Beyond the Mortality Paradox: Redesigning UTI Care for People Living with Dementia through Diagnostic Stewardship

Managing urinary tract infections (UTI) in people living with dementia presents a mortality paradox: clinicians must balance the risks of antibiotic overuse against the dangers of delayed treatment in high-risk phenotypes. Standard diagnostic criteria often rely on classic, localizing markers like fever and dysuria. However, these gatekeeper signs are frequently absent or blunted in dementia care due to age-associated immune dysregulation and immunosenescence. Consequently, infections often manifest as nonspecific neurobehavioral changes, leading to predictable misclassification and harmful diagnostic delays. This paper reframes UTI management in dementia as a clinical pathway and measurement architecture problem. We propose a verification-first service pathway that replaces symptom-first heuristics with objective diagnostic certainty and closed-loop follow-up. The model incorporates physiologic stability triage, risk stratification for vulnerable phenotypes, and a standardized confirmation bundle. To ensure operational reliability, the pathway is linked to four auditable key performance indicators focused on verification completion, avoidable antibiotic starts, time-to-action, and stewardship follow-up. By treating diagnostic infrastructure as a system property, this approach aims to reduce "sticky empiricism" and improve safety in the face of clinical ambiguity.