Abx vs chance improvement in cognition in senior w UTI @ vasc dementia
June 14, 2021 9:40 PM Subscribe
What are the odds a senior with vascular dementia and chronic bladder outlet obstruction (high PVR) would *randomly* show *significant* improvements in cognition on days 3-5 of an antibiotic for a UTI?
Say the antibiotic was a broad spectrum one that hasn’t worked super well in the past but is safer viz a viz risk of exacerbating long QT. I was told by a pharmacist that sometimes if it’s the wrong antibiotic, improvements show up initially but then recede. That’s what I have seen.
Say cognition has decreased any time there was an infection, and returned with treatment (by that antibiotic or one more targeted to culture results.)
Basically I fucking know that (certain) antibiotics make a difference (I log symptoms and effects religiously), and some doctors just won’t treat because they’re concerned with resistance even though the BMJ published an article demonstrating that elderly people tend to get bloodstream infections when they’re not treated for UTIs (here).
Side note if an elderly person who’s carrying 300 ml around has very high leukocyte esterase and pink goddamn pee and more than baseline confusion and no sign of other infection, I am inclined to call it a UTI, even if there isn’t a culture (at that particular lab, on that particular day) or nitrates.
Say I’m wrong (I super don’t think so but say I am). What else could explain MUCH improved cognition on days 3-5 of probably the wrong antibiotic? Is it possible that antibiotics could have some salutary effect on vascular dementia?
Say the antibiotic was a broad spectrum one that hasn’t worked super well in the past but is safer viz a viz risk of exacerbating long QT. I was told by a pharmacist that sometimes if it’s the wrong antibiotic, improvements show up initially but then recede. That’s what I have seen.
Say cognition has decreased any time there was an infection, and returned with treatment (by that antibiotic or one more targeted to culture results.)
Basically I fucking know that (certain) antibiotics make a difference (I log symptoms and effects religiously), and some doctors just won’t treat because they’re concerned with resistance even though the BMJ published an article demonstrating that elderly people tend to get bloodstream infections when they’re not treated for UTIs (here).
Side note if an elderly person who’s carrying 300 ml around has very high leukocyte esterase and pink goddamn pee and more than baseline confusion and no sign of other infection, I am inclined to call it a UTI, even if there isn’t a culture (at that particular lab, on that particular day) or nitrates.
Say I’m wrong (I super don’t think so but say I am). What else could explain MUCH improved cognition on days 3-5 of probably the wrong antibiotic? Is it possible that antibiotics could have some salutary effect on vascular dementia?
bwonder2's experience is also my experience. This was in the context of a nursing home and very limited mobility, but "unusally bad days" were often UTI days, and the difficulty was working out what the baseline was. I don't think that the antibiotics treat the dementia, but I think that carers and loved ones tend to set their expectations day by day, and I strongly suspect that there are low-level UT issues that don't manifest themselves clearly for a while and the process of working that out with people with dementia is hard.
posted by holgate at 1:34 AM on June 15, 2021 [2 favorites]
posted by holgate at 1:34 AM on June 15, 2021 [2 favorites]
Best answer: It's common knowledge in hospitals that a UTI often presents with serious cognitive decline, and that once the infection is cleared up the patient will improve mentally.
I'd also be wary of accepting tests as being meaningful when they contradict other signs. I worked for one of the local medical labs. They were considered excellent because their tests were overall about 75% correct. For some labs, and some tests, it can drop below 50%, which means you might as well flip a coin.
For reasons not clear to anyone, the medical profession tend to value a set of values displayed on a monitor over a close physical examination of the actual patient. Common sense would indicate that this is not the best way to approach these matters.
posted by AugustusCrunch at 1:46 AM on June 15, 2021 [16 favorites]
I'd also be wary of accepting tests as being meaningful when they contradict other signs. I worked for one of the local medical labs. They were considered excellent because their tests were overall about 75% correct. For some labs, and some tests, it can drop below 50%, which means you might as well flip a coin.
For reasons not clear to anyone, the medical profession tend to value a set of values displayed on a monitor over a close physical examination of the actual patient. Common sense would indicate that this is not the best way to approach these matters.
posted by AugustusCrunch at 1:46 AM on June 15, 2021 [16 favorites]
holgate and bwonder's experiences also reflect mine from when I was caring for my father.
posted by unicorn chaser at 2:36 AM on June 15, 2021
posted by unicorn chaser at 2:36 AM on June 15, 2021
My father had a TBI. He’s had two UTIs since and each one caused a huge decline. His neurosurgeon picked up on the first one because it is that common. For sure UTIs can impact on cognition in the elderly.
posted by warriorqueen at 3:20 AM on June 15, 2021 [3 favorites]
posted by warriorqueen at 3:20 AM on June 15, 2021 [3 favorites]
Best answer: Vascular dementia causes a stepwise decline- plateau, decline, new plateau, another decline. It does not improve.
UTI absolutely can cause dramatic mental decline, and will improve with treatment. That said, it is also pretty common (esp in elderly women) to essentially have a permanent UTI- the second one is treated, bacteria recolonize. It is still worth treating - especially because you have been documenting symptoms! - but be prepared for a long, antibiotic-juggling course.
posted by aint broke at 5:59 AM on June 15, 2021 [4 favorites]
UTI absolutely can cause dramatic mental decline, and will improve with treatment. That said, it is also pretty common (esp in elderly women) to essentially have a permanent UTI- the second one is treated, bacteria recolonize. It is still worth treating - especially because you have been documenting symptoms! - but be prepared for a long, antibiotic-juggling course.
posted by aint broke at 5:59 AM on June 15, 2021 [4 favorites]
(In case anyone is wondering, "ABX" can be used as an abbreviation for "antibiotics".)
posted by alex1965 at 6:13 AM on June 15, 2021
posted by alex1965 at 6:13 AM on June 15, 2021
Response by poster: Thanks everyone, totally on board with you.
Anyone have an idea as to why someone with VD would have cognitive improvements on days 3-5 of the wrong antibiotic? Could that be explained by chance?
posted by cotton dress sock at 9:06 AM on June 15, 2021
Anyone have an idea as to why someone with VD would have cognitive improvements on days 3-5 of the wrong antibiotic? Could that be explained by chance?
posted by cotton dress sock at 9:06 AM on June 15, 2021
Bateria can respond to more than one antibiotic, or it could be an infection cause by a different strain of bacteria. But yes, UTI cause sudden dramatic cogative decline and successful treatment reverses that back to whatever the baseline of the patient was.
posted by AlexiaSky at 9:25 AM on June 15, 2021
posted by AlexiaSky at 9:25 AM on June 15, 2021
I’m confused. By what measure is it “the wrong” antibiotic? I thought you didn’t have a culture to target… And you can’t actually ever say definitively that a thing did not happen “by chance” — that’s not how inferential statistics work.
I think I’m missing something. I feel like you might be angling for a particular response here, as if to prove some doctors wrong, but I don’t know that that’s something we can do for you. If they don’t trust a caregiver, they’re definitely not going to trust a bunch of internet randos.
Is getting a new provider for this person a thing you could do? IANAD, but intuitively I’d be pretty unhappy if I had responsibility to care for an elder with cognitive impairment and the doctor I had to work with didn’t trust me about something as basic as “she’s more confused than usual and she’s pissing blood.”
posted by eirias at 9:31 AM on June 15, 2021 [2 favorites]
I think I’m missing something. I feel like you might be angling for a particular response here, as if to prove some doctors wrong, but I don’t know that that’s something we can do for you. If they don’t trust a caregiver, they’re definitely not going to trust a bunch of internet randos.
Is getting a new provider for this person a thing you could do? IANAD, but intuitively I’d be pretty unhappy if I had responsibility to care for an elder with cognitive impairment and the doctor I had to work with didn’t trust me about something as basic as “she’s more confused than usual and she’s pissing blood.”
posted by eirias at 9:31 AM on June 15, 2021 [2 favorites]
My experience in caring for my father echoes that of all of the other folks who have chimed in. Every UTI was accompanied by cognitive decline and we would see improvement when the infection was treated with antibiotics.
posted by bedhead at 9:38 AM on June 15, 2021 [2 favorites]
posted by bedhead at 9:38 AM on June 15, 2021 [2 favorites]
One more voice in the chorus - an infection can absolutely lead to a decline and then improvement after treatment. My father had vascular dementia. During the last 6 months of his life he had a really drastic downturn where we were pretty sure he was being admitted to the hospital the last time. Turns out his sudden downturn was an infection, and after treatment he was pretty much back where he was prior to being admitted. (He continued to decline, unfortunately.)
posted by jzb at 10:09 AM on June 15, 2021 [1 favorite]
posted by jzb at 10:09 AM on June 15, 2021 [1 favorite]
Best answer: Anyone have an idea as to why someone with VD would have cognitive improvements on days 3-5 of the wrong antibiotic? Could that be explained by chance?
posted by cotton dress sock
When someone has a UTI it is not uncommon for there to be multiple strains of bacteria involved. The antibiotic administered could have relieved the systemic stress caused by one strain while leaving the patient still symptomatic because it didn't have an effect on others.
Not every person with dementia shows deterioration when they have a UTI. It seems likely that the dementia is only made worse in specific cases which could have to do with the bacterial strain or where else in the body the infection has spread, or if the infection has managed to trigger an immune system reaction which is the mechanism that creates the neurological symptoms. But we don't know yet how this works. For all we know there are other types of infections that also cause neurological problems. If someone with pneumonia has symptoms we might simply call it delirium.
posted by Jane the Brown at 10:55 AM on June 15, 2021 [2 favorites]
posted by cotton dress sock
When someone has a UTI it is not uncommon for there to be multiple strains of bacteria involved. The antibiotic administered could have relieved the systemic stress caused by one strain while leaving the patient still symptomatic because it didn't have an effect on others.
Not every person with dementia shows deterioration when they have a UTI. It seems likely that the dementia is only made worse in specific cases which could have to do with the bacterial strain or where else in the body the infection has spread, or if the infection has managed to trigger an immune system reaction which is the mechanism that creates the neurological symptoms. But we don't know yet how this works. For all we know there are other types of infections that also cause neurological problems. If someone with pneumonia has symptoms we might simply call it delirium.
posted by Jane the Brown at 10:55 AM on June 15, 2021 [2 favorites]
Response by poster: > By what measure is it “the wrong” antibiotic? I thought you didn’t have a culture to target…
He failed amoxicillin twice. There was one culture showing bacteria sensitive to Macrobid. Took Macrobid. UTI went away for a bit. Symptoms soon returned. Now the culture is negative with leukocyte esterase still quite high (& no indication of a different kind of infection). GP says it’s nothing, “probably just dementia” (does refer to urologist because of urinary retention). I hate how his GP handled that, take him to a walk-in doc who says it’s nothing.
Fever and delirium. ER. ER doc wanted catheterization and to admit. IM thought otherwise and gave him Clavulin (amoxicillin + clavulanic acid). Three days after that, urinary frequency decreased, cognition improved, until day five. Fever again. Virtual walk-in doc (it’s a weekend evening and who knows what the ER would recommend). At that point the optimal option was Cipro or Septra, Septra is ordered. Pharmacist tells me because of his long QT syndrome and several other cardiac risk factors, not advisable, absent an EKG following the course (walk-in doc couldn’t order an EKG for some administrative reason). Fever subsides and I think maybe I’ll wait til Monday, the consultation with the urologist is then anyway. Urologist plans to do a scope re obstruction, but thinks high LE and pink pee aren’t a big deal…
>Is getting a new provider for this person a thing you could do?
I mean I guess but this sample across specialties suggests only some will treat anyway. They’re all up in arms about antibiotic resistance and think bloody pee in old people is fine.
I could fill that septra and beg someone off the street to do an EKG, I suppose.
posted by cotton dress sock at 7:07 PM on June 15, 2021
He failed amoxicillin twice. There was one culture showing bacteria sensitive to Macrobid. Took Macrobid. UTI went away for a bit. Symptoms soon returned. Now the culture is negative with leukocyte esterase still quite high (& no indication of a different kind of infection). GP says it’s nothing, “probably just dementia” (does refer to urologist because of urinary retention). I hate how his GP handled that, take him to a walk-in doc who says it’s nothing.
Fever and delirium. ER. ER doc wanted catheterization and to admit. IM thought otherwise and gave him Clavulin (amoxicillin + clavulanic acid). Three days after that, urinary frequency decreased, cognition improved, until day five. Fever again. Virtual walk-in doc (it’s a weekend evening and who knows what the ER would recommend). At that point the optimal option was Cipro or Septra, Septra is ordered. Pharmacist tells me because of his long QT syndrome and several other cardiac risk factors, not advisable, absent an EKG following the course (walk-in doc couldn’t order an EKG for some administrative reason). Fever subsides and I think maybe I’ll wait til Monday, the consultation with the urologist is then anyway. Urologist plans to do a scope re obstruction, but thinks high LE and pink pee aren’t a big deal…
>Is getting a new provider for this person a thing you could do?
I mean I guess but this sample across specialties suggests only some will treat anyway. They’re all up in arms about antibiotic resistance and think bloody pee in old people is fine.
I could fill that septra and beg someone off the street to do an EKG, I suppose.
posted by cotton dress sock at 7:07 PM on June 15, 2021
Response by poster: Update: I went back to one of the doctors he’s seen recently. They ordered an EKG. On Septra, mid-regimen, his cognition (verbal fluency @ STM) has improved moderately.
(I neglected to mention, he actually has mixed dementia, FTD + vascular + past TBIs. No expectation of it all going away, just the worst of the UTI-related decrements. Urologist is at the end of the month and this is great.)
posted by cotton dress sock at 9:21 PM on June 22, 2021 [2 favorites]
(I neglected to mention, he actually has mixed dementia, FTD + vascular + past TBIs. No expectation of it all going away, just the worst of the UTI-related decrements. Urologist is at the end of the month and this is great.)
posted by cotton dress sock at 9:21 PM on June 22, 2021 [2 favorites]
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posted by bwonder2 at 11:28 PM on June 14, 2021 [12 favorites]