Any guide to urinary tract infections (UTIs), should begin by clearly stating that the first step in the treatment of UTI is a visit to the doctor if symptoms are mild or a trip to the Emergency Room if symptoms are severe. This guide is not intended to replace or contradict the advice of a physician. What follows is intended only for informational purposes. The best way to use this information is to help you communicate better with the doctor.
Both the medical community and popular culture frequently blame increased confusion or mental status changes on UTIs. And we will discuss why this is probably a bad idea, but before we do we will remind caregivers that a rapid change in mental status is a potential sign of a stroke and therefore a medical emergency that requires a 911 call! TIME IS BRAIN.
This article hopes to explain urinary tract infections. First, we will review the urinary system to see what it is and how it is supposed to work. Then we will discuss what a UTI is, and what it is not. Next, we will discuss how UTI symptoms can be different in people with dementia and will describe how UTI is diagnosed. Finally, we will review some of the treatments your doctor may prescribe and some of the ways that you can try to prevent the next infection.
A Caregivers Guide to the Anatomy of the Urinary System
Our kidneys – we have two – are located at the level of our lower ribs towards the back in our flanks. Our kidneys filter toxins from our bloodstream. The kidneys use water from our blood to carry waste products out of our circulation. The kidneys then collect this combined water and toxin mixture – urine – and funnel it into a tube called the ureter that leads to our bladder. Because we have two kidneys, we also have two ureter tubes. Each ureter tube then drains into the funnel-shaped balloon-like organ called the bladder. Finally, the neck of the bladder funnel connects to a tube called the urethra (short in females, longer in males) which leads to the outside world.
The bladder’s job is to store urine until the brain decides the time is right for it to empty. When the bladder is trying to store urine, it relaxes its walls so that it can stretch and it closes the neck of the funnel area which leads to the outside of the body. That way we don’t constantly leak urine everywhere!
When we decide it’s convenient, our brain tells our bladder to empty itself. When emptying, the bladder walls squeeze inward and the tip of the funnel is opened. Urine is allowed to flow into the urethra and then out of our bodies and – hopefully – into the toilet.
A Definition of Urinary Tract Infection for Caregivers
A UTI is an infection of the urinary system: it can involve either the bladder or one of the kidneys. A bladder infection is caused by bacteria reaching the bladder from the urethra. In females the urethra is shorter, so bacteria doesn’t have as far to go in order to reach the bladder. This is why UTIs are so much more common in women than men. If the bladder is infected for long enough, eventually bacteria will find their way back up the ureter tubes all the way to the kidneys.
Note, simply having bacteria in the urine is not the same thing as having a bladder or kidney infection. If someone feels totally fine, but happens to have bacteria in the bladder, this is called “asymptomatic bacteriuria.” This does not require treatment with antibiotics unless the person develops symptoms. In fact, using antibiotics too frequently opens up the possiblity for really awful complications like C. Diff Colitis. (Gordon, 2013)
Fortunately, most UTIs remain in the bladder and are easily treated with antibiotics. However, when bacteria reach the kidneys things are much more serious. So, it is important to pay careful attention to any changes in your elderly loved one’s urinary habits so that infections can be treated before they become more severe.
What are the types of UTI and how do you treat them?
There are four major types of urinary tract infections that require specific treatment.
Lower Urinary Tract Infection
When someone has a lower urinary tract infection, only their urethra or bladder is infected (or both). Lower UTIs can be diagnosed through a simple urine drip test. Some of the major symptoms of such UTIs are:
- Dysuria – burning or painful sensation when peeing,
- Urgency – the immediate need to pass urine,
- Bloody or cloudy urine,
- Bad-smelling urine,
- The feeling that you are not urinating fully,
- Lower abdominal pain,
- Urinary incontinence – when urine leaks out involuntarily, and
- Confusion or delirium that develops extremely quickly (one or two days).
To see which bacteria are infecting the urinary tract, a urine sample is sent to a laboratory. This sample is usually requested by the doctor if the senior has had two or more UTIs recently, has any abnormalities concerning the urinary tract, or there is blood in the urine during the dip test. Along with taking antibiotics for the course of three days, treatment for lower UTIs can involve pain medication that helps the patient be more comfortable.
If the patient is male, prostate disease or other conditions may be the cause of a UTI. For male patients, treatment may require visiting a urologist for further inspection. Urologists may suggest ultrasound scans of the bladder and kidney, rectal examinations for ensuring there is nothing wrong with the prostate gland, blood tests, or a cystoscopy that uses a camera to look inside the lower urinary tract.
Upper Urinary Tract Infection
When someone has an upper urinary tract infection, their kidneys and ureters are infected (sometimes, the urethra and bladder may be infected as well). This type of UTI is far more dangerous since it can lead to kidney damage. If left untreated, an upper UTI can be life-threatening, and sometimes bacteria show up in the patient’s blood. Some of the major symptoms of such UTIs are:
- Those symptoms mentioned for the lower UTI,
- Flank/back pain on one side or rarely both,
- Tenderness between the ribs and hips,
- Shaking chills,
- Fever (over 38.0 C or 100.4 F)
- Nausea and vomiting.
Since this type of UTI is more serious, antibiotics may be prescribed for 7 – 14 days. In some cases, a doctor may send the patient to the hospital so that antibiotics can be given by IV or for close monitoring.
Indwelling catheters, otherwise known as foley catheters, are tubes designed to remain inside the bladder and allow urine to drain into a bag outside the body. When inappropriately placed, these catheters significantly increase a person’s risk for a urinary tract infection. These catheters have strict criteria for use, and doctors and nurses have made conscious efforts to avoid using them unless they are absolutely necessary. If your loved one has an indwelling catheter, you should make sure the doctor is aware of the reason it was placed. INDWELLING FOLEY CATHETERS SHOULD NOT BE PLACED SOLELY FOR INCONTINENCE.
It is very likely that if someone is using an indwelling catheter, they will have bacteria in the urine when a urine culture is performed. So in these cases, it is important to avoid treating asymptomatic bacteriuria. In addition to the symptoms listed above, a patient with an indwelling catheter may experience bladder spasms. Bladder spasms can be identified by leakage of urine around the catheter (once the catheter has been confirmed to be unkinked and in the proper position).
So, it is best for you and you’re elderly loved one to avoid these, if possible. If someone has a problem of urinary retention they must be evaluated by a Urologist. A urologist should recommend, whenever possible, that a caregiver learn how to perform clean intermittent catheterization (CIC). A urologist will often encourage the bladder to be catheterized at least 4 times a day.
If frequent infections are a consideration the Urologist may want catheterization to be done more frequently. Many people initially object that this method of routine catheterization can be very uncomfortable for someone with dementia. While this is true, it ignores the discomfort people suffer from having a constantly indwelling catheter. Unless death is very close, it will almost always be more comfortable to do CIC rather than resorting to a longterm indwelling catheter.
If your elderly loved one has to use a catheter and displays any of the above-mentioned symptoms, you should send a urine sample to the lab and the doctor will likely start the patient on a course of antibiotics immediately.
A Recurrent UTI (rUTI) according to the American Urological Association is diagnosed after “two separate culture-proven episodes of acute bacterial cystitis and associated symptoms within six months or three episodes within one year.” The AUA offers guidelines on the treatment of these infections in women. These recurring infections require treatment beyond just taking antibiotics for the present infection.
In women, a Urologist or primary doctor may recommend treatment involving topical estrogen cream to help the vaginal tissue improve its ability to mount defenses against bacteria. More rarely, a daily antibiotic will be given. At minimum the patient should be referred for evaluation and testing by a Urologist. Constipation should be identified and treated.
A Caregivers Guide to Recurrent UTIs
- Urine stasis: Urine does not normally contain bacteria. However, as people age and the flow of urine becomes weaker, the risk of bacteria increases significantly.
- Catheters: A catheter is a tube that is placed into the bladder to help urine empty into a bag. This often results in bacteria in the urine but does not need treatment unless UTI symptoms begin to show.
- Poor hygiene: As mentioned before, women are more likely to get UTIs. Incorrect toilet paper wiping – going from back to front – was once thought to cause UTI but with better research that’s no longer believed to be the case. Now it’s just recommended that men and women bathe frequently.
- Sexual activity: Sex is also more likely to cause UTIs in some women.
- Dementia: since it becomes more difficult to maintain personal hygiene with a dementia diagnosis, the risk of UTIs increases.
- Structural changes in the urinary tract: abnormal changes in the physical shape of the tract can lead to difficulties with passing urine and cause UTIs.
- Weakened immune system: diabetes or other diagnoses can weaken the senior’s immune system and increase the risk of a urinary tract infection.
UTI in Dementia Patients
Unfortunately, dementia patients may not be able to communicate with you how they feel, so it is important that you know what changes to look out for and when to seek help. Pain while urinating or refusal to urinate are the most important early signs. Later signs include fevers, chills, and evidence of systemic illness. These signs require medical evaluation right away and necessitate a trip to the emergency room. Finally, the new onset of urinary retention can be caused by infection and should also be evaluated by urine culture.
A Caregivers Guide to UTIs and Confusion
It’s vital that if your family or friends see changes in your elderly loved one, they seek help immediately. We’ve said this many times, but sudden changes in mental status are an emergency and should be treated as a stroke until a stroke is ruled out. TIME IS BRAIN.
The diagnosis of an uncomplicated bladder infection is almost never a sufficient explanation for a change in mental status or delirium. This is one of the most common misdiagnoses in medicine. If a doctor tells you that a urinary tract infection is the cause of a loved one’s confusion, then we encourage you to respectfully show them the following excerpts (links to the full sources provided).
“We recommend that, in evaluating elderly patients with delirium, all clinically plausible etiologies be considered, including a change of environment such as hospitalization, especially in those with baseline cognitive impairment. A reflexive examination of the urine in delirious elderly patients, with an end of the search for explanations, if the urine is abnormal, is simply not sufficient and, based on our review, has no sound scientific justification.” (Balogun, 2013)
How can caregivers reduce the risk of a UTI?
There are several ways to avoid UTIs in patients with dementia.
Call the doctor and whenever there is a concern for infection obtain a clean, (and in the case of incontinent women, a catheterized) urine specimen for culture whenever possible. Just because a dipstick is positive, does not always mean there is an actual infection. UTI is very common but it is still over-diagnosed and over-treated. Often, irritative bladder symptoms may be due to other problems like constipation, poor hygiene, holding behaviors, or attempts to urinate forcefully. Often, Urologists will wait until there are actual culture-proven infections before starting preventative antibiotics.
Ask your doctor if a referral to a Urologist might be helpful. Doctors are human – and often a simple nudge in the form of a question can be helpful to necessary to avoid doing the same thing over and over.
Ask your doctor if it is okay to increase fluid intake. As we’ve discussed elsewhere, the body’s ability to manage large changes in fluid intake weakens as we age. So you want to ask the doctor before you make changes to an elderly person’s fluid intake. That said, the more often a person flushes the bladder out, the less time there is for bacteria to multiply into a number large enough to infect the bladder or to climb back upwards toward the kidneys. If your elderly loved one is battling diabetes, make sure to avoid sugary drinks.
Avoid holding urine in the bladder for too long. – Remind the person you are caring for to use the bathroom regularly. Holding urine can be a major cause of a UTI. When we are little, the first thing we learn how to do in order to avoid wetting ourselves is to hold our urine. We don’t learn how to comfortably let our bladder empty itself over a toilet until a little later. For both children during potty training or elderly people with neurological problems like dementia, a timed voiding schedule can be a major help. We recommend a trip to the bathroom to empty the bladder be done 7 times a day or more if needed.
Maintaining good hygiene – Make sure that your senior’s lower body is cleaned at least once a day using unperfumed soap. Do not use talcum powder. Placing wet wipes in the bathroom may also help encourage good hygiene in patients with dementia.
For any other questions concerning UTIs in the elderly diagnosed with dementia, you can view the sources below or reach out to your trusted medical professional.
- Urinary tract infections and dementia, Alzheimer’s Society, https://www.alzheimers.org.uk/get-support/daily-living/urinary-tract-infections-utis-dementia
- Types of UTI and how they are treated, Alzheimer’s Society, https://www.alzheimers.org.uk/get-support/daily-living/types-of-UTI-dementia
- Gordon, Lesley B et al. “Overtreatment of presumed urinary tract infection in older women presenting to the emergency department.” Journal of the American Geriatrics Society vol. 61,5 (2013): 788-92. doi:10.1111/jgs.12203
- Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline (2019), https://www.auanet.org/guidelines/guidelines/recurrent-uti
- Time Is Brain—Quantified, https://www.ahajournals.org/doi/full/10.1161/01.str.0000196957.55928.ab
- Balogun, Seki A, and John T Philbrick. “Delirium, a Symptom of UTI in the Elderly: Fact or Fable? A Systematic Review.” Canadian geriatrics journal : CGJ vol. 17,1 22-6. 5 Mar. 2013, doi:10.5770/cgj.17.90