence of some type of pulmonary lesion in the initial survey, 64 were classified as having inactive tuberculosis. The remaining 18 had other diseases such as bronchiectasis, massive pleural calcifications and pneumonia. (See Table III) . It is worth noting that retakes in surveys of the aged are con siderably higher than in surveys of a general population. In the above surveys approximately 20 per cent of the patients were re-examined on 14 x 17 inch films as compared to the usual 3 or Table IV: Table shows marked increase in number of retakes required in examining old people on survey equipment. It also demonstrates the high percentages of lesions that must be regarded with suspicion necessitating long follow-up studies . In spite of such high percentages only 0.5 per cent of the cases in the survey showed active disease. Population Hagerstown. Md . 1948-49 Pet.
Total People Examined Total Retakes Requested Total Negative Retakes Total Cases Tuberculosis 90 (1.47) Minimal 27 (0 .14) Mod. Adv. 6 (0.03) Far Adv. TOTAL 123 Total Cases Other Diseases
*
Baltimore City Hospitals Infirmary Baltimore. Md 1949 Pet .
18,856 668 (3.5)
581 119 (20.5)
463 (2.4)
7 ( 1.2)
123 (0.6)
67 (11 .5)
47 (0.2)
45 ( 7.7)
38 (6.5 ) 24 (4.1 ) 5 (0.86) TOTAL 67
*Figures obtained through courtesy of Dr. P. S. Lawrence, Biostatistician, U.S.P.R.S.
106
BEACHAM AND MACHT
Jan., 1952
4 per cent re-examined in general surveys. Reasons for this may be classified as follows: A) Technical Difficulties : 1) Involuntary motion - Parkinsonism, deafness, weakness, "crankiness". 2) Positioning - Kyphosis, arthritis and other bony deformities. 3) Artifacts - patients conceal personal belongings under clothes. 4) Clerical-maintenance of order and line-up; patients give wrong names or forget their names; incontinence causes frequent leaving of line. B) Increased incidence of residue of diseases of earlier life-scars and fibrosis from pulmonary infections earlier in life are common. It is of interest to compare this survey of an aged group with one of an average population of all ages (Table IV) .
Discussion
The few articles which have appeared in the literature lead one to feel that a high incidence of active pulmonary tuberculosis might be found in a mass chest survey of an infirmary for the aged. One would think this to be especially likely in a public institution where all of the patients are indigent cases. The exact opposite proved to be the case. There was low incidence of active disease. The explanation probably lies in the fact that admission to the infirmary of this particular hospital is preceded by a screening physical examination at the Department of Welfare. A more careful history and a physical examination are then performed in the general hospital through which the patient is admitted to the home for the aged. In recent months, since the 1949 survey began, a routine admission chest x-ray fUm has become an established procedure. SUMMARY
1) Mass surveys of elderly persons in a home for the aged are difficult to carry out. 2) The incidence of old, inactive pulmonary disease is high. 3) Quite the opposite of other reports in the literature was discovered. The incidence of active pulmonary tuberculosis in the aged is very low in this group probably because of the careful screening admission examination. In this study only three active cases of tuberculosis were discovered and one of them was a known case already under observation.
Vol. XXI
CHEST SURVEYS OF THE AGED
107
4) The incidence of diseases, other than tuberculosis, is high. Especially common were lesions of the cardiovascular system. RESUMEN 1) Un trabajo en masa sobre la salud de los anctanos en asilos para ellos, es dificil . 2) La incidencia de tuberculosis antlgua Inactiva es alta. 3) Muy diferente en 10 encontrado en otras publ1caciones rue 10 que se descubri6. La Incidencla de tuberculosis pulmonar activa es muy baja en este grupo, probablemente debido a la cuidadosa selecci6n para la admisi6n. En este estudio solo se encontraron tres casos de tuberculosis y uno de ellos era un caso ya conocido bajo observaci6n. 4) La incidencia de otras enfermedades aparte de la tuberculosis es alta. Especialmente son comunes las lestones cardiovasculares. RESUME 1) Les examens systematiques des personnes agees placees dans les etabllssements de vietllards sont tres difficiles a mener a bien. 2) La rrequence de la tuberculose ancienne et inactive est tres etevee . 3) Les auteurs ont fait des constatations tout a fait opposees a celles qui peuvent etre relevees dans la litterature. La trequence de la tuberculose pulmonaire active est tres basse dans le groupe qui a ete examine. Ceci ttent sans doute au soin avec lequell'examen systematique est fait Iors de I'entree. Dans cette etude, on ne put mettre en evidence que trois cas de tuberculose active, et l'un d'entre eux etait deja connu auparavant et mis en observation. 4) La rrequence d'autres affections que la tuberculose est eievee. Les lesions de I'apparell cardio-vasculaire en particulier sont nombreuses. REFERENCES 1 Beacham, E. G.: "Tuberculosis Control Program in a Municipal General Hospital," Bull. U. 01 Md. Med. School, July 1949. 2 Medlar, E. M.: "The Incidence of Pathologically Significant Tuberculosis in Routine Necropsies in Private and Public General Hospitals," New York State J . Med., 47:582, 1947. 3 Medlar, E. M.: "Incidence of Tuberculous Pulmonary Cavities in Unexpected Deaths Investigated at Necropsy," Arch. Int. Med., 80 :403 , 1947. 4 Myers, J. A.: "Old Age: The Last Stand of the Tubercle Bacillus," Geriatrics, 3:197, 1948.
In the 1942 survey 670 persons had 35 mm . film inspections of their chests. All films were interpreted by a physician from the United States Public Health Service National Institute of Health, Division of Tuberculosis. In 1945 the survey was repeated. This time 636 persons were photofluorographed on 70 mm. film. All films were interpreted by a phthisiologist. In 1949, 581 inmates of the same group were surveyed on 70 mm. film, but this time the films were interpreted by a radiologist. The findings are summarized and compared in Table 1. There have been several recent papers illustrating variations in the interpretations of survey films depending on the ability, experience and degree of fatigue of the reader. The present report is also of interest because the same group of patients was surveyed three times, the films of each survey being read by a different type of specialist. The films of the first survey were read by an epidemiologist whose basic outlook was that of a clinician in the research field . The films of the second survey were read by a specialist in chest diseases who was interested primarily in tuberculosis, and who had probably had more experience with that disease than either of the two other readers. The films of the third survey were read by a radiologist who was not influenced from -Assistant Chief, Tuberculosis Division, Baltimore City Hospitals. tFormer Chief of Radiology, Baltimore City Hospitals. Now Chief of Radiology, Washington County Hospital, Hagerstown, Maryland. 102
Table I : Note "over-readin g" of films by clinician, "un der - reading" of films by phthisiologist and "mean-betw een -the- tw o" by ra diologist. 1942 U.S.P.H .S . M .D .
1945 Phthisiologist
1949 Rad iologis t
1942 U.S.P.H .S. M .D .
Number of C a s es
Total No. Chests Examined Healthy Ches ts Tuberculosis Abnormalities of Heart and Aorta Other Diseases
1945 Phth isiologist
x ~
Perce n t a ges
670
636
581
554
469
71.1
87.1
80.7
88
49
85
13.1
7.7
14.6
24
25
14
3.6
3.9
2.4
82
8
13
12.2
1.2
2.2
1949 Rad iolo gis t
M .D .
1942 U .S .P .H .B.
::I:
..,UJ I:'il
UJ
~<:
I:'il
><
0
1945 Pht hlslolog ist
1949 Rad iologis t
M .D .
Nu mb er of Ca s es
0
UJ
Table II : Sho wing break-down and comparison of findin gs no ted in posi tive cases in all three surveys. 1945 P h t his iologist
!2.
1949 R ad iologis t
476
1942 U .S .P .H .B.
<
"'.l
~
I:'il
>
P erc e n t a ges
0
Total Ches ts Examined Total No. Cases Thought to be Tuberculosis Minimal Tuberculosis Moderately Advanced Far Advanced Suspicious Lesion
670
636
581
88
49
85
22
16
18
17
2 46
I:'il
tl
13.0
7.7
14.6
38
3.2
2.5
6.5
24
2.7
2.7
4.1
3
5
0.3
0.5
0.8
13
18
6.8
2.0
3.1
0
c.>
BEACHAM AND MACHT
104
Jan., 1952
either the clinical standpoint or from the phthisiologist's viewpoint, but who initiated the survey with two objectives in mind: (1) To find active tuberculosis. (2) To compare the results of his survey with the others that had been performed previously. This description of the readers is given because many intangible factors are thus brought into the picture. It is interesting to note that the results show the epidemiologist "over-read" the films (71 per cent negative) , the phthisiologist "under-read" the films (87 per cent negative) and the radiologist hit a middle path (80.7 per cent negative) . Apparently the phthisiologist's more varied experience with tuberculosis enabled him to consider inactive or insignificant many lesions which the other two readers considered positive. The clinician found a significant percentage of other diseases (12.2 per cent cardiac enlargement, etc.) which the phthisiologist tended to ignore. However, again the radiologist took the "middle path" averaging 2.2 per cent positive cases. Those cases showing any type of inflammatory change in the lungs, regardless of apparent age of the lesion, were listed as being suspicious for tuberculosis of undetermined activity. They were further subdivided into four groups. Table II illustrates the breakdown of these findings. Cases having positive findings in the 1949 survey were referred to the medical service of the general hospital for careful study. Many had been seen there previously and already had undergone sufficient study to establish a final diagnosis. Table III: Final classification of cases of 1949 survey after extensive clinical , laboratory and radiological follow-up. Per cent of 85 Positive Cases
Fibroid Infiltration Minimal Mod. Adv. . Far Adv. Fibrocalcific Changes Minimal Mod. Adv. Exudative Lesions Minimal Mod. Adv. . Other Diseases
. . 28 . 16 5· 8 1 2 7**
Per cent or Total Survey Cases (581 cases)
49
57.7
8.4
9
10.5
1.5
9
10.5
1.5
18
21.2
3.0
·1 active case of pulmonary tuberculosis in this group. ··2 active cases of pulmonary tuberculosis in this group. 0.5 per cent of 581 cases had active tuberculosis.
"
Vol. XXI
CHEST SURVEYS
OF THE
105
AGED
There were six patients known to have had active pulmonary tuberculosis at one time, but who had eventually been considered as arrested cases. Of these, two had undergone thoracoplasties and a third one had been re-admitted to the tuberculosis division as an active case. There remained 79 patients with chest lesions suspicious for pulmonary tuberculosis. All of these cases had serial 14 x 17 inch films repeated at six week intervals until activity was noted or until the lesion was considered static. History, physical examination and sputum studies were carried out in all but 17 cases. It was not possible to obtain sputa or gastric cultures on these cases because of their age, mental and physical conditions.
Results Of this entire group only three had positive cultures. Following complete evaluation over a 10 month period on the total group of 85 patients who had roentgen evidence of some type of pulmonary lesion in the initial survey, 64 were classified as having inactive tuberculosis. The remaining 18 had other diseases such as bronchiectasis, massive pleural calcifications and pneumonia. (See Table III) . It is worth noting that retakes in surveys of the aged are con siderably higher than in surveys of a general population. In the above surveys approximately 20 per cent of the patients were re-examined on 14 x 17 inch films as compared to the usual 3 or Table IV: Table shows marked increase in number of retakes required in examining old people on survey equipment. It also demonstrates the high percentages of lesions that must be regarded with suspicion necessitating long follow-up studies . In spite of such high percentages only 0.5 per cent of the cases in the survey showed active disease. Population Hagerstown. Md . 1948-49 Pet.
Total People Examined Total Retakes Requested Total Negative Retakes Total Cases Tuberculosis 90 (1.47) Minimal 27 (0 .14) Mod. Adv. 6 (0.03) Far Adv. TOTAL 123 Total Cases Other Diseases
*
Baltimore City Hospitals Infirmary Baltimore. Md 1949 Pet .
18,856 668 (3.5)
581 119 (20.5)
463 (2.4)
7 ( 1.2)
123 (0.6)
67 (11 .5)
47 (0.2)
45 ( 7.7)
38 (6.5 ) 24 (4.1 ) 5 (0.86) TOTAL 67
*Figures obtained through courtesy of Dr. P. S. Lawrence, Biostatistician, U.S.P.R.S.
106
BEACHAM AND MACHT
Jan., 1952
4 per cent re-examined in general surveys. Reasons for this may be classified as follows: A) Technical Difficulties : 1) Involuntary motion - Parkinsonism, deafness, weakness, "crankiness". 2) Positioning - Kyphosis, arthritis and other bony deformities. 3) Artifacts - patients conceal personal belongings under clothes. 4) Clerical-maintenance of order and line-up; patients give wrong names or forget their names; incontinence causes frequent leaving of line. B) Increased incidence of residue of diseases of earlier life-scars and fibrosis from pulmonary infections earlier in life are common. It is of interest to compare this survey of an aged group with one of an average population of all ages (Table IV) .
Discussion
The few articles which have appeared in the literature lead one to feel that a high incidence of active pulmonary tuberculosis might be found in a mass chest survey of an infirmary for the aged. One would think this to be especially likely in a public institution where all of the patients are indigent cases. The exact opposite proved to be the case. There was low incidence of active disease. The explanation probably lies in the fact that admission to the infirmary of this particular hospital is preceded by a screening physical examination at the Department of Welfare. A more careful history and a physical examination are then performed in the general hospital through which the patient is admitted to the home for the aged. In recent months, since the 1949 survey began, a routine admission chest x-ray fUm has become an established procedure. SUMMARY
1) Mass surveys of elderly persons in a home for the aged are difficult to carry out. 2) The incidence of old, inactive pulmonary disease is high. 3) Quite the opposite of other reports in the literature was discovered. The incidence of active pulmonary tuberculosis in the aged is very low in this group probably because of the careful screening admission examination. In this study only three active cases of tuberculosis were discovered and one of them was a known case already under observation.
Vol. XXI
CHEST SURVEYS OF THE AGED
107
4) The incidence of diseases, other than tuberculosis, is high. Especially common were lesions of the cardiovascular system. RESUMEN 1) Un trabajo en masa sobre la salud de los anctanos en asilos para ellos, es dificil . 2) La incidencia de tuberculosis antlgua Inactiva es alta. 3) Muy diferente en 10 encontrado en otras publ1caciones rue 10 que se descubri6. La Incidencla de tuberculosis pulmonar activa es muy baja en este grupo, probablemente debido a la cuidadosa selecci6n para la admisi6n. En este estudio solo se encontraron tres casos de tuberculosis y uno de ellos era un caso ya conocido bajo observaci6n. 4) La incidencia de otras enfermedades aparte de la tuberculosis es alta. Especialmente son comunes las lestones cardiovasculares. RESUME 1) Les examens systematiques des personnes agees placees dans les etabllssements de vietllards sont tres difficiles a mener a bien. 2) La rrequence de la tuberculose ancienne et inactive est tres etevee . 3) Les auteurs ont fait des constatations tout a fait opposees a celles qui peuvent etre relevees dans la litterature. La trequence de la tuberculose pulmonaire active est tres basse dans le groupe qui a ete examine. Ceci ttent sans doute au soin avec lequell'examen systematique est fait Iors de I'entree. Dans cette etude, on ne put mettre en evidence que trois cas de tuberculose active, et l'un d'entre eux etait deja connu auparavant et mis en observation. 4) La rrequence d'autres affections que la tuberculose est eievee. Les lesions de I'apparell cardio-vasculaire en particulier sont nombreuses. REFERENCES 1 Beacham, E. G.: "Tuberculosis Control Program in a Municipal General Hospital," Bull. U. 01 Md. Med. School, July 1949. 2 Medlar, E. M.: "The Incidence of Pathologically Significant Tuberculosis in Routine Necropsies in Private and Public General Hospitals," New York State J . Med., 47:582, 1947. 3 Medlar, E. M.: "Incidence of Tuberculous Pulmonary Cavities in Unexpected Deaths Investigated at Necropsy," Arch. Int. Med., 80 :403 , 1947. 4 Myers, J. A.: "Old Age: The Last Stand of the Tubercle Bacillus," Geriatrics, 3:197, 1948.