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Treatment and Care of the Geriatric Veterinary Patient ebook

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Treatment and Care of the Geriatric Veterinary Patient offers veterinarians a complete guide to treating and managing geriatric canine and feline patients. * Offers practical guidance on managing all aspects of veterinary care in geriatric pets * Takes a holistic approach to managing the geriatric patient, from common diseases and quality of life to hospice, euthanasia, client communications, and business management * Focuses on dogs and cats, with a chapter covering common exotic animals * Provides clinically oriented advice for ensuring quality of life for older pets * Includes access to a companion website with videos, client education handouts, and images

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Table of Contents

Cover

Title Page

List of Contributors

About the Companion Website

Part I: They Just Don't Live Long Enough

1 Introduction

2 Maintaining the Human–Animal Bond

Reference

3 Geriatrics and Fragility

Introduction

Senior or Geriatric … It’s All in a Name – or Is It?

Geriatric Medicine for Humans

Fragility

The Geriatric Life Stage in Dogs and Cats

Summary

References

Part II: The Aging Body Systems

4 Vision Changes

Introduction and Description

Nuclear/Lenticular Sclerosis

Senile Cataracts

Iris Atrophy

Retinal Degeneration

Vitreal Degeneration/Asteroid Hyalosis

Corneal Endothelial Degeneration/Dystrophy

Coping Mechanisms for Owners with Blind Pets

References

5 Hearing Loss

What is Sound?

Causes of Hearing Loss in Pets

Monitoring Pets for Hearing Loss

Advanced Screening for Hearing Loss

Is There Treatment for Age‐Related Hearing Loss?

Management of Geriatric Pets with Hearing Loss

Quality of Life Assessment for Pets with Hearing Loss

References

6 Dentition and the Oral Cavity

Introduction

Conditions

Oral Pain

End of Life decisions

Client Education

References

7 The Nose and Smelling

Decline of Smell

Contributory Factors

Therapy

References

8 Cognitive Dysfunction and Related Sleep Disturbances

Introduction and Background

Common Symptoms of Cognitive Dysfunction

Development and Pathophysiology

Differential Diagnoses

Therapeutic Options

Sleep Disturbances

End of Life Considerations

References

9 Smelly Old Dog

The Skin and the Changes

The Patient: The Gold Standard and the Reality

When We Need to Address “The Elephant”

Crashing and Failing

Treating for Quality of Life and the Human–Animal Bond

References

10 Central and Peripheral Nervous System

The Nervous System and Aging

Disorders of the Central Nervous System

Disorders of the Peripheral Nervous System

General Treatment of Neurologic Disorders

Focus on the Client

References

11 The Aging Kidney

Introduction

Aging at the Glomerular Level

Aging at the Renovascular Level

Aging at the Tubular–Interstitial level

Diseases of the Aged Kidney

Monitoring the Health of the Kidney

Therapies

Special Considerations in the Aging Kidney

How an Aging Kidney Affects Life for the Pet

How an Aging Kidney Affects Life for the Owner

End of Life Considerations

Conclusion

References

12 The Hepatic System

Hepatic Diseases of the Dog

Hepatic Diseases of the Cat

Treatment

Focus on the Client

References

13 The Respiratory System

Healthy Aging of the Respiratory System

The Suffering of Dyspnea

The Larynx

The Airways

Bronchitis

Asthma

The Pulmonary Parenchyma

The Pleural Space

The Thoracic Wall

The Why

Acute Management of the Patient Suffering from Dyspnea

References

14 Mobility Issues

Musculoskeletal Changes

Treatment Goals

Physical Treatment Modalities

Physical Rehabilitation

Making a Plan

References

Online Resources

Appendix 14.1 Example neurology checklist.

Appendix 14.2 Example orthopedic checklist.

Appendix 14.3 Example mobility checklist.

15 Age‐Related Gastrointestinal Conditions and Considerations for Nutrition

Age‐Related Gastrointestinal Changes

Common Gastrointestinal Conditions

Pharmacology and Therapeutic Considerations

Nutrition and Digestion

Palliative Care Considerations

Conclusion

References

16 Urinary and Fecal Incontinence

Urinary Incontinence

Fecal Incontinence

Other Help for Pet Owners

References

17 Thermoregulation

Body Temperature Physiology: A Brief Review

Hypothermia

Hyperthermia

Geriatric Diseases That Affect Temperature Regulation

Effects of Hypo‐ and Hyperthermia

Geriatric Pet Management: Preventing Hypo‐ and Hyperthermia

Quality of Life Assessment for Geriatric Pets as it Pertains to Thermoregulation

References

18 Managing Pain in Geriatric Patients

General Considerations

Behavioral Considerations

Diagnostics

Treatment

Drugs for Treatment of Long‐Term Pain

Emerging and Future Therapies for Chronic Pain

Physical Modalities

End of Life Decisions

Sedation and Anesthesia

Case Studies

References

Further Reading

19 Exotic Animal Geriatrics

Introduction

Geriatric Conditions of Ferrets

Geriatric Conditions of Rabbits

Geriatric Care of the Guinea Pig

Euthanasia of Exotic Pets

References

Part III: What Matters Most in the End

20 Understanding the Behavior of Geriatric Patients to Enhance their Welfare

The Effect of Aging on the Behavior Body System

Environmental Enrichment for Geriatric Dogs and Cats

Behavior Management of Geriatric Dogs and Cats

Behavior Problems of Geriatric Dogs and Cats

References

21 Environmental Enrichment and Senior Pets: The Next Best Thing to the Fountain of Youth

References

22 Where Are all the Grey Muzzles?

Introduction

Developing a Geriatric Service in the Clinic

Examination and Conversation

Geriatric Wellness Plan

Nursing Care in Hospital

Follow‐Up and Tracking Advanced Aging Pets

In Summary

Appendix 22.1

Appendix 22.2

23 Veterinary Hospice in Your Practice

What Hospice is NOT

Hospice Definition

How to Start Adding Hospice to Your Practice

Education and Consultation

Hospice Handouts

Palliative Care

Follow‐Up

Conclusion

References

Further Reading

Resources

24 Quality of Life Assessment and End of Life Decisions

Bogey

The Million Dollar Question: When will I know It’s “Time?”

The Three Core Components to Evaluating Quality of Life

Quality of Life Assessment Tools

Pain and Anxiety

Suffering

Waiting Too Long

What About a Natural Death?

Weigh Your Options Carefully

Bogey Continued

References

25 Anticipatory Grief and Preparation for Pet Loss

Anticipatory Grief

Preparing Families for Loss

What if Families are Reluctant to Discuss Grief?

Conclusion

References

26 The Look

27 Convenience and Aggressive Pet Euthanasia

Introduction

Euthanasia Definitions

Euthanizing Aggressive Pets

28 Letting Go – Handling Euthanasia in Your Practice

The Most Difficult Appointment

Stage 1: Setting up the Euthanasia Appointment

Stage 2: During the Appointment

Stage 3: Memorial Items

Stage 4: Body Care

Stage 5: Following‐Up and Ensuring the Client’s Return

In Summary

A Word on Compassion Fatigue

References

29 The Final Chapter

Peak–End Rule

What Families Experience

Endings Matter

Making it GOOD for Serissa

References

Index

End User License Agreement

List of Tables

Chapter 03

Table 3.1 Age chart (courtesy of Fred L. Metzger, DVM, DABVP).

Chapter 08

Table 8.1 The DISHA acronym (Landsberg

et al

., 2010, 2012).

Table 8.2 Symptoms of diseases that mimic or overlap with symptoms of cognitive dysfunction syndrome (modified from Landsberg

et al

., 2011).

Chapter 10

Table 10.1 Common nervous system disorders of geriatric dogs and cats.

Chapter 11

Table 11.1 Age‐related diseases associated with glomerulonephritis (Langston et al., 2008).

Table 11.2 Common age‐related causes of chronic kidney disease.

Table 11.3 Considerations around the development of chronic kidney disease in an aging pet.

Chapter 14

Table 14.1 Range of motion exercises.

Table 14.2 Strengthening exercises.

Table 14.3 Massage techniques.

Chapter 17

Table 17.1 Normal rectal temperatures of various domestic mammals.

Chapter 19

Table 19.1 Some behaviors associated with pain and illness, by species (adapted from Bays

et al

., 2006).

Chapter 20

Table 20.1 Stress‐related behaviors.

List of Illustrations

Chapter 01

Figure 1.1 Serissa, 2 years old, in her therapy dog vest, waiting to visit residents in a nursing home.

Figure 1.2 Serissa, 14 years old, attempting to get a stick through the baby gate that is in place for her safety.

Figure 1.3 Serissa and Mary.

Chapter 03

Figure 3.1 Margaret and Edward Gardner dancing in the 1970s.

Figure 3.2 Grandma Gardner (and her youngest son, my father, Allan) at Thanksgiving dinner 1995.

Chapter 04

Figure 4.1 Normal ocular anatomy.

Figure 4.2 Nuclear sclerosis in a dog. Note the outline of the lens nucleus, often described as a “lens within a lens”. This dog has no visual deficits.

Figure 4.3 Direct illumination of a senile cataract in a dog. Note the dense nuclear sclerosis and the presence of multifocal opacities in the lens cortices.

Figure 4.4 Iris atrophy of the pupillary margin with subsequent dyscoria (misshaped pupil) in a geriatric dog.

Figure 4.5 Asteroid hyalosis (form of vitreal degeneration) in a dog.

Figure 4.6 Diffuse corneal edema in a dog with advanced corneal endothelial degeneration. Note the blue color to the cornea caused by diffuse edema.

Chapter 06

Figure 6.1 Severe periodontal bone loss of the mandible in an older dog has led to a pathological fracture.

Figure 6.2 Chronic osteitis/alveolitis in an older cat. The surrounding bone around the maxillary canines is expansile and enlarged and the teeth are super‐erupted.

Chapter 07

Figure 7.1 Geriatric patient Smudge.

Figure 7.2 Geriatric patient Serissa, whose pigmentation change caused more alarm to the owner than her decreased ability to smell.

Figure 7.3 Chase, 12 years old, has an aggressive nasal tumour and subsequent epistaxis.

Chapter 08

Figure 8.1A Nevada, a 13‐year‐old Labrador mix with cognition issues, having a moment of relaxation.

Figure 8.1B Nevada panting and pacing – owners report that 75% of her waking day is in this state; eyes wide, ears back, panting, drooling and pacing into and out of every room.

Figure 8.2 Prevalence of owner‐reported signs in senior dogs. Fears and phobias include generalized anxiety; compulsive includes repetitive and stereotypic behavior; cognitive dysfunction include disorientation, wandering, waking and anxious at night. Behavior signs were combined from three studies: a Spanish study of 270 dogs older than age 7 years presenting with behavior problems, 103 dogs referred to a veterinary behaviorist, and a search of the Veterinary Information Network of 50 dogs aged 9–17 years.

Figure 8.3 Prevalence of owner‐reported signs in senior cats. Soiling includes marking; cognitive dysfunction includes disorientation, wandering and night waking; and fear/aggression includes fear and hiding. Behavior signs were combined from a Veterinary Information Network data search of 100 cats aged 12–22 years and 83 cats from three different behavior referral practices.

Figure 8.4 Cognitive wellness checklist for canines and felines.

Figure 8.5 Beds placed on the ground in “safe” spots for the pet to sleep on.

Chapter 09

Figure 9.1 Twelve‐week old Pug (left) and same dog at 10 years old (right).

Figure 9.2 Decubital ulcers in a 16‐year‐old Poodle (post mortem).

Figure 9.3 Deep pyoderma with maggot infestation in a 14‐year‐old mixed‐breed dog following a prolonged period of immobility (post mortem).

Chapter 10

Figure 10.1 Anisocoria in a geriatric cat.

Figure 10.2 Worn nails in a patient with unilateral conscious proprioception deficits.

Chapter 11

Figure 11.1 Sunny, with glomerulonephritis.

Figure 11.2 Renal failure in a cat, Mr Barney.

Figure 11.3 Quality of life.

Chapter 12

Figure 12.1 Patient whose only sign of liver disease was icterus on the ear pinnae.

Figure 12.2 Hepatic encephalopathy initial presentation.

Figure 12.3 Gall bladder mucocele formation in a geriatric patient with suspected hyperadrenocorticism. Gall bladder mucoceles may display echogenic membranes or striations often described as a stellate or striated pattern, similar to that of a sliced kiwi fruit (“kiwi sign”).

Figure 12.4 Biliary cystadenoma in a geriatric female cat that presented with anorexia and icterus.

Chapter 13

Figure 13.1 Patient being nebulized.

Chapter 14

Figure 14.1 WSAVA body condition score.

Figure 14.2 WSAVA muscle condition score.

Figure 14.3 Therapeutic laser.

Figure 14.4 Neuromuscular electrical stimulation.

Figure 14.5 Electro‐acupuncture.

Figure 14.6 Dr. Buzby’s ToeGrips.

Figure 14.7 HelpEmUp Harness.

Figure 14.8 Stroller.

Figure 14.9 Brain game.

Figure 14.10 Cat on the balance disk.

Figure 14.11 Cavalettis.

Figure 14.12 Underwater treadmill.

Chapter 15

Figure 15.1 Lily, tube feeding.

Figure 15.2 Benny, showing gastrointestinal weight loss.

Figure 15.3 Meli, showing gastrointestinal weight loss.

Chapter 16

Figure 16.1 Serissa not only had sphincter laxity but also had diabetes and Cushing’s disease, which led to constant urinating in the house (on rugs). Her owners used a doggy diaper, but used female sanitary napkins as they were easier to use and more economical.

Figure 16.2 Algorithm to aid in diagnosis of fecal incontinence.

Figure 16.3 B.D is a fussy, senior chihuahua with a very small bladder. Choosing a soft carpet to urinate on was preferred over the outside cold or rainy weather. Wearing a doggie diaper helps her to ‘hold it’ and prevents ‘accidents’ in the house, thus maintaining the human animal bond.

Chapter 17

Figure 17.1 Bodhi, an 18‐year‐old cat in kidney failure, started to lay on his owner’s laptop.

Figure 17.2 Bodhi’s family purchased him a cat bed containing a warming pad.

Figure 17.3 Geriatric dog wearing a Kool Collar® to help keep him cooler in the warmer months.

Chapter 18

Figure 18.1 Appropriate recovery cage for a geriatric patient. Warmth is provided by a circulating water blanket, absorbable bedding allows urine to drain in case of an accident, soft padding is present as many of these patients will have joint pain, a blanket provides additional warmth and the dog’s own toy provides comfort. The dog is also wearing a harness to assist with helping the dog to rise.

Figure 18.2a,b,c Radiographs of pelvis and lower back showing hip dysplasia with severe degenerative joint disease in both hips.

Figure 18.3 Diagnosing degenerative joint disease: (a) Stance of a normal cat. (b) Stance of a cat with hip osteoarthritis.

Figure 18.4 An easy‐access litter box for cats with impaired mobility.

Figure 18.5 Raised food bowls are more comfortable for cats with joint disease.

Figure 18.6 Facilitating access to favorite resting places is important for quality of life.

Chapter 19

Figure 19.1 Rabbit receiving laser therapy.

Figure 19.2 Rabbit paw impression and fur clipping.

Chapter 20

Figure 20.1 Dog with lens sclerosis.

Figure 20.2 Very patient geriatric dog with younger housemate.

Figure 20.3 Geriatric cat with bilateral retinal detachment and hypertension that was restless and had increased vocalization.

Chapter 21

Figure 21.1 Most dogs love going to the dog park, lake or beach – often times it is just to sniff and make friends with other humans but at other times it is to play with others of their own kind.

Figure 21.2 Roxy, 13, gets a weekly walk in her special stroller where she enjoys sniffing the air, as well as passers by.

Figure 21.3 Roxy, 13 years old, using the Aikiou food puzzle toy to search for treats.

Figure 21.4 Ethel, 11 years old, with enrichment toys with foods and treats, encouraging her prey drive.

Figure 21.5 Roxy’s owners used an empty beer box with different compartments to put treats in.

Figure 21.6 Feeding Roxy on top of a cat tree not only encourages her to climb but also putting treats up there a part of her daily ‘hunt for treats’ game.

Figure 21.7 Newspaper enrichment – hide treats in layers of newspapers and let the pets hunt.

Chapter 22

Figure 22.1 The text message that the veterinary specialist sent to me when my Doberman had a laryngeal tie back. I cannot put into words the feeling of relief I felt when I received this message.

Chapter 23

Figure 23.1 Hospice patient Andy enjoys his meals when they are mixed with baby food.

Chapter 24

Figure 24.1 Bogey at four years old.

Figure 24.2 The three components of quality of life.

Figure 24.3 Hospice patient Yogi in a cart used for walks. Yogi’s owner was willing to do whatever it took to allow Yogi to enjoy his final days.

Figure 24.4 Bogey on his favorite couch. It was important to the family that Bogey was still able to get on his couch – even with assistance. And they wanted this final moments to be on the couch.

Figure 24.5 Grey Muzzle App screens.

Figure 24.6 Three categories for quality of life and intervention.

Figure 24.7 Bogey’s quality of life scale on the wall.

Figure 24.8 Bogey gracing the 2014 Christmas card.

Figure 24.9 Bogey’s passing on his favorite couch.

Chapter 25

Figure 25.1 All family members should be offered the opportunity to partake in ceremony or memorial services.

Figure 25.2 By the age of eight, children have full understanding of aspects of death and bereavement.

Chapter 26

Figure 26.1 Smudge as a healthy senior Bernese Mountain Dog.

Figure 26.2 Smudge, 14 years old, moments before she was euthanized in the snow, at her home by, her mom, Dr. Faith Banks.

Figure 26.3 Dr. Faith Banks and Smudge.

Chapter 28

Figure 28.1 This dog loved being in his car and the owner asked if the euthanasia could be done there. There is no reason why this cannot be done. For those large dogs that cannot move, nothing is worse than having an owner struggle to get them into the clinic.

Figure 28.2 Every moment of the euthanasia appointment should take into account the bond between the owner and the pet.

Figure 28.3 Veterinarians can help to provide owners with cherished memorials for their beloved pets.

Chapter 29

Figure 29.1 Serissa, October 1st 2014 at 3 p.m. – having fun!

Figure 29.2 October 1st 2014, our last snuggle.

Guide

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Treatment and Care of the Geriatric Veterinary Patient

Edited by Mary Gardner and Dani McVety

 

 

 

 

 

 

 

 

 

 

 

 

 

This edition first published 2017© 2017 John Wiley & Sons, Inc

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law.Advice on how to obtain permision to reuse material from this title is available at http://www.wiley.com/go/permissions.

The right of Mary Gardner and Dani McVety to be identified as the authors of the editorial material in this work has been asserted in accordance with law.

Registered OfficesJohn Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USAJohn Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

Editorial OfficeJohn Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA

For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com.

Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content that appears in standard print versions of this book may not be available in other formats.

Limit of Liability/Disclaimer of Warranty

The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. The publisher and the authors make no representations or warranties with respect to the accuracy and completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or website is referred to in this work as a citation and/or potential source of further information does not mean that the author or the publisher endorses the information the organization or website may provide or recommendations it may make. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this works was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.

Library of Congress Cataloging‐in‐Publication Data

Names: Gardner, Mary, 1973– editor. | McVety, Dani, 1981– editor.Title: Treatment and care of the geriatric veterinary patient / edited by Mary Gardner, Dani McVety.Description: 1st edition. | Hoboken, NJ : John Wiley & Sons, 2017. | Includes bibliographical references. Identifiers: LCCN 2017013228 (print) | LCCN 2017014319 (ebook) | ISBN 9781119187233 (pdf) | ISBN 9781119187226 (epub) | ISBN 9781119187219 (pbk.)Subjects: | MESH: Veterinary Medicine–methods | Geriatrics–methods | Dogs–physiology | Cats–physiology | Aging–physiologyClassification: LCC SF745 (ebook) | LCC SF745 (print) | NLM SF 768.5 | DDC 636.089–dc23LC record available at https://lccn.loc.gov/2017013228

Cover design: WileyCover image: Courtesy of Mary Gardner

List of Contributors

Laura Devlin Bacon, DVM, DABVP

Faith Banks, DVM

Brad Bates, VMD, MS

Cheryl A. Braswell, DVM, DACVECC, CHT‐V

Melanie Hasson Cohen, DVM

Shea Cox, DVM, CHPV, CVPP, CPLP

Steve Dale, CABC

Mary Gardner, DVM

Amanda Grant, DVM

Heidi B. Lobprise, DVM, DAVDC

Dani McVety, DVM

Tammy Perkins Johnson, DVM, CCRP, CERP, CVA, cVSMT

Michael Petty, DVM, CVPP, CMAV, CCRT, DAAPM

Sheilah Robertson, BVMS (Hons), PhD, DACVA, DECVA, CVA, MRCVS

Carlo Siracusa, DVM, MS, PhD, Dip. ACVB, Dip. ECAWBM

Meredith Voyles, DVM, DACVO, MS

Kayla Waler, DVM

Dawnetta Woodruff, DVM

About the Companion Website

This book is accompanied by a companion website:

www.wiley.com/go/gardner/geriatric

The website provides videos, client education handouts, and images.

Part IThey Just Don't Live Long Enough

“It’s paradoxical that the idea of living a long life appeals to everyone, but the idea of getting old doesn’t appeal to anyone.”

— Andy Rooney

1Introduction

Mary Gardner

My heart tightens as I watch her “spaghetti legs” quiver as she drinks happily at her bowl and washes down her dinner. The menu tonight was …”whatever she wants.” It’s only a matter of time when the chapter of my story with Serissa ends abruptly and the companion that acted as my shadow for 14.5 years will leave my world. The thought brings tears to my eyes and that pesky lump to my throat.

“Hey baby girl, you want to go outside?” I say in the sweetest voice I can muster up and she looks at me with adoration, wags her pathetically haired tail and gives me a weak and croaky “BARK” as if to say “Heck yeah!” Serissa navigates the bathmats that I laid down for her and struts to the door like a runway model. At one time she was a majestic beauty of a Samoyed and even worked as a therapy dog in nursing homes (Figure 1.1) – now she was a thin, patchy haired, skinny, old girl with hot garbage breath. She was a frail geriatric herself.

Figure 1.1 Serissa, 2 years old, in her therapy dog vest, waiting to visit residents in a nursing home.

But, before we could get to the door, she pops a squat and urinates on the bathmat. In past years, this would be a naughty thing, but today, I could care less! Her legs quiver harder and she almost tumbles over. She finds her balance, quickly finishes, and Serissa's thoughts go back to being outside with mom. Nothing brings more joy to my face than seeing her sweet face turn to look at me as if to say, “You coming?” (Figure 1.2).

Figure 1.2 Serissa, 14 years old, attempting to get a stick through the baby gate that is in place for her safety.

I was taught many things in veterinary school, but dealing with an aging and terminally ill pet was left out of the classroom lectures. In fact, most of the textbooks we read and lectures we sat through did not cover the process of aging and death. Instead, we were taught the mantra that “Old age is not a disease!” But, aging does change quality of life for the pet and the owner. We did discuss senior wellness and preventative medicine but really digging into why the body ages and what happens as things fall apart was not covered in detail. At the time, even the education of euthanasia was left to a two‐hour discussion. Luckily, now at my alma mater the University of Florida (Go Gators) a comprehensive ‘end of life’ course is offered.

The lifespan of companion animals continues to get longer and longer. Just a few decades ago, a pet over the age of 10 years was an anomaly – it was not “normal”. But as we advance in technology, as the pet–parent bond grows stronger and more intimate and our societal views on companion animals shift, we are seeing a much larger population of pets reaching a much higher age and many sail into their “twilight” years with a lot of vigor. But, what we are fighting against is still “not normal” – our bodies will eventually fail, no matter how many patch jobs we put in place.

I remember clearly as a new veterinarian when a colleague looked at radiographs of a 15‐year‐old cat and said “Ehh – it’s just old cat lungs.” He flipped off the light and boldly walked into the room to deliver the “good news”. I sat there thinking, “but that isn’t good … it must possess some problem for the cat and what does it mean for him to have areas of fibrosis in his lungs?.” But my deep thoughts were cut off quickly when my next patient came in, Abagail, a 13‐year‐old FBD (“Florida Brown Dog” or, as others would just call her, a “mixed breed”). She had a three‐month history of staring into space, acting as if she is lost, and is often found in odd places. I internally sigh because I know how frustrating cognitive disorders can be and how limited our options currently are at this time. But, I still cannot wait to see Abagail and her parents.

As much as I love a bunch of kittens and the rubbing of a puppy belly, there is absolutely nothing better than a gray muzzle. I adore hearing the stories of how they came to be in the family, the memories the pet was present for, and how great their loss will be when it comes time to say goodbye. I left general practice in 2010 and since then have exclusively helped families with home‐based veterinary hospice, geriatric consultations and end of life care. I have sat on many couches, on hundreds of master beds, have wormed my way behind toilets and scaled many a cat tree in my practice – and I love it. The conditions I see may range from mobility to organ failure or simply “old age” (yes, I said it), but one thing always remains the same, the enormous love the family has for their aging pets. It is an honor to help those families through the aging process, the disease progression and finally, the moment they say goodbye.

This book was inspired by my desire to learn on a practical level why pets age, how each body system is effected by the aging process and how owners and the veterinary staff can manage the changes that occur. There is a plethora of fantastic textbooks about each of the body systems and the disease they encounter, but this book is meant to be a reference manual specific to the aging process, the care of the geriatric pet and a guide to help you with the most precious time owners have with their pets.

Fourteen and a half years seemed to have flown by as I laid next to Serissa and snuggled with her one last time while she drifted off to a peaceful sleep. Her presence in my heart will always remain. I will miss that smile, her smell, the scratching on the wall as she ran in her sleep, and even that whining in the middle of the night as her mind became more confused with cognitive impairments. How blessed I was to have such a wonderful companion who was with me through veterinary school and would bring joy to me in a millisecond. Caring for her as she aged was extremely difficult for me financially, physically and emotionally, but I would do it for 20 more years if possible. Although terribly missed, thoughts of her now only bring a smile to my face (Figure 1.3).

Figure 1.3 Serissa and Mary.

Serissa’s story lives on throughout my work, where her conditions and experiences helped me to further research and dig deeper into the body system. I am sure she is smiling, too, with her geriatric cohorts, as they realize that their experiences will offer insight to the veterinary community and ease the distress of pet owners when dealing with their pet’s twilight years.

2Maintaining the Human–Animal Bond

Dani McVety

The industry of veterinary medicine started in a much different place than we find ourselves today; we started as mechanics. In a world where horses and cattle accounted for the vast majority of our transportation, keeping these animals healthy was an important role. As the animal population has moved closer and closer to our homes, and even into our beds, the responsibility of keeping these pets healthy has more in common with a pediatrician than any other aspect of medicine.

Pets are not just animals that happily coexist with humans in a mutually friendly way; for more than half of the population, pets are family members. A survey conducted by the American Veterinary Medical Association (2012) found that of 63.2% considered their pets to be family members. Another 35.8% considered their pets to be pets or companions and only the remaining 1% considered their pets to be property. Furthermore, similar to the human caregiving model, women are typically the primary caregivers of pets; the study showed that 74.5% of pet owners with primary responsibility for their pets were female. It is easy to see how our industry has undergone such a drastic change from caring for animals in the barnyard to the family members that share the homes and beds with their “mom” or “dad.”

Maintaining the human animal bond is just as important at the end of a pet’s life as it is at any other time. In a 2012 survey at the Lap of Love Veterinary Hospice, about 25% of over 1000 respondents reported that they would not return to the clinic that euthanized their pet, mostly because it was “simply too hard to return.” Similarly, every veterinary professional can account for the clients with “do not put in exam room 2” written on their client file because one of their pets was euthanized in that room.

Losing any family member can be traumatizing and heartbreaking. And of course we usually do not chose the human family members we have in our life (aside from our spouse), nor do we choose to add another after one has been lost. We do, however, actively make the choice to bring a pet into our heart and home, and the probability of making that choice again when the loss of a previous pet has been stressful and harrowing goes way down. Therefore, given that we know that pet owners can be traumatized by the loss of a pet and that this trauma may lead to a disconnect from their veterinary office, it makes sense that our profession would take great care with our geriatric patients and the people that love them through the entire end of life phase. Starting by practicing conscientious geriatric care (which is an underlying purpose of this book) and ending with a peaceful death process, the support of the human–animal bond through the loss of a pet will ensure that these families will open their hearts and homes to another animal when the time is right.

As veterinary hospice practitioners, we can give you story after story of the immense emotions that come with the loss of a pet. And, for most of us, we realize at some point that this loss represents something very important in their life: The old man whose wife died a year ago, and now, as his dog dies, he is losing the last connection he had to her; the mother whose son was killed in a motorcycle accident month before, and now must say goodbye to his cat; the woman whose dog woke her up seven years ago in a house fire, saving her life, and now due to old age, she feels like she is not returning the favor by making the decision to euthanize. Their pet represents something major in their life, or a series of events, and perhaps that is the case for any major loss in our life.

It is not uncommon for us to hear these phrases in a home:

“This is worse than the death of my parents.”“I feel like I don’t have a reason to live without my pet.”“He was the only one that got me through that part of my life.”“She was the only one I trusted.”“This is the hardest thing I’ve ever been through.”

It is clear to anyone in the veterinary or pet profession that the human–animal bond moves our industry. It is, in a large way, the product that we are selling to the consumer. They are in our clinics because of the bond they have with their pet. Without that bond, there is no reason to keep their pet healthy, buy him or her good food, purchase toys, or buy them clothes!

It takes just a few minutes to walk down the aisle of a large pet store to realize how differently that human animal bond can be supported. To some, it is rhinestone‐studded collars; to others, it is mentally stimulating toys, and to still others, it is a safety jacket worn while hunting with his owner. The important part is that all of them love their pet. And just as differently as we choose to entertain and “dress” our animals, our clients will choose different ways of medically caring for them. The barn dog or cat may not have the same consistent veterinary care that we provide for our own pet, but that does not mean that pet is less loved; he is simply differently loved.

A second underlying theme of this book is how to support each of those families and pets through this geriatric phase. You will find many helpful tips, ideas, exercises, medical protocols, and much more to help you connect with and support the clients who need just a little more help at this important time. This may come in the form of extra time spent in the exam room to explain exactly why their geriatric cat is not hearing them shake the food bowl any more (see Chapter 5 on auditory changes) or why their dog’s bark has changed (see Chapter 13 on the respiratory system). Use these tips to connect with your clients and find news ways to support the bond they have with their own pets.

Just as some veterinarians will go mentally blank when needing to make medical decisions for their own personal pets, our clients are already starting from “zero” when it comes to this kind of knowledge. And in the case of geriatric pets, some of us forget that this 12‐year‐old, 80‐lb mixed‐breed dog is more like an 85‐year‐old person. We tend to understand more readily why our fellow humans are aging and what they are going through, but are not as easily able to connect with the natural aging process in pets (or we simply do not want to accept it).

Let this book be a guide for you and your clients. Use these tools to help connect with, describe, and assist the families we are privileged to help at a time when they are most confused about the wellbeing of their animal family member. We hope that it brings additional support to all parties involved.

Reference

American Veterinary Medical Association.

US Pet Ownership and Demographics Sourcebook

. Schaumburg, IL: 2012.

3Geriatrics and Fragility

Mary Gardner (Research Assistant Stacy Glass)

Introduction

Determining who was going to pick up Margaret, the 89‐year‐old matriarch of the Gardner family, for Thanksgiving was usually more of a debate than what type of pies we would bake that year. You see, Grandma Gardner was fragile – we often compared her to an egg – and she needed special assistance in many facets of her life. She still lived alone in a small condo in South Florida, but this New Jersey transplant was in no way fully independent. Grandma Gardner was a shadow of her younger self, muscle atrophied, age‐spots dotting her hands and face, thick glasses, thin skin and extremely wobbly. She needed help rising from a chair, assistance into the car, and could only lift about three pounds; with her, everything involved extra consideration, even purchasing milk. We had to buy a quart instead of a gallon, as the gallon was too heavy for her to lift unassisted. We also had to help cut her food into smaller pieces, as her ability to swallow properly became a challenge, and we certainly could not tell her too many jokes while she ate, as she had a boisterous laugh which predisposed her to aspiration! Regardless, she still had most of her wits about her, and honestly, she was a delight to be around, the member of the family with the least drama and the best advice!

Fetching Grandma Gardner for an outing was no small feat. The person appointed to this task had to have the “right” car: One large enough to fit her walker with enough room in the front seat for her to stretch out, yet just the right height and size for her to easily get into, with a steady arm assisting her, of course. She also had to be comfortable enough to properly handle her cherished homemade apple cake (a secret family recipe which she tightly held on to). When picking her up, it was imperative to remember her sweater as even with the 85‐degree Florida weather and 90 percent humidity, she still became easily chilled. Plus, this person had to be willing to leave early to take her home in the event she tired before everyone else.

I was always the appointed one, as I had the perfect car. Frankly, I genuinely enjoyed the opportunity to pick her up. I loved being in her condo, seeing the pictures she dearly treasured (especially of her and my late Grandfather, Figure 3.1), hearing the sound of the grandfather clock, and the unique, yet pleasant smell. I don’t know what it was – but the smell of Grandma’s house was one that I adored. Of course, the candies she kept fully stocked in the dish on the end table were also a plus!

Figure 3.1 Margaret and Edward Gardner dancing in the 1970s.

Grandma Gardner (Figure 3.2) was not in the best of “health.” Most of the ailments she had trouble managing were from the natural declining progression of life; nonetheless, in no way was she ready for hospice. Apart from something drastic happening, she had years left, and it was safe to say that she also was not your “normal” older person – or senior citizen. She was what I consider a “geriatric,” a term that is often unclear, generating multiple questions: What exactly is a geriatric? What graduates someone from a senior to a geriatric? Is there technically a difference between the two terms? Does “geriatric” relate to the need for much greater care, being at risk for more disasters, or is it simply a term used once someone has made it to a certain age?

Figure 3.2 Grandma Gardner (and her youngest son, my father, Allan) at Thanksgiving dinner 1995.

As a veterinarian who concentrates exclusively on geriatric pets, hospice and euthanasia, I can see the parallels that our companion animals have to humans as they mature, age and inevitably decline. A nine‐year‐old Labrador may fit the criteria of a “senior” while still functioning perfectly fine in the home. However, a 12‐year‐old Labrador with no terminal disease looming might have a much harder time managing the ailments that plague the advanced aged pet. Thus, the family must care for the elder pet differently. Think back to the reference of picking up Grandma Gardner (in her late 80s); this experience involves much different efforts than picking up my father who is a bit younger, in his mid‐60s. As extra assistance was required for Grandma Gardner, the advanced aged Labrador may also need the same type of consideration. For instance, the food bowl may need to be raised, the floor lined in bath mats, nightlights added to the dark hallway, and a ramp installed to get up the back steps or into the car. Although there is evidently more care taken for the further aged Labrador the question is raised: Is there technically a difference between senior and geriatric pets? Are they treated differently in terms of veterinary medicine? Regardless of the definition, I believe that they should be treated differently because they indeed, are different.

Senior or Geriatric … It’s All in a Name – or Is It?

My journey into understanding geriatrics began with seniors and was relatively basic, with the goal of answering broad questions such as: what does “senior” mean, and how do human and veterinary medicine define it? The word “senior” arose in the late thirteenth century from Latin seniores meaning “older.” Its original use in the English language dates back to the 1510s as a definition of rank, suggesting “higher in rank, longer in service.” It was also used at this time as an addition to a personal name indicating “the father” when father and son had the same name (for example, Allan Senior and Allan Junior). The term “senior citizen” was first recorded in 1938 to define an elderly person, one who is past the age of retirement; however, the term had nothing to do with the individual’s medical state.

An article titled “Ageism in Language” in a newsletter from the American Society of Aging (ASA, 2007) presented the following question to readers, “What term(s) do you think are appropriate when referring to people aged 65‐plus?” The most commonly used expressions and percentage of individuals considering each term ‘appropriate’ were:

older adults = 80%

elders = 41%

seniors = 33%

senior citizens = 11%

elderly = 10%.

Based on these statistics, is the word “senior” becoming a word of the past? Are more people beginning to use the term “older adult” to define those over the age of 65? Should we, as veterinarians, be saying “older pet” rather than “senior pet?” This concept led me to researching how the American Veterinary Medical Association (AVMA) uses the term “senior.” In my research, I was unable to find an actual definition; nonetheless, the AVMA does offer a page on their website that addresses the question, “When does a pet become ‘old’?” Their answer:

It varies, but cats and small dogs are generally considered “senior” at seven years of age. Larger breed dogs tend to have shorter life spans compared to smaller breeds and are often considered senior when they are 5 to 6 years of age. Contrary to popular belief, dogs do not age at a rate of seven human years for each year in dog years.”

(AVMA, 2017).

Both the AVMA and the ASA offer no clear definition of what a “senior” is; however, I learned that the term does not relate as much to “biology” as I thought it would, which led me to wonder, what is a “geriatric?”

Geriatric Medicine for Humans

The US elderly population is expected to dramatically rise over the coming decades (the same can be said for the elderly pet population); thus, increasing the need for more focus by physicians on geriatrics. Since advancements in human medicine most often precede veterinary medicine, I decided to take a look into the history of human geriatrics to get an understanding of how it came to fruition, what a geriatrician does, and if there are parallels we can make in veterinary medicine. Accordingly, a human geriatrician must first be a family medicine physician or internal medicine physician to qualify for the certification of geriatrics. The certification is referred to as a certificate of added qualifications (CAQ). Fewer than 10,000 of the 120,000 practicing general internists and family physicians in the United States have earned a CAQ in geriatric medicine (Warshaw et al., 2003). To get their CAQ, the physician must first complete a fellowship program and then sit for the exam. The five most reputable schools offering a fellowship program for geriatric medicine are:

John Hopkins

University of California, Los Angeles

Icahn School of Medicine at Mount Sinai

Duke University

Harvard Medical School Teaching Hospital.

While geriatric medicine cares for the older population, the specialty itself is quite young. Box 3.1 shows a timeline of the growth of human geriatric medicine (Forciea, 2014).

Box 3.1 The Growth of Human Geriatric Medicine

1943

The American Geriatric Society was organized and held its first annual meeting.

1945

The Gerontological Society of America was established in the United States.

1965

President Lyndon Johnson signed the legislation establishing Medicare, a health insurance program for the elderly.

1966

Dr Leslie Libow developed the first fellowship training experience in geriatric medicine at City Hospital Center in New York.

1974

National Institute on Aging was founded, sponsoring training at many levels.

1976

Congress authorized the first Geriatric Research, Education, and Clinical Center (GRECC).

1976

The Veterans’ Administration began to sponsor innovation in the care of the elderly through its Geriatric Research and Education Clinical Centers.

1977

The first professorship in geriatrics in the United States was established at Cornell University.

1982

The first department of geriatrics at a major teaching center, Mount Sinai Medical School (Dr Libow’s institution) was started.

1988

The American Boards of Internal Medicine and Family Practice jointly offered a certifying examination for a Certificate of Added Qualifications in Geriatric Medicine (CAQGM). At this time, there were 62 fellowship programs in internal medicine and 16 in family practice.

1995

The initial geriatric fellowship programs had a two‐year requirement, but in 1995 it was reduced to one year. While there are a few institutions that offer a second and third year of additional geriatric training, most of the fellows in geriatrics prefer the one‐year fellowship.

In May 2016, I attended a conference for human geriatricians in Long Beach, California. It was quite eye opening on many levels, although two primary themes were accentuated. First, the care‐givers themselves are a major concern when caring for a geriatric. At the conference, much emphasis was placed on their mental and physical wellbeing. Recognizing that family members comprise a majority of the care‐giving team, a primary goal of human geriatrics is to find new ways of educating and supporting that team and to alleviate care‐giver fatigue.

Second, dementia is a massive and widespread ailment in human health. I was thoroughly shocked at the severity of this problem within our society and, consequently, how difficult it is on the care‐giving unit. My uncle recently passed away from early onset Alzheimer’s disease, and I personally witnessed how extremely taxing it was on my aunt. Thankfully, she was a nurse, but that did not discount the fact that she was first a wife. I often felt exhausted just from looking at how consumed she was with the care of Uncle Gene.

A woman I chatted with at the conference was a mental health counselor, and was very interested in how our families deal with their aging pets. I spoke with her about anticipatory grief, care‐giver fatigue and pet loss grief, all very similar in both of our worlds. As we sipped our morning coffee I told her that I was still confused as to what a “geriatrician” really does and asked if she could help to clarify. I knew that they “cared for elderly people,” but how is that different from a family physician? Fortunately, she laid it out quite simply for me. First, the family physician refers the patient to a geriatrician. The geriatrician then has two main roles: 1) To monitor all of the medications the patient is on (since many see multiple specialists, polypharmacy is a huge concern); and 2) To deal with dementia – and there it was, another reference to that awful ailment!

Geriatrics, from geras, old age, and iatrikos, relating to the physician, is a term I would suggest as an addition to our vocabulary, to cover the same field in old age that is covered by the term pediatrics in childhood, to emphasize the necessity of considering senility and its disease apart from maturity and to assign it a separate place in medicine.

(Forciea, 2014).

Would a specialty in geriatrics make sense in veterinary medicine? Do we have as much of a problem with polypharmacy? Do many of our patients suffer from a form of dementia? I can only answer “yes” to the third question, as I see it in over 50% of my patients, but I feel that the primary care physician (as well as the internist, oncologist, cardiologist and neurologist) are skilled at handling that illness in our companion animals.

Many of the paths that veterinary specialties take are modeled after human specialties, often coming to fruition decades after the human medicine program. With that, I do not believe that veterinary medicine has to always follow human medicine. Although we often have similarities and fundamentals that are in line with each other, the two professions do not have to function in exactly the same way. Veterinary medicine does not have a pediatric specialty, so why would we need one for geriatrics? At this point, I do not think we do; however, with the continued improvement of veterinary medicine, and as technology becomes more advanced, the elderly pet population is going to continue to expand. It is imperative that veterinarians, technicians and students understand the aging process, what it means to have old‐age symptoms, how families can manage these symptoms, and how we, as veterinarians, can offer support to families. Better education in these avenues is necessary, and should start in veterinary schools. After reaching out to all of the veterinary schools in the United States, I was unable to find a single school that offered a course specifically in geriatrics. Veterinary programs incorporated “senior” content in many of their classes, but a course specific to geriatrics may unfortunately be in the distant future.

Fragility

Regardless of the label we use (senior or geriatric) I am mainly concerned with those pets that are fragile and need extra consideration, like my grandmother – the “fragile egg.” Fragility is one of those complex terms that has a multitude of definitions, meanings and criteria. The concept itself is fragile!

Fragility is a syndrome where one has increased vulnerability and decreased physical function; thus, increasing the probability for adverse outcomes. In humans, the prevalence of fragility in older populations (65 years and older) is about 9.9%, and 25–50% in people aged 85 and older. (Liu et al., 2012). So, what classifies one as “fragile?”

Classifiers of the fragility syndrome for humans include various combinations of the following indicators:

weakness (including grip strength)

fatigue/exhaustion

weight loss

impaired balance

decreased physical activity

slowed motor performance (gate speed)

social withdrawal

mild cognitive dysfunction

increased vulnerability to physiological stresses.

It has been proposed that, to be classified as geriatric, one must exhibit at least three of the following criteria:

weakness

weight loss

slowed mobility

fatigue

low levels of activities.

I can easily link this to a multitude of older pets presenting at least three of those conditions, thus raising the question of when pets (or humans) are considered “fragile” are they also “geriatric?” The answer remains unclear.

The criteria of “slowed mobility” interested me, as I always thought that my geriatric patients, as well as Grandma Gardner, had a turtle’s pace because of some underlying disease, like arthritis or sarcopenia. Yet, my grandmother never expressed pain or weakness when walking. One lecture I attended at the geriatric conference discussed gait speed (the “normal” pace of a person’s walking) in relation to fragility, as well as dementia. To better clarify this phenomenon, I spoke with the presenter (Manuel Montero‐Odasso, MD) afterwards. He explained that, based on studies, in the absence of pathologic issues resulting in gait disorders, pace may slow down as a person ages for no physical reason. Individuals experiencing this slowed mobility are completely unconscious of the decrease in speed. Additionally, he described the theory that the part of the brain indicating our normal pace is in the same location where pathology is found in many humans with dementia; thus, the person possibly is not aware of their slower walking speed. Consequently, he concluded that a slower gait pace not only indicates a greater risk of falling but it could also be a predictor of upcoming dementia (Montero‐Odasso et al., 2012).

After learning this, I hightailed it to the next lecture at a speed no one could keep up with! Exhausted from my fast clip to the next lecture, I sat in the back and waited eagerly to learn more about our aging human population. Speaking of exhaustion, it also happens to be a criterion for fragility. Exhaustion is the perception of inadequate energy levels to meet one’s demand. Measuring levels of exhaustion in humans varies. Some studies ask questions like, “How often have you had a hard time getting going?” and “How often does everything seem an effort?” A response of “Most of the time,” or ‘A moderate amount of time” would classify that individual as exhausted. The trouble with exhaustion is that it is self‐reporting and it is therefore a difficult criterion to assess in our companion animals.

Interestingly, observational data have suggested that exhaustion and weight loss tend to develop later than other components of fragility, and may identify people at greater risk for subsequent rapid decline (Whitson et al., 2011). Not to anthropomorphize, but in my own observation, those pets with unexplained weight loss and whom seem to have a “lack of energy” decline much faster than those animals not exhibiting those concerns.

The process of decline, vulnerability and fragility is unfortunately not well defined, and there is little research in fragility in animals – most that has been done was in mice, to help determine the effects of fragility for humans; however, considering and treating certain advanced aged pets as fragile may provide new opportunities for prevention, health promotion and improved care for both the pet and the family unit.

The Geriatric Life Stage in Dogs and Cats

As mentioned earlier, the AVMA does not have a defined set of rules to include a pet in the senior category. Furthermore, they do not provide classification on the geriatric life stage. In fact, they often use the two terms interchangeably. Although I have yet to find a clear distinction between the two, I do believe, in theory, that they are different and we should approach each pet individually. If signs of advanced ageing, fragility and vulnerability exist, we should handle the treatment and care of the pet differently.

Pet parents may be more open to assistance if they felt that we as a profession understood the changes in their pet as well as the struggles they face physically and emotionally during the twilight years of their pets. Table 3.1 is a chart that I find useful to give to all my clients with advanced aged pets. It helps them to appreciate the stage their pet may be at, and opens the door to better conversations about care. There is a great deal of information in Chapter 22 of this textbook on how you can market, manage, handle and treat geriatric pets in your clinic.