Urinary tract infections (UTIs) are common in older adults—especially older women—and in the case of adults with dementia and Alzheimer’s, UTIs can lead to behavioral changes, worsening confusion and declining cognitive symptoms. It is important that caregivers and home health aides understand how to prevent UTIs from occurring and are able to spot typical and atypical symptoms that might present themselves before the infection gets worse.
In severe cases, an untreated UTI could lead to sepsis, increasing the risk of permanent cognitive changes and death.
Laura Coyle, chief executive officer of HomeWell Care Services of New Jersey, said education and early intervention are the best ways to prevent UTIs from happening in the first place, and to decrease the likelihood that an infection gets to a point that a patient might not be able to come back from. Some believe UTIs create lasting harm and increase the progression of dementia and Alzheimer’s, but there is no indication that a person cannot return to their baseline cognitive status after having a UTI, Coyle said.
The best outcomes are seen in stable, physically healthy clients. When there are other medical comorbidities, Coyle said it gets more complicated—but that is why it is so important to detect and treat a UTI early.
“If the infection is severe and treatment is delayed, the client can progress to sepsis, and then the risk for permanent cognitive changes increases,” she said.
At HomeWell Care Services of New Jersey, caregivers are educated on UTI detection and early reporting upon hire. But that’s not all.
“Moving forward, during their employment, we host quarterly in-person caregiver training sessions where that topic is covered again and reinforced,” Coyle said. “And then client-specific training in the home on a case-by-case basis, because we want to teach them specific symptoms for that specific client on that personalized care plan—what they’re looking for, and to report it immediately.”
Coyle shared what caregivers should know and look for when they suspect a patient might have a UTI:
Warning Signs
Despite UTIs being common in the older population, it can be difficult to tell if someone has a UTI, especially if they are cognitively impaired and can’t remember or verbalize their symptoms. Here are some warning signs a caregiver should look for when it comes to UTIs and “silent” UTIs.
Typical Symptoms Include:
- Burning or pain with urination
- Frequent urination or urgency
- Cloudy or foul-smelling urine
- Blood in the urine
- Lower abdominal pain
- Pelvic pressure
- Bladder spasms
- Fever or chills
Atypical Symptoms Include:
- New or worsening confusion
- Unsteadiness or fall
- A sudden behavior change that can present as agitation, withdrawal or lethargy
- Loss of appetite
- Fatigue or weakness
- Incontinence or increased incontinence
- Restlessness
- New onset of urinary retention
In a patient already diagnosed with dementia or Alzheimer’s, it can be hard to tell if a patient is exhibiting some of these symptoms because they present similarly. In those cases, Coyle said to focus on atypical, vague symptoms.
“(If) they’re ‘off,’ they’re not themselves, it doesn’t hurt to test,” she said.
Next Steps
UTIs in someone with dementia or Alzheimer’s can cause significant changes in behavior, commonly referred to as “acute confusional state” or “delirium.” If someone has entered this state, Coyle suggested checking the vital signs first.
“Sometimes those are an indicator of an underlying condition,” she said.
Vital Signs Include
- Temperature
- Blood pressure
- Heart rate
- Oxygen saturation
- Blood glucose level (if they are diabetic)
Then, quickly notify the physician and seek medical attention, especially if they are in a state of delirium and have an onset of increased confusion as they need to be evaluated for any underlying conditions.
Worsening Conditions
In some cases, if the UTI is not treated in a timely manner, the patient can develop urosepsis, a type of sepsis that originates in the urinary tract.
“Urosepsis is one of the leading causes of hospital admission in the geriatric population,” Coyle said. “It still has a relatively low mortality rate.”
Studies show timely intervention significantly reduces the progression that leads to severe sepsis and death; however, overall health and mobility status also contribute to improving or declining health.
“In frail, bed-bound, cognitively impaired seniors—the most fragile population—septic shock can progress within one to three days of an onset of a UTI,” Coyle said. “So in that population, that’s a much higher mortality rate.”
Prevention is Key
Many steps can be taken to lower the risk of patients developing a UTI or sepsis, through early prevention methods.
Prevention steps include:
- Identify risk factors early on and know the client’s or family members’ history of UTIs
- Ensure proper perineal hygiene
- Change frequently if incontinent
- Promote adequate hydration
- Encourage regular voiding, which can be every two to three hours
- Avoid unnecessary catheter use such as an indwelling ( also known as a Foley catheter),, as it leads to a higher risk for UTIs
- If a catheter is necessary, ensure that daily catheter care is carried out, such as washing the catheter close to the perineal area
- Support a healthy diet
- Train clients, families and caregivers on good infection control practices such as proper use of gloves, proper hygiene techniques, early signs of infection and what to do if an infection is suspected
- In-home nurses should implement the following practices:
- Regular nursing check-ins and assessments for higher-risk clients
- Establish a care plan with personalized interventions to reduce the risk of UTIs
- Keep a UTI log or record to track each episode of a UTI, tracking the date, the symptoms, treatment, so you can identify trends.
- Use a sensor system or a bed pad that can alert nurses to wetness during the night
- Utilize community resources such as telehealth visits for homebound clients or mobile urgent care services, so the patient can be seen the same day and have a physical assessment done
Coyle acknowledges that it can be challenging when attempting to detect UTIs in dementia and Alzheimer’s patients.
“It's so challenging in someone with dementia and Alzheimer's, because they could have a good day or a bad day just strictly for that reason, because they have Alzheimer's,” Coyle said. “So, you have to look for those vague physical symptoms too. That little bit of weakness (or) that (difference in) appetite, coupled with that bad day, that needs to be on their radar.”