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'Care of the Geriatric Horse,' presented by Dr. Jen Gold, DACVIM-LAIM internal medicine specialist. This presentation is a great resource for all horse owners!

'Care of the Geriatric Horse,' presented by Dr. Jen Gold, DACVIM-LAIM internal medicine specialist. This presentation is a great resource for all horse owners!

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  • B vitamins and Vit C are generally produced by the microbes in the hind gut. In aged horses they have shown a decreased ability to manufacture these vitamins.
  • 85% of horses diagnosed with PPID are greater than 15, has been seen in horses as young as 7. All breeds can get this disease more common in Morgans and ponies

The Geriatric Horse The Geriatric Horse Presentation Transcript

  • Care of the Geriatric Horse
    Jenifer R Gold, DVM, DACVIM
    Mountain Horse Medical Center
    April 2011
  • Definition of a Geriatric Horse
    General Care
    Nutrition
    BCS
    Gastrointestinal tract
    Dentistry
    Pasture
    Diseases
    Euthanasia
    Outline
  • A horse > 20 years of age
    Recent study indicates anywhere from 7.5-20% of equine population in the US is geriatric1-2
    Definition-What is a Geriatric Horse?
    1Baseline reference UDSA:APHIS 1998
    2Harper F.Large Anim Vet 1992
  • Horses do not age at the same rate as humans.
    Geriatric Horses
  • Provide a safe and comfortable environment
    Adequate feeding protocols
    Provide good nutrition
    Attention to ambient temperatures
    Grooming care
    Parasite Control
    Dental Care
    General Care
  • One of the most important parts of geriatric care is maintenance of body condition.
    Older horses tend to lose weight to due
    Parasites
    Poor dentition
    Competition with pasture mates
    Disease
    Nutrition
  • The Henneke System is an objective evaluation of a horse's body condition
    Developed in 1983 by Don R. Henneke, Ph.D.
    Based on both visual appraisal and palpable fat cover of the six major points of the horse that are most responsive to changes in body fat.
    Neck
    withers (where the neck ends and the back begins)
    the shoulder area
    ribs
    loins
    the tailhead area
    What is Body Condition Score (BCS)?
  • Poor — Animal is extremely emaciated.
    Spinousprocesses,ribs, tailhead, tuber coxae, and tuber ischii project prominently
    Bone structure of withers, shoulders, and neck is noticeable
    No fatty tissue can be felt.
    BCS- 1
  • Moderate
    Back is level.
    Ribs cannot be visually distinguished but can be felt easily.
    Fat around tailhead is somewhat spongy.
    Withers appear rounded over spinousprocesses
    shoulders and neck blend smoothly into the body.
    BSC-5
  • Extremely fat
    Obvious crease is seen down the back.
    Patchy fat appears over ribs.
    Bulging fat is seen around tailhead
    Bulging fat along withers, behind shoulders, and along neck.
    Fatalong inner thighs may cause thighs to rub together. Flank is filled with fat.
    BSC-9
  • Horses too thin or too fat are prone to develop secondary diseases
    Of particular concern
    Hepatic Lipidosis
    Why is BSC important?
  • If an animal is too fat or too thin
    They go off feed for a short time for any reason
    Mobilize fat
    Blood becomes lipidemic/lipemic
    Fat accumulates in the liver
    Hepatic Lipidosis
  • Lethargy
    Weakness
    Anorexia
    Decreased water intake
    Diarrhea
    Clinical Signs of Hepatic Lipidosis
  • Intravenous fluids
    Nutritional support
    Treatment of underlying issue
    Treatment
  • A well balanced diet is important for the geriatric horse because…
    Digestion of fiber decreases
    Ability to manufacture and absorb vitamins decrease
    B vitamins
    Vitamin C
    Decrease in kidney function
    Calcium stones may build up
    Decrease in liver function
    Jaundice, weight loss, lethargy, loss of appetite, intolerance for fat and protein in diet.
    Nutrition
  • Confinement?
    No-Turnout with a friend!
    Weight loss reasons: Poor dentition
    Reduction in digestion - parasites, microbial constituents, B Vitamins
    Nutrition
  • Selection of Feed
    Highly palatable
    Easy to chew & swallow
    Clean & dust free
    Highly digestible pellets or extruded feeds
    Contain enough high quality fiber to aid digestion. High quality hay – no alfalfa.
    Chopped hay, hay cubes or pellets
    Soaked feeds or mashes…Enough so they are easily palatable, doesn’t have to be a soup
    Nutrition
  • Geriatric horses should be fed a senior feed
    Senior feeds offer the horse increased protein, minerals, and vitamins.
    Specially formulated for our older horses
    Small feedings three to four times a day is ideal.
    ¼ to ½ cup of corn or vegetable oil may be added daily as an extra source of calories.
    Nutrition
  • Older horses are prone to weight loss, especially in the colder months, and require more calories to maintain their body condition.
    Soaked alfalfa cubes or pellets are also a good feed to offer older horses.
    Dengie hay is a good choice for older horses too
    because it is less dusty,
    minimizing any flare-ups of heaves,
    a disease that will be discussed later.
    Nutrition
  • Review of Equine Digestion
  • Comparisons of digestion
  • Differences in rates of passage
    Equine
    rush through foregut
    time delay in cecum
    rush through rectum
    Ruminant
    Slow recycling flow of digesta
  • Water
    Essential for all body functions
    Temperature regulation
    Feed digestion
    Amount of water intake
    Level of exercise
    Ambient temperature
    Quality of feeds in ration
    Proportion of diet that is forage
    Minimum 1 gallon/100 lbs BW/day
  • Dentition
  • Aged horses may lose some of their teeth
    Have sharp edges on their teeth or a "wave mouth”
    Leads to an impaired ability to chew hay, grain, or hay cubes.
    Frequent teeth floating by a veterinarian will ensure good oral health
    Correct any defects that may impact a horse's ability to chew
    MUST NOT BE OVERFLOATED!
    Dentition
  • Parasite Control
  • Fecal egg counts are important
    False negative tests can occur especially with encysted stronglyes.
    Important to work out de-worming program with your veterinarian
    specific to your horse/ranch
    De-worming
    Help maintain good body condition
    Keeps geriatric horses
    Parasite Control
  • Experts consider them the #1 nematode problem in horses today.
    They can account for up to 90% or more of a horse’s worm burden (and 75% of them may be encysted)
    Encysted small strongyles:
    Are undetectable in routine fecal examinations
    Usually don’t visibly affect the horse until he becomes ill
    Can survive the effects of most common de-wormers
    Small Stronglyes
  • It has a 3-stage life cycle
    Unlike many parasites it can do something in its larval stage that creates a huge danger to horses
    Under certain (common) conditions, stronglyescan bury themselves in the wall of the large colon and “encyst”
    When they do, hard to kill and even harder to detect
    Can remain in this state for up to three years.
    Encysted stronglyes
  • No way of knowing how heavy an encysted small strongyle load a horse is carrying
    Fecal analysis cannot measure worms in the encysted state.
    Horses may not show outward sighs of a parasite problem until it is too late.
    Encysted Strongyles
  • Encysted small strongyles can cause severe clinical signs and even death.
    When thousands to millions of the fourth stage larvae (L4) emerge simultaneously from the intestine wall.
    Encysted Strongyles
  • Listlessness, weakness
    Anorexia
    Recurring colic
    Diarrhea
    Weight loss
    Peripheral edema (swelling)
    Death
    In less severe cases, horses may exhibit decreased performance, poor food utilization, and a dull hair coat.
    Clinical Signs
  • Fenbendazole is the only de-wormer that treats the encysted strongyles.
    Other de-wormers ieIvermectin, Moxidectin and pyrantel get the other stages.
    Moxidectin does get the L3 stage but that’s not encysted.
    Treatment
  • If your horse is on a daily de-wormer
    It’s still important to have your veterinarian perform a fecal egg count twice a year during spring and fall.
    That way you’ll know if your horse needs a supplemental treatment to reduce a specific parasite population.
    Horses on daily dewormer still need additional treatments to target encysted small strongyles, bots and tapeworms.
    Daily De-wormer
  • When a new horse arrives on your property
    Quarantine the newcomer and
    Monitor the horse for signs of contagious respiratory diseases and fecal parasites.
    Obtain a fecal sample and treat the newcomer for parasites before turning the horse out on your pastures.
    For long-term additions to your herd, treat the horse with a larvicidal dose of Fenbendazole
    Followed by ivermectin or moxidectin with or without a tapeworm treatment.
    New Horses
  • An effective parasite management program includes more than just de-wormers.
    Rotate pastures if possible.
    Ideally it is best to rest pastures when the weather is hot and dry.
    Cross-graze pastures with cattle or other ruminants.
    Beyond Deworming…
  • Remove manure from pastures and paddocks.
    Harrow pastures only during hot, dry periods and keep horses off for several weeks.
    Consult your extension agent regarding proper composting techniques.
    Avoid overstocking your pastures.
    Beyond Deworming
  • Older horses often lose their place in the herd hierarchy
    May be bullied by younger horses in the pasture.
    Allow them time in the pasture alone or with another older horse.
    This will eliminate stress on the horse and allow them proper grazing time.
    Adequate pasture time is vital to minimize orthopedic issues and stiffness.
    Pasture Environment
  • Additional considerations
    Placing older horses in a pasture with a flat surface
    Monitor weather conditions
    Often have significant osteoarthritis
    May have stiffness and weakness in the hind-end
    Predisposing them to fall in slippery conditions such as severe rain, snow, or ice.
    Pasture Environment
  • Geriatric horses are more sensitive to extreme weather conditions than younger horses
    Older horses often have hirsutism (an overlong haircoat)
    Not able to thermoregulatecorrectly
    They may also have areas of patchy sweating
    Important to clip them
    Use blankets in colder weather
    Provide a cool environment during hot months.
    Daily brushing is advisableto help with circulation
    Temperature and Grooming
  • Pituitary Pars Intermedia Dysfunction (PPID)
    Heaves
    Laminitis
    Uveitis
    Common Diseases of Geriatric Horses
  • Otherwise known as Cushings disease
    Usually seen in horses > 15 years of age
    Malfunction/micro/macroadenoma of the intermediate lobe of the pituitary
    PPID
  • Cushings versus PPID
    Equine
    Intermediate lobe
    Dopamine-dependant
    No negative feed back
    Dog
    Adrenal or Anterior Pituitary
    Cortisol-dependant
    Negative feedback
  • HPA axis and Homeostasis
    Hypothalamus
    CRH
    Corticotropinreleasing hormone
    (+)
    Anterior Pituitary
    Cortisol (-)
    ACTH
    Adrenocorticotropin hormone
    (+)
    Cortisol (-)
    Adrenal Gland
    Cortisol (-)
    Cortisol
  • PPID
    Hypothalamus
    Dopamine (-)
    Intermediate lobe of the pituitary
    Dopamine (-)
    Pro-opiomelanacortin (POMC)
    Excess Cortisol Side-effects
    ACTH
    Β-Lipotropin
    ϒ-MSH
    CLIP
    ϒ-Lipotropin
    α-MSH
    Β-Endorphin
    Adrenal Gland
    β-MSH
    ϒ-Endorphin
    α-Endorphin
    Adrenal Hyperplasia < 20%
  • Depend upon the stage of the disease
    Classic symptom is Hirsuitism
    Excessively long curly hair coat
    Early signs
    Late shedding out
    Excessive hair on legs and face
    Clinical Signs
  • Laminitis
    Lethargy
    Excessive drinking and urination (PU/PD)
    Excessive sweating
    Excessive muscle loss
    Repeated infections
    Sinusitis (primary)
    Sole abscesses
    Tooth root abscesses
    Infertility
    Bulging supraorbital fat pads
    Other Clinical Signs
  • No test 100% sensitive/specific
    Hirsuitism-No other disease causes this process
    ACTH Hormone Concentrations:
    Veterinarian draws a blood sample (except in fall-End of August-end of October)
    Can still have false negatives/positives
    Consider PPID if ACTH > 50 pg/ml any other time of year
    Consider PPID if ACTH > 100 pg/mL in autumn
    Diagnosis
  • Dexamethasone Suppression Test-
    Veterinarian comes out end of day, takes blood sample, administers (40 μg/kg) which is typically 20 mg of dexamethasone. Comes out next day around noon.
    If cortisol values are not decreases ie < 1 ng/dl cortisol =PPID
    Diagnosis
  • Oral Domperidone Challenge Test:1
    Your veterinarian comes out
    Administers one tube (25 mL gel; 2.75 grams) domperidone (Equi-Tox®) orally
    Collect EDTA blood samples at 0, 2, and 4h
    If single sample method is used,
    collect a blood sample 2h (Fall) or 4h (rest of year) after the owner administers the domperidone
    Measure ACTH concentrations; + if > 100 pg/mL
    Diagnosis
    1Miller et al. Vet Pathol2008
  • Why? Determines Management/Prognosis:
    Leave one flake grass hay in stall after 10 PM
    Collect blood sample in the morning (no stress)
    Insulin concentration > 20 μIU/mL (mU/L) indicates hyperinsulinemia (presumed insulin resistance)
    Check glucose for evidence of hyperglycemia
    Within reference range in majority of case 
    Insulin Resistance (IR)
  • Drug Therapy-Pergolide (Compounded):
    Type: Dopamine agonist
    Action: Inhibition of PI cells
    Dose: 1 mg total dose/day (up to 5 mg)
    Response: Improved “energy” / activity, muscle mass, haircoat
    Side-effects: Transient anorexia / depression
    "Pergolide cloud or veil"
     
    Take off Pergolide for 2 days, then re-start at lower dose, working back up to 1 mg total daily dose
    **If no response to one type of compounded Pergolide, then switch to another.
     
    Pergolide
  • Increase in “energy” and activity-IT WORKS!
    Improvement in physical appearance
    Lower incidence of associated problems
    Laminitis
    Sole abscesses
    Sinusitis
    PUPD
    Proper shedding of the winter hair coat the following season
    Back to ”old self”!
     
    What to expect with Pergolide
  • Cyproheptadine:
    Synergistic activity with Pergolide; use if no response to Pergolide alone
    Type: Serotonin antagonist
    Action: Reduces excitation of PI cells
    Dose: 0.25 mg/kg SID for 2 weeks
    Increase to BID for 2 months
    125 mg for 500-kg horse
    Response: Improvements in hirsutism, laminitis, lethargy, ACTH levels, and DST results
    Side-effects: Drowsiness and ataxia
    Adjunct Therapy
  • Drug Therapy with Pergolide
    Lab Monitoring
    Proper Nutrition
    IR or non-IR?
    Hoof Care
    Routine Dentistry
    Custom Wellness Programs
    Body Clipping
    Activity
    Laminitic, or non-laminitic
    IT WORKS!!!
    Treatment-Whole Horse Management
  • Heaves/Recurrent Airway Obstruction
  • Old Disease
    “Heaves are produced upon the diaphragm by too much food in the stomach and bowels and is cured by lessening the quantity of food to occupy the same space. After the horse is turned out to grass a few days, the heaves will usually disappear, from the fact that the bowels are generally relaxed by exercise and pure air”… 1903 D. Magner2
    2B Rush ACVIM 2006
  • Review of RAO
    NO LONGER CALLED COPD
    Not similar to the human form of COPD
    Similar to human asthma
    Seen mostly in horses > 7 years of age
    Most common exacerbation is winter and spring
    No gender or breed predilection, though females seem to be more prone.
  • Review of RAO
    12% of mature horses have some degree of environmental-induced lower airway disease
    50% of horses that present for evaluation of respiratory disease have heaves
    Heritable component
    10% incidence in horses with healthy parents
    44% incidence in horses with 2 affected parents
    Intermediate incidence in horses with one parent affected
  • Etiology of Heaves/RAO
    Hypersensitivity reaction
    Primary allergens thought to be
    Aspergillus fumigatus,
    Thermoactinomyces vulgaris,
    Faenia rectivirgula
  • Pathophysiology of Heaves
    Delayed hypersensitivity reaction
    Natural defense mechanisms are hyper-reactive
    Inflammation occurs in excess
    Massive infiltration of neutrophils
    Proliferation of mucosal cells
    Leads to thickening in the airway walls and obstruction of normal air flow during breathing
  • Bronchoconstriction
    Mucosa is thickened by inflammation
    Increase in mucous secretion
    Acetylcholine causes constriction of smooth muscle
    Thus…BRONCHOCONSTRICTION
  • Inflammation & Bronchoconstriction Leads to…
    Pulmonary hypertensions is consistent finding
    Due to hypoxic vasoconstriction and alveolar hyperinflation
    Horses with end stage heaves have increasedright heart size
  • Usually based on clinical history and signs
    Heave line, increased respiratory effort at rest.
    Bronchoalveolar lavage
    Presence of neutrophils
    Can be as high as 50-70% neutrophils
    Horses with >20% neutrophils will likely have impaired lung function
    Diagnosis
  • Bronchoalveolar Lavage Fluid
    Normal horse
    Heavy horse
    <5% Neutrophils
    >20% Neutrophils
  • Treatment
    Environmental management is key
    Wet hay
    Pelleted feed
    Pasture versus stall-unless summer pasture associated disease
    Improve ventilation of barn
  • Anti-inflammatories
    Corticosteroids are drugs of choice
    Can be administered intravenously, per os, or inhaled
    Inhaled steroids allows high dose of steroids with much less systemic side effects.
  • Corticosterids
    Horses treated with systemic steroids usually breathing more comfortably
    In 24-72 hours depending upon the severity of disease
  • Inhaled Corticosteroids
    Beclomethasone is less expensive
    Greater systemic effects than fluticasone
    Fluticasone expensive
    Less systemic effects, better efficacy
    Potency of Aerosolized Corticosteroids-
    fluticasone>beclomethasone>flunisolide
    Need to be used with bronchodilators
    Bronchodilator given several minutes
    Prior to corticosteroid
  • www.equinehaler.com
    Equine AeromaskTM by TrudellMedical Group
    Aerohippus by Trudell Medical Group
    Types of Inhalers
  • Bronchodilators
  • Albuterol
    Albuterol good for rescue therapy
    Can be used every 15 minutes for up to 2 hours to sequentially dilate small airways
    Also improves pulmonary distribution of aersolized medications
    Speeds mucociliary clearance
    Salmeterol-long acting bronchodilator
    Good for 6-8 hours
  • Clenbuterol
    Provides long acting β2 stimulated bronchodilation for horses with moderate to severe heaves
    Also a mucokinetic agent which increases mucociliary clearance
    Can cause cardiac problems with long term use
    Terbutaline not effacious
  • B2 Agonists
    Important to continue to administer corticosteroids
    This prevents down regulation of β2 receptors which comes with regular use or overuse
    In humans with asthma that use bronchodilators alone-deterioration of asthma control
    Down regulation of β2 receptors documented in horses after 12 days of clenbuterol
    Corticosteroid administration accelerates recovery from down regulation in horses tx with clenbuterol
  • Mild to Moderate RAO
    Ideal management is with environmental management
    Aerosolized corticosteroids
    Pre-exercise bronchodilation
  • Horses with moderate to severe RAO
    May need daily low dose long term aerosolized corticosteroid therapy
    Have to judge depending upon the horses response to tx.
    Cannot treat horses with systemic steroids long term due to side effects.
    Thus…..
    Environmental management and inhaled corticosteriods are the key!!!!
  • Laminitis
  • Suspension of the axial skeleton of the animal within the hoof
    Dissipate concussive forces during locomotion.
    There are about 600 pairs of interleaved laminae
    The epidermal laminae attached to the hoof wall and the dermal laminae attached to the coffin bone.
    Digital Laminae
  • Compromise of this interaction between laminae
    The mechanism of which remains unclear
    Currently the subject of much research.
    Laminitis literally means inflammation of the laminae
    Controversial whether this is the primary mechanism of disease
    Evidence of inflammation occurs very early in some instances
    Laminitis
  • The first is classical inflammation, which includes infiltration of potentially destructive white blood cells.
    The second is ischemia-reperfusion injury.
    Researchers have observed both decreased and increased blood flow to the laminae.
    Ischemia-reperfusion injury reconciles both observations
    Third is metabolic derangements
    Lead to impaired cell function
    Proteolyticenzyme activation has been proposed to be the primary mechanism for development of laminitis.
    Three Mechanisms Proposed
  • Diseases Associated with Laminitis
    Due to a plethora of diseases
    Acute condition
    Grain overload
    Strangulating gastrointestinal lesions
    Retained placenta
    Chronic Condition
    PPID
    Metabolic Syndrome
    Tendon injuries
  • Lameness
    Depression
    Anorexia
    Reluctance to move or lift its feet to be cleaned
    Increased pulsations in digital arteries “pounding”
    Clinical Signs
  • Physical examination
    Examination of hoof
    Radiographs-if in acute stages may not have radiographic changes
    Venogram
    Diagnosis
  • Supportive care
    Deeply bedded stall
    Pain medication
    Icing feet-if in the early stages
    Icing helps if you start 48 hours before clinical signs start
    DMSO, acepromazine….
    Packing hooves/soft rides or other means
    Multiple therapies really means we don’t understand the disease well…
    Treatment
  • Treat primary or underlying disease
    Farrier work is key especially with chronicity
    If severe rotation, sinking or both
    If exceptionally bad; salvage procedure cutting deep
    digital flexor tendons
    Euthanasia may be recommended in severe cases
    Treatment
  • Horses with PPID have higher rate of foot abscessation
    Must be treated aggressively
    Important to not mistake laminitis with foot abscesses and visa versa
    Abscesses
  • Equine Recurrent Uveitis one of the most common ocular diseases of the horse
    Most common cause of blindness
    Thought to be an immune mediated disease
    Characterized by periods of inflammation
    Inactive periods where inflammation may be difficult to discern
    Uveitis
  • Photophobia
    Swelling and reddening of the conjunctiva
    Excessive tear production
    Discharge from eye
    Corneal edema
    Constriction of pupil
    Squinting of eye
    Clinical Signs
  • Trauma
    Leptosporosis
    Brucellosis
    Onchocerciasis
    Strangles
    Influenza
    Tooth abscessation
    Causes
  • Ophthalmic examination
    Blood work: CBC, Biochemistry panel
    Serology for lepto and other diseases
    Diagnosis
  • Based on underlying clinical disease
    Topical and systemic anti-inflammatory medications
    Antimicrobial medications to decrease intraocular inflammation and further damage to eye
    Antifungals may be added depending upon where you and the horse live.
    Treatment
  • Surgical intervention
    Vitrectomy-removal of vitrous
    Seems to work better than Europe than here…
    Suprachorodialcyclosporinimplantion
    Works well but eye has be be quiescent
    Chronic Treatments
  • Tough decision
    Sometimes the decision is made for you…
    Quality of life
    Suffering?
    We are blessed with the ability to relieve pain and suffering….
    Saying Goodbye
    • The following are AAEP guidelines to assist in making humane decisions regarding euthanasia of horses.1
    • A horse should not have to endure continuous or unmanageable pain from a condition that is chronic and incurable.
    • A horse should not have to endure a medical or surgical condition that has a hopeless chance of survival.
    • A horse should not have to remain alive if it has an unmanageable medical condition that renders it a hazard to itself or its handlers.
    Considerations for Euthanasia
    1AAEP Guidelines for Euthanasia 2011
    • A horse should not have to receive continuous analgesic medication for the relief of pain for the rest of its life.
    • A horse should not have to endure a lifetime of continuous individual box stall confinement for prevention or relief of unmanageable pain or suffering.
    Considerations for Euthanasia
    1AAEP Guidelines for Euthanasia 2011
  • Questions?
    • Initial breakdown of feeds
    • Salivary secretions from Parotid gland
    • Secrete saliva only during eating, ~10 gal/day
    Mouth
  • Esophagus
    Esophagus
    Can’t vomit, strong cardiac sphincter muscle in stomach prevents
    Digestive upset = Colic
    Choke
    Obstruction within esophagus
    Fast eaters
  • Stomach
    Stomach - small, frequent, meals; initiates digestion, like non-ruminant
    10% of tract
    Limited digestion
    Gastric ulcers
  • Small Intestine - 30% of tract
    Digestion of
    Starch 65-75%
    Protein, AA’s 60-70%
    Fat 90%
    Ca absorption 95-99%
    Phosphorous 20-25%
    Fast rate of passage
    No gall bladder
    Small Intestine
  • Large Colon
    Large Colon
    Absorbs
    H20
    VFA’s
    AA
    Phosphorus, 50%
    NaCl
    Small Colon
    Absorption of H20
    Fecal ball formation