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 ].
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.
- Urinary Tract Infections in Older Adults: Current Issues and New Therapeutic Options.
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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.
Urinary tract infection among older patients in the home care services
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. Infect Control Hosp Epidemiol. Interobserver variability in the assessment of clinical criteria for suspected urinary tract infection in nursing home residents.
Clinical features to identify urinary tract infection in nursing home residents: a cohort study. J Am Geriatr Soc. Infections and antibiotic resistance in nursing homes. Clin Microbiol Rev. Nicolle LE. Urinary tract infections in long-term—care facilities. Clinical uncertainties in the approach to long term care residents with possible urinary tract infection. J Am Med Dir Assoc. The association of bacteriuria with resident characteristics and survival in elderly institutionalized men.
Ann Intern Med. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis.
Nelson JM, Good E. Urinary tract infections and asymptomatic bacteriuria in older adults. Nurse Pract. Antimicrobial resistance in urinary pathogens among Swedish nursing home residents remains low: a cross-sectional study comparing antimicrobial resistance from to BMC Geriatr. A Systematic Review. Can Geriatr J. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. Clarifying confusion: the confusion assessment method.
International Journal of Geriatric Psychiatry: A journal of the psychiatry of late life and allied sciences. American Psychiatric Association. Washington: American Psychiatric Pub; Definitions of infection for surveillance in long-term care facilities. Am J Infect Control. Development of minimum criteria for the initiation of antibiotics in residents of long-term—care facilities: results of a consensus conference.
Potentially preventable complications of urinary tract infections, pressure areas, pneumonia, and delirium in hospitalised dementia patients: Retrospective cohort study.
- Seniors Are Prone to UTIs!
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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.nn.threadsol.com/68734-cell-phone-viber.php
6 Things You Should Know about UTIs in Older Adults – Health Essentials from Cleveland Clinic
Geriatr Gerontol Int. Nursing home residents attending the emergency department: clinical characteristics and outcomes. Geriatric syndromes in elderly patients admitted to an inpatient cardiology ward. J Hosp Med. Gallerani M, Manfredini R. Seasonal variation in the occurrence of delirium in patients admitted to medical units of a general hospital in Italy.
Acta Neuropsychiatrica. A health survey of the very aged in Tampere, Finland. Age and Ageing. The coming of age of a joint elderly medicine-psychiatric ward: 18 Years' experience. Int J Clin Pract. Inappropriate testing for urinary tract infection in hospitalized patients: an opportunity for improvement. Characteristics and determinants of survival in oldest old nursing home residents admitted to hospital with an acute illness compared to their younger counterparts. Aging Clin Exp Res. Why the elderly fall in residential care facilities, and suggested remedies.
J Fam Pract. Downstream impact of urine cultures ordered without indication at two acute care teaching hospitals. Which clinical indicators and resident characteristics are associated with health care practitioner nursing home visits or hospital transfer for urinary tract infections?