Understanding Urinary Tract Infections (UTIs) and their effect on the person with Dementia will enable you to identify, treat and understand what is happening. UTIs are very common in the elderly, particularly in those with dementia. Unfortunately, a UTI can cause sudden and extreme behavioural changes, such as confusion which is referred to as Delirium. The onset of delirium can happen in as little as one to two days, so if you notice a sudden change in behaviour, chances are your loved one may have a urinary infection. So what do you need to know?
What Are Urinary Tract Infections?
A UTI happens when bacteria enter the body through the urethra – the tube that passes urine from the bladder to the outside of the body. As the bacteria move through the urinary system, it causes infection as it goes. Urinary infections are more common in women (with some studies suggesting up to 4 times more prevalent) due to a shorter urethra. A UTI can affect any part of the urinary system – kidneys, ureters, bladder and urethra – but they are most common in the lower urinary tract – the bladder and urethra.
What Can Cause A Urinary Tract Infection?
Urine is normally sterile, but this is not always the case in the elderly. As we age, it is common for us to have bacteria in our urine, which is known as bacteriuria. Our flow of urine may not be as strong and we may have issues emptying our bladder completely which in turn allows bacteria to grow within the sterile environment of the bladder.
As dementia advances, attending to and maintaining an adequate level of personal hygiene can be very difficult. As mentioned above, in women the urethra is shorter than men and closer to the anus making it easier for bacteria to gain entry to the urinary system. If a woman is unable to clean herself properly after a bowel moment, you may find that an infection begins within a few days. As we know, attending to personal hygiene and changing clothes frequently can be a big issue in those with dementia and this, in turn, can cause an increase in the risk of a urinary infection.
Other common risk factors include:
- A compromised immune system due to illnesses such as diabetes or undergoing chemotherapy for cancer.
- Changes in the internal structure of the pelvic area. For example, an enlarged prostate (men) or prolapse in the bowel or womb (women) can put pressure on the bladder, therefore making it harder for the bladder to empty fully.
- Incontinence pads that are not changed frequently enough can lead to urinary infections too.
As mentioned, the bladder is a sterile environment. If a catheter is in situ, bacteria have a direct entry into the bladder. Keep this in mind when emptying catheter bags. A bag does not need to be emptied every time urine is passed. It is not unusual to wait until the bag is nearly full before opening the valve. Remember, the more you open it the more chance there is of bacteria entering the bag and urinary system. The valve that you open and shut must be kept clean and away from dirty surfaces. Consider purchasing a catheter bag stand and a male urine bottle and brush to assist you with maintaining high standards of hygiene.
Signs and Symptoms of A UTI in Dementia Patients
In approximately 30-40% of cases, a fever isn’t present because the immune system is unable to mount a response to the infection due to the effects of ageing, so it is entirely possible for an infection to be present without a fever. In those with dementia, a sudden increase in confusion would suggest that it would be appropriate to rule out an infection. Other symptoms include:
- Urine that appears cloudy
- Bloody urine
- Strong or foul-smelling urine odour
- Frequent or urgent need to urinate
- Pain or burning with urination
- Pressure in the lower pelvis
Depending on the stage of the illness, you may find that your loved one may find it difficult to express an urgent need to urinate, pain, burning or pressure. Sometimes it falls upon the carer to notice these symptoms as your loved one cannot express what or how they are feeling. As the disease progresses, this is where continuity of care will be most important. Ensuring that a high standard of care, along with minimal changes in staff or family members and stringent, accurate record keeping will help detect any changes in behaviour, health or mental state quickly and allow for diagnosis and treatment of any illnesses to begin as soon as possible.
What to Do Next?
If you suspect that your loved one has a urinary tract infection, the first thing you need to do is get a urine sample as it will need to be sent to the lab for a culture (finding out what bug is causing the infection) and sensitivity (assessing which antibiotics will kill the bug). Getting a sample from a person that has dementia can be difficult, but it is vitally important for the treatment of the infection.
In the person that is ambulatory
Assist them to the toilet and explain that you are going to help them get a sample of urine. Sometimes, we need to be economical with the truth, as the truth can cause distress. This is perfectly okay and is encouraged when you are caring for a person with memory issues. You may find that mentioning a urinary infection is met with protests of everything being okay, so it may help to say that it is part of the yearly physical or refer back to an old memory that may still be intact. Every person with dementia is different, therefore it is not a one size fits all approach.
In the person who uses incontinent wear
This is generally a trickier situation to obtain a sample from because it can not be obtained from the incontinence pad. The above approach may work, but depending on how mobile your loved one is, you may be transferring straight from the bed, in which case it would help to have a commode available. The sample must be collected in the sample pot and not in the commode container.
In the person with a catheter
Generally speaking, an indwelling catheter (i.e. one which is in-situ 24/7) is only placed in the person with dementia when they are bedbound as it would pose too much of a risk for being tampered with or pulled out. If your loved one needs a urine sample and has a catheter in place – do not take the sample from the bag. In this situation, a sample must be taken from the source and is usually done by a nurse or a doctor. If you suspect a urine infection in a person with a catheter, call your general practitioner or community nurse for further instructions.
A culture and sensitivity test generally takes 24-48 hours to produce results as the bacteria needs this period of time to grow. You may find that once you bring the possibility of a urinary infection to the attention of your primary care doctor, they will use a dipstick to test the urine. These sticks are useful in telling us whether or not there are specific elements of an infection present in the urine. Should the urine test positive for nitrates, blood or leukocytes then the specimen will be sent to the lab for a full culture and sensitivity test to take place.
Depending on the severity of the symptoms your doctor may start antibiotics pending the results of the culture and sensitivity test and then adjust the antibiotics once the results are back.
A culture and sensitivity must be done in every suspected case of urinary tract infection. Even if it has only been weeks since the last one.
Recurrent infections may require a long-term, prophylactic antibiotic. This means your loved one would take an antibiotic every day to prevent the infection recurring. If you feel that your loved one has been dealing with more infections than normal, it may be worth it to speak with your doctor regarding the possibility of prophylactic treatment.
How to Prevent UTIs
Maintaining personal hygiene and ensuring the use of clean underwear can greatly reduce the occurrence of infection. Encouraging frequent toilet trips, regularly changing incontinence wear and emptying a catheter bag only when necessary help reduce the risk of bacteria entering the urinary system. In some patients with dementia, staying adequately hydrated can be an issue and this can also lead to infections, so encourage fluids as best you can.
If you are really struggling with recurrent urinary infections in your loved one, getting help from your primary care doctor, public health nurse and being referred to an incontinence nurse can be helpful. Remember, dementia care is a team effort and you are not expected to deal with this on your own. Availing of the services that are around you and speaking to others who are for someone with dementia can provide you with tips, tricks and solutions that you may not have thought of previously.
As always, I would love to hear about your experience with Urinary Tract Infections in the person with dementia. Have you done something different to what is mentioned above? Do you know a more effective way to collect a urine sample? If so, please do get in touch. You can leave a comment below, find me on Twitter or email me
As always, the information in this article is informational only and is not intended to replace medical advice. If you should be concerned about your or your loved one’s health, please contact your doctor to discuss matters further. You can read my disclosure policy here.