Urinary Tract Infections in older adults

As older adults age, a lot of changes start happening within them, mostly related to the body's routine functioning, physical changes and cognitive prowess. The body’s immune systems or their natural ability to fight off infections get weakened over time. There is also the female hormone oestrogen decline and deficiency seen in menopausal and postmenopausal women respectively. There is another factor of the weakening of pelvic floor muscles that makes it harder to completely empty out the bladder, and the bad bacteria breed well inside inactive urine. This leads to an increased risk of urinary tract infections in older adults.

A urinary tract infection (UTI) is the bacterial infection of the urinary tract which includes the urethra (the canal through which the body releases urine outside), urinary bladder (the chamber where urine gets collected to be flushed out later), ureters (the canals joining the bladder and kidney) and the kidneys (the organs that creates urine).

While older women are at higher risk of developing infections due to the anatomical differences in play, it also affects older men too. In older women, oestrogen deficiency can lead to an overgrowth of the bad bacteria (E. coli), raising the risk of infection. In older men, kidney stones, bladder stones, enlarged prostate (benign prostatic hyperplasia, or BPH), and bacterial prostatitis can increase the chances of urinary tract infection.

Oestrogen, with its slightly acidic nature, supports the good bacteria or microbiome in the vagina to continue to flourish, grow and become healthier. This ensured that the bad bacteria, even though being present in our large intestine and stools, did not manifest itself as a predominant illness since the good bacteria discouraged the bad bacteria’s growth. Without that acidic barrier, the bad bacteria can more easily grow and work its way up the urethra and urinary tract because the tissue between the urethra and vaginal opening loses that acidity too.

The common symptoms of UTIs in older adults are:

Fever or high body temperature,
worsened urinary urgency or frequency,
acute dysuria or painful urination,
suprapubic tenderness or pelvic pain,
costovertebral angle pain tenderness or back pain, along with, delirium or confusion,
high pulse rate, and low blood pressure in the absence of fever in older adults.
Restlessness, hallucination, social withdrawal, agitation, nausea and vomiting are other signs of UTI in older adults.

Urine tests (routine, microscopic and culture) are usually the confirmatory diagnostic methods. A positive urine culture with no more than 2 uropathogens (abnormal organisms) and pyuria (pus in urine) confirms the diagnosis of UTI.

UTIs become more serious and repetitive as adults age. It tends to cause complications. Untreated UTIs could lead to complications like:

Confusion and delirium – Research has shown adults older than 70 and those with dementia are at higher risk of suffering confusion from a UTI. This may be because the inflammation from a UTI has a better chance of affecting the brains of the older adult. UTI can spread from the urethra to the bladder to the kidneys and into the bloodstream, which can then spread into the brain (due to the blood vessels that supply the brain being weaker) and cause confusion that can lead to injury or distress. Also, they may simply be unable to communicate their symptoms. Up to half of people with dementia visit an emergency room in a given year, and the most frequent diagnosis is a UTI. Thus, delirium can be caused by UTI, or UTI can occur due to impaired maintenance of personal hygiene as a result of delirium, leading to unfavourable outcomes.
Bladder infection – Most UTI infections reach the bladder since the overgrown bad bacteria tends to work its way up the urinary tract from urethra. However, because UTIs are more common among older women, and may take longer to diagnose, the bladder could suffer more damage. An untreated UTI can lead to a bladder infection.
Kidney Infection – a UTI-related bladder infection will travel to the kidneys. A sudden, severe kidney infection (pyelonephritis) can cause permanent kidney scarring and damage. Sepsis – A prolonged, untreated UTI could result in a potentially life-threatening form of infection called sepsis. This risk heightens if the infection has travelled to the kidneys.

Furthermore, apart from weakened immune systems and hormone deficiency, older adults have a higher risk of UTIs for many reasons, such as a history of these infections (recurrent infections), dementia, a prolapsed bladder (loose, hanging bladder), and bladder or bowel incontinence.
Bladder obstruction, cancers, recent renal transplant or underlying urologic abnormality can also increase the risk of UTIs in older adults.
Conditions more common in older adults, such as Alzheimer’s disease, Parkinson’s disease, kidney disease and diabetes can lead to urinary retention and lack of bladder control, which can affect your chances of getting UTIs.
Older people that wear adult diapers are also at a higher risk of this infection if they are not changed regularly enough.
Older adults can get urinary infection through a catheter, as other organisms may be present that can lead to a UTI.
There is also a high risk of developing recurrent UTIs. Recurrent urinary tract infections (UTIs) are defined as 2 infections within 6 months or 3 within 1 year.

Treatment for UTIs in older adults varies depending on the symptoms.

Regular signs are generally managed in 7-14 days by antibiotics or antifungal medications, but if confusion, agitation, and other related symptoms are involved, antipsychotics are used.
Advanced cases of UTIs, which can lead to things like kidney damage and sepsis, can be treated with an intravenous antibiotic regimen (requires hospitalisation).
It is important to note that early antibiotic treatment is common in bacteriuria (bacteria in urine) without symptoms of UTI, however, it is known to cause delirium therefore, the initiation of antibiotics should be delayed in asymptomatic patients until a confirmed diagnosis of UTI is established.
For Recurrent UTIs, Methenamine is a nonantibiotic prescription medication that is useful for UTI prevention. In some instances, taking daily low-dose antibiotics for 4 to 6 months is the most effective way to stop the cycle of infections.
If UTIs get developed after intercourse, taking preventive antibiotics after sex also helps.

To help reduce the risk of UTIs so one doesn't have to deal with them:

drink plenty of water, reduce or avoid caffeine and alcohol, change adult diapers as soon as they get wet, and wipe properly when finished in the bathroom (front to back).
UTIs also tend to be more common in warm weather so make sure to wear cotton underwear and regularly maintain personal hygiene.
Don't use douches
Urinate as soon as the urge hits
For UTI prevention, vaginal oestrogen is very effective and is safe for most women as it reduces the risk by 50%-60%.
Taking a probiotic with Lactobacillus, a bacterium that is associated with good vaginal and bladder health will increase the local immunity.
Taking supplements like cranberry, vitamin C, and d-mannose can also be considered. These are not harmful but have not been proven to reduce infections. Cranberry should be avoided if discomfort is present since it can irritate the bladder.
Staying hydrated with at least 1.5 L of water daily will flush out the bad bacteria, but don’t overdo it. Aim for urine that is pale yellow to gold.
Older women can apply low-dose vaginal cream to support the tissue and maintain good bacteria.
Eating high-probiotic food, which supports good bacteria will be very helpful.

In older women, UTIs are often associated with Vaginal Dryness that causes painful sex in sexually active females. This combination of genital and urinary symptoms in older women (who are menopausal and postmenopausal) is called Genitourinary Syndrome of Menopause (GSM). GSM is characterised to have a drastic impact on the quality of life of affected women. Different treatment modalities have emerged to treat the condition's bothersome and life-changing symptoms. First-line treatment consists of non-hormonal therapies such as lifestyle changes, lubricants, and moisturisers, while hormonal therapy with locally administered intravaginal oestrogen products is considered the "gold standard" in more persistent cases.

Some seniors might not feel comfortable bringing up the symptoms of discomfort to caregivers or loved ones, or they may not experience any urinary symptoms, so it's important to be aware of and watch for the UTI symptoms specific to seniors. A UTI left undiagnosed - or misdiagnosed as symptoms of dementia or ageing - can be extremely harmful to a senior's health. Keeping watch for the signs of UTIs in older adults to help protect their overall health will be highly beneficial.