We all want to help our patients enter the third act of life gracefully, but what exactly does that mean and how can it be achieved? This is an area where our colleagues in human medicine have traditionally better defined the needs of an ever-growing senior population. Gerontologists take into consideration the biological, physiological, and psychological changes that occur with aging. An entire specialty devoted to the care of the human geriatric patient clearly illustrates the need for an alternative approach to the mature human population. There is greater awareness of steps we can take in middle age to improve our physical and cognitive health. We all want to do what is necessary to hurt less, move more, and stay sharp later in life. This focus on helping humans age well helps us support the pets in our care. By drawing parallels to ourselves, we help clients see the need to take steps now to ensure their pet is in excellent shape later in life. Over the past four decades, dog life expectancy has doubled and house cats are living twice as long as their outdoor counterparts. Armed with these facts, it is time to devote significant consideration to the maturing patient. Repositioning wellness examinations The first step toward helping the aging pet is to get them through the door on a regular basis. We can’t help what we can’t see, so wellness programs are the key to compliance. Ideally, this starts twice yearly at puppyhood or kittenhood. Aging for pets is not like flipping a switch. Different breeds of dogs age at different rates. They don’t suddenly become geriatric just because they hit an arbitrary age number. Confusion is created by having an “age cutoff” for mature patient exams. This leads to a lack of consistent staff-to-pet owner communication and client dissatisfaction. For example, the owner of a seven-year-old Chihuahua will not appreciate being told their dog is a “senior.” The American Animal Hospital Association’s (AAHA’s) 2012 Canine Life Stages Guidelines recommends defining life stages, rather than ages (Joe Bartges, 2012). According to the guidelines, life stages should be delineated as follows: puppy, junior, adult, mature, senior, and geriatric. Because standards are necessary for any functioning veterinary hospital, age delineation is required. This can be far more accurate than just claiming “seven years” to be the magic number for an aged dog. Most human publications denote ages for the following life stages: youth—less than 18 years; young adult—18 to 35 years of age; adult—36 to 55 years of age; and senior—56 years old or older (geriatric is more a question of frailty than age). The American Kennel Club (AKC) provides the chart to the right on its website (bit.ly/2vV4vpF): Taking the human life stages and AKC chart into consideration, the chart below is an example of how life stages can be more accurately defined for the veterinary patient: Utilizing these life stage examples, a wellness program can be crafted to better meet the needs of the patient based on age and adult size. The age at which screening laboratory testing should begin is another point of discussion. What is the magic age where lab work becomes useful? Some contend it is always useful and it is always justified. Beginning annual wellness lab work when the patient is a young adult trains the client to expect testing… every year. The argument that normal screening tests aren’t valuable is debatable. Not only is a patient baseline incredibly useful, but in rare instances, early indication of disease is caught at the treatable stage. Even if n=1 for catching that early indication of disease, it’s worth it. Lab work prior to sterilization procedures in puppies is usually recommended. Why, then, wouldn’t we continue to follow these tests over the patient’s lifetime? Life stage-focused examinations Beyond the usual nose-to-tail physical examination that should accompany any wellness visit, life staging allows the practitioner to create a “wellness focus” based on common conditions seen during that period of a pet’s life. That’s not to say the practitioner should skip other parts of the exam or fail to mention, for instance, nutrition or dental health at every visit. Far from it. Wellness focus is simply a framework to ensure bits of history and physical clues are investigated thoroughly during the course of a normal visit. This framework might give clues that would indicate the patient is suffering from the most common medical or behavioral issues for that life stage. It also ensures detailed communication from the veterinarian to the pet owner about the “focus” topics. There is a theology of sorts in the business world that clarifies business goals and trajectory. That doctrine is to “select, focus, and simplify.” This can also be applied to the veterinary hospital. We have all practiced under pressure to see our patients in less and less time. Fifteen-minute appointments are now a “thing.” In this environment, it’s easy to miss something. Focused examinations based on life stages help avoid patient problems slipping through the cracks. The following are examples of examinations based on taking a life stage approach: 1) Puppy/youth: focus on disease/parasite prevention, safety (e.g. avoiding toxins [xylitol, chocolate], not using retractable leashes), behavior, and home dental care, which sets the pet up for a lifetime of health 2) Young adult: focus on safety, nutrition, behavior, and dental care 3) Adult: focus on orthopedic issues, dental care (because that conversation should happen during every visit), cognitive decline, and weight management 4) Senior: focus on orthopedic issues, brain aging, dental care, and pain Dogs don’t get dentures You may notice dental care is a focus for every life stage. This is not by accident. With periodontal disease affecting more than 80 percent of dogs and 70 percent of cats over the age of three, this is the most common condition veterinarians see in patients young and old alike. Although you may be discussing dental care at every life stage, the focus of these conversations will be different. The puppy exam sets the client expectation that dental care is important and includes home dental care and professional cleanings. Moving onward in age to the young adult and maturing adult patient, the conversation shifts slightly to ongoing home care with annual professional cleanings. But what do you say when you see the senior patient? Is there an age where the senior patient is “too old” for a professional dental cleaning? If you’re guilty of telling a client their pet is too old for anesthesia or too old for a dental, you aren’t the only one. That needs to stop, though. Dental disease is a source of pain and suffering. There is no such thing as “too old.” Not only that, but age is not a disease. Most dental specialists will tell you the vast majority of their patients are elderly. More than almost any other condition, dental disease negatively impacts patient quality of life. Turning a blind eye to that pain and discomfort simply because the patient is “old” is not the solution. Beyond the dental procedure itself, what is your process for educating your client about home dental care? Are you sending the owner of a puppy out your door with a toothbrush and a pamphlet on brushing? Or does the post-dental cleaning patient leave with a bag of chews and a sample of toothpaste? Neither scenario is likely to result in ongoing client compliance, which is one of the biggest obstacles facing the veterinary patient. FYI: dentistry is at the top of the noncompliance list. So why do we continue to do the same thing and expect a different result? Consider packaging your dental procedure with a home care product that facilitates improved client compliance. This may include water additives, food additives, and monthly shipments of enzymatically treated chews. These are helpful in addition to the recommendation to brush. The Veterinary Oral Health Council (VOHC) is an independent organization that reviews research. Recommended oral health care products for dogs and cats appear on its website (vohc.org). Consider choosing your products from this list and pay attention to those that are user-friendly to encourage client compliance. Stay ahead of the pain As the patient enters adulthood and beyond, osteoarthritis (OA) and other orthopedic woes should be a life stage-focus. Osteoarthritis is the most common form of rheumatic disease in humans and dogs, affecting approximately 25 percent of the canine population. OA affects close to 50 percent of the human population older than 65 years of age, according to the Centers for Disease Control and Prevention (CDC). With this in mind, all adult canine patients should undergo a gait analysis at the beginning of the examination. This simple task is an overlooked tool in the examining veterinarian’s armamentarium. Because forced plate analysis studies aren’t readily available, simply watching the patient ambulate can facilitate detection of subtle gait abnormalities. Much like trotting a horse during a lameness examination, watching the aged canine patient ambulate should be considered standard of care. Palpation of joints for range of motion and evidence of discomfort, as well as careful evaluation of muscle mass for atrophy, are also part of a thorough orthopedic examination. If evidence of OA exists, treatment is best approached in a multimodal fashion. Talk to your client about weight reduction; physical therapy and exercise; and pharmaceutical and nutraceutical intervention. There is a wide range of pharmacologic and nutraceutical interventions available for the dog with OA. Anti-inflammatories and glucosamine products are the cornerstone of treatment. Although it may seem like one joint supplement is as good as the next, recent human and animal studies1-3 showed supplements containing the novel ingredient undenatured type II chicken collagen (UC-II) indicate better results compared to the combination of glucosamine and chondroitin alone and at least as beneficial as an NSAID in alleviating mild to moderate osteoarthritis pain. UC-II exerts joint health benefits via oral tolerance, thereby initiating anti-inflammatory and cartilage protective pathways that prevent the immune system from damaging its own joint cartilage. Almost like a “reverse vaccination,” UC-II teaches the immune system to stop attacking the free collagen in the injured joint. Preventing the ongoing cycle of damage caused by joint inflammation is helpful for not only the OA patient, but the one predisposed to it, too. Like the cavalier King Charles Spaniel receiving omega-3 fatty acids from a young age due to breed disposition for myxomatous mitral valve disease, the young Labrador or German shepherd may benefit from early joint supplementation. Moving up the “age ladder” to the “senior” or “mature” veterinary patient, the life stage-focused examination should include the patient’s cognitive health. Clients tend to consider evidence of cognitive decline as normal or expected, and often fail to volunteer that information during the veterinary visit. How often have we heard, “He’s just getting older…”? This happens because pet owners don’t know they have options to slow this natural decline. Cognitive changes remain underdiagnosed and undermanaged conditions in the aged veterinary patient. Historical questions are vital to the treatment of the whole patient. A thorough aged patient history should include open-ended questions about nighttime waking, confusion, storm anxiety, separation anxiety, house-soiling, and restlessness. The mature Labrador who has always gone upstairs at night to sleep in the kid’s bedroom, but hasn’t done so in the past three to six months describes a point of significant history. Is he painful? Is he confused? Is he anxious? Only with a thorough history that asks the right questions can we begin to get the full picture of our patient’s cognitive health. Therapeutically approaching the cognitively declining patient includes a combination of nutraceuticals, pheromones, and pharmaceuticals. Omega-3 fatty acids and products containing resveratrol, ginkgo biloba extract, and vitamin E have been shown to improve brain aging in dogs. S-adenosyl-L-methionine (SAMe) has traditionally been used for hepatic dysfunction in dogs and cats. It may also help maintain cell membrane fluidity, receptor function, and the turnover of monoamine transmitters, which is helpful in cases of cognitive dysfunction. SAMe deficiency is a characteristic of human Alzheimer’s disease patients. Dog appeasing pheromone (DAP) and the feline F3 facial pheromone help support the aging patient. Pheromones comfort and reassure a pet experiencing anxiety and stress from the physiological condition of aging, as well as cognitive decline. Pharmaceutical intervention with medications such as selegiline hydrochloride can be beneficial for cognitive dysfunction. Dopamine is a key neurotransmitter in the brain. Human studies link decreased dopamine levels to impaired cognitive dysfunction. A selective inhibitor of monoamine oxidase B (MAO-B), selegiline blocks the breakdown of dopamine, helping to regulate cognitive brain functions. If aging gracefully is an art, veterinarians are the artists. In art, as in life, creating a masterpiece takes time and thoughtful care. The great masters understand how every brushstroke and layer influences the next. Like them, veterinarians must consider how our actions at every life stage affect the next one. Keeping that thought in mind ensures our success in painting a comfortable, happy, and healthy picture for the aging pet. Susanne Heartsill, DVM, is veterinary services manager at Ceva Animal Health. She is a passionate advocate of the human-animal bond, and the mother of two (human) daughters and numerous four-legged children. Dr. Heartsill’s areas of interest include parasites, zoonotic diseases, and minimizing their impact on the human-animal bond. In 2018, she joined Ceva where she hopes to make a global difference for companion animals and their humans. References 1 Lugo, J.P., Saiyed, Z.M., Lau, F.C. et al. Undenatured type II collagen (UC-II) for joint support: a randomized, double-blind, placebo-controlled study in healthy volunteers. J Int Soc Sports Nutr 10, 48 (2013). https://doi.org/10.1186/1550-2783-10-48 2 Stabile M, Samarelli R, Trerotoli P, et al. Evaluation of the Effects of Undenatured Type II Collagen (UC-II) as Compared to Robenacoxib on the Mobility Impairment Induced by Osteoarthritis in Dogs. Vet Sci. 2019;6(3):72. Published 2019 Sep 4. doi:10.3390/vetsci6030072 3 Comparative therapeutic efficacy and safety of type-II collagen (UC-II), glucosamine and chondroitin in arthritic dogs: pain evaluation by ground force plate. Gupta RC1, Canerdy TD, Lindley J, Konemann M, Minniear J, Carroll BA, Hendrick C, Goad JT, Rohde K, Doss R, Bagchi M, Bagchi D.
