Urinary Tract Infection in the Elderly: Important things to Remember

Aging causes more than just wrinkles and gray hair. It affects the whole body from teeth to the immune system. These changes affect how health professionals assess and screen illnesses, from infections to mental health. 

When working with elderly patients always remember how the various systems in the body start to change. Here’s a quick overview:

Cardiovascular

Stiffening of the blood vessels, and arteries making it more difficult for the heart to pump blood through them. The heart muscles change and adjust to the increased workload and can increase the risk of high blood pressure and other cardiovascular problems. ( strokes, blood clots).

Bones, Joints and Muscles

Bones shrink in size (prime reason for elderly “shrink”) and density. This also causes a weakening in the bones which causes an increased risk for fractures. Muscles lose strength, endurance and flexibility  These changes also affect coordination, stability and balance. 

Digestive System

There is an increased risk for constipation, due to lack of exercise, lack of fluid intake, low fiber diet, medications, and medical conditions such as diabetes.

Bladder and Urinary Tract

Bladder becomes less elastic which increases the urge to urinate. Weakening of bladder muscles and pelvic floor muscles. This makes it difficult to empty the bladder completely or ability to control the bladder resulting in bladder incontinence. With men enlarged prostate contribute to urinary issues. Medical conditions of diabetes, metabolic syndrome, nerve damage, medications, and caffeine affect bladder and urinary health.

Cognitive and Mental Function

Memory and thinking skills are affected because of the age related changes to the brain. Changes in conceptual reasoning, memory, and processing speed, all decline over time. There's slower inductive reasoning, slower problem solving, diminished spatial orientation, as well as decrease in perceptual speed.

Eyes, Ears and Mouth

Age related changes in the ability to focus on objects close up, increased sensitivity to glare and decreased ability to adapt to varying levels of lights. The eyes lens becomes more cloudy or clouded (cataracts). Hearing becomes diminished, and increased difficulty hearing high frequencies and difficulty following conversations in a crowded room. Gums pull back from teeth, making teeth more vulnerable to decay and infection.

Skin

In ageing, the skin becomes thin, and less elastic. Skin becomes more fragile and the fatty tissue just below the skin decreases . Skin starts to bruise easier, and there is less production of natural oils. Skin wrinkles and age spots develop as well as small skin growth known as skin tags.

Metabolism

Metabolism decreases typically resulting in weight gain.

Sexualtiy

Health issues, decreased testosterone for men, and estrogen for women can affect sexual activity. Any health condition can affect sexual health such as diabetes, high blood pressure, decrease in hormones, depression, and anxiety.

Immune system

The immune system is slower to respond, there is an increased risk that the eldery do not respond as effectively to vaccines because of these changes. Elderly are at an increased risk to develop autoimmune disorders. This is where the immune system mistakenly attacks and destroys healthy body tissues.

The body takes more time to heal, and there is also a decrease in immune cells.The immune system is also decreased in its ability to detect and correct cell defects and there is also an increased risk for cancer.

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Urinary Tract Infection in the Elderly

As you can imagine, a common but dangerous infection of getting older is a urinary tract infection. 

A urinary tract infection is when bacteria gets into the urethra and travels up into the bladder and kidneys. Urinary tract infections tend to increase with age because of so many bodily changes.

Unfortunately, it’s difficult to diagnose in the elderly. Most elderly have bacteriuria in their urine and rarely require antimicrobial treatment. Bacteriuria is often a result of the aging process and is associated with hormonal changes.

Patients with the following diseases/ailments are more at risk for urinary tract infections:

Diabetes (Type 2) 

Type 2 develops when the body becomes resistant to insulin or when the pancreas is unable to  produce enough insulin. High blood glucose levels can increase the risk of urinary tract infections, it also affects blood flow, nerve and sensory function.

Parkingtons disease, Alzheimer's disease

Often because of having to wear incontinence briefs and if not changed often enough could cause an infection.

Other risk factors

History of urinary tract infections, dementia, cather use, bladder incontinence, and prolapse bladder.

In females:

Estrogen deficiency, estrogen may help protect the vagina from the overgrowth of E. Coli and when there is a decrease in estrogen (typically due to menopause) it can increase a female's risk of an infection.

In Males:

Bladder stones, kidney stones, an enlarged prostate, and bacterial prostatitis (which can cause recurrent infections that affect the prostate which results in swelling and inflammation). 

Weakened Immune System

The immune system is unable to mount a response to the infection. There is a reduction in the production of T and B cells which impacts the ability of the lymphocytes to effectively respond to infection and increases the potential for urinary tract infections or other illnesses.

Weakening of the Bladder Muscles and Pelvic Floor

Both can lead to increased urinary retention (incomplete emptying of the bladder) and incontinence. Incontinence is at an increased risk due to the close contact of incontinence pads and other incontinence products with their skin. These products introduce bacteria into the urethra. 

Other Causes:

• Bowel Incontinence
• Immobility ( lying in bed for extended periods of time)
• Surgery of an area around the bladder

 

Signs and Symptoms of a Urinary Tract Infection in the Elderly

• Urethral burning with voiding and pelvic pain
• Frequent urination
• Urgency (frequent and urgent need to urinate)
• Fever 
• Chills
• Urine with abnormal colour 
• Sudden confusion
• Delirium (quick onset)
• Sudden and unexplained change in behaviour
• Increased confusion, agitation, and withdrawal
• Feeling of pressure in the lower abdomen or pelvis
• Cloudy, thick, or odorous urine
• Blood in urine
• Fatigue 
• Nausea and or vomiting
• Impaired motor skills/loss of coordination (when not present prior)
• Dizziness 
• Inability to perform common daily tasks such as dressing, eating, ADLs (not present prior)
• Acute behavioral and functional changes (often are only symptoms present in the elderly)
• Hallucinations (in some) 
• falling

 

How to Diagnose Urinary Tract Infection in the elderly 

If you suspect that your patient may have a urinary infection there are a variety of methods to confirm the diagnosis. One, or all, of the following may be utilized:

Urinalysis:

This tests the urine for infection by checking the appearance and concentration and content of urine.

Tests for sugar, blood, acidity PH

Specific gravity, concentrated particles, protein, bilirubin, nitrates, leukocytes, (Diptest).

Ultrasound

Used to check bladder and kidney irregularities that may require treatment.

X-ray

Helps highlight and monitor kidney stones, tumors, that can affect urine flow, causing pain, and potential infections. It also highlights the urethra, bladder, and kidneys.

Cat Scan

Provides clear three dimensional images of the urinary tract and can detect infections,  stones, cysts and tumours.

Culture and sensitivity test:

This test can detect bacteria in the urine. It can identify the microorganism that's causing the urinary tract infection and help determine the necessary antibiotic to resolve it. A urine sample is collected using the most common method of “mid-stream clean catch” to avoid contaminating the sample.

Treatment of Urinary Tract Infections

Treatment of urinary tract infections usually consist of antibiotics as well as supportive measures to treat and deal with the accompanying systems of the infection itself. Elderly patients should also be monitored for side effects of antibiotics. The side effects consists of fever, rash, diarrhea, nausea, headache, tendon ruptures, (rare) and nerve damage.

Common treatments:

• Drinking plenty of fluids
• Pain medication 
• Changing incontinent pads frequently
• Monitor for side effects of antibiotics
• Monitor for changes in cognition, behavior
• Medication for increased anxiety, agitation
• Health teaching in prevention of urinary tract infections (if cognitive abilities are not impaired)

Complications can arise if the urinary tract infection goes untreated, and symptoms are not  recognized early on. The following is a list of potential complications.

Permanent Kidney Damage

Untreated urinary tract infections can affect the ability of the kidney to function and potential risk of developing scars, and can lead to high blood pressure and kidney infection and kidney failure.

Sepsis

If the urinary tract infection is not treated it can spread to the kidneys. Urosepsis is the term used when it's a result of an urinary tract infection. This can be a life threatening event and must be treated immediately. 

The symptoms of Erospesis are pain near the kidney on the lower side of the back, nausea with or without vomiting, extreme fatigue, reduced urine volume or no urine, trouble breathing, or rapid breathing, confusion, unusual anxiety levels, changes in heart rate such as palpitations, or rapid heart rate, weak pulse, fever, and profuse sweating.

Progression to Severe Sepsis

Progression to severe sepsis. Septic shock and organ failure.

 

Encouraging Preventative Measures

As people age, the risk for urinary tract infection increases. Taking preventative measures can potentially reduce the risk of an urinary tract infection and subsequent kidney and bladder damage and complications that may occur. 

Always remind your eldery patients of the following:

Maintain Bladder Health and Regularity

A urinary voiding schedule (hourly schedule). Drinking more water will help with this scheduling and will increase the urge to urinate more frequently as it helps prevent the build up of bacteria. 

Maintain a Healthy Body Weight

Sedentary behaviors increase the risk of urinary tract infections. Exercise and weight management even in small increments can decrease the potential risks of an urinary infection.

Smoking

Decrease or stop smoking. 

Kegel Exercises

This increases the muscle strength of the pelvic floor and muscles. 

Decrease Consumption of Urinary Irritants

Like caffeine, acidic foods, alcohol, and carbonated beverages.

Avoid Constipation

 Suggest an increase in dietary fiber.

Increase Fluid Intake

Water helps prevent the build up of bacteria. Cranberry juice can help fight bacteria.

Incontinence Briefs

There is an associated increased risk of urinary tract infections with the use of briefs due to close contact. 

They should be checked every couple of hours, and soiled briefs should be immediately changed. The patient or wearer should be wiped and cleaned prior to a change of briefs. Women should be wiped from front to back.

Catheterized Patients

Use of catheters can increase the risk of an urinary tract infection because it irritates the urethra and bladder and also promotes the growth of bacteria. Gloves should be used during catheter insertion and perineal cleaning, which should be done twice daily. 

Sexually Active Women

Women should always go to the bathroom and empty their bladder after intercourse. 

Avoid the use of irritating feminine hygiene products

Women who are on hormone replacement therapy to be monitored by their health professional regarding usage, dosage, and side effects of hormone replacement therapy.  Proper hygiene of the perineal area, and after washroom use wiping from front to back. 

Encourage a Health Lifestyle

Maintaining an overall healthy lifestyle can help prevent and manage age related illnesses.  Encouraging elderly clients to follow these guidelines can help them maintain their health and independence:

• Regular exercise 
• Stay socially active. 
• Consumption of a healthy diet  (fiber rich, low fat and low cholesterol)
• Regular medical, dental, and optometrist appointments
• Take all prescribed medications
• Limited consumption of alcohol 
• Decrease or stop smoking 
• Drink plenty of fluids
• Rest (sleep as required)
• Mental health and emotions health 

 

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Author Bio 

Mance Granberg, RPN 

Mance Granberg is a First Nations Abenaki from Quebec and a RPN who has been nursing for over 18 years. He's had the opportunity to nurse in a variety of disciplines from correctional nursing to Geriatric nursing.