Urinary tract infections (UTIs) in seniors are a complex issue. It is crucial for family caregivers to become familiar with the unique signs of UTI in the elderly. Without rapid diagnosis and treatment, UTIs can cause serious side effects like delirium and can even lead to kidney infections and sepsis.
The first thing to understand is that elders experience different symptoms compared to young or middle aged adults and those symptoms can be much more severe. Older adults, particularly those with dementia, may not realize there is an issue or be able to communicate their UTI symptoms to caregivers. Furthermore, fever and other physical symptoms like burning and urgency might not occur in the elderly at all.
UTI, Dementia and Delirium in the Elderly
In many cases, the only indicator that a senior has a UTI is an acute change in their mental status. This could present as unusual behavior changes, confusion or delirium that begins suddenly. It is important to distinguish delirium from dementia because the symptoms are very similar. Delirium is often a temporary change in brain function caused by a potentially reversible condition, such as an infection, hypoglycemia, medication side effects, etc. On the other hand, dementia is characterized by a chronic, progressive decline in mental status that may or may not be reversible, depending on the cause (e.g. Alzheimer's disease, Parkinson's disease, normal pressure hydrocephalus, B12 deficiency, hypothyroidism).
Diagnosing a UTI in a healthy senior can be difficult to begin with, but this task is even more challenging when an elder has dementia. It is possible to have UTI-induced delirium on top of preexisting dementia, and it would typically be characterized by a sharp decline (within hours or days) in awareness and cognition. Dramatic mood swings, delusions and behavioral changes may also be present. Of course, it can be tough to figure out what a patient’s baseline mental status is, as symptoms of Alzheimer’s disease and other forms of dementia can fluctuate widely. While it can be a struggle to get a loved one to go to the doctor and participate in appointments, both initial and ongoing cognitive testing is very important for monitoring the course of the disease and detecting other health issues.
In cases where an official baseline has not been established, a family caregiver or other individual who regularly interacts with the senior must monitor their cognitive function and behavior to determine what is “normal” and detect anomalies to the best of their ability. Otherwise, an elder may be presumed to have permanent symptoms of dementia when, in fact, they are experiencing temporary cognitive issues due to a UTI. A key distinction in determining whether delirium, agitation or confusion is caused by a UTI is whether treatment with antibiotics results in any improvement in mental status.
Curative and Preventative Treatments for UTI in Seniors
While some elders tolerate antibiotics well and recover quickly, others (with or without dementia) have such vulnerable immune systems that they suffer from recurring urinary tract infections. Fortunately, there are some things that can be done to minimize the recurrence of UTIs, such as testing for and treating other underlying conditions that may be contributing to infection.
Ensure Good Hygiene to Prevent UTI
UTIs are common among seniors with urinary incontinence and/or fecal incontinence. Prompt and proper toileting and continence care can minimize the likelihood of stool bacteria from entering the urethra and causing an infection. Always change soiled adult diapers as quickly as possible to prevent UTIs and skin irritation. Furthermore, female patients should never wipe from back to front.
Urinary Retention or Obstruction Can Cause UTI
Conditions such as prostate enlargement in senior males and neurological damage due to diabetes, stroke or multiple sclerosis (MS) may lead to urinary retention. When this happens, a senior is unable to completely empty their bladder and urine accumulates and stagnates within. This will eventually result in bacterial colonization (bacteriuria) and possibly UTI.
Urinary retention is diagnosed by measuring a senior’s post-void residual, which is the amount of urine that remains in the bladder after urination. To obtain a post-void residual measurement, a catheter is inserted through the urethra and into the bladder after urinating to drain any leftover urine. Sometimes an ultrasound machine can be used to take this measurement. A residual of 100 mL or more indicates that the bladder is not emptying properly.
If urinary retention is significant and/or cannot be corrected by treating the underlying condition (such as taking medications for enlarged prostate), intermittent catheterization is an option for ensuring complete voiding. However, catheterization must be done several times throughout each day, and that may not be feasible for an elderly patient, depending on their physical and mental health and their caregiver situation. Patients for whom intermittent catheterization is not an option may need a long-term urinary catheter, but these can also increase the risk of UTI. Ultimately, choosing the best plan of care involves weighing the risks and benefits of all options. Many seniors must use a long-term urinary catheter despise the increased risk of UTI because unmanaged urinary retention can cause more serious problems like kidney damage from urine backflow.
Another cause of incomplete voiding is urinary obstruction caused by a kidney stone stuck in a ureter (the tube that connects each kidney to the bladder). This blockage can contribute to recurrent UTIs and even kidney infections. Diagnostic imaging, such as an ultrasound or CT scan, can be used to diagnose a ureteral stone and treatment must usually be provided by a urologist.
Long-Term Antibiotic Therapy Can Prevent Recurring UTIs
When a senior experiences chronic urinary tract infections, it may be wise to ask their doctor about an extended prescription for antibiotics to treat the existing UTI and prevent the infection from coming back. To determine which antibiotic would be most efficient, a doctor will typically ask for a urine sample and send it to the lab for a urine culture. This will tell the doctor what types of bacteria are causing the repeated infections and what antibiotics these bacteria are already resistant to.
Commonly used preventative antibiotics include Bactrim (sulfamethoxazole/trimethoprim), Macrobid (nitrofurantoin), Keflex (cephalexin) or fluoroquinolones. While it can be very effective, low dose antibiotic therapy does have its limits. They are typically prescribed for anywhere from six months to two years, but there is the risk that the bacteria will eventually become resistant to treatment and the senior will need to find a new prescription that is more effective.
Topical Estrogen Creams Help Fight Recurrent UTI in Women
Topical estrogen creams are a viable treatment option for post-menopausal women who experience frequent UTIs. Natural estrogen levels plummet after menopause and low levels of this hormone have been linked to an increased risk of recurrent UTIs. Topical hormone therapy comes in gels, creams and vaginal suppositories and has been shown to help improve the female urinary tract’s natural defenses against invasive bacteria. While it is not as well-known or widely used as other therapies, it may be worthwhile to ask your loved one’s gynecologist or urologist about this treatment option.
Fluids, UTI and the Elderly
Some seniors are advised to drink plenty of fluids to encourage frequent urination, which can clear out any lingering bacteria and reduce the occurrence of UTIs. While staying hydrated can help “flush out the bladder” and prevent the development of kidney stones, liberal fluid intake may not be safe for all elderly people.
Seniors with congestive heart failure and/or advanced kidney failure must carefully monitor their fluid intake otherwise they may experience excess fluid buildup in the body, known as a volume overload. This extra fluid can cause swelling (edema) in the extremities and pulmonary edema that can make it difficult to breathe. Unfortunately, many elders struggle to drink adequate fluids, especially those with dementia. Drastically changing fluid intake should be discussed with a loved one’s physician first.
Alternative Treatments for UTI
Cranberry products are touted as a preventative measure against recurring UTIs, and some people swear by cranberry juice, pills and extracts. However, the medical community is still undecided as to whether this actually works. In other words, if cranberries are effective, the benefits may just be modest. For some, it's worth a try.
D-mannose is another supplement that is commonly used to help prevent UTIs. It is believed that D-mannose, a type of sugar, prevents bacteria from sticking to the lining of the urinary tract, allowing it to be more easily flushed out. The supplement may also help to balance both “good” and “bad” bacteria in the body.
Seniors are often managing multiple health conditions and taking several different medications. The best UTI treatment and prevention strategy for each individual may vary, and any of the above ideas should be discussed at length with one's medical providers.