Common Infections in the Elderly - Part 1 - Urinary Tract & Skin

By Anna Hazard

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​Part 2 : Respiratory & Gastrointestinal Infections

Introduction

The risk of infections poses an increasing danger as people age to the point that more than 33% (greater than 1/3) of all deaths of those 65+ can be attributed to an infectious disease. In particular, gram-negative bacteria are responsible for more infections in the elderly than in younger adults.
 
Seniors are overall more susceptible to infections due to diminished immune responses, decreased physical reserves, a greater likelihood of the presence of chronic diseases & medications for treatment which can cause further complications, as well as a greater chance for requiring invasive procedures that leave them more vulnerable to infections. In addition, there are higher rates of exposure to infection (including more dangerous antibiotic resistant strains) at hospitals and institutional group settings such as nursing homes & senior care centers.
 
Besides a greater overall susceptibility, early detection & treatment of older adults for infections can be further complicated by symptoms which are more subtle & nonspecific and generally manifesting differently than in younger patients. One of the most common symptoms of infection is fever, which may not be noticed within an older adult due to an aging person's poorer body temperature response. Due to their white blood cell count often not rising as high as the norm in a younger adult, many of the common blood tests will not properly detect infections in the elderly.
 
Some common symptoms for various infections within seniors include loss of appetite, weight loss, loss of balance & falling, cognitive impairment & decline in functioning, delirium & other mental changes, as well as an increase in respiratory rate.

Infections

Urinary Tract Infections (UTI)

This is the most common type of infection found within the elderly. It's often mild & can be easily treated with proper early detection, but without treatment complications can arise leading to the spread of infection to the kidneys or degenerating into sepsis.

Risks & Causes

• UTI's tend to crop up more commonly in patients with incontinence issues. This includes those with neurogenic bladders that have increased residual urine output & incomplete emptying of the bladder, men with prostate enlargement, women with increased vaginal pH or vaginal atrophy due to postmenopausal estrogen depletion.
• The use of catheters and other incontinence objects (specifically the more invasive, the greater the risk) also increases the chance for developing a UTI.
• The presence of diabetes (especially type 2 diabetes mellitus) also raises the risk of UTIs due to the impairment of the immune system, poor metabolic control, and incomplete bladder emptying due to autonomic neuropathy.​

Prevention

• Drinking lots of liquids will help prevent blockages, especially to those with long-term indwelling catheters.
• A balanced diet of fiber containing foods such as fruit & vegetables to help prevent a constipated bowel pressing on the bladder.
• Bed sheets, bed pads, underwear, and other affected clothing should be changed immediately after incontinence
• If possible, limit the use of urinary catheters.
• Topical estrogen therapy for women and prescription or surgical treatment of enlarged prostates for men can help alleviate some of the issues that increase the risk of UTIs.

​Symptoms

• Classic UTI symptom such as a burning sensation, pain or difficulty when urinating, changes in urinary frequency, tenderness in the suprapubic/hypogastric/lower abdomen region, as well as fever may not be present in older adults.
• Many seniors have completely asymptomatic (no external symptoms at all) UTI. These are often not treated with antibiotics due to potential adverse reactions and to help prevent the further development of drug-resistant microorganisms.
• Other symptoms common for seniors with UTIs include...
  • Changes in behavior
  • Confusion
  • Nausea & Vomiting

Skin Infections

Types of Infections

• Viral (Shingles, Herpes Zoster & Simplex)
  • Herpes Zoster
    • This infection tends to become more prominent with age due the waning of cellular immunity causing reactivation of the varicella virus dormant in dorsal root ganglia within older adults.
    • It takes the form of skin lesions that spread of discrete reddened patches to groups of fluid filled cavities that fill with pus and crust over within 7 - 10 days.
    • Pain is the most common symptom if this infection with corticosteroids prescribed for the discomfort while the infection itself is treated with anti-viral therapy.​

• Bacterial (Cellulitis, Erysipelas, Necrotizing Fasciitis, Staph)
  • MRSA (Staph Infection, Methicillin-resistant Staphylococcus aureus)
    • MRSA is particularly dangerous to the already vulnerable elderly as it carries a higher risk of death due to its resistance to typical antibiotic treatment.
    • MRSA is a great risk for the elderly in instutionalized settings (hospitals, therapy centers, nursing homes etc) due to the closely packed presence of potential carriers (those who have poor function or mobility)
    • The bacterial for MRSA is most commonly found in nasal mucus and in the pharanx.
    • Most often it takes the form of sores or boils on the skin, but can also infect the bloodstream, the lungs, or the urinary tract.
  • VRE (Vancomycin-Resistant Enterococci)
    • This is the second most common infection within the urinary tract & within skin wounds. It can also cause further complications by spreading. to the blood stream
    • Like MRSA, it's also prevalent in institutionalized settings where it can cause serious complications for those already ill or injured.
    • While healthy people can be colonized with no symptoms or danger, due to its high level of antibiotic resistance, VRE has a mortality rate approaching 50 percent for bacteremia infected patients.
    • Symptoms for skin infection via VRE include soreness, redness, heat, and swelling as well as fluid leakage.

• Fungal (Yeast Infection, Coccidioidomycosis, Denture Stomatitis)
  • Infections by opportunistic fungi tend to increase with age as seniors are more likely to be taking immunosuppressive drugs, receiving more aggressive treatments of chemotherapy, or having more invasive treatments such as surgeries or transplants which makes them more susceptible.
  • Cutaneous Candidiasis (Yeast Infection)
    • This infection is usually caused by Candida albicans, which is often present in body folds and is triggered by prolonged exposure to moisture & warmth in those areas.
    • Candidiasis is common in people who are obese, have limited mobility, or have diabetes. Other predisposing factors include the poor nutrition and the use of antibiotics, topical corticosteroids, or immunosuppressive drugs.
    • Symptoms include a rash with itching, cracking skin, pustules or blisters usually within the folds of the skin, in the edges of finger or toenails, as well as the corner of the mouth.
  • Denture Stomatitis
    • Commonly caused by Candida infections (which are normally present within the mouth),  symptoms take the form of inflammation & redness of the oral membrane/gums beneath a denture with possible pinpoints of bleeding.
    • Predisposing factors include wearing an upper complete denture (particularly old dentures, ones not removed for sleep, or kept properly clean) as well as dry mouth, diabetes, or a high carb diet.
  • Sporotrichosis (Rose Gardener's Disease)
    • Caused by the fungus Sporothrix schenckii found within soil & plants and thus poses a particular risk to gardeners and those who handle cats which are another primary carrier. The most common form causes skin infections by entering through scrapes & cuts, but sporotrichosis can also take hold within the lungs, joints & bones, or brain.
    • Symptoms for cutaneous sporotrichosis include lesions that can develop into boils or ulders on the skin near its original entry point as well as along veins/arteries & lymph nodes.​

• Pressure Sores
  • Pressure sores (also known as bed sores or decubitus ulcers) become tend to become present in patients with impaired mobility, cognition, and nutrition. The presence of incontinence also increases the chances of developing bed sores.
  • They are caused by patches of skin developing ischemia (inadequate blood supply) due to uneven pressure across the body.
  • The lesions are further complicated by other local infections in the area such as cellucitis, osteomyelitis, and bacteremia.
  • Typical signs of infection in bed sores include the presence of redness, heat, tenderness, a foul odor, as well as a discharge from the lesion.

​Risks & Causes

• These is an increased risk to the elderly for developing various skin infections due to the cellular immunity of skin waning with advancing age, the atrophy of the epidermis & dermis skin layers, as well as elderly skin generally being more fragile, easily damaged, and as well requiring longer to heal properly.
• Dry skin often present within the elderly can be itchy and prone to breakage which serves as entry points for pathogens.
• The presence of incontinence which increases with age also increases the risk of developing skin infections, especially in the genital/perineal area, due to the acids causing skin irritation as well as the waste providing a good breeding ground for bacteria.

Prevention

• Good hygiene & handwashing is essential, especially when it comes to incontinence & the handling of bodily secretions.
• Lesions & other potential infection sites should be kept clean & dry at all times.
• A patient's positioning of their body should be changed repeatedly through the day (such as with alternating pressure mattresses) so that one area of skin is not under constant pressure.
• For particularly serious infections that can be spread (such as antibiotic resistant staph infections), the patient should be isolated from other seniors until no longer contagious.

Symptoms

• Symptoms vary depending upon the exact cause of infection, its severity,  the region where it resides. Common skin infection symptoms include rashes, itching, lesions, postules & blisters, skin crusting, or localized pain, redness, & inflammation.

Further Information

American Family Physician [1,2] | National Center for Biotechnology Information [1, 2, 3] | Family Practice Notebook | Family Med | Silverchair | Antimicrobe.org | Science Direct | Oxford Academic | SemanticsScholar.org