How do utis cause confusion in the elderly

But this practice puts them at higher risk of infection because the bacteria has an opportunity to build up. It is important to remember that older adults living in a group setting such as senior communities or nursing homes are more likely to be resistant to the antibiotics most often prescribed for UTIs. They might require something stronger, as well as a longer course of antibiotics to combat the urinary tract infection.

Louis Children's Hospital. An additional five quality items were added to the quality assessment to determine if studies described the criteria used for confusion, UTI and bacteriuria, and if their criteria for UTI and confusion were valid and reliable.

Criteria for confusion were deemed valid and reliable if accepted criteria were utilised, including: the Confusion Assessment Method, the Organic Brain Syndrome Scale or the Diagnosis and Statistical Manual DSM criteria [ 15 , 16 , 17 ]. The modified checklist finally consisted of 14 quality items, grouped into: reporting, internal validity, external validity and criteria Table 2.

The risk of bias for each quality item was reported as low risk of bias, high risk of bias, unclear risk of bias or not applicable. Although the broad search strategy described was employed to enable the meta-analysis of data from included studies if deemed feasible, due to the heterogeneity of the data and the variety of definitions for confusion and UTI reported between the studies, meta-analysis was not conducted. Alternatively, a qualitative synthesis of the findings from the included studies was performed, structured around the quality of data, consistency of definitions and the evidence for the association between confusion and UTI.

Searches identified a total of records Fig. After duplicate records were removed, remained. These articles were then screened by title and abstract against the inclusion and exclusion criteria, leading to the exclusion of articles, as it appeared they clearly did not fulfil the eligibility criteria.

Eleven potential records were excluded as their full texts were unable to be obtained. The full texts of the remaining 54 articles were closely examined.

Two studies were also excluded as UTI and confusion were not assessed concurrently [ 51 ] and reported UTI was combined with other parameters [ 52 ]. Three additional studies that met the inclusion criteria were identified by searching the references of relevant articles and searching for studies that cited these articles. No studies were deemed suitable for quantitative synthesis. A total of 22 articles met the inclusion criteria and were included in the systematic review.

Flow diagram showing identification of studies for inclusion in this systematic review according to PRISMA guidelines. The quality of the studies included in this review varied considerably Fig. This is partially due to inclusion of all studies that reported data on the rate of confusion in patients with suspected UTI or bacteriuria, or vice versa, even if it was not the main objective of the study. In terms of internal validity, all applicable studies were deemed to have used appropriate statistical tests; however, half of the studies did not clearly describe other principle confounders in their comparison groups.

The external validity, however, of all studies, was generally very high. The quality of the criteria used to define UTI, bacteriuria and confusion varied considerably and was generally quite poor. Two studies employed a reproducible definition of UTI although neither employed published explicit criteria developed through expert consensus.

Many studies utilised discharge coding from patient databases which resulted in the reliability of their criteria being unable to be determined [ 59 , 60 , 61 , 62 , 63 , 64 , 65 ]. Two studies were identified that used criteria that were clearly inappropriate [ 66 , 67 ]. Three studies did not provide a definition for UTI, as they reported confusion in association with validated criteria for bacteriuria only [ 3 , 68 , 69 ]. Only one of these studies utilised an appropriate definition of bacteriuria and validated criteria for delirium [ 3 ].

Three of the studies which provided a definition for UTI also defined criteria for bacteriuria [ 56 , 58 , 67 ]. Almost all studies provided a definition of confusion criteria, but only eight studies used criteria that were valid and reliable Table 3 [ 3 , 54 , 55 , 60 , 66 , 70 , 71 , 72 ]. Five studies used criteria for confusion which were clearly not valid or reliable [ 65 , 67 , 68 , 69 , 73 ], and nine were unclear in their criteria used Table 4 [ 53 , 56 , 57 , 58 , 59 , 61 , 62 , 63 , 64 ].

There were four large retrospective cross-sectional studies, and among the remaining studies the number of patients in each study varied considerably from small community samples of 9 to larger hospital samples of Tables 3 and 4. The majority of the studies identified were cross-sectional in design.

In the two remaining studies, one conducted in a nursing home and the other in a psychogeriatric unit, the demographics of the patient sample were not provided. They were believed to be representative of an elderly population by their care setting. Interestingly, only two of the included studies had the explicit aim of exploring the association between confusion and UTI; however, ten studies did partially explore this association.

Twelve studies analysed the correlation between suspected UTI or bacteriuria and confusion Tables 3 and 4. No study used validated definitions of both confusion and UTI, so this association could not be reliably established. Only one study by Juthani-Metha et al. They found an association between bacteriuria and confusion with the relative risk being 1.

Following this review, it is evident that all of the studies which have explored the association between suspected UTI and confusion are methodologically flawed, due to poor case definition for UTI or confusion, or inadequate control of confounding factors introducing significant bias.

Subsequently, no accurate conclusions about the association between UTI and confusion can be drawn. One study of acceptable quality shows an association between confusion and bacteriuria. However, this sample of patients in whom they tested bacteriuria and pyuria were patients already suspected of having a UTI, introducing a bias into their calculation [ 3 ].

In summary, none of the 22 publications had sufficient methodological quality to enable valid conclusions. Frail residents are more likely to have bacteriuria [ 74 ]. Frailty also predisposes for cognitive decline [ 75 , 76 ]. Hence, there might be an indirect link between confusion and bacteriuria, easily misinterpreted as UTI causing confusion. This might explain some of the trends found in the existing literature.

Studies including hospitalised patients are likely to also include patients with pyelonephritis, a condition likely to result in confusion in a fragile elderly person. However, the typical nursing home situation usually involves the suspicion of confusion caused by a lower UTI acute cystitis in an afebrile patient. The primary aim of this review was not to evaluate the association between pyelonephritis and confusion. The primary question was if lower UTI with no fever in residents without a urinary catheter, with or without localised symptoms such as acute dysuria, urgency or frequency, is associated with confusion.

This review concludes that current evidence does not provide a clear answer to this question. The strengths of this review are mainly due to its methodological quality; that it utilised a broad search strategy, with no limits to age or date applied. This allowed for studies that were representative of an elderly population and without the explicit aim of reporting the relationship between confusion and UTI to be identified.

Another strength of this review was the registration of a protocol with pre-specified objectives and methods. The use of a second reviewer independently assessing the quality of selected studies also increases the quality of the review.

Limitations included limiting articles to English and being unable to assess the eligibility of the unobtainable full-texts. This review also did not attempt to include studies from the unpublished literature, introducing possible publication bias. Insufficient evidence is available to accurately determine if an afebrile lower UTI in elderly patients without an indwelling urinary catheter causes confusion.

Although studies exist that suggest there may be an association, they are significantly limited by their methodological quality. This is largely due to the frequent use of unreliable criteria for UTI and confusion, and frequently poor controlling for confounding factors. A reasonable attempt to resolve this issue are the McGeer and Loeb criteria [ 1 , 8 , 19 ].

However, it should be kept in mind that in the case of confusion these criteria are expert recommendations that cannot be confirmed due to the lack of an appropriate gold standard. This review highlights the importance of conducting well-designed studies and demonstrates that further high-quality research exploring the relationship between lower urinary tract infection and acute confusion is required.

A well-designed, large observational study with validated criteria for UTI and confusion may provide further insight into this association. However, the optimal solution to clarify this issue would be a randomized controlled trial comparing the effect of antibiotics versus placebo in patients with new onset or worsening confusion and presence of bacteriuria while lacking specific urinary tract symptoms. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria.

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Potentially preventable complications of urinary tract infections, pressure areas, pneumonia, and delirium in hospitalised dementia patients: Retrospective cohort study. BMJ Open. The cost of hospital-acquired complications for older people with and without dementia; A retrospective cohort study. Perioperative urinary retention, short-term functional outcome and mortality rates of elderly hip fracture patients.

Geriatr Gerontol Int. Nursing home residents attending the emergency department: clinical characteristics and outcomes. Treatment for UTIs should begin with narrow-spectrum antibiotics, say Dr. Lathia and Dr. These drugs are less likely to lead to antibiotic resistance and problematic side effects than broad-spectrum antibiotics. Other common narrow-spectrum must be used with caution when patients have chronic kidney disease or take blood pressure medication, as many older adults do; or because their side effects can be serious in older adults.

Do you give the older adult in your life cranberry juice or probiotics to prevent a UTI? The supplement, which has few side effects, sticks to bladder receptors that normally attract the E. Researchers also believe D-Mannose may keep bad bacteria from colonizing the digestive tract, which can harbor the bacteria responsible for UTIs in women.

Following these tips should help your aging relative stay healthy, productive and out of the hospital. Urinary tract infections UTIs are common. But they increase the odds for delirium, hospitalization and death in older adults who are frail.