- Email: [email protected]
Geriatric Health Care Program for Veterinarians, Veterinary Technicians, and Office Managers
Implementing a Successful Senior/ Geriatric Health Care Program for Veterinarians, Veterinary Technicians, and Office Managers William D. Fortney, DVM
KEYWORDS • Geriatric • Aging • Senior • Health care KEY POINTS • A successful, comprehensive senior health care program can significantly increase the quality of life and longevity of all older dog and cats. • Regularly scheduling a senior wellness examination is one of the most important steps pet owners can take to keep their older pets healthy. • Since each organ ages at a different biological rate, the assessment of a patient’s overall health status should be based on a screening of each organ function. • Early benchmark changes of aging are commonly identified on ⬙routine⬙ senior profiling, further validating the value of routine screening testing protocols of healthy older patients. • A senior health care program implies both a preventative wellness strategy and a comprehensive therapeutic approach to the management of acute and chronic conditions in aging dogs and cats.
INTRODUCTION
Senior health care, geriatric health care, senior wellness, geriatric wellness, and senior care are all terms for specific health care programs that are designed to improve the routine veterinary health care of older dogs and cats. While the veterinary profession may not agree on what to call the program, what age to start the program, what diagnostics evaluations to include in the program, or even how often per year the patient should be evaluated, we are all in agreement that the program should significantly increase the older patient’s quality of life and their longevity. In the early 1990s, the concept of a geriatric wellness and geriatric health care program was being considered in veterinary teaching hospitals. Veterinarians were The author has nothing to disclose. Department of Pathobiology and Diagnostic Medicine, Kansas State University College of Veterinary Medicine, Manhattan, KS 66506, USA E-mail address: [email protected] Vet Clin Small Anim 42 (2012) 823– 834 http://dx.doi.org/10.1016/j.cvsm.2012.04.011 vetsmall.theclinics.com 0195-5616/12/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
824
Fortney
doing a good job of managing age-related diseases once they were made aware of the patient’s problem(s). However, in general neither the veterinarians nor the owners were aggressively “looking” for subclinical or early problems. “Senior Care” exploded in the mid 1990s when Pfizer Animal Health implemented the national marketing concept of Senior Care. In essence, their Senior Care model was the newly emerging geriatric health care program but was also a set of marketing tools and education client brochures that dovetailed with their new senior-specific line of products. In the past 2 decades, senior/geriatric health care programs evolved as the recognized platform for healthy old pet evaluations, preanesthetic protocols, and approach to testing clinically ill animals and chronic drug monitoring protocols. AGING
It is difficult to totally understand older dog and cat health programs without at least having some understanding of how animals age. An animal’s life can be divided into 4 stages; pediatric, adult, senior (mature, middle age), and the traditional geriatric (senior/super senior). The senior/middle age years represent the transition period between the relatively “healthy” adult years and the traditional “geriatric” age period where serious age-related diseases are significantly more prevalent. The senior (transition) period signals the patient’s initial decline in physical condition, organ function, sensory function, mental function, and immune responses.1 During this period of progressive decline, it would be appropriate on all veterinarians to take an age-specific history of the senior patient, perform complete age-related physical examinations, recommend selected diagnostic screening testing, advocate a premium senior diet, and provide weight consultations, plus increasing the caregiver’s awareness and educate him/her on age-related disease symptoms. Although the exact time of each life stage could be argued for each breed, it is generally agreed that cats live longer than dogs; smaller breed dogs live longer than larger breed dogs; and each life stage has a corresponding chronologic difference. In the early 1980s, Dr Richard T. Goldston took a more scientific approach to this premise.2 The result was various versions of the popular human/pet age analogy charts. The current human/pet age analogy chart (Fig. 1) helps clarify the longevity versus size concept for both clients and hospital staff. These relative age charts also emphasize the concept of comparable ⬙time compression⬙ differences between humans and animals. The take home message being that animals require shorter intervals between routine wellness testing than humans, in pets, all chronic diseases progress much faster than similar conditions in people and the need for repeated drug monitoring intervals to be undertaken more often in older dogs and cats. Hanging an age analogy chart in each exam room is a useful and inexpensive marketing strategy. DECLINING PHYSIOLOGIC RESERVES HELPS DEFINING AGING
Aging is the sum of the deleterious effects of time on the cellular function, microanatomy, and physiology of each body system. Aging is not a specific disease but rather a complex process of genetic, biological, nutritional, and environmental factors all contributing to the progressive regression called aging. These factors affect varying rates of progressive and irreversible degenerative changes of all body tissues and organ systems. The rate of the physiologic decline and lack of reserves varies between species, breeds, and even littermates. Individuals at equal chronologic ages may experience different alterations. For some organs, the level of decline may be rapid and dramatic, while for others organs, the changes are much less significant.
Successful Geriatric Care Program
Fig. 1. The current human/pet age analogy chart.
Long-term physiologic declines of the major organ systems lead to an altered patient response to stressors, infections, and various drugs. Therefore, it is the declining physiologic reserves that tailor our medical approach to the geriatric patient. These biological aging changes manifest in progressive deteriorations in physical condition, organ function, mental function, and immune response, but not necessarily correlating with the patient’s birth date. The actual age of an organism is referred to as “chronologic”
825
826
Fortney
aging and should be distinguished from “biologic” aging, which is the relative functional age of each of an individual’s diverse organ systems. Using the patient’s age as a point of reference for their collective decline is appropriate. However, because each organ has a different rate of biologic aging, any critical assessment of a patient’s overall health status should be based on a complete health screening of each specific organ function if possible. It is not uncommon in practice to see a 20-year-old cat with the kidneys of an adult or, conversely, a 6-year-old cat with geriatric kidneys. This is the basis for advocating a senior laboratory and diagnostic evaluation in apparently healthy pets starting at 7 years of age. At some critical stage in the progressive decline, the physiologic “tipping point” for that organ is reached.3 All of that particular organ’s physiologic reserves are exhausted, resulting in overt changes in diagnostic tests; biochemical parameter(s), and/or the onset of clinical symptoms. These measurable points are referred to as “benchmarks” of organ aging. Usually, these slowly progressive benchmarks are often subtle, undetected, or misinterpreted by the owner until the patient is stressed by an unrelated illness, boarding, medications, or general anesthesia. Increasingly, those early benchmark changes are identified on “routine” senior profiling, further validating the value of routine screening testing protocols of healthy patients. INTRODUCTION TO SENIOR/GERIATRIC HEALTH CARE PROGRAMS
Senior pets represent 30% to 40% of patients, and this number will most likely increase as technology and education progress.4 This movement in pet population demographics is due to several interconnected factors involving owners, animals, and the veterinary profession. As a result, senior medicine will continue to be an increasing profit center for practices. The evolving positive attitudes most owners have toward their pets (the “human– animal” bond) has significantly contributed to increases in their pet’s life expectancy. Today, a large group of animal caregivers consider their pets as being “family members.” They are more willing to invest the time, the resources, and the commitment necessary to appropriately prevent and manage the chronic infirmities often associated with aging. In parallel with the rise of the “human-animal bond,” the veterinary profession, along with the pharmaceutical industry, has responded with significant developments in comprehensive health care options, diagnostics, and therapies. Enhanced senior diets, improved dental care, superior diagnostic techniques, new drugs, safer anesthetic protocols, newer surgery techniques, advances in cancer chemotherapy, pain management strategies, and the use of multimodal management strategies are changing the senior health care landscape. Advances in procedures, diagnostics, and equipment once reserved for referral centers are now accessible to the primary care veterinarians to provide their older patients the high quality care that even the “average” pet owner is now expecting and is also willing to pay for. Every senior/geriatric care health program is based on 2 premises: first, there are fundamental differences in the specific diseases, behavior problems, and the nutritional needs of the older pet; and, second, prevention and/or early detection of age-related problems can have a very positive impact on the patient’s quality of life and longevity. 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. Armed with the knowledge gleaned from the health screening, the progressive veterinarian is better positioned to prevent and/or manage problems
Successful Geriatric Care Program
in the earliest stages, thereby increasing the available options and improving the overall outcome. In many respects, senior/geriatric care health programs have changed the traditional reactive veterinary sick animal “fix it shop” approach to a more proactive wellness health care tactic. Long-term health and patient well-being for older pets are the emphasized points of this platform. The strategy supports routine screening (history, physical examination, and diagnostics) of patients for early signs of disease, when the patient has the most options and the best opportunity for success. WHY BUILD A SENIOR CARE PROGRAM IN YOUR PRACTICE?
Scheduling regular wellness examinations is one of the most important steps pet owners can take to keep their pets healthy. Since the risk factors for developing age-related diseases increase with aging, senior wellness examinations are more important than ever. Early detection of any health problem, especially age-related diseases, is paramount to long-term management success. The earlier the detection of any health or behavioral problem, the more options that are available to either cure the condition or slow the progression of the problem. By advocating more comprehensive histories, performing more complete physical examinations, and recommending more diagnostic testing of older pets, the clinician is providing higher-quality veterinary medicine for his/her senior patients. A great deal of professional satisfaction for the veterinarian and staff comes from helping those long-established senior patients live longer, healthier lives; also, managing most age-related disease in the early phases is far more professionally rewarding than the “end stage.” Finally, while the veterinary profession has been very successful at providing comprehensive pediatric health care programs for decades, there are almost 2.25 times as many senior pets as puppies and kittens.5 Dogs are puppies for 1 year but are seniors for 4 to 10 years. A senior/geriatric health care program implies both a preventative wellness strategy and a comprehensive therapeutic approach to the management of acute and chronic conditions in aging dogs and cats. The program emphasizes prevention, early detection, and timely medical intervention, combined with client education. Senior Care Program Essential Components
Four essential components of any Senior Care program should include: 1. Preventative health programs 2. A comprehensive patient health assessment (discovery) - Age-specific history - Complete age-related physical examination - Laboratory evaluation - Additional diagnostics 3. A formal review period where all the findings are communicated to the owner 4. Formulating specific short- and long-term action plans and scheduling a follow-up. Just like there is no perfect veterinary hospital, there is no perfect blueprint for a senior/geriatric health care program that fits all practice scenarios. Instead, each practice must develop and tweak a program specifically catered to the client’s wants, the practice’s ability to provide appropriate services, and the associated financial issues.
827
828
Fortney
When implementing a senior/geriatric health care program, the first critical decision each hospital must make is establishing the minimum database “boundaries” of the recommended health assessment. For example, exactly how detailed should the agerelated history be? Which diagnostic screening tests should be included in the health assessment? The ultimate decisions for such a program are based on several interrelated factors including patient age, presence or absence of disease, current conditions and medications, and owner’s interests and resources. Most hospitals initially use a basic (simple) screening strategy. However, over time, many expand the program to more extensive comprehensive health evaluations. 1. Routine preventive health program
A senior/geriatric health program must start with a comprehensive preventive health program, appropriate risk assessment of vaccine recommendations, endo and ecto parasite control, proper dental care, nutritional advice, weight counseling, and exercise guidance. Since the patient is already scheduled for annual evaluations, it is logical that preventive care be an integral part of the entire program. 2. Comprehensive health assessment
The primary purpose is discovery—to identify early disease conditions, recognize behavior problems, and establish a database for successive evaluations. To be comprehensive, the health assessment must include an age-specific history, complete agerelated physical exam, and more appropriate laboratory and diagnostic evaluation. An age-specific history using a medical, behavioral, and dietary history is the starting point of a complete health assessment. Pet owners can be invaluable sources of information on the overall health of their pets. Observant and well-trained owners can detect subtle changes in their pet’s activity levels, elimination patterns, and behavior. Often this vital information is unapparent to the veterinarian and veterinary technician in an examination room setting. Owner’s observations, medication skills, and monitoring abilities are paramount to the overall success in managing certain chronic diseases. Therefore, the goal must be to convince each owner to become a much more active partner in the health care of their aging pet including their observation skills. Using a hardcopy history questionnaire greatly expedites time utilization if done in the waiting room, ensures that all the standard questions are asked, and educates the caregiver on those critical pain, disease, and behavior warning signs. A complete age-related physical examination is the second part of the comprehensive health assessment. While a regular physical exam is part of any good health care evaluation, the senior/geriatric patient requires a more extensive examination. In addition to a standard physical, the additional examinations should include a weight assessment and gentle palpation of each skeletal joint for indications of osteoarthritis. Digital rectal examinations of the prostate and the presence of masses are worth the time and effort. Extra time should be taken for an extensive dental/oral examination, as well as diligent palpation of the mammary glands for skin and subcutaneous masses. Each tumor identified should be accurately measured and mapped in the medical record. Unless you are sure it is benign, a fine needle aspiration and cytology is appropriate. Some practitioners believe a Schirmer tear test in their older dogs is prudent. An appropriate laboratory evaluation is the third portion of the comprehensive health evaluation. There is no arguing that the minimum laboratory database will result in early detection of age-related diseases that definitely benefit older pets. Routine testing of the clinicopathologic database is a critical component in the management of mature, senior, and geriatric patients because blood and urine testing allows one
Successful Geriatric Care Program
to detect subclinical abnormalities at a time when preventive and therapeutic intervention may have the most benefit.6 Precise comparisons of the laboratory values (normal and abnormal) changes seen in serial/sequential tests over 2 or more occasions (referred to as trending) is a helpful diagnostic and prognostic tool. Trending may help in recommending future baseline testing intervals.7 The larger the data trends between samples, the shorter the testing interval should be. Advantages of baseline testing in senior patients include (1) helping to establish a diagnosis in a patient with a known illness, (2) assessing and monitoring potential adverse drug reactions, (3) providing assessment of the patient’s anesthetic risks, (4) perhaps uncovering subclinical/undetectable disease in apparently healthy patients, and (5) establishing a “normal” laboratory baseline for direct comparison at a later date when the patient has an obvious illness. In addition, senior profiling allows veterinarians to select safer sedation/anesthesia protocols. However, the debate remains regarding what screening tests are appropriate for an apparently “healthy” senior/geriatric dog or cat. That argument will not be solved in this article. The laboratory profiling and additional diagnostics, part of a simple program, a complex program, or something in-between, is a choice the practice decision maker will make early on. As stated earlier, what constitutes a minimum laboratory and diagnostic database is complicated and not easy to determine. While it would be nice to run all of the tests available, it is not practical or affordable for most clients. Fortunately, some compromise will be found based in the overall practice philosophy and the logistics of providing the testing, combined with the average client’s level of financial interest. A reasonable starting minimum database for the “healthy” older patient should include a complete blood count, biochemical profile with electrolytes, complete urinalysis (specific gravity, urine testing sticks, and urine cytology), fecal flotation, and heartworm and tick-borne disease testing in appropriate patients.8 The minimum senior feline database includes a complete blood count, biochemical profile with electrolytes, complete urinalysis (specific gravity, urine testing sticks, and urine cytology), fecal flotation, a total thyroxine, and feline leukemia/feline immunodeficiency virus testing in appropriate feline patients.9,10 Based on the incidence of Cushing disease and hypothyroidism in dogs, some practices routinely incorporate thyroid and adrenal screening in their senior/geriatric health care programs.8 Additional diagnostic testing is the final portion of the comprehensive health examination. While arguably not part of a minimum database of the healthy older pet, various additional diagnostics are commonly incorporated into many successful health care programs. Those supplementary diagnostic tests include an electrocardiogram, thoracic radiographs assessing the cardiac silhouette and the presence of a mass(s), abdominal imaging (radiography or ultrasound) for any organ abnormalities, blood pressure measurement in cats, and ocular tonometry in dogs. For a list of additional tests, access the latest AAHA Senior Care Guidelines.8 3. Review period
Once the comprehensive health assessment is complete and the results finalized, it is time to inform the caregiver of the findings followed but any short- and long-term action plans and timelines. A formal review period is the time where all the normal and abnormal findings are communicated to the owner in person or via phone, mail, e-mail, or some combination. Obviously that choice is a practice one. Given a choice, I have always promoted a “face-to-face” conversation. However, good news is very easy to convey with any
829
830
Fortney
method, while bad news in not. One of the advantages of pet-side laboratory testing is the rapid results turnaround requiring just a little extra time in the waiting area before receiving the review. In addition to a phone call, my family physician mails me a copy of my laboratory test results, a common practice in human medicine screening programs. The author suggests at least considering sending a copy of the laboratory results home with the owner. This value-added document can be shared with others in the home and the report often becomes part of the patient’s private medical record. Obviously sending the report alone will invoke additional questions and time, so sending a corresponding piece, “Understanding Your Pet’s Blood Work,” minimizes the questions and increases the perceived value of the tests.11 Good examples of this great continuing education tool can be found online. Regardless of how your practice elects to manage the review period, the author suggests that you provide a written evaluation (a health “report card”) of the pet’s summary health report for the owner to take home to share with any other caregivers and a copy for your medical records. It is commonplace to send home any appropriate client education materials used to help reinforce any health issues at home and distributed to the other home caregivers. To be optimally effective, this step must occur in a timely fashion and not several days later. Two common errors caregivers of older pets make are (1) failure to observe subtle changes in their pet’s activity or patterns and (2) assumption that nothing can be done about old age diseases. Regardless of the cause, the owner’s failure to inform the veterinarian of the early symptoms often results in a missed opportunity to help the pet when it could actually help the most. As the pet ages, each owner must assume an increasing responsibility for the overall health care of their pets. Our task as a health professional is to help our clients fulfill that role. One of the most important steps pet owners can take to keep their pets healthy is to become a better observer and reporter. By using educational tools including brochures and the practice’s website, and combining education with some training, most clients can be become an important member of their pet’s health care team. Their awareness of any change in their pet can be invaluable . . . only if they know what to look for. Recognition of even mild changes in a pet’s habits, activity patterns, behavior, weight, eating, or elimination patterns may be a signal that something serious is developing. While many other owners do observe many of those subtle symptoms and changes in behaviors in their older pet, sadly those observations are often misinterpreted as just part of “normal aging” and that “nothing can be done about the condition.” The owners failure to inform their veterinarian of the early symptoms usually results in a missed opportunity to manage the early condition when it could actually help the most. As a result, their pet continues to suffer from the lack of medical attention and care. Tragically after weeks, months, or years of suffering, the pet is finally presented to the veterinarian for euthanasia. Some examples of commonly assumed “just old age” conditions include inactivity (chronic pain, arthritis, or a systemic illness), bad breath (dental disease), decreased appetite (chronic pain, dental disease, or a systemic disease) decreased vision (cataracts), periods of disorientation or confusion (cognitive dysfunction syndrome), and early-morning stiffness (arthritis). The slowly progressive symptoms of osteoarthritis are commonly misinterpreted by the owner. They assume the dog or cat is just slowing down and not wanting to play as much due to an old age–related lack of energy. Even minimal education could alter many of these outcomes.
Successful Geriatric Care Program
The most common serious problems in older dogs include cancer, heart disease, kidney disease, liver disease, osteoarthritis, and cognitive dysfunction syndrome. In cats, cancer, kidney disease, heart disease, diabetes, and thyroid disease top the list. It is important for owners to observe the early warning signs of the most common life-shortening diseases in elderly pets. Equally important is that they report them to their veterinarian as soon as possible. Waiting for the next annual examination may be too late. A partial list of warning signs that owners should look for includes: • • • • • • • • • • • •
Changes in weight, especially weight loss Decreased appetite or inappetance Increased water consumption Changes in elimination patterns (urine or stool) New lumps or bumps or swellings, or changes in existing ones Persistent cough Difficulty breathing or breathing heavily or rapidly at rest Sudden collapse or bout of weakness Difficulty climbing stairs or jumping Foul mouth odor or drooling Seizure, convulsion, or fit Pain.
4. Short- and long-term action plans and a follow-up
During the review period, the clinician and the client need to formulate specific short and long-term action plans for each new problem identified. If no problem(s) are found, then continue the annual or bi-annual evaluations as scheduled. Either way, specific recommendations for diet, exercise, and dental care should be explicitly communicated. Dietary recommendations should be based on the health needs of the patient and not on cost alone. Those factors influencing the diet selection includes quality of ingredients, specific antioxidants shown to modify the aging process, and a research-based formulation. Any dental procedures, medication, therapies, retesting, or additional testing should be discussed and scheduled. Timely follow-up telephone calls and written reminders are essential components and critical in the overall success of any senior/geriatric health care program. A critical part of any follow-up is scheduling the next appointment prior to leaving the hospital if for a healthy patient. Setting a routine appointment time even if it is 6 months or 1 year later reinforces the program timetable. A standard practice policy of a phone call-back within 72 hours of the examination to discuss questions, concerns, medication issues, dietary needs, etc; it also sends an honest message of caring to the owner. Senior/geriatric health care reminders should not be vaccine and parasite related but rather focused on wellness and the advantages of health evaluations. While infectious disease preventatives are important, the emphasis is shifted to that of wellness and age-related disease prevention program and strategies. MAKING THE PROGRAM SUCCESSFUL
Obviously the professional rewards are proportional to the success of the program. And while success is never guaranteed, the 10 steps listed later may help you reach your program’s ultimate goals. A successful program requires a large tool box. Tools for client education, health data gathering and health reporting tools, patient diagnostic and management charts,
831
832
Fortney
plus program implementation tips are currently available for successfully implementing a senior/geriatric health care program in your practice. Reinventing the wheel is time consuming and can be frustrating. Veterinary articles and seminars are good sources of ideas and suggestions. One course of information is the earlier mentioned AAHA Senior Care Guidelines.8 Other sources of support are marketing tools, the products, and services various industries have available for old dog and cat health care. For example, IDEXX (Westbrook, ME, USA) can provide practices with advanced age-related in-house diagnostics and referral laboratory diagnostic services. In addition, they can also include some marketing and implementation tools necessary to make your program more successful. TEN STEPS TO MAKE A SENIOR/GERIATRIC HEALTH CARE PROGRAM SUCCESSFUL
1. The practice decision maker must be convinced that a senior/geriatric health care will become a significant asset to the practice before investing the time, energy, training, and resources necessary in developing and maintaining the program. However, because of the commitment necessary for success and growth, this program is not for every practice and— depending on the level of interest and finances—may not appeal to every client. Unfortunately, this is not a “build it and they will come” plan. 2. Convince the entire staff of the significant health benefits the program offers the senior pet. Critical to the success or failure of a senior/geriatric health care program is the involvement and buy-in of your staff. In fact, ownership of the program by every staff member is essential. Staff incentive programs will also help the senior/geriatric health care program patient base grow and maintain the program’s momentum. 3. Create a very specific and detailed program including age of onset, frequency of visits, scheduling periods, fee structure, educational materials, and marketing strategies. Decide exactly which tests are to be included in the program. Finally, ensure every member of the staff is “program proficient” and can sufficiently understand the particulars. 4. Convince the owners of the significant health benefits the program offers their aging pet. A percentage of your practice (ie, the “A-list caregivers”) will readily accept the program, but the rest will need repeated convincing. Increased client knowledge usually equates to increased client acceptance and compliance. Early and persistent owner education is a long-term investment in a senior/geriatric health care program. 5. A well-designed market strategy correlates with success. Use newsletters, reminder cards, invoices, telephone directory ads, Web pages, and social media to educate your current and prospective clients on age-related problems and solutions. Client marketing efforts should emphasize all the advances in veterinary medicine including newer diagnostic testing, improved anesthetics and anesthetic monitoring equipment, behavioral drugs, newer arthritis therapy options, leading edge cancer chemotherapy, more effective cardiac medications, dental care, and nutritional advancements that are available. 6. Bundle the fee structure to include a senior pet discount. Discount the fee for all the services and also consider a cost reduction in the senior diets for any patients already on the program. 7. Start slow and be patient and the program will grow. A senior/geriatric health care program is a long- term hospital investment. It is much easier to add a test and expand the program than take one away because the cost was considered
Successful Geriatric Care Program
excessive for the average owner. Unfortunately, an overzealous program coupled with underdelivery of value is commonplace. The seeds of program success and client subscription actually begin when outlining a life-long preventive health care program the first time a new owner visits the practice, even for puppies or kittens.5,12 8. Since a comprehensive health examination will require more time in the exam room, try to schedule these appointments during slow days or during periods of the day when you can devote the time necessary for a complete evaluation. 9. An attractive 3-color trifold brochure for your practice’s program is an easy and time-saving marketing tool. The brochure should be uniquely branded to your practice. Highlight the specifics of your program (age of onset, visits per year, etc), but keep the piece simple for an easy read. Emphasize the advantages of the health program to the older pets and the early warning disease signs to watch for. 10. Periodic program review by your clients and staff is essential in maintaining the consistently high standard of care you have established for your senior patients. Do not be afraid to modify the program to meet the emerging minimum database protocols. SUMMARY
A senior/geriatric care health program is a more inclusive wellness program than those recommended for all healthy “adult” pets. Older dogs and cats have a different set of needs and challenges than when they were younger. Aging in animals is similar to aging in people except at an accelerated rate. To offset this faster aging process and increased “time compression” and to detect potentially serious conditions at the earliest stages, most progressive small animal practices are now recommending examinations every 6 months even with healthy senior/geriatric dogs and cats. Initially, the program starting at around 7 years of age for both species is commonplace. Comprehensive health evaluations, including senior profiling, allow veterinarians to more successfully diagnose and manage an early condition. The detection of underlying diseases also impacts pharmaceutical selections and chronic drug monitoring. In addition, the routine laboratory evaluation supports safer sedation/anesthesia protocols. REFERENCES
1. Mosier JE. Effect of aging on body systems of the dog. Vet Clin North Am Small Anim Pract 1989;19(1):1–13. 2. Goldston RT, Hoskins JD. Geriatrics and gerontology of the dog and cat. Philadelphia: WB Saunders; 1995. 3. Fortney WD. Declining physiological reserves: defining aging. Nestle Purina Companion Animal Nutrition Summit Proceedings, March 2010. Available at: http:// breedingbetterdogs.com/pdfFiles/articles/CAN2010_updated.pdf. Accessed April 10, 2012. 4. Metzger FL. Senior and geriatric care programs for veterinarians. Vet Clin North Am Small Anim Pract 2005;35(3):743–53. 5. Hoskins JD, McCurnin DM. Geriatric care in the late 1990s. Vet Clin North Am Small Anim Pract 1997;27(6):1273– 84. 6. Epstein M, Kuehn NF, Landsberg G, et al. AAHA senior care guidelines for dogs and cats. J Am Anim Hosp Assoc 2005;41:81–91. Available at: https://www.aahanet.org/ PublicDocuments/SeniorCareGuidelines.pdf. Accessed April 10, 2012. 7. Fortney WD. Interpretation of baseline testing in senior patients. DVM InFocus, Sept 2007.
833
834
Fortney
8. AAHA senior care guidelines for dogs and cats. Available at: https://www.aahanet. org/Library/SeniorCare.aspx. Accessed April 10, 2012. 9. Rebar A, Metzger F. The veterinary CE advisor: interpreting hemograms in cats and dogs. Vet Med 2001;96(Suppl 12):1–12. 10. American Association of Feline Practitioners/Academy of Feline Medicine. Panel report on feline senior care. Available at: http://www.aafponline.org/about_guidelines.htm. Accessed April 10, 2012. 11. Purdue University College of Veterinary Medicine, Small Animal Clinic. Understanding your pet’s blood work. Available at: http://www.vet.purdue.edu/vth/SACP/documents/ understandingyourpetsbloodwork.pdf. Accessed April 10, 2012. 12. Rucinsky R. Implementing a geriatric wellness program. Proceedings of The Central Veterinary Conference; Baltimore (MD), April 2009. Lenexa (KS): Advanstar; 2009.
KEYWORDS • Geriatric • Aging • Senior • Health care KEY POINTS • A successful, comprehensive senior health care program can significantly increase the quality of life and longevity of all older dog and cats. • Regularly scheduling a senior wellness examination is one of the most important steps pet owners can take to keep their older pets healthy. • Since each organ ages at a different biological rate, the assessment of a patient’s overall health status should be based on a screening of each organ function. • Early benchmark changes of aging are commonly identified on ⬙routine⬙ senior profiling, further validating the value of routine screening testing protocols of healthy older patients. • A senior health care program implies both a preventative wellness strategy and a comprehensive therapeutic approach to the management of acute and chronic conditions in aging dogs and cats.
INTRODUCTION
Senior health care, geriatric health care, senior wellness, geriatric wellness, and senior care are all terms for specific health care programs that are designed to improve the routine veterinary health care of older dogs and cats. While the veterinary profession may not agree on what to call the program, what age to start the program, what diagnostics evaluations to include in the program, or even how often per year the patient should be evaluated, we are all in agreement that the program should significantly increase the older patient’s quality of life and their longevity. In the early 1990s, the concept of a geriatric wellness and geriatric health care program was being considered in veterinary teaching hospitals. Veterinarians were The author has nothing to disclose. Department of Pathobiology and Diagnostic Medicine, Kansas State University College of Veterinary Medicine, Manhattan, KS 66506, USA E-mail address: [email protected] Vet Clin Small Anim 42 (2012) 823– 834 http://dx.doi.org/10.1016/j.cvsm.2012.04.011 vetsmall.theclinics.com 0195-5616/12/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
824
Fortney
doing a good job of managing age-related diseases once they were made aware of the patient’s problem(s). However, in general neither the veterinarians nor the owners were aggressively “looking” for subclinical or early problems. “Senior Care” exploded in the mid 1990s when Pfizer Animal Health implemented the national marketing concept of Senior Care. In essence, their Senior Care model was the newly emerging geriatric health care program but was also a set of marketing tools and education client brochures that dovetailed with their new senior-specific line of products. In the past 2 decades, senior/geriatric health care programs evolved as the recognized platform for healthy old pet evaluations, preanesthetic protocols, and approach to testing clinically ill animals and chronic drug monitoring protocols. AGING
It is difficult to totally understand older dog and cat health programs without at least having some understanding of how animals age. An animal’s life can be divided into 4 stages; pediatric, adult, senior (mature, middle age), and the traditional geriatric (senior/super senior). The senior/middle age years represent the transition period between the relatively “healthy” adult years and the traditional “geriatric” age period where serious age-related diseases are significantly more prevalent. The senior (transition) period signals the patient’s initial decline in physical condition, organ function, sensory function, mental function, and immune responses.1 During this period of progressive decline, it would be appropriate on all veterinarians to take an age-specific history of the senior patient, perform complete age-related physical examinations, recommend selected diagnostic screening testing, advocate a premium senior diet, and provide weight consultations, plus increasing the caregiver’s awareness and educate him/her on age-related disease symptoms. Although the exact time of each life stage could be argued for each breed, it is generally agreed that cats live longer than dogs; smaller breed dogs live longer than larger breed dogs; and each life stage has a corresponding chronologic difference. In the early 1980s, Dr Richard T. Goldston took a more scientific approach to this premise.2 The result was various versions of the popular human/pet age analogy charts. The current human/pet age analogy chart (Fig. 1) helps clarify the longevity versus size concept for both clients and hospital staff. These relative age charts also emphasize the concept of comparable ⬙time compression⬙ differences between humans and animals. The take home message being that animals require shorter intervals between routine wellness testing than humans, in pets, all chronic diseases progress much faster than similar conditions in people and the need for repeated drug monitoring intervals to be undertaken more often in older dogs and cats. Hanging an age analogy chart in each exam room is a useful and inexpensive marketing strategy. DECLINING PHYSIOLOGIC RESERVES HELPS DEFINING AGING
Aging is the sum of the deleterious effects of time on the cellular function, microanatomy, and physiology of each body system. Aging is not a specific disease but rather a complex process of genetic, biological, nutritional, and environmental factors all contributing to the progressive regression called aging. These factors affect varying rates of progressive and irreversible degenerative changes of all body tissues and organ systems. The rate of the physiologic decline and lack of reserves varies between species, breeds, and even littermates. Individuals at equal chronologic ages may experience different alterations. For some organs, the level of decline may be rapid and dramatic, while for others organs, the changes are much less significant.
Successful Geriatric Care Program
Fig. 1. The current human/pet age analogy chart.
Long-term physiologic declines of the major organ systems lead to an altered patient response to stressors, infections, and various drugs. Therefore, it is the declining physiologic reserves that tailor our medical approach to the geriatric patient. These biological aging changes manifest in progressive deteriorations in physical condition, organ function, mental function, and immune response, but not necessarily correlating with the patient’s birth date. The actual age of an organism is referred to as “chronologic”
825
826
Fortney
aging and should be distinguished from “biologic” aging, which is the relative functional age of each of an individual’s diverse organ systems. Using the patient’s age as a point of reference for their collective decline is appropriate. However, because each organ has a different rate of biologic aging, any critical assessment of a patient’s overall health status should be based on a complete health screening of each specific organ function if possible. It is not uncommon in practice to see a 20-year-old cat with the kidneys of an adult or, conversely, a 6-year-old cat with geriatric kidneys. This is the basis for advocating a senior laboratory and diagnostic evaluation in apparently healthy pets starting at 7 years of age. At some critical stage in the progressive decline, the physiologic “tipping point” for that organ is reached.3 All of that particular organ’s physiologic reserves are exhausted, resulting in overt changes in diagnostic tests; biochemical parameter(s), and/or the onset of clinical symptoms. These measurable points are referred to as “benchmarks” of organ aging. Usually, these slowly progressive benchmarks are often subtle, undetected, or misinterpreted by the owner until the patient is stressed by an unrelated illness, boarding, medications, or general anesthesia. Increasingly, those early benchmark changes are identified on “routine” senior profiling, further validating the value of routine screening testing protocols of healthy patients. INTRODUCTION TO SENIOR/GERIATRIC HEALTH CARE PROGRAMS
Senior pets represent 30% to 40% of patients, and this number will most likely increase as technology and education progress.4 This movement in pet population demographics is due to several interconnected factors involving owners, animals, and the veterinary profession. As a result, senior medicine will continue to be an increasing profit center for practices. The evolving positive attitudes most owners have toward their pets (the “human– animal” bond) has significantly contributed to increases in their pet’s life expectancy. Today, a large group of animal caregivers consider their pets as being “family members.” They are more willing to invest the time, the resources, and the commitment necessary to appropriately prevent and manage the chronic infirmities often associated with aging. In parallel with the rise of the “human-animal bond,” the veterinary profession, along with the pharmaceutical industry, has responded with significant developments in comprehensive health care options, diagnostics, and therapies. Enhanced senior diets, improved dental care, superior diagnostic techniques, new drugs, safer anesthetic protocols, newer surgery techniques, advances in cancer chemotherapy, pain management strategies, and the use of multimodal management strategies are changing the senior health care landscape. Advances in procedures, diagnostics, and equipment once reserved for referral centers are now accessible to the primary care veterinarians to provide their older patients the high quality care that even the “average” pet owner is now expecting and is also willing to pay for. Every senior/geriatric care health program is based on 2 premises: first, there are fundamental differences in the specific diseases, behavior problems, and the nutritional needs of the older pet; and, second, prevention and/or early detection of age-related problems can have a very positive impact on the patient’s quality of life and longevity. 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. Armed with the knowledge gleaned from the health screening, the progressive veterinarian is better positioned to prevent and/or manage problems
Successful Geriatric Care Program
in the earliest stages, thereby increasing the available options and improving the overall outcome. In many respects, senior/geriatric care health programs have changed the traditional reactive veterinary sick animal “fix it shop” approach to a more proactive wellness health care tactic. Long-term health and patient well-being for older pets are the emphasized points of this platform. The strategy supports routine screening (history, physical examination, and diagnostics) of patients for early signs of disease, when the patient has the most options and the best opportunity for success. WHY BUILD A SENIOR CARE PROGRAM IN YOUR PRACTICE?
Scheduling regular wellness examinations is one of the most important steps pet owners can take to keep their pets healthy. Since the risk factors for developing age-related diseases increase with aging, senior wellness examinations are more important than ever. Early detection of any health problem, especially age-related diseases, is paramount to long-term management success. The earlier the detection of any health or behavioral problem, the more options that are available to either cure the condition or slow the progression of the problem. By advocating more comprehensive histories, performing more complete physical examinations, and recommending more diagnostic testing of older pets, the clinician is providing higher-quality veterinary medicine for his/her senior patients. A great deal of professional satisfaction for the veterinarian and staff comes from helping those long-established senior patients live longer, healthier lives; also, managing most age-related disease in the early phases is far more professionally rewarding than the “end stage.” Finally, while the veterinary profession has been very successful at providing comprehensive pediatric health care programs for decades, there are almost 2.25 times as many senior pets as puppies and kittens.5 Dogs are puppies for 1 year but are seniors for 4 to 10 years. A senior/geriatric health care program implies both a preventative wellness strategy and a comprehensive therapeutic approach to the management of acute and chronic conditions in aging dogs and cats. The program emphasizes prevention, early detection, and timely medical intervention, combined with client education. Senior Care Program Essential Components
Four essential components of any Senior Care program should include: 1. Preventative health programs 2. A comprehensive patient health assessment (discovery) - Age-specific history - Complete age-related physical examination - Laboratory evaluation - Additional diagnostics 3. A formal review period where all the findings are communicated to the owner 4. Formulating specific short- and long-term action plans and scheduling a follow-up. Just like there is no perfect veterinary hospital, there is no perfect blueprint for a senior/geriatric health care program that fits all practice scenarios. Instead, each practice must develop and tweak a program specifically catered to the client’s wants, the practice’s ability to provide appropriate services, and the associated financial issues.
827
828
Fortney
When implementing a senior/geriatric health care program, the first critical decision each hospital must make is establishing the minimum database “boundaries” of the recommended health assessment. For example, exactly how detailed should the agerelated history be? Which diagnostic screening tests should be included in the health assessment? The ultimate decisions for such a program are based on several interrelated factors including patient age, presence or absence of disease, current conditions and medications, and owner’s interests and resources. Most hospitals initially use a basic (simple) screening strategy. However, over time, many expand the program to more extensive comprehensive health evaluations. 1. Routine preventive health program
A senior/geriatric health program must start with a comprehensive preventive health program, appropriate risk assessment of vaccine recommendations, endo and ecto parasite control, proper dental care, nutritional advice, weight counseling, and exercise guidance. Since the patient is already scheduled for annual evaluations, it is logical that preventive care be an integral part of the entire program. 2. Comprehensive health assessment
The primary purpose is discovery—to identify early disease conditions, recognize behavior problems, and establish a database for successive evaluations. To be comprehensive, the health assessment must include an age-specific history, complete agerelated physical exam, and more appropriate laboratory and diagnostic evaluation. An age-specific history using a medical, behavioral, and dietary history is the starting point of a complete health assessment. Pet owners can be invaluable sources of information on the overall health of their pets. Observant and well-trained owners can detect subtle changes in their pet’s activity levels, elimination patterns, and behavior. Often this vital information is unapparent to the veterinarian and veterinary technician in an examination room setting. Owner’s observations, medication skills, and monitoring abilities are paramount to the overall success in managing certain chronic diseases. Therefore, the goal must be to convince each owner to become a much more active partner in the health care of their aging pet including their observation skills. Using a hardcopy history questionnaire greatly expedites time utilization if done in the waiting room, ensures that all the standard questions are asked, and educates the caregiver on those critical pain, disease, and behavior warning signs. A complete age-related physical examination is the second part of the comprehensive health assessment. While a regular physical exam is part of any good health care evaluation, the senior/geriatric patient requires a more extensive examination. In addition to a standard physical, the additional examinations should include a weight assessment and gentle palpation of each skeletal joint for indications of osteoarthritis. Digital rectal examinations of the prostate and the presence of masses are worth the time and effort. Extra time should be taken for an extensive dental/oral examination, as well as diligent palpation of the mammary glands for skin and subcutaneous masses. Each tumor identified should be accurately measured and mapped in the medical record. Unless you are sure it is benign, a fine needle aspiration and cytology is appropriate. Some practitioners believe a Schirmer tear test in their older dogs is prudent. An appropriate laboratory evaluation is the third portion of the comprehensive health evaluation. There is no arguing that the minimum laboratory database will result in early detection of age-related diseases that definitely benefit older pets. Routine testing of the clinicopathologic database is a critical component in the management of mature, senior, and geriatric patients because blood and urine testing allows one
Successful Geriatric Care Program
to detect subclinical abnormalities at a time when preventive and therapeutic intervention may have the most benefit.6 Precise comparisons of the laboratory values (normal and abnormal) changes seen in serial/sequential tests over 2 or more occasions (referred to as trending) is a helpful diagnostic and prognostic tool. Trending may help in recommending future baseline testing intervals.7 The larger the data trends between samples, the shorter the testing interval should be. Advantages of baseline testing in senior patients include (1) helping to establish a diagnosis in a patient with a known illness, (2) assessing and monitoring potential adverse drug reactions, (3) providing assessment of the patient’s anesthetic risks, (4) perhaps uncovering subclinical/undetectable disease in apparently healthy patients, and (5) establishing a “normal” laboratory baseline for direct comparison at a later date when the patient has an obvious illness. In addition, senior profiling allows veterinarians to select safer sedation/anesthesia protocols. However, the debate remains regarding what screening tests are appropriate for an apparently “healthy” senior/geriatric dog or cat. That argument will not be solved in this article. The laboratory profiling and additional diagnostics, part of a simple program, a complex program, or something in-between, is a choice the practice decision maker will make early on. As stated earlier, what constitutes a minimum laboratory and diagnostic database is complicated and not easy to determine. While it would be nice to run all of the tests available, it is not practical or affordable for most clients. Fortunately, some compromise will be found based in the overall practice philosophy and the logistics of providing the testing, combined with the average client’s level of financial interest. A reasonable starting minimum database for the “healthy” older patient should include a complete blood count, biochemical profile with electrolytes, complete urinalysis (specific gravity, urine testing sticks, and urine cytology), fecal flotation, and heartworm and tick-borne disease testing in appropriate patients.8 The minimum senior feline database includes a complete blood count, biochemical profile with electrolytes, complete urinalysis (specific gravity, urine testing sticks, and urine cytology), fecal flotation, a total thyroxine, and feline leukemia/feline immunodeficiency virus testing in appropriate feline patients.9,10 Based on the incidence of Cushing disease and hypothyroidism in dogs, some practices routinely incorporate thyroid and adrenal screening in their senior/geriatric health care programs.8 Additional diagnostic testing is the final portion of the comprehensive health examination. While arguably not part of a minimum database of the healthy older pet, various additional diagnostics are commonly incorporated into many successful health care programs. Those supplementary diagnostic tests include an electrocardiogram, thoracic radiographs assessing the cardiac silhouette and the presence of a mass(s), abdominal imaging (radiography or ultrasound) for any organ abnormalities, blood pressure measurement in cats, and ocular tonometry in dogs. For a list of additional tests, access the latest AAHA Senior Care Guidelines.8 3. Review period
Once the comprehensive health assessment is complete and the results finalized, it is time to inform the caregiver of the findings followed but any short- and long-term action plans and timelines. A formal review period is the time where all the normal and abnormal findings are communicated to the owner in person or via phone, mail, e-mail, or some combination. Obviously that choice is a practice one. Given a choice, I have always promoted a “face-to-face” conversation. However, good news is very easy to convey with any
829
830
Fortney
method, while bad news in not. One of the advantages of pet-side laboratory testing is the rapid results turnaround requiring just a little extra time in the waiting area before receiving the review. In addition to a phone call, my family physician mails me a copy of my laboratory test results, a common practice in human medicine screening programs. The author suggests at least considering sending a copy of the laboratory results home with the owner. This value-added document can be shared with others in the home and the report often becomes part of the patient’s private medical record. Obviously sending the report alone will invoke additional questions and time, so sending a corresponding piece, “Understanding Your Pet’s Blood Work,” minimizes the questions and increases the perceived value of the tests.11 Good examples of this great continuing education tool can be found online. Regardless of how your practice elects to manage the review period, the author suggests that you provide a written evaluation (a health “report card”) of the pet’s summary health report for the owner to take home to share with any other caregivers and a copy for your medical records. It is commonplace to send home any appropriate client education materials used to help reinforce any health issues at home and distributed to the other home caregivers. To be optimally effective, this step must occur in a timely fashion and not several days later. Two common errors caregivers of older pets make are (1) failure to observe subtle changes in their pet’s activity or patterns and (2) assumption that nothing can be done about old age diseases. Regardless of the cause, the owner’s failure to inform the veterinarian of the early symptoms often results in a missed opportunity to help the pet when it could actually help the most. As the pet ages, each owner must assume an increasing responsibility for the overall health care of their pets. Our task as a health professional is to help our clients fulfill that role. One of the most important steps pet owners can take to keep their pets healthy is to become a better observer and reporter. By using educational tools including brochures and the practice’s website, and combining education with some training, most clients can be become an important member of their pet’s health care team. Their awareness of any change in their pet can be invaluable . . . only if they know what to look for. Recognition of even mild changes in a pet’s habits, activity patterns, behavior, weight, eating, or elimination patterns may be a signal that something serious is developing. While many other owners do observe many of those subtle symptoms and changes in behaviors in their older pet, sadly those observations are often misinterpreted as just part of “normal aging” and that “nothing can be done about the condition.” The owners failure to inform their veterinarian of the early symptoms usually results in a missed opportunity to manage the early condition when it could actually help the most. As a result, their pet continues to suffer from the lack of medical attention and care. Tragically after weeks, months, or years of suffering, the pet is finally presented to the veterinarian for euthanasia. Some examples of commonly assumed “just old age” conditions include inactivity (chronic pain, arthritis, or a systemic illness), bad breath (dental disease), decreased appetite (chronic pain, dental disease, or a systemic disease) decreased vision (cataracts), periods of disorientation or confusion (cognitive dysfunction syndrome), and early-morning stiffness (arthritis). The slowly progressive symptoms of osteoarthritis are commonly misinterpreted by the owner. They assume the dog or cat is just slowing down and not wanting to play as much due to an old age–related lack of energy. Even minimal education could alter many of these outcomes.
Successful Geriatric Care Program
The most common serious problems in older dogs include cancer, heart disease, kidney disease, liver disease, osteoarthritis, and cognitive dysfunction syndrome. In cats, cancer, kidney disease, heart disease, diabetes, and thyroid disease top the list. It is important for owners to observe the early warning signs of the most common life-shortening diseases in elderly pets. Equally important is that they report them to their veterinarian as soon as possible. Waiting for the next annual examination may be too late. A partial list of warning signs that owners should look for includes: • • • • • • • • • • • •
Changes in weight, especially weight loss Decreased appetite or inappetance Increased water consumption Changes in elimination patterns (urine or stool) New lumps or bumps or swellings, or changes in existing ones Persistent cough Difficulty breathing or breathing heavily or rapidly at rest Sudden collapse or bout of weakness Difficulty climbing stairs or jumping Foul mouth odor or drooling Seizure, convulsion, or fit Pain.
4. Short- and long-term action plans and a follow-up
During the review period, the clinician and the client need to formulate specific short and long-term action plans for each new problem identified. If no problem(s) are found, then continue the annual or bi-annual evaluations as scheduled. Either way, specific recommendations for diet, exercise, and dental care should be explicitly communicated. Dietary recommendations should be based on the health needs of the patient and not on cost alone. Those factors influencing the diet selection includes quality of ingredients, specific antioxidants shown to modify the aging process, and a research-based formulation. Any dental procedures, medication, therapies, retesting, or additional testing should be discussed and scheduled. Timely follow-up telephone calls and written reminders are essential components and critical in the overall success of any senior/geriatric health care program. A critical part of any follow-up is scheduling the next appointment prior to leaving the hospital if for a healthy patient. Setting a routine appointment time even if it is 6 months or 1 year later reinforces the program timetable. A standard practice policy of a phone call-back within 72 hours of the examination to discuss questions, concerns, medication issues, dietary needs, etc; it also sends an honest message of caring to the owner. Senior/geriatric health care reminders should not be vaccine and parasite related but rather focused on wellness and the advantages of health evaluations. While infectious disease preventatives are important, the emphasis is shifted to that of wellness and age-related disease prevention program and strategies. MAKING THE PROGRAM SUCCESSFUL
Obviously the professional rewards are proportional to the success of the program. And while success is never guaranteed, the 10 steps listed later may help you reach your program’s ultimate goals. A successful program requires a large tool box. Tools for client education, health data gathering and health reporting tools, patient diagnostic and management charts,
831
832
Fortney
plus program implementation tips are currently available for successfully implementing a senior/geriatric health care program in your practice. Reinventing the wheel is time consuming and can be frustrating. Veterinary articles and seminars are good sources of ideas and suggestions. One course of information is the earlier mentioned AAHA Senior Care Guidelines.8 Other sources of support are marketing tools, the products, and services various industries have available for old dog and cat health care. For example, IDEXX (Westbrook, ME, USA) can provide practices with advanced age-related in-house diagnostics and referral laboratory diagnostic services. In addition, they can also include some marketing and implementation tools necessary to make your program more successful. TEN STEPS TO MAKE A SENIOR/GERIATRIC HEALTH CARE PROGRAM SUCCESSFUL
1. The practice decision maker must be convinced that a senior/geriatric health care will become a significant asset to the practice before investing the time, energy, training, and resources necessary in developing and maintaining the program. However, because of the commitment necessary for success and growth, this program is not for every practice and— depending on the level of interest and finances—may not appeal to every client. Unfortunately, this is not a “build it and they will come” plan. 2. Convince the entire staff of the significant health benefits the program offers the senior pet. Critical to the success or failure of a senior/geriatric health care program is the involvement and buy-in of your staff. In fact, ownership of the program by every staff member is essential. Staff incentive programs will also help the senior/geriatric health care program patient base grow and maintain the program’s momentum. 3. Create a very specific and detailed program including age of onset, frequency of visits, scheduling periods, fee structure, educational materials, and marketing strategies. Decide exactly which tests are to be included in the program. Finally, ensure every member of the staff is “program proficient” and can sufficiently understand the particulars. 4. Convince the owners of the significant health benefits the program offers their aging pet. A percentage of your practice (ie, the “A-list caregivers”) will readily accept the program, but the rest will need repeated convincing. Increased client knowledge usually equates to increased client acceptance and compliance. Early and persistent owner education is a long-term investment in a senior/geriatric health care program. 5. A well-designed market strategy correlates with success. Use newsletters, reminder cards, invoices, telephone directory ads, Web pages, and social media to educate your current and prospective clients on age-related problems and solutions. Client marketing efforts should emphasize all the advances in veterinary medicine including newer diagnostic testing, improved anesthetics and anesthetic monitoring equipment, behavioral drugs, newer arthritis therapy options, leading edge cancer chemotherapy, more effective cardiac medications, dental care, and nutritional advancements that are available. 6. Bundle the fee structure to include a senior pet discount. Discount the fee for all the services and also consider a cost reduction in the senior diets for any patients already on the program. 7. Start slow and be patient and the program will grow. A senior/geriatric health care program is a long- term hospital investment. It is much easier to add a test and expand the program than take one away because the cost was considered
Successful Geriatric Care Program
excessive for the average owner. Unfortunately, an overzealous program coupled with underdelivery of value is commonplace. The seeds of program success and client subscription actually begin when outlining a life-long preventive health care program the first time a new owner visits the practice, even for puppies or kittens.5,12 8. Since a comprehensive health examination will require more time in the exam room, try to schedule these appointments during slow days or during periods of the day when you can devote the time necessary for a complete evaluation. 9. An attractive 3-color trifold brochure for your practice’s program is an easy and time-saving marketing tool. The brochure should be uniquely branded to your practice. Highlight the specifics of your program (age of onset, visits per year, etc), but keep the piece simple for an easy read. Emphasize the advantages of the health program to the older pets and the early warning disease signs to watch for. 10. Periodic program review by your clients and staff is essential in maintaining the consistently high standard of care you have established for your senior patients. Do not be afraid to modify the program to meet the emerging minimum database protocols. SUMMARY
A senior/geriatric care health program is a more inclusive wellness program than those recommended for all healthy “adult” pets. Older dogs and cats have a different set of needs and challenges than when they were younger. Aging in animals is similar to aging in people except at an accelerated rate. To offset this faster aging process and increased “time compression” and to detect potentially serious conditions at the earliest stages, most progressive small animal practices are now recommending examinations every 6 months even with healthy senior/geriatric dogs and cats. Initially, the program starting at around 7 years of age for both species is commonplace. Comprehensive health evaluations, including senior profiling, allow veterinarians to more successfully diagnose and manage an early condition. The detection of underlying diseases also impacts pharmaceutical selections and chronic drug monitoring. In addition, the routine laboratory evaluation supports safer sedation/anesthesia protocols. REFERENCES
1. Mosier JE. Effect of aging on body systems of the dog. Vet Clin North Am Small Anim Pract 1989;19(1):1–13. 2. Goldston RT, Hoskins JD. Geriatrics and gerontology of the dog and cat. Philadelphia: WB Saunders; 1995. 3. Fortney WD. Declining physiological reserves: defining aging. Nestle Purina Companion Animal Nutrition Summit Proceedings, March 2010. Available at: http:// breedingbetterdogs.com/pdfFiles/articles/CAN2010_updated.pdf. Accessed April 10, 2012. 4. Metzger FL. Senior and geriatric care programs for veterinarians. Vet Clin North Am Small Anim Pract 2005;35(3):743–53. 5. Hoskins JD, McCurnin DM. Geriatric care in the late 1990s. Vet Clin North Am Small Anim Pract 1997;27(6):1273– 84. 6. Epstein M, Kuehn NF, Landsberg G, et al. AAHA senior care guidelines for dogs and cats. J Am Anim Hosp Assoc 2005;41:81–91. Available at: https://www.aahanet.org/ PublicDocuments/SeniorCareGuidelines.pdf. Accessed April 10, 2012. 7. Fortney WD. Interpretation of baseline testing in senior patients. DVM InFocus, Sept 2007.
833
834
Fortney
8. AAHA senior care guidelines for dogs and cats. Available at: https://www.aahanet. org/Library/SeniorCare.aspx. Accessed April 10, 2012. 9. Rebar A, Metzger F. The veterinary CE advisor: interpreting hemograms in cats and dogs. Vet Med 2001;96(Suppl 12):1–12. 10. American Association of Feline Practitioners/Academy of Feline Medicine. Panel report on feline senior care. Available at: http://www.aafponline.org/about_guidelines.htm. Accessed April 10, 2012. 11. Purdue University College of Veterinary Medicine, Small Animal Clinic. Understanding your pet’s blood work. Available at: http://www.vet.purdue.edu/vth/SACP/documents/ understandingyourpetsbloodwork.pdf. Accessed April 10, 2012. 12. Rucinsky R. Implementing a geriatric wellness program. Proceedings of The Central Veterinary Conference; Baltimore (MD), April 2009. Lenexa (KS): Advanstar; 2009.