Nursing Assessment of the Geriatric Cat and Dog: Physical Assessment
Equine Cushing's Disease (Pituitary Pars Intermedia Dysfunction)
Equine Cushing's disease, also known as pituitary pars intermedia dysfunction (PPID), is a common disease in horses, especially among those older than 15 years of age. Certain breeds, such as Quarter Horses, are more predisposed to the disease than other breeds such as Thoroughbreds. It is caused by excessive hormonal secretions (pro-opiomelanocortin [POMC]-derived peptides) from the pituitary pars intermedia (PI), which stimulate excessive cortisol release from the adrenal glands. In the brain, the hypothalamus is the master endocrine gland; it controls many activities of other endocrine glands. The hypothalamus resides above the pituitary gland and has neurons with long axons that synapse on melanotrophs in the pituitary PI. Dopamine secreted by these hypothalamic neurons inhibits the production of POMC by the pituitary PI. However, loss of dopamine in Cushing's disease leads to excessive production of POMC by the pituitary gland. POMC is converted into different hormones, including adrenocorticotropic hormone (ACTH), which stimulates the adrenal glands to produce excessive cortisol. Clinical signs of Cushing's disease vary among patients. The affected horse may exhibit one or more clinical signs, including hirsutism (over-long hair coat), patchy sweating, lethargy, polyuria/polydipsia (PU/PD), laminitis, "potbelly" appearance, and muscle wasting on the dorsum. Other possible clinical signs include spontaneous lactation in mares without foals, tachypnea (increased respiratory rate), and immunosuppression resulting in parasitism. Horses with Cushing's disease are more prone to concurrent diseases, such as recurrent uveitis, heaves (recurrent airway obstruction), and sinusitis. Abnormalities noted on blood work (CBC and chemistry profile) include hyperglycemia (blood glucose level >180 mg/dl), increased liver enzymes, neutrophilia, lymphopenia, and anemia. In the past, many older horses with Cushing's disease were misdiagnosed as having hypothyroidism (low thyroid hormone levels). One of the common clinical signs thought to indicate hypothyroidism in horses was the presence of a thickened crest neck. It is now recognized, however, that hypothyroidism is not common in horses, and the thick neck is due to abnormal fat deposition. Measuring baseline thyroid hormone levels (e.g., thyroxine [T4], triiodothyronine [T3]) is not reliable in horses. These levels can be decreased for many reasons and should not be used as a screening test. Thyroid supplementation should be used only when indicated in equine patients. Diagnosis of Cushing's disease is made on the basis of the horse's history, signalment, physical examination, and ancillary diagnostic blood tests. Three tests are typically used: dexamethasone suppression test (DST) to assess cortisol response; serial measurements of ACTH, insulin, and dextrose; and thyrotropin-releasing hormone (TRH) stimulation. The DST is not always reliable and can yield inconsistent results. This test requires steroid administration, and steroids are associated with laminitis in horses. Horses with Cushing's disease are prone to laminitis and/or may have a current episode of laminitis, so steroid administration is often contraindicated. Serial measurements of ACTH, insulin, and dextrose can be more accurate than DST findings. Steroids are not used in this test, so it is a good option for many horses with Cushing's disease. However, one sample may not be diagnostic, so taking three blood samples in one day (AM, noon, PM) is optimal. ACTH levels increase in the fall as compared with January or May, so results should be interpreted on the basis of time of year. Despite various available diagnostic tests, owners of geriatric horses sometimes refuse diagnostic tests. Empirical treatment should be considered if the owner refuses diagnostic tests, and the horse's history, signalment, and physical examination findings are consistent with Cushing's disease. The primary treatment for Cushing's disease is a dopamine agonist, pergolide. The authors recommend use of Prascend® (pergolide mesylate) since it is the only FDA approved treatment for Cushing's disease, rather than continued use of compounded pergolide. Many 450-kg horses respond well to 1 mg or 1.5 pergolide orally once a day, but the dose needs to be altered on the basis of response to treatment. Many clinical signs will improve with treatment, but hirsutism usually remains. Numerous horses with Cushing's disease appear quiet and depressed, but once treatment is initiated, they become much more alert and act younger. Rechecking blood tests after starting medication will aid in determining the optimum pergolide dose. Another medication, cyproheptadine, was used in the past to treat Cushing's disease. It is not as effective as pergolide and is more expensive. General management is important for horses with Cushing's disease. The horse should have his teeth floated every 6 months or yearly to maintain oral health. Regular foot care every 4 to 5 weeks will keep him more comfortable and will prevent an over-long toe, which can aggravate lameness or laminitis. Regular deworming and manure management, such as weekly removal from the pasture, will aid in parasite control. Horses with Cushing's disease have poor thermoregulation and patchy sweating associated with hirsutism. These patients are more comfortable with regular body clipping to minimize hirsutism and using blankets in the winter. Clipping also permits better assessment of the horse's body condition. Nutrition is important with aged equine patients and those with Cushing's disease. Feeding small amounts of a senior diet often, adding corn oil ( cup daily) and grass pasture, and avoiding lush pastures are beneficial. Alfalfa hay or soaked alfalfa cubes or pellets can help maintain an older horse's body condition. Alternate sources include processed hay, such as Dengie hay
Hyperthyroidism
A common disease in middle-aged and older cats, the clinical syndrome of hyperthyroidism is caused by excessive production of thyroid hormone. This leads to an increase in metabolic rate and clinical signs including increased appetite with concurrent weight loss, polyuria and polydipsia, lack of grooming, and vomiting. Life-threatening cardiac complications can also occur. Early detection of hyperthyroidism is important because excellent therapeutic options are available. Therapy, such as administration of radioactive iodine, can be curative, and if done early enough, some of the cardiac changes induced by the disease may be reversible.
Technician note
A horse with a swollen, painful eye is considered an emergency because the eye can rupture if it is not treated quickly.
Feeding Tubes
A more permanent type of tube is an esophagostomy tube, which is placed while the patient is under general anesthetic through an incision directly into the esophagus from the neck. A slightly larger tube may be used for this type of feeding supplementation, and thus the choice of a liquid or slurry diet is more varied. The external end of the tube is generally sutured to the skin under the neck, and a bandage is placed around the neck to reduce the risk of accidental dislodging. Animals tend to tolerate these tubes well because they do not interfere with the pet's nostrils/face and they cause minimal discomfort. Esophagostomy tubes can be left in place for several months, and pet owners can use these tubes at home to facilitate administration of oral medication, as well as fluids and food. Finally, the most permanent type of feeding tube is one that goes directly into the stomach. A gastrostomy tube may be placed surgically or with endoscopic assistance and typically is an even larger-diameter tube. It is away from the face and neck and rarely interferes with normal daily activities of the patient. It is ideal for patients with esophageal disorders because the esophagus is avoided entirely. Its drawback is that its placement is much more invasive, and complications, although uncommon, can be devastating and life threatening (e.g., bacterial infection in the abdomen if the tube leaks). Feeding tubes are reserved for specific occasions and generally are not recommended as a "life support" type of measure. The animal should have a reasonable quality of life other than its inability to adequately obtain nutrition.
Pain Medications
A primary goal of the veterinarian and the veterinary technician is to provide medical care and comfort to the sick patient. In some cases, particularly in the terminally ill patient, controlling pain is all that can be done. However, one of the most difficult challenges is to accurately assess the level of pain experienced by a particular patient. Unlike humans, dogs and cats have subtle ways of expressing their discomfort, and owners may not be aware that their pet is in pain. However, owners may report general malaise, inappetence, or decreased activity in their pet, or they may notice an unwillingness to climb stairs or jump onto or off of the couch. When assessing patients, veterinary technicians should be able to recognize signs of discomfort that may include tachycardia, tachypnea, elevated temperature, unwillingness to use a limb or to posture for normal eliminations (especially in pets with severe hip osteoarthritis or lumbar pain), and yelping when a limb is manipulated. The decision to start a geriatric patient on medications to control pain should not be taken lightly. Many geriatric patients have underlying organ insufficiency, and nearly all pain medications used in veterinary medicine have some potential for organ toxicity or other adverse effects. Careful patient monitoring is essential for detecting complications early and reducing the likelihood of permanent damage. Complete blood work should be performed before any type of pain medication is used in a geriatric patient and should be performed serially while the animal is receiving these medications. The most common drug classes that veterinarians prescribe to manage pain in geriatric patients are (1) nonsteroidal anti-inflammatory drugs (NSAIDs), (2) steroids, and (3) opiates. Each has its own potential benefits and risks. NSAIDs are typically administered orally or parenterally and are potent analgesic, anti-inflammatory agents. Some have antipyretic activity as well. They are the medications used most commonly for managing the pain of DJD, chronic intervertebral disc disease, and other forms of osteoarthritis. Side effects are rare and may include gastrointestinal (GI) ulceration and renal and hepatic toxicity. In the past, these drugs have rarely been used to manage pain in older cats. However, the development of newer formulations of NSAIDs has made their use a practical option in some cats. Steroids, more specifically, glucocorticoids, also have potent anti-inflammatory effects. Unfortunately, long-term use of steroids (in some cases, even short-term use) may lead to significant side effects that can detrimentally affect quality of life in these patients. Glucocorticoid side effects may include excessive thirst and urination, increased susceptibility to systemic infection, increased panting, muscle weakness, GI ulceration, and thromboembolic complications. For these reasons, glucocorticoids are usually given for pain control only as a last resort. Opiates are narcotic drugs that produce some degree of analgesia. In humans, these drugs are known to have the potential to become habit forming and to cause sedation and respiratory depression. Several types of opiate receptors are present in the brain, and different opiates have been developed to work in the area of interest in specific patients. Finally, nutraceutical products are becoming more popular as adjunct therapies for managing DJD in dogs and cats. Although nutraceuticals are not "medicines," they can improve quality of life for senior patients by supporting improved joint functioning and having a positive effect on joint cartilage.
Respiratory Disease
A respiratory examination evaluates respiratory rate, respiratory effort, and the presence of nasal discharge or coughing. Older horses often have heaves (recurrent airway obstruction) and will have an increased respiratory rate and effort. Chronic cases develop a heave line (hypertrophy of abdominal muscles) resulting from increased effort to exhale.
Subcutaneous Fluids
A vast majority of dogs and cats receiving at-home care are eating and drinking on their own, but some pets require additional fluid support to maintain adequate hydration. Many of the geriatric diseases commonly seen in veterinary medicine (such as chronic kidney disease) can predispose to dehydration. If a patient is at risk for inadequate fluid intake or dehydration, owners may be taught to administer subcutaneous fluids. One or more in-office training sessions may be needed before owners are comfortable administering injections to their pet. However, the steps involved are relatively simple, and most owners can master this skill. Owners should be advised that warming fluids before administration can make the procedure more pleasant for the pet. Also, owners should be warned that the fluid will often become dependent. In other words, although fluid injections are usually given between the shoulder blades or along the back, before they are absorbed into the body, gravity often causes fluids to travel down the side of the animal and settle ventrally. If fluids are administered too far forward in the scruff area, the front limbs may swell as the fluid settles ventrally into the legs. This is not a matter of pathologic significance, but it is something owners often recognize. Owners should also be aware that administering excessive quantities of fluid, especially in cats, can be detrimental and may lead to fluid overload if cardiac function is compromised. Owners of any animal receiving subcutaneous fluid should report any change in respiratory pattern to the veterinarian because this could indicate fluid overload or heart disease.
Abdomen-Abdominal palpating may be limited in pets that are obese, but gentle palpating to assess for pain or distention is recommended.
Abdominal palpation to assess for pain, distention
Plan: What's next?
Address immediate concerns. Determine whether more in-depth evaluation and or diagnostic testing may be warranted. Recommend adjustments to current treatments regimen. Develop an contingency plan if the pets condition should deteriorate. Manage the owners expectations so they know what is coming next. Schedule follow-up assessment.
Physical Examination-Equine
An annual physical examination is crucial in maintaining good health of the aged horse. Often problems are found on a thorough examination. An annual body condition score is helpful in determining whether the aged horse is maintaining an adequate body condition. Acute or chronic weight loss indicates an underlying problem, such as lack of teeth, inability of the GI tract to absorb nutrients, or neoplasia. The horse's hair coat should be short and smooth. If it is long and wavy and is not shedding out completely in the spring, the horse has Cushing's disease, which is discussed later in the chapter. Common problems in older horses include heaves, laminitis, dental problems, sinusitis, equine recurrent uveitis (ERU), neurologic deficits, and DJD.
Vision- Equine
An ophthalmic examination is performed to check the horse's eyes for diseases such as ERU and cataracts. It is not uncommon for an older horse to have significant visual impairment that is discovered only during an ophthalmic examination. Many older horses are housed on the same farm for years and are able to compensate for loss of vision. If they are moved to a new location, the owner will discover that the horse has difficulty maneuvering in the new environment as a result of decreased vision.
Decubital Ulcers
As has been mentioned, one of the more common reasons why animals need at-home hospice care is that they have lost their ability to ambulate well and thus spend a significant amount of time in recumbency. This can be especially worrisome in large dogs, which are more prone to developing sores and ulcers at pressure points along their bodies. These "decubital ulcers" develop most commonly around the elbows, shoulders, tarsi, and hips. Decubital ulcers result from pressure and/or rubbing against a surface, so they can be found anywhere on the body that spends a large amount of time adjacent to the floor. The best way to prevent such ulcers is to encourage the pet to stand and walk on a regular basis—at least every 4 to 6 hours—and to ensure that the animal does not spend excessive time lying on one side of the body. Extra pads and cushioning, such as an air mattress or a thick comforter, should be provided. Keeping the pet clean and dry of urine and feces is essential to help prevent development of sores and skin infections. Shaving the hair near the perineum, groin, and rear legs can facilitate bathing and drying, and corn starch can be applied to help reduce moisture. If ulceration does occur, a topical antibiotic ointment and a protective bandage may be applied to reduce further trauma to the area. The difficulty with bandaging the area is that often the bandage itself causes skin trauma because the sore remains in close contact with the bandaging material, and healing is delayed. If the sore is noted over a joint, such as the elbow or tarsus, a doughnut type of bandage can be fashioned, so that the sore itself remains exposed but cannot rub against surfaces, thus limiting continued trauma.
Technician notes
As in humans multi-systematic abnormalities increase on frequency with advancement of age, making screening tests an essential part of the annual geriatric patient evaluation. Orthopedic disease is one of the most common debilitating diseases in older animals; it may be managed with appropriate medical and nursing care. It is important for clinicians to make patient comfort a priority.
Cardiac Disease
Chronic Valvular disease resulting from thickening of the heart valves affects many older dogs, especially smaller breads, but occurs less commonly in cats. Larger-breed dogs, although also affected by CVD, may develop different cardiac diseases, such as dilated cardiomyopathy. Cats more likely to develop hypertrophic cardiomyopathy (HMC)- a condition in which the heart muscle becomes thickened. Hypertrophic cardiomyopathy can affect younger cats, but many are middle aged, at the time of initial presentation. Cardiac disease in pets can lead to arrhythmia, congestive heart failure, and other complications, such as renal damage secondary to reduced renal perfusion. It is important that a thorough auscultation is performed in every geriatric patient, and testing should be discussed if a murmur or arrhythmia is heard. Any reports of fatigue, exercise intolerance, collapse, or cough should be investigated further, because all of these may be secondary to cardiac disturbances. These clinical signs, with or without evidence of an arrhythmia or murmur, warrant diagnostic investigation.
Respiratory disease
Commonly reported in older patients and may be due to chronic lower airway disease, such as bronchitis, or upper airway disease, such as collapsing trachea, or laryngeal paralysis. Any abnormal Kung sounds or owner complaints of coughing, exercise intolerance, or change one breathing rate or effort should be evaluated immediately.
Appetite Stimulants
Decreased appetite with associated weight loss is a serious problem in some geriatric cats and dogs. The first thing to bear in mind when an animal's appetite begins to wane is that there is usually an underlying cause, such as a systemic illness, orthopedic pain, or a central neurologic depression. Every effort should be made to identify and treat an underlying condition. If no underlying cause is found, or if the appetite remains poor even with treatment of the underlying illness, medications such as antiemetics and appetite stimulants may be administered.
Neurologic Abnormalities
Development of inflammatory or neoplastic lesions in the brain may lead to altered mentation or behavior changes. Any onset of behavior or mentation change should prompt a veterinary evaluation in an effort to find a medical cause. Veterinary patients, like humans, can display signs of cognitive dysfunction with age. Clinical signs such as altered sleep-wake cycles, house soiling, confusion, and irritability can strain the critical human-animal bond. Pet owners should be counseled about how to manage cognitive changes in their aging pets, and veterinary professionals should strive to manage owner expectations regarding this condition.
Diabetes Mellitus
Diabetes mellitus, caused by insufficient production of insulin or by an inability of insulin to work at its receptors, affects middle-aged to older dogs and cats. Insulin is required for glucose to enter cells, and glucose is the nutrient needed by body cells to perform their normal functions. Diabetes mellitus leads to polyuria, polydipsia, and increased appetite (polyphagia), along with weight loss. It predisposes animals to infection, especially in the urinary tract, because glucose overloads the kidneys and is spilled into urine. Glucose is an excellent source of nutrients for bacteria, so animals with diabetes mellitus are at risk for urinary tract infection. Diabetic animals typically require daily injections of insulin by their owners to properly manage the disease. Dietary modification can also be beneficial in many cases.
Endocrine Conditions
Endocrine diseases in general can be managed once diagnosed,but they can be life threatening if proper attention is not given. Because these diseases occur with increasing frequency in middle-aged to older veterinary patients, owners should be made aware of their clinical signs and should visit a veterinarian for evaluation if one of these diseases is suspected.
Technicians note
Geriatric horses are likely to have general health problems. An annual physical examination is important to identify and treat problems early.
Technician note
Geriatric horses often have multiple problems that require careful monitoring and treatment to ensure optimal health and longevity
Chronic Diseases of the Geriatric Horse
Geriatric horses often have multiple problems that require close attention to minimize complications. Cushing's disease is common in older horses and can cause immunosuppression. It also leads to or exacerbates other diseases, such as heaves (recurrent airway obstruction), ERU, laminitis, and sinusitis. For successful management of these other conditions, Cushing's disease requires treatment with pergolide to minimize immunosuppression.
Hyperadrenocorticism
Hyperadrenocorticism, also known as Cushing's disease, is caused by excessive production of glucocorticoids, such as cortisol, released from the adrenal cortex. Elevations in blood glucocorticoid levels cause a variety of clinical signs, such as polyuria, polydipsia, muscle wasting, and increased appetite. In addition, elevated glucocorticoid levels inhibit the function of neutrophils and diminish their ability to adequately protect against infection. With appropriate treatment, hyperadrenocorticism can be managed, and infection and other complications limited.
Body Condition - weight loss or gain can be easy to overlook. if practical, owners should weigh their pets in between assessments, so that weight changes can be monitored.
If possible, patients should be weighed each assessment. Standardized body condition scoring charts can be incorporated j to this evaluation. Online chart vet.osu.edu
Technician note
In addition to caring for the needs of geriatric patients, veterinary personnel should address the needs, fears, and concerns of pet owners who provide home care for their elderly or hospice animals.
Changing Nutritional Needs of Aging Pets
Inappropriate nutrition can adversely affect the health and longevity of all pets, particularly elderly ones. Nutritional assessment therefore is an important part of veterinary geriatrics. Each assessment begins with a medical history, a physical examination, and laboratory screening tests. Because numerous dietary formulations are available for senior cats and dogs, the ideal nutritional regimen should meet the nutritional and caloric needs of each individual patient, taking into account the animal's specific health challenges, such as obesity, diabetes or heart disease. The 2008 Senior Care Guidelines of the American Association of Feline Practitioners (AAFP) recommend that each geriatric patient be placed on a dietary regimen that supports an ideal body condition score, and that addresses underlying health risks and illnesses. Although these guidelines are intended for elderly cats specifically, their underlying principles are appropriate for elderly dogs as well.
Pain-Pain assessment (especially chronic pain) can be subjective and difficult to quantify. When in doubt about whether to provide pain medication, it is recommended to err on the side of caution and presume that a pet may be painful if this cannot be confirmed.
Increased pulse rate; increased respiratory rate; changes in mobility body posture, or attitude; vocalization; changes in grooming habits, and changes in appetite or drinking are just s few indicators of pain.
Management, Nutrition, and Nursing Care of the Geriatric Horse
Management of the aged horse is paramount in maintaining optimal health and keeping the horse comfortable. Frequent hoof trimming every 4 weeks is important to maintain the horse's comfort, especially when he has DJD and lameness. If the horse's foot grows too long, this changes the angle of the leg and makes walking more difficult. Routine dental floating every 6 months will keep the horse comfortable and eating well, and will prevent problems such as wave mouth. It is notoriously difficult to maintain weight and body condition in older horses. It is especially difficult to improve a horse's condition if he has lost weight or is already thin. Additional considerations must be noted in treating geriatric horses. These horses seem more sensitive to certain medications, such as sedation and NSAIDs. This sensitivity may be seen as a combination of decreased muscle mass and renal and/or liver insufficiency, but many geriatric horses tolerate only one-half of a typical dose of sedative given intravenously. For example, the clinician should give only 75 mg xylazine and 1 mg butorphanol or 2 mg detomidine and 1 mg butorphanol to an average 450-kg (1000 lb) horse. Many of these horses receive daily NSAID treatment for chronic DJD (osteoarthritis). They may be given 1 g of phenylbutazone orally daily for a few years, because without medication they are in significant pain. When administering NSAID medication, the owner should be aware of potential side effects, such as renal failure or right dorsal colitis. It is important to monitor the horse's attitude, appetite, manure production, renal values (creatinine, blood urea nitrogen [BUN]), urinalysis, and PCV and total protein. If any changes in these values are reported, the patient and the treatment protocol should be reassessed. General management recommendations include regular deworming, frequent manure removal, and low stocking density (e.g., a few horses in a large pasture) to minimize parasite burden in a pasture. Performing periodic fecal egg counts is helpful in assessing whether the deworming schedule is adequate. It is not uncommon to have a false-negative test result from fecal examination, but the horse has a parasite burden, so regular deworming is important, even if the fecal examination test result is negative, and fecal egg counts offer a quantitative method that can be used to assess deworming protocols. Regular vaccination is recommended, using the recommended vaccine protocol for the area. If the horse has a history of vaccine reactions, pretreatment with an NSAID, such as phenylbutazone or flunixin meglumine, is recommended. Many horses develop more severe reactions over time, so geriatric horses with a history of vaccine reaction are at higher risk. If the horse still shows a reaction despite pretreatment, only necessary vaccines should be administered to minimize complications. Annual physical examinations are important in maintaining the health of a geriatric horse and in detecting problems. Many geriatric horses seem to develop renal and liver insufficiency over time, so annual blood tests (e.g., CBC, chemistry profile) are important for monitoring their health. Management is paramount to maintaining a healthy geriatric horse. Geriatric horses can have a good quality of life with proper care, but they require close monitoring. Many are turned out in pasture and are not monitored well. They may have poor body condition hidden by a thick hair coat, so it is best to train the owner to assess the horse's body condition. Clipping older horses and placing a blanket in the winter keep these older horses comfortable. Geriatric horses with an over-long hair coat are not able to thermoregulate well, may have patchy sweating, and are prone to develop dermatitis. It is also advisable to clip over the jugular vein before administering intravenous medications to easily visualize the vein and avoid the carotid artery. Frequent pasture turnout is ideal for maintaining body condition and GI tract health, and for minimizing stiffness. It is important to turn the geriatric horse out with other horses in equal condition. Otherwise, the older horse will be at the bottom of the hierarchy and may not have adequate access to food. If the older horse is in poor body condition, feeding him individually is important to ensure that the horse is receiving enough food and to assess appetite. Feeding free-choice high-quality hay with supplementation of alfalfa (hay or soaked alfalfa cubes or pellets) will aid in maintaining weight. Feeding an equine senior feed is also important for maintaining weight or providing calories when the horse has lost teeth. Corn oil ( to cup per day) added to the feed provides additional calories.
Nursing Care for the Hospice Patient
Many animals that are at the point of needing hospice care have their normal mental faculties but have physical disabilities that prevent them from performing typical daily activities. This is seen commonly in animals with severe orthopedic or spinal cord disease, in cases where the patient is mentally appropriate and has a good appetite but cannot ambulate on its own. Teaching pet owners to care for their recumbent pets at home is therefore critical if the animal is to survive and live comfortably. Veterinary technicians play a key role in providing this valuable instruction. Pet owners need to know how to keep their animals clean and comfortable and how to determine when they should give pain medications. In addition, owners should be taught to turn recumbent animals on a regular basis—at least every 4 to 6 hours—to limit formation of decubital ulcers, or bed sores (see later discussion). Animals that spend more time on one side than on the other can also develop atelectasis in the lung lobes on the "down" side, which can lead to respiratory compromise and pneumonia. Therefore, recumbent patients should be encouraged to ambulate regularly, if at all possible. Animals should always be in sternal recumbency when fed, to help prevent accidental aspiration of food material or vomitus. Appetite should be monitored closely because a decline in appetite may indicate that the pet's condition is deteriorating.
Hydration Status- Pet owners assume that if a pet seems to be drinking ( especially drinking more, as with diabetes, kidney disease, or feline hyperthyroidism) that dehydration should not be possible. Owners may need help understanding that their pets illnesses may be affecting his/her ability to maintain hydration. If dehydration becomes a concern, subcutaneous fluid injections can be helpful.
Mucous membrane color and capillary refill time, skin turgor
Mental status-Pet owners may report that their pet "doesn't seem to be himself". Although a full neurologic assessment may not be practical, obvious signs of disorientation or altered mental state should be evaluated more thoroughly by a veterinarian.
Observe pet for signs of disorientation or other altered behavior.
Neurologic Deficits
Older horses can develop mild or progressive neurologic deficits as a result of trauma or chronic changes, such as cervical fractures compressing the spinal cord. Clinical signs in an affected horse include depression, decreased proprioception, dragging toes, ataxia, and reluctance to turn the neck. Diagnostic tests include a thorough physical and neurologic examination, blood tests such as liver function tests, cervical radiographs, and cerebrospinal fluid aspiration. Treatment includes anti-inflammatory medications and small paddock turnout and stall confinement, if needed. These horses are often weak and may lose their position in the hierarchy. Therefore, it is important to place them with other horses in similar condition and to feed them individually to ensure that they are receiving adequate nutrition
Neurologic Abnormalities
On general neurologic examination, older horses may drag their hind feet and may have blunted toes. This change may be due to neurologic deficits or musculoskeletal pain (e.g., DJD in the hocks). The horse's neck should be examined for evidence of pain. Offer the horse a carrot or a handful of grain to encourage the horse to touch nose to shoulder. If the horse is reluctant or is unable to perform this action, this may indicate the presence of neck pain. Sometimes this is due to fracture of the cervical vertebrae that can be diagnosed on cervical radiographs.
Orthopedic Disease
Osteoarthritis is also known as degenerative joint disease (DJD), and it can affect cats and dogs of any breed. Animals that are overweight tend to be more severely affected because excess weight leads to increased stress on joints. Use of nutraceuticals, anti-inflammatory medications, and other medications to control discomfort has dramatically improved the quality of life of many geriatric veterinary patients with DJD. Additionally, with the introduction of physical therapy and rehabilitation centers in veterinary medicine, strides have been made in the management of orthopedic problems. Household modifications can help pets with joint pain and limited mobility; these include ramps, skid-proof mats placed on the floor, and elevated food and water bowls (for pets with neck pain).
Oral health
Owner complaints of halitosis, difficulty chewing, dropping food from the mouth, or excessive salvation should prompt an thorough oral exam. Signs of periodontal inflammation, tartar and caucus accumulation, and/or fractured teeth may require intervention. More likely to require routine dental procedures to ensure oral comfort. Owners should be made aware of at home prophylaxis they can preform, such as daily tooth brushing and oral rinses, to limit the progression of dental disease. Also instruct owners to check their pets gums and tongue for growths or lesions and to contact the veterinarian if they show signs of oral discomfort.
Urine Scalding
Patients that have limited mobility or are recumbent may have urinary incontinence or may consciously urinate in a recumbent position. Urinary incontinence is common among patients that have spinal cord disease. Innervation to the external urethral sphincter arises from spinal cord segments at S1 to S3; therefore, spinal cord disease in this area often leads to "lower motor neuron" bladder dysfunction, whereby the sphincter does not close tightly, and urine leaks. Additional causes of urinary incontinence include decreased mobility, such that the bladder becomes too full and begins to leak. Without proper attention, such as regular expression of the bladder or frequent walks to allow elimination, the animal may dribble urine uncontrollably. If urine leakage occurs, it may stain and soak the fur and scald the skin. If left untreated, this can eventually lead to sores and skin infections. This condition is painful and contributes to a poor quality of life. This situation becomes quickly intolerable for many pet owners and serves as a reason for choosing euthanasia over continued attempts to care for a sick pet. It is important to keep these patients clean and dry at all times. Shaving the perineum, groin, and rear legs and applying corn starch as described earlier can facilitate keeping the patient clean and dry. Some pet owners prefer to use diapers to help keep the area around the pet clean, but these must be checked and changed frequently. Bladder expression may lead to urine on the fur and skin; it is important for the clinician to be aware of this when expressing the bladder, and to always clean and dry the patient afterward.
Oral and Nasal Health-Equine
Performing an oral examination is important because older horses often are in poor body condition, are unable to chew properly, and drop food when chewing. Many older horses are missing teeth or have sharp points (hooks) on their teeth, preventing normal chewing (Figure 35-4). The most severe change is called a wave mouth. This condition occurs when the horse's teeth are of different lengths, preventing normal chewing action. Geriatric horses are prone to chronic sinus infection, so the presence of nasal discharge and a dull sound when the sinuses are percussed indicate that the sinus cavity contains fluid.
When is the Right Time for Euthanasia?
Pets are often thought of as members of a family and therefore are provided excellent veterinary medical care throughout their lifetime. Some owners go to extreme lengths to save the life of a seriously ill pet; other owners do not want their pet to suffer or cannot afford expensive medical care. Regardless of the situation, veterinary personnel are often asked when the time is right for a pet to be euthanized
Technician note
Providing pain relief is one of the most important responsibilities of veterinary professionals. When uncertain about whether a pet is in pain, err on the side of caution; assume that the pet is painful, and provide appropriate analgesia.
Vital signs- (especially blood pressure) should be checked when the patient is minimally stressed. Depending on the pet, this may be at the beginning of the appointment or at the end (after the pet has gotten used to new people and started to settle down).
Temperature, Pulse, Respiration, blood pressure (if recommended)
Gastrointestinal Disease
The GI tract is assessed initially by evaluating the consistency and amount of manure. Manure should have a normal consistency and should not contain large pieces of hay or grain. If large pieces are present, the horse has poor chewing ability to grind food well and needs an oral examination. The presence of diarrhea may indicate chronic colitis or malabsorptive disease.
Technician note
The decision to euthanize a beloved family pet is a difficult one, and owners often seek guidance from veterinarians and veterinary technicians whom they know and have grown to trust.
Common Problems in Aging Horses
The general physical examination of a geriatric horse follows the same guidelines as an examination performed on a younger horse. However, aged horses are more prone to certain problems, which are highlighted in the following discussion. Also, refer to Tables 35-3 and 35-4 for a list of questions that aid in performing nursing evaluations of geriatric horses. The horse should have a body score performed on physical examination. This system offers an objective way to determine the horse's condition and to assess whether weight loss occurs over time. Refer to Chapter 10, Table 10-3, for the Equine Body Condition Score scale. A score of 1 indicates that the horse is emaciated, and 9 indicates obesity. The horse's attitude is assessed as bright and alert or depressed (Figure 35-3). Many older horses appear quiet and depressed, but this attitude is often due to Cushing's disease and can improve with treatment. The hair coat should be short and shiny. If it is dull, is excessively long and wavy, and is not shedding completely in the spring (hirsutism), the horse has Cushing's disease.
Skin Disorders
The horse's integument is examined for dermatitis and abrasions, especially around bony areas, such as the pelvis. Reproductive organs are visually examined. Elderly male horses may develop tumors on their sheath (prepuce) or penis. These tumors are often squamous cell carcinoma and require treatment. The rectal area is evaluated for the presence of melanomas and normal anal tone.
Orthopedic Disease
The musculoskeletal examination is an important part of a general physical examination. Older horses are prone to laminitis and may have changes, such as rings on the hoof wall, indicating chronic laminitis (Figure 35-5). They also often have DJD in multiple joints (e.g., carpus, hock) and become stiff without regular pasture turnout (Figure 35-6). Muscle atrophy is common, especially on the dorsum and around the gluteal area (Figure 35-7).
Physical Assessment
What to check
Feeding Tubes
The use of feeding tubes for the geriatric patient is a controversial issue. Although providing basic nutrition is regarded by some as a medical obligation, except in extreme circumstances, others may consider nutritional support in the hospice care setting to be inhumane if the patient is otherwise debilitated. Veterinary patients cannot talk, and one of the most important indicators of how an animal feels is the presence or absence of an appetite. However, some pets are more "finicky" than others, so an apparent loss of appetite should be considered in the context of what is normal for the pet. Also, appetite loss can result from various factors, including diet change and certain medications, so it is not always an indication of a pet's sense of well-being. In a recumbent, debilitated patient, anorexia may mark the time to consider euthanasia of the pet. However, this approach cannot be applied in every case. If pet owners are not ready to consider euthanasia, efforts must be directed toward maintaining the patient's ability to obtain nutrition. Feeding tubes are necessary sometimes, as in cases in which the animal's alimentary tract is abnormal (megaesophagus) but the patient is otherwise enjoying a good quality of life. As we discussed earlier, animals often need subcutaneous fluids at home to maintain proper hydration. Feeding tubes may be used for providing fluid and nutritional support to select animals. Feeding tubes can also facilitate administration of oral medications, which can be particularly problematic in cats. Many types of feeding tubes are available in veterinary medicine. Some are used for short-term management, others for long-term support. The most common short-term feeding tube is a nasoesophageal tube. Animals may be sent home with this type of feeding tube, but it is typically used on a temporary basis when the animal is expected to begin eating on its own relatively soon. This flexible, soft, thin-diameter tube is introduced into the nasal cavity and then is advanced past the nasopharynx and into the esophagus. The external end of the tube is generally held in place by a suture (or surgical glue) to the side of the pet's face. Because of their location, animals can easily paw at nasoesophageal tubes, causing early removal; therefore, an Elizabethan collar must be worn at all times. Additionally, types of food given through the tube are limited and must be of liquid consistency.
Heaves (Recurrent Airway Obstruction)
This disease can be acute or chronic in nature. Some horses are affected only a few weeks each year, other horses are affected year-round. Usually, if a horse acutely develops signs of heaves, it eventually becomes a chronic condition and requires careful management to minimize clinical signs. Horses with heaves are often allergic to dust or mold in the environment. Horses living in a dusty stable with minimal pasture turnout, exposed to cobwebs, straw, and hay, are prone to developing heaves. This allergic reaction leads to inflamed airways and constriction of smooth muscle in the airways, causing narrowed airways and difficulty breathing, especially during exhalation. Clinical signs on physical examination include increased respiratory rate (tachypnea) and increased effort (dyspnea), nostril flare, and dry cough. The horse will not have a fever and may have a clear nasal discharge. Horses with chronic heaves are often in poor body condition with a heave line (extreme development of the external abdominal oblique muscles as a result of increased effort on exhalation). The horse may extend his head on exhalation to improve airflow. On thoracic auscultation, wheezes will be heard on both sides of the chest, especially on expiration. A rebreathing bag (large trash bag) may be used to encourage the horse to inhale deeply, permitting better thoracic auscultation. After the bag is removed, a horse with heaves will cough and will take a long time to return to normal breathing. Additional diagnostic tests include blood tests (CBC, chemistry profile), transtracheal wash, bronchoalveolar lavage (BAL), and thoracic radiographs. Abnormalities on blood tests include increased total protein and increased fibrinogen concentration. Samples of airway secretions can be obtained on transtracheal wash or BAL and submitted for cytology and culture to differentiate heaves from infection (e.g., pneumonia). Changing the horse's environment to minimize allergens is the most important part of therapy. Increasing pasture turnout, soaking hay for 4 hours before feeding, and eliminating dusty bedding are vital for minimizing clinical signs. Medication to control inflammation and bronchoconstriction is administered systemically (e.g., IV, IM, PO) or locally (e.g., using an inhaler). Steroids (e.g., dexamethasone, fluticasone) are used to decrease inflammation, and bronchodilators (e.g., clenbuterol, albuterol) dilate narrowed airways. Local treatment using an Equinehaler (Equine Health, Hørsholm, Denmark) or an AeroMask Equine Medical System (Trudell Medical International, London, Ontario, Canada) provides effective treatment while minimizing possible side effects. However, this method is expensive because inhalers for human patients are used. It also requires a dedicated caregiver initially giving medications a few times daily. Systemic steroids are effective but have been associated with laminitis in horses. Horses with heaves require management changes, close monitoring, and early treatment at onset of clinical signs, but can live comfortably for a long time if treated properly.
Cardiorespiratory system- Respiratory distress can be subtle, and pet owners can easily overlook minor changes in breathing effort.
Thoracic auscultation to assess heart rate and rhythm, to detect heart murmurs, or to assess pulmonary sounds.
Technician Note
Veterinary technicians are responsible for teaching owners about early signs of age-related disorders. Changes in eating, drinking, and urination habits, for example, may be associated with conditions that can be managed well, if identified and treated early.
Technician note
Veterinary technicians who teach owners about how to care for their pet at home help to extend the life of the pet and avoid costly hospitalizations or premature euthanasia. Administering subcutaneous
End of Life Issues
When a geriatric horse is no longer enjoying a good quality of life, euthanasia may be considered by the owner and/or recommended by the veterinarian. Considerations for euthanasia include poor body condition or rapidly losing weight, refractory pain (e.g., acute, severe laminitis), and severe DJD, leading to chronic, severe lameness. Additional considerations include episodes of the horse falling frequently and impending cold weather. Cold weather, snow, and icy conditions are difficult for older horses to manage. If the horse slips on the ice, it may be impossible to lift the horse up again, necessitating euthanasia. These geriatric horses have often been a part of the family for years, and the entire family would like to be present for the horse's final moments. A scheduled euthanasia can allow the family to say goodbye and can offer a peaceful end to a beloved horse.
Kidney disease
Chronic renal failure is one of the most common, especially cats. In addition to causing increased urination (polyuria) and water intake (polydipsia), kidney disease can cause complications, such as anemia, gastric upset, anorexia, weight loss and muscle weakness. Routine screening for proteinuria, azotemia, and other abnormalities associated with kidney disease should be part of any diagnostic evaluation in a senior pet. With early detection, diet changes, fluid support, and specific medications may be used to slow progression.
Cardiac Disease-Equine
Cardiac auscultation is important for assessing a resting heart rate and the presence of murmurs or arrhythmias. It is helpful to feel the pulse at the same time that the heart rate is auscultated to ensure that they are synchronous with one another. Feeling the pulse also ensures that the pulse is strong and has a normal rhythm. Mitral regurgitation is the most common valvular lesion in horses older than 15 years of age. This condition gives rise to a systolic murmur on the left side of the thorax. Aortic regurgitation also occurs in older horses and is clinically associated with a diastolic murmur on the left side. The most common arrhythmia in older horses is atrial fibrillation. It is often an incidental finding on physical examination. The rhythm is irregularly irregular, and the horse has an elevated resting heart rate (>44 beats/minute). Many horses can tolerate this arrhythmia for years and appear healthy but may exhibit exercise intolerance at high levels of exercise.
Hypothyroidism
Hypothyroidism is relatively common among middle-aged and older dogs, although younger dogs can also be affected. The condition is caused by inadequate production of thyroid hormone. Clinical signs include weight gain, lethargy, and muscle weakness—changes that pet owners may mistake for simple signs of aging, or "slowing down." Screening of patients that exhibit clinical signs is an important step toward confirming a diagnosis, initiating therapy, and improving quality of life for dogs with this disease. Hypothyroidism is well managed with oral thyroid hormone supplementation.
Geriatric Horses
As a result of advances in equine management and nutrition over the past few decades, many horses are living beyond 30 years of age. Some of these horses are pasture pets and are well loved by their owners but are not referred to a veterinary hospital when problems arise. Factors such as advanced age, inability to ride in a trailer, and economics play a part in the owner's decision to not refer the patient. Therefore, many equine veterinarians in private practice manage geriatric horses on the farm. Aged horses are often defined as greater than 20 years old. Many of these horses are older than 30 years of age; they often live into their late 30s or even early 40s. Aged horses suffer from a myriad of problems, including poor body condition, lack of teeth, Cushing's disease (pituitary pars intermedia dysfunction), musculoskeletal disease such as degenerative joint disease (DJD or osteoarthritis), and chronic laminitis. Cushing's disease, a common disease of older horses, is discussed in detail in this chapter.
Carts and Slings
As animals age, orthopedic and neurologic disease can lead to severe impairment in ambulatory abilities. Small dogs and cats can be carried to some extent, but this may be difficult or impossible with large dogs. Products have been developed that make this type of problem manageable for many owners, while still providing a good quality of life for the pet. Slings can be used to support the hind end of an animal that has normal use of the front end of its body and still maintains some control of the hind end. Typically, slings fit around the caudal portion of the body, just cranial to the hindlimbs, allowing the caretaker to simply support the hindlimbs while the animal ambulates. A sling works best if the animal can still use the hindlimbs to some extent, and often the sling is used merely as a support and fail-safe device if the pet is prone to falling. If the animal is only mildly affected, a Bottom's Up leash (Watson's Pet Co., Santa Monica, CA) and a soft blanket or towel can be used as a sling (Figure 35-1). For animals that maintain little to no function of their hindlimbs, as often occurs with spinal cord injuries, carts are available for purchase. The hindlimbs fit into the apparatus, allowing the animal to use its front limbs to move around (Figure 35-2). Animals typically adapt to these devices quite
Technicians note
Cushing's disease is common in older horses. Clinical signs vary, but horses often have hirsutism (excessive long hair growth) and depression. Cushing's disease can cause immunosuppression and can exacerbate other diseases, so diagnosis and treatment are imperative to maintain the health of the geriatric horse.
Hospice Care for the Aged and Dying Cat and Dog
Despite the best efforts of veterinary professionals, at some point many companion animals develop terminal diseases. Technicians play a large role in ensuring that aged and dying patients are kept as comfortable as possible at home.
Dental Problems and Sinusitis
Geriatric horses often develop dental disease as they age. As their teeth wear down or fall out, the opposing tooth will become too long or will develop points (sharp areas on the tooth). This causes abnormal occlusion, and the horse will not be able to chew properly. The most severe abnormality is called wave mouth. The horse will have abnormal occlusion of all teeth and extreme difficulty chewing food. Wave mouth is a common problem in geriatric horses. Clinical signs of oral abnormalities include poor body condition, slow chewing, dropping a lot of grain or hay from the mouth, discomfort when chewing, and whole grain in manure. A thorough dental examination should be performed at least annually on horses 20 years of age or older to prevent oral abnormalities. When proper dental care is provided, many older horses are able to chew their food well and maintain their body condition. Chronic sinusitis is common in older horses and is often caused by tooth root abscessation or immunosuppression due to Cushing's disease. One or more sinuses may be affected. Clinical signs include purulent, unilateral nasal discharge, and a reddish color may be present. Percussing the sinuses in the middle of the horse's head will elicit a dull sound, indicating fluid accumulation. Diagnostic tests include an oral examination to look for tooth root abscessation, upper airway endoscopy, skull radiographs, and evaluation for Cushing's disease. Treatment includes administration of long-term antimicrobials, flushing the sinuses under general anesthetic, removal of an infected tooth root, and pergolide if Cushing's disease is present.
Equine Recurrent Uveitis (ERU, or Moon Blindness)
Geriatric horses often develop eye problems, and the leading cause of blindness in horses is equine recurrent uveitis. ERU is a progressive disease that causes frequent episodes of inflammation and degeneration in one or both eyes. Some breeds, such as Appaloosas, are more commonly affected. Clinical signs include a swollen and painful eye, photophobia, corneal edema (blue tint to cornea), a corneal abrasion or ulceration, miosis (constricted pupils), neovascularization (blood vessel growth on cornea), anterior uveitis (inflammation in the front chamber of the eye), hypopyon (cellular debris in the eye), and hyphema (hemorrhage in the eye). A horse with a swollen, painful eye is treated as an emergency because the cornea is thin (1.5 mm thick) and has no blood supply, and the eye can rupture if not treated quickly. Horses live in a contaminated environment and may develop bacterial and fungal ulcers that can be resistant to therapy. Diagnostic evaluation includes sedating the horse to perform a thorough ophthalmologic examination, applying fluorescein stain to evaluate the cornea for ulceration, and taking samples for cytology and culture. When a corneal ulcer is present, the damaged corneal epithelium will stain bright green, showing the extent of the ulcer. Both eyes should be evaluated because many geriatric horses will have cataracts and degenerative retinal changes. If the horse lacks vision in the clinically unaffected eye and the other eye is swollen and painful, the horse may become scared and may react differently than it normally would. Treatment depends on whether primarily inflammatory changes or a corneal ulcer is present. If no ulcer is present, topical steroids (e.g., dexamethasone, prednisolone) and other medications (atropine, serum, and systemic NSAIDs, such as flunixin meglumine) are used to eliminate inflammation and dilate the pupil. If an ulcer is present, topical antimicrobials and other medications (atropine, serum, and systemic NSAIDs, such as flunixin meglumine) are given until the ulcer resolves, and then steroids can be used if needed. Mild cases can be treated with topical ointments or solutions. Severe cases require frequent treatment; it is often difficult to treat a horse with a painful eye, so a subpalpebral catheter can be placed for ease of treatment. Sometimes surgery is also required to aid healing. Once the episode has resolved, preventive treatment, such as using a fly mask and anti-inflammatory medications, is often needed to minimize additional inflammatory flares. Enucleation (removal of the affected eye) is the last resort in older horses because both eyes are often affected. Without treatment, the horse will be in pain, and the affected eye will become smaller over time.
Musculoskeletal System
Geriatric horses often have multiple sites of DJD (osteoarthritis) and can be lame at the walk and trot. Lower limbs, hocks, carpi, and cervical vertebrae are most commonly affected. Soft tissue problems include degeneration of the suspensory tendon. Diagnostic tests include lameness examination, local anesthetic for nerve blocks, sonographic evaluation, and radiographs to identify affected areas. Treatment includes local joint injection of steroids to relieve clinical signs, but this cannot be repeated too many times. Many of these horses require long-term NSAIDs (e.g., phenylbutazone, firocoxib) to have a good quality of life. Monitoring the horse using diagnostic tests, such as chemistry profile, packed cell volume (PCV), total protein, and urinalysis, is an important part of using these medications. Although side effects, such as renal insufficiency or right dorsal colitis, may be noted with long-term NSAID use, it is paramount to keep these geriatric horses comfortable at the end of their lives. Firocoxib is a cyclooxygenase (COX)-2 inhibitor that should spare gastric mucosal protection and renal blood flow. Pasture turnout as much as possible is important because older horses become stiff when standing in the stall for too long. Regular foot trimming every 4 weeks and use of shoes are often vital in maintaining the horse's comfort.
Laminitis (Founder)
Laminitis is a devastating, sometimes fatal disease in young and older horses. Although extensive research has been conducted, the pathophysiology of laminitis is not clear. It may be acute or chronic in nature, and all four feet may be affected or just one or two feet. Ultimately, the soft tissue in the foot (laminae) holding the bone (distal phalanx, or P3) and hoof wall together becomes inflamed and necrotic. The horse initially may develop separation of the hoof wall from the bone. In severe cases, the bone will rotate, sink, and penetrate the bottom of the foot (sole), necessitating euthanasia. Laminitis may be a complication of a primary problem (e.g., postcolic surgery) or may develop acutely with no apparent cause. However, laminitis most commonly occurs in the geriatric horse as a result of Cushing's disease. Some breeds (e.g., Quarter Horse, ponies) are more prone to developing laminitis. Laminitis is a painful condition because the horse is standing on the affected foot and often cannot find relief from pain. Clinical signs of laminitis include reluctance to walk and turn, bounding digital arterial pulses (palpated over the fetlock near the sesamoid bones), rings on the hoof wall, depression, and inappetence resulting from discomfort. Diagnostic tests include radiographs of the feet and additional tests to diagnose the inciting cause. If the inciting cause is identified, treatment is directed at the disease. For example, if Cushing's disease is diagnosed, treatment with pergolide is paramount to control laminitis. Treatment for laminitis is often symptomatic and includes shoeing changes (e.g., blunting the toe), footpads, deep bedding in the stall (e.g., sand), and use of NSAIDs (e.g., phenylbutazone). It is ideal if the horse will lie down to relieve pressure from affected feet. Laminitis may be acute or chronic; geriatric horses often develop chronic laminitis and require regular foot care every 4 weeks to minimize clinical signs. Recovery can be complete, or permanent damage to the laminae may occur, so long-term care is directed at the individual patient.
Neoplasia
One of the most common diseases of geriatric patients. Cancer may affect a single organ or multiple organs, depending in the type and stage of disease. Early detection is crucial in providing appropriate therapeutic measures to increase life span and improve quality of life.
Expressing Bladders
Pets with orthopedic diseases, such as hip osteoarthritis, may have a difficult time posturing to urinate and/or defecate. Additionally, animals that are recumbent or have spinal cord injuries or other forms of spinal cord disease may be unable (or unwilling) to urinate on their own. Owners can be taught to express their pet's bladder to allow complete voiding. Bladder expression is a painless procedure if done correctly. Different methods may be used to perform this procedure, with the main focus on applying gentle pressure to the urinary bladder by squeezing both sides of the bladder in a front-to-back motion. Bladder expression can be performed with the pet standing, or in recumbent patients lying in lateral recumbency. Place one hand on each side of the patient's abdomen and move the hands caudally toward the pelvis until a soft, round structure that feels similar to a water balloon is palpable. This is the urinary bladder, and once it is found, gentle pressure (directed toward the rear of the patient) should be applied to it. The amount of pressure that should be applied varies with the individual, but with the right amount of pressure, urine will be expressed through the urethra, and a nice stream should be maintained until the "balloon" feels empty. Excessive pressure should never be applied because it is possible to rupture the urinary bladder. It is always important to express as much urine as possible from the bladder. When urine sits in the bladder, especially in a patient that is unable to void on its own, cystitis becomes more likely. Therefore, any animal that requires regular bladder expression should be evaluated by the veterinarian on a routine basis, and urine cultures should be performed periodically. Additionally, it is important that owners routinely clean the patient's fur and skin of urine after expressing the bladder to prevent urine scalding (see later discussion).
Kidney Disease
The horse's renal system can be assessed by evaluating the amount of water consumed daily and the frequency of urination. Annual urinalysis is important to assess the concentrating ability of the kidneys and to ensure that urine does not contain substances such as protein or glucose.
Summary
The veterinary community can contribute to the health and well-being of geriatric veterinary patients in many ways. Because pets have become an integral part of modern family life, the need for home and barn support for these animals is increased today. Veterinary technicians can help to provide at-home hospice care for these patients, in addition to the routine geriatric care provided at veterinary hospitals. It is important to remember that hospice care should be provided only while the animal maintains a good quality of life. Once the quality of life declines to an unacceptable level, euthanasia should be considered. Geriatric horses are living longer today; many are living well into their 20s and 30s when properly cared for and closely monitored. They often make excellent companions for younger horses and provide much enjoyment for their owners. Medical problems must be detected early and treatment initiated promptly to provide optimal quality of life for the geriatric equine patient. As in small animals, once the horse's quality of life declines to an unacceptable level, euthanasia should be considered. The veterinary technician can provide thorough patient assessment and nursing care, and can teach clients how to provide care at home.
