A Synopsis of Current Medical Advice on Urinary Tract Infections in Older Adults

http://commonhealth.wbur.org/2012/01/uti

Risk Assessment, Causes, & 

Prevention of Urinary Tract

Infections in Adults over Fifty

Evelyn Smith

 

As the body ages, urinary tract infections become more frequent—in post-menopausal women because the vagina loses the “good” bacteria that protected it from e-coli bacteria—and in men where an enlarged prostate produces similar affects. While the most recent evidence suggests that drinking of cranberry juice to prevent urinary tract infections appear to be over-hyped, research over the last two decades has confirmed that topical estrogen helps women to control the production of “bad” bacteria in the vagina, which is often swept into the bladder. 

Most other preventive measures, however, require only common sense, which an older adult can easily follow until admitted to a nursing home:  Flush out the intestinal tract regularly by drinking plenty of water and practice proper hygiene.  The immobile and incontinent elderly, however, must depend upon caretakers to ensure that they drink enough liquids and have their adult diapers changed regularly. 


Popular Advice on Urinary Tract Infections

Earhart, M. (2010, July 26).  Causes of urinary tract infection in women over 80.  Livestrong.com. Retrieved from http://www.livestrong.com/article/185012-causes-of-urinary-tract-infection-in-women-over-80/

While urine normally is sterile and contains no bacteria, the chances of harmful bacteria getting into the urine from the urethra increase with age (Earhart, 2010, para. 1).  Postmenopausal women experience a loss of estrogen that thins the walls of the urinary tract, making it more susceptible to infection since vaginal cells lose their resistance to E coli bacteria, increasing the growth of harmful bacteria in close proximity to the urethra (Earhart, 2010, para. 2).  Antibiotic medications as well as soaps and lotions also kill off lactobacilli.  Antihistamines may additionally dry the tissues in the urinary tract and thus trigger infection (Earhart, 2010, para. 2).

 Age-related bladder prolapse, or cystocele, gets in the way of the complete emptying of the  bladder while a stroke may result in urinary retention (Earhart, 2010, para. 3).  Urinary incontinence and leakage are more common in elderly women, so this contributes to urinary tract infection.  In particular, the elderly in long-term care facilities have an increased chance of suffering from urinary tract infection because of immobilization, dehydration, incontinence, and the use of urinary catheters if the LTC facility practices catheterization (Earhart 2010, para. 4).  Diabetics have a higher risk of testing positively for bacteria in their urine without showing any other symptoms (Earhart, 2010, para. 5).

Elderly urinary tract infections. (2012, November 28).  A Place for Mom.  Retrieved from http://www.aplaceformom.com/articles/elderly-urinary-tract-infection

Two of the most common signs of urinary tract infections in the elderly—a change in behavior that might be mistaken for dementia and urinary incontinence—may or may not indicate an UTI, although other possible symptoms including general discomfort, tiredness, blood in the urine.  Pain in the groin or rectum as well as back and side pain points to a possible bladder or kidney infection (Place for Mom, 2012, para. 2 & 8).  Once urinalysis indicates bacteria in the urine, and a urine culture reveals which kind, antibiotics ordinarily make urine infections relatively easy to cure even if the bacteria that infect nursing home residents may be resistant to antibiotics (Place for Mom, 2012, para. 9 & 10).   If an UTI isn’t caught and cured, it can lead to sepsis, or the infection of the bloodstream (Place for Mom, 2012, para. 3).

Post-menopausal women are more at risk for UTIs since they produce less estrogen, so hormone replacement therapy may prove advantageous while catheter use, diabetes, and kidney stones may make all older adults more susceptible to UTIs (Place for Mom, 2012, para. 13 & 14).  Accordingly, drinking four to six 8-ounce glasses of water daily keeps urine clear while urinating promptly when necessary, taking showers rather than baths, wiping from to back, and women avoiding douching and feminine deodorants all help prevent UTIs (Place for Mom, 2012,  para. 11 17-18).

Malani, P. N. (2008, January 7).  Diagnosis and management of urinary tract infections in older women. Clinical Geriatrics, 47-53.  Retrieved from http://www.clinicalgeriatrics.com/articles/Diagnosis-and-Management-Urinary-Tract-Infections-Older-Women

Asymptomatic bacteria is the most common bacterial urinary tract infection found in up to 55 percent of women in Long Term Care facilities while urinary tract infections that produce symptoms occur less commonly but take on increasing importance because of what causes them—incontinence and dysfunction bladders as well as changes in the vaginal mucosa that decreases the amount of lactobacilli in the vagina while increasing the presence of pathogenic E coli-bacteria (Malani, 2008, para. 1-2).  An e-coli bacterium causes 70 percent of all urinary tract infections, although women living in institutions are at risk for infection for anti-microbial resistant bacteria.  While healthy women living at home are more likely to show outward symptoms associated with urinary tract infections, women living in assisted living and long-term care facilities often suffer from urinary tract infections that a physician or nurse practitioner has misdiagnosed as pneumonia or gastroenteritis (Malani, 2008, para. 3-4).

Serafin, J. (2012, September 12). Why are urinary tract infections in women so common?  Caring.com. Retrieved from http://www.caring.com/questions/elderly-women-urinary-tract-infections

• Older women retain urine or incompletely empty the bladder because of underlying gynecological problems, urethral structure, severe constipation, the side effects of medication, and neurological diseases;

• The bladder after menopause contains decreasing amounts of the healthy bacteria lactobacillus while fecal bacteria starts to increase;

• The urethra is very close to the rectum, and if the woman is incontinent, recurrent urinary tract infections result since this necessitates frequent diaper changes and cleaning.
  
  

• Many elderly don’t drink enough water, although drinking eight glasses of water or clear fluid daily cleans out the intestinal tract.

(Serafin, 2012, para. 1-6)

Sollitto, M. (2013).  Urinary tract infections in the elderly.  Agingcare.com. Retrieved from http://www.agingcare.com/Articles/urinary-tract-infections-elderly-146026.htm

When bacteria in the bladder or kidneys multiplies in the urine, this can lead to acute or chronic kidney infections to which the elderly are susceptible because of the suppressive immune systems that come with age (Sollitto, 2013, para. 1-3).  Moreover, the elderly don’t always run a low-grade fever that usually accompanies a urinary infection since the body is unable to respond to the infection even as it shows other typical symptoms—cloudy, bloody, foul-smelling urine, the frequent urge to urinate, pain or burning upon urinating, pressure in the lower pelvis, night sweats, shaking, and chills—not to mention possible confusion that is sometimes mistaken for dementia (Sollitto, 2013, para. 4-5).

Diabetes, urinary retention, catheter use, bowel incontinence, an enlarged prostate, immobility, surgery around the bladder, and kidney stones all make older adults more likely to suffer from urinary tract infections (Sollitto, 2013, para. 6).  However, this risk can be reduced cleanliness and hygiene--wearing clean changes of cotton underwear daily [or regularly changing adult diapers in incontinent adults], keeping the genitals clean, wiping front to back, and in women, refraining from douching—and nutrition—drinking two to four quarts of fluids daily, avoiding caffeine and alcohol, and drinking cranberry juice* (Sollitto, 2013, para. 7).

Understanding urinary tract infections in the elderly. (2013). Parentgiving, Inc.  Retrieved from http://www.parentgiving.com/elder-care/understanding-urinary-tract-infections-elderly/

Urinary infections can occur anywhere along the urinary tract—the kidneys, the bladder, and the urethra (Parentgiving, 2013, para. 1).  Women, however, are more susceptible than men since their urethra is shorter and closer to the anus while older adults are more vulnerable because of their suppressed immune systems (Parentgiving, 2013, para. 2).  While younger healthy adults totally empty their bladder when urinating, a weakness in an older bladder’s muscles causes them to retain urine.  Moreover an enlarged prostate in men and bladder prolapse in women can hold back urinary flow (Parentgiving, 2013, para. 3).

Since sometimes a urinary tract infection may be misdiagnosed as dementia, the urine should be checked regularly for cloudiness, blood, and strong or foul smell, and caregivers should question older patients about the frequent urge to urinate, pain and burning upon urination, and lower pelvis pressure (Parentgiving, 2013, para. 4).  Once a physician diagnoses a particular type of UTI, he or she usually prescribes an antibiotic (Parentgiving, 2013, para. 5). Preventive measures for women include not douching or using feminine hygiene products and wiping front to back.  Both men and women with no family history of kidney stones also need to drink plenty of water, and wear daily-changed cloth undergarments.  Long-term care residents need their adult diapers changed regularly (Parentgiving, 2013, para. 6).  Although this article also recommends drinking cranberry juice (Parentgiving, 2013, para. 6), recent studies* downplay its effectiveness. 

Urinary tract infections—adults. (2013, February 27).  Medline Plus.  Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/000521.htm

Medicine classifies urinary tract infections as bladder or kidney infections or urethritis since bacteria enters the urethra and bladder, but it can spread to the kidneys (Medline Plus, 2013, para. 1-2).  Women are more susceptible to such infections since their urethra is shorter and closer to the rectum than the male’s, and while using a diaphragm or pregnancy makes younger women susceptible to UTIs, menopause increases this risk in older women as does the use of catheters, incontinence, narrowed urethras, kidney stones, immobility in all older adults, and an enlarge prostate does in middle age and elderly men (Medline Plus, 2013, para. 4 & 6).

Symptoms usually include cloudy, bloody, and/or strong smelling urine, low fever, pain upon urinating, lower abdomen cramps, back pain, and the strong urge to urinate and as the infection spreads to the kidneys chills, shaking, night sweats, fever over 101 degrees Fahrenheit, flushed skin, nausea and vomiting, and confusion in the elderly (Medline Plus, 2013, para. 7-8).  Routinely, urinalysis studies urine samples for white and red blood cells, bacteria, and nitrates while urine cultures determine which antibiotics to use.

With antibiotic treatment, mild bladder infections clear up in 3 days in women and from 7 to 14 days in men while a kidney infection means taking antibiotics for one or two weeks if the patient drinks plenty of fluids and takes al the medication.  After beginning treatment for a bladder infection, symptoms often disappear within 24 to 48 hours infection, but it takes at least a week for a kidney infection to disappear.  UTI infections are more severe in the elderly, the pregnant, and patients who have kidney stones as well as those who have recently suffered from urinary tract infections or have been previously diagnosed with cancer, diabetes, Multiple Sclerosis, spinal cord injuries (Medline Plus, 2013, para. 9-10 & 13, 15 & 18).   

Since complications of a urinary tract infection include sepsis and damage to the kidneys, a physician should be called upon experiencing back or side pains, chills, fever, or vomiting (Medline Plus, 2013, para. 19).  Possible prevention measures include the use of estrogen creams in the vagina, wearing sanitary pads instead of tampons, no douching—in women, and for all adults—taking showers instead of baths, keeping the genitals clean, urinating before and after intercourse, and wiping front to back (Medline Plus, 2013, para. 20).

Preventing Urinary Tract Infections:

Some Scholarly Studies 

Recent studies disclose that drinking cranberry juice is not as effective as earlier studies indicated as shown by a comparison of a 2001 study and a 2012 study; however, topical estrogen does significantly decrease the incidence of urinary tract infections.

Kontiokari, T., Sundqvist, K., & Pokka, T. et al.  (2001, June 30). BMJ, 322.  doi: 10.1136/bmj.322.7302.1571.  Retrieved from http://www.bmj.com/content/322/7302/1571.short

A 12-month randomized  British trial that required the daily drinking of  50 milliliters either of cranberry-lingo berry juice, lactobacillus GG drink, or no treatment at all to prevent urinary tract infections in women found a 20 percent reduction in urinary tract infections in the cranberry-lingo berry juice drinkers while the lactobacillus group found no reduction in URIs in a relatively small sampling of women.

Jepson, R. G., Williams, G., & Craig, J. C. (2012, October 17).  Cranberries for preventing urinary tract infection. Cochrane Library. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001321.pub5/abstract

In the third update of a study originally published in 1998 and updated in 2004 and 2008, a randomized, controlled trail and a quasi RCT of cranberry products found that cranberry products, whether in drink and pill form, are less effective over the long term than earlier studies indicated in preventing urinary tract infections in women. This study analyzed a larger group of participants than the originally studies did.

Della Martina, M., Xodo, S, & Vogrig E. et al. (2012, August).  [Hormone replacement therapy and urogenital disease in postmenopausal women]. Minerva Ginecologica. 64(4), 337-334.  Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22728578

Italian researchers note that since urogenital atrophy in postmenopausal women not only causes incontinence, prolapse, dyspareunia, vaginal dryness and recurrent urinary infection, topical use of estrogens may lower the risk of urinary tract infection as well as decreasing urogenital shrinkage.

Rez, R. & Stamm, W. E. (1993, September 9).  A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. New England Journal of Medicine. 309, 753-756. doi: 10.1056/NEJM199309093291102. Retrieved from http://www.nejm.org/doi/full/10.1056/nejm199309093291102#t=articleResults

Approximately 10 to 15 percent of women over age 60 have a greater risk of contracting urinary tract infections because vaginal pH increases while Lactobacilli disappear, and Enterobacteriacae take over the vagina—all of which increases susceptibility to URIs (Rez, 1993, para. 1).  A randomized, double-blind, placebo-controlled trial with 93 participants confirms earlier studies that topical estrogen creams significantly reduce UTIs for postmenopausal women.  In this study, vaginal pH decreases from 5.5 to 3.8 while the ratio of Enterobacteriacae declines from 67 to 31 percent while the placebo rates remain the same (Rez, 1993, para. 12). 
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*Recent medical research plays down the effectiveness of cranberry juice in the prevention of urinary tract infections.

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