Excellent point, and as I recall, there have been several studies highlighting our tendency to overdiagnose UTI and especially to overattribute behavioral changes to UTI in this population.  Honestly, some specialties seem notorious in this regard, including psychiatry.  That being said, an especially common cause of new behavioral change in an institutional setting is a change in staff.  Not an easy possibility to explore, or to address, at 2am.

NS wrote:

We often get calls from the nursing home and/or ALF(s) where we follow patients with the nurse requesting an order to obtain and send a urine specimen for urinalysis and urine culture to r/o UTI for almost every episode of mental status change. There was an instance when a patient had urine tests done almost every 2 weeks during a 6 week period because of perceived mental status change (with underlying baseline cognitive impairment) every few weeks and the concern about an undiagnosed UTI though there were no other clear indicators which is not uncommon in older adults as part of "atypical presentation". Still, in the absence of fever, abdominal or pelvic area or back pain, dysuria, hematuria, concentrated urine, cloudy urine, foul smelling urine, urinary frequency, urinary urgency, nausea, vomiting, or chills, I find it hard to keep on ordering urine tests as though a positive urine test can explain the mental status change. Bacteruria and pyuria are not uncommon in older persons residing in instituional settings but do not always indicate a UTI. 

Thanks!

Thank you, Dr. Appelbaum, I agree.  Also agree with your comment about less skilled staff working overnight in many or most cases.  A key word in my original post was 'again,' this is ostensibly a patient with dementia and known, ongoing behavioral problems.  We can talk about how this should be evaluated and managed during the day; it's more challenging and more controversial to decide what to do in the middle of the night.

Jonathan Seth Appelbaum, MD wrote:

With the caveat that I have not done direct nursing home care in years, as I have taught medical students and residents, ALL cases of delirium need a full evaluation, starting with a history and exam with some basic lab test--before ordering any medication.  Unfortunately in most nursing homes the least skilled staff works the graveyard shift.

I'm curious about how people approach an all-too-common problem.  You're on call and receive a phone call from a SNF or a hospital at 2am, "Mr. Jones [a patient with known dementia] is agitated again and needs something."  How do people approach this?  What questions for the nurse, what evaluation if any, what meds?