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The role of the veterinary nurse in the management of senior pets

It’s important to be proactive, not reactive, in the management of our senior patients

09 July 2020, at 8:35am

It is important to remain mindful that old age is not a disease, it is merely a number. Nor is age a reason not to treat a patient for a disease process in their senior years. Perhaps rather than concentrating on age, what is more relevant is the general health status of the animal. Do we have an accurate definition of what constitutes “geriatric” in our pets or patients? Probably not, due to diverse differences between species and breeds. But, with the advancement in nutrition and medical interventions, we do know that domestic animals are living longer.

The management of senior pets, especially dogs, starts when they are young. We should be educating owners about the risks of repetitive activities and advising about joint protection from an early age. We can be showing owners how to train their puppies to use a ramp and communicating the importance of weight management throughout all life stages. We need to be engaging with owners at the start of their animal’s life, before clinical symptoms become apparent or damage has occurred.

RVNs are highly qualified, skilled professionals and nurse-centric care is an essential part of any senior patient treatment plan. However, we know that animals in their senior years will often present with complex needs, have comorbidities (eg osteoarthritis, kidney disease, hypertension, endocrine disorders, heart disease, diabetes, cognitive dysfunction syndrome, dental disease, cancer) and their condition can change rapidly. Therefore, we must endeavour to provide the highest level of nursing care, through a programme of evidence-based nursing.

The RVN is instrumental in the provision of nurse-led clinics, inpatient monitoring and community-based care. We are often responsible for the development of care provision plans based on individual needs. Be prepared! Know what questions to ask and allow sufficient time.

Objectives for a successful senior patient clinic include: encouraging a thorough diagnosis; creating a treatment plan based on defined objectives incorporating the immediate and long-term care of the patient by a dedicated team and ensuring continuity of care; prioritising defined objectives and agreeing assessment strategies for patient reviews and the identification of measurable changes for owners to observe. A multimodal treatment approach including palliative care should be encouraged and you should aim for early detection of developing disease processes. Owner compliance should be developed, enabling objective observations and identifying the need for external therapists and specialists in a timely manner through the provision of regular assessments and health reviews.

The parameters regularly assessed in a senior patient nurse clinic should include blood pressure, urinalysis, blood profiles, weight management (body condition scoring is often more relevant than weight alone), muscle condition scoring, nutrition, mobility, pain and mentation.

We are often the vital conduit between pet, owner, vet and the wider support network, including therapists and specialists. Building trust and aiding the development of owner compliance is essential in achieving effective patient care. Continuity of care for senior patients is essential. Through the identification of clear objectives for individual patients we can more easily manage the correct interventions for each patient. We should be striving for early detection of disease processes, recognising emerging health issues and checking on the correct usage of medications. We need to facilitate the implementation of appropriate lifestyle, nutritional and medical management plans. Practices may prefer different approaches for treatment management plans but it is important to know what’s available in your practice toolbox.

So, what is a multimodal treatment approach? I often explain it to owners as a treatment jigsaw. We need all the pieces, in the right place, at the right time, to get the best result! We should be thinking of the bigger picture, incorporating all aspects of the animal’s life, including lifestyle and exercise management alongside referrals to relevant specialists and veterinary therapists in a timely manner.

I encourage all owners to keep mobility and well-being diaries for their pets. This might include brief entries about mobility and exercise tolerance or activity, pain, appetite and general demeanour. These can be discussed during clinics and help to build a picture over time, identifying trends and measurable changes.

Try to assign your senior patients to a dedicated nurse and vet team – a coordinated approach ensures the best patient outcomes for both immediate and long-term treatment plans. Senior animals regularly require an extended veterinary support network, including specialists and therapists; therefore, effective communication between people responsible for the care of an individual patient is essential. This ensures subjective assessment and interpretation of measurable changes, especially when determining levels of pain. Each team member should be utilising the same pain assessment tool but inevitably there will be some level of subjectivity in individual interpretation.

The mechanism of pain is complex and the pain experience for each pet and their owner will be different. We must be mindful of the individuality of the pain experience for our patients and remain aware that most animals will not vocalise their pain. Be aware of subtle signs indicating a changing pain state and be able to effectively question and educate owners how to recognise these signs in their pet.

Unlike acute pain, chronic pain is often expressed visually rather than vocally and so careful owner questioning is imperative when assessing a patient. We need to give client-specific outcome measures (Lascelles et al., 2007) and remember that pain management should be implemented in a timely manner and assessed regularly. Interestingly, Dohoo and Dohoo (1996) found that veterinary nurses consistently scored pain experienced by an animal more highly than vets and significantly influenced the use of analgesia.

There are many visual indicators of pain, such as lameness, a change in body posture, tail carriage or gait, reluctance or hesitation going up/down steps, the inability to roll, stretch or shake fully, changes in exercise tolerance or even changes in coat pattern. Behavioural changes can also be indicators of pain, such as reduced interactions or changes in behaviour towards owners or other animals, licking or chewing joints, changes in sleep patterns or positions, pacing, changes in eating habits or increased sensitivity to noise or external stimuli. Hyperactive behaviours can be a sign of pain and these are often breed-specific in dogs. Disproportionate pain response to touch could indicate the presence of neuropathic pain.

Although well tolerated at home, orthopaedic issues are easily exacerbated in the clinic environment on slippery floors, therefore we must ensure that patients are able to safely navigate their way around the clinic and don’t leave more painful than when they arrived. Many senior animals also have degrees of sensory and mentation impairment and we must always account for this for clinic or inpatient care. Canine cognitive dysfunction syndrome is often under-diagnosed but can lead to a decline in quality of life for both the dog and the owner (Landsberg et al., 2012). The clinic or hospital environment can easily become overwhelming for these patients. Therefore, home visits should be considered where appropriate for these vulnerable patients.

Hospitalised senior patients require specialised care plans, based on preparation and adaptation, taking into consideration physical, visual and auditory capabilities alongside overall levels of cognition. They will require physical and mental stimulation and physical therapy – passive range of movement exercises, regular mobilisation, non-slip mats and supportive orthopaedic bedding. Carefully consider position-ing during diagnostic procedures to reduce overextension of joints, fascia and muscles, particularly in arthritic patients where this could subsequently induce painful flare-ups.

Provide advice sheets and follow-up calls or emails between appointments. It has been suggested that 40 to 80 percent of medical information provided by healthcare practitioners is forgotten immediately (Kessels, 2003). There-fore, timely follow-up communications between appointments are beneficial to improve client bonding, resulting in better owner engagement and the subsequent improved welfare of our patients.

Inevitably, within the remit of senior patient care, we have a vital role to play in guiding and supporting owners through their journey of anticipatory grief and in the pro-vision of palliative care. This emotional toll on owners and staff should not be underestimated during this process. By supporting the owner through this journey, we are inadvertently supporting our patient also. We should be mindful of owner vulnerability during this time but try to remain objective about quality of life versus quantity of life.

Key points

  • Old age is not a disease
  • Be proactive not reactive
  • Multimodal treatment approach
  • Named nurse/vet team
  • Build trust and develop owner engagement
  • Remove barriers to clinic attendance

We should regularly ask ourselves “How can we improve our patient’s life within the remit of a structured treatment plan and resist allowing treatment plans to be defined by age alone?”

References
Author Year Title
Dohoo, S. E. and Dohoo, I. R. 1996 Postoperative use of analgesics in dogs and cats by Canadian veterinarians. The Canadian Veterinary Journal, 37, 546–551
Kessels R. P. 2003 Patients' memory for medical information. Journal of the Royal Society of Medicine, 96, 219–222
Landsberg, G., Nichol, J. and Araujo, J. 2012 Cognitive dysfunction syndrome. Veterinary Clinics of North America: Small Animal Practice, 42, 749-768
Lascelles, B., Hansen, B., Roe, S., DePuy, V., Thomson, A., Pierce, C., Smith, E. and Rowinski, E. 2007 Evaluation of client-specific outcome measures and activity monitoring to measure pain relief in cats with osteoarthritis. Journal of Veterinary Internal Medicine, 21, 410-416

Kirsty Cavill, BSc(Hons), RVN, MIAAT, owns and runs Paws Canine Myotherapy Care, providing musculoskeletal rehabilitation for dogs. She is a member of the International Association of Animal Therapists, head nurse with The Vet Connection, nurse advisor with Canine Arthritis Management and a street nurse with StreetVet.

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