Falls and postural balance in chronic obstructive pulmonary disease

© 2014 Dr. Cristino Carneiro OliveiraChronic obstructive pulmonary disease (COPD) is a major cause of breathlessness and disability associated with functional impairment and reduced quality of life. The presence of chronic conditions has been related to a higher fall risk in the elderly, and individuals with COPD may be at an increased fall risk due to the respiratory and systemic manifestations of the disease. Balance deficits are one of the most important risk factor for falls in older adults and preliminary evidence suggests that people with COPD may present with impaired postural balance compared to healthy older adults. However, limited information is available regarding falls and postural balance in the COPD population, particularly during an acute exacerbation. In addition, an increased fear of falling is prevalent among individuals with advanced age and is not exclusive to those who have experienced a prior fall. Although an increased fear of falling has been related to impaired physical function, decline in activities of daily living, and increased fall risk in older adults, the physical determinants and consequences of this fear have not been examined in those with COPD. An increased fall frequency has been reported among people with COPD, this is an important research outcome. However, the lack of a standardised reporting in COPD could influence the interpretation of falls data in this population. The integrative review described in Chapter 2 demonstrated a variety of study designs and falls definition used to investigate falls outcomes and associated risk factors in the COPD literature. Based on the current literature, risk factors associated with higher odds of having a fall in those with COPD are: fall history in the prior 6 months, coronary heart disease, use of supplemental oxygen, female gender and age. However, the lack of standardised falls outcome reporting and the use retrospective study design or limited follow-up make it difficult to draw definite conclusions. In Chapter 6, a prospective 12-month cohort study with falls monitoring was conducted using international recommendations for falls outcome reporting. Individuals with COPD presented a high fall incidence rate. Smoking history, number of medications, history of falls, fear of falling, and higher score on fall risk assessment questionnaire were identified as fall predictors. In addition, smoking history, number of hospitalised days due to acute exacerbation and advanced age contributes to an earlier time to first fall following initial assessment. The second area of work in this thesis systematically reviewed the assessment instruments used to evaluate postural balance and fear of falling in people with COPD. Different instruments with heterogeneous content have been used to assess these two outcomes in COPD. This systematic review described in Chapter 4 identified the need of use of standardised assessment methods and best evidence on their measurement properties reported in the COPD population. Recommendation is given about suitable instruments to assess balance and fear of falling in clinical practice. Further evaluation of balance performance in COPD included a controlled, cross-sectional study outlined in Chapter 7. This study investigated balance performance in hospitalised patients with COPD during an acute exacerbation compared to community-dwelling stable COPD and healthy controls. Falls incidence following hospital discharge was also recorded. Impairment on anteroposterior control of balance was found in the majority of balance tasks studied compared with healthy controls. Increased dyspnoea and reduced muscle strength were associated with balance deficits during an acute exacerbation of COPD. In addition, increased fall incidence rate and a high number of injurious falls were observed during 12-months following hospital discharge. Fear of falling assessment in COPD was the third area of investigation in this thesis. The proportion of fearful individuals and the level of fear in a sample of people with stable COPD were investigated and compared to age- and gender-matched healthy controls. A higher proportion of individuals and higher fear of falling scores were found among those with COPD compared to controls. Increased fear of falling was associated with impaired postural balance, lower quadriceps strength, reduced physical activity and higher fall risk