Vivian is an 88-year-old Caucasian female brought into the office by her caregiver. Complains of dark, cloudy, foul-smelling urine, with new confusion and night-time hallucinations
Case # 3
Case Description
Vivian, an 88-year-old Caucasian female presented with dark, cloudy, foul-smelling urine, confusion, night sleep disturbances, and hallucinations of spiders crawling under the bed at night followed by poor oral intake, lethargy, and agitation the next morning. Vivan also reported mild fever, lower abdominal pain, urinary frequency, and dysuria and had two suspected UTI treatments over the past 12 months. She has a history of hypertension, stage 2 of chronic kidney disease, diverticular disease, osteoporosis, previous hip fracture, and vesicovaginal fistula. She lives with a caregiver following the death of her husband three years ago. Physical examination indicated tachycardia with a pulse rate of 109, cloudy urine with leukocytosis, and positive nitrates pointing at a possible UTI associated with delirium.
Subjective Data.
Data Provided
Symptoms
Dark, cloudy, and foul-smelling urine
Confusion
Hallucinations at night
Mild fever
Lower abdominal pain
Urinary frequency and dysuria
Medical History
Hypertension, stage 2 chronic kidney disease, diverticular disease, and vesicovaginal fistula
Osteoporosis
Two suspected UTIs in the past 12 months
Medications
Olmesartan, Alendronate, and vitamin D3
Social History
Widowed, stays with a 24-hour caregiver, and has no history of alcohol use or smoking
Objective Data
Data Provided
Vitals:
Blood pressure 110/70, Pulse: 109, Respiration Rate: 17, Temperature: 99.0
0
F, BMI 22.
General: Restless although oriented to place and person
Cardiovascular: Tachycardic with no murmurs or extra heart sounds
Respiratory: the lungs are clear on auscultation. The abdomen is soft and non-tender
Genitourinary: +++ leukocytes, pH 6.0, and positive nitrites
There is no notable edema of the extremities.
Diagnostic Tests, Procedures, Laboratory Work
Diagnostic Tests and Rationale
Complete blood count for WBC count to assess leukocytosis
A basic metabolic panel (BMP) assesses electrolyte imbalance and renal function in stage 2 CKD
Post-void residual (PVR) scan is used to rule out urinary retention, which is common in the elderly population. According to Nuotio et al. (2019), PVR is common in women with hip fractures. Vivian has a history of hip fracture thus a possible risk factor for elevated PVR.
Urine culture and sensitivity confirms urinary tract infection (UTI), and isolates the causative organism and the appropriate antibiotic (Mehboob et al., 2021).
If delirium persists, CT/MRI rules out possible stroke or brain abnormalities
Differential diagnoses
Urinary Tract infection UTI-induced delirium. Vivan presented with classical symptoms of UTI such as urinary frequency, dark, cloudy, and foul-smelling urine accompanied by delirium and hallucinations. According to Pipili and Grapsa (2019) cited UTIs as the main cause of delirium in elderly patients.
Vesicovaginal fistula associated UTIs. The recurrent episodes of UTIs in the past 12 months and the foul-smelling urine are indicative of UTI predisposed from the fistula. Mourad and Higazy (2023) noted fistulas as a major predisposing factor to chronic UTIs.
Urosepsis is evidenced from fever, tachycardia, and alteration in mental status. van Lelyveld-Haas et al. (2022) noted that sepsis in elderly can present atypically.
Medications, treatments, or other interventions for each differential
UTI-induced delirium can be treated with oral nitrofurantoin 100mg twice daily or use Fosfomycin if resistant. According to van Lelyveld-Haas et al. (2022), UTI management prevents nephrotoxicity in chronic kidney disease.
Vesicovaginal fistula requires referral to a urologist for surgical repair. Surgical repair of genitourinary fistulas is crucial in preventing recurrent UTIs (Gonzales-Alabastro et al., 2023).
Urosepsis can be confirmed by positive culture results and can be managed by intravenous fluids and ceftriaxone. Treatment focuses on covering gram-negative bacteria.
Key
Social Determinants of Health (SDoH)
Isolation or loneliness predisposes to the risk of delirium (Tait, 2022). The patient is a widow living with a full-time caregiver thus feeling isolated and lonely.
Mobility: The patient had a prior hip fracture which increases fall risk.
Care access: The patient needs regular monitoring for UTIs secondary to the fistula.
Collaborative care referrals and patient education needs
Relevant Referrals
Urologist to assess the fistula for repair
Geriatrician to manage delirium management
Physiotherapy to prevent fall incidences
Patient Education such as maintaining
hydration status to prevent UTIs,
Timely identification of delirium symptoms such as confusion
Individual hygiene such as proper perineal care to reduce the risk of UTI prevalence.
Additional Data Required
Hydration status, i.e., fluid intake and signs of dehydration
Cognition: mental status before the illness and any history of dementia
Recent history of antibiotic uses: can predispose to resistance and recurrent UTIs
Bowel habits such as constipation exacerbate UTI symptoms
Risk of delirium from mobility changes and recent falls
Additional Data Required
Neurological examination to evaluate possible delirium or dementia.
Post-void urine to rule out urinary retention
Urine culture and sensitivity to identify the specific causative organism and the appropriate antibiotic for management
Vivian is an 88-year-old Caucasian female brought into the office by her caregiver. Complains of dark, cloudy, foul-smelling urine, with new confusion and night-time hallucinations
References
Gonzales-Alabastro, C., Goyette, B., & Kielb, S. J. (2023). Urethrovaginal Fistula Repair. In
Female Genitourinary and Pelvic Floor Reconstruction
(pp. 693-705). Cham: Springer International Publishing.
https://doi.org/10.1007/978-3-031-19598-3_41
Mehboob, M., Hakim, M., Ullah, O., Lodhi, S. S., Anees, M., Khalil, I., & Shuja, M. N. (2021). Identification and characterization of urinary tract infectious bacteria and its antibiotic sensitivity.
BioScientific Review
,
3
(3), 43-62.
https://doi.org/10.32350/BSR.0303.04
Mourad, M. S., & Higazy, A. M. G. A. (2023). Fistula. In
Handbook of Neurourology: Theory and Practice
(pp. 1-13). Singapore: Springer Nature Singapore.
https://doi.org/10.1007/978-981-16-7939-1_84-1
Vivian is an 88-year-old Caucasian female brought into the office by her caregiver. Complains of dark, cloudy, foul-smelling urine, with new confusion and night-time hallucinations
Nuotio, M. S., Luukkaala, T., & Tammela, T. (2019). Elevated post-void residual volume in a geriatric post-hip fracture assessment in women-associated factors and risk of mortality.
Aging Clinical and Experimental Research
,
31
, 75-83.
https://doi.org/10.1007/s40520-018-0946-5
Petrosillo, N., Granata, G., Boyle, B., Doyle, M. M., Pinchera, B., & Taglietti, F. (2020). Preventing sepsis development in complicated urinary tract infections.
Expert Review of Anti-infective Therapy
,
18
(1), 47-61.
https://doi.org/10.1080/14787210.2020.1700794
Pipili, C., & Grapsa, E. (2019). Urinary Tract Infections in the Elderly.
Clinical Nephrogeriatrics: An Evidence-Based Guide
, 87-101.
https://doi.org/10.1007/978-3-030-18711-8_6
Tait, D. (2022). The patient with delirium.
Tait D, Williams C, Barton D, et al. Acute and Critical Care in Adult Nursing
,
3
, 209-226.
https://www.torrossa.com/en/resources/an/5282165#page=220
van Lelyveld-Haas, L., de Lange, D., & Martin-Loeches, I. (2022). Sepsis in older adults. In
The very old critically ill patients
(pp. 463-483). Cham: Springer International Publishing.
https://doi.org/10.1007/978-3-030-94133-8_30
Vivian is an 88-year-old Caucasian female brought into the office by her caregiver. Complains of dark, cloudy, foul-smelling urine, with new confusion and night-time hallucinations