CHANGE IN STATUS

Mrs. B. was an 83-year-old who usually ate 90-100% of all of her meals. The nurse reported to me she did not touch her breakfast and ate only a little of her lunch. The rest of her activities were normal for her. I examined her and thought she acted her usual except for her appetite. She was afebrile, lungs were clear, and her vital signs were stable.

Mrs. V. was an 89-year-old who was declining in health but still got up to eat her meals in the dining room. She needed one of the aides to push her to the dining room. She was weak but responded appropriately. The nurse reported Mrs. V. did not want to get out of bed today and would not eat any of her meals. I examined her and saw she was not acting like her normal self. She was afebrile, lungs were clear, and her vital signs were stable.

Mrs. G. was a 92-year-old who had a history of dementia but was usually appropriate with occasional confusion. The nurse reported Mrs. G. was more confused than normal. I examined her and determined she did have increased confusion. She was afebrile, her lungs were clear, and her vital signs were stable except her blood pressure was slightly lower than normal.

All of the above patients had a CBC, BMP, UA and C&S ordered. This was routine for any patient in the nursing home with a change in status to rule out infection. After getting the results back it ws obvious all of these patients had the same medical diagnosis. All had urinary tract infections (UTI’s). The UA comes back fairly quickly first within the first few hours after sending out the urine sample. What is diagnostic of a UTI is increased leukocytes, possible blood but not always, clarity, and most importantly, the nitrates are positive. The C&S takes appromimately 48 hours. The purpose of the C&S is to determine what organism(s) are growing and what antibiotics it is sensitive to, or what works best to kill it. In the nursing home population there are many resistant bacteria which make treating the elderly challenging. What I have found in my population of patients is the quinolone class of antibiotics (Levaquin, Cipro) are usually resistant. I have been having luck with the cheaper and older antibiotics Bactrim DS and Macrodantin.

The nursing home population is susceptible to UTI’s due to poor hygiene, poor fluid intake, incontinence, and diabetes as the most common. The importance of recognizing a change in the elderly patient can make the difference between treating a UTI and urosepsis. Urosepsis will end them up in the hospital and can kill the elderly patient. Because of a weak immune system as well as the other factors I listed above they are highly susceptible to infections.  

Over the past few months I have had quite a few patients with UTI's. It seems I have at least five patients with a UTI at any given time. What I have learned is when the nurse says so and so is not acting like themselves, no matter how minor, I will always check their urine. I have learned more than not they have an infection.