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get protect. And I was just gonna mention quickly from, um, just on the end of downs. Talk there. And if anyone uses them and the Rx guide line up for the trust about a policy, there's also policy on there. It's the Northern trust, probably care guideline. And for sort of opiate conversion on symptom management in the last couple days of life, it's really practical, very helpful. If you're in a situation weekend or no. 95. Um, just for about for prescribing advice on there's a section specifically on it for Cupid. Palliative care is well, which hopefully were saying last dose, but, um, very practical, Very slap. So, um, none of it. So, uh, you see my screen? Yeah. You sure? Yes. And get the thumbs up from a call, okay. And so I'm chatting on the very exciting topic of UTI. So in the elderly population, um, so it's something that's obviously incredibly common on incredibly high burden on or for the 65. So, um uh oh, so just just to introduce the top back, so a lot of what I'll be speaking about is the sort of extension of what Emily was speaking about earlier. So, um, within within the population, um, infection doesn't present the way that we typically like infection present on a makes it potentially quite challenging exactly from the any side of things in terms of working. Right, um, for exactly gaining with. So, um, so you're sort of typical dysuria frequency roaring fever won't always be there on it. Requires a little bit of additional work from us to try and clarify what's what exactly is happening with these patients That's often confined it by the fact that these patients may have a baseline of cognitive impairment were maybe presenting with delirium because of infection on that can make getting a clear history, um, more, more difficult. Um, so yeah, so this so the older population are at higher risk of UTI so on. And that's related to higher prevalence of issues such as, um, continents per hi, Jane. Urinary Stasis from responding prostatic hypertrophy and, um, higher prevalence of patients with long term catheters. And so just that's where the last point when considering UTI diagnosis and treatment, um, in terms of benefit versus risk for these patients, I think we're all fairly aware from today about it. You know the potential risk for these patients in terms of polypharmacy, um, renal insults on about a crisis resistance. But it's just to think about the other side of risk for these patients in terms of diagnosing a patient any day with the UTI. Um, first of all, if they don't have a UTI, it'll under giving them unnecessary treatment, you may be contributing Teo delirium. You, maybe for that prevent the room from getting home and on d. Um, and also, once they're given that label of UTI a lot of the time, people don't think about the alternatives like constipation. Um, I'm a little chat briefly about that later on as well. Um, yeah. So in terms of symptoms, be looking out for sometimes. And the medications do you come along and they do. You have a documented Parex ear, particularly from nursing homes. So, um, if you do you have a patient who's initially home resident on there. Obs have bean stable at triage. Do you definitely have a look at the note from national homes? Um, so they will often document if there has bean a proxy history or if a patient has complained about more typical symptoms at some stage. Prior Teo, proud of becoming more on well, so for accidents, urea frequency hematuria and can definitely indicative of an acute urinary infection. Um, but I think mawr classically. The patients we do, you say, are the sort of more non specific patients coming in on our except nauseous and with a new delirium or often is the function of the client and our feet. Um, so when you're trying to tease, like with these patients, you know what what exactly is the cause for this decline and just really had an importance of taking a fair A history from the patient, if possible. But if that's not possible, really think about your collateral history. So who clean? I were getting more relatives coming in the day, but if they're not physically there with the patient, is there someone you can rang? The phone is an exit. Can he knows what's been going on? Or do you need to bring the nursing home or residential home to get a class or less tree? A lot of the time. That is the most valuable source of information for these patients, particularly if they are delirious or confused because of infection. And also just the importance of there a physical examination for and four sign or signs of UTI, but also those additional causes. You know, thinking is this a UTI? Is that why they're our feet for how they have a stroke? Because that's something you don't want to miss and a little bit about Diagnostics is well so and so when thinking about your signs of infection. So we have your typical markers off sepsis, So tachycardia, hypertension, maxilla. But a lot of time in this population those could be wanted. You know, if this patient's on, ah, be two blocker, they won't necessarily have a tachycardia. It doesn't mean that they're not be hydrated or or unwell and similarly, what we would classify as a you know, hypertension of a systolic last time like day. Every patient at home has a BP of 160. You know, they may well have a relative hypertension of a systolic of 120. So it's it's just trying to tease out, you know, from what normal is for for these patients, because it doesn't necessarily meat. What would be normal in terms of our more classic criteria. Um, so, yeah, so in terms of favor, more specifically, um, unfortunately, it is and absent in patients presenting with serious infection. And actually, there's very good evidence that on acute febrile a response, um, the patient can actually develop a fever. Is is actually a protective factor. It's, you know, an indicator that the patient's immune system is robust on working. So if you think about a patient twos lacking the fever in spite of serious, serious infection, and those are your patients, actually you have, ah, higher morbidity and higher mortality. Um, so again. So Emily touched on this area in terms of her and biological model of frailty. So you have You have to think about why that February response has been blunted. And it's just regulation of, um, hypothalamus reduced indulgence. Parents being released on be reduced. Brian thought of aiding thermogenic test. So, um, so you might want to consider a slightly lower threshold for these patients so you consider a temperature 30 78 potentially as a significant per xia or temperature increase of over one degrees Celsius. From what? Maybe they're normal would be classified in the national home that that considered a significant And and as I've noted there, don't ignore hypothermia again, just from hypothalamic to function. And sometimes these people present as a cold sepsis instead of the classic Parexel we say. And so this is really a month within the diagnosis of UTI. Stay on older population. All are sort of standard diagnostic aids Bill are a little bit less helpful. Um, andi on it's not necessarily as definitive as they would be in a younger population. So, um, in terms of, you know, raised white cell count race crp, Um, both. Conversely, you may not have a classic response. You may not have a raised by itself, but you may not have a race therapy, but also it actually may be raised all the time. So again, it's trying to work right. What is normal for each individual patient, um, has there being on acute change from normal So again, and coming back to that's with proinflammatory state from the biological model of frailty, they may normal, except the CRP of 50. Um, it isn't necessarily something that you have to so automatically treat for diagnosed as a UTI. Um, I'm gonna talk a little bit more about your analysis in a second. Um, but in terms of urine culture again within, within an older population again, it's not a failsafe rule. If you have, ah, start year old lady or mount presenting with a positive urine culture two days go to Syria on a fever, you can be fairly sure that what you're saying is a UTI and treat it where is in an older population that could be lots of different confining factors. So in terms of midstream, urine's have just touched on the fact that you know, getting a clean catch isn't necessarily logistically always easy. And there could be a lot of contamination, particularly if there is per, um, General urinary hiding, um, on in terms of touching on catheter specimens, a space that's asymptomatic, um, back area and is almost a hunter sent. Once people have had long term catheters in for over four weeks. Um, so having a positive culture a few days ago doesn't necessarily mean that this patient has a UTI, Um, and that's in unfortunate catheterized on on catheterized population, so you can have a symptomatic bacteria, a symptomatic type area and just on higher frequency as we as we get older. So and that's just a few. And, um, first I find the actual up to 20% of any woman over the age of 75 that increases up to 50% for patients in long term care facility. So again, that's just a reflection of. And you're higher levels of incontinence for general care and hygiene. Um, so moving on specifically to your analysis and so a lot of time sitting in an e on you will be handed Ah, your analysis for patient and it will be positive for nitrates and leukocytes. And the assumption is okay. This patient has a UTI that's generally not going to always get a case, particularly in in the older population. So my so the first point on that would be I know there's a difficult in terms of medical admissions, for there's, ah, sort of non specific requirements that every medical admission get a chest X ray and a UTI. Whilst that can be helpful, it doesn't necessarily mean it's something we need to act on. So if a patient you know is presenting over the age of 65 with a different diagnosis and which is quite clear, unless you're specifically concerned that they have a urine infection. Urinalysis isn't necessarily helpful, um, so in terms of what the urinalysis actually means. So the two main things we're often focused on would be presence of leukocytes, which indicates area. But again, if we go back to my previous note of up to 20% of all women over the age of 75 can have a sterile part area or an asymptomatic bacteria. The presence of like the sides doesn't necessitate that they have a UTI and similarly with nitrites. So there's no explanation of what nitrites are. So, um, they indicate the presence of Andrew. Seriously, I buy the pathway that and robaxin racy. I I'd realize nitrates, nitrites, but that needs a couple of different things. So first of all, it needs. You have an adequate dietary intake of the night trips, which may not be the case particularly well nourished population em on. It also requires, um, enough time incubating within a bladder. So if a patient has incontinence, you won't necessarily get a positive nitrates even if there is infection. Um, but also he could get a positive nitrates and I trade if there's a chronic asymptomatic fracture. So unfortunately, nothing it's clear in this population, I think, is the is the general summary. So there is probably a degree that of negative predictive value is more helpful than positive, stricter, valued off post of your analysis. But, uh, again it since what Emily was pointing earlier. Unless you have a clinical suspicion of a patient presenting with new urinary symptoms on evidence of new infection, it's not actually necessarily a helpful test on can lead to over treatment of what is not an acute UTI. Um, more specifically, there's a, um from nice guidelines for management of older people and in terms of considering diagnosis of UTI nicest specifically stated, there is no helpful role for your analysis and I'm a catheterized patients. So, um so that's a slightly simpler point, okay? And so this is, um, quite helpful flow chart from from the sign guidelines in terms of diagnosis and management of older people that you're suspecting urinary infection and on again it's based on the the low criteria for, um, these Do you think this patient has a non urinary infection given different symptoms on then, based on whether patient has a urinary catheter or not. So, um, patients with um with like Jeremy catheters will present in cycling different ways. Um Onda. It's in terms of which patients you need to treat which patients are likely to have a year urinary infection on which patients are safer to monitor. So again it is focusing on those more specific symptoms. So this area, New York and see new frequency um, Frankie Materia new flank pain rather than those of just non specific Our feet presentations. So and again you'll see Dine the bottom again Sign has not really recommended. Um, using urine dipstick is definitive. And it's a diagnostic tool for UTI and an older population and highlight of the importance of, you know, sending cultures and microbiology prior to starting on biologics. Um, so just moving on to, uh, just a few points on management. So again, just highlight that that same message of only treat on test patients that you clinically think have new UTI symptoms with physiological evidence of acute infection. Why I'm trying to harp that point on is to try to reduce the number of unnecessary patients we're giving antibiotics to on the on or the patients that were wrong. They diagnosing with UTI. So, um well, I mean by Confirmation Valley bias is. And once you give a patient diagnosis of UTI, which girl found a day and I also do myself But once they're given that title, it carry street. So I had a patient yesterday. He we took for a laparotomy because they'd come in, I think about three or four days ago with super pubic pain, vomiting on a positive urine dipstick. Um, but they had their incarcerated femoral hernia reduced last night. INTRAOPERATIVE lee, but it come in medically, had a diagnosis of uti for up to 48 hours before anything else was considered. So our diagnosis that we give a patient in a day those have standing and can carry through and it can delay, um, delay other diagnosis if we label them was a UTI S o. R. Are truths of diagnosis is important for patients today. Eso again just a more practical management points for any And so, if you're considering giving patients antibiotics if they are meeting, that's criteria of new UTI symptoms with evidence of infection and in terms of Europe, Eric Antibiotic, their baby. Do try and see if they have had previous posted MSU's of Weakens Direct, um, or narrow, narrow spectrum antibiotic on if not obviously follow just policy and again, sort of trying to keep things. Now spectrum is to reduce the risk of resistance and reduce risk of having a cardiogenic infections like c diff Quite helpful Point can also be if, um if you if it's a patient who has a UTI, but he's well enough to go home. Um, you know, within our sort of something new system, there is a non option for GP review, and I would encourage you to use this specifically for this population. Um, you know, there is increased risk of antibiotic resistance with increasing age on different start patients on apparent therapy, and we send a culture and, you know, in any about the time we can't, um, we can't act on that. But if they're seeing their GP and 48 72 hours, they they're antibiotic therapy can be adjusted to him or her ability biotic and on, uh, yeah, So consider not just one. Your discharging patients with you guys ran e. Um, so, yeah, so has a whistlestop care of you guys in the elderly. So, um, main take home message is really are, you know, think specifically about the diagnosis. And don't use that other sort of get out of jail free calls, um, for an a patient or something with sort of non specific symptoms by by using UTI as a diagnosis, you know, you could miss a significant other diagnosis, and that helps. It's significant consequence on patient journeys and don't depend on the urinalysis. Um, Andi, as I was saying, you think specifically about what? Antibiotics will be helpful for the patient particularly, and considering polypharmacy and what other meds they might be on. Um, I'm just the importance of safety, and I think the stations and follow up with our GPS and and that's it, Um, I don't think it will have made The treatment of beauty is any clearer in this population. But unfortunately, with a lot of conditions and in their late you treatment isn't simple. And it's really focusing on, um, you know, good physical examination, really taking the most of the cannot of collateral history and on history from the patient, if possible. And is there any questions? Thanks so much for me. That's great. I guess that's really we're going to deterred. Playful is we need to really have something hard to hang on to say that this is a UTI we can't just be saying or there we bit confused. This is a UTI just because, you know, there's a positive urine. So really, that's the big point that we really can't drive from that don't just behind vague they weapon that you think you've got uti get vision. Um, any other crashes are coming up for Jenny GI seconds. Anything key? She focused and thanks and enjoyed your talk. So I think that's probably off the Benjani. So thank you and thank you. Right? Swimming is well.