Please reply to the following discussion with one or more references. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Cite resources in your responses to other classmates.
Responses must consist of at least 350 words (not including the greeting and the references), do NOT repeat the same thing your classmate is saying, try to add something of value like a resource, educational information to give to patients, possible bad outcomes associated with the medicines discussed in the case, try to include a sample case you've seen at work and discuss how you feel about how that case was handled. Try to use supportive information such as current Tx guidelines, current research related to the treatment, and anything that will enhance learning in the online classroom.
References must come from peer-reviewed/professional sources (No WebMD/Mayo Clinic or Wikipedia please!).
Cause of acute delirium in elderly patients with dementia
Many older people, with and without dementia can be all of a sudden be affected by delirium, which is defined as acute sudden confusion. When an elderly patient becomes confused very suddenly, it is important to look at all possible underlying causes. Mayne et al. (2019) state that “non-specific symptoms, such as confusion, are often suspected to be caused by urinary tract infection (UTI) and continues to be the most common reason for suspecting a UTI”. Delirium in the elderly is usually associated with lengthened hospital stays, complexed care, institutionalization, along with high mortality rates, difficulties for the caregivers and increased healthcare costs. Signs and symptoms associated with UTIs in the elderly include confusion or delirium, increased lethargy, blunted fever response, new-onset incontinence, as well as anorexia (Rodriguez-Manas, 2020). There are various risk factors associated with UTIs in a male patient. Some of these include prostatic hypertrophy, diabetes, or both, which can lead to high post-void residuals.
A confused patient who has recently become delirious should be investigated for the source of the delirium. Krinitski et al. (2021) state that “the diagnosis of UTI requires not only confirmed bacteriuria but also the presence of genitourinary symptoms, which often cannot be reliably confirmed in the many delirious individuals who are unable to adequately express themselves”. However in this case study, it is know that the patient is experiencing urinary incontinence, which further justifies the diagnosis of UTI.
A urinary analysis and culture are both highly suggested for this patient. When bacteria from the UTI has been detected in the elderly, providers usually “consider behavioral or mental changes, including delirium, as non-urinary manifestations of UTI, especially in patients with cognitive impairment, from whom local urinary tract symptoms are often difficult to obtain” (Krinitsky et al., 2021). Depending on the bacteria that is growing, different types of antibiotics may be used.
Males experience disturbed normal voiding mainly due to their benign prostatic hyperplasia (BPH). Due to their enlarged prostate, “generation of a retrograde turbulent urine flow, enabling the ascension of uropathogens to the bladder and eventually into the prostate, which explains the high frequency of prostatic involvement in males with UTI” (Smithson et al., 2019). As such, fluoroquinolones such as cipro can be used in order to treat the UTI with adequate prostatic diffusion.
It is also important to note that normal voiding in the elderly patients is the first line of defense against UTIs. In a patient with dementia however, it may be difficult to trust that they will void regularly and that they take their medications properly and at the right time. Nothing that the patient’s MMSE score dropped from 18 to 12, this patient has progressed from moderate to severe dementia. Because of this change of cognition, it would be more beneficial and appropriate for this patient to be admitted to the hospital for IV antibiotics. A referral to the emergency department is therefore warranted.
Krinitski, D., Kasina, R., Klöppel, S., & Lenouvel, E. (2021). Associations of delirium with urinary tract infections and asymptomatic bacteriuria in adults aged 65 and older: A systematic review and meta-analysis. Journal of the American Geriatrics Society, 69(11), 3312–3323. https://doi.org/10.1111/jgs.17418
Mayne, S., Bowden, A., Sundvall, P., & Gunnarsson, R. (2019). The scientific evidence for a potential link between confusion and urinary tract infection in the elderly is still confusing – a systematic literature review. BMC Geriatry, 19(32). https://doi.org/10.1186/s12877-019-1049-7
Rodriguez-Mañas L. (2020). Urinary tract infections in the elderly: a review of disease characteristics and current treatment options. Drugs in context, 9, 2020-4-13. https://doi.org/10.7573/dic.2020-4-13
Smithson, A., Ramos, J., Nino, E., Culla, A., Pertierra, U., Friscia, M., & Batisda, M. T. (2019). Characteristics of febrile urinary tract infections in older male adults. BMC Geriatrics, 19(334). https://doi.org/10.7573/dic.2020-4-13
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