How to manage an elderly patient with dementia, UTI, rhabdomyolysis, and frequent falls?

Management of Elderly Patient with Dementia, Rhabdomyolysis, UTI, and Falls

Critical Initial Assessment

This patient's confusion and falls are most likely NOT caused by the UTI, and the bacteriuria should be carefully evaluated to determine if it represents true symptomatic infection versus asymptomatic bacteriuria before continuing antibiotics. 1

The IDSA 2019 guidelines explicitly state that current evidence does not suggest a causal relationship between bacteriuria and presentations without classic localizing UTI symptoms, such as changes in mental status or falls. 1 Treatment of asymptomatic bacteriuria in patients with delirium has not been shown to have any beneficial impact on clinical outcomes compared to no treatment, including reducing severity or duration of delirium. 1

Determining True UTI vs Asymptomatic Bacteriuria

Look for these specific acute-onset localizing symptoms to confirm true symptomatic UTI: 1, 2

• Acute dysuria, frequency, or urgency (new onset)
• New urinary incontinence
• Costovertebral angle tenderness
• Fever >37.8°C, rigors/shaking chills
• Clear-cut delirium (defined as acute change over hours to days with fluctuating course, not chronic baseline confusion from dementia) 1

In this patient, the key question is whether the confusion represents: 1

• Acute delirium (sudden change from baseline over hours to days with fluctuating severity)
• Chronic baseline dementia-related confusion
• Delirium from other causes (dehydration, rhabdomyolysis, pain from rib fracture)

The IDSA guidelines emphasize that delirium tends to have a fluctuating course, and careful observation with evaluation for other contributing factors such as dehydration is a strategy for reducing unnecessary antimicrobial use. 1

Antibiotic Decision Algorithm

If NO acute localizing genitourinary symptoms or systemic signs of infection are present: 1

• STOP antibiotics - This is asymptomatic bacteriuria
• The IDSA makes a strong recommendation against treating asymptomatic bacteriuria in older adults because there is high certainty for harm and low certainty of any benefit 1
• Treatment increases risk of C. difficile infection (OR 2.45), antimicrobial resistance, and poorer functional outcomes 1

If fever, rigors, or severe sepsis presentation with no other apparent source: 1

• Continue empiric antimicrobial therapy pending culture results
• For older patients with severe clinical presentations consistent with sepsis syndrome where an alternate infection site is not apparent, institution of empiric antimicrobial therapy may be appropriate 1

If true symptomatic UTI confirmed with localizing symptoms: 2

• Males inherently have complicated UTI due to anatomic factors 2
• Await sensitivity results and tailor therapy accordingly
• Avoid fluoroquinolones in elderly patients due to disabling adverse effects 1, 2

Rhabdomyolysis Management (CPK 4456)

Aggressive IV fluid resuscitation is the cornerstone of treatment: 3

• Goal urine output: 300 mL/hour 3
• This patient has already received IV fluids, which should be continued
• Monitor for fluid overload given elderly status

Monitor and correct electrolyte abnormalities: 3, 4

• Check potassium, phosphate, calcium levels
• Hyperkalemia is a life-threatening complication requiring immediate treatment 3, 4
• Early detection and careful treatment of electrolyte disturbances is crucial 4

Bicarbonate and mannitol do not have strong evidence for improved outcomes 3

Monitor renal function closely: 3, 4

• Current creatinine 1.03 is acceptable, but trend values
• Acute kidney injury is the most common and serious systemic complication 4
• Renal replacement therapy should be determined case-by-case if AKI develops 3

Identify and address underlying cause of rhabdomyolysis: 3

• In this patient: likely immobility from falls, rib fracture pain limiting movement, possible dehydration from poor PO intake
• Address pain control for rib fracture to prevent further immobility

Falls Management

The falls are NOT caused by the bacteriuria 1

• Falls are common among older populations who also have high prevalence of asymptomatic bacteriuria, often leading to inappropriate UTI diagnosis and antimicrobial therapy 1
• 48% of nursing home patients who fell had pyuria and bacteriuria but this does not establish causation 1

Evaluate actual fall risk factors: 1

• Dehydration (contributing to both falls and rhabdomyolysis) 1
• Pain from rib fracture limiting mobility
• Baseline dementia affecting judgment and gait
• Medication side effects (review all medications for sedating effects)
• Environmental hazards at assisted living facility

Physical therapy consultation already placed - ensure they assess: 1

• Gait stability
• Assistive device needs
• Safe transfer techniques
• Muscle strength (may be compromised by rhabdomyolysis)

Delirium vs Dementia Workup

Evaluate for reversible causes of acute confusion beyond UTI: 1

• Dehydration (likely given poor PO intake and rhabdomyolysis) 1
• Pain (rib fracture)
• Medications (review for anticholinergics, sedatives)
• Electrolyte abnormalities from rhabdomyolysis
• Hypoxia (though chest x-ray unremarkable)

The troponin elevation (70) requires evaluation:

• Rule out acute coronary syndrome as cause of confusion
• May be elevated from rhabdomyolysis itself or demand ischemia

Disposition and Monitoring

This patient requires admission for: 3

• Rhabdomyolysis management with aggressive hydration and monitoring
• Serial CPK, creatinine, electrolytes
• Evaluation of troponin elevation
• Assessment of acute vs chronic confusion
• Fall risk mitigation

Avoid these common pitfalls: 1, 2

• Do not attribute confusion to UTI without acute localizing symptoms 1
• Do not continue antibiotics for asymptomatic bacteriuria 1
• Do not use fluoroquinolones in elderly patients 1, 2
• Do not overlook dehydration as cause of both confusion and rhabdomyolysis 1
• Do not fail to address pain control for rib fracture 3

Monitor hydration status closely and perform repeated physical assessments 1, 2