UTIs in Older Adults: Symptoms, Diagnosis, and Treatment
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Urinary tract infections (UTIs) can and do affect people of all ages. But for a variety of reasons, they occur more frequently in older adults, and particularly in older women.
Learn why UTIs become more common with age, how to spot the symptoms of a UTI in yourself or an older person you care for, and what to do if you suspect that you or someone else has a UTI.
What is a urinary tract infection (UTI)?
UTIs are common infections that happen when bacteria (usually from the skin or rectum) enter the urethra and infect the urinary tract, according to the Centers for Disease Control and Prevention (CDC). The infections can affect several parts of the urinary tract, but a bladder infection (cystitis) is the most common type.
How is a UTI diagnosed?
“A urinary tract infection is diagnosed by having overgrowth of bacteria in the urine (based on a urine culture), as well as having symptoms that indicate the overgrowth is causing some kind of inflammatory process in the lower urinary tract,” says Candace Parker-Autry, MD, assistant professor of urology at Wake Forest University School of Medicine and urologist at Atrium Health Wake Forest Baptist, both in Winston Salem, North Carolina.
In a urine culture, a urine sample is incubated in a lab for 24 to 48 hours to see what microoganisms — such as bacteria or yeast — grow in the urine.
“Those symptoms can include things like painful urination, blood in the urine, increased urinary frequency or urgency, urinary incontinence, or nighttime voiding. Some abnormality of the urinary tract in terms of a symptom or symptoms is necessary in diagnosing a urinary tract infection,” says Dr. Parker-Autry.
Is the diagnosis of a UTI different for elderly people?
It’s a common misperception that older people have different symptoms or that they may have a UTI without symptoms, says Parker-Autry.
The diagnostic criteria for a UTI is not different for elderly people, according to the Infectious Diseases Society of America (IDSA).
“To be correctly diagnosed with a UTI, a person needs to have overgrowth of bacteria in the urine and symptoms that are consistent with a urinary tract infection,” Parker-Autry says.
Some symptoms that people assume indicate a UTI, such as urine odor and confusion in the elderly, are usually caused by other conditions that should be ruled out before testing for a UTI, per the IDSA. Generally, urine cultures shouldn’t be taken unless patients have symptoms that are consistent with a urinary tract infection, including burning during urination, frequent urination, or abdominal pain or tenderness on the back near the lower ribs.
“Often, there can be an assumption that when an older adult comes in with confusion, that this is associated with urinary tract infection because they have an overgrowth of bacteria in the urine,” says Parker-Autry.
But one thing that does change with age is it’s more common to have this overgrowth of bacteria, called asymptomatic bacteriuria (ASB), in comparison with younger adults, says Parker-Autry.
“Asymptomatic bacteriuria is the presence of bacteria in the urine of a person who has no signs or symptoms of a UTI, and it’s not the same as having a urinary tract infection, or UTI,” she says.
It’s estimated that 30 to 50 percent of people in nursing homes have ASB, per the IDSA.
The distinction is important, because, according to StatPearls, in most cases people with asymptomatic bacteriuria will never go on to develop a UTI, and they won’t benefit from the treatment. In fact, treating bacterial overgrowth that’s not an actual infection may increase the risk of other health issues (more on that later).
Can the symptoms of a UTI be harder to identify in older adults?
Some older adults may not be able to verbalize symptoms, or (due to aging or certain medications) their baseline, or normal, behavior may resemble certain symptoms of a UTI, such as frequent urination, says Ronan Factora, MD, a physician at the Center for Geriatric Medicine at Cleveland Clinic in Ohio.
“That makes it harder to know if they are experiencing symptoms, but what you’re looking for is change — anything different from the baseline. So if the person is already going to the bathroom very frequently, you’ll just be looking for a change from that,” he says.
Dr. Factora recommends noticing: Is the urination even more frequent? Is it associated with pain? Is now more frequent both night and day?
“And they don’t have to have a fever, but a UTI can come with a low-grade fever, which for older patients can be 99 degrees F or higher, or two degrees above their baseline temperature. Keep in mind that core body temperature in older adults can be lower than the general population,” says Dr. Factora.
Elderly adults can also experience a change in mental status when they have a UTI — but that can also be caused by many other conditions or infections, he says.
“It can be very difficult to say that’s related to the bladder. It could be underlying dementia, poor sleep, or other types of infections. That’s why a person needs to have bladder symptoms for a diagnosis of a UTI,” he says.
Why does a UTI sometimes affect an elderly person’s mental status?
Delirium — a mental state in which a person is confused and disoriented — can accompany any infection, including a UTI, especially if a person has underlying dementia, says Dr. Factora.
“We see people get delirious when they have kidney infection or if they have pneumonia; it’s not unusual. The reason behind that is not really clear: It may be caused by inflammatory substances that are being released by the body’s immune system trying to fight off that infection,” he says.
It could also be that that person is not able to express that they’re having painful or bothersome symptoms, and this might lead to behaviors like pacing or being irritated, says Factora.
Does being old raise the risk of getting UTIs? Are the risks different for men and women?
Being older can raise the risk of developing a UTI, says Parker-Autry.
“In women, there are hormone-related changes in the lower urinary and reproductive tract after menopause,” she says. Lower circulating levels of estrogen triggers a change in the pH (acidity) of the vagina and thins the skin, which increases the risk of both UTIs and recurrent UTIs, she says.
“Changes in the bladder during aging can also cause incomplete bladder emptying, which can also contribute to recurrence and presence of urinary tract infection,” says Parker-Autry.
For older men, there can be enlargement of the prostate, and they may also gradually lose the ability to empty completely as the bladder wall weakens, and both factors contribute to the likelihood of urinary tract infections, she says.
Outside the use of catheters (thin tubes used to drain urine from the bladder), UTIs aren’t as common in elderly men as they are in women, she adds.
Does being sedentary raise the risk of a UTI in older adults?
On its own, simply being sedentary doesn’t increase your risk of a UTI, says Factora. “However, if it comes along with decreased cleanliness after using the bathroom or a lack of continence care (if the elderly person is incontinent) that could make a UTI more likely,” says Factora.
How can an older person reduce their risk of a UTI?
Proper hydration can help reduce the risk of a UTI, says Factora. “When you drink plenty of fluids, it allows the bladder to keep on flushing out its contents, including bacteria that tends to stick around the bladder wall. So if you maintain adequate hydration and drink plenty of fluids during the daytime, it helps to reduce your risk of UTI,” he says.
Maintaining appropriate hygiene around the urethra can also make a UTI less likely, says Factora. “The urethra is the opening of the tube that connects the bladder to the outside. Keeping that area clean can reduce the risk of urinary tract infection, because those bacteria can move up the urethra into the bladder,” he says.
That’s more of an issue in people who have a vagina, because the urethra is shorter and closer to the anus compared with people with a penis, says Factora.
Does having dementia increase the likelihood of a UTI?
Having dementia may make it difficult for a person to speak up and say that they’re having these new symptoms, and so having a UTI that goes undetected may be an issue for people with dementia, says Factora.
“The other thing that may be related to dementia is the loss of ability for self-care, which happens in moderate to severe dementia. That lack of ability to perform appropriate hygiene after using the bathroom could be a risk factor for urinary tract infection,” he says.
Are there chronic medical conditions that raise the risk of UTIs in older people?
People with type 2 diabetes are at greater risk for having UTIs, both as a result of having the condition and because certain diabetes medications are also associated with a higher risk, says Factora.
Pelvic surgeries, hysterectomies, and treatments for prostate cancer or enlarged prostate can all increase the risk of UTIs and more complex UTIs, he says.
What are signs that caregivers or family members should look for indicating an older person may have a UTI?
Signs to look for would include a change in frequency or urgency of urination, making more trips to the bathroom, and any presence of a low-grade fever — “Be sure to check the temperature with an accurate thermometer,” says Factora.
“My threshold for treating the infection is pretty low, but a patient needs to have one of those symptoms in order for me to be convinced that it is truly a urinary tract infection,” he says. That being said, in rare cases, the only sign of a UTI is a change in mental status, but that’s the exception, not the rule, says Factora.
Is it appropriate to use a home UTI test to see whether an older person has a UTI?
“Taking an at-home UTI test is a convenient option,” says Factora. “You just have to be careful that you do that test in the context of the presence of other symptoms, because if you test positive, the next question is, ‘What are you going to do about it?’” he says.
The person being tested should have UTI symptoms that compel you to think that there’s something going on, says Factora.
“If they have the symptoms of a urinary tract infection, do the test, and that way, if it’s positive, you can get it treated as if it’s a true infection. But if there’s no symptoms, and you do it, and it’s positive, that needs to be approached differently; it doesn’t necessarily indicate a UTI,” he says.
A urine culture offers an advantage, especially if a person has had recurrent urinary tract infections or they’ve been on a lot of antibiotics, says Factora.
“That’s because the results of that culture can indicate which bacteria are causing the infection, and therefore which antibiotics will or will not work to treat the infection in that person. That’s not something that the home test will tell you.”
What is the treatment for UTIs in elderly people? Is it different from treatment for a younger person?
“The treatment is very similar in an older versus younger person in terms of duration and the types of antibiotics that are typically used,” says Factora.
There are a few exceptions to that: For example, if a person has had pelvic surgeries or has a more complicated UTI, they may need to be on antibiotics for longer, he says.
What about elderly people with recurrent UTIs?
In an older person with recurrent UTIs, there’s a concern that recurrent use of antibiotics could lead to development of bacterial resistance, making future treatment with oral antibiotics potentially challenging.
“In that case, you may have to use a more powerful antibiotic to kill off the bacteria causing the infection, but it might kill other types of bacteria as well, including the good germs that protect the body against harmful infections, like C. difficile infection,” Factora says.
People 65 and older are at higher risk of Clostridioides difficile, according to the CDC. The infection causes diarrhea and colitis (an inflammation of the colon), and can cause rare complications such as toxic megacolon, sepsis, or even death.
“That’s why we must be very careful about distinguishing between asymptomatic bacteriuria and true UTIs, and not overtreating. People can develop resistance down the line, and that may increase the risk of developing C. diff,” says Factora.
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