Urinary Incontinence and Urinary Tract Infections: Prevention and Risks

By Pamela D Wilson CSA, CG, MS, BS/BA

Urinary incontinence is common among older adults and represents a stressful and often embarrassing situation resulting in increased isolation evidenced by fear of venturing out into the public due to the possibility of an accident. Older people are less likely than younger people to discuss incontinence with their doctor. Only about half of older people with incontinence seek help for their symptoms because they believe incontinence to be a normal part of aging. 1

Urinary tract infections are common among older adults. Forty to fifty percent of adult women have a history of at least one urinary tract infection. Urinary tract infections sometimes also infect the bladder and the kidneys. Prevention of recurring urinary tract infections requires evaluation to determine common factors resulting in recurring infections. Urinary tract infections are a frequent cause of hospitalization for older adults and are a major cause of gram-negative sepsis, a life threatening condition, in hospitalized patients. 2

Becoming more educated about ways to manage urinary incontinence and to treat urinary tract infections is important for caregivers of all backgrounds. While medications may be beneficial, frequent use of antibiotics may increase sensitivity and use of medications to treat symptoms of an overactive bladder. Prescription medications to treat an overactive bladder or urge incontinence may cause memory impairment or confusion, dry mouth, blurred vision, constipation, an increased heart rate, hyperthermia or increased pupil size.

Managing urinary incontinence may seem like a full time job. Many older adults will restrict fluids to limit episodes of incontinence; this action results in dehydration and mental confusion that sometimes results in seeking medical attention at the hospital emergency room. Others will take medications that have significant negative side effects (see below).

For older adults with advanced health issues who are supported by family caregivers, a 2-hour toileting schedule is recommended to avoid accidents. This schedule may be difficult or impractical for family caregivers who work or who have other responsibilities to attend to during the day. Family caregivers find it difficult to cope with ongoing incontinence episodes that result in frequent changes of clothing and linens and daily washing of bedding. Incontinence is one of the main reasons older adults are admitted to assisted living and skilled nursing communities.

Incontinence is common in individuals diagnosed with dementia. According to Martha Klay3, the prescription of medications to treat an overactive bladder in individuals diagnosed with dementia may be harmful. Individuals diagnosed with dementia have lower levels of acetylcholine in the nervous system. Muscarinic receptors in the bladder are responsible for managing urge incontinence. However, these muscarinic receptors are activated by acetylcholine and are treated with agents that deplete acetylcholine, such as oxybutynin and tolterodine. These medications often result in symptoms of dry mouth and increased confusion in older adults. The following medications have anti-cholinergic properties and should be cautiously prescribed to older adults due to the increased risk for adverse effects.

  • Diphenhydramine
  • Hydroxyzine
  • Cyproheptadine
  • Disopyramide
  • Codeine
  • Propantheline
  • Tricyclic anti-depressants such as amitriptyline, imipramine, etc.
  • Oxybutynin
  • Tolterodine
  • Ranitidine
  • Cimetidine
  • Doxepin
  • Atropine

To listen to an interview with Martha Klay about treating urinary incontinence and urinary tract infections, click here.

While urinary tract infections are common, many times low levels of bacteria exist that do not indicate infection. Contamination in urine collection is a frequent pitfall in diagnosing urinary tract infections. Clean catch specimens are recommended but may be difficult to collect; assistance by a family caregiver or a nurse may be required. In certain situations catherization to obtain a specimen is also an option.

Because many urinary tract infections present with acute symptoms like pain and mental confusion, the dipstick is the generally accepted screening test. Urinary tract infections may also be diagnosed by microscope viewing. For individuals experiencing frequent infections a culture is often completed to identify and to select the most appropriate antibiotic.

Because of the high frequency of suspected urinary tract infections in care communities and nursing homes, the McGeer Criteria is often utilized to support accurate diagnoses of urinary tract infections. The protocol includes monitoring the following: a fever of 100.4 or greater, new or increased burning from urination with frequency or urgency, flank or suprapubic pain or tenderness, change in the character of urine and worsening of mental or functional status. Utilizing this protocol in studies at Jefferson house eliminated the need for urine screening and antibiotic treatment in 94% of patients utilizing the symptom protocol.3

When in doubt, regarding solutions for urinary incontinence or in discovering the best methods to treat ongoing urinary tract infections, consult your primary care physician, a urologist or for women a uro-gynecologist to obtain the best results. Advocate for yourself and ask questions to ensure you receive the information and care beneficial to your situation.

1 Gibson, William & Adrian Wagg. (2014). New horizons: urinary incontinence in older people. Age and Ageing 43:157-164, doi: 10:1093, ageing/aft214

2 Franz, Martina and Walter H. Horl. (1999) Common errors in diagnosis and management of urinary tract infection. I: Pathophysiology and diagnostic techniques. Nephrol Dial Transplant 14(11) 2746-2753, doi: 10.1093/ndt/14.11.2746

2 Klay, Martha. Managing urinary incontinence in residents with dementia – reviewing the date and providing suggestions to reduce the anticholinergic load. The Director, Vol. 13, Number 4.

 

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©2014 Pamela D. Wilson, All Rights Reserved.
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