LIFE STAGES: FOCUSING ON OLDER FELINE PATIENTS

Transcription

1 LIFE STAGES: FOCUSING ON OLDER FELINE PATIENTS Janette L. Vani, DVM Instructor of Veterinary Technology and Undergraduate Academic Advisor Veterinary Technology Program College of Veterinary Medicine 736 Wilson Rd, A-5 Veterinary Medical Center Michigan State University East Lansing, MI Cats are the most popular pet in the United States, yet their veterinary care is troubling. Owners think that cats don t need routine medical care, because they are seen as being self-sufficient and signs are often difficult to detect. Understanding the life stages of the cat will help to provide optimal health care to our feline patients. It will help the owner understand the importance of regular veterinary care. It starts with the kitten and is reinforced with each visit as they continue to age. The owners will receive a consistent message from the entire veterinary team. By early detection of abnormalities or changes, disease management and quality of life can improve. The cat is broken down into 6 life stages. The life stages are as follows: Kitten from 0-6 months of age; Junior from 6 months to 2 years of age; Adult or Prime from 3 to 6 years of age; Mature from 7-10 years of age; Senior from years of age; and Geriatric at 15 years and older. As we look at our population of cats, the number of older cats is increasing. With better care, many cats are living into their late teens and some into their twenties. Changes that associate with aging in cats can result in a progressive reduction in the ability to cope with physiologic,

2 immunologic, and environmental stress. As a cat gets older, the incidence of decrease increases, and the disease may or may not be clinically evident. As cats get older, we should strive to achieve these following goals: to deliver high quality care for our aging cat; promote longevity and improve the quality of life; recognize and control health risk factors; early disease detection; and improve and maintain residual organ function. There are many changes that happen in older cats that are associated with getting older. These changes can affect multiple areas of the cat s body. For our senior cats, it is recommended to have at least semi-annual exams. If a disease has been identified, then the frequency of exams may need to be increased for better monitoring. Disease usually develops in middle aged cats, and as cats age, there is an increase in the frequency of behavioral problems that develop. With more frequent exams, there is an opportunity to communicate with the owner and to discuss any concerns they have. Cats may be able to compensate for early disease and therefore will appear to be okay, but their health can change quickly. When they are unable to compensate, then they will present as being ill. Owners may not recognize or even realize the importance of subtle changes in their cat. Earlier detection of disease will allow easier disease management, be less costly, provide a better quality of life, and more successful treatment. When evaluating our older cats, a comprehensive history, which includes open ended and specific questions, will allow us to uncover any subtle signs or behavior changes of the cat. A thorough physical examination allows us to be able to detect problems that may not be obvious. The cat should initially be observed from a distance to evaluate breathing, gait, stance, and vision. Vital signs should be compared to previous visits, and any weight gained or lost should be addressed. A tip of nose to tail examination should be completed and include: skin and coat

3 analysis, oral exam, retinal exam (for signs of retinal detachment or hypertension), thyroid gland, heart rate and rhythm, murmurs, abdominal palpation, joint thickening, and muscle atrophy. A minimum database of testing should be completed annually starting at the mature stage of a cat s life (7-10 years). The minimum database should include a complete blood count (CBC), serum chemistry profile, urinalysis, +/- T4, and blood pressure. These tests can help to detect any preclinical disease that the cat may have. As the cat ages, the frequency of testing should increase as health changes can occur rapidly. Trends and progression of values should be watched and may require re-evaluation. Additional extensive testing beyond the minimum database may be required if there are abnormalities with the history or physical exam; a disease is suspected or revealed; or if trends change or become apparent. Interpretation of the test results may be complex and different parts of the testing may need to be evaluated together. A urinalysis should be performed via cystocentesis in the older cat. In the older cat, it is possible for a bacterial infection to be present even in the absence of inflammation. Those cats in which there is presence of disease or if the specific gravity is dilute (even up to 1.030) should have a culture and sensitivity performed. There is care that every cat should receive no matter what their life stage is. Basic care that should be given to all cats includes: parasite prevention (including heartworm preventative), fecal examinations, dental care, weight management, vaccination, and retrovirus status. All cat owners should be educated to help improve the comfort and health care of cats. All 5 resources should be made available to all cats, which includes water, food, litter box, social interactions, and resting/hiding areas. Cats should have easy access to food, water, and litter. They should be provided with attention and grooming. A quiet, safe sleeping area with a stable and predictable routine should be made available. Nutrition recommendations need to be individualized to each cat and will vary based on the body condition score of the cat and if any disease is present. A good diet is palatable, is balanced and complete, maintains ideal body weight, gives fecal normal character, and gives a healthy skin and hair coat. Older cats should be fed small, frequent meals to help increase digestive availability. Older cats are prone to dehydration and constipation, so adequate water intake is important. Water intake can be increased by feeding canned food, using multiple water dishes or fountains, tuna or clam juice ice cubes or adding directly to the water, and adding water to dry food. Diet changes may need to be done gradually to avoid altering the gastrointestinal flora and causing vomiting, diarrhea, or a decreased appetite. Cyproheptadine, which increases appetite, and Mirtazapine, which decreases nausea and increases appetite, can be used at the lowest effective doses. Older cats may need lifelong replacement of B vitamins if they have a decreased appetite or gastrointestinal disease. Weight and body condition score should be monitored and watched for trends. Weight management for both the obese and underweight cats is important. Obesity usually starts in young cats. It is a risk factor for developing diabetes mellitus, osteoarthritis, respiratory distress, lower urinary tract disease, and early mortality. Obesity is a metabolic disease with hormonal, metabolic, and inflammatory changes caused by increased calorie intake with a decrease in expended energy. It can be complicated by other diseases and diets. Underweight

4 cats have low body condition scores usually as a result of either underlying disease, change in metabolism and hormones, or decreased ability to digest protein. Loss of body mass indicates chronic disease and can be a predictor of mortality. The underlying disease needs to be identified and corrected to help improve body mass. Older cats can develop muscle atrophy, which is secondary to chronic osteoarthritis or nerve damage. Muscle wasting in older cats can be related to lack of exercise, poor diet, severe kidney disease, and neoplasia. If older cats have loss of muscle mass, it is usually related to inadequate protein intake or digestibility. These cats will need to be fed a high quality protein diet, such as canned food, without exacerbating any underlying conditions. Some older cats may require feeding tubes in order to receive proper nutritional support; they can also help by giving medications and fluids to the cat. Often dental care is overlooked in older cats. It is a significant cause of morbidity and can lead to a general decline in health. Signs of oral pain in a cat may be thin body condition score, dropping food, chewing on one side of the mouth, eating more slowly, eating less, and a decreased interest in food. Just because a cat is older does not mean that treatment of dental disease should be avoided. The older cat should be stabilized first if necessary. Avoiding treatment of dental problems will lead to a poor quality of life. Although anesthesia may seem scary in the older cats, they can successfully be anesthetized. Anesthesia risk factors include increased age, poor health, and weight extremes. Pre-anesthetic testing and preparation should be tailored to each individual cat, and any underlying abnormalities should be corrected prior to anesthesia if possible. Intravenous fluids should be provided to all the older cats and carefully monitored. Older cats have decreased ventricular compliance and cardiac reserve, which makes them more susceptible to volume overload and depletion and less tolerant to changes in intravascular volume. A cat s body condition and disease can have effects on the way that anesthetic drugs are metabolized and drug doses may need to be decreased. Blood pressure should be continuously monitored during anesthesia. Hypoxia is common in older cats due to poor lung compliance and decreased lung reserve capacity; these cats may need to be pre-oxygenated and ventilated during anesthesia. Hypothermia is also common in older cats, so temperature should be monitored frequently, every 15 minutes, through recovery. Heated cages, hot air blankets (Bair hugger TM ), hot water blankets (although watch the nails- can poke holes in them), HotDog patient warming (some reports of thermal burns), and booties on their feet are ways to help keep and warm up our older cats during anesthesia. Older cats should receive pain management for all procedures. By using presurgical analgesia, the amount of anesthesia needed and the risk of anesthetic or drug reactions are decreased. All cats should be handled gently, but is even more important for our older cats, as many of them have signs of muscle wasting and osteoarthritis. We provide pain management because some cats do not show obvious signs of being in pain. It is a professional obligation to keep a patient free from pain and contributes to successful case outcomes. By providing pain management, it shows we are committed to compassionate care and enhances the vet-client-patient relationship. Quality of life is enhanced, and optimum recovery from illness, surgery, or injury is obtained. How can we tell if our older cats are in pain? Unfortunately, there is no gold standard for

5 assessing pain, although many scales are out there. Pain should be treated as the fourth vital sign. We need to observe the patient and watch for loss of normal behaviors, development of new behaviors, and maintenance of normal behaviors. Signs of pain may be subtle and can include: decreased activity, reluctance to jump on surfaces, not going up or down stairs, difficulty standing after lying down, decreased appetite, and overgrooming or licking a particular area. Ways to treat pain include both medical and non-medical treatment options. Medical treatment options include drugs such as opioids, non-steroidal anti-inflammatory drugs (NSAIDs), Tramadol, and Gabapentin. Opioids, such as buprenorphine, can be use as premedications prior to surgery and may play a role in the treatment of cancer pain and palliative care patients. No NSAIDs are approved for long term use in cats in the United States. They are used off-label when used for long term use. Meloxicam has been approved for use in other countries, but only a one time injection has been approved and labeled in the United States. Robenacoxib is labeled for use in young cats for 3 days after surgery and has not been approved for long term use or for use in older cats. Caution must be used when administering NSAIDs off-label. They may react with other medications, can cause gastrointestinal toxicity and nephrotoxicity, and should not be used in animals in low flow states. Lab monitoring should be performed when NSAIDs are used. Tramadol is bitter tasting to cats. Gabapentin is an 8-12 hour dosing. Non-medical treatment options include nutraceuticals and supplements, such as omega fatty acids and glucosamine/chondroitin sulfate. It can also include acupuncture, physical rehabilitation, therapeutic laser, weight optimization and environmental modifications. Many clinical conditions can affect cats as they get older. We will focus on the most common ones: Hypertension, chronic kidney disease, hyperthyroidism, diabetes mellitus, inflammatory bowel disease, neoplasia, degenerative joint disease, and cognitive disorders.

6 Hypertension is a common disease that older cats get and can be idiopathic or secondary to other diseases, such as chronic kidney disease, hyperthyroidism, and drugs. Hypertension is damaging to the eyes, brain, heart, kidneys, and central nervous system. Blood pressure should be annually measured using a Doppler machine once a year in cats >10 years of age. A baseline blood pressure is a good idea to obtain when the cat is 7-10 years old. The blood pressure should be taken in the room with the owner after the cat has acclimated to the room for 10 minutes. Multiple measurements should be taken as cats can have anxiety-related hypertension. Chronic kidney disease most often begins in middle age. Early detection can be found by obtaining minimum database tests and watching for trends. The most common clinical signs are polyuria, polydipsia, inappetance, nausea, poor hair coat, muscle wasting, and weight loss. Chronic kidney disease should be staged based on IRIS (International Renal Interest Society) guidelines. Initially, fasting serum creatinine is looked at and then SDMA (symmetric dimethylarginine- new kidney biomarker). The stages range from at risk to Stage 4. Some animals have a creatinine that is within reference ranges, but they have chronic kidney disease. These guidelines help to management chronic kidney disease. The stages are further substaged by proteinuria and blood pressure. Proteinuria is a marker of severity and should be monitored with urine protein to creatinine ratios (UPCs). Urine cultures should be performed on chronic kidney disease cats even in the absence of inflammation as they may have a bacterial infection due to the dilute nature of their urine. Treatment for chronic kidney disease is supportive and may include diet change, feeding tubes, potassium supplements, phosphate binders, fluids and anti-nausea medications. Monitoring should be done every 3-6 months if stable or more frequently if the patient is not stable. Hyperthyroidism is also a common condition of older cats, which involves the thyroid gland. Most cats will have bilateral disease and 98% are benign adenomas where as 2% are carcinomas of the thyroid gland. Clinical signs seen with hyperthyroidism include weight loss, polyuria, polydipsia, polyphagia, increased vocalization, agitation/increased activity, tachypnea, tachycardia, vomiting, diarrhea, unkempt hair coat, lethargy, apathy, and inappetance. Hyperthyroidism is diagnosed by persistently elevated T4 or T4 + free T4 by equilibrium dialysis with clinical signs. Many cats will have concurrent diseases with hyperthyroidism, such as thyrotoxic cardiac disease, hypertension, chronic kidney disease, gastrointestinal disease, insulin resistance, and retinopathy. Hyperthyroid cats should have a fundic exam and a blood pressure performed at every visit. The minimum database should consistent of a T4, although additional testing may be necessary to diagnosis hyperthyroidism, such as thyroid scintigraphy, free T4 by equilibrium dialysis, TSH, and T3 suppression test. Additional testing such as thoracic radiographs, echocardiogram and abdominal imaging may be necessary to evaluate nonthyroid disease. Treatment of hyperthyroidism consists of treating the hyperthyroidism and addressing any other underlying diseases that may be present. Treatment options consist of radioactive iodine, medication (Methimazole), surgery, and iodine deficient diet. Radioactive iodine is permanent and the gold standard treatment for most cats. Untreated hyperthyroidism can lead to morbidity and mortality. Cats being treated for hyperthyroidism should be monitored 2-4 weeks after treatment starts or there is a change in dose and every 4-6 months if stable.

7 Another common older cat disease is diabetes mellitus. Diabetes in cats is similar to human diabetes type 2. There is beta cell dysfunction in the pancreas that leads to insulin deficiency. Clinical signs seen with diabetes are weight loss, polyuria, polydipsia, polyphagia, weakness, plantigrade stance, anorexia, and depression. Risk factors for diabetes are cats over the age of 7 years old, obese cats, Burmese, indoor, and male neutered cats. Diabetes is diagnosed by persistent hyperglycemia and glycosuria. Stress hyperglycemia is commonly seen in cats during stressful situations, but usually this will resolve in a few hours. A fructosamine test can also be performed which looks at the average blood glucose level of the proceeding week. These results may be normal in a cat that has recently developed diabetes or has a mild case of diabetes. It is common to see concurrent pancreatitis with diabetes mellitus in cats. The main treatment goal for diabetic cats is to eliminate clinical signs. The hyperglycemia should be controlled below the renal threshold (252 mg/dl) and hypoglycemia should be avoided. Treatment for diabetes includes weight loss if the cat is obese, a carbohydrate restricted diet such as exclusively canned foods, and medications. Long acting insulin in the treatment of choice, but if owners refuse to administer the insulin, then oral hypoglycemic drugs, such as Glipizide, can be tried. Insulin should be dosed based on the cat s ideal weight. Because of stress hyperglycemia, monitoring should be performed at home if possible and appropriate; blood glucose monitors validated for cats should be the only ones used. Blood glucose curves should be performed 5-7 days after starting or after a dose change. Fructosamine levels can also be checked. Some cats will go into remission, and those cats should stay on the low carbohydrate diet and should be monitored for returning clinical signs. Complications of diabetes mellitus include hypoglycemia which can be life threatening and diabetic ketoacidosis, which cause the cat to be ill and require hospitalization. Inflammatory Bowel Disease can commonly be seen in adult cats and requires lifelong treatment. Clinical signs are non-specific and so can be confused with other diseases. Clinical signs include weight loss, vomiting, diarrhea, increased appetite, and polydipsia. In addition the minimum database, additional gastrointestinal specific tests may be performed (folate, vitamin B12, TLI, PLI). IBD can occur with pancreatitis and cholangiohepatitis or they may occur separately. Small cell lymphoma and IBD can look very similar; the ideal way to diagnose is to obtain full thickness biopsies of the intestines. Neoplasia is commonly seen in our older cats. Weight loss without any other cause is a common clinical sign in these cats. Neoplasia causes cancer cachexia with loss of fat and muscle mass. Diagnostic tests should be pursued before body condition score deteriorates, as body condition score is indicative of survival times. Many cancers are treatable or manageable, especially lymphoma which has high remission rates and survival times with treatment. Owners will need to be educated about animal chemotherapy and how it is different from human chemotherapy. Less side effects are seen in animals as compared to humans. The goal of treatment is to control the cancer and improve the quality of life. Palliative treatment is increasing the cat s quality of life without increasing survival time. This is a mainstay of cancer treatment and may include pain management, nutritional support, and anti-nausea medications.

8 Degenerative joint disease (DJD) is very common in older cats. 22% of all cats have evidence of DJD and 90% of cats over 12 years of age have DJD. Cats may have radiographic signs of DJD without any clinical signs, or they may have clinical signs of DJD without radiographic signs. Signs of DJD can be subtle and mistaken just as old age. The owner should be questioned about the cat s mobility and joints should be palpated on physical exam. DJD should be both managed and treated in cats. Cats with DJD should have easy access to their resources. Food and water should be moved to floor level and slightly raised, so they don t have to bend or jump. Ramps or stairs should be placed around the house to allow them access to common areas. They should have large litter boxes with low entry and high sides and fine consistency litter to provide easy access and for those that are unable to squat when going to the bathroom. If the cat is obese, it should be addressed to decrease the stress on the joints and exercise should be increased. Treatment of DJD depends on the severity and the presence of other diseases and should be a multimodal approach. Treatment options include diet (Hill s J/D); supplements (omega fatty acids); nutraceuticals (glucosamine/chondroitin sulfate); pain medication during flare ups or if the disease progresses; and non-drug treatment (massage, therapeutic laser, surgery, acupuncture, physical rehabilitation). Cognitive disorders are common in older cats and 50% of cats show signs at 15 years of age. Clinical signs include altered behavior, inappropriate elimination, disorientation, altered interaction with family, altered sleep/wake cycle, changes in activity, and inappropriate vocalization (loud crying at night). Medical causes should be ruled out first and may include systemic illnesses, brain tumor/disease, true behavioral problems (anxiety), and cognitive dysfunction syndrome. Cognitive dysfunction syndrome can be caused by compromised cerebral blood flow, chronic free radical damage, neurodegenerative disorders, and amyloid deposition. No drugs are licensed for treatment of cognitive disorders in cats, like there are in dogs. Diets high in antioxidants can be used to help decrease oxidative damages and improve cognitive function. Environmental change should be kept to a minimum, especially in regard to the litter boxes. In true behavioral cases, anti-anxiety medications may be helpful. As a cat gets older, it is common for them to develop more than one disease. A search for additional diseases should be performed if results from treatment are not optimal. It is common to miss a disease when another is diagnosed. Care needs to be taken when treating multiple diseases because there can be effects from diet, drug interactions, the impact of multiple disease of the cat s health, and treatment of disease may worsen the other diseases. Managing a cat with multiple diseases can be overwhelming. The bond between a client and their cat is maintained by educating clients about administration and scheduling of medications; by exploring other routes for medication administration; by discussing complementary treatment options; and by listening to the owners concerns and needs and addressing them. Finally, we need to consider the quality of life for our older feline friends. The goal at the end of life is to control pain and distress. We need to be able to assess quality of life and teach the owners on how to do so at home. We need to be an advocate for the patient and proved guidance to the owner on end of life decisions. Often we need to help owners answer the question, How do I know when it is time? Many hospitals are starting to develop hospice

9 programs to help with these quality of life issues. Hospice programs allow us to assess the cat s pain, quality of life, and the quality of the relationship with the owner. These cats can be examined every 2-4 weeks for regular communication with the owner. It also allows us to discuss euthanasia options when the time comes to help the owner prepare for the loss and grief. Knowing more about senior cats is important as we will continue to see older cats because of the increase in quality care that they are being given. With this better care, our cat patients may live well into their teens and even into their late twenties. Because clinical signs can be subtle in our older cats, frequent examinations will lead to early detection of disease and early intervention and treatment, which will lead to an improved quality of life. Understanding their life stage needs will improve longevity and quality of life. References: 1. Hoyumpa Vogt A, Rodan I, Brown M, et al. AAFP-AAHA Feline Life Stage Guidelines. JFMS Clinical Practice, 2010; 12: Buffington CAT. Have you implemented the AAFP-AAHA Feline Life Stage Guidelines? DVM360 (2016). Retrieved from: 3. Pittari J, Rodan I, Beekman G, et al. AAFP Senior Care Guidelines. JFMS Clinical Practice, 2009; 11: Sparkes AH, Cannon M, Church D, et al. ISFM Consensus guidelines on the practical management of diabetes mellitus in cats. JFMS Clinical Practice, 2015; 17: Carney HC, Ward CR, Bailey SJ, et al AAFP guidelines for the management of feline hyperthyroidism. JFMS, 2016; 18: IRIS Guidelines: IRIS Staging of CKD in cats (2016). Retrieved from: 7. IVAPM Signs of Pain (2016). Retrieved from: 8. Epstein ME, Rodan I, Griffenhagen G, et al AAHA/AAFP pain management guidelines for dogs and cats. JFMS, 2015; 17: