Integrative Approach to Geriatric and Hospice Care
As veterinarians, we are often faced with situations beyond the scope of what we were taught in veterinary school. I learned this early in my career when working with wildlife and zoo animals. But even in small animal practice, our veterinary training, strong in teaching about medicine and surgical procedures, falls short as we deal with aging, chronic conditions, or hospice. That is where I look to my integrative training.
In my integrative practice, I treat many geriatric pets. My clients tell me that our alternative approach provides a reasonable course of action for their aging animals, and that by having a commonsense plan they feel less helpless and worried about their pets’ condition. They feel empowered by improving not just the quantity, but the quality of their pets’ lives. The final decision for the pet is therefore made with a clearer conscience.
In geriatric medicine, pharmaceutical or surgical intervention is often not an option, but veterinary care is still needed. Integrative options, both modern and ancient, have offered owners and pets a better answer than “oh, she’s just getting old”. With a growing volume of geriatric and hospice cases, it is essential to have a plan that can provide the foundations of health for each patient.
Geriatric cases can be daunting, with long histories of chronic and cumulative problems. But I think about each geriatric case as an opportunity to make a big difference in the animal’s quality of life. With excellent nutrition as the foundation, other conditions associated with aging are easier to manage. That’s why an earnest and very specific conversation about nutrition is the largest part of every geriatric exam in my practice. The owner must be invested in the science and sense of supporting the animal with an appropriate diet in order to ensure the kind of successes I expect.
I have refined the strategies I use for my aging patients into a system that creates a plan for each individual. Starting with a foundation of an excellent, high protein diet with proper moisture content, I can then focus on the integrative options for each individual. These might include supplements, homeopathy or herbs, acupuncture, chiropractic, laser, physical rehabilitation and massage therapies, exercise, and simple ideas for the logistics of home care. Even in hospice care, elements of integrative medicine can improve life for both patient and owner.
FOOD IS MEDICINE
No matter how old, problematic or unwell an animal may be, try food as medicine. An elderly pet that eats a well balanced raw food will be more spry, vital and energetic, and have less pain from inflammatory conditions, than an animal eating dry processed kibble. Treats must also comply with the rules.
Protein: Older animals need more rather than less protein in their diets to maintain their muscle mass and body condition. For most of my geriatric patients, I suggest a diet that is at least 40% protein on a dry matter basis.
Carbohydrates: Should be a very low percentage (less than 30%) of what a geriatric patient eats. A diet high in carbs can cause and worsen inflammatory conditions such as arthritis, autoimmune conditions, hormonal imbalances, allergies, poor hair coat, cognitive issues, obesity, diabetes, gastrointestinal disorders, etc.
Fat: It’s essential for mental health, proper nerve function, hormonal balance, metabolism, skin and hair coat, and many other body functions. Appropriate fat content (over 25%) in the diet of an aging dog or cat is much healthier than a high carb diet. Eating appropriate amounts of fat does not mean the animal will become overweight. Avoiding carbohydrates and eating proper amounts of food and treats is more important for weight management than avoiding fat.
Here is my food ranking for dogs, from 1 to 5. (Food suggestions for cats are the same, but with less force because the “catveat” is: there’s no rule about cats – cats will eat what they will eat).
1. Commercially prepared well-balanced raw food
2. Balanced homemade meals (for most clients this is unsustainable)
3. Freeze dried or air dried raw foods
4. Canned foods
5. If you must, a dry kibble food
RETHINK ALL MEDICATIONS AND SUPPLEMENTS
Re-evaluate all medications and supplements at least monthly. Make sure not to mistake side effects for signs of serious health decline. I have seen this with antibiotics, pain medications, supplements, anti-inflammatories, and thyroid medications.
I have had clients discussing euthanasia because they felt their animal had lost the will to go on, only to be shocked by the reappearance of their energetic pet when a pain medication or antibiotic was discontinued. Sometimes, doses need to be decreased as animals age and wither; sometimes they need to be increased to keep up with current conditions.
Avoid oral medications where topical meds might work. Many skin conditions, resistant infections and even odd lumps can be more safely treated topically than orally. If you need to increase absorption of a medication, add dimethyl sulfoxide (DMSO) as a great carrier for topical medication. As long as the owner or pet isn’t sensitive to sulfas, DMSO topical mixtures can be a great option. I will often combine DMSO with natural lotions like calendula, arnica or even Manuka honey, or homeopathics like Traumeel®, and antibiotics or anti-inflammatories. Keeping an open mind about medications is essential.
Many owners resist giving supplements or medications because they dread giving pills to their aging friends. Our older pets get wise to us, and it can be difficult to push down pills or hide them in a meal. I avoid most commercially-made “pill pockets” because they tend to contain grains or peanut butter, which contribute to inflammation.
Some animals, even geriatric ones, love to eat and will eat anything. Many others who already have developed poor appetites, especially cats, may completely stop eating if anything at all is added to the food. Work with the owner to use pill pockets even if the treatment is a powder or liquid. Offering the medicated “treat” when the pet is hungry may also help. Your goal is quality of life for the whole family, so treatments need to be easy to administer.
For healthy “pill pocket” options, try plain butter (make a butter pat/pill sandwich, put it in the freezer for a minute, and it slides right down), goat cheese, sliced unprocessed meats, sardines, natural liverwurst, and even vanilla ice cream.
I never recommend putting a medication, even flower essences, in drinking water. Water should just be water. Hydration is essential to older animals. I don’t want to risk an animal drinking less because the water tastes bad.
WHAT GOES IN, MUST COME OUT – FECAL AND URINARY INCONTINENCE
Many approaches can improve quality of life for an elderly animal that has fecal or urinary accidents. When conditions like infections, estrogen deficiency, anal gland issues, parasites, cancers, or bladder stones have been ruled out, the next step is to manage the condition by improving the quality and decreasing the quantity of defecation and urination, or by using holistic approaches to actually resolve incontinence.
At my clinic we say (half joking) that when animals eat raw food, even the poop is cute. Firm stool makes fecal-incontinent animals much less burdensome for the owners. Eating a once-daily meal of raw food can be the most helpful solution for fecal incontinence. In many cases, the animal doesn’t have accidents in the house anymore. And if they do, they are easier to predict and clean up.
Raw food once daily is also effective for urinary incontinence. An animal that is not processing dry kibble, but is eating a moistureappropriate food, will drink a more normal amount of water and will not overfill the bladder, thereby decreasing the urge to urinate.
The four F’s of fecal incontinence
Owners may think of an F-word I won’t mention here, when fecal incontinence is discovered. Here are four other F-words that can help owners recover their dogs’ dignity.
1. Food – Decreasing the amount of filler (prevalent in kibble) in food will usually decrease the volume of feces. Raw food really shines here.
2. Frequency – Feeding once a day gives a clear signal about defecation when the food all arrives in the colon at once. If the pet still gets the signal crossed, at least it’s easier for an owner to predict when the animal might need to go.
3. Focus – There are constant distractions from the outside world when an animal goes on a walk. The signal to defecate may not be strong enough to override all the fun stimuli. “The Double Walk” can get the dog to focus on the job at hand. After the first walk, come in for a few seconds. Then head back out the door. The second walk will be less interesting. The first walking will have stimulated the colon, and the dog may have more success.
4. Floor – This technique is based on the principle that you can cause a dog to defecate by taking his temperature rectally, which stimulates the pelvic floor. Just before the last bedtime walk, use a thermometer, or a gloved finger or Q-tip with some lubrication. Put it in the anal opening and gently press a few times on the pelvic floor. Sometimes it just takes a mild stimulation around the anal opening to make a dog poop. Be ready to go right outside. If the owner is not squeamish, this is an effective method for preparing a dog for a good night’s sleep.
MOBILITY – MOVE IT OR LOSE IT
Becoming sedentary with arthritis, general weakness or secondary lethargy can trigger a dangerous downward spiral. Disuse atrophy of leg and back muscles destabilizes the joints and spine, causing unbalanced, hesitant or stilted gait patterns, and increasing discomfort. Even gentle weight-bearing exercise strengthens the muscles and circulates nutritive synovial fluid over the surfaces of the joint. Confidence in the limbs comes from using the limbs, pure and simple.
This is one of the reasons I use underwater treadmill treatments to improve muscle mass and coordination. With the underwater treadmill, the animal is buoyant, and feels weightless while working the whole body, without the risk of falling. The improvement in ambulation, even with infrequent treatments, is surprising.
Take a walk on the wild side
I recommend that clients go on walks where their pets can experience/ smell/see something new. Keep the mind engaged and the body will follow suit. Even if the pace is very slow, do the walks – and make them interesting. For animals that are having cognitive problems, I have had great success using Cholodin to improve mentation and cognition.
Try moving off the beaten track
Dogs and cats benefit from challenging terrain. If walks are only on flat surfaces, fl at may be the only surface the pet can navigate. Make games that include varying surfaces for indoor pets. Outdoors, maneuver the pet over tree roots, gravel, and irregular ground. Step up and down curbs, go around posts, walk in short figure-eight patterns and go up or down inclines or driveways.
Place toys or treats in places where it requires some effort to retrieve them, and don’t forget to play with your aging cats. People play games with dogs at many life stages, but mature cats are often left to sleep all day. Don’t just put treats under their noses; make them do a little work for them. Place treats up a flight of stairs or on top of some climbing toy. Those wire-bouncing fobs and little mouse toys are not just for kittens. And the cat may shed some unwanted weight as well.
Stepping up with confidence
Put in an extra light fixture over the stairs, and perhaps carpet them too. This may sound like a home decor solution, not a veterinary one, but it can be crucial for an aging pet with an optical condition. Animals with lenticular sclerosis can have trouble with low light conditions and depth perception. It may appear that a pet’s arthritis makes him hesitant on stairs when in fact it might be a vision issue. Make sure that irregular surfaces or steps for the older pet are well lit.
The pads on older canine and feline feet can slip more on smooth surfaces. Adding area rugs and other non-skid floor coverings can help them get up and move more confidently. ToeGrips, adhesive foot pads, waxes or non-slip booties, if they aren’t too bulky, can also help. Place carpets, runners, non-skid tape, rough paint, rubber mats or even yoga mats in slippery spots.
MASSAGE – ONE OF THE BEST KEPT SECRETS IN ALTERNATIVE MEDICINE
Massage is effective for so many conditions – musculoskeletal pain, chronic pain, poor healing, scar treatments, postoperative recovery, cognitive issues, chronic conditions, circulation problems, autoimmune problems, allergies, sinus issues, anxiety disorders, neurologic conditions and more. I will hear owners say, “I’m not giving my dog a massage till I get a massage,” which I absolutely understand. We should all have a good massage now and again. But it is unfortunate that we are more comfortable recommending costly medications, surgery and other treatments with potential unwanted side effects, than recommending a simple massage.
Simple massage techniques to teach owners
1. Feet – Once a day, gently squeeze the feet and pull slowly along the toes of a geriatric dog or cat. This physical therapy trick can strengthen the neurological connections from the brain to the foot, improving conscious proprioception (proper foot placement) and leg mobility.
2. Face/head – A light pressure of small circles around the base of the ears can improve circulation and ear health. Facial, cheek and head massage can calm anxious older cats and even improve cognition.
3. Spine/tail – Use light pressure with fingertips in little circles (a la Tellington Touch™) all the way down on either side of the spine to help with overall circulation, lymphatic drainage, and spinal health. Little massage circles invigorate nerves, muscles, lymphatics, tendons and ligaments. Gentle traction in a smooth massaging stroke down the tail can help stretch spinal tendons and ligaments and improve inter-vertebral circulation. A supple spine can mean a more active dog or cat.
THE AGING LARYNX
When dogs start to develop laryngeal paralysis as they age (this typically occurs in large breeds), the condition is considered progressive and difficult to treat. Laryngeal paralysis can be life-threatening because a dog may have trouble keeping cool in the heat if his larynx can’t fully open and allow panting to cool him down. It can even eventually cause airway obstruction. The options in conventional medicine are surgical – the laryngeal tie back – or perhaps trying a tricyclic antidepressant (Doxepin).
Owners may first notice a sort of phlegmy clearing cough when pets first get up (the “old man cough”). This is typically because saliva has pooled around the slightly lax/open larynx and dripped down toward the trachea while the dog was sleeping. Once cleared, the dogs doesn’t usually continue coughing during the day. When I see this sign, I recommend alternative treatments as well as checking the thyroid condition of the dog.
Hypothyroid conditions can predispose a dog to have laryngeal paralysis. It is wise to check the thyroid status of any dog with signs of laryngeal paralysis.
Sometimes properly treating the thyroid problem (supplement twice a day on an empty stomach) can slow the progression of paralysis.
I use acupuncture – there are effective acupuncture points lateral to the larynx – to improve laryngeal function. I have found both dry needles and aquapuncture with vitamin B12 to be helpful. While success can be subjective in this condition, owners feel acupuncture makes a noticeable difference in respiration effort, and are pleased with the treatments.
The best thing about acupuncture in an older animal is that it is an effective treatment without major side effects, and can be tailored to any patient. The geriatric patient often suffers from arthritis pain, anorexia, and multiple other chronic conditions. Acupuncture has been shown to be effective an all these and more. Most older pets tolerate treatments well, and have amazing improvements.
Vitamin B12 aquapuncture
In some cases, injecting a small amount of vitamin B12 into appropriate acupuncture points is useful in older animals because they tend to be deficient in vitamin B12 and the effects can last longer than dry needling. In fact, I recommend single vitamin B12 injections, sometimes weekly, as a tonic for many elderly patients. It can improve energy and appetite.
This is commonly and successfully used for the geriatric patient. Regular chiropractic adjustments are recommended for musculoskeletal issues, stilted gait, neurologic disorders, or animals with amputations. Chiropractic treatments can also improve overall mentation, attitude and sometimes resolve other chronic ailments.
Cold laser light therapy
This therapy has been extremely effective and well researched. There are protocols to decrease swelling and inflammation, reduce scarring, and increase healthy circulation. Laser can be used for many chronic painful conditions of the joints, edema, and also for many chronic skin conditions, including non-healing wounds, resistant infections, and even mites.
ON THE NOSE – DRYNESS AND CRUSTINESS
Crusty noses can be a sign of a significant autoimmune condition or nutritional deficiency, but sometimes older dogs just have dry noses. After ruling out any underlying medical cause, there are a few options to try. My clients feel that Vaseline on the nose is the most reliably effective topical treatment for an elderly dog’s dry nose. I have also had some success with shea butter or coconut oil topically. Vitamin E or fish oils make the nose sticky, not smooth. Bag Balm can be too irritating, and its pungent odor can irritate a dog’s keen sense of smell. Coconut oil taken orally (about 1 tsp daily per 30 lb to 50 lb dog) can ameliorate dry noses somewhat, and improves dandruff, dull hair coats and general gastrointestinal health.
Change plastic bowls to ceramic, metal, or glass bowls, and clean them regularly. Plastic bowls may be a low level chronic irritant to an older animal’s oral/nasal skin. If the older pet doesn’t seem hungry and is looking thin, it may be that she just can’t smell the food. Loss of interest in food with age may be a sign of some significant illness such as cancer, systemic diseases, or dental problems – or the answer may be under her nose. Smell is an important appetite stimulant. Aging animals can have trouble with their sense of smell due to many causes, including previous respiratory disease, or side effects of medication such as some anti-inflammatory meds. These animals may be idly wondering what those scentless clumps are in their food dishes, but dinner doesn’t come to mind – or their olfactory lobes.
To enhance smell, try warming up the food, or mix in some hot water, chicken broth, tripe, or a slurry of meat baby food (one that doesn’t contain onion or onion powder). The dog will more likely come running for supper if you super-size the aroma. Add something new like vanilla ice cream or sardines. When owners have been feeding fresh food, they can offer any “bribe” foods they have learned to use over the years. I’ve noticed that many aging dogs skip their morning meals. Even with enticement and fabulous-smelling food, they just say no. Yet, by supper, they quickly clean their bowls. As long as everything else seems normal – and there’s no vomiting or other signs – many older dogs can do just fine skipping breakfast, if that’s what they choose, and their weight is stable.
In addition to watching a pet’s weight, actively make him slim. If a dog is overweight and his thyroid is normal, believe me, it’s the food. Don’t worry about exercising more, or health issues that preclude exercise. Weight loss is all about food. Decrease the amount fed. Even cut the amount in half. Dogs, as scavengers, don’t go into starvation mode when there is less food. They just eat their fat, a benefit of the species that we don’t take advantage of nearly enough. A recent study stated that over 50% of dogs in our country are obese. We can improve this frightening statistic as we control everything they eat.
An aging and overweight pet faces many health, mobility, energy, and mental issues. Remember, for every pound a dog loses, he feels four pounds less torque on each leg. This is a good incentive to keep an older pet thin. Every pound truly counts!
We can’t make our patients live forever, or extend their lives to match ours. However, there are many simple, common sense actions we can take to improve on their lifespan, and mitigate the effects of old age. Offering multiple options involves clients in the process, thereby increasing client retention and satisfaction. Using these approaches may significantly extend the life of some animals (even ones officially in hospice), and always increases quality of life.
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