A friendly approach to the senior cat consult

Introduction

The term “Senior” is generally applied to cats aged 11 years and over, although it is acknowledged that it may be appropriate to use this term for some cats that are younger than this 1. Over the past few decades, it has become more and more routine for cats to survive far beyond the threshold for the “Senior” life stage, with many now living into their twenties; a recent report documented a 27-year-old cat living in London as the world’s oldest cat 2. Whilst cats aged 15 years and over were formerly referred to as “Geriatric”, following negative feedback from carers, the UK-based charity International Cat Care (ICC) now categorizes these cats as “Super Senior” – a term which has been very well received. ICC also produced a chart estimating the human equivalent age for cats, which is helpful when discussing health and preventative healthcare needs of older animals (Table 1). Age-related health interventions, such as testing of feces for occult blood as a screen for bowel cancer, have been employed for many years in human medicine, and recent Covid vaccination strategies around the world have introduced younger people to this concept. Comparing the age of the feline patient to a human equivalent is helpful in reinforcing recommendations for “life-stage appropriate” preventative healthcare measures.

Table 1. Life stages, corresponding age of cat and human equivalent as developed by International Cat Care under their “cat care for life” initiative.

What physiological changes occur as cats age?

A variety of age-associated physiological changes occur as cats age. These include a reduced ability to smell and taste food, a reduced ability to sense thirst (making older cats more vulnerable to dehydration) and a lesser ability to digest dietary fat and protein. Healthy older cats will usually increase their appetite to compensate for this latter situation, but for some older cats, digestion of essential nutrients is reduced to such an extent that a 25% improvement in appetite would be required to maintain bodyweight. Caregivers should be encouraged to feed their cat a high-quality diet (within affordable financial limits), and offering a Senior diet is appropriate. Some recent data has indicated that feeding such a diet, moderately restricted in phosphate, is of benefit in stabilizing renal function in cats with early renal disease 3.

Senior cats also often suffer from poorer hearing, reduced skin elasticity (which can make assessment of dehydration more challenging), and reduced ability to retract the claws which, along with less scratching behavior, can lead to thickened, overgrown claws (Figure 1). Iris atrophy and nuclear sclerosis are examples of common aging changes affecting the eyes (Figure 2), whilst a compromised immune function can make elderly cats more vulnerable to infections. Behavior changes are also common – sometimes due to underlying diseases such as hyperthyroidism, systemic hypertension and feline dementia – so it is essential that questioning about this is included in the history-taking. For example, many older cats will spend more time sleeping and be less active.

What medical conditions are associated with increasing age?

Common conditions affecting the older cat are presented in Table 2. The older the cat, the more likely it is to suffer from one or more of these possibilities, hence multiple co-morbidities are commonly encountered, especially in Super Seniors. Attention to detail is important in order to accurately document all of the cat’s problems and ensure that the optimum treatment plan is designed. Where multiple issues are present in the same individual, management should generally prioritize those felt to be causing most significant clinical issues for the patient’s quality of life.

Table 2. Health problems affecting the older cat and their approximate prevalence, where known.

What about subclinical illness?

Cats are notoriously good at hiding signs of illness, and many older cats are not presented for assessment unless perceived to be unwell. Unfortunately, this can mean that the cat is only seen at the clinic when at an advanced stage of a disease. However, detailed history taking and physical examination will often reveal subclinical problems in apparently healthy Senior and Super Senior cats, and it is vital to ensure that appropriate healthcare is provided as appropriate. For example, one study in which the author was involved reported that a third of apparently healthy cats aged 10-18 years had a urine specific gravity (USG) lower than 1.035, a value commonly quoted as being the bottom of the normal range for this parameter 9. In the same study around the same number of cats were found to be suffering from significant problems including hyperthyroidism, systemic hypertension and chronic kidney disease. A more recent and larger study revealed that 21% of cats aged ten or older had a USG lower than 1.035, although the proportion of cats ultimately diagnosed with significant subclinical disease was lower than this 10. It is of prime importance that clinicians make maximum use of any veterinary visits involving an older cat to ensure that subclinical illness is detected at the earliest possible opportunity. Many common health problems are very treatable and outcome is improved by early diagnosis and intervention.

What preventative healthcare checks are justified in Senior cats?

The author follows the ICC “Cat Care for Life” guidelines (https://icatcare.org/) which recommend that all cats are assessed by a veterinarian at least once a year throughout their life. All checks should include detailed history taking, discussion of diet and preventative healthcare, physical examination and weight assessment. For the Mature, Senior and Super Senior life stages, more detailed assessments are recommended, including blood profiles, urinalysis and blood pressure assessment.

For the Mature life stage, health assessments are recommended annually, but ICC recommend that Senior and Super Senior cats are seen more frequently – ideally every six months – and that serum thyroxine is included in their blood panel. The author prefers to see Super Senior cats (i.e., those aged 15 years and over) every 3 months if possible, checking blood pressure and urinalysis every 6 months, and blood profiles every 6-12 months.

History taking

Health questionnaires are useful in spotting any problems and in teaching carers what signs to look out for (Table 3), with both open-ended and closed questions important to establish owner concerns and ensure that nothing is missed. Particular attention should be paid towards questions regarding:

• Appetite, current diet and bodyweight
• Thirst and toileting (urine and feces); constipation can be a sign of dehydration in older cats
• Toileting accidents; these can be present in cats with chronic pain, poor mobility, polydipsia, polyuria and feline dementia
• Mental status and behavioral changes; these can be a sign of dementia
• Visual deficits; these may indicate systemic hypertension

Carers should be encouraged to contact the clinic if they notice any change in their cat’s health or behavior, however trivial they think this is.

Table 3. General health questionnaire – please tick the relevant boxes below: answer yes/no/not sure to each question and add any further comments as necessary.

Clinical examination

Many older cats find a visit to the clinic very stressful. Chronic pain, hearing and visual deficits and dementia can increase the stress and anxiety associated with this experience. Where possible, cats should be examined in the base of their carrier if they prefer not to come out voluntarily (Figure 3).

Blood pressure assessment should be performed at the start of the consultation to minimize the impact of stress on systolic blood pressure values (Figure 4). The author favors the Doppler methodology for conscious cats, but it is important to remember that currently no blood pressure measurement device has been validated for use in conscious cats and therefore devices should be used with some caution 12. Ocular examination, including fundoscopy, should be included when assessing blood pressure in order to look for target organ damage (TOD) (Figure 5). In patients with compatible TOD and a high systolic blood pressure reading, the diagnosis of systemic hypertension is confirmed and treatment can be instigated (Figure 6). In patients with high systolic blood pressure readings but no evidence of TOD, repeat assessment is recommended to ensure the readings are genuine, with all efforts made to reduce stress that could result in situational hypertension: transient increases in blood pressure are usually due to stress and/or anxiety.

Figure 5. Examination of the eyes is essential to look for evidence of target organ damage due to systemic hypertension. The author finds distant indirect ophthalmoscopy a helpful technique for fundus examination. In a completely dark room, a light source is aimed at the cat’s eye from an arm’s length distance; (a) once the tapetal reflection is seen a 2.2 Diopter lens is inserted (b) allowing visualization of an inverted view of the fundus.
© Vet Professionals Ltd

Figure 6. Common manifestations of ocular target organ damage include hyphemia (a) and retinal detachment (b). 
© Vet Professionals Ltd

Bodyweight, body condition score and muscle condition score are important components of examination. Clear evidence of loss of muscle mass or weight loss, however gradual, is a cause for concern and should not be ignored (Box 1). If only one or two previous weight records are known then calculation of percentage weight change can be helpful in assessing what may be a significant loss (Box 2). 

Box 2. Calculating percentage weight changes.

In addition to a general and thorough physical examination, senior cats will benefit from particular attention being paid to:

• Palpation of the neck for possible goiter 
• Mobility and orthopedic assessment, where possible/tolerated (Figure 7)
• Oral/dental examination
• Hydration assessment
• Auscultation for new murmurs and arrhythmias (which are often found in cats with conditions such as hyperthyroidism and systemic hypertension)
• Thorough abdominal palpation for masses, and any sources of pain

Blood and urine assessment

Where possible, blood and urine samples should be collected as part of senior preventative healthcare assessments. A wellness profile (ideally including full hematology and serum biochemistry, with a total thyroxine (T₄) added for Seniors and Super Seniors) are invaluable in assessing health of older cats.

A free catch urine sample brought in by an owner is an adequate starting point for USG and dipstick evaluation. If the USG is less than 1.035 then a detailed history should be taken to rule out as many non-renal and physiological causes of producing poorly concentrated urine (such as receiving a liquid diet, diuretics or parenteral fluid therapy). Dipstick testing to check for the presence of glucose (diabetes mellitus) is also recommended. Further tests, ideally using urine collected by cystocentesis, should be considered if an abnormal dipstick parameter or USG is identified. For example, urine sediment examination, culture and a urine protein-to-creatinine (UPC) ratio are indicated in cats with kidney disease.

How can clinic visits be made more cat-friendly?

Many carers are impacted by the stress they witness in their cat attending the clinic, and this can put them off coming back for subsequent checks, especially if these are perceived as non-essential 13. Flexibility regarding the necessity for face-to-face appointments, and support for those cats and owners that find a clinic visit stressful, is recommended. Many committed carers can be “trained” to provide high-quality clinical data from their cat at home, which can then be used to guide treatment decisions. This can include purchase of scales facilitating home weight checks, and recording the cat’s behavior, appetite and toileting in a diary which can be shared electronically. For situations where a visit to a clinic is essential, strategies aimed at reducing stress in both cat and carer should be followed.

“Cat free consults” where the carer attends on their own, or the consultation is conducted by phone or video, can be very popular, offering an opportunity for detailed history taking, discussion and advice in the absence of the cat 14. These appointments can also be valuable opportunities to advise on tactics likely to reduce the stress associated with travel to the clinic when this is needed (Table 4).

Table 4. Strategies for reduction of stress associated with a clinic visit.

Carers may worry that tests and treatments will be expensive and unsuccessful in assisting their cat’s quality or length of life. It is common for carers to feel it is “normal” to have a thin elderly cat with a poor coat, stiff gait or other clinical signs. Carers may also worry that euthanasia will be recommended due to concerns over their pet’s welfare. Education of carers is therefore essential to support successful Senior consults and this should incorporate:

• Explanation of how common subclinical and clinical illness is in Senior cats, alongside discussion on how manageable these are due to advances in modern medicine.
• Emphasis on supporting early diagnosis as a means of reaching the best possible long-term outcome.
• Reassurance that cat-friendly tactics will be employed, and that consultations will not be stressful or painful for the cat to experience.
• Emphasis on the importance of concordance and a collaborative approach to patient care, so that carers feel empowered and involved at every stage. 
• Reassurance that the carer’s perspective on their cat’s needs will take priority, and that any plans made jointly can be changed at any point, if needed.

A relationship-centered approach to client discussions has been reported to be associated with greater adherence to treatment recommendations 16. Offering a range of management styles from “intense and expensive” to “hands-off and cheap” may also be beneficial, as indicated from data relating to veterinarians’ experience of managing diabetic cats and dogs 17.

Conclusion

Successful care of elderly cats requires attention to detail but can often be very rewarding for cat, clinician and owner alike, and maintaining pro-active contact with elderly cats and their carers helps to optimize healthcare through timely detection of illness and appropriate interventions. Many conditions affecting elderly cats can be successfully treated and have a very positive outcome, especially if spotted at an early stage and followed up with an empathetic approach, but this is very much dependent on the clinician and his or her attitude towards preventative care.