“Old age” is neither a disease nor a reason not to treat a patient for illness, yet it is a reason commonly cited by clients who are reluctant to treat their senior pets. As we become better at recognizing and managing age-associated issues in companion animals, it is increasingly common to see dogs and cats reaching—and thriving in—their golden years.
The fact remains, however, that few veterinary professionals have received any kind of training in the specific care or needs of geriatric patients. This article outlines what it means to be “geriatric,” provides general guidelines for managing aging patients and specific recommendations for nursing care in hospitalized geriatric patients, and discusses the role of the veterinary technician in ensuring quality of life for older patients.
WHAT IS A GERIATRIC PATIENT?
Geriatric medicine in humans is a recognized and well-studied specialty. This is much less true in veterinary medicine, although awareness of the specific needs of geriatric patients has been increasing steadily over the past decade. Perhaps the most complicated aspect of working with geriatric animals is that it can be difficult to agree on when a patient is considered “geriatric” because of broad variations among species and breeds.
It is important to note that there is a difference between natural aging and being considered geriatric. In humans, aging is defined as the inevitable and irreversible decline in organ function that occurs over time even in the absence of illness, injury, or poor lifestyle choices.1
A geriatric patient, on the other hand, is an older person who also has some type of impaired function. There is no set age when a person is considered geriatric, but he or she is usually older than 75 years, with at least one chronic illness, physical impairment, and/or cognitive impairment. With regard to animals, perhaps it is best to think in terms of “senior” for a healthy older pet and “geriatric” for a pet that is senior and has health or behavior concerns.
RECOGNIZING SENIOR VERSUS GERIATRIC PATIENTS
The challenge for veterinary professionals is to help owners identify when their senior pet has become geriatric. Ideally, this happens early, when emerging health issues can be addressed and managed to preserve quality of life for as long as possible.
As noted previously, distinguishing “senior” from “geriatric” is especially difficult considering the broad variety in lifespan and health considerations among breeds and species. For instance, 8 years old may be a reasonable age for a golden retriever to be considered senior, but a Great Dane of the same age would likely be geriatric, and a toy poodle may be in the prime of its life. These variations make it extremely difficult to develop generalized answers for owners about age. Individualized communication with clients on the part of the veterinary health care team is necessary.
Perhaps what is more important than age is the pet’s general health status and whether the pet has emerging chronic issues that need to be managed. Many educational tools are available to help owners make this distinction (BOX 1), such as an age wheel or a questionnaire about possible age-related changes. The American Animal Hospital Association (AAHA) and American Association of Feline Practitioners (AAFP) offer senior care guidelines for veterinary professionals that can serve as a great starting point for creating practice-specific senior care information for clients:
As with humans, prevention, early recognition, and management of health concerns are the best ways to provide pets with excellent quality of life.
EDUCATED OWNERS ARE SUCCESSFUL OWNERS
Putting Knowledge into Action
British philosopher and sociologist Herbert Spencer once wrote that, “The great aim of education is not knowledge, but action.”2 To keep older pets healthy for as long as possible, owners must be able to recognize when it is necessary for them to act for their pet’s well-being. No matter how good veterinary medicine becomes at diagnosis and treatment, we still rely on owners—who see and care for their pets every day—to recognize changes and seek medical advice on their pets’ behalf.
In my opinion, the single most important thing veterinary professionals can do for their patients is to educate owners to recognize signs of potential health concerns and know when to call or visit their veterinarian. Ideally, this education should begin from the pet’s puppy or kitten visit and continue every year during the patient’s annual veterinary examination.
Understanding the Annual Examination
Over the past several years, the entire veterinary community has been advocating for annual examinations. When it comes to helping owners make the distinction between “normal” aging and initial signs of illness, annual examinations are important. Many issues that develop over time and may go unnoticed by pet owners may in fact be signs of an emerging health concern (BOX 2).
The American Veterinary Medical Association (AVMA) Partners for Healthy Pets program (partnersforhealthypets.org/) is designed specifically to help practices develop and promote the importance of annual examinations to help improve compliance. The AAFP, AAHA, and many other organizations also offer resources to help the veterinary team educate owners about the importance of preventive health care. Whether your hospital uses existing resources or develops something unique, educating clients about the importance of regular physical examinations by a veterinarian will certainly improve and maintain their pet’s quality of life.
Many treatment options can be employed at the annual examination to mitigate clinical signs and improve the patient’s quality of life. Dental prophylaxis, growth removal, and medical therapy for arthritis or other chronic issues are becoming more routine in senior and geriatric pets. The increase in owner education and willingness of pet owners to pursue medical care for older pets strengthens the need for veterinary technicians to gain a fuller understanding of senior and geriatric nursing.
NURSING CONSIDERATIONS FOR HOSPITALIZED SENIOR OR GERIATRIC PETS
Physical and mental changes associated with aging often require special nursing care. They may include orthopedic changes, changes in body condition, and changes in perception or mentation.3 Recognizing health issues that may influence the course of treatment and addressing those issues are also important. A nursing plan that proactively addresses these concerns and is appropriate for the patient can be extremely helpful in improving outcomes.
First and foremost in nursing care are the basics: In any ward, all patients should always be clean, warm, and dry. Beyond that, it is important to keep patients moving, ensure their comfort, provide good nutrition, and interact with them.
Fulfilling Basic Needs
- Movement: Patients should not be left to lie immobile in cages or runs for long periods. Movement influences many body systems, affecting blood pressure, gastrointestinal (GI) motility, edema, orthopedic pain, body temperature, and muscle strength. The most obvious way to promote movement is walking the pet. If walking is not an option, providing basic physical therapy in the form of passive range of motion exercises, massage, and assisted changes in position (such as standing the patient up for a short time and then helping the patient to lie down again) has been shown in human medicine to improve outcome and shorten hospital stays for a variety of medical issues.4,5 Providing either walks or therapy every 4 hours at a minimum is usually a good starting point in a nursing plan.
- Comfort: Senior patients often have lower muscle mass and reduced mobility than younger pets. They may also have difficulty navigating hard cage or run floors. Additionally, patients with lower body condition scores or those that have friable skin may be at risk for developing pressure-associated injuries when left to lie in a hard cage. Nonslip mats and thicker blanketing may be required to allow these patients to rest comfortably. Purpose-built anti-pressure cage beds are available, but thick blankets, egg crate foam, or other forms of padding can provide patients with increased comfort.
- Nutrition: Senior pets may have GI changes or disease processes that affect their ability to process nutrients. Loss of lean muscle mass occurs naturally with aging and may increase with confinement and lack of sufficient nutrients.6 These patients may require a diet adjustment or even a feeding tube if they are not able to eat on their own. Recognizing issues that may be interfering with eating, such as nausea, food aversion, or pain, is key in helping patients continue to eat voluntarily.
- Interaction and engagement: Hospitalized patients are often stressed, anxious, and frightened. It is incumbent on veterinary technicians to ease their discomfort, even if that discomfort is more mental than physical. Taking some extra time to interact with each patient while on walks or during treatments helps to allay stress, anxiety, and fear. Patients that feel comforted by their caregiver often eat better, accept physical therapy and other treatments more readily, and are more willing to move and walk than patients that do not share a bond with their caregiver.
Addressing Physical Challenges
Physical changes related to normal aging in senior and geriatric patients may pose some challenges to nursing.
- Increased skin fragility/friability: Senior patients may be at an increased risk for skin tears from clippers or other instruments. They may also have small skin masses or other abnormalities or lesions that may be exacerbated by inadequate bedding, clippers, or even restraint. Recognizing these issues and using extreme care when handling these patients often help prevent injury.
- Changes in body condition: Senior patients may present in poor body condition. Whether obese or thin, these patients are at risk for developing hospital-induced injuries such as pressure sores, increased stiffness or joint pain, weakness, decreased mobility, hypothermia, or hyperthermia. Recognizing poor body condition and providing adequate cushioning (both in cages and on surgery or dental tables), regular temperature monitoring, and appropriate nutritional support are key.
- Changes in perception: Patients with poor eyesight and/or hearing may startle easily or not adapt well to the hospital environment. They may be injured by falling or walking off examination tables or cages or bumping into things they are unable to perceive. At times, these pets may be more reactive and may strike out at their caregivers in the hospital because of apprehension about restraint. It is important to proceed slowly with these patients and give them time to adjust to restraint and/or treatment.
- Orthopedic changes: Almost all senior patients that present to a veterinary hospital have some degree of arthritis or orthopedic issues. Although they may be well tolerated at home, orthopedic issues may be exacerbated in the hospital by manipulation (e.g., restraining legs for radiography) or long periods of inactivity. The resulting pain may cause the pet to resist handling or to become fractious. Providing regular walks, physical therapy, and gentle manipulations as well as appropriate pain control for these patients helps them better tolerate hospitalization and treatments.
- Changes related to organ function and/or chronic disease: Senior pets are at a higher risk than their adult counterparts for organ dysfunction, which may or may not be evident. Thorough evaluation by the veterinarian, along with diagnostic testing, is important to help the veterinary health care team recognize organ dysfunction or chronic disease and address its potential effect on the patient’s treatment.
To achieve optimum results, any of these concerns should be well communicated and understood by the technician providing nursing care. This enables the technician to better monitor the patient and recognize changes that may be significant to the veterinarian and the patient’s treatment plan.7
DISCUSSING QUALITY VERSUS QUANTITY OF LIFE
There are myriad theories and opinions about how best to approach end-of-life care. Many veterinary hospitals are developing formal hospice care programs to help owners navigate the end of their pet’s life, including maintaining the pet’s quality of life and recognizing when it has degenerated. The decision to begin hospice care or to euthanize a pet is intensely personal and individual, and every veterinarian has opinions about what constitutes appropriate care.
The veterinary technician’s role often becomes one of providing validation and comfort to the owner. One of the most important aspects of this role is having a thorough understanding of the veterinarian’s and hospital’s policies and procedures so that correct and consistent information is delivered to clients. Evaluating quality of life is often subjective and difficult for owners. In an attempt to provide a standardized evaluation, Dr. Alice Villalobos has developed a Quality of Life Scale to help owners and veterinarians have these discussions (TABLE 1).8
TABLE 1 The HHHHHMM Quality of Life Scale
Evaluate each of the following areas on a scale of 0 to 10, with “0” being unacceptable and “10” being ideal. A total score of 35 or higher is considered an acceptable score for quality of life.
|Adapted from Villalobos and Kaplan.8|
|Hurt: Is the pet receiving adequate pain control (including breathing ability)?|
|Hunger: Is the pet eating enough on its own? Does the pet require hand feeding or tube feeding?|
|Hydration: Is the pet hydrated? Does it need subcutaneous fluids?|
|Hygiene: Is the pet brushed and cleaned regularly, especially after elimination?|
|Happiness: Does the pet express joy or interest? Does it respond to its environment? Does the pet show signs of boredom, loneliness, anxiety, or fear?|
|Mobility: Can the pet get up without assistance? Does the pet want to go for a walk? Is the pet experiencing seizures or stumbling?|
|More Good Than Bad: Do good days outnumber bad days?|
While veterinary technicians are not responsible for making quality of life determinations, understanding the criteria that veterinarians are using and being able to support the veterinarian’s recommendations help to comfort owners in the decision-making process.
Senior patients are becoming a larger segment of the general practice population. Veterinary technicians are often the primary communicators with owners. As such, technicians shoulder much of the responsibility for educating and informing clients about their pet’s care.
Training and positive messaging about preventive health care enables veterinary technicians to be more successful in gaining owner compliance. Proactively communicating with owners of young pets about the pet’s ongoing preventive health care needs, appropriate home care, and early signs of illness gives owners the tools they need to avoid some problems, identify health concerns when they occur, and seek appropriate care.
To effect the best outcome for senior and geriatric pets, veterinary technicians need to be aware of the changes that occur with natural aging and with chronic health issues and to address them when managing a pet’s nursing care. With training, compassion, and proactive pet owner education, veterinary technicians are integral in helping older pets live longer with excellent quality of life.