Best Practices for Nurses in Identifying Urinary Tract Infection's, A Causative Factor of Dementia/Delirium in the Elderly

Submitted by: Elizabeth Kuper
Early in medical history, elderly men and women have suffered from dementia and delirium. It was thought men and women alike were possessed and many were eventually put to death for their abnormal behavior.

Could it be some people with dementia or delirium were suffering simply from what we know today to be urinary tract infections?
Today, modern medicine can reverse some dementia and delirium in elderly clients by implementing assessments, lab work, correct diagnosis and treatment. Recognizing signs and symptoms of a urinary tract infection in the elderly client is a nurses’ responsibility. Treating the client as ordered by the health care provider, along with encouraging adequate hydration, good nutrition and teaching excellent hygiene could restore the client’s baseline cognition and lead to a higher quality of life.
For nurses in a Long Term Care Facility (LTCF), taking care of the resident with dementia and occasional delirium is part of the daily job. Getting to know a resident and understanding his/her baseline cognition is generally helpful in assessing for the possible urinary tract infection (UTI).
The elderly client is extremely sensitive to factors such as surgery and anesthesia, drug toxicity and infections. Delirium can be caused by any of the above. The symptoms of delirium are often misdiagnosed as relating to other conditions. Agitation is a common symptom of delirium. Delirium in nursing homes is most often precipitated by an acute infection or a reaction to a medication. “The majority of aggressive outbursts that occur in long-term care are contributed by a small proportion of individuals, often with acute illnesses such as urinary tract infections,” (Borson, 2007). Common symptoms of urinary tract infections include: sudden reduced ability to focus, sustain or shift of attention, sudden onset of misperceptions, impaired judgment or decreased motor activity, confusion, loss of sense of time or place, changes in levels of alertness, changes in sleep pattern, restlessness, agitation and changes in personality. Delirium is not a normal part of aging. Delirium is a serious condition requiring urgent medical attention. If left untreated, the death rate is high. Finding and treating the cause of delirium can lead to proper treatment of a physical or mental problem, and help restore the client’s health and quality of life.
Dementia is a mental health issue which includes delirium, delusions, depression and behavior disturbances. Memory loss, language difficulties, failure to identify objects and disturbances in planning and organizing all characterize the early stages of dementia and can be considered part of the normal aging process in some clients with this diagnosis. In other clients, dementia can be caused by many different illnesses including treatable ones like urinary tract infections and vitamin deficiencies.
Nurses are easily side-tracked by the needs of other stakeholders rather than focusing on providing an evidence based nursing response. Advocacy on behalf of the resident is recognized as important, but responses are often overwhelmed by the expectations of doctors and other health professionals, family, unlicensed staff, and perceived documentation requirements. The overall effect is that the response to a suspected urinary tract infection appears to be randomly chosen than based on assessment and knowledge. All seems to suggest reactive, task-based approach to care rather than critical analysis of data pertaining to a specific client according to McMurdo and Gillespie (2007). They express concern that non-specific symptoms including anorexia, malaise and fatigue are often attributed to urinary infection and they council that without clear clinical evidence supporting these symptoms, other causes should be investigated before embracing an antimicrobial response.
Caring for resident’s in a Long Term Care Facility as a nurse for 40 or more hours per week allows the nurse to “get to know” his or her resident. It is the nurses’ responsibility to assess and prevent urinary tract infections. Variances from normal behavior alert the nurse to suspect a possible urinary tract infection in the resident. As stated by Finn (2006), author for Family Practice News, “urinary tract infections constitute one of the most common medical causes of agitation” (para. 5). Signs and symptoms of a urinary tract infection could be agitation, a change in mental status or a decline in general status. According to Lavoie-Vanghan ARNP-C, MSN, a decline in general status has been described as the only certain indication of urinary tract infections in the elderly. There is a wide variation in the way nurses recognize the signs and symptoms of urinary tract infections according to Brown (2007). We tend to use our nose and look for changes in behavior, instinct once you get to know the resident, more frequency of pads they go through and “Gee, he/she’s a bit off.” Assessment should include signs and symptoms of urgency, frequency, dysuria, cloudy or malodorous urine and hematuria. Some elderly clients may or may not present with fever. According to Juthani-Mehta (2006), definitions for Long Term Care nosocomial infections used by some physicians to meet the criteria for a suspected UTI, three of the following must be met:
1) Fever (>38 degrees C) or chills
2) New or increased burning pain on urination
3) New flank or suprapubic pain or tenderness
4) Changes in character of urine, and worsening mental function.
Once an assessment for the urinary tract infection has been done, action is taken per health care provider order to “obtain urine samples using aseptic technique and sterile equipment,” as noted by Kunin (2005). Urine is then sent to the lab to be cultured to identify the causative organism. To ensure the proper antibiotic is ordered, a sensitivity test is performed in the lab also. If positive for infection, the primary physician will give the order for the proper antibiotic treatment for the resident. The nursing assessment will continue throughout antibiotic treatment for side effects of the antibiotic such as nausea, vomiting, diarrhea or rash. As the resident resolves the infection, mentation should return to baseline.
Prevention of urinary tract infections is a continual challenge in the elderly. To help keep the resident on the right track and free from urinary tract infections, fluids must be encouraged if not contraindicated, as dehydration can contribute to urinary tract infections and delirium/dementia. It was clearly stated by Brown (2007), …there was a presumption of a casual link between fluid intake and potential for infection. “In winter you would not expect them (residents) to be getting as much fluid as they would in summer and then at the other end in summer they are not getting enough because it is so hot and they are getting more dehydrated.” This belief was partially supported by data collected concerning urinary tract infections in a nursing home which demonstrated “last year urinary tract infection rates peaked in Winter and then dropped right down in the Spring.” Variations such as environmental temperature control, urogenital integrity and overall health status has impact on outcomes. The long held response to a urinary tract infection to “push fluids” could best be summed up as “presenting optimal fluids in a 24-hour period can be realistic.” In other words, you cannot force fluids down people who don’t want to drink. Co-morbidity such as cardiac conditions and swallowing deficits were seen to constrain how much fluid could be “pushed.”
Good nutrition should be provided for the resident, superior hygiene maintained, prevention from becoming constipated, and employing a scheduled toileting plan, all contribute to decrease frequency of urinary tract infections (Adkins, 1997). Using a daily bowel movement record and behavior sheets can help to document and monitor potential risk factors for urinary tract infections along with accurate nursing assessments of the resident. If all the above requirements are met, the resident may return to his or her baseline cognition and be back on the fast track of their lives again.

Intervention 1 – Recognizing Signs and Symptoms of Urinary Tract Infections

Disadvantage 1 – Urinary tract infections in the elderly present many diagnostic and therapeutic challenges. Signs and symptoms may be confusing, and complications are more likely to occur. Prompt recognition, appropriate treatment and follow-up are essential to minimize the morbidity and mortality. In some elderly patients, the atypical presentation of urinary tract infections and the chronic illness that often occur with aging make diagnosis more difficult, treatment more urgent and complications more common. Elderly patients often have atypical symptoms, including new-onset urinary incontinence, gastrointestinal upset or a change in mental status according to Ziloski and Smucker (1989).
References
Smucker, D., Ziloski, M. American Family Physician. May 1989. Retrieved November 1, 2007. FindArticles.com. http://findarticles.com/p/articles/mi_3225/is_n5_v39/ai_7621759


Disadvantage 2 – As stated by Marx, Hockberger and Walls (2002), editors for Rosen’s Emergency Medicine: Concepts and Clinical Practice, “A urinary tract infection can happen anywhere along the urinary tract. The urinary tract includes the bladder, kidneys, ureters and urethra. Certain people are more likely to get urinary tract infections. Elderly people (especially those in nursing homes) and people with diabetes get more urinary tract infections.” The mental changes or confusion in the elderly are often the only signs of a urinary tract infection; possible spread to the blood should be considered.
References
Hockberger, R., Marx, J., Walls, R., eds. Rosen’s Emergency Medicine: Concepts and Clinical
Practices. 5th ed. St. Louis, MO: Mosby; 2002

Intervention 2 – Dehydration Related to Urinary Tract Infections in the Elderly

Disadvantage 1 – Ensure adequate hydration. “Recommended is 2.5 Liters per day in patients with recurring urinary tract infections. Often the signs and symptoms of urinary tract infections in the elderly are actually caused by dehydration,” (Powers, 2006).
References
Powers, M., BSN, RN. (2006). Gerontological Nursing, University of Massachussettes, Urinary Tract Infection: Guidelines to assessment, treatment, and prevention in the older adult. Lowell, MA.

Disadvantage 2 - “The elderly have a lowered thirst response. This condition combined with other possible effects of aging, including physical dependence on others, such as nursing home staff, often results in failure to maintain a safe level of hydration,” (Rasansky, 2007). Swallowing difficulties and generally poor food intake, common problems of the elderly, add to dehydration problems. Many of the elderly go to bed very soon after eating dinner or their last meal of the day. This often creates too long a time frame between fluid intake. The elderly should be encouraged to drink plenty of fluids before bedtime to prevent dehydration, which is a contributor to urinary tract infections.
References
Rasansky, J. (2007). Retrieved November 1, 2007 from www.nursinghomelawyer.com/nursing_home_law_firm/nursing_home_research/aging_ disease/dehydration.htm - 25k –





References



Adkins, V.K. & Mathews, R.M. (1997). Prompted voiding to reduce incontinence in community-dwelling older adults. Journal of Applied Behavior Analysis, 30 (1), 153-156. Retrieved January 31, 2006, from PubMed Central Database.

Borson, S. (2002). Symptom-Based Approach to the Treatment of Agitation and Aggression. Clinical Geriatrics, 10 (1), 1-12. Plainsboro, NJ.

Brown, S. & Nay, R. (2007. Urinary tract infection: under treated and investigated: a examination of the nursing management of urinary tract infections in nursing home residents experiencing impaired cognition. International Journal of Older People Nursing. 2, 20-24.

Finn, R. (2006). Agitation in dementia: A start TX nonmedically confounding
Environmental, psychological factors, as well as medications, often cause the condition. Geriatric Medicine, Family Practice News. 36 (1). Retrieved from Expanded Academic ASAP February 18, 2997.

Gillespie, N.D. & McMurdo. (2007). Urinary tract infection in old age; over
diagnosed and over treated. Age and Ageing. 20, 297-298. Retrieved from Medline May11, 2007

Hockberger, R., Marx, J., Walls, R., eds. Rosen’s Emergency Medicine: Concepts and Clinical
Practices. 5th ed. St. Louis, MO: Mosby; 2002


Judhani-Mehta, M. (2006). Suspected UTI in Nursing Home Patients: When to
Test (urinary tract infection). Consultant. 46. 1581. Retrieved January 23, 2007, from Expanded Academic ASAP via Thomas Gale.

Kunin, C.M. (2005). Detection, prevention, and management of urinary tract infections. (3rd Ed.). Philadelphia, PA. Lea and Febiger. Retrieved February 10, 2007, from Centers For Disease Control. www.cdc.gov


Lavoie-Vaughan, N. (2005). Prevent UTI’s in the Elderly. Nursing Spectrum.
Masthead Date April 11, 2005. Retrieved February 10, 2007 from http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=13984


Powers, M., BSN, RN. (2006). Gerontological Nursing, University of Massachussettes, Urinary Tract Infection: Guidelines to assessment, treatment, and prevention in the older adult. Lowell, MA.

Rasansky, J. (2007). Retrieved November 1, 2007 from www.nursinghomelawyer.com/nursing_home_law_firm/nursing_home_research/aging_ disease/dehydration.htm - 25k –

Smucker, D., Ziloski, M. American Family Physician. May 1989. Retrieved November 1, 2007. FindArticles.com. http://findarticles.com/p/articles/mi_3225/is_n5_v39/ai_7621759