How to nurse the geriatric patient

Veterinary nurses (RVNs) will come into contact with a vast range of patients during their daily working lives, ranging in size, species, and age. It is important, therefore, that they are aware of the best way to provide nursing care for their geriatric patients, and that they understand the difference in nursing care requirements of these patients and how ageing can affect the nursing process for older feline and canine companions. The age at which a patient is considered ‘geriatric’ varies from breed to breed in dogs, whereas all cats tend to follow a similar species life-ageing process. The larger the dog the shorter the life span, for example, a Great Dane or Bernese Mountain Dog would be classified as geriatric around the age of 7–8 years old; whereas smaller breeds, such as a Jack Russell Terrier or Border Terrier would be classed as geriatric at around the age of 9–10 years old (Mansourian, 2019). The average domestic feline patient is considered mature at around 7–10 years old, and then progresses into their senior years from 11 years onwards, finally entering the geriatric life stage at over 15 years old (ISFM, 2019).

However, it is important not to label a patient as geriatric based on their age alone. After all, age is only a number and ageing is an individual process whereby each patient should be assessed on their own individual merits (Figure 1); performing medical examinations and further tests, such as blood pressure measurement and bloodwork examination to assess liver and kidney function, will help to determine how the ageing process has had an effect on the patient.

When delivering nursing care to geriatric patients, the RVN should be mindful of the use of nursing care models, and implement a care plan to ensure that the patient receives the ‘gold standard’ care they deserve. During the ageing process, the patient's body and its functions start to slow down. It is extremely important that RVNs are able to recognise and understand this process, and how this effects the overall health and wellbeing of patients. As the patient ages, this has a profound affect on the ‘parameters’ measured on ’The Ability Model’ as there is a huge difference between the daily needs or requirements of a young or adolescent patient, compared with those of a geriatric, e.g. assistance with mobility, assistance with grooming, additional bedding to keep warm or to prevent pressure sores from occurring (Figures 1 and 2). It is also important that clients/owners have an understanding of the senior life stage their companions are entering, as they may need to make living adjustments to help with their daily life. Owners must also be aware that with older age comes the increased risk of age-related health complications and chronic disease; nursing clinics for geriatric patients can be a huge benefit during this phase to monitor the patient's current health status and provide one-to-one support for owners (Ackerman, 2012). It has been recommended that geriatric patients would benefit from frequent check-ups, along with performing monitoring techniques such as blood and urine testing, blood pressure checks and potential imaging, should further investigation be required (Sturgess, 2014).

It is of great importance that veterinary professionals honor and protect the human–animal bond, as the client's companion animal is commonly deemed a central part of their family and daily life. Therefore, when dealing with geriatric patients that may have a chronic or life-long illness, nurses must be empathetic and supportive towards clients, while maintaining a sensitive approach to the patient's quality of life (Dawson, 2008). It can be common for clients to delay bringing their geriatric companion to the surgery, out of fear that they will be diagnosed with a serious or life-limiting condition.

The ageing process

The ageing process is a normal and natural phase of life, however it is also a progressive and an irreversible process occurring throughout the entire body. Ageing is a genetically determined process and when these so-called ‘ageing genes’ become activated, they begin to slow down some of the processes that are essential for life. For example, special senses such as hearing and sight can become impaired, renal atrophy and decreased glomerular filtration rate can occur, along with a loss of cognitive brain function (Goldston and Hoskins, 2004).

Looking at the patient as a whole being, the ageing process has an effect on all major body systems, from the skin through to the renal, endocrine and nervous system (Table 1; Figure 3). As the body ages, symptoms such as increasing levels of stiffness and loss of elasticity can occur throughout the body's connective tissue. Cellular changes will also occur, for example, within the immune system. This may decrease the immune system's functionality, potentially making it more difficult for the patient to fight off infections, alongside a decreased ability of phagocytosis due to metabolic changes (Goldston and Hoskins, 2004).

As cells naturally age throughout the ageing process, cellular activity decreases and they lose their ability to divide, renew and produce new healthy cells (Culshaw, 2010).

Metabolic changes naturally occur with ageing, where the body's metabolism slows down, and this can have a profound effect on the homeostatic maintenance within the body. Homeostasis is the process by which the body maintains its internal environment within specific physiological limits. In the geriatric patient, homeostasis can become altered due to the decrease in metabolic rate, cellular function and the poor response of the cells (Kerrigan, 2013).

Throughout literature, many ageing theories have been discussed and researched. The ageing process is a genetic feature within the body, however, there are other factors to consider, such as the influence of free radicals. Free radicals are produced from normal cellular metabolism, some foods/diets, pollution and radiation. Within the realms of the ageing process, the free radicals are produced from cellular metabolism as mitochondria become less efficient in energy production. Free radicals are highly ‘unstable’ molecules that are reactive within the body and ultimately cause oxidative damage to cells (Glennon, 2010). The free radicals damage cellular membranes, leaving the cell's DNA, lipids and proteins vulnerable to further damage; this process will lead to cell damage, cell death, and cell mutation, which may lead to the formation of neoplastic cells (Weeth, 2015). Some veterinary diets and supplements prescribed for geriatric patients contain enzymatic (catalase (CAT)) and non-enzymatic (vitamins A, C and E) antioxidants to combat this process, and to also help boost the immune system.

Nursing care

An understanding of how the ageing process can affect the patient's body will assist RVNs in creating an individualised patient care plan should the patient become hospitalised. Developing a patient care plan for a geriatric patient allows the RVN to identify areas of the patient's health that require regular monitoring, treatment, investigation and nursing assistance (Orpet and Welsh, 2011). The author strongly recommends using The Orpet and Jeffery Ability Model of veterinary nursing to create a patient care plan (Figure 2) (Orpet and Jeffery, 2007). The Ability Model addresses 10 of the patient's vital ‘functions’, which encourages a holistic patient approach, considering their individual daily needs. During the creation of a patient care plan, each of the 10 activities of daily living (ADL) should be thoroughly addressed in a methodical pattern using the following four steps:

• Assessment — this can be performed in the hospital if the patient has been hospitalised for a duration of time; however, if the patient is just being admitted into the hospital, it provides a really good opportunity to ask the owner to complete a questionnaire covering the 10 ADLs including finer details such as ‘what type of food do they eat’ and ‘do they have toileting commands’. This will provides the veterinary nursing team with good background information and an understanding of the patient's current health status.
• Planning — the information gathered from the assessment can be used to set goals for the patient as a result of nursing interventions. It enables the veterinary team to plan what interventions are needed to meet these goals and prioritise what order they need to be done in.
• Implementation — this phase involves delivering the care and documenting the nursing care as it is provided.
• Evaluation — this is a vital part of the nursing process and care plan to ensure that the best, evidence-based care is being provided for the patient, and that the interventions are working for the patient. If the patient did not respond well to the nursing interventions put into action on the care plan or the care plan simply did not work, the nursing process repeats itself with further assessment to determine the next best step to take (Orpet and Welsh, 2011).

Once a patient assessment has been performed and a care plan created, the RVN can begin to implement nursing care and interventions to maximise patient comfort and wellbeing throughout their hospitalisation period. Care plans are not exclusively useful for within the clinical hospital setting, they may also prove beneficial for addressing the patient's needs at home. Owners can use the information gained from a care plan to make changes or adaptations at home (Kerrigan, 2014) to improve the patient's day-to-day quality of life (Figure 4).

There are many factors to consider when delivering nursing care to a senior or geriatric patient. Geriatric patients are going to be at a much higher risk of having developed chronic diseases, with some of the most common diseases including osteoarthritis, endocrinopathies and neoplasia. Kerrigan (2013) has stated that hospitalised geriatric patients must be treated with extra care, for example during handling or restraint, especially if they are to undergo surgical or medical treatment; for each 5 years of our companion animal's life, allow an additional 24 hours to recover. Addressing each and every age-related condition in-depth is be-yond the remit of this article. However, it is possible to identify some of the major elements of geriatric health and consider how nursing care can be adapted for their management.

Alimentary tract

The special senses of smell and taste can be decreased in elderly patients, so they may require special diets and foods that smell nice to encourage eating (Kerrigan, 2013b). They may exhibit ‘fussy’ behaviours towards food; it would be of huge benefit to ask the owner what foods the patient prefers to eat, especially if they are to be kept hospitalised. With the potential for reduced appetite in geriatric patients, diets have been formulated that are more palatable and are highly digestible, which is beneficial because of the decrease in digestive function (Sturgess, 2014).

Periodontitis can be a common problem throughout the senior years, so it is vital to examine the patient's mouth, especially if they are struggling to eat. Inappetence is a cause for concern for geriatrics, particularly if they have a chronic illness, as this can lead to dramatic weight loss. Daily weighing of the patient will prove beneficial to monitor weight loss — make sure to keep regular records of the patient's weight on their hospitalisation records to track changes (Goldston and Hoskins, 2004).

It has also been suggested that geriatrics have a reduced sensitivity to thirst (Goldston and Hoskins, 2004), therefore it would be beneficial to measure fluid intake and monitor for dehydration. Intravenous fluid therapy may be required to support vital organs, such as the kidneys, during periods of dehydration and especially if the patient has chronic kidney disease (CKD) (Aguirre, 2012).

Musculoskeletal system

The geriatric patient often presents with loss of muscle mass, generalised weakness, stiffness, reduced range of motion and commonly, suffer with some degree of osteoarthritis (Imrie, 2016). Comfy, padded bedding and mattresses are essential for the hospitalised geriatric patient to maximise patient comfort, which may assist in promoting rest and sleep (Figure 5). Frequent checks of boney prominences should be performed to check for signs of decubitus ulcer formation and other areas that may benefit from applying a barrier cream to prevent sores (Orpet and Welsh, 2011).

Shallow or level litter trays will assist senior felines in toileting, especially if mobility is an issue as some litter trays have high edges. Encouraging short but frequent walks, exercise or mobility will help alleviate stiff, arthritic joints, promote good circulation, along with providing regular toilet breaks for canine patients. It is also beneficial to provide senior feline patients with opportunities to stretch their legs and walk around for the same reasons, perhaps by giving them space in an empty consultation room. There is a wide range of analgesic medications, supplements, prescription diets and physiotherapy regimens available to assist in the management of osteoarthritis, and these can be discussed with owners. RVNs should be very mindful of the varying degrees of musculoskeletal pain when handling and restraining a geriatric patient. Gentle handling in a comfy position, on a comfortable surface is absolutely necessary for all geriatrics. When performing examinations or inserting an intravenous cannula, be extra cautious and use delicate, gentle pressure when handling and restraining limbs (Figure 6).

Immune system

As mentioned, alongside the decrease in cellular function, there is a decline in the functionality of the immune system. This predisposes the patient to increased morbidity and mortality related to infection, and it also increases the susceptibility of patients to infectious diseases. It is thought that geriatric patients are at an increased risk of wound infections, however, this is most likely due to metabolic anomalies with concurrent pathological diseases such as endocrinopathies (Goldston and Hoskins, 2004). With the potential for increased patient infections, it is always beneficial for the RVN to practice excellent standards of infection control and aseptic techniques during nursing interventions.

Sensory organs and mental status

As patients age, they may lose their ability to smell, hear or see properly; this can lead to odd or ‘out of character’ behaviour such as nervousness or aggression. The owners may report that they are bumping into walls or furniture at home, or they are not so responsive to their name or commands. When nursing patients with visual or auditory impairment, it is crucial to take time and to be gentle when approaching them, especially when they are in an unfamiliar hospital environment (Kerrigan, 2013). Keeping the kennel environment and set-up consistent may be beneficial also, for example, keeping food, water bowls and litter trays in the same place for hospitalised patients. Deaf patients can be a little difficult to approach; however, it may help to tap gently on the kennel door, as this can create a vibration, alerting them of your presence.

Geriatric patients may develop cognitive dysfunction syndrome (CDS), which if severe can have a negative impact on quality of life. Caney (2018) has described CDS as a deterioration in the brain with similarities to Alzheimer's in humans, and it is a progressive disease that will worsen over time. When a patient presents with CDS in the hospital environment, the RVN should make every attempt to reduce patient stress as the patient is likely to be unable to cope well with the change in environment. Patients with CDS can become very disorientated, confused, vocal and distressed when they are taken away from their familiar home environment; familiar blankets, normal home diet, own toys and the use of dog appeasing pheromones (DAP) may be of help in this stressful situation.

For those geriatric patients that liked to be groomed and cleaned regularly and require assistance, those needs should be addressed in the nursing care plan. Grooming and cleaning by the RVN can help to relax, reassure and provide much needed TLC for the patient. Having classical music or a radio playing in the patient ward can also contribute towards reducing patient stress (Engler and Bain, 2017).

Thermoregulation

As patients enter their elderly years, they do have a decreased ability to regulate their own body temperature (Kerrigan, 2013b). Thermoregulation is especially important when considering senior or geriatric patients undergoing a surgical procedure and general anaes-thesia. The RVN should ensure that the patient is supplied with adequate bedding, warm environmental temperatures of around 21°C, and should most definitely consider the use of active patient warming after premedication and prior to anaesthesia (Rigotti and Brearley, 2016).

Conclusion

Ageing is not a disease but a normal and natural process of life. As patients age, they are susceptible to developing chronic and life-long disease. RVNs can make a real difference to both geriatric patients and their owners by understanding the ageing process, education, honoring and acknowledging the human–animal bond, and through effective communication.

RVNs can implement senior clinics to monitor geriatric patients, provide advice on senior/geriatric care, and potentially identify any age-related concerns, to allow prompt treatment and to improve quality of life. The needs of hospitalised geriatric patients should be addressed through care plan — identify the individual needs of patients, be mindful of any underlying pathologies and do not forget to provide a little TLC for our golden oldies.

KEY POINTS

• Having a good knowledge and understanding of the ageing process will assist the registered veterinary nurse (RVN) in providing appropriate nursing care for the geriatric patient.
• Nursing care plans and nursing models can assist in the delivery of ‘gold standard’ nursing interventions.
• With older age, comes the increased risk of chronic disease such as osteoarthritis, immunosupression, renal disease and cognitive dysfunction.
• It is important to educate clients on the natural ageing process and this can be done successfully through a variety of nurse clinics.
• Ageing should be recognised as a natural process of life — not a disease.
• Veterinary nurses need to provide the geriatric patient with extra TLC, gentle handling and consider their individual special needs.