2024 Top Story in Primary Care: Is Altered Mental Status in Older Adults Always a UTI?

Altered mental status is a common presenting symptom in older patients, and, when it occurs, we usually test for and treat urinary tract infections (UTIs) in these patients. Most older adults have asymptomatic bacteriuria, and, in recent years, we have taken a more nuanced approach regarding treating this condition with the Loeb¹ and McGeer² criteria, which require the presence of urinary tract–specific symptoms before testing and treating. A recent review involving 652 older adults — aged 60 years or older, with an average age of 84.6 years — with pyuria or bacteriuria showed no benefit associated with antimicrobial treatment with regard to the duration and severity of delirium.³

The Infectious Diseases Society of America, the American Geriatrics Society, and the Society for Post-Acute and Long-Term Care Medicine recommend assessing older adults for other causes of delirium and closely observing them rather than initiating antibiotics and treating asymptomatic bacteriuria.

When families and staff report mental status changes in older adults, start with increasing hydration. Dehydration is prevalent among older adults, with a prevalence of 37% among community-living older adults⁴ and up to 75% among patients residing in a nursing home.⁵ Dehydration is associated with an increased risk of constipation,⁶ kidney stones,⁷ urinary tract infections,⁸ falls,⁴ and fatal coronary heart disease.⁹ In addition, it can lead to orthostatic hypotension and impaired brain perfusion,¹⁰ with mental status changes and delirium.¹¹ Upon standing, the decreased elasticity of aging vasculature leads to decreased venous blood return, which impairs brain perfusion and lowers diastolic blood pressure.¹²

When patients' families and staff state that the patient always has a UTI when the patient develops mental status changes, I explain that we used to think so. However, with fluid intake, the confusion improves. I further explain why older adults have a high risk of dehydration and engage families to help hydrate these patients, which gives them a purpose. I assure the families that we will reassess the patient in a day to determine whether there is an improvement, and, if not, a urine test will be performed.

For more information watch my presentations on Aging Changes and Fluid Intake.