Abstract
Objectives
Overdiagnosis of urinary tract infections (UTI) among people living with dementia is a nationally recognized problem associated with morbidity from antibiotics as well as multidrug-resistant bacteria. However, whether this problem also exists in the emergency department (ED) is currently unknown.
Methods
To examine the association between dementia and UTI diagnosis in the ED we performed a retrospective analysis of Medicare beneficiaries older than 65 years old who presented to an ED in 2016. A diagnosis of UTI was present in 58,580 beneficiaries, and 321,479 beneficiaries without a diagnosis of UTI served as the comparison group. Our logistic regression model controlled for dementia, older age, female sex, Medicaid status, skilled nursing facility residence, history of prostate cancer, recent urinary catheter use, recurrent UTI, and multiple comorbidities.
Results
In our model, people living with dementia had over twice the odds (odds ratio = 2.27, 95% confidence interval = 2.21, 2.33) of being diagnosed with a UTI in the ED compared to those without dementia despite their lower prevalence of symptoms and signs localizing to the genitourinary tract (3.8% vs 8.9%, respectively).
Conclusion
This is the first study from a national database that examines the association of dementia with UTI diagnosis among older adults who visit the ED. Our study could not establish whether the UTI diagnoses in the ED were accurate but does imply a disproportionate burden of UTI diagnoses in people living with dementia despite their lower prevalence of clinical criterion. Antimicrobial stewardship in the ED should address the complexity of UTI diagnosis in dementia.
Introduction
Background
Up to 50% of people living with dementia present to the emergency department in a given year (compared to 30% of people without dementia) and their most frequent diagnosis on discharge from the ED is urinary tract infection (UTI), including both cystitis and pyelonephritis.1 Accurate diagnosis of UTI in the ED is critical not only to minimize complications from UTI (eg, sepsis may develop in up to 0.5% of UTIs2) but also to prevent antibiotic-associated morbidity (eg, such as Clostridium difficile colitis) and multidrug-resistant bacteria.
Although diagnostic criteria for UTI are straightforward, requiring both symptoms (eg, new dysuria, frequency, or urgency) and laboratory evidence (eg, positive urine culture), the presence of cognitive impairment complicates UTI diagnosis. For example, people living with dementia may have atypical clinical manifestations, struggle to express symptoms, and have higher rates of asymptomatic bacteriuria, particularly if they live in long-term care facilities where false positive urine cultures occur in up to 50% of older adults.3 Accounting for these nuances in a rapid-pace, high-acuity ED only further complicates an already challenging diagnosis.
Importance
Although several guidelines address the diagnostic challenges of UTI in older adults with cognitive impairment, their practical application in an ED setting is limited. For example, the Infectious Disease Society of America's (IDSA) 2008 Clinical Practice Guideline for Long-term Care Facilities specifies dysuria as a key criterion for UTI diagnosis,3 yet many people living with dementia cannot articulate dysuria, especially to an ED physician or nurse unfamiliar with their communication pattern. To offset this difficulty, IDSA also allows for a change in a patient's baseline urinary habits or temperature to count as UTI criterion, but these baseline variables are frequently unknown to the ED physician or nurse asessing the patient. Protocols for UTI diagnosis in community-dwelling older adults4 are similarly impractical for the ED setting. For example, Mody et al proposed that prior to sending a urine dipstick, a frail older adult with nonspecific symptoms should be observed for 24–48 hours,4 which may be neither safe nor feasible for a person living with dementia in the ED.
Goals of the investigation
Although prior research has examined diagnostic patterns of UTI among older adults in the ED,5 little is known about the prevalence of UTI diagnosis specifically in older people living with dementia who visit the ED. Given the challenges of UTI diagnosis posed by cognitive impairment in acute care, our objective was to examine the association between dementia and UTI diagnosis in the ED.