Senior/Geriatric Care: New Frontier in Veterinary Medicine
Fred L. Metzger DVM, ABVP
Senior care will become a critical element embraced by successful practices as veterinary medicine enters the new millennium. Veterinarians commonly encounter senior patients as supported by the AVMA study which reported 28.1% of dogs and 25.4% of cats in the United States were 8 years of age or older. Advances in diagnostics, therapeutics and nutrition coupled with the powerful bond between owners and their older pets creates unique and interesting opportunities for today’s practitioner
Owners are critical components to the successful senior program. Comprehensive histories are especially critical in senior medicine. Owners should be instructed to note changes in water consumption, appetite, body weight, activity level, skin masses and especially behavior. Owners are in the unique position to note subtle changes in daily routines. Behavior changes should not be discounted as “senility” without our best diagnostic efforts.
Early detection leads to earlier intervention. Complete diagnostic efforts are critical because senior pets frequently have abnormalities in multiple body systems. Routine monitoring is especially helpful so trends can be followed and diseases recognized as soon as possible. Routine monitoring of clinico-pathologic data is critical in the management of geriatric patients.
Gaining owner compliance is often the most difficult component of veterinary medicine and senior care is no different. Our practice earns compliance through a five-step process, which takes very little time (usually 5 extra minutes) yet reaps huge rewards for the patient, the client, and the veterinary team.
Definition of Senior
Defining a senior pet is somewhat arbitrary since genetics, nutrition, and environment influence health and vary between patients. Guidelines proposed by Goldston and Hoskins use body weight as the determining factor thus emphasizing the importance of weight control in older patients. Clients and the entire veterinary staff should be aware of the practice’s definition of the senior pet for successful implementation of the program. The distinction between senior and geriatric is an important one because owners frequently classify their older pets as senior and avoid using term geriatric. It appears owners feel the term geriatric implies an older pet with serious medical problems. The Metzger Animal Hospital Age Analogy chart (Figure 1) is the critical education piece for our practice’s entire senior/geriatric program. Perhaps senior could be defined as the “early” age range for older pets and geriatric the later. Therefore, according to Figure 1, a 85 pound golden retriever becomes a “senior” at 7.5 years and geriatric at 10 years of age emphasizing the distinction between senior and geriatric. This classification increases diagnostic opportunities, as owners become educated about senior diseases and our early detection recommendations including routine blood profiling. Common senior diseases
Diseases common to senior patients are frequently the same diseases common to their senior human counterparts. Clients frequently recognize the common geriatric diseases such as diabetes, heart disease, hypothyroidism and cancer. Educating clients about senior diseases also educates about diseases senior citizens might encounter.
Common canine senior diseases include degenerative joint disease, obesity, dental disease, cardiovascular disease, cataracts, keratoconjunctivitis sicca, prostate disease and incontinence. Others commonly encountered include neoplasia, hyperadrenocorticism, hypothyroidism, anemia, hepatopathy, immune-mediated diseases, chronic renal failure and diabetes mellitus. Common feline senior diseases include obesity, dental disease, hyperthyroidism, chronic renal failure, cardiovascular disease, neoplasia, anemia, hepatic lipidosis, and diabetes mellitus.
Comprehensive health screening is very important in the early recognition and successful management of many of these diseases.
Defining the senior health program
Clients should become familiar with the definition of a senior pet and understand the medical benefits of early disease detection. Recommend testing patients when they enter their senior years according to the age analogy chart. Many senior patients require anesthesia for surgical or dental procedures-this is an excellent time to recommend health profiling to improve anesthetic safety and establish baseline values. Explain in layman’s terms the components of your program. Use analogies, as most clients are familiar with blood testing, ECG and blood pressure through association with human medicine. The minimum senior canine database, accessible to all practitioners, includes the CBC, biochemical profile with electrolytes, and complete urinalysis. . The minimum senior feline database, accessible to all practitioners, includes the CBC, biochemical profile with electrolytes, complete urinalysis, and total T4. Practices should include electrocardiography and blood pressure measurement if available. Other components of the senior health program might include radiography, ultrasound, endoscopy, ocular tonometry, endocrine testing (ACTH stimulation, low dose dexamethasone suppression, free T4 by equilibrium dialysis) and others, depending on the particular case.
Senior health program benefits
Earlier detection allows earlier intervention and therefore, improved treatment success. Senior profiling improves anesthetic safety by permitting the postponement of anesthesia or altering the anesthetic plan. Furthermore, pharmaceutical safety is increased through detection of underlying diseases, which may preclude the use of certain drugs. Many dietary recommendations are based on disease diagnosis making senior profiling an important dietary database. Finally, earlier disease management by improved anesthetic, pharmaceutical and dietary recommendations offer our patient’s and client’s the best medical management possible. But how do we make clients understand and say yes?
Achieving client compliance-start early
Client compliance is directly proportional to client knowledge. Clients must be educated by the veterinary staff for success to occur. Senior education is first discussed well before pets reach their senior years. If possible, begin discussing preventative blood profiling during the first puppy visit and relate that puppies, adult dogs and senior dogs have different medical needs and therefore require care depending on their life stage. For example, puppies have different nutritional requirements compared to older dogs. Review the overall plan for “wellness” during the first puppy visit including mention of preanesthetic testing and yearly blood profiling when the patient reaches the senior years. Use the age analogy chart during each yearly visit to help clients understand the aging changes occurring and to emphasize the importance of preventative health and nutritional plans.
Achieving client compliance-continue educating
Preanesthetic testing makes the transition to yearly blood profiling more logical as patient’s age. Baseline results obtained during preanesthetic testing for neutering, dentals, lumpectomies or other anesthetic events provide valuable comparison data for interpretation later in life, plus owners become familiar with the procedure increasing compliance for future profiling.
Yearly profiling should begin when the patient reaches the senior age threshold-veterinarians may understand the recommendation but how about our clients? Educational materials are critical if we expect clients to comply with our recommendations. Report cards summarizing physical exam findings and our medical recommendations are helpful in increasing compliance. Define the senior pet by including age charts on your report card to help educate owners what pets are seniors. Specific brochures explaining the benefits, components and costs of the senior program allow owners and other interested parties to continue the education process at home. Senior wall charts a poster form of the age analogy chart, defines which pets are senior or geriatric and therefore educate owners in the exam room.
Achieving client compliance-it’s the teeth!
Achieving increased client compliance can best be realistically accomplished by combining senior and geriatric blood profiling with ultrasonic dental scaling. Using the senior health profile as a preanesthetic test for dentistry increases anesthetic safety and increases owner compliance by decreasing owner anxiety. Most owners understand the need for dental scaling yet owners of older pets may not comply with your recommendations because they fear anesthesia. A complete senior testing program helps decrease anxiety by increasing safety thus increasing the number of dental procedures and initiating the concept of yearly testing. Furthermore, the majority of older patients require yearly dental scaling setting the stage for yearly testing.
Annual reminder cards help remind clients about vaccines, heartworm testing and other recommended procedures-why not health screenings? Clients are familiar with reminder cards so use them once the senior program has been initiated.
Follow the Metzger Animal Hospital Four Step Program
Step 1- Front office stage
Our front office team members are instrumental in the success of any new program and senior care is no exception. Receptionists actually play two important roles in the senior and geriatric program -as initiators and closers. Receptionists start the senior care experience by identifying which patients will potentially participate in the program. Patients are greeted then weighed on scales in the reception area thereby allowing the front office team member to determine the appropriate age group using the age analogy chart. Clients with senior or geriatric pets are given a copy of the age analogy chart on a clipboard and asked to complete the form in the examination room. Step one completed.Step 2- Technician/assistant Stage
Technicians and assistants initiate step two by assisting clients in completing the age analogy form (if necessary) and reinforcing the concept that the pet is senior or geriatric. If possible, examine the teeth to determine if a dental is required-most older pets have dental disease. Our practice uses dental photographs to increase client compliance by providing visual reinforcement for the doctor’s recommendation. Technicians or assistants usually produce the dental pictures with the clients in the exam room or in the procedure area when trimming nails, cleaning ears, etc. Technicians and assistants end their senior assignment by informing the doctor about the patient’s age and dental status and providing the dental photograph for the continuing education in step three.
Step 3- Veterinarian Stage
Doctors continue the education process by emphasizing the importance of dental health. Let clients grade their pet’s dental health by comparing the dental photograph with a dental wall chart or dental pamphlet available through companies selling take home dental products. Clients must understand that dental disease can contribute to serious medical problems especially in older pets. Acknowledge the owner’s fear of anesthetizing older pets then help dismiss those fears by explaining the benefits of your senior program! Your senior program not only helps improve anesthetic safety but also allows the early detection of laboratory abnormalities-early detection is the basis of the program! Give written recommendations using client dental education handouts then end the appointment. Hand the client completed age analogy chart, the doctor completed recommendation form with dental photo to your front office staff and let them do the rest!
Step 4- Schedule, schedule, schedule!
Your front office staff is the most important component for senior success-they start it and they end it. Receptionists must ask to schedule the senior/geriatric dental or it just won’t happen! If clients need more time or are not interested, simply send a reminder card in one or two months. It is our duty to educate clients about senior care and dental disease-are you?Step 5- Rewards
Successful teams share their rewards-so start sharing. Top performers deserve the top rewards so measure and motivate. Metzger Animal Hospital currently uses the “gold star” reward program to measure team member individual and group (receptionist, technician, and doctor) performance. Each team member involved in the scheduling of a senior or geriatric profile is awarded one gold star; consequently, the receptionist, technician and doctor are individually and instantly rewarded for their efforts. Rewarding the team immediately reinforces the practice goals and provides for friendly competition. Start giving stars to your stars! Interestingly enough, no one has yet to ask me what the stars are worth.
Financial benefits of the senior health program
Senior testing is better medically for our patients because it allows earlier detection of diseases. Senior pets represent over 25% of our patients and this number will most likely increase as technology progresses. Senior medicine will become an increasingly important profit center for veterinarians. Increased income results from increased laboratory testing, reflex testing, increased use of veterinary recommended diets, increased number of dental procedures, increased pharmaceutical income from diseases diagnosed, not to mention the income (vaccine, heartworm testing and preventative, flea products, etc.) derived simply from patients living longer through better medicine. Follow my 5 steps to senior success and join me in the most exciting development in veterinary medicine’s new millennium!