Elder care is a complex area. The various ailments suffered by older patients often have overlapping symptoms, so getting to the root cause can be challenging. Recently, I’ve heard about people blaming behavior on bladder infections. Well, sometimes this is true, but I often see elders going to the emergency room for agitation and coming out with a prescription for antibiotics. What??? Antibiotics do not treat agitation. If the assumption is that any bladder issue is the cause of agitation – that is dangerous.
Is it dangerous to treat bladder infections? No, but much of what I see treated out there is bacteria or white blood cells (WBCs) found in the urine. And sometimes, that can indicate an infection, but those test results alone are not a complete diagnosis.
Normal white blood cell levels in urine are 0-5 and having a level of 6-10 is reported as an infection, and antibiotics are prescribed. There actually is NO clear-cut relationship between the number of WBCs and an infection. A urinalysis should also include testing for epithelial cells. If there are more than 5 epithelial cells, the specimen is contaminated, and a new clean specimen needs to be collected. But, testing alone is not a diagnosis.
What is Critical is the Symptoms. Not Agitation.
Test results are a starting point. Are there other symptoms such as fever, pelvic pain, not eating, lethargy, or actual delirium (sudden onset of confusion, inattention that waxes and wanes)? These are signs of infection.
If so, how high were the WBCs when tested? For example, if someone has >100 WBCs along with agitation, it is more likely related to infection than if they have only 10-20 WBCs.
It is critical to get microscopy to see if there are RBCs (red blood cells) in addition to urine culture. I have seen cultures done without microscopy and microscopy without the culture. Many patients are still being treated with antibiotics without symptoms, with a few WBCs or no culture. The combination of testing, symptoms, and cultures results in a definitive diagnosis.
So? So Why Can’t We Just Treat?
We cannot just treat because the elder’s behavior is not necessarily related to a bladder infection. It may be due to pain, medication side effects, a reaction to a caregiver, lack of sleep, or boredom. Antibiotics should only be used on infections.
When antibiotics are used to treat “smelly urine” or behavior multiple times, you end up with multidrug-resistant bacteria. I recently saw a patient like this. I did not know the person was often treated with antibiotics and was told she had “smelly urine” and requested treatment. I got a straight catheter urine specimen. It was not easy. Older adults often need medication to relax or require sedation to obtain the urine by putting a catheter in their bladder. I was shocked to see the bacteria in the urine was resistant to all oral antibiotics. Then the question became, is the person sick enough to go to the hospital for IV antibiotics.
Another problem of overusing antibiotics is the development of Clostridium Difficile or c diff diarrhea. These harmful bacteria can become quickly resistant and takes over when antibiotic usage kills most of the good gut bacteria. I have seen people die from this.
So, yes, we want to ensure elders don’t have untreated infections, but overtreating lab results when there is not an infection is not good either. Usually, I will treat for behavior or smelly urine once. Then, if there is no change, we only treat if there is additional evidence from an infection’s symptoms and lab results.
Dr Liz Geriatrics
Are you a caregiver that has observed an elder being treated for agitation with antibiotics? Learn what questions to ask, so the patient isn’t overtreated with antibiotics. Dr. Liz Geriatrics can help. Our mission is to educate caregivers so they can give the best of care to their patients or loved ones. Let us help you. Contact us at 650-357-8834 x1.
Elizabeth (Dr. Liz) has over twenty years of experience in providing medical care to the elders. She is board-certified in Internal Medicine, Geriatric Medicine, and Palliative Care Medicine. Dr. Landsverk founded ElderConsult Geriatric Medicine, a house calls practice, to address the challenging medical and behavioral issues often facing older patients and their families.