UTI in the Elderly: Symptoms, Causes, Treatment, and Prevention

Introduction

Urinary tract infection (UTI) is an infection affecting any part of the urinary system, commonly the bladder or kidneys¹. In elderly people, UTI is one of the most common infections and is responsible for about 25% of all infections in this age group².  

UTIs in elderly individuals may be recurrent or resistant to antibiotics. It may present with unclear symptoms, which can cause a delay in diagnosis. These factors can affect treatment and may lead to complications^1,3. This blog will help you better understand how UTIs affect the elderly and what steps you may take to avoid them. 

Understanding Urinary Tract Infections in the Elderly

UTI can affect the upper part of the urinary tract, which includes the kidneys and ureters (the tubes that connect the kidneys to the bladder), or the lower part, which includes the bladder and urethra (the tube that carries urine out of the body) or both.  

Most commonly, it affects the bladder, which is called cystitis. It can also affect the urethra, which is called urethritis. Infection from lower urinary tract can spread to the kidneys, called pyelonephritis⁴. 

In general, UTIs are more common in women because they have a shorter urethra, which makes it easier for bacteria to enter the bladder. In elderly women, due to changes occurring because of low oestrogen levels, the risk of UTIs further increases⁴. Elderly males too are at risk of encountering infections, particularly of upper urinary tract (pyelonephritis), mostly those having systemic conditions like diabetes⁵. 

With other risks like associated medical issues, hospital-acquired infections, and antibiotics-resistant UTIs, older individuals may get serious problems like sepsis, where the infection spreads in the blood and needs hospital care^3,4. Additionally, UTI symptoms in elderly people can be hard to notice because they are not always clear. Instead of the usual pain or burning while passing urine, they may feel weak, tired, or confused. As these symptoms may also be due to other health issues, they need be evaluated properly. Thus, older individuals should be aware of what to watch out for and get treatment early to avoid UTI complications¹. 

Why Are Older Adults More Susceptible to UTIs?

UTIs occur more often in elderly individuals due to the body changes that occur with age. The immune system gets weaker with age, and the natural defence mechanisms, like being able to fully empty the bladder, having slightly acidic urine, and making immune proteins, do not work as well^2,6. 

Particularly in older women, when the oestrogen levels also go low, changes like vaginal dryness (vaginal atrophy) and pushing out of bladder (prolapse) can occur. These can lead to holding of urine in the bladder, which promotes bacterial growth, increasing the risk of UTI. It also reduces the good bacteria (Lactobacillus) which fight against bacteria causing UTI. In elderly males, issues like prostate enlargement may occur, which lead to urinary stasis in bladder and cause infection^2,7. 

Moreover, some older people may use a tube, like a catheter, to pass urine, especially if hospitalised. Bacteria can stick to the tube and form a layer called a biofilm. This makes the bacteria much harder to kill with antibiotics and harder for the body’s immune system to fight. It may also block urine flow, which helps the bacteria to grow, increasing risk of a UTI². 

All these can lead to elderly individuals encountering UTIs more frequently. 

UTI Symptoms in the Elderly

The symptoms of UTI may vary depending on the type, whether it is lower UTI or upper UTI.  

In some older people, there are no signs or symptoms, but bacteria are present when tested in the urine. This is called asymptomatic bacteriuria and usually does not need treatment. 

When the infection is in the lower part of the urinary system, the signs of UTI in elderly commonly seen are: 

• Pain while passing urine 
• Urgent or frequent urination 
• Lower belly pain or back pain near the sides 
• Blood in urine (may look red or pink), and sometimes smelly urine 
• Urine leakage 

In upper UTIs, the symptoms can include 

• High fever or chills 
• Pain in the lower belly or loins 
• Pain in lower back  
• Nausea or vomiting 

Sometimes, older people may not show typical urinary symptoms but may have vague signs like confusion, sleepiness, or changes in behaviour (especially in those with dementia or stroke)^1,8. 

If you notice these symptoms, you need to consult a doctor as soon as possible to get the right treatment. 

What Causes a UTI in the Elderly?

UTI in the elderly usually happens when any organisms such as bacteria, virus, or fungi, enter and infect the urinary tract. The most common cause is by the bacteria E. coli, which normally lives in the gut but can cause problems when it reaches the bladder. Klebsiella, Enterobacter, and Proteus are other bacteria which can cause a UTI. 

Bacteria like Pseudomonas and Enterococcus are commonly seen in people who develop UTIs during hospital stays or while using urinary catheters. In many elderly people, these infections are harder to treat because the bacteria may resist common antibiotics⁹. 

Fungal urinary tract infections, mainly caused by Candida species, are increasingly seen in elderly patients due to common risk factors like diabetes, antibiotic use, and urinary devices¹⁰. 

Viruses rarely cause UTIs in healthy people but those with weak immunity, like after an organ transplant, can get urinary infections from viruses such as BK virus and adenovirus¹¹. 

Most commonly UTI in older people is due to bladder not emptying completely. This is common in men with an enlarged prostate. In women, this may be seen in those having weak bladder muscles, nerve problems (neurogenic bladder), or prolapse. These changes cause urine to stay in the bladder and promote bacterial growth. Hospitalization and use of urinary catheters are other important causes of bacterial entry into the bladder^2,12,13. 

There are certain factors that predispose elderly individuals to UTI. These are discussed in the next section.  

Risk Factors for UTI in the Elderly

Older adults are at higher risk of UTIs due to various medical, physical, or lifestyle-related factors such as^1,2: 

• Having diabetes, cancer, or weak immunity: In these conditions, the body finds it difficult to fight infections. 
• Conditions like dementia, stroke, or Parkinson’s disease: These can cause problems with bladder control and hygiene. 
• Low oestrogen levels in older women: Low oestrogen levels can cause changes in the vagina. Thus, bacteria multiply there and reach the bladder easily. 
• Enlarged prostate in older men: It can block urine flow, so there is leftover urine, and bacteria can multiply. 
• Use of catheters, or having kidney stones or surgical materials: These can damage the bladder’s defences and give bacteria an easy way in. 
• Sexual activity: This raises the risk in both older men and women, as it pushes bacteria into the urinary tract. 
• Hospital stay or frequent antibiotic use: These can increase the chance of getting infections with bacteria which do not respond well to many antibiotics (multidrug-resistant organisms like methicillin-resistant Staphylococcus aureus and Enterococcus). 
• Poor hygiene: This allows germs to enter the urinary area and cause problems. 

Complications of Untreated UTIs in Older Adults

If UTI is not treated at the right time, early in the disease, it can lead to serious, even life-threatening problems. Older adults have a higher risk of complications from UTIs, which include: 

• Kidney Infection (Pyelonephritis): UTIs can lead to pyelonephritis, which happens when the infection spreads from the bladder to the kidneys. This can cause serious problems like acute kidney failure, kidney abscesses (pockets of pus in the kidney), or a rare but life-threatening condition called emphysematous pyelonephritis (a severe kidney infection with gas formation)¹⁴. 
• Sepsis (Blood Infection): It occurs when the infection enters the bloodstream, causing a dangerous, widespread response in the body. In elderly people with UTI, sepsis greatly increases the risk of death, both soon after the infection and up to six months later. It may also lead to long-term effects like muscle weakness, reduced quality of life, and memory or thinking problems (cognitive decline)¹⁵. 
• Resistance: If not treated appropriately, UTIs in older people tend to become resistant to a lot of antibiotics (when medicine no longer works well against the bacteria). This makes them harder to treat and may require stronger medicines, which can have more side effects and increase treatment costs. 
• Recurrent infection: Many get UTI again and again, 2 or more times in 6 months or 3 times a year. These repeated infections increase the chance of antibiotic resistance, which makes management of future UTIs even difficult². 
• Impaired quality of life: Recurrent UTIs may weaken overall health and reduce independence particularly in elderly. These may lead to more doctor visits, tests, and costlier treatment. 

How Are UTIs Diagnosed in the Elderly?

In elderly adults, diagnosing UTI may be challenging, especially if they already have ongoing urinary problems not caused by an infection. That is why doctors may look for signs of UTI in elderly people, along with lab results and overall health, to confirm the infection. It includes: 

• Urine tests: Urine tests may be done to check for pus cells (white blood cells) and bacteria in urine^2,8. The best urine sample is a clean-catch midstream sample. For women, it means cleaning the area and collecting urine midstream in a sterile container. For men, the penis tip is cleaned before collecting the midstream urine¹⁷. It may also give an idea of which antibiotic may work for UTI. However, not all cases of bacteria in the urine need treatment. In asymptomatic bacteriuria, where bacteria are present but there are no symptoms, antibiotics are usually not needed². 
• Dipstick tests: This is a quick urine test to check for UTI and works well in most cases. It looks for signs of white blood cells (called leukocyte esterase) and nitrites, which are chemicals made when some bacteria change nitrates in urine. But some bacteria, like Enterococci and Pseudomonas, which are more common in older adults, do not make this change. In such cases, the nitrite part of the test may come back negative even if an infection is present. 
• Other tests: Some additional tests may be needed in certain cases, even though they are not specific for UTI. Blood tests or other signs of inflammation, like high white blood cells, fever, or raised CRP, may help in diagnosis. A scan, like an ultrasound or CT, can also be done to check if there is any structural change, abscess, or some kind of blockage that may be causing the UTI. These are done when the UTI is not responding to antibiotics after 2 to 3 days^2,8. 

Treating UTIs in Older Adults

UTIs in the elderly are usually treated with antibiotics, which is chosen based on the type of bacteria found in urine, along with other supportive treatment given. 

Antibiotics work by fighting against the bacteria responsible for causing UTIs, including E. coli, Proteus, or Klebsiella. Before starting antibiotics, a urine culture test is taken, and based on that, the antibiotic is decided^2,18. The common antibiotics used include: 

• Nitrofurantoin: For uncomplicated cases, the usual dose is 100 mg twice daily (extended-release) or 100 mg four times daily (regular formulation) for 5 days¹⁹. 
• Trimethoprim + sulfamethoxazole: 160 + 800 mg twice daily for 3 days^4,18. 
• Cephalexin: 500 mg twice daily for 5 days in uncomplicated cases, or 500mg three to four times a day in complicated UTIs²⁰. 

The symptoms are monitored closely and if it does not improve in 2 days, other antibiotics may be used. When the antibiotics do not respond, doctors go for other antibiotics which are given via IV line and may need hospitalisation in some cases and given for 10 to 14 days in complicated cases. In people who get recurrent UTIs, low-dose daily antibiotics may be suggested, also keeping in mind the side effects and the risk of antibiotic resistance^4,12. 

If a urinary catheter is present, it should be removed or changed if it is causing the infection. Hydration is also important because when you drink plenty of fluids, it helps to flush out bacteria faster. 

How to Prevent UTI in Elderly

By doing some simple lifestyle changes, you can help avoid the risk of getting a UTI: 

• Urinating: Do not hold urine when you have the urge to urinate. When urinating, completely clear the bladder. 
• Oestrogen cream: It may help women after menopause to reduce the chance of UTI by restoring the protective bacteria (Lactobacillus) in the vagina, which fight against the bacteria causing UTI in women. 
• Sanitary napkin: Use sanitary pads instead of tampons. Do not use any hygiene sprays or powders for women. 
• Bathing: It is better to use showers than baths. Also, avoid using bath oils. 
• Hygiene: Always wash and keep the genital area clean. When you clean, wipe from front to back after using the bathroom. 
• Sexual activity: Clean the genital area before and after sex, especially before and after vaginal activity. Also, urinate before and after sexual activity. 
• Clothes: Do not wear tight pants. Wear cotton underwear and change it once a day. 
• Hydrate: Drink a lot of fluids but avoid alcohol and caffeine as they may irritate the bladder^16,21,22. 

When to See a Doctor

You should see a doctor if you experience any of these UTI symptoms in the elderly²²: 

• Pain or burning while passing urine 
• Frequent urination 
• Pain in the lower back or lower belly 
• Blood in urine or foul-smelling urine 
• Fever 
• Nausea or vomiting 
• Non-specific symptoms like fever, confusion, or changes in behaviour 

Conclusion

UTI is common in elderly, but it can become serious if not treated early. Recognising the symptoms and consulting a doctor promptly is key. They will do supportive tests and start antibiotics to fasten better results. Also, simple measures like drinking enough water, clearing bladder completely and maintaining good hygienic practices in your daily routine can help avoid the risk of UTIs and its consequent complications in elderly individuals. 

Frequently Asked Questions (FAQs)

References

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