Elderly cats: getting the best from your consultation
Diego Esteban, Claude Muller, Thomas Rieker, Kit Sturgess
History taking is the veterinary surgeons first opportunity to try and identify changes that the owner attributes to just getting older as potentially indicating significant underlying disease. During the consultation, it is important to try and ask open-ended questions, such as “How has your cat been since your last visit?” or “Have you noticed any change in behaviour?” rather than closed questions such as “Is your cat drinking more?” Open questions give the owner greater scope for describing things that are concerning them and are usually a more honest description of changes.
Despite playing an essential role in clinical veterinary practice, history taking can be neglected when the duration of an appointment is short or when complementary tests are given too much importance. The use of a health questionnaire before the appointment will be beneficial as it will help to give clues to potential problems and allow focus in a short consultation period. A full discussion on history taking is without the scope of this article that will focus on key take-home points to remember when an ageing cat is brought for consultation.
A) Nutrition and hydration
Part of the history taking should cover the quantity, type and brand of food and frequency of feeding, as well as identifying any changes in the cat’s preferences and the onset of any digestive problems following such changes. Elderly cats have a reduced ability to digest nutrients and so owners should be advised to give their cat three to four portions of food each day or feed ad libitum but monitor the amount that is eaten. In multicat households there are problems ensuring that every cat is fed properly, but different feeding times or separate feeding areas can be used. Changes in a cat’s food preferences may be due to disorders that decrease the appetite (e.g. renal disease) or painful mouth lesions. It is also important to find out whether the cat’s appetite has increased recently, as this could indicate the onset of diseases such as hyperthyroidism or diabetes mellitus if accompanied by other suggestive clinical signs in general and weight loss in particular.
With changes in appetite, questions should be asked about whether the cat is vomiting and if so what is being vomited, how frequently vomiting is occurring and the relationship between feeding and vomiting. Many owners will not be concerned about their cat’s vomiting habits because their cat has always vomited occasionally and may not have noticed that the cat is vomiting more often. Appropriate questions may help them realise that the cat is vomiting more than usual. Owners tend to be more likely to volunteer that their cat has diarrhoea compared to vomiting. However if the cat goes outdoors, diarrhoea may be present without the owner’s knowledge.
To ensure that cats are well hydrated, all possible sources of water should be made available to encourage the cat to drink. Many owners turn a tap on for their cat (Figure 1) or use cat fountains and yet when asked how much their cat drinks, they do not think it is drinking any more than before. Other cats will drink from large recep-tacles (shared dog’s water) or even from fish tanks (Figure 2) making it hard to assess how much water they are drinking. It is useful to know whether the cat’s litter tray needs to be changed more often than before, which would increase the suspicion of polydipsia. Another strategy to detect polyuria in homes where there are several cats is to use clumping litter. A polyuric cat’s urine may produce a bigger clump of litter than a normal cat. Many if not most cat owners think it is good for their cat to drink a lot of water and so they will be quick to pick up on changes in the amount their cat drinks but many also don’t consider the change to indicate that their cat has a problem. As polyuria drives polydipsia, it is impor-tant that cats already diagnosed with a disease that involves PU/PD are encouraged to take in adequate fluid. Owners should be encouraged to consider using water fountains, changing water frequently or even adding stock cubes to flavour the water to make drinking more appealing. Remember that only 30% of CKD cats are ini-tially reported as PU/PD so diseases that result in PU/PD should not be excluded on history alone especially if the cat has outside access.
B) Other pointers
Other useful general history questions include:
• where the cat likes to rest,
• access to its litter tray,
• hideaways it uses if frightened by visitors,
• favourite places to “keep watch” on the outside world.
Even very observant owners may not notice that their cat has stopped climbing up to high places, but they will all be quick to ask why their cat is defecating outside the litter tray. Osteoarthritis may explain both these changes, which shows that a particular disease can often be sug-gested in different ways during history taking.
Veterinary surgeons know that even geriatric cats should be able to enjoy playing a game despite their age, but owners may actually stop playing with their elderly cats. Asking about playing habits during history taking will reinforce the message that owners should continue to play with elderly cats, as long as games are adapted to the cat’s current disease status (Figure 3).
C) Other pets
Cats that live with other pets may be more susceptible to acquiring certain infections and infestations, especially if the other pet is a dog that is taken out for walks. It is important to coordinate parasite control among all pets in the household, and the owner should be asked which brand they use, and how often the pets are treated. The active substance in permethrin-based ectoparasite products for dogs may be fatal if used in cats. There is a potential risk of toxicity even if only the dog in the household has been treated (Boland, 2010). Compared to younger cats and kittens, elderly cats generally take longer to adapt to changes and this includes adjusting to the arrival of new pets in a household.
D) Clinical history and medication
Finally, history taking should include questions about past illnesses particularly if the cat has been seen at another veterinary clinic; details of any medication that has been previously prescribed and the patient’s response should be recorded. If the cat is currently on medication the owner should be asked about how well the medication is being tolerated, how easy it is to give and how easy the owner is finding it to meet the prescribing directions as these questions will serve to assess compliance. Owners often mistakenly presume that cats have voluntarily eaten medication that has been mixed in food. The clinician should be aware of those drugs that benefit from being given with food improving efficacy or reducing side effects (e.g. most NSAIDs) and those that should not be given with food (e.g. ciclosporin). It is important to find out whether owners are giving the cat nutraceuticals, herbal remedies or alternative medicine as these are often not mentioned by the owner as they are considered safe “natural products“ however, echinacea for example, can be toxic especially at higher dose rates.
2/ Clinical examination
By the time a full history has been taken the cat will have become more acclimatised to the consulting room making the physical examination easier. During the exa-mination, every effort should be made to minimise further exacerbation of the stress associated with putting the cat into a carrier, travelling to the clinic and waiting to be seen. All aspects of good cat handling are amply covered in handbooks and guidelines issued by the International Society of Feline Medicine (ISFM), the AAFP and the CATalyst Council. Cat handling and cat friendly clinics is a very large subject area so only certain, important points will be discussed below.
A) Preparing for the visit: anxiolytics/antiemetics
At home, cats may actually use their carrier as a bed or hideaway, but as soon as the door is closed they become anxious, knowing that they are trapped inside. The carrier should be left where the cat can explore it and become familiar with it during the days preceding the visit. Apart from anxiety, many cats arrive at the clinic with clear signs of motion sickness (Figure 4). Unless the cat lives very nearby, the chances are that it will arrive by car, public transport or even motorbike. The afore-mentioned guidelines recommend anxiolytics such as alprazolam to combat the anxiety caused by travel and the clinic visit. Alprazolam has a good anxiolytic and amnesic effect making a nervous cat’s experience of visit-ing the clinic less stressful and reducing apprehension associated with subsequent visits (Note: this is an off-license drug in most countries and contraindicated if significant liver or kidney disease could be present in an older cat.) An anxiolytic should only be recommended if the cat has been recently seen (at least in the last 6 months). Where possible, a dose should be administered at home a few days before the visit to ensure that the patient in question does not suffer paradoxical excitatory effects that occur in some cats given benzodiazepines. Motion sickness can be treated prophylactically with maropitant (cerenia) but at a much higher dose than as an antiemetic. Other drugs such as selegeline (Note: this is an off-license drug for cats) or nutraceuticals like➢a-casozepine may be useful.
No anxiolytic will make up for poor animal handling, and so the veterinary surgeon should be familiar with all the strategies for improving a cat’s visit to the clinic. Recent statistics have shown that one of the reasons that cat owners take their pets to the veterinary clinic less often than dog owners do, even in countries where the cat po-pulation is larger than the dog population, is the owner’s negative experience at the clinic.
One of the most common errors committed during clinical examinations is immobilising a cat by the scruff of the neck. Although mother cats immobilise and transport their kittens using this technique, inhibiting normal cat behaviour, it is not a pleasant experience and there is some debate about whether it may actually be painful. It is only justified in cats that become so nervous that this is the only way that they can be examined properly without resorting to sedation. Using towels and careful handling, usually makes scruffing unnecessary even in nervous cats. One variation of this type of immobilisation is “clipnosis”, which consists of applying bulldog clips to the skin on the cat’s back (from the neck to the base of the tail) to grip and stretch the skin. Its use is only accepted as a resource at cat shelters, to bring down the cost of procedures that would otherwise require anaesthesia (e.g. blood draws). Some clinicians use it successfully, although not all cats show a positive response.
The use of synthetic pheromones in the clinic (fraction F3) or on the veterinary surgeon’s hands (fraction F4) often helps to reduce feline stress. It is important to remember that pheromones should never be applied in the cat’s presence as the noise of the spray usually frightens the patient. Pheromones will not produce a dramatic effect; an aggressive cat will continue to be so despite the use of pheromones, although they will probably give the vete-rinary surgeon a few extra seconds to perform a quick examination.
Adapting the waiting room is an important step in reducing the stress of visits to the clinic:
• Cats should never have to face another cat or dog whilst waiting.
• Facilities are available to place the cat’s carrier on a shelf or table as cats feel more frightened at floor level.
• Specific hours are reserved for cat appointments.
• A cats-only area is provided in the waiting room.
• Reception staff are trained to identify problems related to cat visits (staff awareness).
• Keeping appointments to time as far as possible.
• Sound proofing and provision of windows with ledges in the consulting room.
B) Examination procedure
Carriers should be opened as soon as the cat arrives so the cat feels less trapped and has the opportunity to explore the consulting room if it wants to or stay in the carrier base (Figures 5 and 6). Examination is split between observational “hands-off” examination and the “hands-on” part involving palpation, auscultation and other procedures. The whole clinical examination is norm-ally performed on the examination table but cats can also be examined on the floor, in the carrier base or on a lap. The aim is to find the place where the cat, clinician and owner are most comfortable.
During this stage, the “examiner’s position” is of utmost importance. Cats tend to feel intimidated if they are appr-oached from the front, especially if there is eye contact. Therefore, it is recommended to stand behind them (Figure 5) and perform almost all of the examination from this position (except when using an ophthalmoscope).
Assessment of mental status, gait, posture and breathing
Normal cats usually will be actively listening when in the consulting room to pick up every sound that is made inside and outside the room.
More confident cats may be expected to start to explore the room during the
history taking phase. Some diseases can alter mental status and although a cat may not be obviously dull, depressed or somnolent, it may simply be quieter than normal. Hepatic encephalopathy and diabetic ketoacidosis are two common causes of such behaviour. By contrast, hyperthyroidism may have the opposite effect, and a cat will be more excitable and even have a characteristic facial expression (Figure 7).
Although cats do not usually feel like walking around the consultation room in a relaxed manner, it is worth obser-ving the gait of elderly cats for signs of osteoarthritis or even the typical plantigrade posture of poorly controlled diabetes mellitus. Elderly cats with osteoarthritis will typically have rigid or stilted hind limb movement, with abducted elbows. A cat’s resting position may also pro-vide information about the state of its joints. Where appr-opriate, giving the cat an opportunity to jump on/off a sur-face to assess their abilities can be of use.
Respiratory rate and character can be better assessed during this first stage, whilst the cat is minimally stres-sed. Movement of the rib cage can be observed using a bird’s-eye view to check for abdominal effort or increased respiratory rate (> 40/minute at rest). Tachypnoea is not always associated with cardio-respiratory disease, but can be observed in cats that arrive with severe motion sickness and/or anxiety or caused by anaemia, hyper-thermia, abdominal enlargement, muscle weakness, thoracic wall trauma, acidosis or pain.
Weight and body condition
Weight is a true reflection of a cat’s health and even small variations should be noted because they are almost always significant. Precision (paediatric) scales with a small error margin are needed to take advantage of this valuable information. The error margin in paediatric scales is usually 5 to 50 g, whereas the scales that an owner uses at home will have an error margin of about 250 g. It is important that owners also understand that even apparently small weight variations are significant. To help get this message home, expressing the weight loss or gain as a percentage change and/or extrapolating the weight change to the equivalent for a person can also be helpful. A 300 g loss in a 3 kg queen may not sound much to a client but is a 10% weight loss for the cat and would be equivalent to a person losing 7-10 kg. If there are no scales for weighing a cat in the consulting room, weighing scales for dogs can be used, preferably as the client arrives and with the cat inside the carrier for security.
Different breeds of cats do not differ in weight as markedly as dog breeds, but it should be remembered that giant breeds such as Maine Coon or Norwegian Forest can weigh up to 9-10 kg are not comparable with some European cats that weigh as little as 2.5 kg. Weight distribution in cats is also different to that seen in dogs. For this reason, scoring systems have been designed, such as the Body Condition Score (BCS), to try and deliver a more objective assessment than weight alone. The BCS is a 9-point scale where 1 is an emaciated cat and 9 is an obese one (Figure 8). It evaluates quantity of body fat. Another measure is the Muscle Condition Score (MCS), which evaluates muscle mass. MCS scales are currently undergoing validation and are expected to be brought into clinical practice in the near future.
In its Nutritional Assessment Guidelines, the World Small Animal Veterinary Association (WSAVA) adopted the BCS and MCS as tools to monitor a cat’s nutritional status. It also includes nutritional assessment as one of the five vital signs.
According to the WSAVA, these vital signs are:
• nutritional assessment.
In the same guidelines, the WSAVA provides a useful list for nutritional screening during history taking to assess whether a cat has significant risk factors that may require nutritional intervention. These points are listed below:
• Historical findings:
- altered gastrointestinal function (vomiting, diarrhoea, nausea, flatulence or constipation),
- past or present diseases,
- currently receiving medications and/or dietary sup-plements,
- unconventional diet (raw, homemade, vegetarian),
- treats, snacks or table food that account for more than 10% of total calories, - inadequate housing.
• Physical findings:
- BCS < 4 or > 5,
- MCS showing mild, moderate or marked muscle wasting,
- unexplained weight change,
- dental disease,
- poor hair coat,
- new diseases.
Please come back next week for Part 2 covering the "Hands-on" physical examination.
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Please see Part 2 for references.