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Assessing and Promoting Quality of Life in Geriatric Patients

Assessing and Promoting Quality of Life in Geriatric Patients

Huisheng Xie, DVM PhD and Vanessa Preast, DVM

Author: Chi Institute/Saturday, November 1, 2008/Categories: TCVM Articles, TCVM Newsletter, 2008 Fall Issue

As companion animals’ life spans increase, geriatric health care becomes a focus of veterinary practice. With geriatric patients, the primary goal is to promote their quality of life rather than cure their diseases. A number of reports have demonstrated that Traditional Chinese Veterinary Medicine (TCVM) could help accomplish this goal.1-3 

Using TCVM in geriatric patients involves assimilating all the diagnostic test results and identifying a disease pattern. This data aids in the choice of treatments which will provide the best possible care for the individual geriatric patient. The treatment protocols may include acupuncture, herbal medicine, harmonizing the animal-human bond, an exercise program, home massage, physical therapy, and/or food therapy. To assess the success of therapy, it is necessary to measure the quality of life before, during and after treatment.

 

Measuring Quality of Life


Determining the quality of life in animal patients is typically a complicated and subjective procedure. In human medicine, doctors can give patients a questionnaire to directly report their feelings and symptoms. Veterinarians must rely on their observations and reports from the pet owners to make assumptions about patients’ quality of life. Fortunately, certain observable cues are fairly reliable measures which can indicate the presence of declining life quality in geriatric animal patients. 

A healthy, well cared-for animal is alert, moves freely, eats and drinks normally, keeps itself well-groomed, and exhibits normal social interactions with house-mates or humans.4During aging, the  animal may develop geriatric diseases which cause pain and altered behaviors. For example, musculoskeletal pain can impede mobility and decrease appetite. We associate health and normal behavior with good life quality, and conversely, we assume illness or pain contributes to poor quality of life. Thus, specific behavioral and physiological observations can provide measures of pain and help determine the animal’s state of well-being5. Behavioral changes such as decreased appetite, urinary or fecal incontinence, reduced activity, sleep loss and irritability are good indicators of decreased quality of life. We have created the life quality score system to measure geriatric patients’ quality of life (Table 1). This scoring system may be used to assess the patient’s baseline status as well as the response to treatment. Training the pet owner to record the score on a daily to monthly basis provides a valuable record of the patient’s ongoing status. 

 

 


1. A happy, alert patient would have a higher score than a depressed or irritable patient;
2. A patient with normal, daily outdoor exercise and indoor activity has a higher score;
3. A patient with a normal, enthusiastic appetite has a higher score;
4. Difficulty with defecation or leakage of feces will lower the score;
5. Difficulty with urination or leakage of urine will lower the score;
6. A patient with great enjoyment of daily life (interactions with people or other animals, exercise, food, etc.) has a higher score. 


The LQS system is comprised of the Life Activity Score and the Pain Score. The Life Activity Score rates the patient’s mental status, general activity level, appetite, defecation, urination, and overall well-being on a scale of 0 (very poor) to 

100 (excellent). This score may also be viewed as the percentage of normal for that patient. In other words, is the patient 100%normal or not at all normal (0%) or some percentage in between? The Pain Score scale is the opposite direction of the Life Activity Score scale. The pain is rated from 0 (no pain) to 100 (severe pain). Because pain is a major factor in declining quality of life, the Pain Score is more heavily weighted in the LQS formula. An adjusted pain score is doubled and then deducted from the Life Activity Score Subtotal to produce the following formula: Life Quality Score (LQS) = Life Activity Score Subtotal – (Pain Score x 2). 

After using LQS with over 500 geriatric patients, we developed a guide explaining how the LQS numbers relate to a patient’s quality of life (Table 2). We feel that geriatric cases with an LQS over 500 often have an excellent quality of life. However, patients with an LQS less than 100 generally have such a poor quality of life that we recommend considering euthanasia.

 

 

Case Example

Jake, a 13 year old castrated male Alaskan Malamute, presented 14 days ago with acute onset of renal failure. He received intensive care and IV fluids, which pulled him through the crisis. However, after treatment, he was still anorexic and very weak. He had lost about 30 pounds during the past 2 weeks. His BUN was 98 mg/dL (normal: 7 - 27 mg/dL) and his creatinine was 7.7 mg/dL (normal: 0.8 - 1.7 mg/dL). At night, Jake had to wear diapers because he had a three-year history of nighttime urinary incontinence. On physical exam, Jake’s ears and back were cool to the touch, his pulse was deep and weak, and his tongue was pale and wet. The owner indicated that he currently walks about 1/2 mile, but he used to walk about 3 miles daily. Jake also prefers warm places. His TCVM diagnosis was Spleen Qi and Kidney Qi Deficiency.

 

Owner observations were used to generate Life Activity Scores and determine Jake’s quality of life at that time Life Activity Score Subtotal to generate a Life Quality Score of 185. This LQS score indicates a poor quality of life, but the attending veterinarian felt this could be improved using TCVM therapy.Jake received treatment including acupuncture and herbal medicines based on his TCVM diagnosis:

Acupuncture: Dry needle at GV-20, Bai-hui and Shan-gen. Twenty minutes of electro-acupuncture (10 minutes at 20 Hz followed by 10 minutes at 80-120 Hz) stimulation of the following points: a) BL-20, bilateral; b) BL-21, bilateral; c) BL-26, bilateral; and d) ST-36 + GB-34

Herbal Medicines: 1) Xiang Sha Liu Jun Zi (Eight Gentlemen), 10 pills twice daily for 4 weeks and 2) You Gui Wan, 5 pills, twice daily for 4 weeks.

Jake responded well to acupuncture. He ate an entire bowl of food immediately after the needles were withdrawn. This was the first time he ate this much food in one sitting since his acute illness. After 2 biweekly acupuncture sessions and 1 month of daily herbal medicine, his appetite became normal, he could walk about 1.5 miles daily, and gained about 10 pounds body weight. 

The LQS system was used to determine his quality of life following TCVM treatments thus far. His “Urination” score remained the same since he continued to have urinary incontinence. His “Appetite” score increased to 60 because his appetite had improved. His “General Activity Level” score also increased because he had been able to walk farther than before treatment. His mental status had improved to be about halfway normal. Jake had minimal pain and 20 points were subtracted from the Life Activity Score Subtotal to generate an LQS of 320 (table 3). Based on this score, his life quality had increased to be in the moderate range.

About four weeks after his initial visit, Jake was doing well. His appetite and thirst had returned to normal, and he had gained another 10 pounds. He also appeared happy and enjoyed his daily 1.5 mile walks. Thus his scores for “General Activity Level”, “Mental status”, “Overall wellbeing” and “Appetite” increased. But, he still had an episode of urinary incontinence and had to wear a diaper. His tonguewas pale and pulse was still weak. Although he was still azotemic (BUN = 88 mg/dL and creatinine = 8.1 mg/dL), his LQS had increased to 510 which suggested he now had an excellent quality of life (Table 3).

He received additional treatment based on his TCVM diagnosis:
Acupuncture: Dry Needle at BL-23, BL-26, KID-3, KID-10, KID-7, and ST-36. Aquapuncture (Vitamin B12 0.2 cc per point) at CV-4, CV-6, BL-39, BL-22 

Herbal Medicine:

1) Discontinue Xiang Sha Liu Jun Zi. 2) Add You Gui Wan, 5 pills twice daily for 3 months and 3) Suo Quan Wan, 8 pills twice daily for 3 months, after 3 months, the urinary incontinence stopped. He continued to be treated with acupuncture once every 3 to 5 months as needed for the rest of his life. Overall, Jake had a great quality of life. He had a normal appetite and thirst, and enjoyed long daily walks. His BUN and creatinine levels continued to range from 80 to 100 mg/dL and 8 to 12 mg/dL respectively; however, the goal of TCVM treatment had been achieved. The TCVM treatment goal was to improve Jake’s life quality rather than cure the renal failure. Jake died 3 years later at the age of 16 due to congestive heart failure.

Top 10 Herbal Medicines for Geriatric patients


As a quick reference, we have included ten most commonly used herbal medicines which are beneficial for promoting quality of life for geriatric patients as below. 

Conclusion 


Pain management and life quality are important aspects of long-term geriatric patient care in veterinary medicine. TCVM has many benefits for geriatric patients and their owners. Acupuncture releases endogenous opioid-like substances from the central nervous system to aid in pain relief, thus improving life quality. Exercise programs, massage, and physical therapy can promote range of motion to arthritic joints while strengthening the surroundng muscles. Home massage also promotes the animal-human bond, thus improving the quality of life for both pets and their care-takers. Chinese herbal medicines, which are designed for specific TCVM patterns, can address the patient’s specific TCVM diagnosis. Food therapy can also address both the nutritional and the energetic needs of geriatric patients. For example, warming foods like garlic, ginger or chicken could help to energize older animals which tend to be “cold,” have a low basal metabolic rate, and low activity levels. In addition to all these benefits, TCVM has the advantage of being minimally invasive, relatively inexpensive and compatible with conventional Western medicine.

 

References
1. H. Xie, C Ortiz.  What acupuncture can and cannot treat. J Am Anim Hosp Assoc. 2006 Jul-Aug;42(4):244-8
2. Xu L, Lao LX, Ge A, Yu S, Li J, Mansky PJ. Chinese herbal medicine for cancer pain. Integr Cancer Ther. 2007 Sep;6(3):208-34.
3. H Xie. Geriatric Medicine: An Integrated Medical Approach. Proceedings of CVC-Central, Kansas City, August 26 to 29, 2006 page 36-39.
4. Scharmann W. Physiologic and ethical aspects of the assessment of pain, distress and suffering. First international conference on the use of humane endpoints in animal experiments for biomedical research. Institut fur gesundheitlichen and Verbraucherschutz und Veterinarmedizin, Diederfdorfer Weg 1. 2005, D-12277 Berlin, Germany.
5. Wisemann-Orr LM, Nolan AM, Ried J, Scott EM. Development of a questionnaire to measure the effects of chronic pain on health-related quality of life in dogs. Am J Vet Res 2004; 65; 1007-1084.

 

 

 

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