Top 5 Tips for Managing Nocturnal Anxiety in Geriatric Dogs
Julia Albright, DVM, MA, DACVB, University of Tennessee
Kevin Pflaum, DVM, Blue Ridge Veterinary Behavior Services, Asheville, North Carolina
Sleep/wake cycle disturbances or nighttime anxiety in geriatric dogs can be suggestive of disease, affect pet owner quality of life (eg, poor sleep), lead to rapid deterioration of the human–animal bond, and even result in euthanasia. Therapies to improve nocturnal anxiety in geriatric dogs are available.
Following are 5 common ways to address nighttime anxiety in geriatric patients.
1. Diagnosis
Differential diagnoses for nighttime waking include pain; pruritus; urge to eliminate; hunger; sensory changes; noise sensitivity; fears or phobias; medication adverse effects; GI, respiratory, endocrine, renal, or neurologic disease; other organopathies; hypertension; neoplasia; and canine cognitive dysfunction.1
Evaluation should start with a thorough patient history and physical examination, including orthopedic and neurologic assessment. Nighttime waking and other signs of cognitive decline can be natural consequences of brain aging changes (eg, neuronal loss, brain atrophy). A validated questionnaire can be used to screen for cognitive dysfunction (see Suggested Reading). Baseline diagnostics should include CBC, serum chemistry profile, thyroid screening, blood pressure assessment, and urinalysis. Further diagnostics (eg, thoracic radiography, orthopedic radiography, abdominal ultrasonography) may be indicated, depending on patient presentation and physical examination findings.2 A trial of empiric therapies for pain, pruritus, nausea, and gastroesophageal reflux may be administered. A treatment plan can be formulated after all potential comorbidities have been addressed.
Referral to specialists may be helpful for complex diagnostic investigation and case management.
2. Environmental Management
Determining the patient’s daily activity pattern can guide specific recommendations.1 Basic guidelines should include establishing a predictable nighttime routine and designating a specific resting area with low sensory stimulation. Darkness is generally ideal, but some dogs may prefer light (eg, night-light). Window film, blackout shades, and/or a white noise machine can help reduce external stimuli. Pheromonatherapy and aromatherapy can contribute to relaxation.1 Soft bedding with low heat (eg, discs and pads used with caution to prevent burns) can be comforting to older dogs.
Consideration of the owner’s sleep quality is also important.3 Owners can be encouraged to try various sleeping arrangements. Moving the dog closer to owner sleeping areas may provide comfort and better rest, or physical and auditory separation from the dog may be needed; however, the dog’s basic needs (eg, elimination, thirst) should be met first. Options for separation include closed doors, baby gates, crates, larger pens, or a leash fastened to a back-clip harness and tethered to a sturdy piece of furniture. Anxiolytic medications for the pet and gradual desensitization to separation arrangements are often necessary to help calm the dog when physically separated from the owners. Noise-blocking devices (eg, ear plugs, white noise machine, loud box fan) can help muffle sounds of the dog’s activity for human members of the household.
3. Enrichment & Behavior Modification
Activities that provide both mental and physical stimulation (eg, walks of appropriate intensity, training sessions, scent-detection games, food puzzles), particularly during the late afternoon or evening, may help tire the dog; mental enrichment can also slow cognitive decline.4,5 Talking to or petting the dog can provide interaction to help the dog stay awake during the daytime and evening hours.
Human responses should not increase distress or reinforce unwanted behaviors. Owners should ignore unwanted behaviors when possible and understand that harsh reprimands can increase anxiety. Short training sessions should ideally be performed throughout the day so the dog can learn to relax on cue.6 The cue can then be used when it is time for bed or if the dog wakes during the night. A leash connected to a neck or head collar can help gently guide the dog to the sleeping location and prevent pacing. The dog should be appropriately acclimated to new tools or protocols during the daytime to avoid excitation or distress.
4. Medications
Pharmacologic treatments can help reduce anxiety and re-establish normal sleep/wake cycles (Table).1 Medications are most effective when used in combination with environmental and behavioral modifications. Sedation effects are often minimal and/or brief compared with effects in humans, and owners should be counseled on goals and expectations for medications.
A 14-day trial of an NSAID or other appropriate analgesic is recommended, potentially prior to starting anxiolytics or sedatives, to assess the role of pain in nighttime activity. Common adverse effects for anxiolytic medications include GI upset and paradoxical excitement or agitation. Fast-acting anxiolytics and sedatives should be given as a trial during the day when the owner is available to monitor for adverse effects. Medications should be started at the low end of the dose range and titrated to effect.
Common Psychoactive Therapeutic Agents For Nocturnal Anxiety In Dogs
Drug | Class | Dosage | Approximate Duration of Effect* |
|---|---|---|---|
Trazodone† | Serotonin antagonist and reuptake inhibitor | 3-10 mg/kg as needed every 8-12 hours10 | ≥4 hours |
Alprazolam‡ | Benzodiazepine | 0.02-0.1 mg/kg as needed every 4 hours11 | 2-4 hours |
Diazepam‡ | Benzodiazepine | 0.5-2 mg/kg as needed every 4 hours11 | 1-2 hours |
Lorazepam‡ | Benzodiazepine | 0.02-0.5 mg/kg as needed every 8-12 hours11 | ≥4 hours |
Clonazepam‡ | Benzodiazepine | 0.1-0.5 mg/kg as needed every 8-12 hours11 | ≥4 hours |
Gabapentin | Alpha-2-delta ligand; anticonvulsant | 5-50 mg/kg as needed every 8-12 hours12 | ≥4 hours |
Pregabalin | Alpha-2-delta ligand; anticonvulsant | 2.5-5 mg/kg as needed every 12 hours13 | ≥4 hours |
Clonidine§ | Alpha-2 agonist | 0.01-0.05 mg/kg as needed every 8 hours13 | ≥4 hours |
Dexmedetomidine§ | Alpha-2 agonist | 125-250 µg/m2 oral transmucosal every 2 hours (maximum, 5 doses in 24 hours)13 | <2 hours |
Acepromazine** | Phenothiazine neuroleptic | 0.5-2 mg/kg as needed every 6 hours14 | ≥4 hours |
*Intensity and duration of effects may vary.
†Trazodone should not be used with selegiline, an antidepressant monoamine oxidase inhibitor, because of risk for serotonin syndrome. Risk is low when trazodone is combined with other selective serotonin reuptake inhibitor antidepressants or tricyclic antidepressants.
‡Benzodiazepines have been linked to the worsening of dementia symptoms in geriatric human patients, but this has not been studied in dogs.15
§Use should be avoided in patients with cardiovascular dysfunction.
**Acepromazine provides chemical restraint with minimal anxiolytic effects and is not recommended for use as monotherapy.
5. Supplements & Diet
Dogs with cognitive dysfunction are often presented with sleep/wake cycle disturbances.7 Dietary supplements, some of which may be beneficial when administered several hours before nighttime, are often administered to geriatric patients due to low risk for adverse effects when given alone or in conjunction with prescription medications. Melatonin, for example, is a naturally secreted hormone and popular sleep aid with a mechanism of action that may allow the patient to fall asleep more quickly but does not aid in sleep duration.8 Owners should be advised to only purchase supplement formulations that are verified for quality control by United States Pharmacopeia.8 Empirical research supporting supplements as sleep aids in dogs is lacking.
Supplements intended to support cognitive function may be considered as treatment adjuncts regardless of primary diagnosis. Products containing antioxidants and medium chain triglycerides can improve cognitive performance.1,5,9
Conclusion
Nocturnal anxiety in geriatric dogs can be acutely disruptive to both the dog and owner. There are multiple potential etiologies, and aggressive intervention is indicated due to severe strain on the human–animal bond. Comorbidities should be treated when possible. Patients can benefit from environmental management, behavior modification, and anxiolytic/sedative medication trials to restore a normal sleep/wake cycle and help the patient and owner sleep through the night.
Prognosis depends on a number of factors, including etiology, underlying anxiety levels, ability to avoid exposure to arousal triggers, owner tolerance for nighttime disturbances, and compliance with recommended treatment. Realistic expectations for outcome should be discussed with the owner.