A urinary tract infection (UTI) occurs when bacteria enter and infect the urinary tract and/or bladder. The most common type of UTI occurs in the urinary bladder and is often referred to as cystitis. When UTIs are left untreated or advance beyond the bladder, they may result in the less common but more serious disease pyelonephritis (Centers for Disease Control and Prevention, 2015). Urinary tract infections are common and can be frequent in those with advancing age.

Home healthcare clinicians need to be aware of and vigilant for signs and symptoms of UTI in aging patients. Infections of the urinary tract for patients without indwelling catheters are second only to respiratory infections in adults over the age of 65 living in the community, with UTIs the most commonly diagnosed infection in older adults (Rowe & Juthani-Mehta, 2013). Women tend to have a higher incidence of UTI than men and the incidence increases for those over 85 years of age (Rowe & Juthani-Mehta).

Older patients have risk factors that predispose them to UTIs. These risk factors include age-related alterations in the immune function, and a greater exposure to nosocomial and environmental pathogens related to communal living environments. Older patients are also more likely to have a host of comorbidities such as diabetes, kidney stones, stroke, dementia, and bowel and bladder incontinence that place them at greater risk for developing a UTI. Disability of function in activities of daily living also increases the risk for UTI. The single greatest predictor for a UTI is a history of UTI. Rowe and Juthani-Mehta (2013) found that women with a history of at least six previous UTIs had an increased risk for developing a UTI that was seven times higher than women without a history of UTI.

Older patients are often unaware of their symptoms or are unable to articulate the nature of their symptoms due to cognitive impairment. Cognitively intact patients often note general feelings of discomfort, uneasiness, weakness, and fatigue; but are frequently unable to articulate other symptoms unless specifically questioned. Patients with cognitive impairment may show a change in mental status such as increased confusion and disorientation, withdrawal, increased falls related to functional decline, agitation, and behavioral changes. Caregivers may report the patient just "seems different" to them. This occurs from a combination of subtle changes that are difficult to identify in older patients. Changes in functional ability and mental status in the cognitively impaired person can easily be considered a normal progression of dementia and are often overlooked as artifacts of the disease. Initial symptoms may be so vague that often treatment is delayed resulting in sepsis and hospitalization for treatment (Rowe & Juthani-Mehta, 2013).

Typical symptoms of UTI that clinicians should screen for include: urinary frequency, burning or pain upon urination, incontinence (or increased incontinence), and/or urinary urgency, increased temperature, suprapubic pain or tenderness, or costovertebral angle pain or tenderness. On gross inspection changes in the character of the urine may yield cloudy, turbid urine, concentrated urine, gross hematuria, or urine with a strong or foul odor. All or some of these symptoms may be observed or reported by the patient or caregiver. It is important for clinicians to follow the assessment with a clean catch urine to rule out or confirm infection and determine the infecting organism to ensure the appropriate selection of antimicrobial agent.

Antimicrobial selection is based upon uropathogen susceptibility profiles, patient comorbidities and tolerance, antibiotic adverse effects, and the potential for drug interactions with other medications. Establishing a diagnosis of UTI and a clear case for treatment requires both confirming laboratory tests and at least two signs or symptoms of UTI. Repeat urine testing after treatment is not recommended, as monitoring for the decrease or absence of symptoms is considered the best indicator of UTI resolution. Older patients with repeated UTIs should be encouraged to seek consultation with a urologist to rule out disease and determine the benefits of prophylactic treatment (Mody & Juthani-Mehta, 2014).

A UTI should not be confused with asymptomatic bacteriuria (ASB), which is the presence of colonization bacteria in the urine without clinical signs or symptoms of infection. Older patients often present with ASB when screened, but are routinely not treated with antimicrobials due to the lack of legitimate infection (Rowe & Juthani-Mehta, 2013). Studies have reported that ASB affects 50% of women over age 70 years (Mody & Juthani-Mehta, 2014). Treating patients with antibiotics when there is no evidence they have a bacterial infection can also lead to "drug resistance" and unnecessary exposure to the adverse effects of antimicrobials.

Home healthcare clinicians have a critical role in educating (preventing), diagnosing, and treating UTIs. Due to the increased risk for both UTI and ASB in the older population, clinicians need to remain updated on treatment modalities and consider education as the first line to prevention and early detection in the management and treatment of UTIs. Patients and caregivers will benefit from education on pericare and hygiene including: wiping from front to back after toileting, taking showers over baths, avoiding the use of powder or irritating feminine products (such as douches and sprays) in the genital area, changing soiled or damp briefs/pads frequently, never double briefing a patient for convenience, starting and maintain regular and frequent toileting schedules, and having the patient attempt to completely empty the bladder when urinating (Mayo Clinic Staff, 2016).

Despite the lack of supporting research, Mayo Clinic Staff (2016) and many other authorities strongly support increased hydration with frequent intake of oral fluids, especially water. The intake of fluids ensures frequent urination and dilution of urine promoting the flushing of bacteria from the bladder before an infection can develop. Patients with fluid restrictions for heart failure need to observe fluid guides for heart failure.

Another strategy without supporting research is the use of cranberry tablets and cranberry juice for UTI prevention. The use of cranberry continues to be studied, but experts are of the opinion that this alternative medicine is harmless and may be used by patients to potentially prevent possible UTI. Patients who are taking anticoagulants such as warfarin, coumadin, jantoven, aspirin, or medications that affect the liver should be aware of interactions (Mayo Clinic Staff, 2016).

With the increase in our aging population, the burden of UTIs in this population is expected to grow. Home healthcare clinicians play a pivotal role in improving the preventive, diagnostic, and management approach that is paramount for improving the health and well-being of our older adults.

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