This article is based on reporting that features expert sources including Halima Amjad, MD, MPH; Ruth Drew, MS, LPC; Amy Goyer
URINARY TRACT infections are an all-too-common, painful nuisance or worse for younger adults, particularly women. Unfortunately, you don’t necessarily outgrow UTIs in older age. For instance, more than 16% of women older than 65 reported having had a UTI within the past year, increasing to nearly 30% in women over 85, according to figures reported in the March 2014 issue of Infectious Disease Clinics of North America. UTIs also increase in older men.
As you age, UTIs may affect you differently. For some seniors, dementia can further complicate UTI prevention and detection.
Your urinary tract includes your urethra, bladder, ureters and kidneys. Urine, which is made in the kidneys, flows down through the ureter tubes to be stored in the bladder. When you pee, urine passes through the urethra, another tube, and out of the body. Cystitis is infection of the bladder, and urethritis is infection of the urethra. A urinary tract infection can involve any part of this system. Although most UTIs affect the lower urinary tract, advanced UTIs can involve the kidneys, which is more serious.
Staying one step ahead of urinary tract infections is a never-ending struggle for adult children of vulnerable older parents. “It’s something that caregivers grapple with all the time,” says Amy Goyer, national family and caregiving expert with AARP and author of “Juggling Life, Work, and Caregiving.” With UTI, she adds, “It’s sometimes very hard to detect.”
Goyer should know. She was the devoted caregiver for several family members, including her late mother, who was affected by stroke, and her late father, who had Alzheimer’s disease. Both developed UTIs despite their daughter’s best efforts, and both suffered lingering consequences.
For the last 15 years of her life, Goyer’s mother had constant urinary tract infections, with symptoms that outwardly seemed unrelated. “The first clue would be that she would fall,” Goyer says. At first, it wasn’t clear what was going on. Eventually, she was able to figure out that her mother was having difficulties related to UTIs.
With UTIs, particularly in older adults, Goyer says, it can make them feel weak or unwell, without being fully aware of what’s going on. For her mother, cognitive impairments from stroke limited her ability to express how she was feeling.
UTIs With a Difference
In a best-case scenario, an older person with a urinary tract infection receives a clear-cut diagnosis, gets the right treatment and soon recovers. However, it’s not always that simple.
Urinary tract infections often manifest themselves differently in older and younger adults. Younger people, more frequently women, with a UTI may experience burning pain when peeing. Older people with UTIs might instead describe discomfort and an overall feeling of unwellness.
Sudden confusion resulting from a UTI is a symptom more likely to affect seniors. Delirium – rapidly developed mental disturbances such as disorientation, hallucinations and rambling speech – is sometimes linked to UTIs in older people. But the connection is complicated, because mental changes like these may also be seen in dementia. Initially, it can be difficult to tease out whether these types of symptoms are caused by dementia or a UTI.
“With evaluation, the clinician should be able to pick up on the fact that it’s a fairly sudden change that, with treatment, should improve,” says Dr. Halima Amjad, an assistant professor of medicine at Johns Hopkins University School of Medicine who sees patients at the Johns Hopkins Memory and Alzheimer’s Treatment Center.
Family members provide valuable context. “Most important is getting a history from the family or friends to find out: How suddenly did the changes in memory or confusion develop?” Amjad says. “Because if there are sudden changes, that’s different from what we expect in dementia, which is more gradual changes.”
For the physical evaluation, patients are checked for fever. Blood tests and urine specimens can help reveal infection and pinpoint the source.
UTI Symptoms in Older Adults
Some UTI symptoms are similar for most adults, while others in older people are more subtle or vague. Here’s what you might experience or notice in an older person:
- Bladder discomfort.
- Peeing more frequently.
- Cloudy or discolored urine.
- Urgency: needing to get to the bathroom more quickly.
- Possible urinary incontinence.
- Generalized feeling of being unwell vs. specific sensation of burning or pain.
It’s important to recognize and evaluate UTIs, which can develop into sepsis – a life-threatening, body-wide condition – if the UTI cannot be controlled.
“Urinary tract infections are common among people living with Alzheimer’s and other dementias,” says Ruth Drew, director of information and support services at the Alzheimer’s Association. “This is partly due to age and partly due to increasing difficulty with hygiene and personal care.”
Detecting UTIs can be a challenge, Drew notes, particularly for someone whose ability to communicate their symptoms is impaired by dementia. In addition to the symptoms above, these are possible indications of a UTI you might also notice as a caregiver:
- Sudden changes in behavior, including confusion, aggression, hallucinations and paranoia.
- Increased difficulty urinating.
- Changes in urine smell.
- Darkening urine color.
“However, some UTIs are present without clear symptoms,” Drew points out. “If you are noticing such behavioral or symptomatic changes in you or your loved one, consult with a doctor.”
Dementia and UTIs
It can be real a gray area when urinary tract infections and confusion first appear: Is the UTI alone to blame, or is this possibly a foreshadowing of signs of dementia to come?
“All older people, to a certain degree, are at risk of becoming delirious with an infection, including a urinary tract infection,” Amjad says. “And we think that people who may have a vulnerable brain are more predisposed to becoming delirious with infections. So we certainly see patients who may have an infection becoming more confused.”
Sometimes the scenario goes like this: An older person who has an infection (such as a UTI or pneumonia) becomes confused. He or she sees a doctor, who prescribes treatment like antibiotics. “They improve with treatment, but within the next couple of years they’re diagnosed with dementia,” Amjad says. “We know that with dementia, changes in the brain, the pathology, are often happening years before we see any symptoms.”
For someone who’s developing Alzheimer’s disease, she says, that sudden episode of infection-related confusion might later be followed with actual clinical symptoms of dementia, like gradual memory loss.
Studies show that UTI can be a primary factor leading to hospitalization for people with Alzheimer’s, Drew says. “It’s less clear, however, exactly how UTIs may affect the progression of dementia itself, and how the treatment of UTIs might improve dementia symptoms,” she adds. While a few recent studies have explored these issues, she adds, more research is needed.
Repercussions from a severe UTI may worsen the trajectory of dementia, even after the initial infection clears up. With her father, Goyer says, “There was one week where he had a marked difference. He was still in that early to mid-stage of Alzheimer’s. He was just suddenly so confused and constantly anxious – and I noticed that he was going back and forth to the bathroom.” When they went to the hospital, it turned out that her father had a UTI along with inflammation of his prostate.
Although her father recovered somewhat from the resulting, precipitous drop in his mental status, Goyer says, “He never quite got back to where he was before that incident.” With dementia, she adds, any loss, trauma, illness like UTI or a fall can take a lasting toll. Forcaregivers, she says, “Part of the challenge is being aware of these things so you can prevent or treat them as soon as possible.”
It’s clearly important for people with significant UTIs to be treated. “Sometimes, there are patients who have a true infection – they have a fever, their blood work is abnormal, the urine looks grossly infected – where certainly treatment is warranted,” Amjad says.
However, caution is needed when in doubt. In some cases, treatment may not always be the best course. ‘Asymptomatic bacteriuria’ is a term for bacteria that while present in the urine, causes no clinical symptoms. “Occasionally, there can be just mild abnormalities, where patients may be getting inaccurately diagnosed or treated, where it would have been appropriate just to wait and see how the patient did over time,” Amjad adds. It could be that a patient’s increasing confusion is due to dementia’s progression rather than because of infection.
“In those cases, treatment could ultimately be more harmful,” Amjad explains. Antibiotics can have side effects like severe diarrhea in some patients. Bacterial resistance is a problem with antibiotic overuse, and is a factor in C. difficile infection, she notes. Clostridium difficile is a bacteria notorious for spreading widespread infections throughout hospitals and long-term care facilities.
“So the antibiotics aren’t without consequences, either,” Amjad says. “It’s more important to have an evaluation and careful consideration of: Is this a real infection we need to treat?”
When UTI treatment is warranted, time for recovery varies. Doctors expect antibiotic courses to be short, with the infection itself soon resolved, Amjad says. “But if someone has become acutely confused, that could take a bit longer,” she adds. For some, recuperation may take a month or more. “With an older person who’s become delirious for any reason, they may take some time to recover. And for some people, they may not recover completely back to where they were before.”
How to Help Prevent UTIs
You can take steps to reduce the risk of UTIs and prevent their complications. Here are some tips to follow for yourself or family members:
Stay hydrated. Drink plenty of fluid, especially water. Doing so will dilute your urine, make you pee more frequently and help flush bacteria from your urinary tract. Older people can lose their sense of thirst, Goyer points out, so you might have to be creative to encourage loved ones to drink more. Flavoring water with fruit like lemon, or using smaller, less daunting glasses, might help. (Serving water to her father in a shot glass seemed to work, Goyer says.)
Try cranberry juice. Some research supports drinking cranberry juice as an anti-UTI remedy, while other studies are inconclusive. However, cranberry juice might help and likely won’t hurt, as the Mayo Clinic website notes.
Watch for symptoms. In addition to changes in bathroom patterns and in the urine itself, follow up on more subtle signs of a possible UTI or other infections. With increased confusion, weakness or fatigue, or a fall, seek an evaluation sooner rather than later.
Keep up with hygiene. Promoting good hygiene is a common-sense measure, but it can be an ongoing challenge for caregivers. Hygiene is not always a factor in UTI development or prevention but may contribute. “Clearly, if someone is incontinent and they’re wearing adult briefs, there can be bacteria growth if those briefs aren’t changed frequently,” Goyer says.
Talk to a specialist. Geriatricians – doctors whose practices focus on older adults – frequently treat patients with both UTIs and dementia. Urologists are also experts. Nurses, who can be excellent resources, often suggest practical approaches for dealing with incontinence, Goyer says. Specialists called urogynecologists, who have training in both women’s health and urology, help women with conditions including UTIs. Ask these specialists about innovations in care that could improve quality of life for your loved one.