Dehydration, Dementia and Urinary Tract Infections - Is There A Link?

Dementia, or neurocognitive disorder, is a term referring to a spectrum of conditions typically characterised by cognitive defects and functional disability.

Dementia and dementia-like conditions include:

• Mild or age-related cognitive decline
• Vascular dementia
• Frontotemporal degeneration
• Dementia with Lewy bodies
• Alzheimer's disease

Of these, Alzheimer's disease is the most common type of dementia. These disorders are associated with widespread death of cells in certain areas of the brain. This may be a result of the aggregation of certain proteins within and without the cells (Lewy bodies or beta-amyloid plaques).

Symptoms and Signs of Dementia

Cases of dementia are often thought of as an effect on the memory and cognition of its patients, but it may have other symptoms and signs, based on the brain regions affected.

These may include:

• Aggression
• Agitation
• Anxiety
• Depression
• Psychosis
• Poor verbal performance and/or sentence construction
• Paranoid delusions
• Hallucinations
• Poor impulse control or attention
• Tremors
• Weakness
• Difficulty in eating or swallowing

Therefore, adequate treatment and care of patients with these disorders ideally extends beyond problems posed by reduced capacities of cognition and recall.

Dementia and Dehydration

Many patients with dementia are found to be dehydrated on admission to hospital. Up to 95% of residential care patients with dementia have problems feeding themselves or being fed.

This may be associated with reduced fluid intake and malnutrition, a consequence of either the loss of independence in feeding or functional impairment when trying to eat or drink independently - for example, a patient may 'forget' how, or be otherwise unable, to open a container or package. Malnutrition or dehydration may also result from the loss of interest or attention while taking a meal.

Dementia and Urinary Tract Infections - Are they linked?

Dementia tends to be associated with other conditions, which may or may not be related to the reduced capacity of the patient to report the problem or address it themselves, thus leaving the problem untreated and able to escalate progressively.

These disorders include:

• Kidney failure
• Pulmonary embolism
• Stroke or similar conditions
• Hip fracture
• Muscular atrophy (deterioration due to prolonged lack or loss of use)
• Cystitis/Urinary tract infections
• Delirium (i.e. extreme acute confusion)

Delirium is commonly associated with dehydration, and may be difficult to distinguish from dementia in acute medical facilities. It is strongly associated with dementia, possibly due to the issues of nutrition as discussed above, and may also be related to the drugs used to treat dementia. In a study of 504 elderly women, Alzheimer's disease was significantly associated with delirium, which was also associated with a diagnosis of urinary tract infection.

A similar study of 395 older women found that approximately 30% suffered from cystitis or urinary tract infections in the preceding year, which was also associated with dementia.

A study of 407 patients discharged from a psychogeriatric facility over two years found that 3.4% of these were diagnosed with delirium and urinary tract infection. 71% of these had dementia. Therefore, a link between dementia, delerium and urinary tract infections is eminently possible.

Urinary tract infection symptoms

Urinary tract infections are associated with many bacterial species, including the common species E. coli. They may present differently in seniors, compared to younger individuals. Therefore, urinary tract infections may be associated with different symptoms in this population, including:

• Fever
• Blood in the urine
• Difficulty urinating
• Tenderness in the ribs or back
• Increased urinary frequency
• Rigor
• Increased urinary urgency
• Increased agitation, confusion and other behavioural changes

Therefore, dementia patients living independently or not in receipt of care are at a higher risk of having these infections go undiagnosed and unchecked. In these cases, the infection may spread further into the urinary tract or beyond into tissues such as the vascular system. The risk of urinary tract infections in the elderly is also influenced by:

• Kidney failure
• Diabetes
• A history of stroke
• Sexual intercourse
• Fluid intake
• Personal hygiene
• Adequate and thorough washing of underclothes and bed linen (i.e. at sufficiently high temperatures to kill bacteria associated with urinary tract infections)

Elderly patients with dementia may have more trouble with some of these factors, due to the cognitive and functional deficits associated with these disorders (as outlined previously). Those concerned with the care of such individuals may contribute to preventing infections by promoting or assisting with hygiene or laundry.

Urinary tract infection treatment concerns

When urinary tract infections are diagnosed, they may be inadequately treated, leading to the increased risk of mortality. Mortality related to urinary tract infection may also be associated with dementia. Treatment for urinary tract infections often takes the form of antimicrobial therapy, such as antibiotic medications. Inadequate treatment of these infections in the elderly is also associated with other factors, including:

• Previous hospital stays
• Recurring urinary tract infection
• Immunosuppression
• Invasive surgeries
• Prior urinary catherisation
• A history of antibiotic use (this may increase the resistance of the bacteria causing the infection, especially if the same antibiotic is used again).

Residential care patients

Residential care patients are also often diagnosed with urinary tract infections. This may be due to antibiotic-resistant bacterial strains abounding in community-type facilities.

This may also be a result of the administration of antibiotics as a prophylactic measure against the same, thus decreasing their efficacy when an infection is contracted. Reduced mobility is also associated with the increased risk of urinary tract infections. A study of over 400,000 residential care home patients found that the ability to walk was associated with a 69% reduction in hospital admissions for urinary tract infection.

Due to the intersection of risk factors and symptoms of urinary tract infections, dementia and dehydration, diagnosis of one of these occurring in a patient with another is understandably difficult.

However, failing to do so may have severe repercussions for the patient. Strategies to diagnose these infections include bacterial cultures and bladder ultrasound. The latter may reduce the need for bladder catherisation (typically used to assess bladder volume and function) which is in itself associated with the increased prevalence of urinary tract infections. Avoiding catherisation may reduce infections by up to 72%.

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