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Compendium September 2009 (Vol 31, No 9)

Feline Focus — 2008 AAFP Senior Care Guidelines

    Cats are the most popular pet in the United States and much of northern Europe.1 Although 78% of owners consider their cats to be family members,2 many cats, particularly seniors, do not receive appropriate preventive care.3,4 With good care, many cats live into their late teens and some into their twenties; the percentage of older cats is increasing.5,6

    Older cats can be classified as mature or middle-aged (7 to 10 years), senior (11 to 14 years), or geriatric (15+ years). In this article, as elsewhere, the word senior is used as a broad category for all older cats, unless otherwise noted.

    The goals of the American Association of Feline Practitioners (AAFP) Senior Care Guidelines are to assist veterinarians to deliver consistent high-quality care to senior cats, promote feline longevity, and improve the quality of life of senior cats.

    The Senior Cat Wellness Visit

    • Use open-ended questions (e.g., "What behavior changes have you noticed in the last few weeks?") to obtain a comprehensive medical and behavioral history. Issues identified with such questions can raise the index of suspicion for early disease. The frequency of behavior problems increases with age.
    • Perform a thorough physical examination to enable detection of problems that may not be obvious to owners or discovered with laboratory testing. Make weight and body condition score (BCS) comparisons at each visit.
    • Examine apparently healthy senior cats every 6 months. More frequent evaluations may be needed once evidence of an age-related disease process is discovered.
    • Obtain a minimum database (MDB; TABLE 1 ) at least annually starting at age 7 to 10 years. Increase the frequency of the MDB as a cat ages. Rely on clinical judgment and discussions with the owner to determine the specific age and frequency of testing for each individual cat. Trends in the MDB can be significant, allowing detection of disease earlier than interpretation of a single sample.

    Interpretation of the Urinalysis

    Interpretation of the urinalysis, particularly the urine specific gravity and protein, is of particular importance in senior cats.

    • Assess proteinuria in the absence of urinary tract infection or gross hematuria. Dipstick protein measurement is inaccurate; the microalbuminuria test or urine protein:creatinine (UPC) ratio may be indicated for confirmation of proteinuria when the dipstick is positive or when the dipstick is negative and the cat has a disease known to promote proteinuria.
    • If the urine specific gravityis <1.035, repeat the measurement on a subsequent sample to evaluate persistence.
    • Conduct urine culture and sensitivity testing in patients with chronic kidney disease (CKD), diabetes mellitus, and hyperthyroidism. Bacterial infection can be present in the absence of an inflammatory sediment, particularly in patients with these conditions,7 or when the urine is sufficiently dilute to potentially cause misinterpretation of the urine sediment.8

    Blood Pressure Monitoring and Hypertension

    • Measure blood pressure at least annually in cats in the senior and geriatric age groups. Some also recommend routine blood pressure monitoring in mature cats to provide baseline measurements for future comparison.
      — Most hypertensive cats have an identifiable cause for their elevated blood pressure, but idiopathic increases in blood pressure may occur in a substantial subpopulation of older cats.9
      — Obtaining an accurate blood pressure requires a consistent approach with attention to detail.10 Measure blood pressure with the owner present in a quiet room. Allowing the cat to acclimate to the room for 5 to 10 minutes can decrease anxiety-associated hypertension by up to 20 mm Hg.

    Nutrition and Body Condition

    • Individualize diet recommendations depending on the BCS.
    • Increase water intake by offering canned food and multiple water dishes. Feeding small meals frequently increases nutrient availability.
    • Measure serum cobalamin (vitamin B12) concentration in any cat with weight loss, diarrhea, or poor appetite that may have gastrointestinal disease. Deficiencies in essential B vitamins can occur with poor intake or intestinal disease.
    • Design or maintain a weight loss plan for obese cats. Obesity is a metabolic disease with hormonal, metabolic, and inflammatory changes; it is a risk factor for diabetes, osteoarthritis, respiratory distress, lower urinary tract diseases, and early mortality.11
    • When possible, identify and correct the underlying health problem in cats with unexplained weight loss. Cats in the senior and geriatric age groups often become underweight, resulting in a low BCS.

    Dental Care

    Oral cavity disease is an often-overlooked cause of morbidity in older cats and can contribute to a general decline in attitude and overall health.12 Age should not exclude the treatment of dental disease.

    Anethesia

    • Provide intravenous fluids and thermal support; monitor blood pressure and body temperature. Older cats require particularly attentive care and monitoring to prevent hypoxia, hypotension, and hypothermia.
    • Attend to comfort and handle gently, particularly for cats with osteoarthritis or muscle wasting.

    Monitoring and Managing Disease

    Chronic Kidney Disease

    • Stage and manage CKD patients using the International Renal Interest Society (IRIS) guidelines.13 The IRIS stage is assigned based on the serum creatinine concentration, UPC ratio, and blood pressure.
    • Monitor blood pressure. CKD is the leading cause of secondary hypertension.
    • Evaluate for proteinuria. A UPC ratio >0.4 warrants consideration of treatment.
    • Recommend feeding a "renal" prescription diet. Use of such diets has been shown to reduce uremic episodes, decrease phosphorus retention, prevent muscle wasting, and increase survival times.14-16

    Hyperthyroidism

    The total thyroxine (T4) level is the appropriate screening test. However, the total T4 level may be equivocal or normal in cats with a concurrent illness.17

    • Interpret free T4 in conjunction with total T4 and clinical signs in cats with normal total T4 and suspected of having hyperthyroidism. The free T4 level can be elevated in cats with nonthyroidal illness.17
    • Monitor affected cats for kidney disease and hypertension.
      — Hypertension may persist or develop after treatment.
      — Even cats with a urine specific gravity >1.035 may have kidney disease that is unmasked after treatment of hyperthyroidism.18

    Diabetes Mellitus

    Although most cats are insulin dependent at the time of diagnosis, early glycemic control may lead to clinical remission. Of particular importance for senior cats is the effect of concurrent disease, such as chronic pancreatitis, on their health status.

    Inflammatory Bowel Disease and Associated Disease

    Inflammatory bowel disease, pancreatitis, and cholangiohepatitis may occur separately or together.

    • Rule out disorders causing digestion/absorption problems in euthyroid, nondiabetic cats with unexplained weight loss, vomiting, diarrhea, and increased appetite and thirst.
    • Include measurement of feline pancreatic lipase immunoreactivity (fPLI), feline trypsin-like immunoreactivity (fTLI), cobalamin (vitamin B12), and folate concentration in the evaluation.19-22

    Cancer

    Weight loss in the absence of other identifiable causes is a common sign of cancer. Pursuing a diagnosis before the cat's body condition deteriorates may affect the outcome.23 Critical components of cancer therapy include pain management, antinausea medication, and nutritional support.

    Osteoarthritis

    Osteoarthritis is a common but underrecognized condition in senior cats. Signs are often subtle behavioral and lifestyle changes that are mistaken for "old age."24 Management is ideally holistic in scope, attending to both the cat and its environment.25

    Cognitive Disorders

    Cognitive changes may result from systemic illness, organic brain disease, true behavioral problems, or cognitive dysfunction syndrome, a neurodegenerative disorder.

    • Rule out all medical illnesses to diagnose a primary cognitive disorder.

    Complex Disease Management

    • Search for additional disease processes when expected therapeutic results are not obtained. The likelihood of developing more than one disease increases with age.

    Be aware of issues surrounding multiple diseases in senior cats:
    — Diagnosing one disease while missing another, or assuming a single disease is severe when signs are due to multiple diseases (e.g., concurrent hyperthyroidism and CKD), is common.
    — Treatment of some diseases may affect concurrent diseases (e.g., hyperthyroidism and diabetes mellitus). 

    Quality of Life

    Hand in hand with the management of chronic illness in senior patients comes the responsibility to control pain and distress, assess quality of life, and provide guidance to the owner in end-of-life decisions. The veterinarian must act as a patient advocate when counseling clients about decisions regarding use or continuation of treatment.26

    Hospice care patients and their owners benefit from examination every 2 to 4 weeks or as deemed necessary to assess comfort, quality of life, and quality of the relationship. Quality-of-life scales can aid tremendously in end-of-life decision making.

    Acknowledgments: The American Association of Feline Practitioners wishes to thank Nestlé Purina, Merial Ltd., IDEXX Laboratories, Inc., Nutramax Laboratories, Inc., and Abbott Laboratories for their support of these guidelines.

    Downloadable PDF

    1. American Veterinary Medical Association. U.S. Pet Ownership and Demographic Sourcebook. Schaumburg, IL: American Veterinary Medical Association; 2007.

    2. Pew Research Center Publications. Gauging family intimacy: dogs edge cats (dads trail both). March 7, 2006. Accessed July 2009 at http://pewresearch.org/pubs/303/gauging-familyintimacy.

    3. Cohen SP. Can pets function as family members? Western J Nurs Res 2002;24(6):621-638.

    4. Adams CL, Bonnett BN, Meek AH. Predictors of owner response to companion animal death in 177 clients from 14 practices in Ontario. JAVMA 2000;217(9):1303-1309.

    5. Broussard JD, Peterson ME, Fox PR. Changes in clinical and laboratory findings in cats with hyperthyroidism from 1983 to 1993. JAVMA 1995;206(3):302-305.

    6. Wolf A. Proceedings of the BSAVA Pedigree Pet Foods Lecture Tour. 2005.

    7. Mayer-Roenne BM, Goldstein RE, Erb HN. Urinary tract infections in cats with hyperthyroidism, diabetes mellitus, and chronic kidney disease. J Feline Med Surg 2007;9(2):124-132.

    8. Chew J, DiBartola S. Recent concepts in feline lower urinary tract disease. Vet Clin North Am Small Anim Pract 2005;35:147-170.

    9. Maggio F, DeFrancesco TC, Atkins CE, et al. Ocular lesions associated with systemic hypertension in cats: 69 cases (1985-1998). JAVMA 2000;217(5):695-702.

    10. Brown S, Atkins C, Bagley R, et al. Guidelines for the identification, evaluation, and management of systemic hypertension in dogs and cats. ACVIM Consensus Statement. J Vet Intern Med 2007;21(3):542-558.

    11. Lund EM, Armstrong PJ, Kirk CA, Klausner JS. Prevalence and risk factors for obesity in adult cats from private US veterinary practices. J Applied Res Vet Med 2005;3(2):88-96.

    12. Richards J, Rodan I, Beekman G, et al. AAFP Senior Care Guidelines for Cats. 1998. Accessed December 2008 at www.catvets.com.

    13. International Renal Interest Society (IRIS) Web site. Accessed July 2009 at www.iris-kidney.com.

    14. Ross J, Osborne C, Kirk C, et al. Clinical evaluation of dietary modification for treatment of spontaneous chronic kidney disease in cats. JAVMA 2006;229:949-957.

    15. Plantinga EA, Everts H, Kastelein A, Beynen AC. Retrospective study of the survival of cats with acquired chronic renal insufficiency offered different commercial diets. Vet Rec 2005;157:185-187.

    16. Elliott J, Rawlings JM, Markwell PJ, Barber PJ. Survival of cats with naturally occurring chronic renal failure: effect of dietary management. J Small Anim Pract 2000;41:235-242.

    17. Peterson ME, Melián C, Nichols R. Measurement of serum concentrations of free thyroxine, total thyroxine, and total triiodothyronine in cats with hyperthyroidism and cats with nonthyroidal disease. JAVMA 2001;218(4):529-536.

    18. Riensche MR, Graves TK, Schaeffer DJ. An investigation of predictors of renal insufficiency following treatment of hyperthyroidism in cats. J Feline Med Surg 2008;10(2):160-166.

    19. Simpson KW, Fyfe J, Cornetta A, et al. Subnormal concentrations of serum cobalamin (vitamin B12) in cats with gastrointestinal disease. J Vet Intern Med 2001;15:26-32.

    20. Forman A, Marks SL, de Cock HEV, et al. Evaluation of serum feline pancreatic lipase immunoreactivity and helical computed tomography versus conventional testing for the diagnosis of feline pancreatitis. J Vet Intern Med 2004;18:807-815.

    21. Steiner JM, Williams DA. Serum feline trypsin-like immunoreactivity in cats with exocrine pancreatic insufficiency. J Vet Intern Med 2000;14:627-629.

    22. Parent C, Washabau RJ, Williams DA. Serum trypsin-like immunoreactivity, amylase and lipase in the diagnosis of feline acute pancreatitis [abstract]. J Vet Intern Med 1995;9:194.

    23. Baez JL, Michel KE, Sorenmo K, Shofer FS. A prospective investigation of the prevalence and prognostic significance of weight loss and changes in body condition in feline cancer patients. J Feline Med Surg 2007;9:411-417.

    24. Boehringer Ingelheim. New survey highlights behavioural changes are key to identifying arthritis in cats. UK Vet 2007;12(6):26-27.

    25. Godfrey DR. Osteoarthritis in cats: a retrospective radiological study. J Small Anim Pract 2005;46:425-429.

    26. Rollin BE. Ethical issues in geriatric feline medicine. J Feline Med Surg 2007;9:326-334.

    This is an abbreviated version of the senior care guidelines, the full text of which can be found at catvets.com/professionals/guidelines/publications/?Id=398 and in the September 2009 issue of the Journal of Feline Medicine and Surgery Clinical Practice. The guidelines are in memory of the late Dr. James R. Richards, who coauthored the initial senior guidelines in 1998 and who loved to say, "Cats are masters at hiding illness."

    References »

    NEXT: Fluid Choice for Resuscitation and Perioperative Administration

    didyouknow

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