That was bad even for her. Even in moderate dementia, even after a recent attack of COVID-19. The change in my mother-in-law was sudden and disturbing. When we spent Easter together, she was fighting for the word “oven” and couldn’t answer when I asked her if she wanted a glass of milk. But she had skillfully said grace, asked my daughter about her school work, and insisted on helping clear the table. By next week, however, she would be militant and paranoid. She refused to eat, refused to bathe. The housekeeper told her he was afraid of her.
And then she fell. In the emergency department, we learned that she had a urinary tract infection or UTI. We also learned that this is probably the reason for the sudden change of personality. It turns out that the brain and urinary tract are deeply connected.
I already knew how dangerous urinary tract infections could be. Earlier this year, the father of a beloved friend, who also had dementia, died when IMP turned to sepsis. The Sepsis Alliance reports that “more than half of adult urosepsis cases are caused by UTIs.”
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Urinary tract infections are common in people of all ages and are usually easily treated. But older people can be uniquely vulnerable to getting them. As was the case with my mother-in-law, they believe that maintaining their hygiene is a greater challenge. And as noted in a 2015 report by Biomed Research International entitled “Lower urinary tract symptoms are associated with an increased risk of dementia in the elderly”, it also notes that “progressive impairment of global brain function can have a significant impact on urination control ‘. In other words, patients may simply forget to urinate when necessary – another risk factor for UTIs.
And where there are cognitive limitations, the situation often worsens after an infection occurs.
“Elderly patients have suppressed the immune system,” explains Dr. Kechia Gaiter, director of perinatal services at NYC Health + Hospitals / Lincoln. “Younger patients have a stronger immune system and unless they are at the root of renal or mental pathology, they can articulate pain with urination, frequency, back pain, etc. and seek treatment.”
When dementia is present, she says that patients often “cannot communicate effectively, drink properly, practice self-hygiene.” An older person with dementia has a tidy deck: they are more susceptible to infection and then limited in their ability to express what they feel and take action 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 couldn’t figure out at first was why he was making her so angry and confused. “IPA is usually a bacterial infection,” explains neuroscientist Dr. Jill Bolte Taylor, author of the forthcoming “Whole Brain: The Anatomy of Choice and the Four Characters That Drive Our Lives.” “Our body recognizes that bacteria are foreign and does not belong inside our body, and responds to invasive bacteria by involving our immune system, thus protecting our body from something that does not belong inside us,” Taylor said. “Our immune response is a whole-body reaction that affects the brain as well as any other part of the body.”
“The brain,” she explains, “is hypersensitive to both a bacterial infection in the central nervous system of the brain and spinal cord, and to the molecular by-products of a 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 changes in the chemistry of our body. “And we see changes in the brain more in older people because,” says Dr. Taylor, “the older the brain, the more sensitive it is to change.” The brain affected by dementia even more so.
“When we are younger, the blood-brain barrier is much stronger and very protective, but as we age, it begins to weaken,” said Ales Fosnight, a certified physician, assistant and medical advisor at Aeroflow Urology in North Carolina. “With the weakened barrier, infections become easier to travel to other parts of the body, such as the brain, and cause more serious problems.”
But that doesn’t mean that UTIs can’t do much damage, even if you don’t qualify for Social Security. A few years ago, my daughter had a major when she was hit with a strep throat. The infectious combination nearly killed her.
“There are absolutely risks of urinary tract infections that affect the cognitive functions of young people as well as the elderly.” Although the immune system is usually good at protecting younger people, for those with concomitant illnesses such as high blood pressure, diabetes or autoimmune disease, it can be weakened and allow these problems to occur. Even for those with a healthy immune system, if treatment is delayed too long, it can lead to septicness among other serious health problems. “Symptoms of IM sepsis, regardless of age, include confusion and anxiety.
For most of us who are not elderly and dealing with dementia, UTI is usually not an emergency of life or death. But for our elderly parents and grandparents, the situation is getting 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 attend the emergency department for a given year” and “nearly one-third of people living with dementia who attend the emergency room ward are diagnosed with UTI. “Yet, as the authors point out, hasty diagnoses create their own potentially fatal problems, such as” antibiotic-related morbidity (e.g., as Clostridium difficile colitis) and many drug-resistant bacteria. “Going to the hospital creates a completely different set of risks for 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 basic. Although it may be almost impossible to understand how often a person with dementia urinates or how well they clean themselves, it may be possible to gently remind them of these things. In addition, however, it is extremely important to recognize the symptoms, as IMP may not manifest itself in them as pelvic pain or pressure. Dr. Taylor recommends that in addition to the usual symptoms, watch for increased signals 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 that will not change. However, she is much calmer, thanks to the range of antibiotics she has received. Two weeks after her trip to the emergency room, my mother-in-law is still weak and still confused. However, it is significantly calmer after a round of antibiotics. She experiences her dementia in every part of her body and every part of her body informs her of dementia. Her brain and bladder are intertwined, just like all of us. Now I know how important it is to respect the relationship.