THE CASE: An 83-year-old woman is brought by her daughter for evaluation because of increasing confusion during the past few days. The patient has early Alzheimer dementia, hypertension, and type 2 diabetes. She takes donepezil(Drug information on donepezil), 10 mg/d; lisinopril(Drug information on lisinopril), 5 mg/d; and glipizide(Drug information on glipizide), 5 mg bid. She is unable to bathe and dress herself as well as previously, has been crying for no apparent reason, and has lost her appetite.
The patient has lost 6 lb in the past 3 weeks and appears more anxious and confused than usual. Her score on the Mini-Mental State Examination is 18, a loss of 3 points since the last visit. She is afebrile; her heart rate is 92 beats per minute. Palpation of the abdomen elicits slight wincing. There is no costovertebral angle tenderness. Lungs are clear and skin is intact. The remainder of the examination is unremarkable.
A complete blood cell (CBC) count, chemistry 7 panel, and urinalysis with culture and sensitivity determination are ordered. A chest radiograph is not ordered because there are no localizing symptoms. No treatment is given on the day of evaluation. The patient’s daughter is told to watch for heightened confusion and to be sure her mother’s fluid intake is increased pending results of laboratory testing.
Acute confusion in elderly persons, especially those with dementia, has a wide differential diagnosis. The most common causes are infection (principally respiratory tract, urinary tract, or skin); new medications; and electrolyte disturbance. Because this patient had not started any new medications, the laboratory workup is likely to be revealing.
Laboratory results show a normal CBC count with no leukocytosis. The chemistry 7 panel reveals a slightly higher blood urea(Drug information on urea) nitrogen level than usual (24 vs 15 mg/dL) and a normal serum creatinine level, which indicates mild dehydration. The urinalysis shows bacteriuria and pyuria; culture results are pending.
How is urinary tract infection (UTI) best managed in elderly persons?
(answer and discussion on next page.)
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