Dr Rod Kersh’s first blog for us is about Urinary Tract Infections or UTI’s. At Dementia Congress this year, we both heard a presentation about how home carers should respond to issues like UTI’s. It is fair to say that Rod didn’t agree with all that was said, so I asked him to share his knowledge and expertise here.
UTI’s have become part of an older persons’ mythology – take an older person to an A&E department, and the likelihood is they will receive a diagnosis of UTI – whether or not this is the case. Or, someone living with dementia in a care home becomes more confused – phone the GP, describe the symptoms (more confused) and, voila, Trimethoprim – the most commonly used antibiotic to treat urine infections.
All of this does sometimes make sense – older people because of a variety of factors – dehydration, constipation, bladder stones, medicines and so on are prone to urine infections, with women being affected significantly more than men.
Urine infections can cause a state of delirium – temporary confusion or disorientation, particularly in older people and those who have dementia.
Yet, these facts do not mean that every older person who is temporarily confused or out of sorts has a urine infection – there are a multitude of other reasons, which by reaching for the antibiotics we can potentially miss.
This brings us to the question that people are likely to ask…
What to do when we suspect someone has a urine infection?
When I started-out in medicine there was a belief that older people were more prone to non-specific symptoms than other people, less likely to have a fever during illness or the other symptoms we know are associated with UTI’s. We now know this is not the case. Older people are as likely as anyone to experience symptoms; therefore, the first questions are – what are the symptoms?
- Frequency – passing urine more often than usual
- Urgency – the need to rush to the toilet urgently
- Dysuria – pain on passing urine
- Pain in the lower abdomen
- New incontinence
- Very high or low temperature
- Blood in the urine
- Worsening or new confusion
In order to diagnose a urinary tract infection, two or more symptoms are required – anything less and antibiotics can do more harm than good.
The only way to really diagnose a urine infection is by sending a sample to the labs for analysis – this can take a couple of days, which means, it is usually best to get a sample as early as you suspect something might be wrong.
To make this all more complicated, older people are prone to a condition called ‘asymptomatic bacteruria’ – this is the presence of bacteria in the urine which is not causing any symptoms and can be found in up to one third of people over the age of 65. Treating asymptomatic bacteruria does not help people and significantly increases the risk of side-effects from antibiotics and the development of bacterial resistance, so that when you really need an antibiotic it is less likely to work.
Here are some suggestions to prevent UTIs and maintain wellbeing…
- Ensure people maintain an adequate fluid intake – older people often under-drink and exist in a state of dehydration (sometimes because of the false belief that not drinking lessens the need to pass water or experience incontinence – the opposite is actually true; more concentrated urine is more irritant and more likely to cause the need to pee).
- Have a universal container available – these are specimen bottles that you can use to send a sample to the lab before a person becomes unwell.
Some questions from Helen…
When you say ‘adequate’ what does that mean in practice? Is it the 8 glasses a day?
Everyone is different – that is the essence of person-centred care; some people manage to get along on minimal amounts of fluid, others drink gallons. Perhaps the best barometer is whether a person is thirsty – although this can be affected by old age and certain conditions such as dementia.
Another way of measuring adequacy is to check the colour of urine – if it is too dark or concentrated, more fluid is required! There are scales that you can have where you can easily tell this.
An easy way to increase fluid intake is to count the number of drinks in a day and aim to increase the volume by a cup or two.
I have seen situations where relatives almost bully their parents or grandparents to drink more – as the saying goes, you can lead a horse to water. People will only drink what they want.
Do GPs accept any type of universal container? Does it need to be sterilised?
You can obtain a sterile universal container from the GP surgery – a sample is best taken at the first sign of an infection, before the older person has become unwell. The signs to look out for are described above.
I know of one home care organisation that routinely tests peoples urine each week- what do you think about that?
This to me is an incredible waste of time and likely overly intrusive. Samples should only be taken when a person has symptoms, otherwise you will detect asymptomatic bacteruria which if treated increases resistance and predisposes to complications like Clostridium difficile diarrhoea.
A commissioner I work with mentioned some specific pants that detect urine infections so that testing is not necessary. What do you think of these?
These are pants function a little like dipsticks – if they are in contact with urine that has bacteria the pads change colour. These like dipsticks have fallen out of favour as they are very inaccurate and likely to give false positives i.e. suggesting there is an infection present when there is not. The pads like dipsticks only suggest an infection, they also do not inform you as to which antibiotic would be best. Using the wrong antibiotic can prolong the illness and result in both bacterial resistance and side effects. Urine samples are best.
Sometimes, in the case of a person who is bedbound or incontinent, it is difficult to obtain a sample; often people are able to provide a sample if they are asked – we sometimes assume they are unable; in situations where no sample can be provided, I would suggest the local care of older people team or continence specialist should be involved.
I will cover situations where people have long-term indwelling urinary catheters in a separate blog.
We were both at an event recently when the presenter talked about how difficult it was to persuade GP colleagues to see people quickly with suspected UTIs – and that it was better to do a urine test and tell the GP the result – what do you think of that?
Practice varies across the country. Most GPs want the best for their patients and will be happy to collaborate in determining the best way to treat a patient. I suspect what we are proposing is a change to the relationship whereby the Wellbeing Worker acts as an advocate for the person they are supporting and advises the GP – ‘I am worried that Enid has a urine infection as she is going to the loo more frequently. I have sent a sample. Can you help?’ – Wellbeing Workers will with time develop very close relationships with the people they support and this knowledge is invaluable to doctors and nurses in their assessments.