Published in 2005 (Mar/Apr)
Senior Care Guidelines Task Force: Mark Epstein, DVM, Diplomate ABVP (Canine/Feline), Chair | Ned F. Kuehn, DVM, MS, Diplomate ACVIM | Gary Landsberg, DVM, Diplomate ACVB | B. Duncan X. Lascelles, BSc, BVSc, PhD, MRCVS, Diplomate ECVS, Diplomate ACVS | Steven L. Marks, BVSc, MS, MRCVS, Diplomate ACVIM | Jean M. Schaedler, DVM, Diplomate ABVP (Canine/Feline) | Helen Tuzio, DVM, Diplomate ABVP (Feline)
This paper provides a working framework for enhancing the well-being of senior pet dogs and cats.Approaches to screening the medical status of senior pets are described in detail, with particular emphasis on establishing baseline data in healthy animals, the testing of clinically ill animals, and assessing senior pets prior to anesthesia and surgery. The management of pain and distress and the application of hospice and palliative care are addressed. Advice on ways to approach euthanasia and dealing with end-of-life issues is also provided. J Am Anim Hosp Assoc 2005;41:81-91.
In the spring of 2004, AAHA gathered together seven respected, experienced veterinarians with a variety of interests, backgrounds, and specialties. Their goal was to create for veterinary practitioners a useful document about Senior Care. These Guidelines were sponsored by a generous educational grant from IDEXX Laboratories.
The purpose of this document is to provide a working framework for veterinarians dedicated to enhancing the well-being of senior pet dogs and cats. Only about 14% of senior animals undergo regular health screening as recommended by their veterinarians.1 The main obstacle to compliance is the lack of a clear recommendation by the veterinary care team.1 Unless otherwise specified, all recommendations in this document apply to both the dog and the cat. Providing optimal care for senior pets:
- Acknowledges and enhances the human-animal bond
- Promotes early detection of abnormalities
- Promotes optimal and individualized medical care that may enhance quality of life and promote longevity
The specific goals of this document are to help the veterinarian:
- Promote early detection of disease in the apparently healthy pet
- Prevent or delay morbidity and mortality whenever possible
- Outline/define common clinical conditions in senior pets
- Define aspects of screening, diagnosis, treatment, anesthesia, and surgery that are pertinent to the senior pet
- Outline principles of assessing and managing pain
- Provide a framework to evaluate quality of life
- Assist clients with decision-making at the end of life
What is “Senior”
The term “senior” has been chosen to describe the aging and older pet. The number of years considered to be “senior” may vary, and one must keep in mind that organ systems, species, and breeds of dogs age at different rates. Several papers have suggested specific ages at which pets should be considered “old,” depending on breed and size, although few recommendations are evidence-based.2-12 Some studies of brain aging in beagles have shown that memory and learning deficits may be found as early as 6 to 7 years of age, with brain pathology found at ³12 years of age.8-11 Many books and articles consider cats to be senior at 7 to 11 years of age.2-5
In humans, 56 to 60 years of age is considered to be the start of the senior years. Middle age begins at 42 to 45 and is the time when senior wellness screening generally starts. Middle age would equate to approximately 7 to 8 years of age for most dogs and cats (except for large-breed dogs that may reach middle age a year or two earlier). As the pet enters its senior years, more frequent testing and more extensive examinations are recommended than for younger pets. Rather than attempt to calculate age equivalents to humans, for practical purposes, this task force suggests that practitioners apply these guidelines to dogs and cats that are in the last 25% of the predicted life span for their species and breed.
Approach to the Apparently Healthy Senior Pet
The purposes of clinical screening of healthy pets are to establish a baseline assessment for future comparison and to detect subclinical abnormalities at a time when preventive and therapeutic intervention may have the most benefit. To illuminate such conditions, there is no substitute for a thorough and complete history and physical examination. A wealth of scientific literature documents the presence of subclinical disease in some healthy-appearing animals; to illuminate such conditions, there is no substitute for a thorough and complete history and physical examination. In addition, subtle changes in laboratory test results may give an indication of the presence of underlying disease.
Elements of a Thorough History
Construct questions that extend beyond the client’s presenting concern and that include physical and behavioral signs.13 Use of both closed (yes/no) and open-ended questions helps to elicit all possible information about quality of life, physical health, specific behavioral changes, and medications (e.g., prescription, over-the-counter, dietary supplements). When possible, to better ensure an accurate and thorough baseline for future comparison, have the client record historical information on a printed form prior to the appointment.
Elements of a Complete Examination
Observe the pet prior to handling, in an open carrier and/or on the floor. Perform a complete physical examination with special attention to the areas of increasing concern in the senior pet. Such areas may include, but are not limited to:
- Risk factor analysis: signalment, breed, lifestyle/use14,15
- Physical condition: weight gain or loss (that may not have been observed by the client); obesity; changes in body condition or conformation
- Evaluation of skin, coat, claw, and nail bed character; detection and assessment of lumps and bumps
- Presence of lymph node enlargement
- Presence of thyroid nodule (cats)
- Hydration status
- Abdominal palpation, especially the size and shape of kidneys and liver
- Vital signs: temperature, pulse, respirations, and pain assessment16
- Cardiopulmonary evaluation: auscultation of heart sounds; heart rate and rhythm; pulse rate and quality
- Evaluation of the central nervous system: mentation; cranial and peripheral nerve reflexes, especially conscious proprioception; vision and hearing
- Orthopedic examination: mobility, gait, range of motion, weakness, pain, crepitation, muscle mass
- Rectal palpation (dog)
Elements of a Minimum Laboratory Database
Tests to be included in the minimum laboratory database for the healthy-appearing senior animals are listed in Table 1. Additional testing is based on breed, age, sex, previous medical history, and ongoing medications.17,18
Preventive care is directed at making recommendations prior to the onset of disease in order to prevent or temper the effects of disease or adverse health conditions. This task force recommends that “senior” wellness tests begin for pets at middle age, to establish baseline values and to insure that there are no clinically silent health abnormalities. During middle age, retesting is recommended at least once a year (equivalent of 4 to 5 human years). Routine health care visits, including a minimum laboratory database, are recommended for senior animals (i.e., those in the last 25% of their predicted life span) every 6 months (equivalent of every 2 to 3 human years).
Focused Areas of Client Education
Such areas include, but are not limited to:
- Increased veterinary attention to dental/oral care and to home dental prophylaxis
- Diet and nutrition
- Digestibility, caloric content, quality of ingredients
- Discussion of any new developments in the use of stage-of-life diets, food supplements, or food additives (e.g., omega-3 fatty acids, nutraceuticals)
- Attention to ingredients that might affect disease in older pets
- Weight control: monitoring of weight gain (especially in the dog) or loss (especially in the cat)
- Parasite control: following published guidelines for fecal examination and parasite prevention19,20
- Maintaining mobility via exercise or therapeutic intervention
- Vaccination only as appropriate for lifestyle, management factors, geographic region, and local jurisdiction21-23
- Mental health: importance of routine and predictable environment; environmental enrichment; companion pets and social interaction; discussion of brain aging; monitoring signs of cognitive decline
- Environmental considerations: housing; indoor/outdoor lifestyle; accommodation of disabilities; avoidance of smoke and toxin exposure
- Potential reproductive disease in nonneutered pets: pyometra, mammary or testicular neoplasia, prostatic disease24
Approach to the Sick or Unhealthy Senior Pet
Common Clinical Conditions
Although senior dogs and cats are affected by many of the same conditions as younger animals, some disorders are of particular significance in the senior pet. These disorders include, but are not limited to, those listed in Table 2.25-39
Malignant neoplasia is a frequent finding in senior pets, and this is often a life-limiting ailment. Lists of the most common neoplastic conditions are found in a variety of texts and articles.40,41 It is important to note that a number of cancers are easily misdiagnosed or overlooked early in their disease process. Special consideration should be given to the following common, but often elusive and illusory, neoplastic conditions:
- Squamous cell carcinoma: appearing as nail bed disease (dog) or facial dermatosis (cat)
- Squamous cell carcinoma, melanoma, and fibrosarcoma of the oral cavity: emanating from the gingiva, tongue, or tonsil
- Osteosarcoma causing lameness
- Fibrosarcoma, mastocytoma, hemangiopericytoma: presenting as soft-tissue cutaneous or subcutaneous masses
- Mammary adenocarcinoma: appearing as a swelling or cyst along the mammary chain
- Lymphosarcoma: producing alimentary signs, soft-tissue masses, and organomegaly (e.g., hepatomegaly in the dog, renomegaly in the cat), and at other extra-nodal sites
- Bladder or urethral carcinoma: presenting as dysuria or hematuria
Evaluation of the Sick Senior Animal
First read and follow the healthy-animal assessment guidelines, above. Obtain a comprehensive history, observe the animal, and perform a complete and thorough physical examination, as described for the healthy senior pet. Pay particular attention to any clinical changes or signs of pain.
- Include in the minimum laboratory database all tests for evaluation of the healthy senior, with the addition of serum electrolytes, phosphorus, bicarbonate, total carbon dioxide, and arterial blood pressure.
- Tests for feline leukemia virus and feline immunodeficiency virus should be performed in potentially exposed cats.
- Possible additional tests are listed in Table 3. Client Communication and Education Clients overwhelmingly prefer to be told about all the best options, even those options the veterinarian may think the client will decline.42 The veterinarian has a responsibility to recommend what is best for the pet, but the chosen treatment must be what is best for both the patient and the client.
- In recommending a treatment for a pet, thoroughly and impartially evaluate and communicate the consequences of the choices for the pet and client. Involve and empower clients in the decision-making process, making clear their role and responsibilities.
- Design treatment protocols that optimize compliance. Ensure clients are capable of administering the treatment plan mentally, physically, and emotionally, as well as by the route and timing prescribed. If the requirements cannot be accomplished, consider alternative delivery systems, routes, and intervals that have been documented to be effective.
- Senior pets receiving treatment have an increased need for more frequent examinations and testing (new and follow-up). Care of senior pets also necessitates more frequent communication with the client and documentation of progression or regression of signs. Educate clients about the pet’s disease state, diagnosis, prognosis, and treatment side effects. Discuss the time commitment and any quality-of-life issues. Educate and communicate with clients both verbally and in writing to better gain a clear understanding of their expectations and revise any expectations that are not realistic.
- Thoroughly document differential diagnoses and assessments in a problem-oriented format. Whenever possible, record a diagnosis and the animal’s short-term, intermediate, and long-term prognoses, even if such assessments are temporarily presumptive or tentative.
Choosing Appropriate Treatments
Consider all of the pet’s conditions and the best available scientific evidence when designing a treatment plan. Specifically, contradictions or contraindications among diseases, drugs, and diets may necessitate prioritizing modalities for an optimal outcome and/or quality of life.
- Avoid indiscriminate use of antimicrobial agents.
- Avoid drugs that may impair mobility and behavior or those that may change blood pressure (e.g., sedative, sympathomimetic, or anticholinergic drugs).
- Consider interactions, compatibilities, and incompatibilities among drugs and biologics.43,44
- Nonsteroidal antiinflammatory drugs (NSAIDs) are commonly dispensed and can be beneficial for senior pets, but precautions include the following:
- Monitor for potential complications, especially when the pet is known or suspected to have hepatic or renal disease, hyperadrenocorticism, or any condition that may predispose to gastrointestinal erosion or ulceration.
- Ensure that the client understands the vital importance of not changing the dose or type of NSAID without consulting the veterinarian.
- Avoid the concurrent use of two NSAIDs or the concurrent use of a corticosteroid with an NSAID, which potentially causes severe side effects.45
Veterinarians and clients share responsibility for monitoring for side effects or complications. Require clients to closely monitor the intake of any medication administered in food. Cats in particular may develop food aversion if they are given medication by this route. Consider using flavored or formulated medications instead. Modify drug dose or dosing interval based on renal and hepatic function. Perform drug concentration testing when appropriate. Each disease state may require specific monitoring tests (e.g., fructosamine or blood glucose curve for diabetes mellitus; tonometry for glaucoma; blood pressure measurements for hyperthyroidism, chronic renal failure, and heart disease). Consider the effects of each drug on other diseases (e.g., furosemide, NSAIDs, or methimazole on renal failure), and alter treatments as necessary based on response.
A formal hospital callback or client follow-up system is crucial to successful case management. Consider other resources such as consultation and/or referral to a specialist based on the type of disease, the veterinarian’s level of expertise, and the available equipment (e.g., magnetic resonance imaging, computed tomography, endoscopy). The use of electronic media and communication to transmit and gather information facilitates remote consultations with specialists.
Anesthesia and Surgery
Patient Assessment. The importance of complete and accurate historical information cannot be overstated, including current medications (e.g., over-the-counter, prescription, alternative, supplements) with regard to their potential impact on anesthesia and recovery. Perform a complete and thorough physical examination, including assessments of weight, temperature, pulse, respirations, and pain.
Consider a preanesthetic blood pressure evaluation, especially in cats. Pay special attention to cardiopulmonary status. If any physical abnormalities are detected (e.g., heart murmur, arrhythmia, poor pulse quality, abnormal respiratory sounds), consider expanding the cardiopulmonary evaluation to include thoracic radiographs, electrocardiography, echocardiography, and/or blood pressure measurements. 28,46 Whether a preanesthetic electrocardiogram is needed for pets without detectable abnormalities is uncertain. There is some evidence that conduction abnormalities may exist subclinically (especially in cats) or be overlooked because of animal disposition, operator error, etc.28,46 An electrocardiogram is strongly recommended when abnormalities are found on auscultation.
Laboratory Evaluations. All healthy senior pets should have wellness screening tests along with measurement of electrolytes and a platelet count, ideally within the 2 weeks preceding anesthesia. However, for healthy senior pets that have had routine wellness tests within the previous 6 months, the practitioner must determine which tests should be repeated or added, based on the pet’s age (e.g., middleaged versus senior), risk factors, and the procedure to be performed. In addition to any tests not done in the previous 6 months, a complete blood count and dipstick urinalysis with specific gravity should be repeated prior to anesthesia. Obtain at least a hematocrit and platelet count if surgery is planned. Remember that automated platelet counts are unreliable in cats, so if the platelet count is low, a manual recount should be performed. Consider further workup if test results are not within the normal ranges.47
When anesthesia of a sick pet is necessary, perform the sick pet screening [Table 3] and compare the results to any earlier wellness screening tests. Perform additional tests as appropriate based on previous, ongoing, or new health issues discovered in the history, examination, and laboratory results. For example, perform coagulation function tests on at-risk animals, such as those with liver disease, malassimilation/ maldigestion disorders, NSAID usage, and breed predisposition.
Client Communication. Before anesthesia, discuss all risks and benefits with the client and obtain written, informed consent for all procedure(s). Prepare postoperative instructions. Provide clients with clear, concise, verbal and written take-home instructions that include information about possible complications, drug effects, nursing care, nutritional management, home monitoring, and after-hours veterinary phone contact.
Patient Management. Create a plan for anesthesia, analgesia, intravenous fluid administration, antimicrobial therapy, and body temperature maintenance during surgery.48,49 Begin analgesia prior to induction of anesthesia, giving special consideration to the combination of systemic analgesia and local or regional anesthetic blocks. Perioperative pain is best controlled by an aggressive, preemptive, multimodal approach.50,51
Intravenous access via an indwelling catheter is necessary for anesthetic induction, intraoperative fluid administration, and administration of appropriate medications. Initiate fluid preloading when indicated (e.g., renal disease, dehydration). When antimicrobial therapy is specifically indicated, begin the medication prior to surgery.52,53 Provide preoxygenation when indicated (e.g., obstructive upper airway disease, cardiac disease) via mask, oxygen cage, nasal cannula, or other methods. Ensure adequate ventilation via endotracheal intubation for general anesthetic procedures. Provide manually or mechanically assisted respiration as necessary.
Based on animal risk factors, consider placing an indwelling urinary catheter to measure fluid output during and after surgery, and/or the measurement of central venous pressure to prevent both under-hydration and over-hydration. Detailed attention to cardiopulmonary and renal functions is crucial for the successful outcome of anesthesia in senior animals. Close monitoring is essential during all stages of anesthesia. The greatest risks to the animal occur during the induction of anesthesia and from the time anesthetic agents are discontinued until full recovery.
One trained person should be dedicated to the monitoring and recording of vital parameters, such as body temperature, heart rate and rhythm, respiration, oxygen saturation via pulse oximetry, blood pressure, and end-tidal carbon dioxide. An apnea monitor is also helpful. Intravenous fluid support is essential, and care should be taken to customize the type and rate of fluids administered (e.g., lower rate with cardiac disease, increased rate with renal failure).54,55 Continue pain management, giving special consideration to constant- rate infusion of intravenous analgesics.
Maintain an open airway via intubation until the animal is swallowing. Continue oxygenation when appropriate, as described in the preanesthetic section of this report. Continue to maintain body temperature and to provide intravenous fluid support at least until the animal is ambulatory (or stable), or for longer as indicated (e.g., dehydration, hypothermia, renal compromise, other metabolic disorders).
Regularly monitor and record vital signs. Continue a preemptive and multimodal approach to pain. The adaptive mechanisms of animals make it difficult to accurately assess their degree and perception of pain; therefore, administer pain medications on a schedule appropriate for the drug(s) and the condition being treated. Do not wait for the animal to show signs of pain.56-58 Continue to assess the individual needs of each animal, as all individuals react differently to pain and to medications for pain.
Provide appropriate nursing care for recumbent animals, including warming and turning, human touch, and compassionate verbal encouragement. When recovery is delayed or prolonged, promote movement via massage, passive motion exercises, and sling-assisted walking.
Pain and Distress
Identify, prevent, and minimize pain. Use pain assessment as the fourth vital sign, using scales such as the University of Melbourne Pain Scale or the Glasgow Composites Measures Pain Scale.59,60 Under-managed or intractable pain may become a criteria for euthanasia.
Identification of Pain
Signs of acute or chronic pain vary and are described elsewhere. 16,56,61-65 Any behavioral change or change in vital signs may be an indication of pain. Signs of pain may be modified by factors such as demeanor (e.g., stoicism) or concurrent drugs. Involve, educate, and continually communicate with the client about recognizing and monitoring for signs of acute and chronic pain.66
Management of Pain
Treatment options vary depending on the type of pain (e.g., acute or chronic). Single drugs or combinations of drugs may be used. To intervene at multiple sites of the nociceptive pathways, use multiple drugs.67 Control pain early in the course of chronic diseases. Chronic pain is best controlled by aggressive initiation of drugs and other modalities, followed by a tapering of the treatments to the minimum schedule or dosage that is still effective. Resources to help veterinarians keep current with new developments and recommendations for managing pain are becoming available, such as www.ivapam.com, which is maintained by the International Academy of Pain Management.
- Treatment modalities that may be applied for pain include oral, injectable, transdermal, or transmucosal drugs; physical therapy and massage; local and regional anesthesia; acupuncture; weight management where appropriate; and/or environmental modification such as a change in bedding, housing, access to the out-of-doors (e.g., ramp, lifting), etc.
- Drugs that may be utilized include NSAIDs, opioids, opiate derivatives, alpha-2 agonists, N-methyl-D-aspartate (NMDA) antagonists, anxiolytics and tricyclic antidepressants, anticonvulsants, bisphosphonates, and local anesthetics. Pain management should be integrated and complementary.68
Educate clients about possible adverse events and/or interactions of drugs. When appropriate, perform laboratory monitoring during drug therapy. Maintain and document communications with clients and reassess the animal frequently. Address anxiety on the part of the client regarding the pet’s pain, disability, and/or physical impairment.
Hospice and Palliative Care
The American Veterinary Medical Association has published guidelines for veterinary hospice care.69 Veterinary hospice care is defined as “giving clients time to make decisions regarding a terminal companion animal and to prepare for [its] pending death. The comfort of the animal must always be considered.”69 In human medicine, “hospice and palliative care are considered to be the model for quality, compassionate care for those facing a life-limiting illness or injury.”70 Palliative care, based on the animal’s specific requirements, might include outpatient/home care; pain management; easy access to food, water, and litter; wound management; a stable and consistent environment; good hygiene and sanitation; clean bedding and padding; and mental stimulation. Visits to the home by veterinarians and/or support staff may be offered or encouraged whenever possible.
Nutritional maintenance is paramount. Balance the pet’s need for a particular therapeutic diet with maintaining caloric intake. Reassess the need for all ongoing medications and treatments in pets with end-stage disease and an anticipated short life span. Consider whether medications should be reduced, stopped, or changed, particularly in light of their side effects and risk-benefit analysis. Medications or combinations of drugs that might otherwise be contraindicated or used cautiously (e.g., narcotics, NSAIDs) may be considered as the best or only choice for maintaining a good quality of life.
Provide guidance and resources for clients to deal with debilitating or chronic disease, with dying and death, and with euthanasia. Consider the client’s state of mind and the impact of the client on the pet. Consider and discuss the client’s realistic ability (given financial, physical, and time constraints) to adequately care for the pet. Discuss the effect of the aged or sick pet on other pets and the potential impacts (both positive and negative) of introducing a new pet.
Discuss specific criteria for reevaluation of the senior animal and for deciding upon euthanasia. When possible, help the client consider end-of-life issues at this time (i.e., during the “anticipatory grief” period), rather than during a terminal crisis.
End of Life and Euthanasia
Making the Decision
During the euthanasia decision-making process and after the decision is made, provide the client with resources about the process and impact of euthanasia on the family and other pets. Such resources include web sites, hotlines, books, brochures, and professional counselors for both adults and children.71-74 Web site examples include www.argusinstitute@ colostate.edu, www.rainbowsbridge.com, www.aplb.org, and www.deltasociety.org. Examples of pet loss support hotlines include those at Washington State University (509- 335-5704), the University of California-Davis (530-752- 3602 or 800-565-1526), Tufts University (508-839-5302), the Chicago Veterinary Medical Association (630-325- 1600), Cornell University (607-253-3932), and the Delta Society (619-320-3298).
Consider and discuss with the client the “five freedoms” to aid in assessing the animal’s welfare and in making an ethical decision.75 The five freedoms include freedom from hunger and thirst; freedom from physical and thermal discomfort; freedom from pain, injury, and disease; freedom from fear and distress; and the freedom to express normal behavior.75 Assess the severity and duration of the animal’s condition with these freedoms in mind and use them to help clients identify their own criteria for treatment or euthanasia. Such criteria might include financial, moral, religious, cultural, physical, and mental/emotional factors.
Avoid imposing one’s own values and emotions on clients. Let clients make informed choices based on all known options. Support clients in their informed choice for euthanasia or for further diagnostic, therapeutic, or palliative care. Be an advocate of the pet and try to factually present options and consequences without promoting inappropriate feelings of regret, self-blame, or guilt.
When the Decision is Made
Discuss with the client the following points:
- The euthanasia process and choices, including: the option for sedation, intravenous catheter placement, home euthanasia or at the hospital, indoor or outdoor location for the euthanasia, the client’s option to be present during and after the euthanasia
- Effects on other family pets and children
- Choices for disposal of the body, including the option of burial, cremation, and return of the remains
Describe specifically what will happen, what the animal may experience, and what the client may see or hear. Create an appropriate area in the hospital for euthanasia; a place the client can give the pet a final farewell. Consider providing the client with a remembrance item such as a paw print casting or lock of hair, followed by a sympathy card.
Veterinary Team Tips
Provide staff training and debriefing on the difficult issues that inevitably arise from being frequently exposed to endof- life events. Such issues include grief management, pet loss support, periodic hospital memorial services, bereavement outlets, and compassion fatigue. Give the staff permission to grieve and express their emotions. Recognize each individual’s limitations. Refer clients to outside resources when available.
This document is intended as a guideline only. Evidencebased support for specific recommendations has been cited whenever possible and appropriate. Other recommendations are based on practical clinical experience and a consensus of expert opinion. There is a need for further research to document some of these recommendations, and it is hoped that in the future, collaborative research involving general practitioners, referral institutions, and commercial laboratories will facilitate a more rapid and comprehensive development of evidenced-based clinical knowledge regarding senior pets.
Veterinarians must base their decisions and actions on their own expertise, experience, and knowledge. Veterinary practitioners are also charged with making decisions for each individual animal based on the best available scientific evidence, in conjunction with clinical experience.
The actual incidence of subclinical disease that is detected by routine screening tests remains undetermined. Practitioners are urged to develop systems for identifying and recording such conditions, perhaps in a collaborative effort with the commercial laboratory most frequently used. It is hoped that in the future such data will allow computation of the incidence, prevalence, risk factors, and effects of early detection and treatment of subclinical diseases.
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