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Veterinarian Technician March 2007 (Vol 28, No 3) Focus: Emerging Infectious Diseases

Case Report: "Medically Managing a Senior Cat"

by Betty Marcucci

    Jamocha, a 16-year-old, spayed, seal point Siamese cat, had several chronic medical conditions. Successful management of these conditions required her veterinarians to be committed to her care and willing to try new treatments to prolong her quality of life. Compassionate veterinary technicians who understood that at times Jamocha could be a cranky senior citizen also played a role in making sure she experienced as little stress as possible. Most importantly, her owner was willing to go the extra mile to make Jamocha comfortable in her golden years.

    History

    In 1993, 3-year-old, spayed Ja­mocha first presented to the clinic for evaluation of frequent vomiting. Occasional vomiting and gagging were two problems she had experienced throughout her life. The veterinarian suspected that chronic trichobezoars (hairballs) were responsible for the vomiting. Laxatone (Evsco, Buena, NJ), a dietary paste lubricant, and pineapple juice were prescribed. Unfortunately, the record from this examination is not specific about the exact treatment protocol, its rationale, or how Jamocha responded. No diagnostic tests were conducted. It can be assumed that she improved, at least for the short term.

    When Jamocha was 5 years of age, two new chronic problems emerged. She presented with severe dorsocaudal alopecia (hair loss) and moderate periodontal disease. At that time, Jamocha was given an injection of a slow-release synthetic steroid, methylprednisolone acetate (5.0 mg/kg SC) to treat the skin inflammation, and the prescription for Laxatone was renewed. The record does not indicate whether any diagnostic tests were conducted or how the periodontal disease was addressed.

    One year later, Jamocha received dental prophylaxis under anesthesia and another injection of methylprednisolone acetate (5.0 mg/kg SC) to address a recurrence of the alopecia. Prior to anesthesia, a minimum database (i.e., packed cell volume, total solids, blood glucose, blood urea nitrogen) was obtained. The results were within normal limits. When Jamocha was 8 years of age, she once again presented with dorsocaudal alopecia and received another injection of methylprednisolone acetate at the same dose as before.

    In 1999, when Jamocha presented for her annual examination at the age of 9, her owner requested that she only receive a rabies vaccination and not the then-annual feline viral rhinotracheitis-calicivirus-panleukopenia combination vaccine because of her chronic allergic condition. Although con­troversial, avoiding excessive stimulation of the immune system may be bene­ficial to patients with chronic al­lergic disease. A presumptive diagnosis of allergic skin disease had been made by Jamocha's veterinarian, who complied with the owner's wishes. A complete blood count (CBC) and chemistry screen were conducted at that time. As might be expected, Jamocha's CBC showed mild eosinophilia (an increased number of eosinophils in the blood) and the chemistry screen revealed a mildly elevated total protein value. In pa­­tients with allergic skin disease, blood cells active in an immune re­sponse, such as eosinophils, may be ele­vated. In addition, total protein may be elevated because of excessive amounts of circulating antibody.

    Later that year, Jamocha returned to the clinic for her second dental prophylaxis. A CBC and chemistry screen were conducted before anesthesia was administered, and the findings were within normal limits. She also received her fourth injection of methylprednisolone acetate (5.0 mg/kg SC).

    First Two Medical Challenges: Asthma and Constipation

    In mid-1999, when Jamocha was still 9 years of age, her owner first noticed that she had developed respiratory signs. The cat began to occasionally sneeze. Four weeks later, Jamocha started ex­per­iencing repetitive epi­sodes of sneezing. The left naris was in­flamed, and the veterinarian was con­cerned that there might be a na­sal polyp, a foreign body, or even a nasal tumor responsible for the in­flammation. Rhinoscopy performed earlier that year at the time of the dental prophylaxis showed no obvious lesions. A biopsy was not conducted.

    By the time Jamocha was 10, she was well managed for oc­casional vomiting, severe seasonal alopecia and miliary dermatitis, and periodontal disease. However, in 2000, her veterinarian noted that the occasional vomiting and gagging that had been attributed to hairballs might, in fact, be true coughing. No abnormalities were noted on physical examination, and no diagnostics were conducted at that time. The occasional vomiting, gagging, and coughing continued into 2001.

    Jamocha turned 12 in 2002. That year, the vomiting increased in frequency, becoming an almost daily occurrence. Her owner also reported that the cat occasionally had tenesmus (straining to defecate). Results from a CBC and chemistry screen were unremarkable. Lateral thoracic radiographs showed increased peribronchial thickening, which is a classic sign of feline bronchial disease, particularly asthma. However, many cats with asthma do not show this or any other radiographic signs of disease. Abdominal radiographs revealed increased stool in the colon. A trial of oral prednisone (0.5 mg/kg bid tapered over 2 weeks) resolved the cough. A presumptive diagnosis of asthma was made based on clinical signs, radiographic evidence, and re­sponse to glucocorticoid therapy. A treatment plan was formulated that included injections of methylprednisolone acetate as needed. An antibiotic trial was not prescribed at this time.

    Jamocha's tenesmus and increased vomiting resolved with the prescription of a liquid osmotic stool softener (1.0 ml lactulose PO bid), continuation of an over-the-counter hairball formula diet, and an on­going regimen of biweekly Laxatone.

    Third Medical Challenge: Hyperthyroidism

    In late 2002, results of routine blood screening demonstrated a slightly elevated alanine aminotransferase value of 128 U/L (normal: 10 to 100 U/L) and a total thyroxine concentration of 6.6 µg/dl (normal: 0.8 to 4.0 µg/dl). These values are consistent with hyperthyroidism; however, Jamocha showed no new clinical signs consistent with the disease. Medical management with methimazole (2.5 mg PO bid) was instituted. After a follow-up evaluation 4 weeks later, the initial dose of methimazole was reduced to 2.5 mg sid.

    Cats that begin treatment with methimazole should be assessed by physical examination and appropriate blood tests every 3 weeks for the first 3 months of therapy; any adverse effects usually occur within this time frame. When the cat stabilizes, periodic assessments should be conducted every 3 to 6 months.

    Medical Management Breakdown: Uncontrolled Asthma

    By 2003, 13-year-old Jamocha's medical management plan included methimazole, lactulose, and injections of methylprednisolone acetate as needed. The continued need for frequent methylprednisolone injections to manage the asthma did not indicate a good prognosis for Jamocha. Frequent or high-dose glucocorticoid treatment is associated with a variety of adverse effects, including polyphagia, polyuria, polydipsia, increased susceptibility to infections, and the triggering or worsening of diabetes mellitus.

    Since her presentation with alopecia in 1995, Jamocha had received periodic injections of time-released glucocorticoids (see box above). When she was 13, she experienced her first adverse reaction to injectable glucocorticoids. Six days after the injection, Jamocha's owner reported that she was "acting differently." She re­portedly was chewing at her flanks, pulling out her hair, not sleeping at night, exhibiting frantic behavior alternating with lethargy, and vomiting more than usual. Be­cause steroids have been reported to alter behavior, the injectable steroids were suspect. Two months later, the veterinarian once again attempted to manage Jamocha's asthma with injectable ster­oids, and once again, the adverse reaction was reported by her owner.

    The medical management of Ja­mocha's asthma was altered to a short course of oral prednisone (0.5 mg/kg tapered over 2 weeks), while alternative forms of treatment were investigated. In late 2003, when Jamocha's medical management of asthma began to break down, few veterinarians outside of academia were prepared to prescribe inhalation medications for asthma. For decades, metered-dose inhalers had been the gold standard for treating adult and pediatric human asthma, but the veterinary community was just beginning to become aware of the possibility of treating animals with inhaled medications due to the groundbreaking work of Philip Padrid, DVM.1

    Jamocha's owner introduced the AeroKat inhaler to her as a positive toy, associated with treats and praise.a The first inhaled medication prescribed for Jamocha was albuterol. Albuterol is a short-acting β2-agonist that relaxes smooth muscle and opens bronchial airways. At two puffs a day of albuterol (90 µg/metered dose), Jamocha required continued oral prednisone at a low dose of 2.5 mg q48h to maintain a 30% improvement in clinical signs, as re­ported by the owner. Because this is not an acceptable level of improvement, in early 2004, Jamocha's inhaled medication was changed to fluticasone, which is a glucocorticoid that acts like an oral steroid to reduce inflammation without the same systemic side effects. Fluticasone and albuterol have widely different mechanisms of action and may be used together safely. However, when untreated patients diagnosed with asthma have daily clinical signs, the foundation of their treatment protocol should be an inhaled steroid. The antiinflammatory properties of a steroid will reduce the underlying chronic inflammation of the bronchial airways. At one puff a day of fluticasone (80 µg/metered dose) and supplemental low-dose prednisone therapy, Jamocha's clinical signs improved by 90%.

    After approximately 1 year on this regimen, the amount of oral prednisone necessary to maintain an acceptable level of clinical improvement had increased to 5 mg sid. In order to decrease the amount of oral prednisone, the fluticasone inhaler was renewed at the higher dose of 110 µg/metered dose. Jamocha then remained free of oral prednisone for 9 months.

    Consequences of Vomiting: Pancreatitis

    When Jamocha was 14, her asthma was fairly well regulated with inhaled fluticasone. However, she experienced a serious episode of constipation. She was given 100 ml saline solution SC and responded to three separate treatments over a 5-day period of a small amount of an osmotic enema administered while she was awake. The amount of pre­scribed stool softener was in­creased, and a diet of soft food only was recommended. For now, her bowel movements were improved.

    For more than a decade, Jamocha had been experiencing periodic epi­sodes of vomiting and gagging that had been variably attributed to hairballs, constipation, or true cough due to asthma. Chronic vomiting is one of the clinical signs of pancreatitis, but it is also a predisposing cause for the condition. The abdominal and gastric contractions required to evacuate the stomach during emesis compress the duodenum and the common bile duct through which pancreatic digestive enzymes normally flow. The resultant chronic backwash of pancreatic en­zymes is associated with inflammation of the pancreas and leakage of the enzymes into surrounding tissues.

    At the age of 15, Jamocha had several bouts of vomiting that persisted off and on for almost 4 months. The vomiting was accompanied by diarrhea, which was a new problem for Jamocha. During this period, a CBC and blood chemistry screen revealed moderately elevated serum levels of amylase, a pancreatic enzyme. Although serum levels of some pancreatic enzymes are not diagnostic for pancreatitis (because other sites within the gastrointestinal [GI] tract produce these enzymes as well as the pancreas), a presumptive diagnosis of pancreatitis was made at that time. Several courses of GI protectants, such as famotidine and sucralfate, and antibiotics were prescribed as needed. The inflammation associated with pancreatitis is often accompanied by the translocation of bacteria from the inflamed GI tract into the surrounding tissues. GI protectants, such as those used in Jamocha's case, help to reduce vomiting and heal the inflamed GI mucosa. Other medications may be used to aggressively treat pancreatitis, which, if severe or left untreated, is often fatal in cats.

    After resolution of the clinical signs of pancreatitis, another episode of severe constipation occurred later in 2005. As in the previous year, the constipation was relieved by administration of an osmotic enema while Jamocha was awake. Once again, the amount of prescribed stool softener was increased. It is not uncommon for senior cats to experience chronic constipation. Jamocha responded well to the treatment.

    Controlled Medical Management

    At 16 years of age, Jamocha's primary problems of asthma, constipation, and hyperthyroidism were being managed medically. The caudodorsal alopecia was managed with periodic short courses of oral prednisone. The vomiting still persisted periodically but was helped by a hairball diet formula, Laxatone, and GI protectants as needed. Finally, Jamocha's periodontal disease had worsened since her last dental prophylaxis in 1999. She was being maintained on bi­monthly pulse antibiotic therapy. Pulse antibiotic therapy is short-term antibiotic treatment delivered at standard doses and regular intervals. It is occasionally prescribed to control chronic infections when the usual treatments are considered unsafe or otherwise impossible. Because all of Jamocha's blood parameters, including liver, kidney, and thyroid values, were within normal limits, another dental prophylaxis was indicated.

    Case Commentary

    In spite of Jamocha's multiple medical problems, her quality of life was quite good. She took her oral and inhaled medications very well. She had few or no signs of arthritis and spent quality time playing and interacting with her owner. As an older cat, she slept a lot but also spent time at the window surveying the natural environment. She was a comfort to her owner, and her owner was a comfort to her. Ultimately, this is the goal with geriatric patients.

    As cats age, the veterinary and home care they require changes dramatically. Veterinary technicians, veterinarians, and clients believe that companion animals are living longer than they have in the past. Although a few studies documenting the average life span of dogs in the United States exist, there are no comparable studies of the life span of cats.2 Yet the subjective sense of the veterinary community is that cats, too, are living longer and healthier lives. In keeping with this belief, the American Association of Feline Practitioners and the Academy of Feline Medicine recently published a joint report on feline senior care.3,4 Following their recommendations (see box) will help veterinary professionals maximize the quality of life of our feline patients for as long as possible. However, that will often mean using our intellectual, financial, and emotional resources to manage the multiple medical problems of aging cats.

    Click here for more resources.

    Conclusion

    Subsequent to writing this article, Jamocha became weak, lost weight, and began to exhibit signs of pain. She passed away on October 16, 2006, about 5 weeks after her 16th birthday.

    1. Padrid P: Feline asthma: Diagnosis and treatment. Vet Clin North Am Small Anim Pract 30:1279-1293, 2000.
     
    2. Marcucci BA: Feline life span at a veterinary teaching hospital in the United States: Unpublished data, University of Pennsylvania, Philadelphia, 2003.
     
    3. American Association of Feline Practitioners/Academy of Feline Medicine: Panel report on feline senior care. J Feline Med Surg 7:2-32, 2005.
     
    4. Stubbs CJ: Providing the best care for senior cats. Vet Med 101(2):110-117, 2006.


    aTo learn more about feline asthma, see "Feline Asthma: Causes and Diagnosis" and "Feline Asthma: Treatment and Prognosis" on pages 807 and 820, respectively, in our December 2004 issue.

    References »

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    Did you know... While older patients have similar dental issues as younger ones, many progressive diseases, especially periodontal disease, can take a greater toll during a pet’s golden years.Read More

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