Savannah's Cognitive Dysfunction Diary

It has been a very good week.

Savannah is sleeping, for the most part, through the night. For the last 8 months this has been an elusive ghost. Savannah is my 18 year old beagle-mix. It took me, her devoted mom, and determined veterinarian months to correctly diagnose her with cognitive dysfunction.

This has caused to her days and nights to be upside down. She would sleep soundly for most of the day, then at 10 pm she would pace, cry, circle, and be restless to the point of anxiety attacks. Sleep is a precious commodity when in short supply. After four years in vet school been I thought I could go back to those 3 hour night sleeps?..Oh, I have learned, I cannot. 

It is impossible for man or beast to function normally without sleep. 

Step one was restoring  sleep. Enter melatonin. 

Melatonin is made by the pineal gland which is located in the brain. It helps to regulate our sleep/wake cycles. We hear about it with people who travel across time zones and get their sleep cycle out of whack. 

Melatonin is available over the counter and dosed as 3 mg twice a day if under 20 pounds, and 6 mg twice a day if over 20 pounds. I started at once a day but I am increasing to twice a day. Savannah has always, and remains, a bear to pill. 

The production of melatonin is influenced by your internal clock, the amount of light in the day, and age. Without an adequate amount, or the correct amounts at the correct times of day your sleep cycle can be affected. Some people use melatonin supplements because they suffer from a "seasonal affective disorder (SAD), or winter depression, and even headaches.

There are some reports that melatonin has anti-oxidant properties, can increase platelet production, and slow down the aging process and even cancer.

Like every drug there are possible side effects; these can include, sleepiness, changes in blood pressure, a decreased body temperature, and feeling groggy. 

I tried anti-anxiety pills. They didn't help her sleep. They didn't really help anything. But I will add there are lots of anti-anxiety options to try. We discontinued it because I didn't want to give it long term and not be able to use tramadol. Sometimes we have to pick our poisons and be aware of the long term consequences to our immediate wants/needs.

The melatonin helped with the sleep. But Savannah's root problem, the cause of restlessness, confusion, circling, and anxiety, is, I believe, her cognitive dysfunction. For that I added;

Selegiline. This drug is primarily marketed for Parkinson's disease. It is prescribed in dogs for anxiety disorders and cognitive dysfunction. For dogs and cats the recommended doses are 0.5-1 mg/kg orally every 24 hours, but it can be increased to 2 mg/kg daily. Possible Side Effects, per WebMD

Neutricks, (apoaequorin) by Quincy Animal Health. It is sold as a supplement for a "healthy brain, mental agility, and cognitive focus." It works by supplementing the "calcium-binding proteins that protect brain cells." These proteins are naturally lost in the aging process. 

Directions for use:

Dogs under 40 lb: 1 tablet daily

Dogs 41-80 lb: 2 tablets daily

Dogs over 80 lb: 3 tablets daily

Best dosed in the morning.

Supplement Facts

Serving Size: 1 5 mg tablet

Servings per container: 60

www.neutricks.com It is available from the manufacturer and many retailers. 

 SAM-e (S-adenosylmethionine) is found naturally in the cells of plants, and animals. W produce less and less of it as we age. There have been many studies done to support that it has many beneficial uses. These include emotional well-being, pain relief associated with osteoarthritis, and aids in the restorative properties in patients with liver disease. It is a supplement and available over the counter.

Tramadol. This very commonly used veterinary drug has helped her immensely to sleep through the night. In veterinary medicine this opioid-like drug is used as an adjuvant, or stand alone, analgesic. It can also be combined with our frequently used NSAID's. Unfortunately, it should not be combined with selegiline (or otjher MAO inhibitors), SAM-e (concurrent use could cause additive serotonergic effects), or TCA's. After a week of sleeping I am switching back to an anti-anxiety drug (alprazolam or amitriptyline). If these don't work I may add acepromazine. I tried a short course of the tramadol because she doesn't tolerate NSAID's at all. at even a tiny dose she had vomiting and diarrhea. And since I am not convinced that her problem has a pain component to it, I don't need to add a problem to rule out the possibility of another. After a week of using tramadol I don't think that she has pain, but she is sleeping, and she is a whole lot less anxious.

Proviable. I give this daily to help replace her good gut flora. The anxiety and ever changing diet has stressed her gi tract to the point of chronic soft stools. I expect she will be on this indefinitely.

Acupuncture is also being given weekly. I do think it is helping.

My point with Savannah's treatment plan is that it is an ever changing, and sometimes unorthodox one. My goal is to continue to provide her with a good quality of life, keep her eating, comfortable, and relaxed.

This weeks victories have been getting her back to sleeping through the night. She got to feel snow again on her nose, she isn't pacing or circling (I think this is directly attributed to her decrease in anxiety and being rested), and she is eating.

In the eating department; I am getting fat, she is getting pickier. I feel like the stay at home mom who eats every batch of leftovers. I am creating at least three options with every meal. Chicken (preferably fried), ham, tuna, and the big hit of the week pizza! is usually gobbled up. But I have also been offering crackers, rolls, and hamburger.

She is becoming more and more poyuric/polydipsic. Likely, secondary to the higher salt diet, increased exercise (she is loving walking around the house and due to the inclement weather the long walks outside are waning. But, it is also the progression of kidney and liver impairment. I will continue to monitor blood and urine every few months.

I will keep you all posted on the twists and turns of my new quest to provide good options to my failing pup.

If you have any pet related questions you can find me at Pawbly, and Twitter @FreePetAdvice.

For related links about Savannah's story see;

Living and Losing the Last Moments with Your Terminal Dog

Another Trick Up Her Sleeve

The Tiniest Steps and the Biggest Hurdles

Savannah, Almost Hospice Care

Caring for Your Older Dog

Savannah's Story

Living and losing the last moments with your terminal dog.

My days are measured in tiny baby steps. Savannah, my beagle mix is 18 years old, and she is slowing down, losing her marbles, and challenging my ability to understand what she needs.

Together we are taking the smallest steps of backward and forward and keeping in mind the ever present looming fear of the slope that lies ahead and the finality of this journey.

She always hated baths.

Measuring Quality of Life;

Savannah is tired, I am tired. It is a battle between a ghost I cannot see who slips into the little cracks of a being that I used to know so well. She is still there in fleeting moments. I can pick her up, she buries her nose in my palm, breathes me in, and showers me with kisses. I am still here for her. For all of her little slips, for the days that grow darker and for the night that calls her.

Measuring quality of life is an intensely personal decision. As a veterinarian I try very hard to not suggest/suppose/presume, etc. what a family is seeing as they live with their ailing/failing pet. It is not my place, nor my ability, to tell you what your pets quality of life is..but I do try to remind clients that we are talking about their pets quality,,and not our unwillingness to be burdened. It is a fine line. If there isn't a pet parent to take care of a pet I can't offer anyone anything.

For me, and for the decisions that I make for Savannah, her quality of life is measured by the following checklist;

1. Eating/drinking
2. Peeing/Pooping...although butt baths are a daily routine,,she sort of slumps as she postures to poop.
3. Wagging tail. A very primal act, but to me it means she is happy. 
4. Sniffing. She is a beagle, this is primal too. If she is on grass or dirt, she is sniffing. Her brain needs to keep working.
5. Sleeping..Well, we are working on this one. We both need to sleep.
6. Happy. OK, this is a toughie. She has good and bad days. I am keeping her out of pain, and spending lots of time with her. 

Many vets use the old adage, "when the bad days out number the good ones it is time." I don't know if I believe this for myself, so I have a tough time using it as a measuring stick.

The decision to say goodbye is certainly one of the hardest moments in many peoples lives. I take it intensely seriously and I try to talk about their pets condition instead of providing benchmarks to use as a pros vs cons tally.

Home Life;

Her life is lived in the small safe places that she can't hurt herself in. The hallway, the front yard tie out, and the back yard at work. She is still happy to have the ground under her feet. To smell the footsteps of the critters that passed by, linger below, and elude my ability to perceive. She is still a beagle. Sniffing, eating, and wanting to live a pampered life.

Basic Hygiene:

But there are bathtubs, butt clean-ups, and pee pads. They are the inevitable landscape of every elderly hospice patient. It is a side of being a parent that not everyone chooses to take on. My husband thinks I am being to anthropomorphic. I remind him that he is entitled to his opinion, and that she is my responsibility, and that I will not choose to let her go because she is a burden.

And I remind him that she is still in there, a little harder to recognize, but still there. She is a different version of herself but she is eating, drinking, peeing, pooping, wagging, and walking. When one of those escapes her I may open up the floor to discussion with him about the next step that is right for her.

She has good days, and bad days, and I am watching her at every tiny step.

I can promise her, and only her, that I will say goodbye, and I will not let her suffer.

Joe dancing..with Charlie.
Can you see Savannah's tie out between the two trees?

Sleeping:

There have been nights where neither one of us get more than an hour or two of sleep at a time.

These almost broke me.

There is a reason that sleep deprivation is used as a form of torture. 

There were times where I got angry. Where I wanted to end it all right then and there. I get it. I understand my clients who give up here. I am not judging, nor am I trying to convince anyone that my way is the right, or the only way.

Sleep can come in waves of 10 hour stretches at 10 am and then be a fleeting uncapturable ghost at 10 pm to 6 am. I have battled back and forth about pinning a diagnosis on her.

My rule-outs;

• She is not in pain.
• She is not hungry, thirsty or in need of bathroom facilities. I know because I offer all of them at least twice.
• She is losing it? Technically called cognitive dysfunction. (Sometimes I believe we are both losing it,,,no sleep does this to you).

Savannah has the best bed in the house..warm, comfy, and highly sought after by the puppies.

The run of nights that that stole any chance of sleep had to end. 

I tried exercising for hours to get her tired. We walked and walked and walked from 6 pm to 9 pm. And then she paced from 9 pm to 9:30, slept an hour and repeated this all night. I can't sleep through her anxiety.

So I tried the anti-anxiety medication alprazolam. It calmed her, but she still didn't sleep.

Ask Your Vet for Help;

So I tried Tramadol. BINGO! Tramadol is used primarily to treat pain. For Savannah it is providing her sleep. BUT! I am also considering adding back an anti-depressant, and/or a cognitive dysfunction drug. And both of these are contra-indicated if using tramadol.

So, here we are, sort of treading water, and sort of unsure which oar, or direction to go in next.

Other things to try; melatonin, and SAM-e, (both are over the counter more natural options), acupuncture, the b/d diet (Science Diet b=brain), 

I already keep her light on for her all night. This help immensely.

At 8:45 pm Savannah gets a half of a 50 mg pill, and she sleeps all night! It has been four glorious nights of sleeping from 10 pm to 6 am. She is happier, calmer, and I am able to function again.

Is she anxious? Is she suffering from dementia? Is it pain? Honestly, I am not sure. I am trying to address all of her needs and keep her eating, drinking, peeing and pooping as we navigate through these uncharted waters.

Eating:

I am offering anything and everything.

We are at the point where sustenance is more important than nutritional value.

Gone are the days of dry kibble and we have almost abandoned any hope of boring prescription food. We make two meals at every feeding. She likes variety, and her tastes change hourly. Lately the Honeycomb, spaghetti, and bread/rolls/buns is her preference. That's after she turns her nose up to chicken, ground beef, and hot dogs.

Maintaining Sanity;

 Yours and your pets. This is a hard one to access. It is a balancing act. Trying to keep track of your ability to make sound decisions for both yourself and your pet. How much time and attention do you have to give? How much does your pet need? They are hard questions to answer, fulfill, and follow through with. I have a very good friend who is taking care of her dog with chronic renal failure. She is sleeping only when her dog sleeps, losing full nights of uninterrupted sleep, and feeling like I am, that precious time is slipping away. We fear that day when we have to say goodbye, and yet we know its quickly approaching.

I told her that we need to move in together. And take shifts. It is a marvelous idea. We all need to band together and provide our own pet hospice support and care taking group.

Exercise;

Keeping the body active is keeping it healthy.

All pets will very quickly lose muscle mass if they are not using them. Encourage walks, make mental stimuli and environmental enrichment a priority. It is as important as eating.

Savannah paces. She has a head tilt so she circles. I can tell if she is pacing/circling because she is hungry, thirsty, needs to go to the bathroom, or is just bored. 

I don't discourage the pacing unless I think it is due to anxiety. And if it is anxiety related, I treat the anxiety.

My goal for her is the same it always has been.

I want her to be happy and healthy. The parameters around these evolve as her condition changes. 

The last few months with her have been some of the most memorable and rewarding. I wouldn't give up one single second of them.

 And I hope there are a few tiny little steps left.

Taken today.

And as a little footnote, I finally have a little dog that I can dress up. These two other pups of mine think they are farm dogs. They hate being dressed up, and they will promptly find a poop pile to embellish their new outfit with.

So everyday Savannah gets a new outfit. And everyday I remind her how beautiful she is!

UPDATE: December 6, 2013

Savannah is doing remarkably well. I have tried a few medications and had some limited success.
Here's whats working right now.

She is eating well. I offer at least three options three times a day. She seems to change her taste bud preference daily, so if something doesn't work today, it might work tomorrow. The options that I offer her are; canned dog food that varies between super expensive and junk food. Canned cat food, same guidelines as dog food. Dry cat food, and dry dog food. For some reason I can't explain she will eat a large T/D (Science Diet for dental disease), like a treat, but only about one a day. Ham, turkey, bologna, rotisserie chicken, hot dogs, ground beef. I have a wide assortment of these on hand and cook a little bit at a time. Tuna, rice, noodles (these are a big hit about every 4th day), cheese, peanut butter (always used to give pills, she is almost impossible! I have been bitten twice, which NEVER happens to me!). Soft rolls, she will always eat these, so I offer them whenever she hasn't eaten well. Cereal, Cheerios, and her personal favorite Honeycomb. But on days that she is especially picky I think outside the box and try junk food. The other night she ate white cheddar cheese crackers like they were the yummiest treat ever. When your pet turns their nose up at food and you are flirting with the cloaked death stalker, you offer anything and everything, try crackers and animal cookies, or something outside of their normal diet.

All of this food juggling has caused an increased amount of fecal output, and the consistency is no longer optimal in neither color nor firmness. The burden that an ever changing diet has had on her gi tract has caused gastro-intestinal pain in the form of cramping, gas distension and the discomfort that diarrhea causes. I know that when she is pacing and moaning at 9 pm after eating a good meal it is because her belly is bothering her. She, like most normal healthy pets, defecates about every 12-24 hours. The more meals I feed a day the more frequently she needs to defecate.

The nights were the big problem. She paced, cried, and would wake up for 45 minutes every 45 minutes. I solved this with 3 mg of melatonin, and tramadol. Tramadol is an opiate used primarily in veterinary medicine for pain. I have seen some pets get anxious on it, so always give it with a disclaimer to monitor closely. Tramadol lets Savannah sleep through the night. After 8 hours of rest she is less anxious, happier, calmer, more focused and clear headed. I should add that both of us are.

SAM-e is also given. It is helps to promote overall healthy brain function, and helps to balance emotions by acting as a mood stabilizer.

I also started her on selegiline. Used in human medicine for Parkinson's disease, dementia, and depression. I do believe it is helping her immensely.

She also get Neutricks, for cognitive dysfunction. These are large chewable tablets. She is not terribly fond of them, and because I have to pill her with all of the medications, the larger pills are significantly more difficult to give.

Last week we started acupuncture. After two treatments and the regimen listed above she is doing far better than she has in the last six months.

I looked at her this morning with my husband and said "Damn, Savannah-dog, you just might make it to summer!" She can bury her nose in the soft ground of 2014 and remind terra firma that there is still one mighty beagle left to reckon with.

Cognitive Dysfunction

'Joy Sessions' capture tender moments with owners and terminally ill pets.

If you have any pet related questions or comments, or hints to help an elderly dog live their life to its fullest please share them here, or you can find me at Pawbly.com, or on Twitter @FreePetAdvice.