Urinary tract infections in elderly people with dementia are a complex issue. The first thing to understand is elders with UTIs may have different symptoms compared to young or middle aged adults. The elderly, particularly those with dementia, may not be able to tell you about urinary burning, increased urinary urge, or lower abdominal pain that is often reported in younger adults with UTIs. Furthermore, fever might not occur in the elderly.
Sometimes, the only thing noted for UTIs in the elderly is an acute change in mental status, which is known as delirium. It is important to distinguish delirium from dementia, because delirium involves a short-term mental status change (over the span of hours or days) that is caused by a potentially reversible condition (such as infections, hypoglycemia, medication side effects, etc). On the other hand, dementia represents a more chronic mental status change (over the span of months to years) that may or may not be reversible, depending on the cause (e.g. Alzheimer's, Parkinson's, B12 deficiency, hypothyroidism, etc).
It is possible to have UTI-induced delirium on top of preexisting dementia, and it would be characterized by a sharp decline (within hours or days) in mental status from the patient's prior baseline mental state. Of course, in a person with dementia, it can be challenging to figure out what the baseline mental status is. To do so requires someone who is in frequent contact with the person with dementia and spends enough time to determine the baseline mental status so that delirium can be detected when it occurs. Otherwise, the elder may be presumed to have chronically altered mental status from dementia when they actually temporarily altered mental status from a UTI-induced state of delirium.
On the flip side, there is a subset of people (such as diabetics, patients with indwelling catheters, etc.) who may have chronic bacteria in the urine (bacteriuria) that generally has no visible symptoms and does not typically require antibiotic treatment. However, these people may get constantly treated for "UTI" that seems to return all the time after the short-term antibiotic course is finished.
A key distinction in determining whether altered mental status in an elder is caused by UTI is whether treating the UTI results in any improvement in mental status. This helps distinguish whether the elder is having recurring delirium from UTI versus something else (e.g. delirium due to another cause or chronic dementia.)
If the elder (with or without dementia) is getting recurrent delirium from UTIs, there are some things that can be done to minimize the recurrence of UTIs.
- Ensure good hygiene. If the patient suffers from urinary incontinence. Staying in a soiled diaper for too long or wiping the wrong way (in a female patient) can result in stool bacteria going up the urethra to cause a UTI.
- Make sure urinary retention or obstruction is not an issue. An elderly male may have enlarged prostate, or a diabetic may have neurological impairment of the bladder, resulting in urine stagnating in the bladder, which will eventually result in bacterial colonization (bacteriuria) and possibly UTI. This can be checked by a nurse obtaining a post-void residual, which is the amount of urine left in the bladder after urinating. To check a post-void residual, a catheter is inserted in the bladder after urinating to drain out any leftover urine in the bladder.
A "post-void" residual of over 50 mL of urine is significant for urinary retention, which increases the risk of UTI. If urinary retention is significant and/or cannot be corrected with medication (such as taking prostate medications for enlarged prostate), intermittent catheterization is an option. However, intermittent catheterization must be done at least several times a day (4 to 6 times ideally), and that may not be logistically feasible for all elderly patients depending on their condition and their caregiver situation. In those cases, they may need a long-term urinary catheter, but the presence of a long-term urinary catheter can increase the risk of UTI. So why have a long-term urinary catheter if UTI risk is increased? Because not having a urinary catheter results in urinary retention which increases UTI risk and cause potential kidney damage from urine backflow.
Another cause of urinary obstruction could be a kidney stone stuck in a ureter (the tube between the kidney and bladder) resulting in urinary obstruction causing recurrent complicated UTIs (kidney infections in those cases). An imaging study, such as an ultrasound or CT scan would help figure that out, and if confirmed, a kidney stone would be managed by a urologist.
- Low dose antibiotics can help. They significantly reduce the recurrence of UTIs. What antibiotic to use depends on the situation, such as what type of bacteria are frequently recurring and what antibiotics are the bacteria already resistant to. Commonly used preventative antibiotics include Bactrim, nitrofurantoin, cephalexin, or fluoroquinolones. The limitation of the low dose antibiotic strategy is the bacteria potentially becoming resistant to the antibiotic over time.
- Consider topical estrogen creams for post-menopausal women. There is evidence of usefulness in this strategy by preventing vaginal dryness and positively reshaping the vaginal flora to help prevent recurrent UTI. It is not as commonly used for various reasons, but unless the elder has had breast cancer, it is a possibility to consider.
- Drink plenty of fluids . This includes urinating frequently can help reduce recurring UTIs. While this can help "flush out the bladder" to help prevent UTIs (and especially useful to prevent kidney stones), liberal fluid intake may not be safe for all elderly people – especially those with one of two conditions: congestive heart failure or advanced kidney failure. In these people, drinking too much fluid can result in excess fluid buildup in the body, known as a volume overload. The extra fluid could build up in the legs and even the lungs. Furthermore, an elderly person may be too far demented to be able to drink plenty of fluids anyway. There are a number of practical considerations that could make this option impractical for the elderly patient with dementia.
- Cranberry juice is touted as a preventative measure against recurring UTIs. The jury is still out whether this actually works or not to prevent UTIs. In other words, it may or may not work, and if it does, it may just have a modest effect; but for some, it's worth a try.
- Probiotics may help. Especially in women if they are administered vaginally (oral versions have not proven effective for UTI prevention), but the studies are limited on the use of vaginal probiotics to limit UTIs. Again, for some, it's worth a try, but ask your doctor about this option before trying it.
The best strategy for each individual's situation can vary, and any of these ideas should be discussed with one's medical providers. Hopefully, this article helps give you an idea of what to talk to your (or your loved one's) health care providers about, regarding the issue of frequent UTIs in the elderly patient with dementia.