Monday, December 16, 2013

Surviving the Delusions


In typical Type A veterinary fashion I am becoming a bit obsessed with Savannah's disease. It has consumed every second of my life to the point of not being able to leave her alone, not sleeping, and every point and both ends of the spectrum. Guilt, desperation, and adoration. Every single degree of the pendulum. 

Like all of my demons I try to slay them by learning studying them. Perhaps there is some Achilles heel I can identify? Perhaps I can alter fate? Bend, twist, contort some facet of this disease? Perhaps I can break through and find Savannah lost in a field of daisy's, just sitting there, face in the sun, eyes squinted almost shut, just waiting for me to pick her up and carry her home? She is trapped in a body that still functions in all of the ways that it should, but lost in a fog I can't seem to lift for longer than a few hours. 


I read an article in the latest Clinician's Brief aptly entitled "Cognitive Dysfunction, How I treat it." I read it hoping for another kernel of information that might lead me to finding Savannah's salvation. No luck. It was a re-iteration of what I have already tried, am trying, have given up on, etc..

There were a few pearls that I haven't spoken about that might help others.

Cognitive Dysfunction Syndrome (CDS), Dr. Margaret Gruen states is much like Alzheimer's in people. I would agree. Savannah has some really good days, or parts of days, and some painfully anxiety ridden confusing and frustrating moments. She is irritated and stubbornly determined to pace, get stuck in ridiculous places, and then cry. She is a toddler stuck in delirium. By Dr Greun's statistics CDS is very prevalent and affects 28% of dogs 11 to 12 years old, and 68% of dogs 16 to 17 years old. In cats it is often a bit harder to identify but is estimated to affect over 50% of cats over 15 years old.

In her article she discusses many of the treatments I have previously mentioned. She makes a very valid point that veterinarians need to do a better job screening and inquiring about the signs associated with CDS. Before Savannah I admit I did not engage my clients in talking about their aging pets mental status. Sure, I would discuss the disease when my client brought up "dementia" or "aging" but I was not proactive like I am with a puppy.

A new puppy visit has a whole list of questions that I ask parents. I talk about vaccines, housebreaking, training, diet, behavior, breed specific concerns, etc. Why haven't I been doing this with my senior patients? I think it is because I took for granted that their parents would mention a problem if there was one. But if it took me all of those months to see it in my own dog how could I expect my clients to identify the slow progressive insidious nature of this wasting disease? OH, the gross neglect that is the ignorance of not living with a disease yourself! 

Dr Gruen's advice on "How She Treats CDS" are as follows;
  1. Treat and manage comorbid medical conditions.
  2. Provide environment and behavior modification.
  3. Provide nutritional support.
  4. Provide pharmacologic support.
My interpretation and practice with my "Real-Life" is;
  1. Savannah at 18 years old is struggling with renal impairment, liver impairment and delusional emotional instability. Managing her comorbidity conditions is, like everything else we are doing, a juggling act. She is on 8 medications, some of them twice a day. The renal and liver diet are not enticing enough for her to even contemplate licking. Diets to manage these are in direct contraindication with Point number 3. Now, that is not to say that you shouldn't try to treat and manage the other diseases that your pet has. As I said in the last blog, you have to know your patient and you have to be ready to be unconventional AND realistic. Your pet may not tolerate the menu of a check list of what they are supposed to be getting/doing. 
  2. Environmental and behavior modification. OK, this is a good point to talk about. A schedule is imperative to try to keep their sleep/wake cycle in some sort of balance. All pets need mental stimuli and as your pet ages and withdraws from the outside world it is important to keep them interested and challenged. Boredom is the root of many behavior issues. When Savannah gets pacing and worked up I dress us both for the winter outside our door and go for a walk. It is the fastest way to get her back in her own head and relaxed. 
  3. Nutritional support. These days it is "try to stay on a good healthy diet that wont exacerbate the kidney or liver, so we start with offering the "best" option and then progressively work down the options to "whatever works." Tonight it was eggs, sausage, and cheez nips.  
  4. Drugs. Oh, the litany of drugs. The good news is that after about two months she will almost take them without snarling like a mountain lion. She's still the same feisty independent uncooperative beagle that she has always been in this department!



Here's what I want to add today. These articles, however helpful, from the experts need to have some "real-people" really living with these patients to put it all in perspective. Now, I write prolifically, and certainly I don't have personal experience with all of the subjects of my blog, BUT, with every article, and paper, and drug sheet that I have read on CDS here is what's missing. 

CDS pets will drive you to the brink. It is the crying baby that won't sleep, the old person who is lost in their own private self imprisoned hell.They don't know who you are, and they don't want you to try to help. It is a frustrating, exhausting, sometimes futile, powerless, ghost you chase. There have been endless nights, days of head banging, circling, pitiful existence where I contemplated just ending the mania. 

There were times where I cried in despair, unable to help, tired of endless loads of soiled laundry. Fights with my husband about "why I was putting us both (me and Savannah, he's not giving butt baths to anyone), through this?" And, my personal favorite, "Don't you think she's suffering." (Thanks, honey. Like, I need more guilt?) There have been nights where I have trudged to bed at 2 am to getup again at 2:30 am and said to her, "If you aren't better by tomorrow I'm giving up." 

Someone needs to tell people that it is "OK to feel these things."

And your vet needs to give you someway to navigate through these turbulent murky waters. Have a disaster plan. This disease warrants it. You will need it, and yes, whether or not you want to admit it, you will use it.

Emergency plan. There were, and will be nights that I pull out the acepromazine, (which I should add knocks her out for a day. It reduces her to a snoring puddle. And awakens her a day later unable to identify her legs or any knowledge of having ever used them. Be very sparing with the ace in old dogs), because if I don't sedate her I'm going to neglectfully walk away from her, or think about doing something I will die over guilt about. I used tramadol on her before, I might use it again, if the ace is too harsh on her. Either way I have something to reduce her anxiety so she can rest.


Hospice. It is a godsend to many people facing the loss of a loved one. Ask your vet for someone to help you on those long dark nights. If there are friends to lean on, ask them to help. 

My mom offers to babysit and tells me often, "I don't sleep when I have Savannah, but you need a break, and I am happy to help you both." She is so right. 

I am seriously thinking about how to add this service to my clinic. The support of others is the only way I have been able to walk away from my head banging, crying, head pressing, disoriented, anxious, afraid, unable to console dog. I understand why exhausted mothers pick up their babies and shake them until they stop. I have stood over the dog I have loved for 18 years and hated her for driving me as insane as she is. We are all humans, we can all break, and we all need a support. 

To not mention this, to send our clients out without a disaster plan and a net to fall in is setting them up for failure and guilt. As is CDS doesn't steal enough?

Dr. Gruens "How I Treat Cognitive Dysfunction," in the December 2013 Clinicians Brief

If you have any questions about this or any other pet related item you can ask me on Pawbly (always free to ask or answer a question). Or find me on Twitter @FreePetAdvice.


5 comments:

  1. Thanks again Krista - your blog posts about Savannah always make me feel better. We're heading into warmer nights here on the Gold Coast & the warmer the night, the more unsettled Isabel (18 yrs) seems to be. The whimpering, wandering through the house, getting stuck in corners & under tables & chairs is so not fun at 2am. Especially when this time of the year I'm running on empty myself! But then the next night she'll settle with no problems so it's a bit of a lottery. All I know is that every night I'm now lying awake listening for Isabel to start wandering - so I'm not getting sleep even when she's settled! But she's my girl & she's been with me for 18 years so what else would I do?

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    1. Hello Judy,
      I hope that things get better, and should you ever find your-sleepy-self awake at 2 am take comfort in knowing that I am very likely also in my pjs looking at Savannah and wondering how many others of us are awake?

      Best wishes and Happy Holidays!
      Krista

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  2. I enjoy your posts Dr. Magnifico and respect your decisions regarding Savannah, I too have had a dog with CCD. In 2008 I asked our vet to put her down when I could no longer bear to live with her condition. I spent some time being concerned that I had made that decision too early but since my dog's death I've had 3 elderly relatives (mom, dad and aunt) confide in me that they would rather die than continue living with their chronic illnesses (my father chose to take his own life). As a result, I've been able to view my decison for my dog as a mercy I wasn't able to extend to my human loved ones. I wish you well as you continue on your journey with Savannah.

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    1. Hello,

      I have/am learning that everyone's journey is different. I am trying to do my best for everyone involved, be that Savannah, my family, and myself. And I am trying very very hard to not judge others who make a different decision than I do/did. I do not walk in their shoes, and I have different resources, abilities etc. My husband, who I love dearly, would have given up long ago.Savannah is an immense handful that has limited our ability to do many things. She is a burden, truly, but I still see enough good parts of good days to warrant the effort.

      I know that there are many many pets, all of my own included, that I have humanely put down when they no longer had any quality of life left. I would like to think that I can apply the human standard of hospice and let nature take its course, but when each pet came to their end I could no longer watch them suffer to die a day later, and by my own hand I put each one down.

      I deeply believe that every person who loves their pet should never feel guilty about saying goodbye when they are terminally ill. There is mercy in letting them go peacefully and with someone who loves them. Too many people feel misplaced guilt about that last decision and lose sight of all of the wonderful time and love their pet got.

      I think that humane euthanasia should be every living things right, pet, person, whoever. I try to not have any disparity on how I treat my patients, or how I feel other people should be treated. Can you imagine how wonderful this world would be if we were all merciful and humane to each other?

      Thank you for reading and for sharing your story.

      My deepest sympathies over your losses.

      Sincerely,
      Krista

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  3. Clearly I've never had it as hard as this, but Jasmine's episodes, which were never identified and no treatment we tried worked, her misery and my inability to help, the way it went on for hours and sometimes days ... I can relate. (((hugs)))

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