Kristen Mauk

Background

Urinary tract infections (UTIs), also called cystitis (inflammation of the bladder), are common among older adults and are more frequent in women. They are a primary cause of urinary incontinence and delirium. Catheter-associated urinary tract infections (CAUTIs) are more common among older adults (Fakih et al., 2012) and is mainly attributed to the use of indwelling urinary catheters. Many indwelling catheters are thought to be unnecessary (Cochran, 2007) and one study noted that physicians were often not aware of the purpose for which their patients had a catheter inserted (Saint, Meddings, Calfee, Kowlaski, & Krein, 2009). UTIs have been show to increase morbidity and mortality, length of hospital stay, and cost of hospitalization (Kleinpell, Munro, & Giuliano, 2008). CAUTI is considered preventable and is not reimbursed by Medicare. Therefore, hospitals will largely assume the financial costs for preventable infections of this type.

Risk factors/Signs and symptoms

Several risk factors are associated with UTIs in general. These include being female, having an indwelling urinary catheter, the presence of urological diseases, and hormonal changes associated with menopause in women. Signs and symptoms of UTIs include urinary frequency and burning or stinging felt during voiding. Pain may be felt above the pubic bone, and a strong urge to void but with small amounts of urine expelled. The most significant risk factor for CAUTI is prolonged use of an indwelling catheter. In hospital-acquired UTIs, 75% are associated with the use of an indwelling catheter (CDC, 2012). In women, signs and symptoms of CAUTI may be more severe than those reported by women by patients in the community who do not have an indwelling catheter. Lethargy, malaise, onset or worsened fever, flank pain, and altered mental status have been associated with CAUTI (Hooton et al., 2010).

Diagnosis

A thorough assessment should be done of the patient’s urinary output, including amounts, color, odor, appearance, frequency of voiding, urgency, and episodes of incontinence. A urine specimen should be obtained if UTI is suspected. Laboratory results will show the type of organism causing the infection, and the sensitivity will tell what medication the organism is susceptible to. These results should be reported promptly to the physician or nurse practitioner caring for the patient and so that a diagnosis and treatment plan can be made.

Treatments

Prevention of UTIs is considered a primary nursing strategy. Elderly female patients can be instructed to make lifestyle modifications such as: increasing their fluid intake; emptying the bladder after sexual intercourse; practicing good perineal hygiene, including wiping front to back after toileting; getting enough sleep; and avoiding stress (PubMed Health, 2011). Although many of these common sense strategies are recommended by primary care providers, there is a lack of scientific evidence to support some of them. Many UTIs will clear up on their own, particularly if the person increases oral fluid intake during early symptoms. However, with many older adults, antibiotic treatment may be needed. In general, a course of three 3 days for healthy adults is thought to be sufficient, but for more resistant bacteria, a longer course more than five 5 days may be needed (PubMed Health, 2011). For those with repeated or chronic UTIs, a low dose of antibiotics taken for 6– 12 months may be indicated (Hooton et al., 2010). If the underlying cause is CAUTI, treatment will be more aggressive. Monitor the patient’s temperature at least every 24 hours (Carpenito, 2013). Encourage fluids. Evaluate the necessity of continuing an indwelling catheter if one is in place.

Alternatives to indwelling catheters should be considered for appropriate patients. Intermittent catheterization, if appropriate, is preferred over indwelling catheter use, especially for long- term maintenance of bladder management (CDC, 2009; Hooton et al., 2010). Condom catheters may be an appropriate choice for some males. If an indwelling urinary catheter is necessary, the catheter should be removed as soon as possible, per the physician or nurse practitioner’s orders, to reduce the risk of CAUTI.

Adapted from Mauk, K. L., Hanson, P., & Hain, D. (2014). Review of the management of common illnesses, diseases, or health conditions. In K. L. Mauk’s (Ed.) Gerontological Nursing: Competencies for Care. Burlington, MA: Jones and Bartlett Publishers. Used with permission.

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What is assisted living (AL)?
A Scandinavian model for senior care, now known as assisted living, made its way into America’s care system in the 1980’s. According to a 2012 report by AARP, there is no standard definition for assisted living (AL). Although individual states and residential facilities can give their own definition of AL, the term most often means that help is provided with meals, social support, medications, dressing and/or bathing and the like with 24-hour per day supervision. The Assisted Living Federation of America (ALFA) (2013) defines assisted living as “a long-term care option that combines housing, support services and health care, as needed”. The focus of AL is on maintaining dignity, respect, and independence of older residents.

In 2010, there were more than 51,000 licensed residential care settings (including assisted living) that reported more than 1.2 million beds (AARP, 2012). A study published by the National Center for Assisted Living (NCAL) cited 31,100 assisted living facilities serving 733,400 persons in 2010.

What is the typical assisted living resident like?
The average age of those in assisted living facilities is 86.4 years (MetLife, 2012). According to the National Center for Assisted Living (2013), the typical resident needs help with at least one activity of daily living (ADL), and most are over the age of 85. More females (76%) live in assisted living settings than males (26%). Thirty-seven percent of persons in AL receive help with more than three ADLs (NCAL, 2012). More than half of persons in AL facilities have some type of cognitive impairment (Alzheimer’s Association, 2009). A growing percentage of persons in AL facilities have Alzheimer’s disease.

What types of services are provided?
Some of the usual services provided in a licensed AL include:
• Assistance with eating, dressing, bathing, toileting
• Access to health services
• Medication management
• Dining services
• 24 hour staffing and security
• Emergency call systems
• Exercise and wellness facilities
• Social and recreational activities
• Housekeeping and laundry
• Transportation
• Access to banking
• Chaplain or religious services
• Memory care

How do I know if I need assisted living?
There are a variety of reasons why persons might choose an assisted living setting. Some people move to AL because they want more socialization than living alone, they want to be nearer to their adult children but do not reside with them, or because they can no longer manage at home. The person in an assisted living facility generally needs some help with activities of daily living, but does not need skilled nursing care. So, AL might be right for you if you wouldn’t be able live at home any longer without help, but you still don’t need to be in a nursing home or need the help of a nurse around the clock. You may be able to do many things on your own but maybe you have difficulty with dressing, meal preparation, or managing your pills.

How do I decide which senior living community to choose?
There are a variety of senior living options, of which assisted living is but one. Often, family members will help you decide which option is best for you, but you should look at all your choices. You should pick a place that offers the services that you need. Cost and location are additional considerations. It is also good to ask about the staffing ratios, what nursing care is available, and what happens if you later need a higher level of care than the AL provides. ALFA provides a Guide to Choosing an Assisted Living Community. This includes a helpful checklist that can be downloaded from their website.

How much does it cost to live in an AL facility?
The cost of AL depends on where you live. Keep in mind that most assisted living is paid for privately, meaning out-of-pocket, and not by insurance. According to MetLife’s Market Survey of Long-term Care Costs (2012), the national average base rate for assisted living was $3,550 per month. This means that a person who lives in an assisted living facility can expect to pay an average of $42,600 per year. Of course this also varies depending on the number of extent of services with which the resident needs help. The base rate generally includes specific services, but each additional service beyond that may add an extra monthly fee. Compare this to an average nursing home rate for a shared room at nearly $84,000 per year for a person needing Alzheimer’s care (MetLife, 2012) or a national median cost of $270 per day in a nursing home that provides 24-hour per day nursing care (Genworth Cost of Care Survey, 2013).

Are there alternatives to assisted living facilities?
So, are there other options besides going to an assisted living facility if you are an older adult who needs a little help? The answer is yes. Adult day services are one community option. Also, many home care agencies offer companions, homemaker aides, or nursing assistants to help people age in place at home. Most of the time, getting these services means a minimum number of hours per day must be paid for. The national average hourly rate for home health aides was $21 in 2012. Homemaker or companions who provide “hands-off” care such as running errands, shopping, housekeeping made a median of $19-20 the same year (Genworth, 2013).

This is where unique options for assisted living services at home are needed and can save consumers money. Senior Care Central offers persons needing assisted living in the home the opportunity to have more control over their care situation at a much lower cost while getting professional, quality care. Imagine that you could set the hours that you want to have a caregiver in the home, and that caregiver could be a nursing student who has a higher level of education than most home health aides. This care option may cost you half the price charged by a home health care agency. SCC’s model promotes aging in place on your own terms and lets you link with caregivers online, browse profiles to choose caregivers you want to contact, and make your care arrangements directly with them.

I had always heard that kidney stones were the closest thing to labor pain and childbirth that a man could experience, but being a woman who had been through labor four times, I didn’t quite believe it or understand the comparison. That is, until the other day…

I was sitting at the computer writing and felt a pain like a muscle cramp in my right side. But, since I couldn’t recall having done anything strenuous the day before, I just figured I had been sitting too long in one spot. Moving around helped for a brief time until the pain returned, more intense and radiating from the right flank around my side and down to my groin. Hmmm….being a nurse I wondered what this could be so I tried the usual techniques as the pain intensified: Tylenol, the massage chair, walking, lying down, sitting up, and having the kids rub my back. Yikes, the pain that can only be described as an unrelenting, constant hurt of the greatest magnitude, a 12 on the pain scale of 1 – 10, which no positioning or over the counter pain medication can touch had me rolling on the floor and telling the kids to call Dad to come home from work now.

Yes, that was just the beginning of my kidney stone experience. In trying to explain the pain to my husband on the phone, he said I sounded so short of breath that he thought I was having a heart attack and called EMS. When they arrived, the pain had subsided and I was left to diagnose myself with a kidney stone, with which the paramedics agreed. But since the pain was completely gone, did I really need to go to the hospital and in an ambulance no less? On their recommendation, the answer was yes.

In the ER, the IV was started and a CAT scan done to confirm our suspicions. Having no history of kidney stones, I was surprised at this painful attack that came on with no warning at all.

The ER doctor came in to see us and said in a thick accent, “Well, you were right. In 5 – 7 days you will have a special delivery!” he laughed.

I glanced at my husband who had turned white and later told me he thought for a second, “you mean she’s having a baby?!” (which at 53 surely would have been some sort of miracle). My first thought was “5 – 7 days of this pain? Are you kidding me?” How will I survive?

Another painful bout came as I lay on the gurney, and four strong IV medications didn’t completely take away the pain. We were told the pain comes from the spasms of the ureter as the stone blocks the flow of urine and irritates the inflamed tissues. Who could imagine that a 2 mm stone the size of a grain of sand could cause so much discomfort? The word intractable pain had new meaning for me now and I wished I had been more sympathetic to people and patients with kidney stones.

They sent us home with a urine strainer and prescriptions for Flomax and a combination of anti-inflammatories and pain medications. Another attack in the car and all I could do was writhe in pain and pray for relief. My husband kept repeating, “I hope I never get one of those”. It is the type of pain that one would do almost anything to stop but that nothing relieves short of passing the stone.

As I took my pain pills, strained my urine, and drank copious amounts of water to help the delivery along, I had time to reflect on the age old debate of kidney stone pain being akin to labor and childbirth. Having some experience in the childbirth area, I still found no way to compare the two in terms of what hurts more, but here were my reflections:

Labor pains were more predictable and increased with intensity as you moved towards the goal of delivery. Kidney stone pain, on the other hand, was unpredictable and had the most intense pain with every bout.

Doctors can predict when the baby will be delivered by closeness of contractions, and examining cervical dilation and effacement. Kidney stone delivery is much less predictable.
If your baby is too big to be delivered vaginally or there are complications, a C-section can be performed. And if your kidney stone is too big to pass, you may have laser treatment to break up the stones or major surgery to retrieve them. Both can mean painful recoveries.

There are medications they can give you for labor and delivery. You can even get an epidural, which I never had, but am told they can make the experience much less painful. But the kidney stone pain didn’t seem to be completely obliterated by anything short of passing it.

In comparing types of pain, I guess I can see where men would say they come close to labor pain with a kidney stone, but 10 hours of back labor was equally as bad, and having your OB doctor turn your baby internally prior to a natural birth still rates as the #1 pain I have ever had (but at least it was over quickly).

And last, but most significantly, with labor and childbirth you expect and usually earn a wonderful, lasting, happy surprise at the end of the process, where you hold your newborn in your arms and experience the glory of motherhood, quickly forgetting the pain that was endured to have your bundle of joy. Whereas, at the end of your kidney stone passing, you collect a little grain of something that goes into a plastic container for the urologist to later analyze and you can’t believe how much that little devil hurt to get out. You may experience relief and joy at the passing, but there are lifestyle modifications to make to try to avoid it ever happening again, and still without the assurance that it can be prevented, so unlike the conception process. Who, having had one kidney stone, would ever make plans to have another?

Fortunately, my stone did not take 7 days to pass and was gleefully collected in a matter of hours.

So, my answer to the question of which is more painful, a kidney stone or labor and delivery, is a simple one: they cannot be compared. It’s like apples and oranges. Different types of pain, but both extremely intense, though the kidney stone is much more unpleasant because the outcome is not a lasting joy for the rest of your life. Since every person experiences pain differently, no one could really answer this question anyway because pain is a subjective experience.

For me, given the choice between labor and a kidney stone, I pick labor. Childbirth is definitely more fun and with rewards that last a lifetime.