Urinary Tract Infections (UTIs) in Older Adults

Urinary tract infections (UTIs) are common in adults 65 and older, mainly due to age-related factors like malnutrition, poor bladder control, and uncontrolled diabetes.

Symptoms in older adults may also differ from those of younger people, with typical symptoms including pain during urination and atypical ones being drowsiness, confusion, loss of appetite, and delirium (a state of confusion and disorientation that usually occurs abruptly and is temporary).

UTIs can be misdiagnosed in older adults, particularly those who are physically weak or in nursing homes, in whom delirium may be mistaken for dementia (progressive impairment in mental functions). Treatment can be more complicated at this stage of life, often requiring a larger arsenal of antibiotics to clear the infection.

Causes of UTIs and Why the Risk Increases With Age

Urinary tract infections are among the most common infections encountered in medical practices. They are caused by bacteria usually on the skin or rectum entering the bladder via the urethra (the tube through which urine enters the body), mostly commonly from bacteria on the skin or rectum.

UTIs can affect people of all ages and sexes. However, females have a higher incidence than males, in large part because their urethras are shorter and situated closer to the anus.

While UTIs can affect anyone, people who are immunocompromised (have a weakened immune system) or are living with diabetes or chronic kidney disease are more vulnerable to infection. These conditions are common in the United States, particularly with older age.

Risk Factors in Older Adults

According to a 2018 study involving 931,945 older adults, the rate of UTIs in adults over age 85 is more than double that of adults age 65 to 74. In fact, after the age of 85, around 74% of men and 85% of women will have been diagnosed with a UTI.

Many factors account for this, including:

• Enlarged prostate
• Exposure to bacteria in skilled nursing facilities
• Functional disability (the inability to adequately care for oneself independently)
• Having multiple comorbidities (coexisting health conditions), including diabetes, chronic kidney disease, or stroke
• History of UTIs (a risk factor at any age)
• Immunosenescence (the aging-related decline of the immune system)
• Impaired cognitive function, including dementia
• Loss of bladder control or bowel control
• Malnutrition (which lowers the ability to fight infection)
• Physical weakness and impaired mobility
• Use of urinary catheters (a tube that allows urine to drain from the bladder)

Common Symptoms

Typical UTI symptoms include:

In severe cases, there may also be fever with chills, nausea and vomiting, and blood in the urine.

Older adults with a UTI can experience these typical symptoms in addition to atypical symptoms, especially in those who are physically weak, cognitively impaired, or bedridden.

In many (but not all) elderly people, a UTI will present with the following:

• Absence of fever
• Delirium (confused thinking and awareness)
• Dizziness and falls
• Increased sleepiness
• Loss of appetite
• Sudden fatigue
• Sudden bed-wetting
• Sudden fatigue
• Sudden onset of confusion

These atypical symptoms in older, physically unwell adults may be missed or attributed to other causes, including medications they may be taking. Delirium, a generally reversible mental state, may be mistaken for dementia, which is not reversible. Because of this, treating a UTI may be delayed until the person’s condition turns critical.

What’s the Best Treatment?

UTI treatment in older adults is similar to that of younger adults but with some key differences. The choice of antibiotics tends to be more targeted. This is due in part to drug interactions (how a drug’s actions in the body are altered by another substance) and contraindications (reasons a drug is not advised or safe to use) that can occur when taking certain antibiotics with medications used to treat diabetes or kidney disease.

For instance, antibiotics known as fluoroquinolones are generally avoided in people with advanced chronic kidney disease due to an increased risk of delirium, hypoglycemia (low blood sugar), and abdominal aortic aneurysm rupture.

Similarly, certain antibiotics can interfere with the control of diabetes and contribute to the onset of type 2 diabetes.

Because of this and other factors, broad-spectrum antibiotics are avoided by many healthcare providers in favor of single-agent antibiotics that target specific bacteria. Doing so also reduces the risk of antibiotic resistance (bacteria becoming less responsive to an antibiotic), a factor especially important to people with recurrent UTIs.

For an uncomplicated UTI, the following oral antibiotics can be used:

• Macrobid or Macrodantin (nitrofurantoin), 100 milligrams (mg), taken once daily for five days
• Bactrim or Septra (trimethoprim-sulfamethoxazole): One double-strength tablet taken twice daily for three days
• Monurol Sachet (fosfomycin): 3,000 mg oral solution taken as a single dose

Nitrofurantoin is considered the first-line option. Fosfomycin is an acceptable alternative if nitrofurantoin cannot be used. Other antibiotics, including Vantin (cefpodoxime), may be used if these preferred options are unavailable.

Other antibiotics may be chosen for people with indwelling catheters who are more likely to have multidrug-resistant bacteria.

Getting a Diagnosis

UTIs in older adults are often missed because many of the symptoms are nonspecific, meaning they could be caused by other conditions, or they are attributed to being labeled “aging-related.”

In the end, the main clue that an older adult has a UTI is the sudden or new appearance of symptoms. This includes the sudden onset of confusion, bed-wetting, or dementia-like symptoms.

Even if a person has dementia, the sudden decline of cognitive function accompanied by the sudden loss of appetite or increased sleepiness may be a sign that a UTI is involved.

Suspected UTI

If a UTI is suspected in someone who is frail or has multiple comorbid conditions, treatment may be started presumptively if the following two conditions are met:

• Presence of urinary symptoms, such as frequent urination, urinary incontinence, or bloody urine
• Urinary symptoms accompanied by either high fever with chills or clear signs of delirium

To diagnose delirium, the healthcare provider will need to exclude all other possible explanations for the altered mental state, including medications and stroke.

Confirming the Diagnosis

Whether antibiotic treatment is started presumptively or not, the provider will need to confirm the diagnosis with two tests:

• Urinalysis: This is the chemical and microscopic examination of a urine sample to check for the presence of white blood cells (WBCs). Without WBCs in urine, a UTI is unlikely.
• Urine culture: This involves transferring a small amount of urine to a sterile plate to see which type of bacteria grows. This can identify the exact bacterial species and help select the correct antibiotics.

In people with an uncomplicated UTI, a urine culture may not be necessary. But for those with severe symptoms or recurrent infections, a urine culture is considered essential.

What Happens If a UTI Goes Untreated in Older Adults?

Many of the atypical symptoms of UTIs in older adults are due to the systemic (whole-body) inflammation caused by the bacterial infection, known as bacteremia.

Because UTIs in older adults may occur without fever, the infection can go untreated for long periods, exposing the body and brain to increasing levels of inflammatory chemicals known as cytokines. This largely accounts for the onset of delirium along with sleepiness and the loss of appetite.

As bacteria continue to multiply, the infection can spread beyond the bladder and urethra into the kidneys, causing a kidney infection known as pyelonephritis. Symptoms tend to be more severe than an uncomplicated UTI, often causing:

• Cloudy, dark, bloody, or foul-smelling urine
• Dull or sharp stabbing pain in your back, side, or groin
• Fever with chills
• Frequent, painful urination
• Nausea or vomiting

In severe cases, pyelonephritis can cause a severe reaction known as urosepsis. In urosepsis, the body launches an exaggerated inflammatory response to the infection and causes damage to cells and tissues.

Urosepsis is a medical emergency. Early signs include fever, low body temperature, rapid breathing, a fast heart rate, confusion, and the swelling of tissues (edema). Left untreated, urosepsis can cause a life-threatening drop in blood pressure, leading to septic shock (a life-threatening response), major organ failure, and death.

Ways to Prevent UTIs

UTIs are common. As such, it can be difficult to avoid. The standard methods of prevention of UTIs include:

• Keeping well hydrated: Older adults are especially prone to dehydration, which can concentrate bacteria in urine. By keeping well hydrated, you can help flush bacteria from your urinary tract. Plain water works best.
• Practicing good hygiene: For females, this includes wiping from front to back after a bowel movement, which reduces exposure to bacteria from stool. Also, avoid long baths; showers are better to prevent skin bacteria from entering the bathwater and your urethra.
• Urinating often: “Holding it in” allows bacteria to multiply in your urine and establish an infection. Doing so also weakens the bladder, making it increasingly more difficult to fully empty it.
• Using vaginal estrogen: A drop in estrogen levels after menopause (cessation of menstrual periods) can throw off the balance of vaginal bacteria. It can also make tissues around the urethra thinner and more susceptible to infection. A topical estrogen cream can help prevent this.
• Wearing breathable cotton underwear: This reduces the heat and moisture around the genitals which promotes bacterial growth. Change your underwear daily, and carry an extra pair with you if you are prone to bladder leakage and have an accident.

If you have a loved one who is physically weak or bedridden, you can reduce the risk of UTIs by:

• Maintaining proper sanitation: This includes changing underwear daily or when soiled, changing wet or soiled bedding immediately, and having someone on hand to assist with regular toileting and bathing.
• Maintaining hydration: The amount of water can vary but is generally around 8.5 cups (2 liters) per day for most adults. Avoid alcohol and caffeine, which can irritate the bladder and promote urination. Monitor water intake closely to avoid dehydration.
• Practice catheter safety: The genitals and groin should be cleaned twice daily in people with indwelling catheters. Urine should be drained from the collection bag when it is two-thirds full. Strict sanitary practices should be maintained when inserting or removing standard catheters.

Summary

UTIs are more common as people age. The symptoms in older adults can differ from those in younger people. In older adults, UTIs may not cause fever but may instead cause loss of bladder control, loss of appetite, increased sleepiness, confusion, dizziness, falls, and delirium.

Older adults are vulnerable to UTIs due to factors such as malnutrition, impaired mobility, loss of bladder or bowel control, comorbid illnesses like diabetes, and aging-related immune function. Treatment for UTIs in older adults involves the same antibiotics used in younger adults, but adjustments may be made for people with recurrent UTIs or who regularly use catheters.