Part 2 Elderly cats: getting the best from your consultation
Diego Esteban, Claude Muller, Thomas Rieker, Kit Sturgess
Ideally the physical examination should start with those procedures that will annoy/upset the cat least ending in procedures that are known/expected to be painful or upset the patient. Patients with chronic pain may change mood very quickly if the painful area is examined first. Although the logical examination order would be to start with the head, the mouth being one of the first parts to examine. If the cat has stomatitis it is advisable to leave this until the end. Similarly, in the case of severe osteo-arthritis (OA), it may be preferable not to examine the joints until the cat is sedated.
When examining elderly cats there are some general points that should be taken into account:
• reduced skin elasticity in geriatric cats – this can give the impression of dehydration,
• weight loss is usually better assessed along the back, where bony prominences will be more palpable, while inguinal fat takes longer to disappear,
• thyroid gland palpation should be a routine part of the examination (Figure 9).
Below is a review of some of the critical points when examining ageing cats, paying special attention to the most common areas that can be easily missed in clinical prac-tice.
Oral disease becomes increasingly common in cats over 6-7 years of age making oral examination a particular focus of the physical examination of older cats. The condi-tion of the mouth will affect a cat’s nutritional status but can also be a source of significant pain or even reflect primary diseases of other organs such as the kidneys or nasal cavity. Halitosis can occur secondary to a number of oral problems from gingivitis to uremic ulcers but can be present associated with non-oral disease such as pneumonia or gastrointestinal dysfunction.
Oral conditions encountered in older cats are most commonly inflammatory/infectious, neoplastic or metabolic.
The inflammatory/infectious group includes changes associated with excess tartar, gingivitis/lymphoplasma-cytic stomatitis and periapical abscesses or fistulas. In the case of gingivitis associated with excessive tartar, it is important to probe below the gum line during dental cleaning in order to properly assess the extent of any lesions that could lead to premature tooth loss if not appropriately treated.
Differentiating neoplastic lesions from inflammatory lesions and vice versa can be difficult on visual examina-tion. Cytology and/or histopathology are necessary in order to achieve a diagnosis. If diagnosed early, some oral cancers can be treated with aggressive surgery and adjuvant chemotherapy/radiotherapy making early dia-gnosis important. Other proliferative or inflammatory processes such as eosinophilic granuloma may actually look worse but carry a better prognosis. In the metabolic group, lesions described as uraemic ulcers are of parti-cular importance. They are always associated with severe acute or acute-on-chronic renal disease requiring aggr-essive intervention. Uraemic ulcers need to be differen-tiated from other causes of tongue ulceration e.g. FCV. These lesions are sometimes located in the buccal mucosa but are more typically found under the tongue (Figure 10).
Feline odontoclastic resorptive lesion (FORL) could also be included under metabolic lesions although the exact cause of this condition is unknown. Lesions occur due to an error in odontoclastic function resulting in excessive destruction. FORL lesions are sometimes inaccurately referred to as “feline caries” because of the hole that occurs in the teeth.
Ocular assessment is an important part of the clinical examination in older cats. Although the clinician may not be an ophthalmologist, certain changes should be easily detected once the clinician has become familiar with the normal variation in healthy patients.
Changes that are easy to detect include most retinal detachments and retinal changes associated with hyper-tension (ranging from mild haemorrhage to marked hyph-aema) (Figure 11). Although cataracts are not very common in cats, nuclear sclerosis of the lens can be found in senior cats. Another age-related change is the appearance of spots on the iris. Successful examination depends on good patient handling as outlined above. Pupil dilation may be needed if the “natural” catecho-lamine release does not cause sufficient mydriasis.
• Quiet well illuminated room that can be darkened.
• Bright focal light to examine the adnexa, anterior chamber and PLR, magnification preferable.
• Dilation of the pupil (mydriasis) if necessary to allow fundic examination – 1% tropicamide allow 20 minutes.
• Distant direct – set at 0 or +1 looking for black opaci-ties on the reflected path from the tapetum.
• Close direct – set at -2 to +2 to find and evaluate the optic disc and then the rest of the fundus. Then focus back through the anterior segment (lens about +10).
In its simplest form requires a light and a hand lens – start with the lens close to the patient’s eye and withdraw until the image fills the field of view. Keep the lens at 900 to the light beam.
3. Auscultation (see also FAQ Heart murmurs in old cats – are they significant?)
Cardiac auscultation of older cats should be used to detect murmurs and abnormal rhythms. In these cats, tachy-cardia, particularly if accompanied by a murmur or gallop rhythm, is often due to cardiac hypertrophy associated with hypertension, hyperthyroidism or hypertrophic cardio-myopathy. If the patient does not have hyperthyroidism and is not hypertensive then further evaluation of the heart may be indicated with echocardiography being the highest yield procedure in cases with murmurs and ECG in cases with arrhythmias. Although pulmonary changes frequently lead to little discernible change on auscul-tation in cats, effusions can be detected associated with decreased intensity of heart sounds. Wheezing or crackles are indicators of severe bronchial disease (mild and mode-rate bronchial disease is rarely detected on auscultation in the absence of clinical signs). Auscultation may also reveal the presence of bowel sounds that might suggest an undiagnosed diaphragmatic hernia (some cats show very few clinical signs at the time the rupture occurs and the condition is only diagnosed at a later date).
4. Abdominal palpation
Other than in obese patients, it is relatively easy to distinguish different organs on abdominal palpation in cats. Mass lesions, localised pain and increased/decreased organ size can be detected.
Formed faeces are frequently present in the colon. Large quantities of faeces could indicate constipation or even megacolon in severe cases. Most cats that have faecal impaction have an associated disease that dries the stool (such as those that involve polyuria/polydipsia), involves anorexia (lack of eating leads to lack of bowel movement) or causes pain (spondylosis deformans). Diet and mass lesions can also result in constipation Apart from the quantity and consistency of the stool, and the presence of air, palpation can detect increased intestinal wall thickness, with or without enlarged mesenteric lymph nodes.
Note – in thin old cats the small intestines often feel more prominent due to a loss of intra-abdominal fat and care needs to be taken not to over interpret this finding.
The kidneys are also easily palpable, and so their size, surface and symmetry can be assessed. Although radio-graphy or ultrasound will often be needed, palpation will focus the diagnostic process and make it easier to explain the need for further tests to the owner. Of the diseases that involve renal asymmetry, ureterolithiasis deserves particular attention. It usually presents as big kidney/ little kidney syndrome in cats with acute renal failure.
The big kidney is usually tender on palpation reflecting recent ureteric obstruction. The contralateral (small) kidney is a sign that ureteric obstruction has previously occurred with eventual fibrosis of that kidney. Often the cat will have shown few if any signs when the first kidney is affected as there is sufficient renal mass left on the other side to prevent azotaemia, it is only when the second kidney is affected that signs suddenly become obvious. An ultrasound will show hydronephrosis and hydroureter and radiography will reveal the location of the stone if it was not observed in the ultrasound.
At the end of the abdominal palpation the anal sacs should be checked to make sure they are empty and non-painful. The anal sacs should not be emptied in a conscious cat since it can be a very painful procedure even if there is no infection. If the cat is affected by another condition that increases their sedative/anaesthetic risk a decision will need to be reached with the owner about emptying the glands with the cat conscious.
5. Joints (osteoarthritis)
It is estimated that up to 90% of cats over the age of 12 suffer from degenerative joint disease and/or arthritis. However, only 50% of cats with OA exhibit lameness. Most clinical findings related to OA refer to changes in the cat’s mobility that an owner observes at home, not at the clinic. To diagnose OA, the sailing term “triangulation” is applied. This consists of assessing three bearings: the first is the information gathered from the presenting sign or complaint and the specific findings of complementary tests. The second refers to the physical examination, and the third covers a comprehensive and systematic review of behavioural changes observed outside the clinic setting. The presence of crepitus or limitation of movement are suggestive of OA, as are muscle atrophy and trigger points. Normal range of movement for cats is showed in Table 1.
Some authors recommend administering sublingual/ intraoral injectable buprenorphine 30 minutes before examining the joints of cats with OA to reduce the discomfort of the procedure and improve compliance with the examination.
6. Skin and Hair Coat
Poor hair coat is one of the first visible consequences of any disease. Grooming for most cats is an important task. Cats that stops grooming themselves will present with knotted hair along their back, dermatitis on the skin under the knots, and accumulation of
dirt in the perianal area with or without dermatitis. If there is oral disease, saliva staining around the cat’s face and forelimbs will be evident in light coated patients. Likewise, with nasal conditions there will be evidence of discharge below the nares. There are a number of potential reasons that a cat will stop grooming including general unwellness, metabolic disease, pain and oral disease.
The clinical signs of some cutaneous neoplasms differ between cats and dogs. The most notable difference is seen in mast cell tumours, they are less common and cats have compact or diffuse forms, with varying degrees of ulceration. However, it is usually well differentiated and after excision prognosis is good.
Ingrowing nails (Figure 12) are a common reason for cats being presented for consultation. Ingrowth is particularly common in older cats as the nails have grown long due to lack of activity and reduced scratching behaviours resulting in the nail tip curling and growing into the paw. If this is not recognised by the owner the paw becomes inflamed and infected, causing pain and the cat presents with lameness. Moving scratching posts in the house to sites that an older cat finds easier to access can reduce the recurrence of nail problems.
Rarely swelling, scabs or purulent discharge in a single toe may be due to metastasis from a bronchial carcinoma. Frequently, the cat will not have any respiratory symptoms and the disease is detected from the toe lesion.
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