AMERICANASSOCIATIONOFFELINEPRACTITIONERS SENIOR CARE GUIDELINES Revised December 2008

©2009 American Association of Feline Practitioners. All rights reserved. AMERICANASSOCIATIONOFFELINEPRACTITIONERS SENIOR CARE GUIDELINES Revised December 2008

Dedicated to our friend, colleague, and co-author of the original AAFP Senior Care Guidelines, Dr. Jim Richards, in memoriam. A passionate cat lover, he was particularly fond of his older “kitty,” Dr. Mew. Two of Dr. Richard’s favorite sayings were: “Cats are masters at hiding illness” and “Age is not a disease.”

PANELISTS: TABLE OF CONTENTS

Jeanne Pittari, DVM, DABVP Introduction/Aging and the Older Cat ...... 3 (Feline Practice), Co-Chair The Senior Cat Wellness Visit ...... 4 ExaminationFrequency...... 4 Ilona Rodan, DVM, DABVP MinimumDatabase...... 5 (Feline Practice), Co-Chair Interpretation of the Urinalysis ...... 6 RoutineWellnessCare...... 6 Gerard Beekman, DVM Nutrition and Weight Management ...... 7 Danièlle Gunn-Moore, BVM&S, Obesity ...... 7 PhD, MACVSc, MRCVS, RCVS Underweight/Loss of Body Mass ...... 8 Specialist in Feline Medicine DentalCare...... 8

David Polzin, DVM, PhD, Anesthesia...... 8 DACVIM-SAIM Monitoring and Managing Disease ...... 9 BP Monitoring and Hypertension...... 10 Joseph Taboada, DVM, Chronic Kidney Disease ...... 11, 12 DACVIM-SAIM Thyroid Testing and Hyperthyroidism ...... 11, 13 DiabetesMellitus...... 13 Helen Tuzio, DVM, DABVP IBD and Associated Disease...... 14 (Feline Practice) Cancer...... 14 Osteoarthritis...... 15 Debra Zoran, DVM, PhD, Cognitive Disorders...... 16, 17 DACVIM-SAIM Complex Disease Management ...... 17, 18 Quality of Life...... 18 Conclusion ...... 18

The AAFP Senior Care Guidelines report was reviewed and approved by the Guidelines Committee and the Board of Directors of the American Association of Feline Practitioners. Aging and the Older Cat: What is Senior? There is no specific age at which a cat “becomes senior.” Individual animals and body systems age at different rates, but one convenient way to view older cats is to classify them as “mature or middle aged” (7-10 years), “senior” (11-14 years), and "geriatric” (15+ years). (FAB) This helps to focus on the varying disease risks of the different groups (e.g. obesity in the mature group; cachexia in the geriatric group). In this document, as elsewhere, the word “senior” is used as a broad category for all older cats, unless otherwise noted. Introduction Cats are the most popular pet in the US and much of With good care, many cats live into their late teens and northern Europe. Although 78% of owners consider their some into their twenties; the percentage of older cats is cats to be family members, many cats, particularly seniors, increasing. (Broussard et al 1995, Wolf 1995) The inevitable do not receive appropriate preventive care. (Pew 2006; biological changes associated wi th aging resultina Cohen 2002; Adams et al 2000) One of the main obstacles progressive reduction in the ability to cope with physiologic, to owner compliance is the lack of a clear recommendation immunologic, and environmental stresses. Along with “normal” by the veterinary team. (AAHA 2003) Guidelines can help aging, the incidence of certain diseases gradually increases. veterinarians to minimize this obstacle, strengthen the Typical changes associated with aging are shown in Figure 1. human-pet-veterinary bond, and improve quality of life There is no clear line between “typical” changes and disease. for cats. For example, many older cats have radiographic evidence The goals of this report are to assist veterinarians to: of osteoarthritis, and it is difficult to determine when I Deliver consistent high-quality care to senior cats. normal aging of the joints actually becomes a pathological I Promote longevity and improve quality of life of senior process; cats with radiographic evidence of OA may or cats by may not have a clinically-evident problem. (Hardie et al • Recognizing and controlling health risk factors. 2002; Clarke and Benett 2006) For the purposes of this • Facilitating and promoting early detection of disease. document, we have included in the “typical changes” • Improving or maintaining residual organ function. diagram those changes which are not surprising or that • Providing guidelines to delay the progression of one might even expect to find as common aging changes common conditions. that would not necessarily result in clinical intervention. I Define aspects of screening, diagnosis, treatment, and anesthesia of senior cats. Reduced stress tolerance Altered social standing Decreased skin elasticity Altered sleep/wake cycle

Decreased hearing FIGURE 1 Changes Associated with Aging* Non-neoplastic iris Pigment changes Lenticular sclerosis Iris atrophy

*Changes often seen in apparently Decreased digestion/ healthy senior cats. absorption of fat Decreased sense of smell

Brittle nails Cat drawing provided by Kerry Goodsall Increased cardiac/sternal contact on films at www.allaboutdrawings.com Redundant aorta Decreased ventricular compliance Decreased lung reserve Costochondral mineralization (decreased chest wall compliance) 3 AMERICANASSOCIATIONOFFELINEPRACTITIONERS Senior Care Guidelines - Revised December 2008 The Senior Cat Wellness Visit I Joint thickening; muscle atrophy. A comprehensive history helps raise the index of suspicion I Changes in parameters from prior exams (e.g., reduced for early disease by uncovering relevant signs or behavior body temperature; changed weight/BCS or heart rate). changes. Initially, open-ended questions should be asked so that the full range of client concerns is understood. (Kurtz 1998, Frankel 1999) Examples of open ended questions are: “How has Max been doing since his last visit?” “What behavior changes have you noticed in the last few weeks?” “What else?”

Open ended questions can then be followed by more specific questions to ask about: I Changes in the cat’s usual behaviors and routines. (Overall et al 2004) • Changes in interactions with people or other pets. • Grooming. • Activity– sleeping patterns, jumping, wandering, reaction to being handled, and ability to navigate to EXAMINATION FREQUENCY IN SENIOR CATS preferred places. The frequency of exams should increase as cats age. • Vocalization. Although there is controversy regarding frequency of • Litter box habits. exams in younger cats (AAHA 2008), panelists agree that I Eating and drinking (amount and behavior); vomiting apparently healthy senior cats should be examined every or signs of nausea. 6 months. Examining these cats at 6-month intervals is I Stool quality (number, volume, consistency, odor, color). desirable because: I Hearing or vision loss (decreased responsiveness, increased I Many disease conditions begin to develop in cats in vocalization). middle age. I Current diet, medications and supplements. I Health changes occur quickly; cats age faster than humans. I Weight gain or loss can be detected and addressed earlier. The physical exam allows for detection of problems that I Cats may appear well despite underlying disease, may not be obvious to owners or uncovered with laboratory compensating until they can no longer do so, then testing. When performing the physical exam, particular presenting as acutely ill. attention should be paid to: I Owners may not recognize the existence or importance I Observation of the cat from a distance to assess breathing of subtle changes. patterns, gait, stance, strength, coordination, vision. I Early detection of disease often results in easier disease I Weight and body condition score (BCS) comparisons management and better quality of life; it is less costly with previous visits. Both nine-point and five- point and more successful than crisis management. BCS scales are available for use. I The frequency of behavior problems increases with age. http://www.purina.org/cats/health/BodyCondition.aspx One study found 28% of pet cats aged 11–14 years accessed 12/1/2008, www.cvm.tamu.edu/clinicalnutrition/ develop at least one behavior problem, increasing to > bcscat.shtml accessed 1/22/09) 50% for cats > 15 years of age. (Moffatt and Landsberg I Skin and hair coat quality. 2003) I Oral cavity, including gingiva, pharynx, dentition I More frequent owner contact provides opportunity for (Holmstrom et al 2005) and sublingual area. concerns to be discussed. I Retinal exam; vascular changes or “cotton wool spots” as early warning of hypertension or retinal detachment. Exam and lab summary sheets allow for a quick review of I Thyroid gland palpation. trends over time. Once evidence of an age related disease I Heart rate, rhythm, murmur. process is discovered, a more frequent monitoring schedule I Abdominal palpation; pain, masses or thickened bowel, may be needed. kidney and bladder size and shape. 4 AMERICANASSOCIATIONOFFELINEPRACTITIONERS Senior Care Guidelines - Revised December 2008 THE MINIMUM DATABASE Regular exams and collection of the minimum database (MDB) progressive increases in serum creatinine concentration can help detect preclinical disease. Consider performing over several months (even within the normal range) may the recommended MDB (as indicated in Table 1) at least be significant. annually starting at age 7-10, with the frequency increasing as cats age. Specific recommendations about age and The incidence of many diseases increases as cats age. More frequency of testing depend on many factors. (Epstein et robust data about disease incidence by age would assist al 2005; Richards et al 1998) practitioners in determining the value and desired frequency of testing, but such data is lacking. Veterinarians must rely Clearly, there is high value to an individual cat to finding on their clinical judgment and individual client discussions early disease, even when many tests yield normal results. based on each unique cat. Regardless of the cat’s age, more However, routine laboratory testing of otherwise apparently frequent or expansive diagnostic evaluation is indicated if: normal animals increases the statistical likelihood of revealing I Any abnormalities are noted in the history or physical test results that are outside of the normal range but are not exam, even if the MDB appears normal. clinically significant. Interpretation of these values and I Any disease is suspected or revealed at the regular decisions for further workup requires clinical judgment in veterinary visits. the context of the specific patient. Additional workups are I Trends or changes in the history or physical exam not always innocuous. become apparent.

When in doubt, re-evaluate the patient to establish persist- Interpretation of certain parameters is complex in senior ence and/or progression of the abnormality. Trends in the cats. Indications for and debates about blood pressure MDB can be significant, allowing for detection of disease measurement and thyroid testing are discussed later in this earlier than interpretation of a single sample. For example, document.

TABLE 1 The Minimum Database “Mature” Cats “Senior / Geriatric” Cats (7–10 yr) ( > 10 yr)

CBC (hematocrit, RBC, WBC, diff, cytology, platelets) ++

CHEM screen At a minimum, include TP, albumin, globulin, ALP, ALT, glucose, BUN, Creatinine, K+, Phos, Na+, Ca ++

UA* (sp gr, sediment, glu, ketones, bili, protein) ++

T4* +/- +

BP* +/- +

5 AMERICANASSOCIATIONOFFELINEPRACTITIONERS Senior Care Guidelines - Revised December 2008 INTERPRETATION OF THE URINALYSIS IN SENIOR CATS I Interpretation of the UA, particularly the specific gravity and protein, is of particular importance in senior cats. (http://www.iris-kidney.com/education/en/education03. shtml, accessed 4/7/09) I Cystocentesis is recommended for the most accurate results. I Although it is rare, hypertension alone may induce polyuria (“pressure diuresis”), so the presence of low urine specific gravity in a patient with hypertension is not specific for kidney disease. (Brown et al 2007) I Dipstick protein measurement is inaccurate; both false negative and false positive results are possible at any ROUTINE WELLNESS CARE specific gravity. The microalbuminuria (MA) test yields Routine wellness care for older cats starts with the exam more reliable results. The MA test or Urine Protein- and the basic care given to cats of all ages, including parasite Creatinine (UPC) ratio may be indicated: 1) for confir- prevention, dental care, weight management, vaccination, mation of proteinuria when the dipstick is positive or 2) and knowledge of retroviral status. (Companion Animal when the dipstick is negative and the cat has a disease Parasite Council www.capcvet.org accessed 12/1/2008; known to promote proteinuria (e.g. hypertension or AAHA Dental Care Guidelines, Holmstrom et al 2005 CKD). (Mardell and Sparkes 2008; IRIS www.iris- www.aahanet.org accessed 121/08, AAFP Retrovirus kidney.com accessed 12/8/08) Guidelines, Levy et al 2008 and AAFP Feline Vaccine I Proteinuria may be a sign of CKD. However, if urinary Guidelines, Richards et al 2006, www.catvets.com accessed tract infection or gross hematuria is present, then reassess 12/1/08) Educate clients about ways they can improve after resolving those problems. If proteinuria persists, comfort and manage their cats’ health care, ensuring the measure the UPC ratio to determine if it is significant five key resources are available (Table 2). Examples include (UPC > 0.4). Significant and untreated proteinuria is a providing attention, grooming, and environmental poor prognostic indicator for cats with hypertension and changes to ease access to food and litter, and providing a CKD. (Riensche et al 2008; Elliott and Syme 2006; stable and predictable routine with a quiet, safe sleeping Syme et al 2006; Lees et al 2005; King et al 2007) area. (Overall et al 2004) I If the urine specific gravity measurement is <1.035, repeat the measurement on a subsequent sample to evaluate persistence. TABLE 2 I Bacterial infection can be present even in the absence of Five Key Resources for Cats an inflammatory sediment. Urine culture and sensitivity is indicated under the following conditions 1. Water • In the presence of CKD, diabetes mellitus, hyperthy- 2. Food roidism. (Mayer-Roenne et al 2007) • Any time the urine specific gravity is sufficiently dilute 3. Litter box to potentially cause misinterpretation of the urine sediment. The precise specific gravity at which this 4. Social interactions becomes significant is not known, but may be as high 5. Resting/sleeping/hiding space as 1.030. (Chew 2005)

6 AMERICANASSOCIATIONOFFELINEPRACTITIONERS Senior Care Guidelines - Revised December 2008 • Cyproheptadine may increase appetite. Mirtazapine both stimulates appetite and reduces nausea; use the lowest effective dose. I The essential B-vitamins are not stored, so a diminished appetite or intestinal disease can lead to deficiencies. Oral and/or parenteral supplements may be needed as indicated by the cat’s condition. Measure serum cobal- amin (B12) concentration in any cat with weight loss, diarrhea or poor appetite that may have GI disease. Nutrition and Weight Management (Simpson et al 2001) Lifelong replacement may be Diet recommendations must be individualized and will required for cats with maldigestive or malabsorptive vary depending on the body condition score (BCS) disease. (http://www.purina.org/cats/health/BodyCondition.aspx I If urinary stones are a problem in seniors, non-acidified accessed 12/1/2008, www.cvm.tamu.edu/clinicalnutrition/ prescription diets can be used that prevent both triple bcscat.shtml accessed 1/22/09) and any disease present. A phosphate and calcium oxalate stone formation. This good diet is palatable, provides complete and balanced helps avoid excess systemic acidification or low sodium nutrition, and helps maintain ideal body weight, normal diets which can contribute to progressive potassium loss fecal character, and healthy skin and hair coat. Several and lead to a hypokalemic nephropathy. (Buranakarl et factors must be considered in cats that are mature or older. al 2004) I Feeding small meals frequently increases digestive avail- I A cat that is over- or under-weight has a problem that ability. The ideal number of meals is not known, but must be managed as a disease. Monitor both increased feeding multiple (e.g. 3-4) small meals per day is a and decreased weight, comparing serial body weights reasonable goal. and evaluating the BCS. (LaFlamme 2005) I Increased water intake is important since older cats are prone to conditions that predispose to dehydration and subsequent constipation. Water intake can be increased OBESITY by feeding canned food and using multiple water dishes. I Since obesity often begins in young cats, “mature” and • It may be difficult to convert cats from dry to canned older cats will receive continuing weight management. food; starting use of canned food at a younger age (Fettman et al 1997; Hoenig et al 2002; Martin et al 2006) could help cats become accustomed to it. I Obesity is a metabolic disease with hormonal, metabolic • Some cats will refuse to eat canned food; cats predisposed and inflammatory changes that requires immediate to dehydration that continue to eat dry food should be attention. It is a risk factor for diabetes, osteoarthritis encouraged to increase liquid intake (e.g. tuna juice ice (OA), respiratory distress, lower urinary tract diseases cubes, water added to dry food, drinking fountains). and early mortality. (Lund et al 2005) I Dietary changes are often recommended. I Obesity is caused by increased overall caloric intake • Diet changes can alter the intestinal flora, leading to relative to energy expenditure. Metabolism also plays a diarrhea, vomiting or loss of appetite. part; feline carbohydrate metabolism differs from non- • Changes may need to be made gradually (over weeks obligate carnivores. (Morris 2002; Hoenig et al 2007) or months in some cats) to be accepted, yet the presence I In cats with specific conditions requiring other diets of disease or food aversion makes a more-rapid change (e.g, CKD), the weight loss plan must be modified, desirable. which may complicate weight management.

7 AMERICANASSOCIATIONOFFELINEPRACTITIONERS Senior Care Guidelines - Revised December 2008 UNDERWEIGHT/LOSS OF BODY MASS guidelines for dogs and cats. I Cats in the “senior” and “geriatric” age groups often (Holmstrom et al 2005 http://www.aahanet.org./Public- become underweight with low BCS scores. This may be Documents/Dental_Care_Guidelines.pdf accessed due to underlying disease, changes in metabolism and 1/22/09) hormones with increasing age, and/or a decrease in the ability to adequately digest protein. I Loss of normal body mass is a clinical sign that is an Anesthesia indication of chronic disease and a predictor of mortality; Although increasing age, poor health status, and extremes of when possible, identify and correct the underlying health weight are identified risk factors during anesthesia, mature problem. (Doria-Rose and Scarlett 2000; LaFlamme and older cats can be successfully anesthetized. (Robertson 2005; Galanos et al 1997) 2006; Brodbelt et al 2007) Precautions to help ensure a safe I Recognize and investigate the cause of changes in muscle recovery include but are not limited to: mass. Muscle atrophy is typically secondary to chronic I Tailor preanesthetic testing and preparation to the OA or nerve damage; muscle wasting is typically associated individual cat’s clinical condition. Begin correction of with lack of exercise, poor diet, severe kidney disease underlying abnormalities pre-operatively whenever possible. or neoplasia. For example, cats with CKD may need prehydration I Cats admitted to veterinary clinics are more likely than and/or fluids in the immediate post-operative period, as dogs to be under weight (median BCS 4/9) with ~60% well as maintenance fluid therapy during the procedure, having recently lost weight. (Chandler and Gunn-Moore to prevent hypovolemia and hypotension. 2004) Attend to adequate and proper feeding while in I Provide and monitor intravenous fluids for all anesthetic the hospital; balance the need for hospitalization with patients. Decreased ventricular compliance and cardiac the cat’s willingness to eat, treating at home if possible. reserve make older cats less tolerant to changes in intravas- I Protein wasting and loss of muscle mass can result from cular volume, making them more susceptible to fluid inadequate protein intake or digestibility. Kidney or overload or volume depletion complications. intestinal disease may further negatively affect this balance. I Recall the changes in drug metabolism with over-or Thus, the key is to feed the cat sufficient high-quality under-weight cats, and with certain disease states. Reduce protein without exacerbating any preexisting or new dosages of drugs with a significant effect on heart rate conditions. In general, if a higher protein diet is desired, (e.g., ketamine or alpha 2 agonists), and in cats with renal canned foods will provide a wider selection of choices. compromise, reduce dosages of anesthetic drugs eliminated I Placement of a feeding tube allows administration of by renal excretion (e.g., ketamine). proper nutritional support and can ease administration I Monitor blood pressure throughout anesthesia, with careful of fluids or medications. attention to cats receiving antihypertensive medication. (Lefebvre and Toutain 2004) I Poor lung compliance and decreased lung reserve capacity Dental Care increase susceptibility to hypoxia in the perianesthetic Oral cavity disease is an often overlooked cause of significant period. Pre-oxygenation and more-frequent bagging may morbidity in the older cat and can contribute to a general be necessary. (Carpenter et al 2005) decline in attitude and overall health. (Richards 1998) A I Since hypothermia is common, evaluate body temperature complete oral exam, plus the owner’s observation of eating every 15 minutes, continuing postoperatively until the cat behavior, will elucidate dental problems. Cats with oral is ambulatory or normothermic. Support body temperature pain may be thin, drop their food, chew on one side, eat by using tools such as a heated cage, hot air blankets, more slowly, eat less, or show less interest in food. Age water-circulating heating pad, and/or booties. (Brodbelt et or the presence of other chronic conditions should not al 2007) exclude the treatment of dental disease that can be under- I Pain management is essential for all dental and surgical taken when the cat is stabilized. Avoiding treatment of procedures. Pre-surgical analgesics (e.g., buprenorphine) painful dental conditions such as odontoclastic resorptive decrease the necessary amount of injectable or inhalation lesions, periodontal disease, or broken teeth contributes anesthesia thereby lowering the risk of anesthetic or drug to diminished quality of life. (Richards 2005 Holstrom adverse reactions. Attend to comfort and gentle handling, 2005) AAHA has published comprehensive dental care particularly in cats with OA or muscle wasting.

8 AMERICANASSOCIATIONOFFELINEPRACTITIONERS Senior Care Guidelines - Revised December 2008 Monitoring and Managing Disease Development of chronic diseases typically starts in mature new or crucial information about those diseases most cats but may not manifest fully for some years. This paper common in senior cats. Figure 2 illustrates common clinical will not review all aspects of diseases, but will highlight conditions in senior cats.

FIGURE 2 Clinical Conditions in Older Cats*

Chronic renal disease Reduced kidney size Lumbar spondylosis Dehydration Abnormal BCS Amyloid plaques Constipation Cognitive decline Deafness

Retinal hemorrhage Retinal degeneration Retinal detachment Decreased vision/blindness

Dental/periodontal disease Thyroid nodule

Osteoarthritis

Neoplasia

Chronic bronchial disease Pancreatitis Hypertension Diabetes mellitus Cardiomyopathy Cholangitis Conduction disturbance Inflammatory bowel disease

*Conditions that impact quality of life/and/or require further diagnosis or treatment.

Cat drawing provided by Kerri Goodsall at www.allaboutdrawings.com

9 AMERICANASSOCIATIONOFFELINEPRACTITIONERS Senior Care Guidelines - Revised December 2008 BLOOD PRESSURE MONITORING AND HYPERTENSION Experts agree that increased blood pressure (BP) may significantly affect feline health and thus should be measured at least annually in cats in the “senior” and “geriatric” age groups. There is some debate about the indications for or frequency of measuring BP in cats in the “mature” age group.

Some recommend routine BP measurement only in mature HYPERTENSION cats with hypertension-associated diseases or signs consistent I Hypertension appears to be recognized most often with target organ damage. Their concern is accuracy, since among cats over 10 years of age. (Maggio et al 2000) “white coat hypertension” is a significant problem in cats; I Hypertension is potentially damaging to the eyes, brain, widespread screening could lead to over-treating or heart, kidneys and central nervous system. performance of unnecessary tests. I Hypertension may be idiopathic or secondary, i.e., associated with a variety of disease states (table 4). Most Others recommend monitoring BP with every MDB cats have an identifiable cause for their elevated BP,but collection, thus providing baseline measurements for future idiopathic increases in BP may occur in a substantial comparison. Taking precautions to reduce anxiety can subpopulation of older cats (possibly ranging from 17% increase accuracy. to 55% in one study). (Maggio et al 2000) I Cats have a significant incidence of anxiety-associated One approach is to obtain one or more baseline values for hypertension. mature cats and then to measure at increasingly frequent I Treat when the BP is 180/120 mm Hg, or in cats with intervals as cats age and their risk of hypertension-associated CKD, when the BP is 160–179/100–119 mm Hg. disorders such as kidney disease increases. Obtaining an A reasonable treatment goal is to reduce BP below accurate BP requires a consistent approach with attention 150/95 mm (no lower than 120 mm Hg for systolic). to detail. (See Table 3.) (Brown et al 2007) It is not (Jepson et al 2007) necessary to shave the hair to get good Doppler contact I The ACVIM has created excellent, detailed guidelines using alcohol and gel. about measuring and interpreting BP and diagnosing and treating hypertension. (Brown et al 2007, TABLE 3 http://www.acvim.org/websites/acvim/index.php?p=94 Improve BP Measurement Accuracy accessed 4/09)

Use the most accurate machine available (currently, Doppler). TABLE 4 Measure blood pressure with the owner present, in a quiet Diseases and Drugs Associated with room. Allowing the cat to acclimate to the room for 5 -10 minutes can decrease anxiety-associated hypertension up to Secondary Hypertension (Brown et al 2007) 20mg Hg. Kidney disease Glucocorticoids Train staff to minimize stress, including minimizing restraint, which would potentially cause anxiety-induced BP increases. Hyperthyroidism Erythopoietin

Monitor sequential measurements to detect trends; base Hyperaldosteronism Mineralocorticoids treatment decisions on multiple measurements. Phaeochromocytoma Sodium chloride Use proper cuff size (30-40% of circumference of cuff site) Nonsteroidal anti-inflammatory drugs and a consistent location on the cat’s body.

10 AMERICANASSOCIATIONOFFELINEPRACTITIONERS Senior Care Guidelines - Revised December 2008 CHRONIC KIDNEY DISEASE (CKD) While kidney disease is most common in older cats, it prevent muscle wasting, and increase survival times. The most likely begins in middle age. (PetProtect Insurance composition of renal diets is more complex than just Company, data on file, personal communication 2008). providing low protein, and their beneficial effects may Diagnosis and management is extensively described else- not be from their low-protein content alone. (Ross et al where. (International Renal Interest Society (IRIS) 2006; Plantinnga et al 2007; Elliott 2006; Polzin 2007; http://www.iris-kidney.com/ accessed 1/22/09; Polzin Elliott et al 2000; Harte et al 1994) Canned diets provide 2007) A few items warrant attention: the benefit of improving hydration. I If the cat will not eat a commercial renal diet, home- I Routine MDB screening and evaluation of trends may prepared, nutritionally-balanced lower protein diets may reveal early disease. CKD-induced polyuria and polydipsia be a reasonable compromise. (Strombeck 1999) Alternately, are often not noted by cat owners. Sometimes-overlooked a feeding tube may be used to provide optimum nutrition. signs include constipation, inappetence, nausea, change I Once the patient is stabilized, continue monitoring in drinking frequency or location, poor hair coat, and every 3 to 6 months, or more often if indicated; the muscle wasting or weight loss. frequency depends on several factors outlined in the IRIS I Some patients with serum creatinine values within guidelines. (http://www.iris-kidney.com/ accessed 4/09) published reference ranges may actually have CKD. Evaluating urine concentrating ability is essential. In the absence of urinary obstruction or non-renal causes of polyuria, serum creatinine values > 1.6 mg/dl (140 umol/l) with urine SG persistently <1.035 are likely to indicate kidney disease in a hydrated patient. I The International Renal Interest Society (IRIS) provides detailed guidelines for the management of CKD. Once CKD has been diagnosed and the patient is stable and hydrated, determine the patient’s PC ratio, and BP.(IRIS) IRIS stage to aid in management. The IRIS Stage is assigned using the serum creatinine concentration, UPC ratio, and BP.(IRIS) (Figure 3) I Investigate and treat electrolyte abnormalities such as hypokalemia, hyperphosphatemia and acidosis. Maintain potassium at >4Meq/dl (>4mmol/l), regardless of reference range normals. (Sparks 2006) Treatment goals for phosphorus restriction are below normal reference values THYROID TESTING AND HYPERTHYROIDISM (<4.5mg/dl (<1.45mmol/l) for stage 2, <5 mg/dl I A T4 should be run any time hyperthyroidism is (<1.6mmol/l) for stage 3, < 6mg/dl (<1.9mmol/l) for suspected, including but not limited to: noting signs of stage 4). (Polzin et al 2009) inappropriate defecation or urination; weight loss; I Monitor BP,since CKD is the leading cause of secondary polyphagia; polydipsia; inappetence; hypertension; heart hypertension. murmur; or a thyroid nodule. I Perform a urine culture as part of the MDB for cats with I Panelists debate about the age at which the T4 measure- CKD, even in the absence of inflammatory sediment. ment should become part of the annual MDB for (Mayer-Roenne et al 2007) healthy-appearing cats. Some think this should begin I Evaluate for proteinuria, a marker for severity of kidney at age 7, whereas others prefer to wait until age 10. disease that has been shown to be a negative predictor of Preliminary data from the UK show an overall incidence survival and may play a role in progression of kidney of hyperthyroidism around 0.5%, with the vast majority injury. Finding a raised UPC (> 0.4) warrants considera- of cases occurring in senior cats . (PetProtect Insurance, tion of treatment. (Lees et al 2005; Syme et al 2006) UK, unpublished data) I Feeding a “renal” prescription diet has been shown to reduce uremic episodes, decrease phosphorus retention, 11 AMERICANASSOCIATIONOFFELINEPRACTITIONERS Senior Care Guidelines - Revised December 2008 FIGURE 3

12 AMERICANASSOCIATIONOFFELINEPRACTITIONERS Senior Care Guidelines - Revised December 2008 HYPERTHYROIDISM DIABETES MELLITUS I Approximately 40% of cats with early hyperthyroidism Diabetes mellitus is an increasingly common disease, most have only mild clinical signs. Early hyperthyroid disease commonly diagnosed in middle age, obese male cats. can be diagnosed 1-2 years prior to obvious signs. (Rand et al 2005; Weaver et al 2006; Behrend 2006) It (Peterson 2005; Norsworthy et al 2002; Norsworthy et remains a significant disease in senior cats, with almost al 2002). half of all diabetics being 10-15 years old. (Prahl et al I Thyroid nodules may or may not be functional so diag- 2007; McCann et al 2007) nosis cannot be made solely on the presence or absence I Interpretation of blood glucose curves remains a challenge of a thyroid nodule. (Ferguson and Freedman 2005) due to stress responses in the hospital setting. Introduction I The total T4 is the appropriate screening test. An elevated of home monitoring by owners (blood collection via ear result indicates hyperthyroidism is present, but a normal veins) may help mitigate the problem associated with result does not rule out hyperthyroidism. (Chastain et al stress. (Reusch et al 2006; Casella and Reusch 2005; 2001) Alt et al 2007) I Should total T4 results be equivocal or normal but I Although most cats are insulin dependent at the time hyperthyroidism is suspected, rule out other illness. Then of diagnosis, early glycemic control may lead to clinical concurrently evaluate a second total T4 plus a free T4 by remission. Recent advances in treatment that can facilitate equilibrium dialysis. earlier and/or tighter glycemic control include I Since free T4 can be elevated in cats with non-thyroidal • Feeding a canned low carbohydrate, high protein diet. illness, interpret free T4 in conjunction with total T4 (Bennett et al 2006) and clinical signs. (Peterson et al 2001) • The availability of new insulins such as long acting I A high free T4 with total T4 in the upper range of normal insulin glargine, that can help achieve ideal mean blood supports the diagnosis. glucose concentrations. (Rand and Marshall 2005) I Thyroid scintigraphy, if available, is important in treat- • Portable blood glucose monitors that can allow clients ment planning for I131 therapy, can be used to assess to perform blood glucose curves at home. Choose a poor response, and is helpful if malignant disease is monitor shown to be accurate with cats, since accuracy suspected. (Broome 2006; Bruyette 2004) Scintigraphy varies greatly. (Reusch et al 2002; Reusch et al 2006) is a good test for localizing the source of thyroid hormone I Of particular importance for senior cats is the effect of production and may assist in diagnosing hyperthyroidism. concurrent disease, such as chronic pancreatitis, on their I Monitor affected cats for kidney disease and hypertension. health status. • Hypertension may persist or even develop after treat- I Corticosteroids can cause increased insulin resistance, ment. (Reinsche et al 2008; Becker et al 2000; Graves further complicating disease management. (Rand and et al 1994) Marshall 2005; Stumpf and Lin 2006) • Hypertension secondary to hyperthyroidism alone may self correct when a euthyroid state is achieved. (Brown et al 2007) • Monitor renal function. Creatinine levels post treatment can rise due to unmasking of existing kidney disease. Even cats with a urine specific gravity >1.035 are at risk for developing unmasked kidney disease following treatment.(Riensche et al 2008) I Transdermal methimazole is an alternative for cats with vomiting or inappetance secondary to oral methimazole. Differences in efficacy and side effects are still being studied. (Sarto 2004; Lecuyer 2006; Trepanier 2005; Trepanier 2007)

13 AMERICANASSOCIATIONOFFELINEPRACTITIONERS Senior Care Guidelines - Revised December 2008 INFLAMMATORY BOWEL DISEASE (IBD) CANCER AND ASSOCIATED DISEASE I Weight loss, in the absence of other identifiable causes, I Inflammatory bowel disease begins in adult cats and is a common sign of cancer. The paraneoplastic syndrome may require lifelong treatment. Increased vomiting or of cancer cachexia causes a loss of fat and muscle mass poor appetite may be more common or have a greater and can occur even in cats that eat well. impact in older cats, so medication changes may be I Pursuing a diagnosis before body condition deteriorates needed. may affect outcome. A recent study found a positive I The clinical signs of IBD are nonspecific and may be correlation between BCS, remission rate and median confused with many diseases of older cats. Additionally, survival time. Cats with a BCS <5/9 had a significantly IBD may influence the diagnostic and/or treatment shorter median survival time (3.3 months) than cats with approach to other diseases when it is present. a body condition score >5/9 (16.7 months). (Baez et al I Rule out a disorder causing digestion/absorption problems 2007) in euthyroid, non-diabetic cats with unexplained weight I Many cancers are treatable or manageable. High remission loss, vomiting, diarrhea, increased appetite and thirst. rates and extended survival times are achievable for many The history may reveal that the cat is ingesting more cats with the most common cancer, lymphoma. (Kiselow calories than should be necessary for normal metabolism. et al 2008; Milner et al 2005) I In addition to the MDB, initial evaluation should include I Educate clients about the differences between human measurement of feline pancreatic lipase immunoreactivity and animal chemotherapy. (fPLI), feline trypsin-like immunoreactivity (fTLI), B12, • Treatment goals are to control the cancer and to and folate concentration, which help create a specific improve the cat’s quality of life, with less frequent and treatment plan. (Forman et al 2004; Simpson et al 2001; less severe side effects than those seen in people. Steiner and Williams 2000; Parent et al 1995; Salvadori • Owners who pursue chemotherapy are usually satisfied et al 2003) (Correct interpretation of the results is available with their decision; they perceive their cat’s quality of at the Texas A&M University, GI Lab website life as higher than prior to treatment. (Tzannes et al http://www.cvm.tamu.edu/gilab/index.aspx 2008) accessed 12/1/2008) I Palliative therapy, designed to improve quality of life I Differentiation of IBD from small cell lymphoma can without necessarily increasing survival time, remains a be challenging. mainstay of therapy in many cats. Critical components • Endoscopically obtained samples are not always sufficient of all cancer therapy include pain management, (Hellyer for definitive diagnosis since lymphoma lesions often lie et al 2007) anti-nausea medication (e.g., ondansetron, deep to the mucosal layer. Full thickness biopsy is ideal, dolasetron, maropitant citrate) and nutritional support. but does not always provide the definitive diagnosis. (Day et al 2008) • Since the treatment for both diseases can be the same, the risk of surgical biopsy has to be weighed against the potential benefits for each patient. • Biopsy is recommended for cats that don’t respond well to treatment for IBD or have ultrasound changes that lead to suspicion of severe intestinal disease or concurrent illness. I Because of the close anatomic relationship between the pancreatic and bile ducts in cats it is important to recognize that IBD, pancreatitis, and cholangiohepatitis may occur separately or together (see complex disease management).

14 AMERICANASSOCIATIONOFFELINEPRACTITIONERS Senior Care Guidelines - Revised December 2008 OSTEOARTHRITIS Osteoarthritis (OA) is a common but under-recognized I Treatment decisions depend on the degree of OA and condition in senior cats. In radiographic studies, prevalence the existence of concurrent diseases. A multimodal or rates have varied from 22% in cats of all ages up to 90% staged approach may be needed. in cats 12 years of age. (Godfrey 2005, Clarke et al • Diets created for management of osteoarthritis may 2005; Hardie≥ et al 2002; Clarke and Bennett 2006). improve joint mobility and comfort. These may include Radiographic evidence is not always consistent with clinical a variety of supplements for which there are varying signs; there may be radiographic changes with no clinical evidences of efficacy. signs, as well as clinical signs with no radiographic • Chondroprotective agents and nutraceuticals may be changes. (Godfrey 2005, Clarke et al 2005) useful in patients with mild to moderate OA. (Beale I Signs are often subtle behavioral and lifestyle changes 2004) mistaken for ‘old age.’ (Boehringer Ingleheim 2007) Use • Additional pain medication can be added at times of a mobility questionnaire to help with diagnosis (Table acute flare-ups, or continually as progression occurs. 5). Palpate for joint thickening, swelling, or pain; Pain management guidelines have been published crepitus or limited range of motion are not routinely (http://www.catvets.com/professionals/guidelines/pub- noted, and pain does not always correlate with radi- lications Hellyer et al 2007) Medication choices include ographic signs of disease. (Hardie et al 2002) opiates (e.g. transmucosal or SQ buprenorphine, I Management is ideally holistic in scope, attending to tramadol), gabapentin, or NSAIDs (e.g., meloxicam) both the cat and its environment. (Godfrey 2005) Improve (Clarke and Bennett 2006) Recent studies have shown access to key resources: good efficacy and safety with oral low dose meloxicam; • Provide food and water at floor level, raised slightly, to (Gunew et al 2008) however, in the United States reduce the need for jumping or bending. meloxicam has not been approved for use beyond a • Add ramps or steps to allow easier access to favored onetime injection; use informed client consent for any sleeping areas. off- label use. Take appropriate precautions, including • Use deep, comfortable bedding. laboratory monitoring, if using any NSAID. • Use large litter boxes with a low entry for easy access, I Non-drug interventions include surgery, acupuncture, and high sides to help for cats that cannot squat (e.g., electro-acupuncture, passive motion exercises, and a dog litter box). A fine-consistency litter is easier on massage. While they may be of benefit in individual the paws. cases, little published data is currently available relating • Manage obesity to reduce the stress on the cat’s joints to their use in cats. (Sparkes 2006) and facilitate exercise.

15 AMERICANASSOCIATIONOFFELINEPRACTITIONERS Senior Care Guidelines - Revised December 2008 TABLE 5 Mobility/Cognitive Dysfunction Questionnaire* Table 5 provided courtesy of Dr. Danielle Gunn-Moore

My cat… Yes No Maybe

is less willing to jump up or down

will only jump up or down from lower heights

shows signs of being stiff at times

is less agile than previously

cries when lifted

shows signs of lameness or limping

has difficulty getting in or out of the cat flap/ cat door

has difficulty going up or down stairs

has more accidents outside the litter box

spends less time grooming

is more reluctant to interact with me

plays less with other animals or toys

sleeps more and/or is less active

cries out loudly for no apparent reason

has become more fearful and/or more aggressive

appears forgetful

*Ensure there have been no environmental reasons for the change.

16 AMERICANASSOCIATIONOFFELINEPRACTITIONERS Senior Care Guidelines - Revised December 2008 COGNITIVE DISORDERS I When considering brain aging in cats and humans, the about administering and scheduling medications, asking age at which 50% of cats and 50% of humans have signs about their abilities and limitations. Multiple treatments of cognitive dysfunction (dementia) is 15 years for cats can be difficult for the patient and the client; it is important and 85 years for humans. (Head et al 2005; Porter et al that the quality of the human-animal bond is maintained 2003; Landsberg 1998) despite multiple treatments. Educate clients on ways to I Signs of cognitive disorders include altered behavior, administer medications in a calm manner that is comfortable inappropriate elimination, spatial or temporal disorien- for the cat. Explore new routes for oral medications, such tation, altered interaction with the family, changes in as treats made to hold pills, food the cat likes, or reformu- sleep-wake cycles, house-soiling with inappropriate lation of medications into treats, liquids, or pastes. Consider urination/defecation, changes in activity, and/or inap- complimentary treatments, such as nutraceuticals, propriate vocalization (often displayed as loud crying at acupuncture, massage therapy, and physical therapy. Listen night). (Moffatt and Landsberg 2003) (Table 5) to clients, asking how treatments are going and exploring I Cognitive changes may result from systemic illness (e.g. their expectations, desires and needs. hyperthyroidism, hypertension), organic brain disease (e.g. brain tumor), true behavioral problems (e.g. separation When expected therapeutic results are not obtained, search anxiety), or cognitive dysfunction syndrome (CDS), a for additional disease processes. While any diseases may neurodegenerative disorder which is believed to result occur concurrently, certain ones occur together more from compromised cerebral blood flow, chronic free often, confounding diagnosis and treatment. radical damage and amyloid deposition. (Gunn-Moore et al 2006; Gunn-Moore et al 2007) Be aware of issues surrounding multiple diseases in senior I Rule out all medical illnesses to diagnose a primary cats: cognitive disorder. I Treatment of some diseases may worsen other, concurrent I Feline treatments are extrapolated from studies of humans diseases. (e.g., treatment of hyperthyroidism can unmask and dogs. Diets enriched with antioxidants and other the severity of kidney disease). supportive compounds (e.g. vitamin E, beta carotene, I The effect of poly-pharmacy or drug interactions. and essential omega-3 and 6 fatty acids) are believed to I The effect of diet on body condition, GI function, kidney reduce oxidative damage and amyloid production, and function, and overall health improve cognitive function. (Milgram et al 2004; I The cumulative impact of multiple diseases. Milgram et al 2005) • CKD, OA, DM, and IBD, when present in any I Environmental management, particularly surrounding combination, can result in significant inappropriate litter box issues, can help the cat and owner maintain elimination. good quality of life. Because these cats are easily stressed, I Diagnosing one disease while missing another, or assuming change should be kept to a minimum or incorporated a single disease is severe when signs are actually due to gradually. multiple diseases. I No drugs are licensed for the treatment of CDS in cats. • When cholangitis, pancreatitis, and/or IBD occur Anti-anxiety medication may be useful in some cases. together, one or more may be missed. (Mansfield and (Crowell-Davis 2008) Selegiline, propentofylline and Jones 2001) nicergoline have all been used with varying degrees of • Chronic pancreatitis may be missed in a diabetic patient. success. (Landsberg 2006; Landsberg and Araujo 2005; (Forcada et al 2008; Xenoulis et al 2008) Landsberg et al 2003; Studzinski et al 2005) • Hyperthyroidism may be missed in cats with kidney or liver disease, or cancer because typical signs are masked and T4 may be suppressed back into the top COMPLEX DISEASE MANAGEMENT of the normal range. (Peterson and Gamble 1990; As cats get older, the likelihood of developing more than Wakeling et al 2008) one disease increases, often with complex effects on • Hyperthyroidism may also be missed in cats with diagnosis and treatment. Explore options to help clients diabetes mellitus since signs are usually similar. manage their pet with multiple diseases. Educate clients

17 AMERICANASSOCIATIONOFFELINEPRACTITIONERS Senior Care Guidelines - Revised December 2008 continued from previous page COMPLEX DISEASE MANAGEMENT • The diagnosis of urinary tract infection in cats with Scale available online in multiple sites including kidney disease, hyperthyroidism, or diabetes can be http://www.veterinarypracticenews.com/vet-practice- complicated, since signs of LUTD, pyuria and/or active news-columns/bond-beyond/quality-of-life-scale.aspx urine sediment are not always present. Diagnosis can accessed 12/1/2008 ) only be confirmed by performing a urinalysis and Such questions might include: bacterial culture (see MDB). (Mayer-Ronne et al 2006) • Is pain well controlled? • Hyperthyroidism and cardiac disease may occur together • Is the cat able to eat, albeit with support? with only one being recognized. • Can the cat navigate to its key resources, albeit with I Hyperthyroidism and concurrent DM: supportive changes? • T4 concentrations may be lower than expected in • Does the cat have more good days than bad days? hyperthyroid cats with DM.(Peterson and Gamble 1990; • Does the cat follow its former predictable routines Crenshaw and Peterson 1996) Insulin requirement for sleeping, resting, grooming, eating, playing and may change after treatment of hyperthyroidism. socializing? • Hyperthyroidism can confuse diagnosis of diabetes mellitus because it can increase serum glucose concentrations Hospitalized cats may become depressed; therefore, allow while reducing serum fructosamine concentrations. clients to keep cats at home whenever possible. If hospital- (Hoenig et al 1989; Reusch and Tomsa 1999) ization is needed, it should be done for the shortest time I Hyperthyroidism and concurrent CKD: possible, and with visiting available for the clients. • Hyperthyroidism may cause increased GFR and thus a decreased BUN and creatinine, with under-diagnosis Hospice care patients and their owners benefit from of CKD. Creatinine may also be low from low muscle examination every 2-4 weeks, or as deemed necessary to mass with hyperthyroidism. Repeat laboratory evalua- assess comfort, quality of life, and quality of the relationship. tion following hyperthyroid treatment to reassess Discussion about what to expect during the process of CKD and the need for treatment changes. euthanasia and options for aftercare can help alleviate • CKD may mask hyperthyroidism. (Peterson and Gamble owner anxiety when the time does come. Helping owners 1990) Measuring free T4 concentration is often needed prepare for loss and grief is a valuable and memorable to diagnose hyperthyroidism in these cases. (Wakeline service that veterinarians can offer. (Chun and Garret 2007) et al 2008) Conclusion/Summary While age itself is not a disease, the aging process induces Quality of Life complex and interrelated metabolic changes that complicate Concurrent with the management of chronic illness in health care. Management decisions should not be based senior patients comes the responsibility to control pain and solely on the age of the patient, as many conditions that distress, assess quality of life, and provide guidance to the affect older cats can be controlled if not cured. Veterinarians owner in end of life decisions. treating senior cats must be adept at recognizing, managing Veterinarians can assist clients in managing home care, and monitoring chronic disease and, when possible, changing the environment as necessary to ensure comfort preventing disease progression, while ensuring a good quality and access to the five key resources (Table 2). The veterinarian of life. With prevention, early detection and treatment of must act as a patient advocate when counseling clients healthcare problems, the human-pet-veterinary bond is about decisions regarding use and/or continuation of strengthened, and the quality of life for cats improved. treatment. (Rollin 2007) Using published quality-of-life scales or an individualized list of behaviors as objective tools The authors deliberated at length about some aspects of can aid tremendously in answering the question, “How do I this paper. Many recommendations are not as definite as know when it’s time?” (RSPCA Five Freedoms Fact Sheet some would desire. The creation of these senior care http://www.wspa-international.org/wspaswork/education/ guidelines has elucidated areas where further clinical downloads_resources.aspx investigation and more evidence are needed to create accessed 12/1/2008 ; Alice Villalobos’ Quality of Life clearer recommendations for optimal health of senior cats. 18 AMERICANASSOCIATIONOFFELINEPRACTITIONERS Senior Care Guidelines - Revised December 2008 ACKNOWLEDGEMENTS

The Senior Care Guidelines have been supported by grants from:

Nestle Purina

Merial Ltd.

IDEXX Laboratories, Inc.

Nutramax Laboratories, Inc.

Abbott Laboratories

Thank you to Pet Protect Insurance for allowing access to their database in order to generate UK prevalence data for kidney disease and hyperthyroidism.

Thank you to Dr. Deb Givin for providing photos of our senior friends.

Disclaimers: Dr. Gunn-Moore, Dr. Polzin, and Dr. Zoran have received funding for previous work from Nestlé Purina. Dr. Taboada has received funding for previous work from Merial Ltd. and Nutramax Laboratories, Inc.

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These guidelines were approved by the American Association of Feline Practitioners (AAFP) Board of Directors and are offered by the AAFP for use only as a template; each veterinarian needs to adapt the recommendations to fit each situation. The AAFP expressly disclaims any warranties or guarantees expressed or implied and will not be liable for any damages of any kind in connection with the material, information, techniques or procedures set forth in these guidelines.

22 AMERICANASSOCIATIONOFFELINEPRACTITIONERS Senior Care Guidelines - Revised December 2008