Is there an association between infections and falls?

Although the list of factors that lead to falls is long and varied, increasing number of reports have identified falls as a manifestation of infections, including Covid-19.1-4

A retrospective study involving over 1400 patients (mean age 72 years) admitted to the hospital for a fall or its complications found coexisting systemic infections (CSIs) in 21% of patients; 26% in those ≥75 years. Urinary tract infection accounted for 55% of CSIs, followed by pneumonia (36%), skin and soft tissue infections (7%), influenza/influenza-like illness (5%), bacteremia (5%), gastrointestinal infections (2%), and others. 1

Risk factors for CSI include preexisting symptoms (eg, weakness, dizziness), inability to get up on own, confusion, age ≥ 50 years and meeting the systemic inflammatory response syndrome (SIRS) criteria on presentation.1 Of note, CSI may not initially be suspected by providers in about one-third or more of the cases, with 15% of patients presenting with “mechanical fall” having a CSI.1,2  Fever or SIRS criteria (≥2) are absent in the majority of patients with CSI.1,2

More recently, reports of falls as a presenting feature of Covid-19 have also appeared in the lay press as well as the literature, with 1 study finding 24% of patients with Covid-19 seek care primarily because of syncope, near syncope, or a nonmechanical fall.3,4

Several factors may explain the association of infections with falls, including impairment of skeletal muscle function (eg, through cytokines, hypophosphatemia), poor oral intake and dehydration. 1 Perhaps that’s why inability to get up by one’s self from a fall in the absence of an obvious reason (eg, fracture) may be a clue to a CSI in patient presenting with a fall.

Bonus Pearl: Did you know that falls are a leading cause of injury and death, afflicting one-third of adults aged greater than 65 years each year?1

Disclosure: The author of this blog also was a coinvestigator in 2 cited studies (ref. 1 and 2)

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References

  1. Manian FA, Hsu F, Huang D, et al. Coexisting systemic infections in patients hospitalized because of a fall: prevalence and risk factors. J Emerg Med 2020;58:733-40. https://www.sciencedirect.com/science/article/abs/pii/S0736467920300214
  2. Blair A, Manian FA. Coexisting systemic infections in patients who present with a fall. Am J Med Sci 2017;353:22-26. https://pubmed.ncbi.nlm.nih.gov/28104099/
  3. Chen T, Hanna J, Walsh EE, et al. Syncope, near syncope, or nonmechanical falls as a presenting feature of COVID-19. Ann Emerg Med 2020 July;76:115-117. https://pubmed.ncbi.nlm.nih.gov/32591120/
  4. Norman RE, Stall NM, Sinha SK. Typically atypical: COVID-19 presenting as a fall in an older adult. J Am Geriatr Soc 2020 July;68:E36-37. DOI:10.1111/gs.16526 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7267373/pdf/JGS-9999-na.pdf

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Massachusetts General Hospital, Harvard Catalyst, Harvard University, its affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

Is there an association between infections and falls?

Should male patients with suspected urinary tract infection routinely undergo a prostate exam?

Yes! That’s because any urinary tract infection (UTI) in men has the potential for prostatic involvement1 —-as high as 83% by one report. 2  

To make the matters more confusing, patients with acute bacterial prostatitis (ABP) often present with symptoms just like those of UTI,  such as urinary frequency, dysuria, malaise, fever, and myalgias. 3  In the elderly, atypical presentation is not uncommon (eg, confusion, incontinence, fall). 4  Under these circumstances, bacteriuria and pyuria may also be related to ABP and the prostate exam should be an important part of your evaluation.

Although the sensitivity of prostate tenderness on digital rectal exam varies widely for ABP (9%-100%), a painful exam should raise suspicion for ABP, and by itself may be an independent predictor for clinical and bacteriologic failure of therapy. 1 Along with tenderness, fluctuance of prostate, particularly in the setting of voiding difficulties and longer duration of symptoms, may also suggest the presence of prostatic abscess. 5,6 

But be gentle when performing a prostate exam and don’t massage it because you could potentially cause bacteremia and worsening of sepsis! 1,7

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References

  1. Etienne M, Chavanet P, Sibert L, et al. Acute bacterial prostatitis: heterogeneity in diagnostic criteria and management. Retrospective multicentric analysis of 371 patients diagnosed with acute prostatitis. BMC Infectious Diseases 2008;8:12. https://bmcinfectdis.biomedcentral.com/track/pdf/10.1186/1471-2334-8-12?site=bmcinfectdis.biomedcentral.com
  2. Ulleryd P, Zackrisson B, Aus G, et al. Prostatic involvement in men with febrile urinary tract infection as measured by serum prostate-specific antigen and transrectal ultrasonography. BJU Int 1999;84:470-4. http://onlinelibrary.wiley.com/doi/10.1046/j.1464-410x.1999.00164.x/pdf
  3. Krieger JN, Nyberg L, Nickel JC. NIH consensus definition and classification. JAMA 1999;282:236-37. http://jamanetwork.com/journals/jama/article-abstract/1030245
  4. Harper M, Fowlis. Management of urinary tract infections in men. Trends in Urology Gynaecology & Sexual Health. January/February 2007. http://onlinelibrary.wiley.com/doi/10.1002/tre.8/pdf
  5. Lee DS, Choe HS, Kim HY, et al. Acute bacterial prostatitis and abscess formation. BMC Urology 2016;16:38. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4936164/
  6. Oliveira P, Andrade JA, Porto HC, et al. Diagnosis and treatment of prostatic abscess. International Braz J Urol 2003;29: 30-34. http://www.scielo.br/pdf/ibju/v29n1/v29n1a06.pdf
  7. Lipsky BA, Byren I, Hoey CT. Treatment of bacterial prostatitis. Clin Infect Dis 2010; 50:1641-52. https://academic.oup.com/cid/article/50/12/1641/305217

 

Should male patients with suspected urinary tract infection routinely undergo a prostate exam?

My patient with a recent fall has a low serum 25 (OH) D level. Can vitamin D (VD) deficiency be associated with falls?

Short answer: Yes! Although the essential role of VD in calcium homeostasis and bone health is widely recognized, the extra-skeletal impact of its deficiency is often overlooked, including its effect on muscle function.  In fact, in 30% of patients, VD deficiency may present as proximal muscle weakness before any biochemical signs develop (eg, hypocalcemia, high alkaline phosphatase), likely mediated through VD receptors in muscle tissue 1,2. 

A recent meta-analysis of fall prevention with supplemental vitamin D concluded that at a dose of 700-1000 IU, supplemental vitamin D reduced falls by 19% within 2-3 months of treatment initiation among patients 65 y or older2; this benefit was not affected by type of supplemental VD, gender, age, or level of independence, and may be independent of additional calcium supplementation.  No fall reduction was observed with a daily dose < 700 IU or achieved serum 25 (OH)D levels below 60 nmol. 

References 

  1. Rasheed K, Sethi P, Bixby E. Severe vitamin D deficiency induced myopathy associated with rhabdomyolysis. N Am J Med Sci 2013;5:334-336.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3784929/
  2. Bischoff-Ferrari HA, Dawson-Hughes B, Orav JE, et al. Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomized controlled trials. BMJ 2009;339:b3692. https://www.ncbi.nlm.nih.gov/pubmed/19797342/

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My patient with a recent fall has a low serum 25 (OH) D level. Can vitamin D (VD) deficiency be associated with falls?