Detecting urinary tract infections in older people can be difficult because many symptoms affect behaviour and can be missed or attributed other illnesses.
Recognising a UTI in the older generation
Those of an older age are vulnerable to UTIs for several reasons:
- The immune system weakens by age increasing susceptibility to infections
- People can drink less fluid because of lack of bladder control – due to the weakening of the pelvic floor muscles. This can lead to incontinence and bladder/bowel prolapse.
- After menopause, women experience a change in the lining of the vagina and also produce less oestrogen, which helps protect against UTIs. Hormone replacement therapy (HRT) can help protect postmenopausal women from UTIs but HRT may increase other health risks and so may not be appropriate for all women.
People with long term health issues and those in nursing homes or long-term care facilities are particularly at risk.
- They may have a reduced ability to take care of themselves – decreased personal hygiene increases the risk of bacterial infection
- Cognitive recognition reduces. This can then lead to a lack of communication especially when unwell
- Wearing soiled underwear or disposable undergarments for too long can also introduce bacteria into the urinary tract
- Back-to-front wiping after a bowel movement can transfer bacteria into the urethra
- Health conditions such as diabetes, kidney infections and stones can increase the risk of a UTI
- In-dwelling catheters or self-catheterising can also increase the chance of infections.
What are the signs and symptoms of UTIs in older people?
Detecting UTI symptoms can be difficult because many of them affect behaviour, so they can be missed or attributed to more serious illnesses. Because their immune systems are not functioning at optimal levels, symptoms often manifest differently and produce the following:
- confusion
- disorientation
- agitation
- decreased mobility
- dizziness
- falling
- incontinence
- lethargy
- urinary retention
- decreased appetite
If an older family member or friend starts acting abnormally, the best step is to get them to their local GP or urgent care centre so the doctors can identify whether or not they have a UTI.
Providing a urine sample
If a urine sample is required, either to do a routine dip test or to be sent to the laboratory for testing, this should preferably be the first urine that is passed in the morning. It may be best to ensure that a supply of sample bottles are kept at home so that a sample can be sent to the laboratory should a UTI be suspected. Your local GP surgery or chemist can provide these.
Diagnosis of UTIs in the older generation
Diagnosis of a UTI is usually based on the symptoms such as pain when passing urine, frequency, urgency, haematuria (blood in the urine) and pelvic region tenderness, but these are present in just half of people aged over 75 with bacterial UTI and less than 10 per cent of care home residents with advanced dementia and suspected UTI.(1,2)
Unfortunately in older people the issue of asymptomatic bacteriuria (ASB) is also applied in care and management when a UTI is suspected. ASB is the presence of bacteria in the bladder urine with no attributable symptoms. It is common in older people (10-20 per cent in the community), especially the most frail (up to 40-50 per cent of care home residents) and universal in those with longterm catheters (3,4 & 5). This often means that even if a dipstick or urine sample is sent for analysis, antibiotics may not be prescribed because the assumption is made that the urine naturally contains bacteria due to the age and situation of the person concerned. The National Institute for Clinical Excellence (NICE) notes in its 2018 Quality Care Flowchart for management of UTI in the elderly that
“Dipsticks become more unreliable with increasing age over 65 years. Up to half of older adults, and most with a urinary catheter, will have bacteria present in the bladder/urine without an infection. This “asymptomatic bacteriuria” is not harmful, and although it causes a positive urine dipstick, antibiotics are not beneficial and may cause harm”.
The diagnosis of UTI is a dilemma for clinicians caring for older adults. Urinary symptoms should still be the initial trigger for UTI evaluation if your family member or friend is able to describe them to the Nurse or GP. If they are in a residential or nursing care home, discuss with the staff and work together to get a diagnosis which includes signs and symptoms especially in the presence of ASB.
Management of UTIs in the older generation
- Ideally, six – eight cups of fluid a day should be consumed and alcohol, because it is dehydrating should be drunk in moderation. Encourage someone with dementia to drink by finding out their preferences and making drinks readily available and visible. Using a brightly coloured glass or cup can help with this.
- Monitor fluid intake for people who are less mobile and at risk of dehydration. Dehydration may cause the person to pass darker, more concentrated urine which may also cause pain on urination.
- Do not hold urine in the bladder for too long as pooled urine can cause bacteria to multiply setting up infection. People with dementia should be prompted to use the toilet on a regular basis. Residential or nursing homes should have clear signage to help find toilets or ideally the toilet seats be a different colour to the toilet pan to help those with dementia.
- If someone has become wet or soiled, they should wash afterwards with mild soap and warm water, and dry carefully before putting on clean clothes and fresh pads, with assistance if necessary.
- Soiled clothes, reusable pads or bedding should be washed immediately.
- Moist toilet tissues may be suitable for minor accidents, but be aware that some can irritate the skin.
- Empty the bladder following sexual intercourse.
- If you are a woman using a diaphragm, consider an alternative form of contraception. Diaphragms may obstruct full emptying of the bladder.
- If you are man using a condom, consider using condoms without a spermicidal lubricant which can increase the risk of UTIs.
- Try to avoid becoming constipated as this can prevent the bladder from emptying properly, which in turn can cause a UTI. Eating foods high in fibre, drinking plenty of liquids and exercising can help to prevent constipation.
- Maintain good hygiene – wash the genitals at least once a day using unperfumed soap and do not use talcum powder.
- Women should wipe ‘front to back’ after using the toilet. Easily accessible, unperfumed wet wipes in the bathroom may help to promote good hygiene.
- When a urinary catheter is being used, follow good infection prevention measures – guidance can be provided by healthcare professionals.
Proper nursing home or long-term care is critical in preventing UTIs, especially for people who are immobile and unable to take care of themselves. They rely on others to keep them clean and dry. Talk to management about how they manage personal hygiene. Make sure they’re aware of UTI symptoms in older adults and how to respond.
D Mannose and E-Coli
While many bacteria can cause a UTI, the most common pathogen for both uncomplicated and complicated UTI is uro-pathogenic Escherichia coli (E. coli) or UPEC. UPEC are responsible for 80%–90% of all uncomplicated UTI and approximately 65% of complicated UTIs. Enterococcus species are the second leading cause of complicated UTI (11%) and the third leading cause of uncomplicated UTI (5%). (6)
UPEC and Enterococcus species can set up infection on the bladder wall due to the distinctive adhesive pili (or hairs) on their surface. It is these that allow these bacteria to stick and thus begin to establish colonies. Think of them as grappling hooks.
D Mannose is a natural, simple sugar that is related to glucose and is available as a powder or tablets and is taken in or with water. D-mannose molecules in the urine may prevent colonisation of the bladder wall by bacteria by attracting bacteria to attach to them. The key is the dosage of D-Mannose. In sufficient concentration in the urine, it may help bacteria to be expelled from the bladder by urination.
Those with ongoing e-coli infections may find a daily dosage of D Mannose can help to manage infections. Keeping hydrated is key to managing a UTI in older years and a teaspoon of D Mannose in a water bottle or cup as part of a daily fluid programme may benefit.
Read more about D Mannose.
Methenamine Hippurate (Hiprex) for UTI prevention in the older generation
Given the high rates of UTI recurrence in older adults, and concerns for multidrug-resistant infections, alternative antimicrobial-sparing options for older adults with recurrent and chronic UTI need to be considered. One such option is Methenamine Hippurate or Hiprex
Hiprex works as an antiseptic rather than an antibiotic, which in turn means there is little risk of pathogenic bacteria developing resistance. In an acidic environment, methenamine is converted to ammonia and formaldehyde. By converting to bactericidal formaldehyde it prevents bacterial growth by destroying the proteins and replication abilities within a bacterium. It is important to note that Hiprex has little antimicrobial activity in an alkaline environment, as formation of formaldehyde does not occur until the pH of the urine falls below 6. To ensure this reaction occurs, some treatment regimens include the use of ascorbic acid (Vitamin C) to further acidify the urinary environment.
There are limited studies available with regards to the efficacy of Hiprex in the older generation but a study published in Therapeutic Advances in Drug Safety in 2019 undertook an evaluation of available appropriate literature in the usage of Hiprex for the elderly (10 studies) and noted:
“The studies included in this review that evaluated effectiveness of methenamine hippurate or mandelate in recurrent UTI prevention collectively resulted in positive results, with each showing a reduction in incidence of UTI or bacteriuria. The doses ranged from 500 mg twice daily to 1 g four times daily. Although the studies were able to show positive results, a collaborative recommendation for use of methenamine as a preventative strategy at doses lower than the FDA-approved doses remains unclear.
There are limited data for the use of methenamine in older adults, especially with impaired renal function; however, this review provides evidence supporting the use of methenamine for prevention of UTI in different populations of adults 58 years and older. However, in all of the studies, once methenamine was discontinued, incidence of bacteriuria or UTI were more common”.
Declining oestrogen levels – how it affects the vagina and the bladder
For women, oestrogen (or estrogen) is needed for the vagina to maintain its natural flora and lubrication. Declining oestrogen levels through the menopause and in later years lead to changes to vaginal PH. A normal vaginal pH level is between 3.8 and 4.5, which is moderately acidic. However this ‘normal PH’ level can change based on your stage of life. For example, during your reproductive years (ages 13 to 49), your vaginal pH should be around or below 4.5.
But before menstruation and after menopause, a healthy pH tends to be higher than 4.5. This matters because an acidic vaginal environment is protective. It creates a barrier that prevents unhealthy bacteria and yeast from multiplying too quickly and causing infection. Thus a high vaginal pH level — above 4.5 — provides the perfect environment for unhealthy bacteria to grow and these bacteria can transfer from the vagina to the urinary tract causing ongoing infection problems.
Thinning of pelvic organ mucosal linings
Thinning of the vaginal and vulval mucosal lining during the menopausal and post menopause years also affects the mucosal wall of the bladder allowing bacterial permeability – in other words it becomes easier for bacteria to become established on or within the cells of the bladder and vaginal walls. Further, the walls of the vagina, urethra and bladder rely on oestrogen as one way to stay toned and able to manage the flow of urine from the bladder. With less oestrogen, these organs lose tone and some degree of function which can lead to increased leakage and “accidents”.
If you think hormones are contributing to urinary tract infection symptoms in either your own situation or someone who is older or you think possible onset menopause or hormone deficiency are causing systemic issues, consider and discuss the following symptoms:
- a change in periods (if applicable)
- vaginal/vulval dryness
- vulval or vaginal pain
- unusual vulval or vaginal bleeding
- mood swings
- energy levels
- loss of libido
- hot flushes
- memory lapse
- increased levels of thrush or bacterial vaginosis
- frequency of urination or increase in UTIs
- bone and joint pain
Hormone Replacement Therapy (HRT)
Any of the above symptoms may lead to the GP or a gynaecologist prescribing Hormone Replacement Therapy if appropriate.
When HRT is administered for menopausal symptoms, it is primarily to restore oestrogen. Supplementing oestrogen levels alone via oral or transdermal routes can cause the lining of the womb to thicken which can increasing the risk of cancer and your GP or specialist should take a full family history for uterine or breast cancers. For this reason, progesterone is given in combination with oestrogen in the majority of cases (unless someone has had a hysterectomy).
More about HRT and the options available.
References
1. Woodford HJ, Graham C, Meda M, et al. Bacteremic urinary tract infection in hospitalized older patients: are any currently available diagnostic criteria sensitive enough? J Am Geriatr Soc 2011; 59: 567-8.
2. D’Agata E, Loeb MB, Mitchell SL. Challenges assessing nursing home residents with advanced dementia for suspected urinary tract infections. J Am Geriatr Soc 2013; 61: 62-6.
3. Ducharme J, Neilson S, Ginn JL.
Can urine cultures and reagent test strips be used to diagnose urinary tract infection in elderly emergency department patients without focal urinary symptoms?
CJEM 2007; 9: 87-92.
4. Scottish Intercollegiate Guidelines Network (SIGN).
Management of suspected bacterial urinary tract infection in adults.
Edinburgh: SIGN; 2012. (SIGN publication no. 88). Available at: www.sign.ac.uk (accessed 17th November 2017).
5. Nicolle LE. Catheter-Related urinary tract infection: practical management in the elderly.
Drugs Aging 2014; 31:110.
6. Foxman B. Urinary tract infection syndromes: Occurrence, recurrence, bacteriology, risk factors, and disease burden. Infect. Dis. Clin. N. Am. 2014;28:1–13. doi: 10.1016/j.idc.2013.09.003.