UTIs In The Elderly: Quick Facts

• UTIs are very common and only increase with age: Half of all women will have a UTI in their lifetime. (1,2)
• UTIs are the most common infection in people over 65, whether they live independently or in nursing homes. (3)
• UTIs cause 5% of all ER visits in the elderly. (4)
• UTIs are more common in elderly women- about 30% of women per year1- at two to three times the rate of men. (5)

Common Risk Factors for UTIs

The cause of UTIs doesn’t change; bacteria travel from the skin, genitalia or gut into the bladder.

Some well-known risk factors for UTIs are: (3,6)

• Sex more than three times a week
• Spermicide use or douching in women
• New or multiple sex partners
• History of UTI as a child
• Abnormal urine pH
• Family members with UTIs
• Prostate problems in men

However, the elderly have several characteristics that increase their chance of getting a UTI.

Risk Factors For UTIs In The Elderly:

For elderly women, a major risk for UTIs is low vaginal estrogen that happens after menopause. There are several reasons for this:

1. Low estrogen changes the vaginal flora, making it less acidic and reducing the number of “good” bacteria, like lactobacilli, which prevent infections.(1)
2. Low levels of estrogen thin vaginal tissues, possibly increasing the risk of UTIs after sex, the risk of cystocele (“dropped” bladder) and urine incontinence, all conditions associated with UTIs.(3,4)

The frequent UTIs in elderly men is related to the increase in prostate problems with age.

1. A large prostate can lead to poor bladder emptying, urine incontinence and prostate infections, all sources of UTIs.(3)
2. Furthermore, frail or physically impaired individuals have a higher chance of having a UTI.3 As we age, our immune system- our natural defense against infection- declines, putting us at increased risk for UTIs.(4)
3. Older people living in nursing homes are more likely to have UTIs compared to those living in their own homes.3 Also, individuals with neurological disorders, such as strokes and Alzheimer’s disease are all at increased risk for UTIs.(4)

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Other health issues that contribute to a higher risk of UTIs in the elderly

As we age, we tend to have more medical problems.

Medical problems, especially conditions like diabetes,(7) increase the risk of UTIs. Diabetes affects the immune system and directly weakens the bladder,(7) leaving individuals prone to UTIs. Other diseases that don’t directly affect the bladder or the immune system still increase hospital stays and medical procedures, which both increase UTI risk.(3,4)

UTIs Symptoms In The Elderly

The characteristic symptom of a UTI is pain with peeing, especially if UTI lasts less than a week. While there are other symptoms of UTIs- peeing more often, cloudy urine, bloody urine- these are less specific and may be due to other conditions, especially in the elderly patients. (5)

The difficulty arises when frail and elderly people can’t fully describe their symptoms. For example, a frail elderly woman who has had a stroke, urine incontinence and occasional painful urination may not notice, or be able to tell her family, that her symptoms are worse. In such a person, vague symptoms may be the only clue to a significant UTI.

These may be additional signs of a UTI in the elderly:

• sleepiness
• delirium
• falls
• dizziness
• fevers
• abdominal or side pain.

In almost half of the time in the frail and elderly, the only reason to suspect a UTI is a mental status change.

Bladder symptoms, such as painful peeing may be absent.(8).

Unfortunately, vague symptoms are not specific to UTIs and it takes care to figure out when these symptoms are really due to a UTI.

Asymptomatic Bacteriuria

A UTI is diagnosed only when there are urine symptoms and a urine sample shows bacteria. Asymptomatic bacteriuria occurs when there are bacteria in the urine without any bladder symptoms- no burning, pain or peeing frequently.

This asymptomatic bacteriuria may be anatomical or functional(3) and tends to run in families. It is also more common in people with incontinence, men with large prostates or diabetic women.(4,9)

Importantly, asymptomatic bacteriuria is very common in the elderly- about 20% of older women and up to 15% of elderly men are diagnosed with a high bacterial count in urine without UTI symptoms.(3)

Asymptomatic bacteriuria should never be treated (4) (except in pregnant women and those having surgery on the bladder or urinary system). Antibiotics lead to drug-resistant bugs, side effects from the medicines and large financial costs.(9) In fact, treating asymptomatic bacteriuria does not reduce the risk of future UTIs(9) or permanently get rid of the bladder bacteria.(4)

In elderly adults, it is difficult to differentiate asymptomatic bacteriuria from true UTI if there are vague or chronic symptoms. This is why it is important that the elderly are thoroughly evaluated before indiscriminately being given antibiotics. Especially in the elderly, antibiotics have many side effects, including kidney and liver damage, and should be used only when needed.

Current Guidelines For Treatment Of UTI In The Elderly

Antibiotics
The tried and true treatment of a UTI is a course of antibiotics. Of course, this should only be given after a confirmed UTI, meaning a urine test showing infection and symptoms compatible with a UTI.

Treatment length depends on the person’s baseline health and the severity of the infection. Generally, an antibiotic course ranges from 1-14 days depending on these factors, as well as the antibiotic is chosen.(4)

Repeating the urine test after finishing the course of antibiotics is not needed.(3)

Recurrent bacteria is common and will only change the plan if the person is symptomatic. It is especially concerning if the person receives multiple courses of antibiotics or never seems to be “cured” from the UTI.

At that point, the health care provider must look for an underlying cause that is not treated by antibiotics, such as kidney stones or interstitial cystitis.

Delayed treatment- a good option

Importantly, up to half of the women are able to get rid of the UTI within a week, without any antibiotics.(10) Research showed that a one or two day course of ibuprofen is an option in healthy patients with a simple UTI.(11)

It’s important that there is a doctor follow up, in case the symptoms continue or get worse.
While some studies showed this to be a safe plan,(10,11) a recent study indicated that postponing antibiotics can put some people at a slightly higher risk of kidney infections and increases the duration of symptoms.(6,12)

With this plan, it’s important to drink lots of water to flush out the bladder. An alternative to ibuprofen (if that is not an option) is Azo.(6)

Prevention of UTI in the elderly

Walking regularly
Elderly patients who are sedentary increase their chance of UTIs, especially in nursing homes. Studies showed that individuals who can’t walk or need help walking were more likely to be hospitalized for a UTI.(4) Getting up to walk on regularly reduces this risk.

Preventive antibiotics
A common option for preventing recurrent UTIs (3 or more UTIs per year) is a daily dose of antibiotics for up to six months to a year. This is controversial because while antibiotics decrease the number of UTIs while prescribed, some patients have recurrent UTIs once they stop the antibiotics. In addition, there is an increased risk of resistant bugs that require even stronger antibiotics.

Read about bacterial biofilms in case if your doctor prescribed antibiotics

Side effects of the antibiotics such as nausea and diarrhea, vaginal yeast infections and skin rashes are also common.(6)

An alternative for women who have UTIs associated with sex is to take a single dose of antibiotics right after sex. This may decrease the number of antibiotics taken and the side effects. This antibiotic should be taken within 2 hours of sexual activity.(6)

Vaginal Estrogen
Vaginal- not oral- estrogen reduces recurring UTIs in post-menopausal women.(5,13,14)

After menopause, the loss of vaginal estrogen changes the vaginal flora, increases the risk of a “dropped bladder,” urine incontinence and poor bladder emptying, all factors that increase UTIs.(13) Replacing estrogen locally can help all of these issues.

In a large meta-analysis- a compilation of several research studies- women treated with topical estrogen reduced their chance of repeat UTI by half.(14) Vaginal estrogen may not be recommended in people with a history of breast or uterine cancer or blood clots. Another option is non-hormonal vaginal lubricants, such as Luvena, or  Salve with Vitamin E and gorgonian extract, which will moisturize and soothe the perineal area.

Supplements

Cranberry
Proanthocyanidin (PAC) is the ingredient in cranberry that blocks E. coli, a common UTI causing bacteria, from attaching to the bladder and causing an infection. There is conflicting evidence as to cranberry’s benefits, likely because research studies did not always provide the recommended amount or correct formulation of cranberry.(6)

To prevent UTIs, 36 – 72 mg of PAC should be taken daily.(4,6,13)

 The type of cranberry is also important; sweetened cranberry juices often have too much added sugar and may not have the recommended amount of PAC.

D-Mannose:
This is a sugar similar to glucose that stops bacteria from sticking to the bladder wall.

There has been concern regarding D-mannose’s effect on blood sugar levels, especially in diabetes. However, new research shows that D-mannose is overall beneficial. It reduces inflammation and may improve autoimmune diabetes (Type 1 DM).(15) However, you should still talk to your doctor about this supplement if you have diabetes.

Probiotics
These “good” bacteria are naturally occurring and keep both the vagina and gut-healthy by limiting “bad” bacteria.

Probiotics can be taken by mouth or as a vaginal suppository. There is some concern that oral probiotics are not as effective (because they must pass through the gut before getting to the vagina). Lactobacilli species, especially L. rhamnosus GR-1 and L. reuteri16 are best for urogenital infections.

There is conflicting research about the benefit of probiotics for UTIs,(1,13,16) but they are consistently beneficial in treating vaginal infections.(16) Despite this, many women swear by probiotics and notice an improvement in the frequency and severity of UTIs when used regularly.

Make sure to adjust your diet, as well to include food that promotes alkaline urine and feeds beneficial bacteria.

Traditional Chinese Medicine (TCM) and Herbal Remedies

Traditional Chinese Medicine (TCM) has used herbal remedies to treat a host of human illnesses for millennia.

Recent research (13) confirms what the Chinese already know. A meta-analysis including almost 300 women showed that these herbal remedies are effective for treating current UTIs and preventing future ones.(1)

TCM also improves the effectiveness of antibiotics when taken together. Among the beneficial remedies was Er Xian Tang (Two Immortals Decoction).

Another study showed a benefit of Angocin, a combination of horseradish root and nasturtium.(17)

Acupuncture– a part of TCM that targets qi (life force) points within the body- also helps prevent UTIs and is effective when done twice a week for four weeks.(13)

UTI Vaccines

Uro-Vaxom® is an oral UTI vaccine. Not available in the US, it has been used in Europe and elsewhere to prevent recurrent UTI for over a decade.

Like other vaccines, it contains small amounts of the cause of infection (in this case 18 different types of killed E.coli). Studies show vaccinated people have less UTIs compared to people without any treatment.(13)
Urovac (or Solco-Urovac) is a vaginal UTI vaccine. Like Uro-Vaxom®, it contains killed E.coli, but it also contains other strains of bacteria that also cause UTIs. It reduces the number of UTI causing bacteria in the bladder and vagina. Urovac was shown to reduce recurring UTI, especially when a “booster” dose was given. Almost one-third of women noticed vaginal irritation.(13) Unfortunately, this too is not available in the US.

Conclusion

UTIs are very common in the elderly. While there are some similarities with other age groups, there are certain things to keep in mind:

• UTIs in the elderly are common and are more challenging to diagnose.
• Delirium and other changes in mental status might indicate an underlying UTI infection.
• Also, they are more susceptible to side effects from antibiotics and this must be kept in mind when treating UTI.
• Despite this, there are many options to treat UTIs in this group.

References:

1. Flower A, Wang LQ, Lewith G et. al. Chinese herbal medicine for treating recurrent urinary tract infections in women. Cochrane Database Syst Rev. 2015 Jun 4;(6):CD010446.
2. Schwenger EM, Tejani AM, Loewen PS. Probiotics for preventing urinary tract infections in adults and children. Cochrane Database Syst Rev. 2015(12):CD008772.
3. Robichaud S & Blondeau JM. Urinary Tract Infections in Older Adults: Current Issues and New Therapeutic Options. Geriatrics and Aging. 2008;11(10):582-588.
4. Rowe TA & Juthani-Mehta M. Diagnosis and management of urinary tract infection in older adults. Infect Dis Clin North Am. 2014 Mar;28(1):75-89.
5. Mody L & Juthani-Mehta M. Urinary Tract Infections in Older Women: A Clinical Review. JAMA. 2014 Feb 26; 311(8): 844–854.
6. Arnold JJ, Hehn LE & Klein DA. Common Questions About Recurrent Urinary Tract Infections in Women. Am Fam Physician. 2016 Apr 1;93(7):560-569.
7. de Lastours V & Foxman B. Urinary tract infection in diabetes: epidemiologic considerations. Curr Infect Dis Rep. 2014 Jan;16(1):389.
8. D’Agata E, Loeb MB, Mitchell SL. Challenges in assessing nursing home residents with advanced dementia for suspected urinary tract infections. J Am Geriatr Soc. 2013 Jan; 61(1):62-6.
9. Nicolle LE, Bradley S, Colgan R et. al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005 Mar 1;40(5):643-54.
10. Knottnerus BJ, Geerlings SE, Moll van Charante EP et. al. Women with symptoms of uncomplicated urinary tract infection are often willing to delay antibiotic treatment: a prospective cohort study.BMC Fam Pract. 2013 May 31; 14():71.
11. Falagas ME, Kotsantis IK, Vouloumanou EK, Rafailidis PI. Antibiotics versus placebo in the treatment of women with uncomplicated cystitis: a meta-analysis of randomized controlled trials.J Infect. 2009;58(2):91–102.
12. Gagyor I, Bleidorn J, Kochen MM et. al. Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: randomized controlled trial. BMJ. 2015 Dec 23;351:h6544.
13. Beerepoot MA, Geerlings SE, van Haarst EP, van Charante NM,  Riet G. Nonantibiotic prophylaxis for recurrent urinary tract infections: a systematic review and meta-analysis of randomized controlled trials. J Urol. 2013;190(6):1981–1989.
14. Perrotta C, Aznar M, Mejia R, Albert X, Ng CW. Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database Syst Rev. 2008;(2):CD005131.
15. Zhang D, Chia C, Jiao W et. al. D-mannose induces regulatory T cells and suppresses immunopathology. Nat Med. 2017 Sep;23(9):1036-1045.
16. Abad CL, Safdar N. The role of lactobacillus probiotics in the treatment or prevention of urogenital infections–a systematic review. J Chemother 2009;21:243-52.
17. Albrecht U, Goos KH & Schneider B. A randomized, double-blind, placebo-controlled trial of a herbal medicinal product containing Tropaeoli majoris herba(Nasturtium) Armoraciae rusticanae radix (Horseradish) for the prophylactic treatment of patients with chronically recurrent lower urinary tract infections. Curr Med Res Opin. 2007 Oct;23(10):2415-22.