Wellness: Health Care
Back from the Brink
The first time I saw Mugsy, he was under anesthesia, prepped for surgery; huge patches of skin over his legs, chest and flanks were beginning to slough and surgical intervention was required. “Is that what I think it is?” I asked Dr. Khorzad, the ER attending in charge of the case.
“Yep. Necrotizing fasciitis,” she replied, avoiding the more sensational and fear-mongering synonym: “flesh-eating disease.”
Mugsy was a gregarious, four-month-old male Shar Pei who had suddenly developed a dime-sized swelling on his chest.
“I thought it was just a bug bite,” said Mugsy’s owner, Chuck. But within 24 hours, his boisterous puppy had collapsed and become septic, and he was in excruciating pain.
Though the media plays up the concept of invisible bugs munching their way through tissue, the disease typically starts out with a minor injury, or even no identifiable trauma. Bacteria inoculated under the skin produce toxins and protein-destroying enzymes capable of cleaving skin from underlying fat and fascia.
“Now he’s doing better,” said Khorzad, as one of our residents began removing dead and dying flesh. “Good job I didn’t reach the owner when I wanted to put him to sleep.”
Her comment sent me backtracking through Mugsy’s history to discover how a failure to communicate had saved the dog’s life.
Shortly after his admission, Mugsy had taken a turn for the worse; his blood pressure plummeted and his pain became intractable. Given his blood work, clinical parameters and response to therapy, Khorzad was convinced that Mugsy could not survive. Ready to recommend humane euthanasia over suffering, she called Chuck, urging him to get to the hospital as soon as possible. But Chuck didn’t pick up. Every call went to voice mail.
It turned out that Chuck was in the middle of a “Tough Mudder” event, running up and down an intense army-style obstacle course in rural New Hampshire. When he finally listened to his messages some five hours later, he jumped into his car and headed straight for the hospital, still covered in mud. Amazingly, by the time he arrived, Mugsy had done the unthinkable. His puppy was more comfortable and his fever was beginning to subside. Mugsy actually wanted to eat.
Chuck told me, “When we first came through the ER, I lay down with him and said, ‘If you’re going to fight, I’ll fight with you.’ As weak as he was, he placed his paw on my hand. I knew he didn’t want to give up. During the race, I wore an armband with his name on it. I didn’t know whether I would be strong enough to complete the course, but I reckoned that if Mugsy could fight, then so would I.”
Roughly one in four people die from necrotizing fasciitis; many are subjected to multiple surgeries, including limb amputation. Fortunately, in dogs, nearly 90 percent survive. Mugsy required only one major procedure, managed to keep all four legs and came back to make a full recovery. Today, he is a healthy one-year-old, with a few lengthy scars to show for his brush with death.
I asked Chuck and Dr. Khorzad what they learned from the five hours that made all the difference.
“I know what would have happened,” said Chuck, “but Dr. Khorzad was always totally up-front with me. A while back, I got in a car accident and damaged the tendons in my hand. Doctors said I’d never catch a baseball in a glove again. Guess what?”
Chuck didn’t dwell on the kismet of being incommunicado. It was enough to be an optimist, a fighter—and, as he said, “it’s not over ’til it’s over.”
I know how it feels to see a dog you had given up on, a lost cause, come back from the brink of death. It’s a humbling and haunting experience. Dr. Khorzad did not make a mistake. Hindsight is not a prognostic tool. She made a call in real time, and as I see it, her fallibility defined her honesty, prioritized her desire to stop suffering. She saw the lesson as a new perspective on future cases.
“As the years pass, I am more and more willing to give a chance to the cases that have a low chance of recovery.” It’s the mindset of a clinician who never ceases to be amazed by the power of canine determination. It’s the silent whisper in an ear, the invisible tap on the shoulder, the reminder that—as was the case with Mugsy—it’s not over ’til it’s over.
Wellness: Health Care
Palliative and hospice care making strides
My first contact from Stryker’s family came via email: “He was just diagnosed with anal cancer and also has a lymph node that is affected. We don’t think we want to put him through two surgeries. Would it be possible to set up a time for you to visit him?”
Stryker, an exuberant eight-year-old chocolate Labrador, met me at the door with a stuffed manatee in his mouth. Tail wagging and full of energy, he was not what one might expect to see during a hospice intake exam. As his family and I gathered on the floor, Stryker vied for my attention. His caregivers’ eyes misted up as they told me about their goals for him and their fears about his diagnosis. Meanwhile, Stryker rolled around, tongue lolling, grabbing various toys. His expression said, Why are you sad? Let’s play!
My examination of Stryker confirmed that there was indeed a large mass occupying the space where his anal sac should be, on the inside left wall of his rectum. The only thing that made the process challenging was the vigorous side-to-side movement of Stryker’s tail. His people watched me, concern and love for this dog evident in their furrowed brows. Stryker’s only concern was my finger in his rectum.
Over the course of about two hours, I heard the family’s story. When Stryker was diagnosed, aggressive surgery was recommended in the same day. His family wasn’t sure they wanted to put him through the procedure, and they needed more guidance, more time to think. When they asked about other options, they weren’t given any, other than my least-favorite phrase in the veterinary vernacular: “Well, you can always do nothing.” Could those really be the only options, aggressive surgery or nothing? It seemed implausible. And fortunately for all of us gathered on the floor that day, it was.
The World Health Organization defines palliative care as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” In my work as a veterinarian exclusively dedicated to geriatrics, hospice and palliative care, I increasingly find myself mapping my own professional purpose to this definition.
Transitions between geriatric care, palliation and hospice are often blurry, to say the least. In an attempt to extract meaningful data, I maintain a spreadsheet of all the patients I have seen; in it is a column in which I try to categorize the nature of the case. I can tell you that it’s not always easy to assign a label. I can also tell you that when I started focusing exclusively on end-of-life care, I had no idea how desperately needed palliative care really was. It became very clear very quickly that people were euthanizing pets—beloved family members, according to more than 80 percent of Americans—because they felt they had no other choice.
These animals were in pain, I was told. I agreed. But when I asked what kind of pain-management strategies had been implemented, the answer was usually “none.” Attempts to alleviate pain and other physical symptoms such as diarrhea, incontinence or decreased mobility were woefully inadequate, or well-intentioned but poorly implemented, with little guidance or followup. I was meeting families who were at their breaking points, and who could blame them? No one wants to live with a vomiting, whining, confused animal who’s in pain and turns the living room into his favorite place to urinate.
But what if these symptoms could be minimized or eliminated? I am increasingly finding that people are willing and able to implement simple solutions to help their pets and preserve the bond they have with them when it is most threatened.
Examples of palliative medical interventions that can help pets with lifelimiting symptoms include:
• Antibiotics for chronic skin, dental or urinary tract infections.
• Anti-anxiety medications for psychological distress associated with limited mobility, nighttime pacing or signs of cognitive dysfunction.
• Pain medications in specific combinations for advanced multimodal pain relief.
• Skilled use of narcotic and non-narcotic medications for adequate pain relief. (This means that your care provider must have a current DEA license.)
• Physical-medical modalities such as heat, massage, physical therapy, laser and acupressure to improve mobility, comfort and muscle tone.
• Complementary therapies such as acupuncture, herbs and homeopathic remedies to address a wide variety of clinical signs. (A credentialed professional trained in these modalities should provide these services.)
• Appetite stimulants to boost caloric intake and improve overall well-being, if appetite is a primary issue and can be improved without undue negative consequences. (The pros and cons of stimulating appetite and an in-depth discussion of the goals of nutrition for each individual patient must take place. This is a tremendous source of stress for people, as well as an important philosophical conversation within hospice care.)
• Mobility aids, environmental enrichment and in-depth assessment of the home environment and other living spaces of the patient to identify areas that may have a negative impact on the animal’s quality of life, and developing strategies to improve them.
Stryker’s care plan involved all of these elements, plus counseling for his family regarding their goals, expectations and hopes for him. The psychosocial aspects of this type of care cannot be underestimated. With a comprehensive care plan, euthanasia is no longer such a low-hanging fruit.
I should say up front that I am not a fan of talking people out of euthanasia. As I make very clear when I lecture veterinary students about communication at the end of life, once people have made that decision, they have given it a tremendous amount of thought— more than they may let on during a traditional veterinary appointment. Once people have reached the place where they are willing to intentionally end the life of their companion animal, I think the best thing I can do is to support them through the process and provide bereavement support after the fact.
That said, this epidemic of euthanizing pets because of the perception that there is no other option breaks my heart a little each time I see it. Striking a balance between supporting people, not rocking the boat of a lifetime relationship with a family veterinarian and honestly responding to families when they look at me wide-eyed and ask “Is there anything else we can try?” is dicey. It’s something I’m becoming better at on the fly, as well as something that drives me with the determination of an Olympian-in-training to develop the best palliative care practice possible, and help others do the same.
As is the case with human hospice and palliative care, early provision of services is key to providing the most comprehensive care and enabling the entire family to benefit from it. People sometimes say, “Someone told me about you, but I’m not sure if my pet is ready for your services yet.” My response is, “If you are already asking the question, your pet is ready now, and likely, so are you.” We don’t have a specific timeline for pets as we do for people, largely because we don’t have a Medicare hospice benefit that will only kick in at a designated time. Far more practically speaking, the question is, what is “terminal” in a pet whose life we can legally end at any time? The definition is murky at times, and this complex ethical terrain is a source of great stress for many people. (Not to mention a fascinating and fulfilling career for me, as I help them navigate it.)
For Stryker’s family, a terminal diagnosis was the catalyst for seeking palliative care and hospice without really knowing what that would entail. Palliation became end-of-life care at some ill-defined point in our journey together. “Doing nothing” ended up being pretty involved, thank you very much. As a result, Stryker’s family reached their goal of giving him a birthday party and celebrating his life before facing his death. Stryker was also able to relax in a custom doghouse built into the deck (constructed while he was in hospice care).
During this fragile and personal time, I became part of Stryker’s family, honed my own clinical skills to provide the best care I knew how, and reaffirmed my decision to take the road less traveled in my professional life. Seven-and a half months after our initial meeting, we gathered again on the floor in the presence of a stuffed manatee, told Stryker that he was the best dog ever and said good-bye.
Spencer on the move!
Spencer is a two-year-old rescued Bulldog who had been paralyzed in his back legs since he has been a puppy. Linda Heinz found him on her back door step, but how he got there remains a mystery. She took him in and gave him a loving home. Her vet thought that Spencer’s injuries sadly pointed to abuse he had suffered as a young pup. He never had a chance to walk like other dogs. But Linda decided to take him to Tampa’s Westcoast Brace and Limb company and asked them to make a prosthetic to help Spencer to walk. Even thought they had never had a canine patient before, they were definitely up for the challenge and fashioned custom braces outfitted with green Crocks for rather adorable “feet” for him. As soon as Spencer was fitted with his new feet, off he went, running up and down the hallways at the clinic, he seemed to never get enough of this new walking sensation. See how Spencer got his “legs,” and how his pal, a blind pig named Porkchop, greeted him.
News: Guest Posts
At her intake at a shelter in April 2012, Bean was a pup with a familiar profile: a Pit Bull whose family could no longer care for her. But it wasn’t long before someone at the Humane Society of Silicon Valley in Milpitas, California did notice something unusual about her.
It was her lack of “boing,” says staff member Finnegan Dowling. “No Pit Bull puppy should be that mellow.”
Bean also had a stiff walk. When she was excited, she hopped like a bunny. They took her for x-rays, but even sedation didn’t relax her joints enough to get pictures, Dowling says, and the vet referred her to UC Davis for an MRI scan.
There, Dr. Karen Vernau, chief of the Neurology and Neurosurgery Service at the Veterinary Medical Teaching Hospital, discovered that her hip joints were improperly formed. Bean’s determined spirit wasn’t lost on Vernau, but her chances of adoption seemed slim.
The five month old pup was suffering from muscular dystrophy, a progressive and currently incurable disease that would affect many parts of her body.
According to notes in Bean’s file at the Humane Society, she was scheduled for a procedure at Davis on May 25. By the 29th, she was diagnosed with myopathy, a neurological condition. But somewhere in between those dates, Dowling says, Dr. Vernau’s relationship with her patient “went from obligation to affection.”
Vernau and her family decided to adopt Bean. As the vet told a reporter, “We didn’t intend to go down this path with her, but she just sucked us in.”
This happy ending was only the beginning of Bean’s harrowing medical story.
Gradually, things got worse. Surgery to correct her hips was followed by relief—then new problems. A massive hernia called for another surgery. Her swallowing improved, but the muscles in her esophagus were failing and there were bouts of vomiting so intense she would sometimes choke and pass out. Bean grew thinner as she struggled with aspiration (food getting into her respiratory tract when eating), which caused pneumonia.
Her vets sought help from colleagues in human medicine, a multidisciplinary approach the university encourages through its “One Health Initiative.” They included Dr. Stan Marks, a gastrointestinal specialist, and Dr. Peter Belafsky, an expert in human swallowing and airway disorders, and others.
With help from the biomedical engineering department, Bean had been fitted with a feeding tube that allowed her to eat several times per day. It worked beautifully, according to Dr. Marks.
But it didn’t stop the vomiting.
Since the vomiting put her life at risk, Belafsky concluded that they would have to stop it by removing her larynx.
Belafsky, who performed the second documented human larynx transplant, knew how profoundly such problems affect a person’s quality of life. And it was clearly true for Bean.
Her surgery, which lasted more than three hours, was the first ever canine laryngectomy. The procedure is typically used to treat human cancer. According to Belafsky, the separation of her breathing and swallowing tubes will prevent food from getting into her lungs when she eats or vomits.
The lessons learned in Bean’s treatment will impact human care, and vice versa, Belafsky said in a press conference after the surgery. Belafsky hopes she will inspire human patients who have also lost their voice and now breathe through a hole in their neck. She may just get a guest membership in the “Lost Cords Club” for people who have had a laryngectomy.
After all, Bean is only two years old, but has slept out more than 100 rounds of anesthesia and undergone eight surgeries and countless other procedures. Her “can’t do list” is long. Can’t bark, breathe or swallow normally. Forget gobbling down a treat, and she can’t swim without drowning due to the tracheostomy tube.
But the list of things she once endured, the choking and pneumonia, has been tossed.
Now when she accompanies Vernau to the hospital, she serves as ambassador and teacher, allowing students to experience canine tube feeding.
At home, Bean is learning new ways to enjoy life, which still holds plenty of the good old stuff – balls to chew, cushy beds, and a loving family that includes two other dogs.
Watch this video about Bean's surgery and recovery.
Wellness: Health Care
It’s about time.
Every so often after an exhaustive consultation, I am the lucky recipient of a peculiar compliment: “I wish you were my doctor!” When I was a young veterinarian, I was thrilled to be held in higher esteem than my colleagues in human medicine. Now, years later, I see the sleight of hand in a trick that flatters my profession at the expense of another.
It’s all about time. Time is critical to people’s sense that their dogs are receiving better quality heath care than they get, not least because much of what vets do takes longer. Veterinarians deal with “signs,” clinical findings that we touch, hear, see, smell and, if we’re unlucky, taste. MDs have the additional benefit of “symptoms,” their patients’ verbal communication of abnormal sensations or changes in bodily functions. This means that MDs can pick up on subtleties, aches and twinges, whereas dogs have to wait until a problem becomes grossly visible, palpable, malodorous, audible or debilitating to a sufficient degree that people finally realize something is not quite right.
Denied the luxury of the spoken word, veterinarians can only interpret the language of animal signs. Pediatricians, who encounter similar problems with young children, are forced to interrogate parents for answers, but similarities end when we approach a dog who does not share his owner’s regard for the man or woman in the white coat. In my world, nothing happens when I say “open wide,” hoping to inspect canine tonsils. Examinations require trust, trust takes time and, with so many new smells and sounds, the distractions are endless.
No wonder our style of medicine seems more personal. Dog owners feel less hurried because, thankfully, we don’t have a choice. I’m certain MDs are just as sympathetic, but they can save time via direct communication—and, for the most part, are less likely to be bitten.
Another major factor in veterinarians’ favor is the relatively small number of animals we serve compared to the volume of people seen by MDs. In an article in the Boston Globe, Judy Foreman (a nationally syndicated health columnist) made some interesting comparisons between two quite different Boston hospitals: Massachusetts General and my place of work, the Angell Animal Medical Center. Mass General sees 1.5 million outpatients a year, compared to about 50,000 at Angell. Patients at Mass General speak about 60 different languages, proving that the spoken word is not always that helpful (although that’s 60 better ways to communicate than I have), and its average number of inpatients at any given time is 800, compared to about 60 at Angell.
What this all means is that vets have more time for their patient and the spokesperson paying the bill. Fewer inpatients mean that blood tests, biopsy results and radiology reports are quick to turn around and their interpretation and communication to the owner is faster, all of which reinforces our superior service. We have more time to discuss the case, to leave written updates, to take pages, to return calls promptly, to go over discharge instructions in more detail. No wonder we look good. In my world, veterinarians are reimbursed for time spent with the family as well as the patient. It is an integral part of the service we offer.
Clearly, the human medical profession has taken notice of the superior patient satisfaction among their veterinary counterparts. A company called Customer Service University (CSU) has produced a 13-minute video called It’s a Dog’s World that highlights the consequences of poor healthcare service. Bob and his Golden Retriever, Max, are injured while out for a walk. As the CSU website boasts, “Bob is treated like a dog at his healthcare facility, and Max gets the royal treatment at his vet’s office.” The unfortunate logic of “being treated worse than a dog” is not lost on me, but I believe most viewers will find some unsettling truths in a tale that ends with Bob’s wife thanking an anonymous doctor for a followup call; the attentive clinician is unmasked as the vet when we hear suggestions on ways to hide medication in dog food.
These days, I have an answer ready when an owner drops the “I wish you were my doctor” compliment: I offer a smile, shake my head and say, “I’m pretty sure your dog would disagree. Ask his opinion the next time I take his temperature!”
Dog's Life: Lifestyle
Dog-related plans for 2014
Years ago, my sister’s New Year’s resolution was to give up New Year’s resolutions, and she was one of the few people who stuck to her plan. (Success rates are generally less than 10%.) Her secret was resolving to do something that she wanted to do anyway. If your resolutions for 2014 are dog-related, make success more likely by choosing to focus on one or a few things that are of real interest to you.
Simple ideas for dog-related resolutions are plentiful. Here are 10 possibilities.
1. Leave that cell phone in your pocket on walks so that you are truly present and spending time with your dog. It’s the time you spend together that builds the relationship, and this is one of the easiest ways to enjoy each other’s company.
2. Try a new activity with your dog. Classes in agility, tracking, fly ball are common in many areas. Hiking, weight pulling, dock jumping, herding, lure coursing and canine freestyle are just a few of the other possibilities.
3. Provide better nutrition for your dog. This is a big task for most of us, but even a few simple steps can make a difference. Try a higher quality dog food, add fresh vegetables to your dog’s diet or vow to measure your dog’s food for every meal so there’s no risk of overfeeding.
4. Give back to the canine community. There are so many ways to help out such as walking an elderly neighbor’s dog, volunteering at a shelter or rescue, fostering a dog, or giving money to an organization that improves the lives of animals.
5. Teach your dog something new. Practical training skills such as walking nicely on a leash, waiting at the door or a solid stay all pay big dividends. Other possibilities are to teach your dog a new game so you can play together more. Fetch, tug, find it, hide and seek, and chase games are all options, though depending on your dog, not every game may be a good fit.
6. Make plans for your dog in the event that you die first. Financial planning so you can provide for your dog when you are no longer here as well as making arrangements for someone to be the guardian for your dog are two important steps.
7. Give your dog more exercise. This can be daunting so plan to make one small improvement to start. Perhaps add 10 minutes to a weekend walk or set up a play date with a dog buddy a couple of times a month. When it comes to increasing activity, every little bit helps, so taking one step in the right direction is a wonderful goal at this, or any, time of year.
8. Take better care of your dog’s teeth. Consult with your veterinarian about a dental cleaning or about brushing at home. Dental care helps improve overall health and can make your dog’s breath more pleasant, too.
9. Make plans in case of a medical emergency. Whether it is putting aside a little in savings each month or investigating pet insurance, the peace of mind that you’ve got it covered in the event of an emergency is worth a lot.
10. Go new places with your pet. Novelty is great fun for most dogs, so try to go a few new places this year. Perhaps a new pet store or a new hiking trail will provide your dog with an experience that is really enjoyable.
Love them or hate them, New Year’s resolutions are common this time of year. Do your plans for 2014 include any dog-oriented New Year’s resolutions?
News: Guest Posts
In honor of November’s National Pet Cancer Awareness Month I would like to share some “hot off the press” wonderfully optimistic news with you. Dr. Nicola Mason from the University of Pennsylvania School of Veterinary Medicine has been researching a new way to treat osteosarcoma, an aggressive and fatal form of bone cancer that has an affinity for growing within the leg bones of large and giant- breed dogs.
Until now, treatment of osteosarcoma has consisted primarily of amputation (removal) of the affected leg with or without chemotherapy. In spite of such aggressive treatment, inevitably tiny clusters of cancer cells eventually grow into metastatic tumors that ultimately become life-ending. Approximately 60% of dogs die within one year of the diagnosis.
A new approach
Dr. Mason’s innovative approach to treating dogs with osteosarcoma involves “cancer immunotherapy” in which the patient’s own immune system is triggered to target and kill tumor cells. In order to use a dog’s immune system to treat osteosarcoma Dr. Mason devised a vaccine consisting of bacteria that have been modified to express a protein called Her2/neu. This protein is known as a “growth factor receptor” and is found on a variety of different cancer cells, including some canine osteosarcoma cells. You may have heard of Her2/neu before because it is commonly associated with breast cancer cells in women. The concept behind the vaccine is as follows: The bacteria stimulates the dog’s “immune system soldiers” to seek out and destroy the bacteria along with cells that express Her2/neu (osteosarcoma cells).
Outcomes to date
Thus far, Dr. Mason has treated 12 dogs with osteosarcoma following amputation and chemotherapy. The dogs received the vaccine once weekly for three weeks. Side effects of the vaccine were minimal. All that was observed was a mild, brief fever following vaccine administration.
The preliminary results have been immensely encouraging. The first vaccinated dog, Sasha has a survival time of 570 days thus far. Two other dogs vaccinated at the beginning of the study are alive and cancer free more than 500 days post diagnosis. Other dogs who were vaccinated more recently are still doing well. These are truly fantastic results.
What comes next?
Some dogs with osteosarcoma are not good candidates for amputation primarily because of neurological or musculoskeletal issues in their other limbs. Treatment options for these dogs are aimed at reducing the pain associated with the tumor. Dr. Mason plans to begin including some of these nonsurgical candidates in her osteosarcoma vaccine study.
Additionally, Dr. Mason is contemplating learning if what she has developed would be an effective means for prevention of osteosarcoma. Certain breeds (Rottweilers, Irish Wolfhounds, Great Danes, Saint Bernards, Doberman Pinschers, and Greyhounds, to name a few) are particularly predisposed to osteosarcoma. It will be fascinating to learn if the osteosarcoma vaccine will effectively prevent this horrific disease in high-risk individuals.
The research results gathered thus far represent a monumental success in cancer treatment and provide significant hope for a disease previously associated with a grim prognosis. Kudos to Dr. Mason for her stunning work! If your dog has osteosarcoma and you are interested in participating in Dr. Mason’s studies, contact her at 215-898-3996 or by e-mail at firstname.lastname@example.org.
If you would like to respond publicly, please visit Speaking for Spot.
Diplomate, American College of Veterinary Internal Medicine
Please visit http://www.speakingforspot.com to read excerpts from Speaking for Spot and Your Dog's Best Health. There you will also find "Advocacy Aids"- helpful health forms you can download and use for your own dog, and a collection of published articles on advocating for your pet's health. Speaking for Spot and Your Dog's Best Health are available at www.speakingforspot.com, Amazon.com, local bookstores, and your favorite online book seller.
Wellness: Health Care
For dogs with Alzheimer's confusion may reign as light falls
A slice of Oregon forest, a fragrant eight-foot noble pine, reigns over our living room in Southern California. I drape the boughs with a final string of lights—silly plastic teddy bears I’ve had for years—and step down from the ladder. It’s growing late on a Sunday afternoon. Our favorite Frank Sinatra carols are playing, scalloped potatoes are bubbling in the oven and the sun is going down over the Pacific Ocean. I’ve been looking forward to this: relaxing in front of the fire, the room lit only by the tree. I should have known better.
Recently, as the days shorten and the curtain of light falls earlier—at four o’clock, now three—Fromer, our 15-year-old Yorkie, goes bonkers! It’s as if the dark sets him off. Now he’s on the floor between my husband and myself, and his ballistic barking drowns out even the roar of the surf.
Five months ago he was diagnosed with terminal renal failure, and given two weeks to live. The vet said I should consider myself his hospice worker. (I don’t know about you, but a hospice worker to a dog was a new one for me.) I gave him subcutaneous fluids, fine-tuned his medications and administered pot roast aromatherapy. By October, my little hospice patient was skipping through the house. The vet cautioned me that Fromer still had renal disease; he was just “temporarily stabilized.”
So, our days were OK; the evenings were something else.
Like a young child squalling over a bogeyman only he can see, at night Fromer got spooked. On this December evening, I forego the pleasure of enjoying the room lit only by the Christmas tree, and switch on every light inside and out. He seems to calm down, but he is licking his paws so feverishly they will be raw if he keeps it up. His tommy- gun barking starts again. Night has turned him into Fromster-the-terrorist-terrier, an impossible-to-please elderly relative.
I poke at the embers to keep the fire from dying out, while Fromer totters off, whimpering in and out the dog door—flap! flap! out, flap! flap! in—the rest of the evening. Until we pack it in and head upstairs. Then he peters out.
When I originally mentioned these symptoms to Stephen Ettinger, our vet, I didn’t get much satisfaction. Dr. Ettinger is an internist, cardiologist and co-author of The Textbook of Veterinary Internal Medicine, said, “Maybe it’s neurological, or he’s cold, or it might be his eyesight.” He reminded me that Fromer’s eyes were failing, making it harder for him to see when the light goes. He didn’t offer any therapeutic help to deal with the situation.
By accident, I stumbled on a Newsweek article (Jan. 31, 2000), “Coping with Darkness,” revolutionary new approaches in providing care to people with Alzheimer’s. The article described how Alzheimer’s patients can become increasingly agitated at the end of the day, and how light is especially important to them in the late afternoon and early evening. Although Fromer hadn’t been diagnosed with Alzheimer’s—dogs also suffer from this disease—the early nights of winter had brought on a behavior in my dog that exactly matched the symptoms of some Alzheimer’s patients.
Now I had a name for what I’d been observing: sundowning. And a definition: According to Harvard Medical School, Department of Psychiatry, sundowning is a syndrome in Alzheimer’s patients of recurring confusion and increased agitation in the late afternoon or early evening. A sundowner is a patient who sundowns.
One antidote to sundowning is increasing the light to eliminate frightening shadows. Except increased illumination only helps patients with intact vision. That explains why flooding rooms with light did not soothe my geriatric friend.
This is now our second Christmas without Fromer. As I untangle those silly teddy bear lights, I remember those awful winter nights, and wonder what I might have done differently.
A half-dozen vets I have spoken with since then say they have never come across sundowning in veterinary literature. They offer replies similar to Allen M. Schoen’s, D.V.M., author of Kindred Spirits, “I am not familiar with the syndrome.”
Until I reach Nicholas Dodman, Director of the Behavior Clinic at Tufts University School of Veterinary Medicine. Dr. Dodman says, “I think you’ve struck on something.”
He explains that this behavior has sort of been recognized but under the global term of sleep disturbance, which is one-quarter of the diagnostic criteria for canine Alzheimer’s. “Did Fromer have canine Alzheimer’s?” asks Dodman. “I would say from what you’ve told me—I never examined him—almost certainly, yes. Since sundowning is a part of Alzheimer’s in people, why wouldn’t it be in dogs as well?”
Johnny Hoskins, a small-animal internal medicine consultant with a specialty in geriatrics and pediatrics, agrees. “I believe dogs go through similar changes as humans as they age.” Dr. Hoskins explains there are certain triggers in older animals when they start having behavioral–mental changes. “In your animal the trigger just happened to be when it was getting dark.”
Dodman says this is the first time he’s heard of this association with dogs and the day/ night junction. He thinks it’s helpful because it adds another layer of detail to nocturnal disturbance syndrome. “It makes it easier for people to recognize and it’s a very clear- cut sign: As light is fading, some dogs, not all dogs, because not all dogs do everything with any disease, but some dogs with canine Alzheimer’s may, when light falls, become even more confused, and upset, and that can lead to this hysterical behavior: barking, pacing, inconsolability. Sundowning. I think that’s a very nice addition to the canine Alzheimer’s syndrome, which previously was just painted as a late-night, throughout the night, problem.”
Dodman explains that vets don’t have a good handle in this area. “They know there are sleep disturbances. But what precisely are they? Vets think that means when the owner goes to sleep at night the dog wakes up and barks and paces. Sundowning makes it more subtle, and more akin to the human syndrome, and it sounds perfectly reasonable.”
Now that we have a definition and a basis for diagnosis, is there a treatment in the canine population? Dr. Hoskins cautions that since there are so many neurotransmitters in the brain, a dog owner should not expect that one single medication will handle all the behavioral-mental changes in his animal. It’s way too late for Monday morning quarterbacking with Fromer, but perhaps others who are currently caretaking an elderly dog will find that these medical suggestions (see sidebar) can make sundowning more understandable and less of a downer.
Dog's Life: Lifestyle
Where are dogs living longest?
It is hard to decide which of the many wonderful qualities of dogs is the best one, but it’s easy for me to say what is the worst thing about dogs: They don’t live long enough. We all wish dogs lived longer and most of us are hungry for information about which factors may give us more time with our dogs. It’s possible that where our dogs live is one such factor.
A state-by-state analysis of dog lifespan shows Montana and South Dakota at the top with dogs living an average of 12.4 years. Other states with long-lived dogs include Oregon, Colorado and Florida where the dogs are typically living over 11 years. In contrast, Mississippi and Alabama have an average lifespan of just over 10 years.
These data come from Banfield Pet Hospital and only include those states in which they have facilities, which means that Wyoming, North Dakota, Maine, Vermont and West Virginia are not included. It also means that the data may only reflect the specific dogs seen in their practices rather than fully representing each state’s dogs.
However, there are a number of reasons that lifespans may vary from state to state. These include nutrition, exercise opportunities, rates of spaying and neutering and the types of disease prevalent in the area. The breeds and sizes of dogs that are most popular in those states may matter, too.
Wellness: Healthy Living
Some Compulsive Disorders Point to the Gut
Canine compulsive disorders (CCDs) take many forms and are generally considered to be behavioral issues. However, recent studies suggest that at least two of them—“excessive licking of surfaces” (ELS) and “fly-biting syndrome,” in which a dog appears to stare at something and suddenly snaps at it—may be related to underlying health issues. Both studies were conducted by researchers associated with the University of Montréal Veterinary Teaching Hospital.
The first set out to investigate surface-licking behaviors to see if there was a medical component: “The objectives of our prospective clinical study were to characterize ELS behavior in dogs and to examine the extent to which it may be a sign of an underlying gastrointestinal (GI) pathology as opposed to a primarily behavioral concern.”
Researchers looked at 19 dogs, 16 of whom exhibited this behavior daily. This group was compared with a control group of 10 healthy (i.e., non-ELS) dogs. Complete medical and behavioral histories were collected for all dogs. The medical evaluation revealed that 14 of the 19 ELS dogs had GI abnormalities; treatment of the underlying GI disorder resulted in significant improvement in a majority of dogs in the ELS group.
The second study examined seven dogs with a history of daily fly-biting behavior. As the researchers noted, “Fly-biting dogs are generally referred to neurologists or behaviorists because the abnormalities are often interpreted as focal seizures or as obsessive-compulsive disorder (OCD).”
As in the ELS study, these dogs were given complete medical examinations and were filmed to determine if the behavior was perhaps more prevalent after eating. The video analyses revealed a significant finding: all of the dogs demonstrated head-raising and neck extension, which can be an indicator of esophageal discomfort, prior to fly-biting.
All of the dogs in this study were found to have a GI abnormality, and one was also diagnosed with Chiari malformation (a brain/skull disorder). The dogs were treated for their medical conditions, and four had complete resolutions of the fly-biting behavior. The authors of this study concluded, “The data indicate that fly-biting may be caused by an underlying medical disorder, GI disease being the most common.”
As Marty Goldstein, DVM, observed in a post related to this research, “These studies don’t mean that primary obsessive/compulsive behavioral issues don’t exist, because they do … [But] if you have a pet with obsessive/compulsive disorders, don’t jump to psychoactive medications before exploring the use of food-allergy testing, changes in diet, and digestive enzymes and probiotics that can repair a damaged GI tract.”
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