Asymptomatic bacteriuria and Dementia Deterioration in Older Females Admited to a Gero-Psychiatric Unit

Abstract

IntroductionBacteria in urine is not considered normal; elderly women may have asymptomatic bacteriuria. Antibiotic use is considered inappropriate in at least 50% of cases, where there is neither fever nor other systemic symptoms, and the only manifestations are abnormal urine (Pyuria>5 WBC) or a positive culture (>100,000 bacteria) (USPSTF, 2008; Nicolle 2005). But these recommendations are based on non-institutionalized individuals and do not consider the sub-population of individuals with impaired cognitive reserve from dementia. Demented patients may not verbalize their symptoms. Dementia and UTIs are known risk factors for delirium. Delirium manifests itself with alterations in thought and behavior; it is clinically challenging to distinguish between new delirium and deterioration of dementia. Infection is one of the most common etiologic causes for delirium and frequently precipitates psychiatric admissions. When an individual with a previously stable dementia manifests a sudden change in behavior, it is often believed that a concurrent delirium may explain the acute change in condition. In an ongoing prospective study seeking to address suspected Urinary Tract Infection (UTI) in late stage dementia (D'Agata, 2013) found that only 16% of those with suspected UTI met their minimum criteria for UTI. Furthermore, only 21% manifest a fever, but over 44% manifest behavior changes. In fact the behavior change was the only documented sign of a probable UTI in 36% of cases (D'Agata, 2013). There are no reported rates of suspected UTI for demented patients admitted to a gero-psychiatric unit. The standard of practice for geriatric psychiatrists has been to treat asymptomatic bacteriuria more aggressively than the national standards. Treating unnecessarily poses risks of antibiotic side effects while not treating is associated with risk of psychiatric decompensation. This preliminary retrospective study would provide information on the consequences of whichever clinical decision was made. The results of this study may lead to a follow-up prospective study.MethodsThis is a retrospective chart review study. A waiver of consent will be obtained from the hospital IRB. We plan to evaluate records of 150 female patients >60 yo that were hospitalized on our gero-psychiatric unit to determine how frequently bacteriuria is associated with behavioral disturbances. The diagnosis of dementia (and subtypes) will be confirmed by the admission history and physical (H&P). The severity of the decline will be assessed by collecting the Global Assessment of Function (GAF) from the H&P, and the activities of daily living assessment (ADL) done by the nurse on admission. We will abstract the Mini-Mental Status Exam (MMSE) recorded within 48 hours of admission and discharge if available. Bivariate analysis by using chi-square and T-test would be used to interpret the data.ResultsThis study has not yet been completed so results are pending.ConclusionsWe are estimating that about 40% of women with dementia will have an abnormal urinalysis (UA) defined as urine with >= 5 WBC and either positive Nitrate or Leukocyte esterase (+1 or above). We will define this population as asymptomatic bacteriuria, the study group. UA is obtained at almost 100% of admissions allowing minimal loss of potential cases. Some individuals may have a urine culture and we will record the number of bacteria, the type and drug sensitivity for a potential future study. We are estimating that patients with a UTI will look 25% worse in their Global Assessment of Function (GAF), ADL assessment and MMSE on admission. We are also anticipating that in those whose abnormal urine is treated will have a better GAF at discharge and are more likely to not see a decline in care setting (more able to return to their prior level of care). IntroductionBacteria in urine is not considered normal; elderly women may have asymptomatic bacteriuria. Antibiotic use is considered inappropriate in at least 50% of cases, where there is neither fever nor other systemic symptoms, and the only manifestations are abnormal urine (Pyuria>5 WBC) or a positive culture (>100,000 bacteria) (USPSTF, 2008; Nicolle 2005). But these recommendations are based on non-institutionalized individuals and do not consider the sub-population of individuals with impaired cognitive reserve from dementia. Demented patients may not verbalize their symptoms. Dementia and UTIs are known risk factors for delirium. Delirium manifests itself with alterations in thought and behavior; it is clinically challenging to distinguish between new delirium and deterioration of dementia. Infection is one of the most common etiologic causes for delirium and frequently precipitates psychiatric admissions. When an individual with a previously stable dementia manifests a sudden change in behavior, it is often believed that a concurrent delirium may explain the acute change in condition. In an ongoing prospective study seeking to address suspected Urinary Tract Infection (UTI) in late stage dementia (D'Agata, 2013) found that only 16% of those with suspected UTI met their minimum criteria for UTI. Furthermore, only 21% manifest a fever, but over 44% manifest behavior changes. In fact the behavior change was the only documented sign of a probable UTI in 36% of cases (D'Agata, 2013). There are no reported rates of suspected UTI for demented patients admitted to a gero-psychiatric unit. The standard of practice for geriatric psychiatrists has been to treat asymptomatic bacteriuria more aggressively than the national standards. Treating unnecessarily poses risks of antibiotic side effects while not treating is associated with risk of psychiatric decompensation. This preliminary retrospective study would provide information on the consequences of whichever clinical decision was made. The results of this study may lead to a follow-up prospective study. Bacteria in urine is not considered normal; elderly women may have asymptomatic bacteriuria. Antibiotic use is considered inappropriate in at least 50% of cases, where there is neither fever nor other systemic symptoms, and the only manifestations are abnormal urine (Pyuria>5 WBC) or a positive culture (>100,000 bacteria) (USPSTF, 2008; Nicolle 2005). But these recommendations are based on non-institutionalized individuals and do not consider the sub-population of individuals with impaired cognitive reserve from dementia. Demented patients may not verbalize their symptoms. Dementia and UTIs are known risk factors for delirium. Delirium manifests itself with alterations in thought and behavior; it is clinically challenging to distinguish between new delirium and deterioration of dementia. Infection is one of the most common etiologic causes for delirium and frequently precipitates psychiatric admissions. When an individual with a previously stable dementia manifests a sudden change in behavior, it is often believed that a concurrent delirium may explain the acute change in condition. In an ongoing prospective study seeking to address suspected Urinary Tract Infection (UTI) in late stage dementia (D'Agata, 2013) found that only 16% of those with suspected UTI met their minimum criteria for UTI. Furthermore, only 21% manifest a fever, but over 44% manifest behavior changes. In fact the behavior change was the only documented sign of a probable UTI in 36% of cases (D'Agata, 2013). There are no reported rates of suspected UTI for demented patients admitted to a gero-psychiatric unit. The standard of practice for geriatric psychiatrists has been to treat asymptomatic bacteriuria more aggressively than the national standards. Treating unnecessarily poses risks of antibiotic side effects while not treating is associated with risk of psychiatric decompensation. This preliminary retrospective study would provide information on the consequences of whichever clinical decision was made. The results of this study may lead to a follow-up prospective study. MethodsThis is a retrospective chart review study. A waiver of consent will be obtained from the hospital IRB. We plan to evaluate records of 150 female patients >60 yo that were hospitalized on our gero-psychiatric unit to determine how frequently bacteriuria is associated with behavioral disturbances. The diagnosis of dementia (and subtypes) will be confirmed by the admission history and physical (H&P). The severity of the decline will be assessed by collecting the Global Assessment of Function (GAF) from the H&P, and the activities of daily living assessment (ADL) done by the nurse on admission. We will abstract the Mini-Mental Status Exam (MMSE) recorded within 48 hours of admission and discharge if available. Bivariate analysis by using chi-square and T-test would be used to interpret the data. This is a retrospective chart review study. A waiver of consent will be obtained from the hospital IRB. We plan to evaluate records of 150 female patients >60 yo that were hospitalized on our gero-psychiatric unit to determine how frequently bacteriuria is associated with behavioral disturbances. The diagnosis of dementia (and subtypes) will be confirmed by the admission history and physical (H&P). The severity of the decline will be assessed by collecting the Global Assessment of Function (GAF) from the H&P, and the activities of daily living assessment (ADL) done by the nurse on admission. We will abstract the Mini-Mental Status Exam (MMSE) recorded within 48 hours of admission and discharge if available. Bivariate analysis by using chi-square and T-test would be used to interpret the data. ResultsThis study has not yet been completed so results are pending. This study has not yet been completed so results are pending. ConclusionsWe are estimating that about 40% of women with dementia will have an abnormal urinalysis (UA) defined as urine with >= 5 WBC and either positive Nitrate or Leukocyte esterase (+1 or above). We will define this population as asymptomatic bacteriuria, the study group. UA is obtained at almost 100% of admissions allowing minimal loss of potential cases. Some individuals may have a urine culture and we will record the number of bacteria, the type and drug sensitivity for a potential future study. We are estimating that patients with a UTI will look 25% worse in their Global Assessment of Function (GAF), ADL assessment and MMSE on admission. We are also anticipating that in those whose abnormal urine is treated will have a better GAF at discharge and are more likely to not see a decline in care setting (more able to return to their prior level of care). We are estimating that about 40% of women with dementia will have an abnormal urinalysis (UA) defined as urine with >= 5 WBC and either positive Nitrate or Leukocyte esterase (+1 or above). We will define this population as asymptomatic bacteriuria, the study group. UA is obtained at almost 100% of admissions allowing minimal loss of potential cases. Some individuals may have a urine culture and we will record the number of bacteria, the type and drug sensitivity for a potential future study. We are estimating that patients with a UTI will look 25% worse in their Global Assessment of Function (GAF), ADL assessment and MMSE on admission. We are also anticipating that in those whose abnormal urine is treated will have a better GAF at discharge and are more likely to not see a decline in care setting (more able to return to their prior level of care).