Tuesday, December 17, 2013

Savannah's Cognitive Dysfunction Diary

by  Krista Magnifico, DVM

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.

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.

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


Krista Magnifico, DVM owns a small animal hospital in northern Maryland, where she practices everyday. She wants to make quality veterinary care available to everyone, everywhere at any time; trying to save the world 1 wet nose @ a time.  Her blog is a diary of he day-to-day life & the animals and people she meets. 

Dr. Krista is also the founder of pawbly.com, free pet advice and assistance.

To contact her, you may leave a comment on her blog, email her or catch her on Twitter or Facebook.

Articles by Dr. Magnifico:
Don't Make This Mistake: Ruby's Death To Heat Stroke 
Parvo: Cora's Story 
Jake's Laryngeal Paralysis
The Tip Of The Iceberg: The Unexpected Dental Dilemma
The Ear Ache That Wasn't Going Away: Tottsie's Story
Cody's Eyelid Tumor
Ruger's Mysterious Illness
The Day The Heart Stood Still: Timber's Story 
Different Definition Of Comfort Food: Levi's Story
The First Seizure: Honey's Story 

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