Clinical Geriatrics

Treatment and prevention of urinary tract infections (UTIs) are important aspects of care for patients with dementia, as UTIs frequently result in superimposed delirium that can accelerate cognitive decline in these patients. When UTIs are recurrent, risk of delirium and subsequent cognitive decline is increased, making this scenario particularly problematic. In addition, management of infections is made more difficult in these patients due to altered voiding patterns and complications from efforts to manage their incontinence (eg, inappropriate use of urinary catheters).¹ Numerous studies have examined interventions for preventing recurrent UTIs. Varying results have been reported for cranberry consumption^2-4 and for agents such as methenamine⁵ and antibiotics.⁶ Probiotics have shown some promise in the treatment of recurrent UTIs.^7,8 Among postmenopausal women, intravaginal estrogen cream,⁹ but not oral estrogen,¹⁰ has been shown to reduce the incidence of UTI in those with recurrent infections. We report a case of advanced dementia complicated by recurrent UTIs resulting in delirium that was successfully managed using a systematic hygiene intervention administered by the family caregiver.

Case Presentation

A 72-year-old woman with a 6-year history of probable Alzheimer’s disease showed a decline in cognition as measured by a decrease in Mini-Mental State Examination score, from 23/30 to 0/30 over those 6 years, despite administration of donepezil and memantine. Her medical history included UTIs and degenerative joint disease of the hips, knees, and lumbar spine, which resulted in spinal stenosis. The frequency of her UTIs escalated until she was having two to three per year. These infections were associated with delirium that further accelerated her cognitive decline. The degenerative dementia, in combination with the arthritic changes, impaired her mobility to the point where she required a wheelchair. This combination of factors also began to produce sacral skin breakdown. At that point, her husband decided to use a systematic hygiene intervention to minimize the risk of recurrent UTIs.

A Systematic Hygiene Intervention 

Every morning after breakfast and every evening after dinner the patient is seated on a bidet-type toilet, which features controls for water pressure and temperature and a spray wand with three spray orifices aligned in an anterior-to-posterior direction (Figure 1). Each orifice is capable of spraying in five different directions. The patient is supported on the system by handrails and a stabilizing back sling. When the patient needs to be moved to a vertical orientation for further cleaning, a ceiling-mounted, portable lift machine with a stand-up sling is used to bring her to an upright position (Figure 2). The stand-up sling is used to transfer her to a wheelchair at the end of the procedure.

For the morning session, the anterior and posterior
orifices are used, but the high-pressure third orifice is not. Each of the five spray directions for the anterior spray orifice is activated at maximum pressure for 5 minutes, then each spray direction for the posterior spray orifice is activated for 2.5 minutes, for a total of 37.5 minutes. For the evening session, less waste has typically accumulated since the previous cleaning, so the spray times are 2.5 minutes for the anterior orifice, and 1 minute for the posterior orifice. Altogether, the daily evening cleaning procedure takes a total of 17.5 minutes. During this time, she receives physical therapy exercises for her legs, is bathed, and the upper half of her body is freshly clothed. At the completion of the cleaning procedure, the perineal area is given a final manual cleaning, the patient is dried, and moisturizing cream is applied; an antifungal cream is also used on occasion. This cleaning procedure occurs regardless of whether there has been a bowel movement. Care is taken to never allow a towel or washcloth to touch the genital area after it is used in the perianal area, and towels and washcloths are thoroughly cleaned after a single use. There is also a need for occasional supplementary manual cleaning of the self-cleaning rods that carry the spray heads.

If loose stools have occurred, the shower is turned on and connected to a hose with a hand-operated bidet wand before the patient is seated, then the wand is used to clean the genital area as she is being seated on the toilet seat. The high-pressure orifice on the toilet’s spray wand is used if the patient has diarrhea or if significant fecal material remains after the lower pressure orifices are used; this approach minimizes the abrasion from wiping. The high-pressure orifice is also used when visual inspection shows obvious retained solid fecal matter in the anal canal. Applying high pressure for several minutes in each of the five positions encourages the bowel movement and decreases the chance of soiling between cleaning sessions. Protective undergarments are then applied and her husband finishes clothing the lower half of her body. One caregiver can manage the procedure with the equipment described here.