Historically, veterinary personnel reacted to existing problems in older animals by waiting until owners elected to seek professional help for their pets, often only once the disease signs were overt or the condition no longer tolerable (Fortney, 2004). Even with overt signs of clinical disease, some owners were still reluctant to bring their pets into the veterinary practice as it was assumed that this was just old age and hence could not be treated or that euthanasia would be the only option available. However the availability of medical information on the internet and television has made interested animal owners much more aware of the health needs of their senior companions. Clients usually form very strong bonds with their ageing pets, not surprisingly as they are likely to have owned them for many years. Such investment in the bond means many owners are demanding and willing to pay for high quality senior health care. The continued advancement of medical knowledge manifested in the availability of more sophisticated diagnostic testing, advances in specialised nutrition, and newer therapeutic options, along with education regarding early warning signs of disease and routine screening for age-related disease has better positioned veterinary professionals to treat age-related problems and provide the high quality health care these owners are demanding (Fortney, 2004).
These factors have led to practices having more elderly patients admitted into their care. Veterinary nurses readily advise clients about the additional needs of elderly animals at home, however they must be careful not to neglect to apply such recommendations to these same animals when they are admitted into the practice and are under their care.
Elderly patients may be diagnosed with various and often multiple conditions which may require medical and/or surgical management. Elderly patients must be treated with extra care; they are less able to adapt to change and they recover more slowly from medical or surgical interference
Admitting the elderly inpatient
Comprehensive histories are especially critical in senior medicine. Detailed information including decrease or increase in food or water consumption, alterations in bodyweight or activity level and behavioural changes are all important pieces of information. Owners are in a unique position to note subtle changes in daily routine, but may not offer such information unless prompted.
It must be remembered that patients may be suffering from diseases other than those for which they have been admitted so concurrent disease and medications must be ascertained. On a busy ward it is easy for veterinary surgeons and nurses to become enthusiastic about treating a particular condition, only to overlook the fact that the patient is also supposed to be receiving medication for a cardiac condition, a prescription diet for chronic renal disease, eye drops for keratoconjunctivitis sicca, and so on (Urquhart, 2001). Hopefully this situation appears to the reader as totally unacceptable nursing care — the reader may however be surprised at the frequency of its occurrence.
Key nursing considerations for the ageing inpatient will now be discussed.
Sensory impairment
Some degree of visual or auditory impairment is likely to be present in ageing animals and while such animals may function quite normally in a protected environment such as the home, the unfamiliar and confusing surroundings of a veterinary practice may lead to nervousness or signs of aggression. Careful owner questioning is essential to determine the pet's normal routine at home; this should be facilitated within the hospital environment as far as is possible. Patients with sensory impairments will need gentle handling; talk constantly to the patient and handle it slowly and gently. Ensure patients with reduced hearing can see any approach or gently tap on the side of the kennel to create vibrations if they are facing away from the front. For patients with reduced vision, talk slowly but constantly to the patient as they are approached. A harness or short lead should be used to guide the patient through doorways and during exercise. Small alterations in nursing actions can create a much more relaxed and hence amenable patient. While such actions may mean patient assessments take a little longer, they will have a big impact on the patient's wellbeing.
Appetite
The elderly patient is quite likely to be fussy about what it eats. The owner must be questioned regarding what the pet is normally fed, the quantity, frequency, likes and dislikes, and this information must be displayed so that all staff are informed — such information becomes useless if only one staff member is aware of it.
Pay close attention to how the senior patient responds to food; lack of interest in food is rarely due to true anorexia. Smell and taste sensation are reduced in ageing patients, and with elderly feline patients in particular this may lead to a lack of appetite. Feeding highly aromatic diets and warming food to body temperature before serving will greatly enhance palatability. Consideration must be given to the presentation of the food; smaller more frequent meals may be more appealing to the elderly inpatient. Older animals, particularly cats, may not like to put their face into a small bowl to eat and may therefore eat more enthusiastically if food is placed onto a flat dish (Figure 1). Some animals, again cats in particular, are social eaters hence may eat more readily if a person is present to provide attention at meal times. Nutrition and fluid requirements will be discussed in the second part of this article.
Periodontitis is also common in elderly patients, so it is essential to perform an oral examination paying close attention to both the teeth and gums in patients refusing or having difficulty with food (Figure 2). Gingivitis, ulceration and damaged teeth are all likely to cause inappetence in a patient. It is remarkable how often appropriate treatment for these oral problems leads to a marked improvement in appetite, activity and overall quality of life.
Thermoregulation
Normal thermoregulatory mechanisms are controlled by the hypothalamus, which initiates vasomotor or metabolic responses to maintain core body temperature within a narrow range, despite widely varying environmental temperatures (Cabell et al, 1997). Ageing animals have decreased thermoregulatory capacity thus may be more heat or cold seeking dependent on the season and the ambient temperature. Regular monitoring of body and environmental temperatures is therefore essential and appropriate and safe forms of heat or cooling systems should be utilised accordingly.
Mental status
Ageing dogs and cats often suffer a decline in cognitive brain function. Cognition, broadly defined, refers to mental processes such as perception, awareness, learning, memory and decision making. Cognition allows the animal to take in information about the environment, process, retain and make decisions on how to act (Shettleworth, 2001). The ageing patient may therefore be less mentally alert which can make them appear as stubborn or withdrawn. Such patients benefit greatly from time, effort and social interaction as this can often reveal the true character of the animal that is prone to ‘switch off’ for periods of time (Urquhart, 2001). It is important to note that behavioural signs can be caused by a number of different medical conditions, which must be differentiated from cognitive dysfunction. Animals suffering from cognitive dysfunction may be especially confused and distressed when taken away from the familiarity of their home surroundings. Careful owner questioning is required regarding the animal's general mental status; does it respond well to commands, does it only respond to certain commands? Disorientated pets do not adapt well to change which makes them difficult to nurse in the practice environment. In some cases it may be pertinent to question whether the pet could be effectively nursed at home, even if their condition would normally warrant admittance to the practice. If animals are to be admitted to the practice, it is essential to ensure there is a balance between mental stimulation interspersed with periods of rest. Elderly animals tend to have frequent naps, and may be irritable if their sleep pattern is disturbed; it is the job of the veterinary nurse to ensure that the animal's environment is conducive to rest wherever possible. Familiar blankets or beds are appreciated by many older animals and facilitating this wherever possible should be considered another way of minimising stress (Figure 3).
The environmental use of synthetic pheromones (pheromonatherapy) may improve the demeanour, appetite and ability to adapt to the stresses that a strange environment can cause to ageing patients. Both canine and feline versions are available and their use should be considered in the hospital setting.
Use of therapeutic agents
With advancing years there are important interrelationships between the loss of physiological reserve due to ageing changes and the result of previous trauma or disease, the effects of any disease present and the effects of drugs being administered (Davies, 2010).
Age-related changes include a reduction in total body water and lean mass, with increased body fat, which increases the concentration of drug in body fluids, and increases concentration and prolongs elimination of fat-soluble drugs. Lipophilic drugs, such as some anaesthetic agents, will be distributed more to body fat and less to plasma, altering their effects and rate of elimination. Reduced serum albumin results in an increased free fraction of protein-bound drugs in the blood (Davies, 2010). As many elderly pets will have some reduced liver mass and hepatic blood flow, this can effectively reduce first pass metabolism and so decrease the rate of biotransformation of some drugs which may prolong activity.
Changes to kidneys including a loss of renal reserve, combined with a loss of functional nephrons and reduced glomerular filtration rate, will reduce drug elimination rates, which may prolong drug effects and lead to drug accumulation (Davies, 2010).
Nies (2001) suggested that overall the risk of adverse drug reactions may increase by three to sevenfold as patients get older. Because of the underlying changes in many elderly animals and the effects such changes can have on drug metabolism, it is important to fully evaluate each patient and select therapeutic agents which are the safest for the patient (Figure 4). As ageing patients are likely to have concurrent disease, veterinary nurses need to be aware of the effects of polypharmacy and monitor patients closely for adverse drug interactions (Wolf, 2006).
Tender loving care
While it is certainly not acceptable, it is perhaps understandable that in a busy veterinary practice, the ‘tender loving care’ aspect of nursing is sometimes overlooked. However, despite staff and time limitations, this is undoubtedly one of the most important aspects of nursing care. As discussed, elderly inpatients are often frightened and confused so need that little bit of extra care more than ever; these patients really do need, and benefit greatly from, a little bit of extra care and attention compared with younger patients. Remember elderly patients are generally the patients that are less able to compensate for any shortfall in nursing care; that little bit of extra attention might just help identify why the patient is withdrawn, inappetent and so on (Urquhart, 2001).
Conclusion
Ageing animals are less tolerant of a busy hospital environment and changes to their daily routine. Acclimatisation to a busy and noisy ward therefore may take them a little longer than younger, more out-going patients. Veterinary nurses play a pivotal role in helping to make their stay as stress free as possible, providing quality, individualised patient care and acting as vocal advocates for the ageing patient that requires a little more tender loving care.
Part two of this article will discuss ageing of individual body systems and consider their specific nursing requirements.