Evaluación Clínica del Paciente Geriátrico

Introduction

Geriatric health care program is a challenge to the clinical vets to improve the health care of older dogs and cats. Commonly, the veterinary profession may not agree on what to call the program, or even how often per year the patient to be evaluated and what are the specific protocols to exam the animals and finally the importance of the communications with their owners.

Using the patient´s age as a point of reference for their collective decline is appropriate. However, each organ has a different rate of biologic aging; a critical assessment of a patient overall health status should be based on a complete health screening of each specific organ function if possible.

The comprehensive health assessment is an essential component of a senior health program to identify early disease condition, recognize behavior problems and establish a database for successive evaluations.¹ The first step is a complete age specific history; the second step is related with the physical examination, where the geriatric patients require a more extensive examination. The third step included the appropriate laboratory evaluation and additional diagnostic testing.

In this meeting we can find a guideline for an exceptional physical examination focused in common diseases in older patients, the early recognition improves the quality of life for dogs, cats and their owners. The minimum canine and feline database are included and an analyses for each one of the most important findings in the routine exam.

Chronological or Biological Aging

Aging is the result to the effects of time on the cellular function, organs and body systems. It´s not a disease, but is a complex process to show the progressive declining of behavior and health among others abilities, when there are different influences such as nutrition, environmental factors, genetics and the special care from the pet owners.²

There is a common guideline to classify the aging stage (Figure 1)¹ but it's not enough at all, and the clinician have to do efforts to build an individual classification for each patient, accord to the physical examination and data base in his country and region.

Figure 1. The human/pet age analogy chart1

Clinical Screening

The clinical screening is an important tool to establish a baseline assessment for future comparison and to detect subclinical disorders; however, the clinician must have care to identify all of diseases as possible but starts an intelligent program care and creates a good communication with the pet owner.

Frequently the care program includes a preventive plan, a specific anamnesis, a complete physical examination, laboratory evaluation and others diagnostic tools.

The objective of age-specific history, must be to convince each owner to become a much more active partner in the health care of their older pet including their observation skills. In this point there are specifics questions for the specific problems; for example, in the cognitive dysfunction syndrome (CDS) that affect more than 22% of the geriatric population, owner-based observational questionnaires are very useful to check behavioral and cognitive deficits.³

Physical changes can be recognized by the owner such as obesity, lameness, skin changes, muscle mass decrease and dental tartar between others. An exhaustive check list for each corporal system is necessary to identify the early senior diseases.

Physical Examination

The geriatric patient requires a more extensive examination that should include a weight assessment, exhaustive palpation of lymph nodes, digital rectal examination to see some tumors and prostatic size.

The musculoskeletal system is frequently affected, osteoarthritis (OA) is a common cause of pain and dysfunction in geriatric patients. However, sometimes they can demonstrate only a little change in behavior. Is very important to classify the clinical signs in dogs and cats (Table 1) to guide the specific therapeutic and management.⁴

Table 1. Common clinical signs of osteoarthritis

The chronic kidney diseases occur commonly in older dogs and cats, the clinical manifestations are hyporexia, vomiting, ulcerative stomatitis, the kidney palpation is not frequently, but often is possible to palpate irregular shapes and sizes.⁵

The thorax auscultation of pulmonary and cardiac sounds are obligatory in the physical examination, slightly more than 10% of dogs and equal percentage of cats seen by a veterinarian have some form of heart disease, with an ageing population, close to 90% of the dogs with heart disease have mitral regurgitation. In this disorder the 99% of this dogs have an audible cardiac murmur. Thus the physical examination of cardiopulmonary system offers close to 80% of the diagnostic findings.⁶

The metabolic and endocrine system diseases are frequently present in geriatric patient, dermatologic manifestations, polyuria, polydipsia, polyphagia, and changes in weight, are common in dogs with diabetes, hyperadrenocorticism and hypothyroidism.

The effects of age, concurrent illness, and administered medications complicate the diagnosis of thyroid dysfunction, and others endocrine diseases in geriatric patients, thus, it is important to be focused in the clinical signs and the complementary tests.⁷

The neurologic disorders in older dogs and cats includes degenerative and inflammatory nervous diseases in the central nervous system. The vertebral instability is more frequent in some breeds and easy to identify, however, the cognitive and vestibular syndrome represent a diagnostic challenge. The specific questionnaire and neurologic examinations of each patient will be necessary to identify the stage and offer the best management.⁸

The screening panel. There is a minimum database accessible that includes complete cell count, biochemical profile with electrolytes, and complete urinalysis. The specific panel, including renal testing (e.g., urine protein/creatinine ratio, urine culture), thyroid confirmatory tests (e.g., free T₄ by equilibrium dialysis, canine thyroid-stimulating hormone [TSH], tyro-globulin autoantibodies), adrenal profiling, hepatic function tests (e.g., bile acids, ammonia tolerance), endocrine function tests (e.g., serum fructosamine, glycosylated hemoglobin, insulin, ionized calcium, parathyroid hormone [PTH], PTH-like peptide), and blood gases among others. Other frequently performed senior procedures include imaging (e.g., survey, contrast, and dental radiography; ultrasound; echocardiography; CT; MRI), cytology, histopathology, laparoscopy (especially hepatic biopsy), and endoscopy (e.g., gastroduodenoscopy, colonoscopy, bronchoscopy).¹

Conclusion

Geriatric profiling allow veterinarians to more successfully diagnose and manage an early condition. The benefits include anesthetic safety, pharmaceutic safety, dietary recommendation, earlier disease management offers a life span of the patients and their owners.

References

1.  Fortney WD. Implementing a successful senior/geriatric health care program for veterinarians, veterinary technicians, and office managers. Vet Clin North Am Small Anim Pract. 2012;42(4):823–834. Available from: http://dx.doi.org/10.1016/j.cvsm.2012.04.011.

2.  Metzger FL. Senior and geriatric care programs for veterinarians. Vet Clin North Am Small Anim Pract. 2005;35(3):743–753.

3.  Rosado B, González-Martínez, Pesini P, et al. Effect of age and severity of cognitive dysfunction on spontaneous activity in pet dogs - Part 1: Locomotor and exploratory behaviour. Vet J. 2012;194(2):189–95. Available from: http://dx.doi.org/10.1016/j.tvjl.2012.03.025.

4.  Beale BS. Orthopedic problems in geriatric dogs and cats. Vet Clin North Am Small Anim Pract. 2005;35(3):655–674.

5.  Bartges JW. Chronic kidney disease in dogs and cats. Vet Clin North Am Small Anim Pract. 2012;42(4):669–692. Available from: http://dx.doi.org/10.1016/j.cvsm.2012.04.008.

6.  Hamlin RL. Geriatric heart diseases in dogs. Vet Clin North Am Small Anim Pract. 2005;35(3):597–615.

7.  Scott-Moncrieff JC. Thyroid disorders in the geriatric veterinary patient. Vet Clin North Am Small Anim Pract. 2012;42(4):707–725. Available from: http://dx.doi.org/10.1016/j.cvsm.2012.04.012

8.  Golini L, Colangeli R, Tranquillo V, Mariscoli M. Association between neurologic and cognitive dysfunction signs in a sample of aging dogs. J Vet Behav Clin Appl Res. 2009;4(1):25–30. Available from: http://dx.doi.org/10.1016/j.jveb.2008.09.033