Understanding UTI with Confusion in Older Adults

Medically reviewed by Dr. Temitope Rude, MD

Urinary tract infections (UTIs) cause one-quarter of all hospitalizations of older people in the United States yearly. UTI symptoms in seniors may be difficult to spot, as they don’t always match those younger people experience when they develop urinary infections. Sudden confusion is one warning sign of UTI in elderly patients that may get overlooked. This article will discuss why it happens and what family members and other caregivers can do to help someone with UTI-associated delirium or confusion.

What Is UTI Delirium?

UTI delirium is the term for a sudden change in cognitive ability that occurs in older adults as part of the symptoms of UTIs. Around one-third of elderly patients who develop UTIs experience delirium. People who develop UTI delirium may exhibit the following warning signs.

Lack of Awareness

UTI delirium can make a person disappear into their mind. They may no longer be able to focus on things or change topics sporadically during a conversation. If you ask them questions, they may repeat the same answers or redirect the conversation to another topic. Older adults may become withdrawn and not interact with others or their environment if they’re experiencing confusion with a UTI.

Cognitive Difficulties

UTI delirium can impact memory. In mild cases, this may manifest as forgetfulness of recent events or struggling to remember certain words. More severe cases can leave a person unsure who or where they are. The mental state associated with severe delirium can also leave a person unable to understand speech, read, or write.

Behavioral and Emotional Challenges

Emotional and behavioral symptoms often accompany delirium in older adults, exhibiting signs of agitation and anger. Depression is another common symptom of delirium from UTIs and may show up as listlessness, hopelessness, sadness, and a loss of interest in favorite activities. Conversely, some people seem euphoric while in a state of delirium. With severe symptoms, people may call out, moan, make odd sounds, or even experience hallucinations.

If your loved one is experiencing any new symptoms of cognitive impairment, contact a medical professional immediately. Your doctor will be able to give the best advice on treatment course whether that be further courses of antibiotics, if the delirium is caused by UTI, or if a trip to the hospital for further testing is warranted. 

Why Does UTI Cause Confusion in the Elderly?

Although we understand a lot about urinary tract infections, doctors still don’t fully understand why UTIs trigger confusion in seniors. More research will help determine exactly why some seniors become confused. Still, a previous study conducted at Cedars-Sinai by a team headed by Dr. Shouri Lahiri, director of the hospital’s Neurosciences Critical Care Unit and Neurocritical Care Research unit, provides a good starting point for future investigations.

Based on observations made in this animal study, researchers concluded that a specific protein known as interleukin 6 (IL-6) may be to blame. The immune system releases this protein in response to the presence of bacteria like Escherichia coli (E. coli). Although its job is to help the body fight off the infection, in older women and men, levels of this protein may become too high and negatively impact brain function. The researchers found that administering an antibody that fights IL-6 to laboratory mice suffering from UTI-related delirium eased symptoms while allowing the rodents to navigate a Y-shaped maze.

More well-designed studies involving large groups of human patients will test this theory further. Still, it indicates a link between the immune response and confusion associated with UTIs.

How Long Does it take for Confusion from UTI to go away?

In most cases, delirium from UTIs goes away, but how quickly it resolves varies. In some cases, delirium may begin to ease within 24 hours after the start of antibiotic treatment. In other cases, it may persist for several weeks after clinical symptoms start.

Factors that Can Affect Recovery Time:

• Overall Health Status: Individuals with weakened immune systems or chronic illnesses are more prone to extended recovery times.
• Promptness of Treatment: Early intervention with antibiotics and hydration can reduce confusion by controlling the infection and eliminating toxins more quickly.
• Type and Severity of Infection: UTIs that have spread to the upper urinary tract or bloodstream tend to cause more severe symptoms, extending recovery time.
• Baseline Cognitive Function: Individuals with pre-existing cognitive impairments, such as dementia, may experience slower or incomplete resolution of confusion.
• Supportive Care: Managing symptoms like fever and electrolyte imbalances through supportive care helps restore cognitive clarity and speeds recovery.

Common Causes of UTI in Older Adults

As previously mentioned, UTIs are one of the most common reasons for hospital stays among seniors. Many studies indicate that older individuals are at an increased risk for UTIs, and there are many reasons why, including:

• Urinary retention: Changes in the bladder and the pelvic floor muscles can make it more difficult for the bladder to empty. This problem increases the risk of bacteria becoming trapped in the urinary tract, giving rise to infection.

• Incontinence: Many older adults struggle with incontinence issues and bedwetting. Not changing incontinence protection often enough or inadequate incontinence skin care could introduce bacteria to the urethra, resulting in infections.

• Menopause: Hormonal changes during menopause leave older women more vulnerable to the bacteria that cause UTIs. However, asymptomatic bacteriuria, or bacterial colonization, is very common in elderly women and does not always warrant treatment. Medical advice is needed to avoid an overuse of antibiotics.

• Enlarged prostate: Men with difficulty urinating due to an enlarged prostate are more at risk for urinary retention and infections.
• Lack of mobility: Older adults who struggle to perform daily living tasks may be unable to maintain their hygiene habits, increasing the risk of UTIs. They may also have difficulty making it to the bathroom and may hold in urine as a result. People who don’t urinate often enough are less likely to flush bacteria out of their urinary tracts, increasing the risk of UTIs.

• Immune system issues: As we age, our immune systems become less able to defend our bodies from infections properly. Older people may not be able to fight off bacteria quickly, so UTIs are more likely to develop. In addition, seniors are more likely to experience more severe infections when bacteria from the lower urinary tract enter the kidneys.

Recognizing UTI Symptoms in Elderly Adults

Older adults may experience classic UTI symptoms, plus other less common warning signs. As a caregiver for an older adult, keep an eye out for the following symptoms:

• Frequent urination
• Burning sensation upon urination
• Pelvic pain and pressure
• Not being able to empty the bladder when urinating
• Sudden, sharp decline in cognitive ability, behavior, emotional state, or awareness
• Low blood pressure
• Loss of appetite
• Drowsiness
• Increased heart rate
• Unsteadiness when walking
• Sleep changes
• Fever
• Nausea

Get medical attention if your loved one shows any of the above symptoms. You can see the family doctor with mild symptoms, but severe symptoms warrant a trip to the hospital emergency department.

How Is UTI with Confusion Treated?

The treatment for UTI with confusion is a course of antibiotics to eliminate the underlying infection. Seniors may need to take more antibiotics or be on them longer. Sometimes, doctors may want to admit a person to the hospital to receive antibiotics intravenously. If an older adult with UTI-associated delirium remains at home, a caregiver should be present around the clock for their safety.

Managing and Caring for Older Adults with Confusion from UTI

If you’re caring for someone with UTI confusion, follow these tips:

• Keep them hydrated: Encourage your loved one to drink plenty of water and other fluids to support urine production.

• Ensure that they stay clean and dry: If your loved one wears incontinence protection, change the pads or underwear regularly. Cleanse their private area thoroughly with a spray or wipes. Continue to follow a good incontinence care routine to help prevent future UTIs.

• Use antibiotics as prescribed: Make sure your loved one takes them on schedule and in the manner their doctor recommends. This routine may mean taking the drug on an empty stomach or with food. Even if their symptoms resolve sooner, use all of the antibiotics prescribed.

• Reassure them: Don’t try to correct your loved one if they say things that don’t make sense or misremember something. If they become depressed, anxious, or agitated, reassure them that they’re safe and that you’re here for them.
• Be on the lookout for changes in condition: If your loved one develops new symptoms or delirium worsens, let their doctor know.

​The Connection Between UTI with Confusion in Adults with Alzheimer’s and Dementia

So far, we’ve discussed UTI delirium in seniors who don’t have mental health issues or cognitive impairment. The situation becomes more complicated in individuals who have mental illness, dementia, and Alzheimer’s disease. Seniors with one of these medical conditions may exhibit symptoms of delirium even when they don’t have an active infection. Additionally, they may not be able to adequately communicate that they’re in pain or experiencing other symptoms. As a result, professional and family caregivers may find it difficult to tell when these older patients have UTIs.

Alzheimer’s and dementia patients often have one or more key UTI risk factors. They may wear daytime or overnight incontinence protection, have mobility problems, or struggle to maintain a proper hygiene routine. This issue means that people with cognitive disorders may develop UTIs more frequently.

For years, concern about the higher risk for UTIs associated with Alzheimer’s and dementia led doctors to prescribe treatments for UTIs as a precautionary measure. The line of thinking was that even if home test strips or a lab-analyzed urine sample didn’t show signs of an infection, it was better to administer antibiotics to prevent more serious upper UTI infections.

Unfortunately, inappropriate antibiotic use for those with Alzheimer’s and dementia without UTIs can trigger delirium symptoms. Caregivers may then mistake the delirium as a UTI symptom and believe the patients did have an infection all along, leading to a significant overdiagnosis of UTI in seniors with memory loss. Over time, this has led to antibiotic resistance (microorganisms that evolve to no longer respond to conventional antibiotics).

The good news is that the medical community is becoming increasingly aware of this problem. At many hospitals and long-term care facilities, it is no longer commonplace for medical staff to preventatively administer antibiotics to patients with cognitive health conditions. Instead, doctors now go by the results of the urine culture and avoid antibiotics unless bacteria are present in samples.

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Dr. Temitope O. Rude is a Clinical Assistant Professor at Stanford Urology. Dr. Rude received her B.A. in Neurobiology at Harvard University, and her MD from Stanford University. She completed her urology residency at New York University, followed by a fellowship in Female Pelvic Medicine and Reconstructive Surgery (FPMRS) at USC in 2020. Her research focuses on improving patient-reported outcomes post-surgery for pelvic organ prolapse, alongside groundbreaking work in the medical and surgical management of neurogenic bladder and complex voiding dysfunction.

Sources:

Cedars-Sinai. (2021, Dec. 2). Unlocking the cause of UTI-induced delirium. Cedars-Sinai Newsroom. https://www.cedars-sinai.org/newsroom/unlocking-the-cause-of-uti-induced-delirium/

Dutta C, Pasha K, Paul S, Abbas MS, Nassar ST, Tasha T, Desai A, Bajgain A, Ali A, Mohammed L. Urinary Tract Infection Induced Delirium in Elderly Patients: A Systematic Review. Cureus. 2022 Dec 8;14(12):e32321. doi: 10.7759/cureus.32321. PMID: 36632270; PMCID: PMC9827929.