2d. Aging and Critical Care

Question 1

What are some diseases associated with aging?

Answer 1

thyroid conditions, dental dz, neoplasia, congitive dysfunction, endocrine disorders, cardiac dz, osteoarthritis, chronic renal dz

Question 2

How is energy affected in geriatric cats?

Answer 2

as a result of the inc in MER in cats above 12 yrs, some guidelines suggest inc caloric intake by up to 25% in senior patients
however the change in MER is not uniformly seen in all senior animals, so why should we make uniform recommendations
What if this change in caloric intake was made in a cat whose MER had not yet increased

Question 3

How does obesity affect geriatric cats?

Answer 3

obese cats >8yrs have 3x the mortality risk than tht of cats w/ optimal BCS
exacerbate comorbidities common in older animals - diabetes mellitus, FLUTD, osteoarthritic

Question 4

How are osteoarthritis and obesity linked?

Answer 4

52% of dogs and 41% of cats with OA are also obese
weight loss of as little as 6% has been shown to improve lameness in arthritic dogs
weight loss plans should be considered in obese pets even if ideal BCS cannot be achieved

Question 5

What is the risk of geriatric cats being underweight?

Answer 5

Having BCS <5/9 also associated w/ inc mortality risk
animals w/ poor BCS should be evaluated carefully for comorbidities
adjust caloric intake as needed to maintain BCS - higher caloric density may be necessary
Reasonable starting estimates for caloric needs in mature animals
Cats: 1.1-1.6 x RER
Dogs: 1.4 X RER

Question 6

How is fat affected in geriatric cats?

Answer 6

have reduced ability to digest fat
occurs in 10-12% of cats 7-12yrs of age
33% of cats greater than 12 yrs of age
Providing appropriate lvls of fat can inc caloric density and improve palatability
essential fatty acids (ie. linoleic) can help maintain normal skin and coat condition

Question 7

What is muscle wasting?

Answer 7

sarcopenia: muscular atrophy as a result of aging - common cause of muscle weakness in older animals

Question 8

What is cachexia?

Answer 8

muscle loss due to medical conditions like chronic kidney dz and heart failure

Question 9

How is protein and muscle mass affected in geriatric cats/

Answer 9

important in maintaining lean muscle mass, protein synthesis and immune function
Some evidence of decreased protein digestibility in senior cats - 20% of cats over the age of 14
In dogs, an increased protein to calorie ratio may be necessary - ensures appropriate protein intake with lower caloric needs

Question 10

Why do we care about quality vs quantity with protein?

Answer 10

adequate protein is necessary to maintain lean muscle mass and meet dietary needs
improving protein quality can assist in meeting protein needs w/o adjusting amounts
consider AA profile and bioavailability of protein

Question 11

Why do we worry about fibre in senior pets?

Answer 11

constipation common - reduced water intake, limited activity, reduced colonic motility
dietary fibre promotes normal intestinal motility
also decreased postprandial glycemic effects in diabetic dogs
Fibre does decrease caloric density - can promote weight loss, also aids in satiation
poor option in underweight seniors

Question 12

What are some minerals of concern in geriatrics?

Answer 12

calcium, phosphorus, sodium

Question 13

Why do we worry about calcium in geriatric patients?

Answer 13

osteoporosis not commonly diagnosed in pets
however some loss in bone mass is seen in older cats (+7yrs)
older cats maintain lower urinary pH
increased risk of hypercalcemia (idiopathic, neoplastic, renal) - inc risk of calcium oxalate urolithiasis
moderate calcium lvls recommended to reduce risk of calcium oxalate

Question 14

Why do we worry about phosphorus in geriatric patients

Answer 14

restriction of P important in the management of CKD
25% of dogs and 30% of cats affected
often not diagnosed until later stages
moderate restriction of P can be helpful against advancement of subclinical CKD

Question 15

Why do we worry about sodium in geriatric patients?

Answer 15

may be harmful in patients w/ hypertensive conditions - obesity, CKD, endocrinopathies
dogs w/ cardia dz have decreased ability to eliminate excess Na
moderate restriction could be helpful to reduce risks in these patients

Question 16

What are antioxidants?

Answer 16

normal O metabolism results in highly reactive free radical molecules
O molecules split into single atoms w/ unpaired electrons, they scavange body to find matching electron > can result in body damage
prolonged oxidative stress (aging) results in free radical damage - may account for many associated degenerative changes of aging
Antioxidants have excess electrons available to donate
Eg. vitamin C, and E, selenium

Question 17

What is cognitive decline?

Answer 17

physical changes occur in the brain associated w/ aging
atropy of tissues
loss of neurons and synapses
reduced glucose utilization
chronic inflammation
reduction of myelination

Question 18

What is DISHAA?

Answer 18

tool to help evaluate cognitive decline
D - disorientation
Social /I/nteraction
/S/leep/wake cyles
/H/ouse soiling
Learning and memory
/A/ctivity
/a/nxiety

Question 19

What are useful supplements for cognitive support and why?

Answer 19

Antioxidants - Vit C, E, selenium, mitigate oxidative stress
Anti-inflam - omega 3 fatty acids DHA and EPA, reduce inflam
Arginine - neural activity during cognitive tasks associated w/ inc in blood flow, mediated by nitric oxide, which is metabolised from L-arginine
B vit - important for neurodevelopment and cognitive function

Question 20

What are medium-chain triglycerides?

Answer 20

brain dependant on glucose for energy
age reduces ability to utilize glucose
reduce glucose metabolism may lead to brain cell death and brain mass
alt energy source req to support normal function
ketone metabolism unaffected by age
ketones can provide energy to brain during prolonged fasting and low glucose availability

Question 21

Why might texture and palatability matter with geriatric patients?

Answer 21

risk of dental dz inc w/ age - pets w/ advanced oral dz may have difficulty grasping and chewing food, appropriate oral care important, consider alternative textures when COHATs not an option
Sense of smell dec - primary driver of palatability in D/C,

Question 22

What are the major consequences of malnutrition?

Answer 22

decreased immunocompetence
dec tissue synthesis and repair
altered drug metabolism

Question 24

Who should receive nutritional support?

Answer 24

Rule of thumb, healthy adults can withstand not eating for 3 days. all others are immediate
High risk animals
<80% of RER for 3 days, anorexia for >3days
weight loss, underweight, muscle wasting, illness >3d, growth, hepatic lipidosis (cats)

Question 25

Why the 3 day rule?

Answer 25

malnutrition becomes more severe after 3 days
causes metabolic shifts, inc risk of metabolic complications, enterocyte atrophy, dec immune function

Question 26

In terms of food deprivations, what do healthy animals rely on?

Answer 26

endogenous fuel
1) glycogen stores - depleted very quickly
2) fat tissues (variable storage)
3) muscle protein - fuel to meet metabolic needs, maintain blood glucose

Question 27

In terms of food deprivation, what happens in illness/trauma individuals

Answer 27

muscle-sparing adaptation is absent
catabolize lean muscle mass to prod glucose
glucocorticoids, glucagon, inflam mediators

Question 28

What is the difference between starvation and illness

Answer 28

Simple starvation > adaptation > muscle sparing
Dz/trauma > no adaptation >catabolism

Question 29

What are the benefits of feeding?

Answer 29

bacterial fermentation in the bowel prod SCFA
feeds enterocytes, maintains epithelial barrier, supports mucus layer, down-regulates inflam
they’ll feel better when they eat

Question 30

What are the cons of syringe feeding?

Answer 30

not advised for longer term, poor intake of significant calories, stress, nausea

Question 31

What are the pros of feeding tubes?

Answer 31

proactive placement
various sizes/routes
long-term option
medication

Question 32

What are the cons of parenteral nutrtion?

Answer 32

intractable vominiting
severe malabsorption
neurological disorders

Question 33

What do we need to look for in recovery diets?

Answer 33

complete and balanced
digestible
tube feeding possible
palatable
high protein*
high fat*

Question 34

What is glutamine?

Answer 34

AA - important for cellular processes
concentractions dec following injury and catabolic states - conditionally essential during serious injury or illness.
When supplemented causes;
reduced rate of infectious complications, reduces mortality rates in critically ill patients, inc protein metabolism and nutrient absorption, intestinal and pancreatic repair and regeneration, improved gut barrier func and systemic immune func

Question 35

What feeding amounts do we give to critical patients?

Answer 35

dependant on duration of anorexia
Day 1: provide 20-50% if RER
divided into 4-6 feedings
administer feedings over 10-15 minutes
most tolerate 5-20ml/kg per feeding
Gradually increase to 100% RER over 2-7 days

Question 36

What happens if the patient is fed too much and/or too quickly?

Answer 36

metabolic complications
refeeding syndrome (rare)
GI side effects (nausea, regurg, risk of aspiration)

Question 37

What do we need to look for when monitoring anorexic patients in hospital?

Answer 37

inc blood glucose
dec magnesium, potassium and phosphorus

Question 38

Once an anorexic patient leaves, how long do we monitor for?

Answer 38

q 1-2wks for weight, BCS, MCS
adjust feeding schedule to maintain weight and BCS