- Email: [email protected]
Geriatric Care in the Late 1990s
0195-5616/97 $0.00
GERIATRICS
+ .20
GERIATRIC CARE IN THE LATE 1990s Johnny D. Hoskins, DVM, PhD, and Dennis M. McCurnin, DVM
Years of research into disease, development of vaccines, improvement in canine and feline diets, establishment of pediatric health care programs, and widespread distribution of quality medicine as well as the education of animal owners on the need for preventive care are paying off. Today's dogs and cats are living longer. In fact, although the average life expectancy for a cat just two decades ago might have been 4 to 6 years, it is not uncommon to find cats living 15 years or longer these days. Life expectancies for dogs have also increased for many of the same reasons. Interestingly, the oldest recorded cat was 34 years old and the oldest dog was 29 years old.' Older people tend to own older dogs or cats with which they have formed a strong bond. These owners are often "empty nesters" who have replaced their children with older dogs, cats, or both. When care is needed or health management recommendations are made, they usually want a level of service comparable with that available to themselves or other family members. In addition to a strong family attachment, older people often have the financial resources and scheduling flexibility to allow a high level of medical care to be provided. It is estimated that by the year 2030, the number of people aged 65 and older will have almost doubled and will represent more than 20% of the total population. 6 This rapid increase in senior citizens is due primarily to the natural aging process of the baby boomers, those born between 1946 and 1965. Nutrition, exercise, and preventive health programs are now practiced by many people on a daily basis and most likely have accounted for the lengthened human life expectancy. As the bond between humans and animals has become better understood, the true value of the dog or cat in the family has been recognized and articulated by health care professionals and the general public. During this same time
From DocuTech Services, Inc., Baton Rouge, Louisiana (JDH); and the Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, Louisiana (DMM)
VETERINARY CLINICS OF NORTH AMERICA: SMALL ANIMAL PRACTICE VOLUME 27 • NUMBER 6 • NOVEMBER 1997
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period, the members of the general public have become more aware of the effect of the aging process on themselves and are aware when a beloved dog or cat is showing some of the same aging changes. In addition, a great deal of interest and research has been directed into the field of human oncology, the relationship between high-cholesterol/high-fat diets and the incidence of heart disease, and overall preventive health. Every day there are new discoveries made through research, and both people and animals are living longer, healthier lives. All of these changes have set the stage for preventive medicine and the development of geriatric programs for our dogs and cats. As people live longer, healthier lives, they expect parallel programs for their animals. During the 1980s, the number of practicing veterinarians grew, although the population and economy became stagnant. This resulted in the profession becoming more aware of potential new practice markets. The area of geriatrics has continued to remain a relatively untapped market even in the face of changing public opinion and scientific knowledge. Geriatric dogs and cats have a different set of clinical and owner challenges than do puppies and kittens. Some owners are willing to spend exorbitant amounts of money and time to extend an animal's quality of life in the final months; for example, heroic efforts are attempted in some oncology patients with minimal clinical results but maximum owner satisfaction. Veterinary medical practices should be ready now or within the next 5 years to accept these challenges to provide more in-depth geriatric health care programs for the increasing number of older owners and their aging dogs and cats. Historically, veterinarians have been more likely to have comprehensive pediatric programs rather than comprehensive geriatric programs. The young, healthy animal has been viewed as the most profitable and most enjoyable type of patient. According to a r ecent report by the American Animal Hospital Association,! how"-ever, the dog and cat population in the United States will remain stable during the next 10 years. This trend follows the human population's slow growth pattern. Given the stable dog / cat and human populations and the slowly increasing number of small animal practitioners, income per veterinarian is projected to decline over the next 5 to 10 years. This economic forecast may come true unless the veterinary practice community focuses on providing services to a wider range of patients.
INTEGRATING GERIATRIC CARE
An active geriatric health care program is a clinical area that needs to be developed or expanded in most veterinary practices. Geriatric care should be a natural extension of current pediatric and maintenance programs that are already in place. The scope of services offered should start during the animal selection process (even as early as helping prospective owners select the best animal for their lifestyles) and end with bereavement counseling at the time the animal dies. The geriatric part of the program should fit into the overall package of services at whatever age chosen as being geriatric such as 8 years of age and older. Veterinary practices vary in the percentage of dogs and cats in each age group, but, in general, geriatric animals in most v eterinary practices will typically range from 25% to 40% of the total caseload. Exceptions exist in those practices located in or near a retirement community (such as Sun City, AZ) which may have a higher percentage of both geriatric animals and owners.
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DEFINING THE TERM "GERIATRIC"
Dictionaries define "geriatric" as "pertaining to old people," and the World Health Organization7 has defined "middle-aged" as being 45 to 59 years, " elderly" as being 60 to 74 years, and "aged" as being over 75 years old. Unfortunately, there is no similar classification for our domesticated species, and there is no specific definition of a geriatric dog or cat, although we all recognize external signs of increasing age such as graying of the muzzle, stiffness in movement, changes in posture, and reduced responsiveness to outside stimuli. Because the aging process varies with specific dog and cat breeds and an animal's lifestyle, the age at which a geriatric health care program should be implemented also varies. A geriatric health care program could begin in the United States for dogs and cats at the following ages2 : • • • • •
Small dogs (<20 lb): Medium dogs (21-50 lb ): Large dogs (51-90 lb): Giant dogs (>90 lb): Cats (most American breeds):
9 to 13 years 9 to 11.5 years 7.5 to 10.5 years 6 to 9 years 8 to 10 years
HEALTH CARE PROGRAM
Dogs or cats entering the veterinary practice for the first time should be integrated into the proper service area of the overall health care program based on the animal's age and special needs. As an example, the pediatric program might extend from birth to 1 year and would be followed by the maintenance program (1-8 years), continuing to the geriatric program (8 years and older). The development and utilization of these various programs start from a basic practice philosophy that understands and supports quality care for the different life stages. A comprehensive geriatric health care program can provide a way to target key geriatric-related health problems, to institute preventive health care measures, and to detect disorders early enough for effective medical and surgical managemenU A list of commonly encountered geriatric diseases is found on page 1276. Education of the dog or cat owner about health risks to geriatric patients and possible preventive measures is key to the success of this program. The acceptance of an older dog or cat into the health care program should depend on its general health status, which may be determined from the animal's history, physical examination, and other diagnostic procedures, and not on actual age. The health care program may include different levels of health evaluation (e.g., program 1 for the apparently healthy patient, program 2 for the patient with minor health concerns, and program 3 for the patient with major health concerns as outlined in the list on page 1277). Clinical evaluation of a geriatric dog or cat initially begins with taking a complete medical and surgical history and performing the physical examination. Basic information about the animal such as breed, age, and sex as well as owner concerns is obtained from the history. After the history is obtained, the physical examination is performed in a systematic manner. Although the examination may be easier to complete by proceeding from head to tail, it is advisable to examine and record observations according to body systems. Special concerns
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Commonly Encountered Geriatric Diseases Geriatric dog Diabetes mellitus Prostatic disease Obesity Cardiovascular disease Degenerative joint disease Cataract(s) Cancer Dental disease Keratoconjunctivitis sicca Hypothyroidism Urolithiasis Hyperadrenocorticism Anemia Urinary incontinence Hepatopathies Chronic renal disease
Geriatric cat Inflammatory bowel disease Diabetes mellitus Feline hepatic lipidosis Chronic renal disease Obesity Cancer Dental disease Hyperthyroidism Urolithiasis Anemia Hepatopathies Cardiovascular disease
are directed to specific age-influenced body systems as outlined in the list on page 1278. The "golden key" to any successful maintenance and geriatric health care program is the continual use of baseline laboratory monitoring as early in the · animal's life as possible. At any stage in life, abnormal values must be followed up on and additional procedures added as necessary. The real value in laboratory monitoring would be in having baseline or trend information for comparison when needed. Education of the owner as to the value of obtaining this baseline or trend data sets the stage for continual monitoring during the rest of the animal's life. Early owner education allows a high quality of service to be provided with a higher level of success and satisfaction. When the veterinarian waits to recommend blood profile monitoring until disease or failure is suspected, it is more difficult for the owner to understand the value of preventive medicine. Common sense tells us that if the owner believes in the value of regular profile monitoring, then as the animal(s) ages, increasing the number and frequency of profiles also makes medical sense. Owner education today will provide for a comprehensive geriatric program in the future. The owner of a geriatric dog or cat should be encouraged to have the animal examined by a veterinarian at least once a year. At this annual examination, a checklist of health care services can be used to ensure that all the steps in a health care program are followed (Appendix). Another important aspect in the geriatric health care program is education of the animal owner, specifically in the areas of nutrition, preventive health care, exercise, the normal aging process, cancer and its effects, and bereavement. A list of topics to be covered is found on page 1278. If appropriate, pet loss services for the owners of geriatric dogs and cats, memorialization, and the hospice concepts applicable to veterinary medicine are also discussed. Unabridged attention must be directed toward instructing the pet owner in regard to certain
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Health Screening Levels for Geriatric Dogs and Cats Program 1 History and physical examination, including eyes and rectum Packed cell volume and total protein levels Blood urea nitrogen and glucose leveJs Complete urinalysis Consultation regarding nutrition, teeth, ears, nails, and skin care Weight control program Program 2 History and physical examination, including eyes and rectum Complete blood cell count and blood chemistry profile Complete urinalysis Consultation regarding nutrition, teeth, ears, nails, and skin care Weight control program Program 3 History and physical examination, including eyes and rectum Complete blood cell count and blood chemistry profile Complete urinalysis Electrocardiography and thoracic radiography, possibly echocardiography Consultation regarding nutrition, teeth, ears, nails, and skin care Weight control program Ancillary diagnostic procedures Echocardiography Abdominal ultrasonography Thyroid gland function tests Adrenal gland function tests Blood pressure evaluation Liver, pancreas, and small intestinal function assays
potential problems specific to geriatric dogs and cats as specified in the list on p age 1279. IMPLEMENTATION OF THE HEALTH CARE PROGRAM
A health care program should be fashioned t o meet the s pecific needs of the geriatric dog or c at and the owner. 5 A successful program r equires a team approach that includes the receptionist, et chnician, ward attendants, veterinarian, a nd animal owner. To obtain optimal results, everyone f rom the hospital staff to the veterinarian to the owner should completely understand the intent of the program and its benefits. The first step in the initiation of a geriatric health care p rogram i sfor the veterinarian to understand the full scope and need for geriatric health care services in the daily routine of the vete rinary hospital. The program must then be explained completely to the hospital staff, including how it fits into their daily activities. Ideas and changes should be solicited from the ho spital staff as these may imp rove the implementation of the program. Because the receptionist
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Systematic Physical Examination of the Geriatric Dog and Cat Abdominal palpation Dental examination Ears and eyes inspection Thyroid gland palpation Musculoskeletal evaluation Rectal examination and prostate gland palpation Skin, hair coat, and nail examination Thoracic auscultation
Education of the Owner about the Geriatric Dog and Cat Nutrition Restrict protein, phosphorus, and sodium intake Provide fewer calories (only in overweight dogs and cats) Preventive health care Dentistry Health screening recommendations Annual vaccinations Heartworm check Fecal examination Feline leukemia virus and feline immunodeficiency virus tests Grooming routine Oncology Early cancer detection Medical or surgical considerations Exercise Exercise requirements Exercise and feeding activity Normal aging process General information on the aging process (e.g., vision and hearing loss, muscle tone, skin and hair coat changes) Changes to watch for at home Housing environment Food and water consumption (appetite) Abnormal urination and defecation Body weight changes Activity level changes Abnormal odors Skin lumps/masses/sores that do not heal Constant coughing/sneezing Vomiting/diarrhea Bereavement Support during the last few weeks of life if needed Final discussions and support following death of the animal Resolution of animal loss with the owner to allow another animal to be obtained by the family
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Problems Specific to Geriatric Dogs and Cats Weight stasis-obesity Cancer-present or not Halitosis-oral disease Lusterless hair coat-skin changes Changes in behavior Arthritis-altered rising or walking Anesthesia risk Loss of vision and hearing Heart murmur-heart failure Urine production-kidney failure Coughing-chronic bronchial (airway) disease Urine or fecal incontinence
is the first person with whom the animal owner has contact, it is important that this individual fully understands the health care program so that he or she can explain the program in layman terms to the animal owner. The veterinary technician also has an important and very visible role in this program; many inhospital procedures as well as laboratory procedures, radiographs, and electrocardiograms can be done by the technician. The daily activities of the health care program should be worked out to include appointment schedules, office and examination room procedures, maintenance of health records, provision of laboratory support, and an animal owner consultation period to review all findings, recommendations, and subsequent examinations. When geriatric patients are scheduled, appointments should be made during the slower time periods if possible. By scheduling these patients during less busy periods during the day, week, or year and encouraging animal owners to use these time periods, additional services can be provided with minimal additional overhead cost. Adequate time is set aside for owner consultation so that a complete case review is possible. The consultation should start with a private discussion between the hospital staff and the owner, without the geriatric dog or cat present, regarding various test results or other important items such as revisits or recommendations. The veterinarian should always participate in a portion of the consultation period. Specific recommendations to the owner should be provided in writing. Next, the owner makes payment for the services and schedules another appointment if necessary. Finally, the animal is reunited with the owner, and any final items are discussed or demonstrations are made using the pet. UTILIZING TECHNICAL SUPPORT STAFF
Most of the daily in-hospital evaluation procedures performed on geriatric dogs and cats can utilize a well-trained veterinary technician. All laboratory tests, radiographs, and electrocardiograms can be performed by the technician, with the results made available to the veterinarian prior to owner consultation. The veterinarian and hospital staff should have all necessary clinical materials, results, and recommendations organized and ready well in advance of owner consultation.
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The technician, in particular, can be invaluable in providing additional owner education on specific conditions and home care needs. The owner, and specifically the older owner, should always have an opportunity to ask questions about the findings, recommendations, follow-up care, and fees. This is where the technician can really benefit the health care program through his or her patient and understanding manner with the owner, always remembering that when talking to older people, one needs to talk slowly and loudly as well as repeat information several times. Repetition of information to the owner leads to effective communication.
MARKETING PLAN
A marketing plan for a geriatric health care program could be as simple as informing owners (clients) about this service as they first enter or return to the veterinary practice. Alternately, it could become more complex through advertising, newsletters, and a recall system. Probably the safest plan to start with is to think small, keep it simple, and develop the program one owner at a time. A safe marketing plan would be to start with in-house training of hospital staff with their own animals or a few dedicated owners so that staff can completely perform and communicate the program to owners in a professional way as they visit the veterinary practice. When the basic program is running smoothly, then the program can be enlarged through a recall system. The recall could be initiated by utilizing a hand-generated list from owner files or through a computer search by age range. After this list of owners is developed, an informational newsletter, individual letter, or telefax could be sent highlighting the geriatric health care program and services available. A newsletter or pamphlet could also be handed directly to qualified owners as they come into the veterinary practice. Another marketing program to help expand geriatric activities is to offer a monetary incentive (such as a percentage of gross income or dollar amount per owner) to the hospital staff member responsible for owners making appointments for preventive care services. This specific incentive does not have to be a large percentage or amount, but it does provide a rationale for the staff member to work on the program. Contact by the staff member may be made by phone, letter, telefax, or in person. As staff members go about their personal lives, they have many opportunities to market veterinary services. If there is an incentive system in place to account for this activity, the program will have better success. Providing each staff member with marketing tools such as personal business cards will also aid in this effort. Another spin-off of an active geriatric health care program is the opportunity to provide additional services to the owner such as vaccinations, patient evaluation, animal care product sales, and so forth. Seeing the owner on a regular basis provides this opportunity which improves the overall patient care being provided by the veterinary practice. The veterinarian is advised to start now to develop a geriatric health care program by recommending the most complete diagnostic services to each owner and geriatric dog or cat. Providing the groundwork for quality services now will result in a quality geriatric program in the future.
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CONCLUSIONS
Geriatric health care remains a virtually untapped area in spite of changing public views and scientific knowledge on aging. As owners live longer, healthier lives and become more aware of age-related changes in themselves, they discover that their dogs and cats also undergo age-related changes. The number of geriatric dogs and cats will continue to grow into the next century. As the senior citizen segment of society increases, the number of geriatric dogs and cats also increases. Senior citizens usually have older dogs and cats and are willing to invest in quality health care services. A geriatric health care program can expand veterinary services in a practice and is a natural extension of pediatric and adult maintenance programs. References 1. American Animal Hospital Association: A Study of the Companion Animal Veterinary Service Market. Lakewood, CO, 1995 2. Goldston RT: Geriatrics and gerontology. Vet Clin North Am Small Anim Pract 19:1202, 1989 3. Hoskins JD: Geriatric preventive medicine. In: Geriatric Medicine. St. Louis, Ralston Purina, 1993, pp 5- 10 4. Matthews P (ed): The New Guinness Book of Records 1995. Enfield, UK, Guinness Publishing, 1994 5. Mosier J: How aging affects body systems in the dog. In: Geriatric Medicine: Contemporary Clinical Medicine and Practice Management Approaches. Lenexa, KS, Veterinary Medicine Publishing, 1987, pp 2-6 6. Turnwald GH, Baskett JJ: Effective communication with older owners. JAVMA 209:725726, 1996 7. World Health Organization: Report of a Seminar on the Health Protection of the Elderly and Aged and the Prevention of Premature Ageing, Copenhagen, 1963 Address reprint requests to
Johnny D. Hoskins, DVM, PhD 17755 Crossing Boulevard Baton Rouge, LA 70810
APPENDIX
A Preventive Health Care Program for Geriatric Dogs and Cats
I. Geriatric dog A. Conduct a general physical examination and record the body weight B. Check for external parasites and dermatophytes and initiate appropriate therapy 1. Fleas, ticks, and ear mites (Otodectes cyanotis) 2. Mange mites, especially Demodex canis and Sarcoptes scabiei 3. Dermatophytes, particularly Microsporum species and Trichophyton men-
tagrophytes C. Conduct fecal examination (fecal flotation test) D. Check for heartworm disease (Knott or occult test) E. Adjust the dosage of heartworm preventive medication according to body weight, especially for diethylcarbazamine products F. Deworm with broad-spectrum anthelmintic product G. Vaccinate with DA2PLPC* and rabies vaccine and, possibly, kennel cough and canine Lyme borreliosis vaccine H. Adjust the diet according to health needs and, if necessary, change grooming procedures I. Trim the nails and clean the ear canals J. Discuss age-related changes that are occurring K. Provide the owner with educational pamphlets on such topics as: 1. Identification, treatment, and control of fleas, ticks, and ear mites 2. Dental, skin, nail, and ear care 3. Grooming and nutrition 4. Management of normal and abnormal behaviors 5. Exercise and its importance L. Fill in the annual health record for the owner II. Geriatric Cat A. Conduct a general physical examination and record the body weight B. Check for external parasites and dermatophytes and initiate appropriate therapy 1. Fleas and ear mites (0. cyanotis) 2. Mange mites, especially Notoedres cati, Demodex species, and Cheyletiella species 3. Dermatophytes, particularly Microsporum species and T. mentagrophytes C. Perform fecal examination (fecal flotation test) *This refers to the use of a vaccine to protect against canine distemper, infectious canine hepatitis (canine adenovirus type 2), canine parainfluenza, leptospirosis, canine parvovirus type 2, and canine coronavirus.
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D. Vaccinate with FVRCP,* chlamydia, feline leukemia virus, rabies, and feline infectious peritonitis vaccines E. Deworm according to fecal examination results F. Adjust the diet and grooming procedures as needed G. Discuss age-related changes that are occurring H. Provide the owner with educational pamphlets on such topics as: 1. Identification, treatment, and control of fleas, ticks, and ear mites 2. Dental, skin, nail, and ear care 3. Management of normal and abnormal behaviors 4. Exercise and its importance I. Fill in the annual health record for the owner •This refers to the use of a vaccine to protect against feline viral rhinotracheitis, feline ca!icivirus infection, and feline panleukopenia.
GERIATRICS
+ .20
GERIATRIC CARE IN THE LATE 1990s Johnny D. Hoskins, DVM, PhD, and Dennis M. McCurnin, DVM
Years of research into disease, development of vaccines, improvement in canine and feline diets, establishment of pediatric health care programs, and widespread distribution of quality medicine as well as the education of animal owners on the need for preventive care are paying off. Today's dogs and cats are living longer. In fact, although the average life expectancy for a cat just two decades ago might have been 4 to 6 years, it is not uncommon to find cats living 15 years or longer these days. Life expectancies for dogs have also increased for many of the same reasons. Interestingly, the oldest recorded cat was 34 years old and the oldest dog was 29 years old.' Older people tend to own older dogs or cats with which they have formed a strong bond. These owners are often "empty nesters" who have replaced their children with older dogs, cats, or both. When care is needed or health management recommendations are made, they usually want a level of service comparable with that available to themselves or other family members. In addition to a strong family attachment, older people often have the financial resources and scheduling flexibility to allow a high level of medical care to be provided. It is estimated that by the year 2030, the number of people aged 65 and older will have almost doubled and will represent more than 20% of the total population. 6 This rapid increase in senior citizens is due primarily to the natural aging process of the baby boomers, those born between 1946 and 1965. Nutrition, exercise, and preventive health programs are now practiced by many people on a daily basis and most likely have accounted for the lengthened human life expectancy. As the bond between humans and animals has become better understood, the true value of the dog or cat in the family has been recognized and articulated by health care professionals and the general public. During this same time
From DocuTech Services, Inc., Baton Rouge, Louisiana (JDH); and the Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, Louisiana (DMM)
VETERINARY CLINICS OF NORTH AMERICA: SMALL ANIMAL PRACTICE VOLUME 27 • NUMBER 6 • NOVEMBER 1997
1273
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HOSKINS & McCURNIN
period, the members of the general public have become more aware of the effect of the aging process on themselves and are aware when a beloved dog or cat is showing some of the same aging changes. In addition, a great deal of interest and research has been directed into the field of human oncology, the relationship between high-cholesterol/high-fat diets and the incidence of heart disease, and overall preventive health. Every day there are new discoveries made through research, and both people and animals are living longer, healthier lives. All of these changes have set the stage for preventive medicine and the development of geriatric programs for our dogs and cats. As people live longer, healthier lives, they expect parallel programs for their animals. During the 1980s, the number of practicing veterinarians grew, although the population and economy became stagnant. This resulted in the profession becoming more aware of potential new practice markets. The area of geriatrics has continued to remain a relatively untapped market even in the face of changing public opinion and scientific knowledge. Geriatric dogs and cats have a different set of clinical and owner challenges than do puppies and kittens. Some owners are willing to spend exorbitant amounts of money and time to extend an animal's quality of life in the final months; for example, heroic efforts are attempted in some oncology patients with minimal clinical results but maximum owner satisfaction. Veterinary medical practices should be ready now or within the next 5 years to accept these challenges to provide more in-depth geriatric health care programs for the increasing number of older owners and their aging dogs and cats. Historically, veterinarians have been more likely to have comprehensive pediatric programs rather than comprehensive geriatric programs. The young, healthy animal has been viewed as the most profitable and most enjoyable type of patient. According to a r ecent report by the American Animal Hospital Association,! how"-ever, the dog and cat population in the United States will remain stable during the next 10 years. This trend follows the human population's slow growth pattern. Given the stable dog / cat and human populations and the slowly increasing number of small animal practitioners, income per veterinarian is projected to decline over the next 5 to 10 years. This economic forecast may come true unless the veterinary practice community focuses on providing services to a wider range of patients.
INTEGRATING GERIATRIC CARE
An active geriatric health care program is a clinical area that needs to be developed or expanded in most veterinary practices. Geriatric care should be a natural extension of current pediatric and maintenance programs that are already in place. The scope of services offered should start during the animal selection process (even as early as helping prospective owners select the best animal for their lifestyles) and end with bereavement counseling at the time the animal dies. The geriatric part of the program should fit into the overall package of services at whatever age chosen as being geriatric such as 8 years of age and older. Veterinary practices vary in the percentage of dogs and cats in each age group, but, in general, geriatric animals in most v eterinary practices will typically range from 25% to 40% of the total caseload. Exceptions exist in those practices located in or near a retirement community (such as Sun City, AZ) which may have a higher percentage of both geriatric animals and owners.
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DEFINING THE TERM "GERIATRIC"
Dictionaries define "geriatric" as "pertaining to old people," and the World Health Organization7 has defined "middle-aged" as being 45 to 59 years, " elderly" as being 60 to 74 years, and "aged" as being over 75 years old. Unfortunately, there is no similar classification for our domesticated species, and there is no specific definition of a geriatric dog or cat, although we all recognize external signs of increasing age such as graying of the muzzle, stiffness in movement, changes in posture, and reduced responsiveness to outside stimuli. Because the aging process varies with specific dog and cat breeds and an animal's lifestyle, the age at which a geriatric health care program should be implemented also varies. A geriatric health care program could begin in the United States for dogs and cats at the following ages2 : • • • • •
Small dogs (<20 lb): Medium dogs (21-50 lb ): Large dogs (51-90 lb): Giant dogs (>90 lb): Cats (most American breeds):
9 to 13 years 9 to 11.5 years 7.5 to 10.5 years 6 to 9 years 8 to 10 years
HEALTH CARE PROGRAM
Dogs or cats entering the veterinary practice for the first time should be integrated into the proper service area of the overall health care program based on the animal's age and special needs. As an example, the pediatric program might extend from birth to 1 year and would be followed by the maintenance program (1-8 years), continuing to the geriatric program (8 years and older). The development and utilization of these various programs start from a basic practice philosophy that understands and supports quality care for the different life stages. A comprehensive geriatric health care program can provide a way to target key geriatric-related health problems, to institute preventive health care measures, and to detect disorders early enough for effective medical and surgical managemenU A list of commonly encountered geriatric diseases is found on page 1276. Education of the dog or cat owner about health risks to geriatric patients and possible preventive measures is key to the success of this program. The acceptance of an older dog or cat into the health care program should depend on its general health status, which may be determined from the animal's history, physical examination, and other diagnostic procedures, and not on actual age. The health care program may include different levels of health evaluation (e.g., program 1 for the apparently healthy patient, program 2 for the patient with minor health concerns, and program 3 for the patient with major health concerns as outlined in the list on page 1277). Clinical evaluation of a geriatric dog or cat initially begins with taking a complete medical and surgical history and performing the physical examination. Basic information about the animal such as breed, age, and sex as well as owner concerns is obtained from the history. After the history is obtained, the physical examination is performed in a systematic manner. Although the examination may be easier to complete by proceeding from head to tail, it is advisable to examine and record observations according to body systems. Special concerns
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Commonly Encountered Geriatric Diseases Geriatric dog Diabetes mellitus Prostatic disease Obesity Cardiovascular disease Degenerative joint disease Cataract(s) Cancer Dental disease Keratoconjunctivitis sicca Hypothyroidism Urolithiasis Hyperadrenocorticism Anemia Urinary incontinence Hepatopathies Chronic renal disease
Geriatric cat Inflammatory bowel disease Diabetes mellitus Feline hepatic lipidosis Chronic renal disease Obesity Cancer Dental disease Hyperthyroidism Urolithiasis Anemia Hepatopathies Cardiovascular disease
are directed to specific age-influenced body systems as outlined in the list on page 1278. The "golden key" to any successful maintenance and geriatric health care program is the continual use of baseline laboratory monitoring as early in the · animal's life as possible. At any stage in life, abnormal values must be followed up on and additional procedures added as necessary. The real value in laboratory monitoring would be in having baseline or trend information for comparison when needed. Education of the owner as to the value of obtaining this baseline or trend data sets the stage for continual monitoring during the rest of the animal's life. Early owner education allows a high quality of service to be provided with a higher level of success and satisfaction. When the veterinarian waits to recommend blood profile monitoring until disease or failure is suspected, it is more difficult for the owner to understand the value of preventive medicine. Common sense tells us that if the owner believes in the value of regular profile monitoring, then as the animal(s) ages, increasing the number and frequency of profiles also makes medical sense. Owner education today will provide for a comprehensive geriatric program in the future. The owner of a geriatric dog or cat should be encouraged to have the animal examined by a veterinarian at least once a year. At this annual examination, a checklist of health care services can be used to ensure that all the steps in a health care program are followed (Appendix). Another important aspect in the geriatric health care program is education of the animal owner, specifically in the areas of nutrition, preventive health care, exercise, the normal aging process, cancer and its effects, and bereavement. A list of topics to be covered is found on page 1278. If appropriate, pet loss services for the owners of geriatric dogs and cats, memorialization, and the hospice concepts applicable to veterinary medicine are also discussed. Unabridged attention must be directed toward instructing the pet owner in regard to certain
GERIATRIC CARE IN THE LATE 1990s
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Health Screening Levels for Geriatric Dogs and Cats Program 1 History and physical examination, including eyes and rectum Packed cell volume and total protein levels Blood urea nitrogen and glucose leveJs Complete urinalysis Consultation regarding nutrition, teeth, ears, nails, and skin care Weight control program Program 2 History and physical examination, including eyes and rectum Complete blood cell count and blood chemistry profile Complete urinalysis Consultation regarding nutrition, teeth, ears, nails, and skin care Weight control program Program 3 History and physical examination, including eyes and rectum Complete blood cell count and blood chemistry profile Complete urinalysis Electrocardiography and thoracic radiography, possibly echocardiography Consultation regarding nutrition, teeth, ears, nails, and skin care Weight control program Ancillary diagnostic procedures Echocardiography Abdominal ultrasonography Thyroid gland function tests Adrenal gland function tests Blood pressure evaluation Liver, pancreas, and small intestinal function assays
potential problems specific to geriatric dogs and cats as specified in the list on p age 1279. IMPLEMENTATION OF THE HEALTH CARE PROGRAM
A health care program should be fashioned t o meet the s pecific needs of the geriatric dog or c at and the owner. 5 A successful program r equires a team approach that includes the receptionist, et chnician, ward attendants, veterinarian, a nd animal owner. To obtain optimal results, everyone f rom the hospital staff to the veterinarian to the owner should completely understand the intent of the program and its benefits. The first step in the initiation of a geriatric health care p rogram i sfor the veterinarian to understand the full scope and need for geriatric health care services in the daily routine of the vete rinary hospital. The program must then be explained completely to the hospital staff, including how it fits into their daily activities. Ideas and changes should be solicited from the ho spital staff as these may imp rove the implementation of the program. Because the receptionist
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Systematic Physical Examination of the Geriatric Dog and Cat Abdominal palpation Dental examination Ears and eyes inspection Thyroid gland palpation Musculoskeletal evaluation Rectal examination and prostate gland palpation Skin, hair coat, and nail examination Thoracic auscultation
Education of the Owner about the Geriatric Dog and Cat Nutrition Restrict protein, phosphorus, and sodium intake Provide fewer calories (only in overweight dogs and cats) Preventive health care Dentistry Health screening recommendations Annual vaccinations Heartworm check Fecal examination Feline leukemia virus and feline immunodeficiency virus tests Grooming routine Oncology Early cancer detection Medical or surgical considerations Exercise Exercise requirements Exercise and feeding activity Normal aging process General information on the aging process (e.g., vision and hearing loss, muscle tone, skin and hair coat changes) Changes to watch for at home Housing environment Food and water consumption (appetite) Abnormal urination and defecation Body weight changes Activity level changes Abnormal odors Skin lumps/masses/sores that do not heal Constant coughing/sneezing Vomiting/diarrhea Bereavement Support during the last few weeks of life if needed Final discussions and support following death of the animal Resolution of animal loss with the owner to allow another animal to be obtained by the family
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Problems Specific to Geriatric Dogs and Cats Weight stasis-obesity Cancer-present or not Halitosis-oral disease Lusterless hair coat-skin changes Changes in behavior Arthritis-altered rising or walking Anesthesia risk Loss of vision and hearing Heart murmur-heart failure Urine production-kidney failure Coughing-chronic bronchial (airway) disease Urine or fecal incontinence
is the first person with whom the animal owner has contact, it is important that this individual fully understands the health care program so that he or she can explain the program in layman terms to the animal owner. The veterinary technician also has an important and very visible role in this program; many inhospital procedures as well as laboratory procedures, radiographs, and electrocardiograms can be done by the technician. The daily activities of the health care program should be worked out to include appointment schedules, office and examination room procedures, maintenance of health records, provision of laboratory support, and an animal owner consultation period to review all findings, recommendations, and subsequent examinations. When geriatric patients are scheduled, appointments should be made during the slower time periods if possible. By scheduling these patients during less busy periods during the day, week, or year and encouraging animal owners to use these time periods, additional services can be provided with minimal additional overhead cost. Adequate time is set aside for owner consultation so that a complete case review is possible. The consultation should start with a private discussion between the hospital staff and the owner, without the geriatric dog or cat present, regarding various test results or other important items such as revisits or recommendations. The veterinarian should always participate in a portion of the consultation period. Specific recommendations to the owner should be provided in writing. Next, the owner makes payment for the services and schedules another appointment if necessary. Finally, the animal is reunited with the owner, and any final items are discussed or demonstrations are made using the pet. UTILIZING TECHNICAL SUPPORT STAFF
Most of the daily in-hospital evaluation procedures performed on geriatric dogs and cats can utilize a well-trained veterinary technician. All laboratory tests, radiographs, and electrocardiograms can be performed by the technician, with the results made available to the veterinarian prior to owner consultation. The veterinarian and hospital staff should have all necessary clinical materials, results, and recommendations organized and ready well in advance of owner consultation.
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The technician, in particular, can be invaluable in providing additional owner education on specific conditions and home care needs. The owner, and specifically the older owner, should always have an opportunity to ask questions about the findings, recommendations, follow-up care, and fees. This is where the technician can really benefit the health care program through his or her patient and understanding manner with the owner, always remembering that when talking to older people, one needs to talk slowly and loudly as well as repeat information several times. Repetition of information to the owner leads to effective communication.
MARKETING PLAN
A marketing plan for a geriatric health care program could be as simple as informing owners (clients) about this service as they first enter or return to the veterinary practice. Alternately, it could become more complex through advertising, newsletters, and a recall system. Probably the safest plan to start with is to think small, keep it simple, and develop the program one owner at a time. A safe marketing plan would be to start with in-house training of hospital staff with their own animals or a few dedicated owners so that staff can completely perform and communicate the program to owners in a professional way as they visit the veterinary practice. When the basic program is running smoothly, then the program can be enlarged through a recall system. The recall could be initiated by utilizing a hand-generated list from owner files or through a computer search by age range. After this list of owners is developed, an informational newsletter, individual letter, or telefax could be sent highlighting the geriatric health care program and services available. A newsletter or pamphlet could also be handed directly to qualified owners as they come into the veterinary practice. Another marketing program to help expand geriatric activities is to offer a monetary incentive (such as a percentage of gross income or dollar amount per owner) to the hospital staff member responsible for owners making appointments for preventive care services. This specific incentive does not have to be a large percentage or amount, but it does provide a rationale for the staff member to work on the program. Contact by the staff member may be made by phone, letter, telefax, or in person. As staff members go about their personal lives, they have many opportunities to market veterinary services. If there is an incentive system in place to account for this activity, the program will have better success. Providing each staff member with marketing tools such as personal business cards will also aid in this effort. Another spin-off of an active geriatric health care program is the opportunity to provide additional services to the owner such as vaccinations, patient evaluation, animal care product sales, and so forth. Seeing the owner on a regular basis provides this opportunity which improves the overall patient care being provided by the veterinary practice. The veterinarian is advised to start now to develop a geriatric health care program by recommending the most complete diagnostic services to each owner and geriatric dog or cat. Providing the groundwork for quality services now will result in a quality geriatric program in the future.
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CONCLUSIONS
Geriatric health care remains a virtually untapped area in spite of changing public views and scientific knowledge on aging. As owners live longer, healthier lives and become more aware of age-related changes in themselves, they discover that their dogs and cats also undergo age-related changes. The number of geriatric dogs and cats will continue to grow into the next century. As the senior citizen segment of society increases, the number of geriatric dogs and cats also increases. Senior citizens usually have older dogs and cats and are willing to invest in quality health care services. A geriatric health care program can expand veterinary services in a practice and is a natural extension of pediatric and adult maintenance programs. References 1. American Animal Hospital Association: A Study of the Companion Animal Veterinary Service Market. Lakewood, CO, 1995 2. Goldston RT: Geriatrics and gerontology. Vet Clin North Am Small Anim Pract 19:1202, 1989 3. Hoskins JD: Geriatric preventive medicine. In: Geriatric Medicine. St. Louis, Ralston Purina, 1993, pp 5- 10 4. Matthews P (ed): The New Guinness Book of Records 1995. Enfield, UK, Guinness Publishing, 1994 5. Mosier J: How aging affects body systems in the dog. In: Geriatric Medicine: Contemporary Clinical Medicine and Practice Management Approaches. Lenexa, KS, Veterinary Medicine Publishing, 1987, pp 2-6 6. Turnwald GH, Baskett JJ: Effective communication with older owners. JAVMA 209:725726, 1996 7. World Health Organization: Report of a Seminar on the Health Protection of the Elderly and Aged and the Prevention of Premature Ageing, Copenhagen, 1963 Address reprint requests to
Johnny D. Hoskins, DVM, PhD 17755 Crossing Boulevard Baton Rouge, LA 70810
APPENDIX
A Preventive Health Care Program for Geriatric Dogs and Cats
I. Geriatric dog A. Conduct a general physical examination and record the body weight B. Check for external parasites and dermatophytes and initiate appropriate therapy 1. Fleas, ticks, and ear mites (Otodectes cyanotis) 2. Mange mites, especially Demodex canis and Sarcoptes scabiei 3. Dermatophytes, particularly Microsporum species and Trichophyton men-
tagrophytes C. Conduct fecal examination (fecal flotation test) D. Check for heartworm disease (Knott or occult test) E. Adjust the dosage of heartworm preventive medication according to body weight, especially for diethylcarbazamine products F. Deworm with broad-spectrum anthelmintic product G. Vaccinate with DA2PLPC* and rabies vaccine and, possibly, kennel cough and canine Lyme borreliosis vaccine H. Adjust the diet according to health needs and, if necessary, change grooming procedures I. Trim the nails and clean the ear canals J. Discuss age-related changes that are occurring K. Provide the owner with educational pamphlets on such topics as: 1. Identification, treatment, and control of fleas, ticks, and ear mites 2. Dental, skin, nail, and ear care 3. Grooming and nutrition 4. Management of normal and abnormal behaviors 5. Exercise and its importance L. Fill in the annual health record for the owner II. Geriatric Cat A. Conduct a general physical examination and record the body weight B. Check for external parasites and dermatophytes and initiate appropriate therapy 1. Fleas and ear mites (0. cyanotis) 2. Mange mites, especially Notoedres cati, Demodex species, and Cheyletiella species 3. Dermatophytes, particularly Microsporum species and T. mentagrophytes C. Perform fecal examination (fecal flotation test) *This refers to the use of a vaccine to protect against canine distemper, infectious canine hepatitis (canine adenovirus type 2), canine parainfluenza, leptospirosis, canine parvovirus type 2, and canine coronavirus.
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D. Vaccinate with FVRCP,* chlamydia, feline leukemia virus, rabies, and feline infectious peritonitis vaccines E. Deworm according to fecal examination results F. Adjust the diet and grooming procedures as needed G. Discuss age-related changes that are occurring H. Provide the owner with educational pamphlets on such topics as: 1. Identification, treatment, and control of fleas, ticks, and ear mites 2. Dental, skin, nail, and ear care 3. Management of normal and abnormal behaviors 4. Exercise and its importance I. Fill in the annual health record for the owner •This refers to the use of a vaccine to protect against feline viral rhinotracheitis, feline ca!icivirus infection, and feline panleukopenia.