This was bad, even for her. Even with middle-class dementia, even after a recent battle with COVID-19. The change in my mother-in-law had been abrupt and disturbing. When we spent Easter together, she had been fighting for the word for “oven” and could not answer when I asked if she would like a glass of milk. But she had rightly said mercy, asked my daughter about her schoolwork, and insisted on helping clear the table. By the following week, however, she had become warlike and paranoid. She refused to eat, refused to bathe. Her housekeeper said she was afraid of her.
And then she fell. In the emergency room, we learned that she had a urinary tract infection or UTI. We also learned that this was probably the cause of the sudden personality change. The brain and urinary tract are found to be deeply connected.
I already knew how dangerous urinary tract infections can be. Just earlier this year, the father of a beloved friend who had also had dementia died when a UTI turned against sepsis. The Sepsis Alliance reports that “more than half of the cases of urosepsis among older adults are caused by a UTI.”
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Urinary tract infections are common among people of all ages and can usually be easily treated. But the elderly can be uniquely vulnerable to getting them. As was the case with my mother-in-law, they may find themselves keeping their hygiene more challenging. And as a 2015 report from Biomed Research International entitled “Lower Urinary Tract Symptoms Associated with Increased Risk of Dementia in the Elderly” also notes, “the gradual deterioration of global brain function may have a significant impact on oral control.” In other words, patients can simply forget to urinate when they need to – another risk factor for UTIs.
And where there are cognitive limitations, the situation often gets worse when an infection begins.
“Elderly patients have suppressed the immune system,” explains Dr. Kecia Gaither, Director of Perinatal Services at NYC Health + Hospitals / Lincoln. “Younger patients have stronger immune systems, and unless they have underlying kidney or mental pathology, they are able to articulate pain with urination, frequency, back pain, etc. and seek treatment.”
When dementia is present, she says, patients are often “unable to communicate effectively, drink appropriately, practice self-hygiene.” An elderly person with dementia has the pile stacked: they are more susceptible to getting an infection and are then limited in the ability to express what they are feeling and take steps to relieve symptoms, creating a rapidly escalating physical and mental health crisis.
Given her condition, I could understand how my mother-in-law could get a UTI. What I could not understand at first was why it made her so angry and confused. “A UTI is generally a bacterial infection,” explains neuroanatomist Dr. Jill Bolte Taylor, author of the upcoming “Whole Brain Living: The Anatomy of Choice and the Four Characters That Drive Our Life.” “Our body recognizes that the bacteria are foreign and do not belong in our body, and responds to the invasive bacteria by turning on our immune system, which is how our body protects itself from something that does not belong in us,” Taylor say. “Our immune response is a response to the whole body that affects the brain as well as all other parts of the body.”
“The brain,” she explains, “is hypersensitive to both bacterial infection in the brain’s central nervous system and spinal cord, as well as the molecular byproducts of bacterial infection elsewhere in the body. We notice problems in the brain because it is easy for us to detect radical changes there. in response to minor shifts in our body chemistry. “And we see more brain changes in older people because Dr. Taylor says, “The older brain is more sensitive to change.” The dementia-affected brain, even more so.
“When we are younger, the brain barrier in the blood is much stronger and it is very protective, but as we get older, it begins to weaken,” says Aleece Fosnight, a board-certified medical assistant and medical advisor at Aeroflow Urology in North Carolina. “With the barrier in a weakened state, it becomes easier for infections to travel to other parts of the body such as the brain and cause more serious problems.”
But that does not mean that UTIs cannot harm a world even if you are not eligible for social security. A few years ago, my daughter had an underlying condition when she suffered a case of strep throat. The contagious combination almost killed her.
“Absolutely there is a risk of UTIs affecting the cognitive functions of young people as well as the elderly,” says Fosnight. “Although the immune system is usually good at protecting younger people, for those with comorbidities, such as high blood pressure, diabetes or an autoimmune disease, it can weaken and cause these problems to occur. Even for those with a healthy immune system, if the treatment is delayed for too long, it can lead to becoming septic among other serious health problems. Among the symptoms of sepsis from a UTI, regardless of age, are confusion and anxiety.
However, for most of us who are not elderly and dealing with dementia, a UTI is usually not a life or death accident. But for our elderly parents and grandparents, the situation becomes more complicated.
According to a 2020 report in the Journal of the American College of Emergency Physicians, “Up to 50% of people living with dementia are present in the emergency department in any given year,” and “nearly one-third of people living with dementia living with dementia visiting the emergency department is diagnosed with a UTI. “Yet, as the authors point out, rapid diagnoses create their own potentially fatal problems as” antibiotic-related morbidity (e.g. Clostridium difficile colitis) and multidrug-resistant bacteria. “Going to the hospital creates a completely different set of risks of exacerbating the vulnerable patient’s problems, even if they have a UTI.
So what can we do to protect ourselves and our loved ones? Prevention is challenging, but primary. While it may be almost impossible to know how often a person with dementia wanders, or how well they clean themselves, it may be possible to gently remind them of these things. More than that, however, it is crucial to recognize the signs because a UTI may not manifest in them as pelvic pain or pressure. Dr. Taylor recommends that in addition to the usual symptoms, keep an eye out for an uptick for cues such as “confusion, delirium, agitation, hostility.”
Two weeks after her trip to the emergency room, my mother-in-law is still weak and still confused. She still has dementia and it will not change. However, she is significantly calmer thanks to the round of antibiotics she was given. Two weeks after her trip to the emergency room, my mother-in-law is still weak and still confused. However, she is significantly calmer after a round of antibiotics. She experiences her dementia in all parts of her body and every part of her body informs her dementia. Her brain and her bladder are intertwined, just like all ours are. I now know the importance of respecting the connection.