Urinary Tract Infections in the aging population

The rate of urinary tract infection rises in both sexes as they age (Cove-Smith & Almond, 2007). In younger populations the infections are more prevalent in women (Petersen, 2016). However, the reasons for UTIs change as the individual ages, as does the potential for hospitalization and the risk for sepsis.

Symptoms for UTIs can also be different among those over 65, presenting difficulty in diagnosis and treatment. Symptoms for UTIs in the elderly (65 years+) can include increased urge to urinate, fever, dysuria (painful urination), pain and tenderness in the pubic or lower back, dizziness and trouble thinking clearly (De Vecchi et al., 2013). Unfortunately, many of the elderly also suffer from incontinence, pain in the lower back, poor balance and increased difficulty thinking clearly even absent of neurological deficits or diagnosis.

Doctors are likely to test for UTIs only when there are at least two symptoms present and often do not take balance, dizziness or cognitive impairment into consideration. Fever is often not involved if the infection is isolated to the bladder or urethra. Cognitive impairment can also mean a delay in the individual being aware of the symptoms they have and sharing them with a health care professional.

Asymptomatic bacteriuria is present in as many as 16%-18% of women over 70 although they may have incontinence, frequent urge and pyuria (white blood cells in the urine) (Mody & Juthani-Mehta, 2014). Asymptomatic bacteriuria is generally left untreated and clears up on its own within days. The difference in diagnosis for asymptomatic bacteriuria and UTI lies strictly in the physical symptoms presented.

Risks for UTIs increase as we age due to incontinence, failure to void the bladder completely due to weakened muscles, diabetes, catheterization, and general declining health. Those who are in care facilities, rehabs or nursing homes are at increased risk for multi microbial infections as well as drug resistant strains of microbes increasing their risk above and beyond aging. In younger populations the majority of UTIs are cause by Escherichia coli, but in the aging population there are often more than one microbe present. In a study done in Italy Aetiology and antibiotic resistance patterns of urinary tract infections in the elderly: A 6-month study they identified 393 micro-organisms in just 328 infections in nursing homes. The microbes causing infection are also more likely to be resistant to antibiotics. The treatment of UTIs in these locations must take into consideration known resistant bacteria in their facility to personalize treatment plans. Frequent antibiotic use increases resistance as well, bringing the need for that to be considered in the antibiotic regimen prescribed. That is also why asymptomatic bacteriuria is not treated.

Treatment is as much about prevention in the aging population. Catheters are frequently overused in care facilities. Limiting catheter use lowers the risk for UTIs. There have been no successful methods for preventing colonization of bacteria with catheter use. Within days, even a closed system catheter has a 50% of colonization. 45-75% of all hospital acquired UTIs can traced back to catheterization. Avoiding catheterization is preferable when possible. Women can use a topical estrogen therapy to lower the pH of the vagina, thereby limiting colonization Gram negative microbes by increasing the colonization of lactobacilli. Cranberry juice can be helpful and treating asymptomatic bacteriuria before catheterization when possible.

Doctors often tell patients with incontinence to avoid liquids after a certain time in the evening to avoid involuntary urination or waking to urinate during the night when they are sleeping. Many people with incontinence limit their fluid intake completely, not just in the evening. This increases their risk for UTIs and should be discussed with all elderly.

UTIs often clear up on their own, and even without antibiotic treatment can have symptom improvement within a week up to 50% of the time. Doctors should consider delaying a treatment while waiting for confirmation when the physical symptoms of incontinence and increased urge, as those two symptoms can be attributed to many causes in the elderly. Supportive treatment such as increase fluid intake is appropriate during the wait for laboratory confirmation. 3 day antibiotic treatments have shown equally effective as 7 day treatments and have a higher compliance rate, making them a better option baring resistant strains that require specific antibiotics.

Diagnosing a UTI in the aging population can be challenging, and treating them in community living situations must be individualized for best outcomes. Managing the muscle atrophy common to the urinary system would be one of the easiest ways to limit infections. Complete voiding would prevent colonization in the bladder. Incontinence brings a risk of colonization in absorbing pads. Limiting use of catheters and treating based on the specific bacteria would also increase positive treatment outcomes in community housing environments.

References

Cove-Smith, A., & Almond, M. K. (2007). Management of urinary tract infections in the elderly.

Trends in Urology, Gynaecology & Sexual Health, 12(4), 31–34. doi:10.1002/tre.33

De Vecchi, E., Sitia, S., Romano, C. L., Ricci, C., Mattina, R., & Drago, L. (2013). Aetiology and antibiotic resistance patterns of urinary tract infections in the elderly: A 6-month study. Journal of Medical Microbiology, 62(Pt_6), 859–863. doi:10.1099/jmm.0.056945-0

Mody, L., & Juthani-Mehta, M. (2014). Urinary tract infections in older women. JAMA, 311(8), 844. doi:10.1001/jama.2014.303

Petersen, D. (2016). Nat 211: Anatomy and Physiology II. Portland, Oregon: ACHS.

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