Abnormal vital signs, cognitive impairment, and acute hemodynamic changes are just beginning to be researched in the elderly who become ill and confused. Paula and I think that this research must be expanded to all ages, especially the patients with patterns of altered mood and mental status currently understood to be “mental” illness. Vital signs [ including respiratory rate at rest] can easily be measured at the moment of ED arrival as part of routine clinical care. Cognition can easily be measured using the Six-Item Cognitive Impairment Test (6-CIT). [takes 4 minutes] “Mental” illness causes significant morbidity [disability, ill health, suffering] for long periods of time, long enough for all doctors, including psychiatrists and neurologists,, etc..] to look to begin looking into possible circulatory problems affecting metabolism.
Vital signs and impaired cognition in older emergency department patients: The APOP study 2019
Background/objectives: Cognitive impairment is a frequent problem among older patients attending the Emergency Department (ED) and can be the result of pre-existing cognitive impairment, delirium, or neurologic disorders. Another cause can also be acute disturbance of brain perfusion and oxygenation, which may be reversed by optimal resuscitation. This study aimed to assess the relationship between vital signs, as a measure of acute hemodynamic changes, and cognitive impairment in older ED patients.
Design: Prospective cohort study.
Setting: ED’s of two tertiary care and two secondary care hospitals in the Netherlands.
Participants: 2629 patients aged 70-years and older.
Measurements: Vital signs were measured at the moment of ED arrival as part of routine clinical care. Cognition was measured using the Six-Item Cognitive Impairment Test (6-CIT).
Results: The median age of patients was 78 years (IQR 74-84). Cognitive impairment was present in 738 patients (28.1%). When comparing lowest with highest quartiles, a systolic blood pressure of <129 mmHg (OR 1.30, 95% confidence interval (95%CI) 0.98-1.73)was associated with increased risk of cognitive impairment. A higher respiratory rate (>21/min) was associated with increased risk of impaired cognition (OR 2.16, 95% CI 1.58-2.95) as well as oxygen saturation of <95% (OR 1.64, 95%CI 1.24-2.19).
Conclusion: Abnormal vital signs associated with decreased brain perfusion and oxygenation are also associated with cognitive impairment in older ED patients. This may partially be explained by the association between disease severity and delirium, but also by acute disturbance of brain perfusion and oxygenation. Future studies should establish whether normalization of vital signs will also acutely improve cognition.
PLoS One 2019 Jun 20;14(6):e0218596.doi: 10.1371/journal.pone.0218596. eCollection 2019. Vital signs and impaired cognition in older emergency department patients: The APOP study , Jacinta A Lucke 1 2, Jelle de Gelder 1, Laura C Blomaard 1, Christian Heringhaus 3, Jelmer Alsma 4, Stephanie C E Klein Nagelvoort Schuit 4, Anniek Brink 4, Sander Anten 5, Gerard J Blauw 1, Bas de Groot 3, Simon P Mooijaart 1 6 PMID: 31220173 PMCID: PMC6586336 DOI: 10.1371/journal.pone.0218596 Free PMC article https://pubmed.ncbi.nlm.nih.gov/31220173/
It just may be possible that the future of medical and physiological investigations of patterns of mental illness [altered mental status and mood and locomotor activity] has finally begun to arrive, due to the new interest in the chronic disturbance of vital signs and it effects on brain perfusion and cognition and the body.
Abnormal respiratory rate is key because the motor aspect of breathing involves peripheral nerve fibres, ganglions, involuntary aspects of the respiratory skeletal muscles, and all locomotor skeletal muscles, the chemical makeup of blood, the function of the kidneys and the heart and thermodynamics , etc…. if the motor aspect of breathing cannot easily react correct gradual pH imbalance during a respiratory crisis.
Muscle is a entire organ system, parts of which can break over the course of one’s life. A broken leg may heal completely, yet be at risk of breaking again more easily under mechanical strain, or may cause pain with age or may result in a limp. If the same occurs to the respiratory muscles or nerves which move air in and out of the lungs, then regular respiratory rate at rest may be different from the mean rate, and the bigger the difference, the more abnormal-even in health, the more at risk our breathing will be under further mechanical stress- whether due to upper respiratory obstruction, or fever, or exposure to unventilated air or a combination of all these factors.
How did we not think of this before?
There is a reason why the vital signs are Vital.
And vital signs at rest [respiratory rate heart rate, blood pressure, body temperature] are unconscious , for the most part, as is the perfusion of the brain and the other organs [most of them in the periphery of the body] and cognition [we do not think about thinking, we just do it].
It is exciting, and we have a lot more to learn about the autonomic nervous system and the underlying operations and reflexes that prepare all that we do, from moving to singing to peeing to eating to breathing and to thinking. It is pretty cool!