O7.5 Falls in COPD

Accidental falls are an important and underestimated problem in people with COPD. As in older adult populations, falls in people with COPD are associated with increased injury-related mortality and risk for hip fractures, which impose a substantial economic burden on health care systems worldwide (Berry 2008).

Chronic obstructive pulmonary disease was the second most prevalent condition among patients presenting with hip fractures to emergency departments (Johal 2009). A large cohort study demonstrated a higher risk of hip fractures has been found in patients with COPD in comparison to a matched non-COPD sample (hazard ratio 1.78; p<0.001). In addition, patients who used inhaled bronchodilators and inhaled corticosteroids (n=10,362) had an even higher falls risk (HR 2.04, 95% CI 1.72 to 2.41, p<0.001) in comparison to those not using inhalers (n= 5,877, HR  1.63, 95% CI 1.40 to 1.89, p<0.001) (Huang 2016). Importantly, one study with robust methodology suggests that a history of falls in the six months prior to hospital admission is the strongest predictor of all-cause mortality in patients with severe COPD (odds ratio 3.05, 95% CI 1.40 to 6.66, p<0.005) (Yohannes 2016). A systematic review has reported a falls incidence rate in COPD of 1.17 to 1.49 falls/person-year (Oliveira 2021). In a large 4-year follow-up cohort study, the incidence rate of fall in patients aged ≥35 years who had a new diagnosis of COPD was higher compared with a matched cohort of non-COPD patients in primary care. Patients with COPD were 55% more likely to have a fall compared to people without COPD (adjusted HR 1.55; 95% CI 1.50 to 1.59) (Hakamy 2018).

The risk factors for falls identified in the COPD population are similar to those in older adults: advanced age, previous fall history, female gender, increased number of medications and comorbidities (Roig 2011). Risk factors specifically related to the physical and psychosocial effects of COPD include muscle weakness, impaired postural balance, use of supplemental oxygen, increased ‘fear of falling’ and heavy smoking history (Oliveira 2015, Beauchamp 2009).  Of these, polipharmacy (use of ≥ 5 medications) is particularly important in those with multiple comorbidities, and was identified as a falls risk factor in two prospective studies in people with COPD (Roig 2011, Oliveira 2015). The relationship between medication type and falls risk is well established in older adults (Park 2015). Particularly the use of the falls risk increasing drugs (FRID’s) including sedatives, hypnotics, antidepressants and benzodiazepines (Park 2015). Of note, patients with COPD were 47% more likely to have a fall than non-COPD patients when adjusting for smoking status, use of antidepressants and diuretics (adjusted HR (aHR) 1.47; 95% CI 1.43 to 1.51) (Hakamy 2018). The adverse effects of systemic corticosteroids on muscle strength (Decramer 1994) and consequently balance (Beauchamp 2012) could also indirectly contribute to increased risk of falling in COPD.

The fact that COPD, consistent with many other chronic diseases, is associated with frailty and increased fall risk suggests that these patients may benefit from generic falls prevention programs designed for older adults. In addition, the findings of specific risk factors for falls in patients with COPD highlight the need for specific preventive interventions in this patient population. The importance of balance training has been increasingly recognised in COPD as an important falls prevention strategy. For instance, Tai Chi exercises, which are characterised by posture alignment, weight shifting and circular movements that incorporate elements of muscle endurance and strengthening, balance, relaxation and breathing, have demonstrated significant improvement in body sway and functional balance in patients with COPD (Leung 2013). The benefits of specific balance training added to a 6-week conventional pulmonary rehabilitation program have also been documented in a RCT (Beauchamp 2013). Specific balance training including progressive stance tasks, transition, gait and functional strengthening exercises was superior to PR alone in improving functional balance in patients with COPD (Beauchamp 2013).

Given the higher fall frequency and prevalence of hip fractures in people with COPD, falls prevention programs targeting modifiable risk factors should be considered for this patient population.