Providing the best care for senior cats

Cats are living longer because of a greater focus on routine healthcare for pets. As their veterinarians, we are challenged with the task of helping these cats live long, high-quality lives. The American Association of Feline Practitioners and the Academy of Feline Medicine (AAFP/AFM) Panel Report on Feline Senior Care1 provides a consensus on important goals and recommendations to help you care for senior cats. This article highlights many of the principal points in that report in conjunction with my clinical experience.

What age is considered geriatric in our feline patients?

Cats begin to show age-related changes between 7 and 10 years; most show changes by 12 years.1 A decline in overall body condition and a general unkempt appearance may be noticeable. Some cats do not show any outward age-related changes until later years, possibly lulling owners into believing their pets have no aging concerns. Also, clients do not like the term geriatric, so using the term senior care may be more appropriate as you discuss the concerns of an older cat with the client. Cats are considered to be senior at age 7 and older.

What are the goals of senior care?

The goals are to manage and monitor chronic disease, prevent disease progression, and provide a good-quality life. To help practitioners meet these goals and establish a minimum standard of care, the AAFP/AFM panel report set forth objectives to promote the longevity of feline senior patients and improve their quality of life by

• Recognizing and controlling health risk factors

• Detecting disease during the preclinical phase

• Correcting or delaying the progression of existing disorders

• Improving or maintaining residual function.1

An important point in the panel report was to start a senior preventive healthcare program for cats between 7 and 11 years of age, which should continue for the rest of their lives.1

What is the recommended healthcare program for senior cats with no clinical signs of disease?

Obtain a complete medical and behavioral history at every patient evaluation. The details in these histories can help you identify problems before the onset of clinical signs. For example, an owner may comment that the cat seems more affectionate or more aggressive recently. This subtle change in behavior could be a clue that the pet has hyperthyroidism and may precede more obvious signs such as an increased appetite and weight loss.

Performing a thorough physical examination at least every six months, including vital signs (temperature, pulse rate, respiration rate, mucous membrane color and refill time, hydration status), helps you establish what is normal for a particular cat and recognize early physical changes, such as a heart murmur, pain, small irregular kidneys, or a thyroid nodule. Also be sure to evaluate a patient's weight and body condition and compare your findings with those from previous examinations. You may identify a trend in weight gain or weight loss before the change is apparent to the client.

Blood pressure measurement is a desirable part of every physical examination in cats of all ages. While the panelists who wrote the guidelines did not reach a consensus on routine blood pressure measurement in senior cats with no clinical signs of disease, the importance of identifying systemic hypertension before organ damage or retinal hemorrhage or detachment in senior cats is well-known. Since measuring your blood pressure is one of the first things done when you visit a physician's office, your clients are familiar with this procedure and will likely accept this recommendation for their own cats. By measuring a cat's blood pressure annually from a young age, you will establish a baseline for this cat, which will help you decide if the cat suffers from systemic hypertension as it ages or is stressed during a hospital visit. The goal for a normal blood pressure in a cat is 145 to 160 mm Hg or less (systolic reading).2

Perform other routine diagnostic tests in a healthy senior cat with no clinical signs of disease at least annually, including a minimum of

• A complete blood count consisting of a hematocrit; red blood cell count, indices, and morphology; a white blood cell count; a differential white blood cell count (evaluated cytologically); a total protein concentration; and a platelet count

• A measurement of serum creatinine and potassium concentrations and serum alanine aminotransferase and alkaline phosphatase activities

• A total thyroid (T4) concentration by radioimmunoassay

• A complete urinalysis collected by cystocentesis, including urine specific gravity, urine sediment cytology, and glucose, ketones, bilirubin, and protein measurement

• A feline leukemia virus (FeLV) antigen test and a feline immunodeficiency virus (FIV) antibody test if the cat has not been tested previously or if it is at risk of exposure

In addition, the AAFP/AFM report states that fecal analysis and parasite control should be done in cats at risk of exposure to internal and external parasites, so consider performing a fecal examination (centrifugation and a direct smear).

These tests provide a good overview of the principal organ systems and will help you identify problems early.1

What is the recommended healthcare program for senior cats with clinical signs of disease?

As stated above, obtain a complete medical and behavioral history at every patient evaluation. The information you gather will help you develop your list of differential diagnoses and may provide important clues that lead to a correct and timely diagnosis.

Perform a thorough physical examination at least every six months, depending on the patient's medical condition and health status. Some patients may need to be seen more often if they have rapidly progressing or changing clinical signs. Weight evaluation and comparisons and body condition scoring are essential in assessing a pet's clinical condition as well as evaluating a pet's response to therapy.

Blood pressure measurement is even more important in cats with clinical signs. High blood pressure can be caused by many of the diseases and conditions seen in everyday practice (e.g. hyperthyroidism; diabetes mellitus; renal, hepatic, and cardiac insufficiency; obesity) as well as by less commonly seen diseases (hyperadrenocorticism, pheochromocytoma, mineralocorticoid-secreting tumors [primary hyperaldosteronism]). Also, many of the clinical signs seen in senior cats could be due to high blood pressure, including acute blindness (due to retinal hemorrhage or detachment), hyphema, dilated pupils, increased tortuosity of retinal vessels, decreased or increased appetite, vomiting, increased water consumption, increased urination, weight loss, lethargy, heart murmurs, seizures, collapse or syncope, abnormal behavior, proteinuria, and epistaxis. Moreover, high blood pressure can be a silent killer with no overt clinical signs. Also keep in mind that the primary problem can be essential hypertension—high blood pressure with no identifiable cause. As mentioned earlier, normal blood pressure in cats is 145 to 160 mm Hg or less (systolic reading).2

Other diagnostic tests that should be performed annually or more often, depending on the underlying disease, in senior cats include

• A complete blood count—a hematocrit; red blood cell count, indices, and morphology; a white blood cell count; a differential white blood cell count (evaluated cytologically); a total protein concentration; and a platelet count

• A complete serum chemistry profile with electrolytes

• A total T4 concentration by radioimmunoassay

• A complete urinalysis collected by cystocentesis, including urine specific gravity, urine sediment cytology, and glucose, ketones, bilirubin, and protein measurement

• An FeLV antigen test and an FIV antibody test in any sick cat, even if it has been previously tested (these viruses can be an underlying cause of many of the clinical signs seen in cats)

Also as stated above, the AAFP/AFM report states that fecal analysis and parasite control should be done in cats at risk of exposure to internal and external parasites, so consider performing a fecal examination (centrifugation and a direct smear). In senior cats with clinical signs of disease, also consider heartworm antigen and antibody testing if indicated.

What diseases are common in senior cats?

Eight conditions that we commonly see in senior cats are hyperthyroidism, chronic renal failure, systemic hypertension, cancer, diabetes mellitus, inflammatory bowel disease, cardiac disease, and dental disease. Remember that senior cats are more likely than younger cats to experience multiple problems at once. If you focus on managing one disease, you may miss other problems. The case presented in "Still thriving after all these years" at the end of this article highlights why it is important to follow the AAFP/AFM panel report guidelines.

What is the best diet for senior cats?

No single diet is good for all senior cats. Senior diets are available, but they may be too nutritionally restricted or otherwise not meet the needs of some senior cats. The focus should be to find a diet that will provide weight management and maintenance based on an individual cat's needs. Avoid obesity and any marked weight changes. Weight loss is common, and dietary modifications may be needed to help a senior cat maintain a steady weight. Some of these cats thrive on diets with a higher caloric content, such as kitten foods.3

For senior cats with ongoing clinical disease such as renal or gastrointestinal problems, special diets are available. But it can be challenging to get a cat to eat a special diet; it is more important that the cat eats something to maintain its body condition even if it will not eat the special diet. If a cat will not eat a special diet, other therapies may be indicated to address the disease.

Increasing the moisture content in the diet can also be beneficial in senior cats, especially those with renal insufficiency or failure. Canned cat foods are often a good option for these cats. It may also be prudent to offer tuna juice and other broths, as this may increase fluid consumption.

How often should senior cats have their teeth cleaned?

Bacteria associated with dental tartar and dental pain due to diseased teeth and gums contribute to the overall decline of all geriatric patients.4,5 Older cats should continue to receive regular dental cleanings and extractions to make sure good dental health is maintained. With good dental health, secondary infections are less likely, as is decreased food intake due to dental pain.

Since dental procedures require general anesthesia (see also "What special anesthetic considerations do senior cats have?" below), and renal compromise due to hypotension is a concern, all senior cats should receive intravenous fluids before, during, and after their dental procedures. A good fluid choice for cats with underlying cardiac disease is 0.45% sodium chloride solution administered at a conservative rate to provide renal support and avoid fluid overload. Choose kidney-friendly anesthetics such as isoflurane and sevoflurane6 for these patients, with a goal to minimize hypotension. I often use a slow propofol intravenous induction followed by maintenance with an inhalant anesthetic such as sevoflurane. This protocol allows for a smooth, controlled induction and intubation, with the pet receiving intravenous fluids and being monitored during the induction period. Begin antibiotic therapy at least one hour before the dental procedure.5

What behavior issues are more common in senior cats?

Probably the most common behavior concerns in cats are inappropriate urination and defecation. In older cats, these behaviors are likely related to arthritis or any condition that causes pain or decreased mobility, other underlying diseases, or cognitive dysfunction. A comprehensive history as well as a complete physical examination and diagnostic workup will help identify these underlying conditions. Treatment should first be aimed at the health problems. Behavior modification may later be needed.

Another behavior concern in geriatric cats is a change in attitude, usually described as the cats' becoming more aggressive or cranky. Underlying disease or pain should also be considered as possible causes of these attitude changes. Cats with hyperthyroidism will often show behavior changes such as increased irritability or affection because of their disease.

Clients will comment that their cats are slowing down in their old age. While this is possible, it is prudent to make sure this lethargy is not due to an underlying disease such as cardiac disease, hypertension, or other metabolic concerns.

Cognitive dysfunction is more difficult to diagnose. In the absence of any physical causes, one or more of the following behavioral changes may be observed—decreased reaction to stimuli, confusion, disorientation, decreased interaction with the client, increased irritability, slowness in obeying commands, alteration in sleep patterns, decreased responsiveness to sensory input, increased vocalization, and problems performing learned behaviors.7

How do I manage pain in older cats?

Pain is pain, no matter the patient's age. Start to treat pain, whether acute or chronic, as soon as possible. Give special consideration to any underlying conditions or drug interactions. Some causes of chronic pain include degenerative joint disease, inflammatory diseases, dental disease, and neoplasia. Acute pain can be caused by trauma, surgery, neoplasia, and conditions such as pancreatitis, urinary tract disease, and gastrointestinal disorders. A variety of oral and injectable pain medications are available for use in cats.8 I like to use piroxicam (1 mg daily) in cats with acute and chronic pain. Nutraceuticals such as glucosamine, chondroitin sulfate, and omega-3 fatty acids may also help alleviate some forms of pain.9

What special anesthetic considerations do senior cats have?

Advanced age is not a reason to avoid anesthesia in these patients. But take underlying conditions into account when selecting anesthetic agents and administering supportive care. Intravenous fluids before, during, and after the procedure are suggested to prevent renal compromise due to hypotension from general anesthesia and to provide vascular access if needed in an emergency.6

Monitoring senior cats before and during anesthesia is also important. Obtain blood work before any anesthetic procedure. Obtain preanesthetic blood pressure measurements and electrocardiograms in all cats, and continue to monitor these parameters while the cat is anesthetized. Other techniques that may be used are pulse oximetry, esophageal stethoscope auscultation, and respiratory monitoring (capnography). Maintaining body heat is also critical as many of these patients have decreased body fat. Postprocedure blood work may also be indicated, depending on the cat's clinical condition.

How often should senior cats be vaccinated?

Assess the risk of exposure to disease in each senior patient based on details from the medical and behavioral history. Cats that are inside only have little risk of contacting other cats with disease. They may benefit from the three-year vaccination program. An inside-outside cat has a higher risk for exposure to diseases from other cats but may be well-protected with the three-year vaccination program. Discuss the risks and benefits of vaccinations with owners to determine the appropriate vaccination protocol for their pets. Rabies vaccines should be given in accordance with the AAFP/AFM Advisory Panel on Feline Vaccines10 and local laws.

REFERENCES

1. American Association of Feline Practitioners/Academy of Feline Medicine Panel Report on Feline Senior Care. J Feline Med Surg 2005;7:3-32.

2. Hypertension Consensus Panel, American College of Veterinary Internal Medicine (report), in Proceedings. 20th Annu Vet Med Forum, 2002.

3. Laflamme DP. Nutrition for aging cats and dogs and the importance of body condition. Vet Clin North Am Small Anim Pract 2005;35:713-742.

4. DeBowes LJ, Harvey CE. Disorders of cats: the oral cavity and dental disease. In: Geriatrics and gerontology of the dog and cat. Philadelphia, Pa: WB Saunders Co, 1995;128-134.

5. Holmstrom SE. Geriatric veterinary dentistry: medical and client relations and challenges. Vet Clin North Am Small Anim Pract 2005;35:699-712.

6. Carpenter RE, Pettifer GR, Tranquilli WJ. Anesthesia for geriatric patients. Vet Clin North Am Small Anim Pract 2005;35:571-580.

7. Landsberg G, Araujo JA. Behavioral problems in geriatric pets. Vet Clin North Am Small Anim Pract 2005;35:675-698.

8. Smith LJ. Answering your questions: practical analgesia in cats. Vet Med 2005;100:602-610.

9. Beale BS. Use of nutraceuticals and chondroprotectants in osteoarthritic dogs and cats. Vet Clin North Am Small Anim Pract 2004;34:271-289.

10. 2000 Report of the American Association of Feline Practitioners and Academy of Feline Medicine Advisory Panel on Feline Vaccines. J Feline Med Surg 2001;3:47-72.

Still thriving after all these years

Zeke, a 16-year-old male castrated domestic longhaired cat, is a great example of how a well-organized senior care program can identify and address underlying diseases as they occur and provide a long, good-quality life. At age 16, Zeke's current health concerns include obesity, inflammatory bowel disease, hypertrophic obstructive cardiomyopathy, and diabetes mellitus. How did my colleagues and I at North Georgia Veterinary Specialty Care successfully get Zeke to age 16?

Zeke is a 16-year-old domestic longhaired cat with multiple, yet successfully managed, health problems.

An ongoing problem...

Obesity (body condition score of 5 of 5) had been an ongoing problem for Zeke since age 7. We counseled Zeke's owner about weight loss for Zeke and started Zeke on a high-fiber diet. Zeke's weight stabilized on this diet but no weight loss was noted. The results of yearly blood work, urinalyses, total T4 concentrations, fecal examinations, and blood pressure measurements were normal each year. Zeke also returned every six months for a thorough physical examination, including evaluation of all vital signs and his weight.

A second problem arises...

Zeke began vomiting almost daily at age 12. He had lost a little weight but was still overweight (body condition score of 4). The results of blood work, urinalysis, a total T4 concentration, and blood pressure measurement were normal. Because Zeke was showing clinical signs of disease, we performed an FeLV antigen test and an FIV antibody test, and the results were negative. Abdominal radiographs revealed no abnormalities. Since Zeke lived in a heartworm-endemic area, we performed a heartworm antibody test, and the results were negative. The results of Toxoplasma gondii serology (IgM, IgG) were also negative. The results of a feline-specific serum trypsin-like immunoreactivity and pancreatic lipase immunoreactivity test were normal, but the folate concentration was elevated and the cobalamin concentration was low, suggestive of bacterial overgrowth or other small intestinal disease. The results of the fecal examination were negative for intestinal parasites.

Broad-spectrum anthelmintic administration and diet changes (intestinal, hypoallergenic) did not alleviate Zeke's clinical signs. We performed gastroduodenoscopy, and the histologic results revealed that the stomach and small intestine contained moderate to severe infiltrates of lymphocytes and plasma cells scattered beneath the surface and accumulated at the villous tips, consistent with a diagnosis of moderate to severe lymphocytic-plasmacytic gastroenteritis.

We prescribed prednisolone (5 mg once daily) and started Zeke on a low-residue intestinal diet. He showed a good response to the drug and diet therapy, with control of the vomiting. We eventually lowered the prednisolone dose to 2.5 mg once a day for maintenance therapy. During the first 12 months after diagnosis, the owner brought Zeke in for a thorough physical examination, including evaluation of all vital signs and his weight, every three months.

At age 13, Zeke continued to do well on therapy. He was still overweight (body condition score of 4), but his weight was stable. The results of blood work, urinalysis, a total T4 concentration, a fecal examination, and blood pressure measurement continued to be normal. He returned six months later for a physical examination, and all parameters were stable.

A third problem appears...

At age 14, Zeke was still doing well at his yearly checkup. The results of blood work, urinalysis, a total T4 concentration, a fecal examination, and blood pressure measurement were normal. However, several months after this checkup, Zeke had a sudden onset of episodes of collapse, which could have been either seizures or syncope. Each episode was short, and he recovered quickly. The episodes seemed to occur in association with excitement, especially at feeding times. Blood work, urinalysis, a total T4 concentration, and blood pressure measurement were repeated, and the results were still normal. The results of an FeLV antigen test and an FIV antibody test were also negative.

We performed a cardiac evaluation, which included thoracic radiography, six-lead electrocardiography, and echocardiography. Cardiomegaly was noted on the thoracic radiographs, but no evidence of pulmonary congestion was present. The electrocardiographic findings were normal. The echocardiogram revealed marked hypertrophy of the left ventricular free wall and obstruction of the left ventricular outflow tract by the interventricular septum, consistent with a diagnosis of hypertrophic obstructive cardiomyopathy.

We thought the left ventricular outflow tract obstruction was the cause of the syncope (collapse episodes). Zeke began receiving atenolol (12.5 mg daily) to address his cardiac disease, as beta-blockers are the drug of choice when some component of left ventricular outflow tract obstruction is noted. He continued to receive prednisolone (2.5 mg once daily) and the low-residue intestinal diet. He returned several weeks after this diagnosis was made for a physical examination. He had improved while receiving this therapy, and his syncopal episodes had resolved. He continued to return every three months for follow-up examinations.

At Zeke's annual comprehensive checkup at age 15, his health problems included obesity (body condition score of 4), inflammatory bowel disease, and hypertrophic obstructive cardiomyopathy. He was clinically doing well. The results of blood work, urinalysis, a total T4 concentration, and blood pressure measurement were normal. His follow-up cardiac evaluation (six months after the initial diagnosis) showed no progression of his cardiac disease. We repeated blood work, urinalysis, a total T4 concentration, and blood pressure measurement six months later, and all values were normal.

And a fourth problem develops...

At age 16, Zeke was again presented for his checkup. No unusual clinical signs were noted by the owner or found on physical examination. He was still overweight (body condition score of 4). This time when blood work, urinalysis, a total T4 concentration, and blood pressure measurement were performed, two striking abnormalities were present: a marked hyperglycemia (> 350 mg/dl) and glucosuria. A fructosamine concentration was also elevated. We diagnosed diabetes mellitus.

Cats with inflammation of their intestines often have ongoing inflammation in their liver and pancreas (triaditis). We did not think the low-dose corticosteroid therapy being administered to control Zeke's inflammatory bowel disease caused the diabetes mellitus. We prescribed intermediate-acting insulin therapy (Humulin L—Eli Lilly). We chose this insulin because of its effectiveness in cats, in my experience. Good control was obtained with a moderate dose (3 U) of this intermediate-acting insulin twice a day. Zeke's cardiac evaluation was stable, showing no progression of his heart disease. Zeke did not exhibit any insulin resistance from the concurrent use of corticosteroids, so no changes were indicated in his other drugs or diet. He remained overweight but was at a stable weight.

... but Zeke is still going strong

So here we are with Zeke at age 16. He has multiple health problems—obesity, inflammatory bowel disease, hypertrophic obstructive cardiomyopathy, and diabetes mellitus. These problems are being successfully managed with medical therapy. The owner diligently brings Zeke in for follow-up checkups. A blood glucose curve was performed to determine Zeke's nadir. He now returns monthly for a blood glucose check at his nadir, as well as a fructosamine concentration measurement if needed. Echocardiographic examinations are performed every six months. The guidelines as outlined by the AAFP/AFM Panel Report on Feline Senior Care have helped us reach the goals of managing and monitoring chronic disease, preventing disease progression, and providing a good quality of life for Zeke. He still enjoys running to his food bowls for his meals, with no recent syncopal episodes reported.

Cynthia J. Stubbs, DVM, MS, DACVIM

North Georgia Veterinary Specialty Care

3550 Lawrenceville-Suwanee Road, Suite 112

Suwanee, GA 30024

This article is adapted from Dr. Stubbs' 2005 CVC proceedings paper.