Subtle Infections May Cause Falls In Elderly

Farrin A. Manian, MD, MPH, FACP, FIDSA, FSHEA Inpatient Clinician Educator, Department of Medicine, Massachusetts General Hospital Visiting Associate Professor, Harvard Medical School, Boston, MA Interview with:
Farrin A. Manian, MD, MPH, FACP, FIDSA, FSHEA
Inpatient Clinician Educator,
Department of Medicine,
Massachusetts General Hospital
Visiting Associate Professor, Harvard Medical School
Boston, MA 02114

Medical Research: What is the background for this study? What are the main findings?

Dr. Manian:  Falls are a leading cause of injury and death, afflicting about one-third of adults over 65 years of age annually.  Although there are many potential causes for falls, infections have received very little attention, with previous published reports primarily revolving around institutionalized elderly with dementia and urinary tract infection.

We found that the spectrum of patients at risk for falls precipitated by infections goes far beyond the institutionalized elderly with dementia and urinary tract infection.  In fact, the majority of our patients fell at home and did not have a diagnosis of dementia.  In addition, besides urinary tract infections which accounted for 44.1% of cases, bloodstream (40.0%) and lower respiratory tract infections (23.0%) were also frequently represented.  Although the mean age of our patients was 76 years, 18% were younger than 65 years.  We also found that the signs and symptoms of these infections at the time of the presentation for the fall were often non-specific (e.g. weakness or mental status changes) or absent, with only 44% of patients meeting the criteria for systemic inflammatory response syndrome and only 20% having fever or abnormal temperature possibly related in part to advanced age.  These factors may make it difficult for the patient, family members and healthcare providers to readily consider infections contributing to the fall.  In fact a coexisting systemic infection was not initially suspected by providing clinicians in 40% of our patients and 31% of those who were later diagnosed with a bloodstream infection.

Medical Research: What should clinicians and patients take away from your report?

Dr. Manian:  As clinicians, I think we should not rush to judgment as to the cause of a fall until we gather as many facts as possible surrounding it.  It is often easy to label a fall as “mechanical” (e.g. tripping over a rug, or slipping) but this is only a descriptive term and does not necessarily explain all the factors that might have led to it.  Two-thirds of the falls in our study were considered mechanical despite coexistence of a systemic infection.  So I think we need to go beyond describing how a fall occurred and routinely dive deeper into why it happened in the first place.  This means asking specific questions about how the patient was doing during the hours or days that might have led to the fall. Were there any new signs or symptoms that the patient or the family noticed that might have indicated something such as an infection was brewing?  Once an infection is suspected, appropriate evaluation and treatment can then be initiated simultaneously with the usual workup for fall-related injuries.

For patients and families, seeking physician advice even when a fall does not result in a significant injury may lead to earlier diagnosis and treatment of a coexisting infection as well as interventions that may reduce the risk of future falls.  Ultimately, everyone should be more attentive to new but potentially subtle signs and symptoms of an infection, particularly when involving an elderly (such as increased weakness or confusion), that may necessitate medical attention hopefully before a fall occurs.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Manian:  We need to better define the extent of falls associated with coexisting infections in a variety of settings, such as homes, extended-care facilities, and hospitals. We also need to better explore patient factors or signs and symptoms that may lead to a more timely identification of those who present with a fall in the setting of a coexisting infection in hopes of minimizing any delays in the diagnosis and treatment of such infections.


IDWeek 2015 abstract discussing: 
Coexisting Systemic Infections (CSIs) in Patients Presenting with a Fall: Tripped by Objects or Pathogens?
Session: Poster Abstract Session: Bacteremia and Endocarditis

Friday, October 9, 2015
Alexander Blair, MS, Harvard Medical School, Boston, MA and Farrin a. Manian, MD, MPH, FIDSA, FSHEA, Massachusetts General Hospital, Boston, MA

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Farrin A. Manian, MD, MPH, FACP (2015). Subtle Infections May Cause Falls In Elderly 

Last Updated on October 12, 2015 by Marie Benz MD FAAD