Suggested geriatric screening parameters

Re: Suggested geriatric screening parameters

Gareth Dowdeswell — Thu, 19 May 2011 17:07:04 GMT

With regards to chasing abnormalities on biochem panels, I think surely most vets apply some common sense? A slightly raised crea or urea probably isn't too much to be excited about, but if they're both high then further investigation/monitoring is probably a good idea.

[quote user="Julian Earl"]

Fair enough. Even though I'm not old now, I was obviously old in 1995 because it wasn't major surgery (arthroscopy) and I wasn't high risk.

[/quote]

Possibly the guidelines have changed since 1995? My mother had pre-ops prior to a hip replacement last year, no major health problems but is 60 so does that count as old for NICE?

Re: Suggested geriatric screening parameters

Julian Earl — Tue, 10 May 2011 13:15:47 GMT

[quote user="Michael Woodhouse"]

[quote user="Julian Earl"]

[quote user="Michael Woodhouse"]

In humans they don't do routine pre-anaesthetic bloods. [/quote]

Oh yes they do. I had knee surgery years ago and was blood tested the month before,plus on the day before, then the op was postponed and I was re-tested three months later. Not only that, when they came round with the multiple consent forms, I signed but someone had forgotten to tick one of the boxes and I had to sign the very same forms again after they had ticked the box. And you thought we were paranoid?

[/quote]

If you have a spare hour go and read the NICE guidelines on this. When I read them if I remember correctly unless you were old, or high risk or having very major surgery there were no routine bloods taken. They advised against urine samples in asymptomatic patients.

Linky

I stand by my original statement.

[/quote]

Fair enough. Even though I'm not old now, I was obviously old in 1995 because it wasn't major surgery (arthroscopy) and I wasn't high risk.

Re: Suggested geriatric screening parameters

Michael Woodhouse — Sun, 08 May 2011 22:05:43 GMT

[quote user="Julian Earl"]

[quote user="Michael Woodhouse"]

In humans they don't do routine pre-anaesthetic bloods. [/quote]

[/quote]

Linky

I stand by my original statement.

Re: Suggested geriatric screening parameters

Julian Earl — Sun, 08 May 2011 21:52:46 GMT

[quote user="Michael Woodhouse"]

In humans they don't do routine pre-anaesthetic bloods. [/quote]

[quote user="Anthony Todd"]

"I have rarely been able to manually express a bladder in a conscious cat"

There used to be cat litter that was insoluble so you could pour the sample off or, sometimes, just putting the litter tray in a bin bag and they pee on the plastic works a treat.[/quote]

Katkor, still available.

Re: Suggested geriatric screening parameters

Michael Woodhouse — Sun, 08 May 2011 17:02:22 GMT

[quote user="amanda nicholls"]I have rarely been able to manually express a bladder in a conscious cat, how hard do you have to squeeze? I find cats react worse to having their bladder squeezed than to a quick cysto.[/quote]

It's not so much about how hard you squeeze, just modest pressure that is maintained. If I can easily palpate a bladder I'd say I could express it. The cats never seem to mind, usually I got the owner to hold the kidney dish whilst I restrain cat and squeeze bladder.

Re: Suggested geriatric screening parameters

Anthony Todd — Sun, 08 May 2011 09:52:34 GMT

"I have rarely been able to manually express a bladder in a conscious cat"

Me to; they're really hard to express even when they're under GA [I always expressed very full bladders in C/Ss] You have to press hard for a minute or longer and, I think I've heard of bladders being ruptured??

In males it could be easier just to catheterise then after local infusion of the urethra.

There used to be cat litter that was insoluble so you could pour the sample off or, sometimes, just putting the litter tray in a bin bag and they pee on the plastic works a treat.

Re: Suggested geriatric screening parameters

Amanda Nicholls — Sat, 07 May 2011 21:18:39 GMT

[quote user="Michael Woodhouse"]

Just squeeze the bladder and collect urine into a kidney dish. No need for an invasive cysto for a dipstick.

[/quote]

I meant to reply to this in my earlier post. I have rarely been able to manually express a bladder in a conscious cat, how hard do you have to squeeze? I find cats react worse to having their bladder squeezed than to a quick cysto. Owners don't seen to mind either, especially after I have explained the katkor option. And no I don't charge extra for a cysto in case you were thinking it was done to improve the bottom line!

Re: Suggested geriatric screening parameters

Amanda Nicholls — Sat, 07 May 2011 20:55:03 GMT

[quote user="robloxley"]

Do you mean single lab figures out of range (remembering that a % of normal animals have parameters outside the reference range), or that 40% had clinically relevent findings e.g. diabetes/hyperthyr/CRF?

For example the number of apparently healthy animals coming back with abnormalities of liver enzymes. How many of these have clinically relevant liver disease? How many of these does the lab work influence and improve the clinical outcome? If you follow them all up with bile acids, ACTH stim, scans and biopsies, you're doing an awful lot of testing on 'well' animals. I'd be interested to see some clinical data following 'wellness testing', as IMHO the yield in well animals is pretty low.

[/quote]

I only work with cats. Of the cats I am refering to as having abnormal findings, most of the cats were diagnosed with CRF, all were IRIS stage 1 or 2 based on creatinine and had USG <1.035. At least now we can gradually introduce a renal diet while the cats are still eating well, stop all dry food! avoid renotoxic drugs and monitor progression closely, 3 monthly weight check, BP and retinal examination and 3 or 6 monthly urinanalysis (including UPC + culture). Keep the PO4 within IRIS range relevant to stage.

If liver enzymes are less than 3 times upper ref range and no clinical signs of liver disease, I advise monitor cat and retest in 3-6 months unless the owner wants to check DBA (I give them the option as they will probably go and look it up on the internet!). If I was including cats that had at least one change on the biochem panel it would be close to 100%.

2 of the cats had T4 close to top end of ref range and were retested within 6 months and T4 had increased, had lost weight etc and were started on treatment. 1 cat had a slightly high blood glucose but normal fructosamine, diet was changed to wet DM (cat was obese) and the blood glucose (and now fructosamine) have continued to rise despite weight loss and appropriate diet!

None of the owners had brought their cat in for a check up because they were worried about pu/pd, even in cats with sp.g. <1.020 the owners were not reporting pu/pd. Some owners accept changes in older cats as old age and some just don't notice. I would much rather promote preventative healthcare than be presented with the emaciated hyperthyroid cat with CHF and CRF that is suffering when it's disease could easily have been managed.

Re: Suggested geriatric screening parameters

Anthony Todd — Sat, 07 May 2011 20:54:47 GMT

[quote user="Michael Woodhouse"]Not really fair to throw in testing for already diagnosed disease[/quote]

True, and I got my wires crossed. Should point out that my T2 diabetes was discovered in a routine test; I felt fine, no symptoms as far as I knew.

[quote user="Michael Woodhouse"]I am all for testing where there are any clinical signs[/quote]

I'm all for testing when there are no clinical signs and so is my friend with his bleeding bowel carcinoma caught early by the aforementioned faecal blood onto the cardboard and posted off....

I'm really trying to set the bar for a reasonable number of positives in a reasonable number of patients for which we need some statistics which I'd hoped were available somewhere.

If it can be shown that 45%, say, of cats over 12 have one of the three conditions then I reckon best practice might be to recommend screening and, as has been suggested, scrapping boosters.

Re: Suggested geriatric screening parameters

Rob Loxley — Sat, 07 May 2011 20:15:24 GMT

[quote user="amanda nicholls"]In cats over 8 (total 43 cats) 40% had abnormalities. In cats over 12 (total 19 cats) 47% had abnormalities.[/quote]

We do a fair amount of 'wellness testing' and find a fair amount of minor lab 'abnormalities' in otherwise well pets; obviously some may be suffering preclinical disease, but are we treating the lab results or the animal? IME the kind of significant finding such as those highlighted in Idexx (et al's) newsletters are the exception rather than the rule.

Don't think I'm not a supporter of 'Wellness' testing, but I feel the history and clinical examination (and I'd argue by the vet - no disrespect to the VNs and realising this thread is not about mini-vets...) are more important steps than the lab work per se, and we need to always bear that in mind when chasing down that abberant ALP.

For example I can think of the dog with mild increased ALP, followed up by positive ACTH and LDDST that is started on vetoryl, without stepping back and asking whether it had historical and clinical signs of Cushing's, and whether it's positive tests we due to it being sooo stressed in the vets...

Re: Suggested geriatric screening parameters

Amanda Nicholls — Sat, 07 May 2011 19:46:33 GMT

[quote user="Michael Woodhouse"]

What are you calling 'abnormal'? The Merck Vet Manual has a feline Creatinine reference range of 49-165mmol/l are you taking 170 as abnormal?

I am all for testing where there are any clinical signs, but chasing number [in my opinion] is more about your bottom line and getting the use out of the expensive biochemistry analyser than a benefit to the patient. A thorough clinical examination and history should allow us to target testing where is is needed.

In humans they don't do routine pre-anaesthetic bloods.

[/quote]

I don't have an expensive biochemistry analyser, all samples are sent to NWL, clients are charged the list price and a modest fee for materials, collection and interpretation and follow up call. I have an ISTAT as it is far more relevant than in house cbc/biochem and it doesn't pay for itself but gives me peace of mind I can do the best for my patients in an emergency situation. I am certainly not the money grabber you imply! We are not talking about pre GA bloods for cat spays but best practice as advocated by the FAB.

As for interpreting results, I follow IRIS guidelines and would not over react to one abnormal result in an animal without compatible signs.

Re: Suggested geriatric screening parameters

Louise6732 — Sat, 07 May 2011 19:27:23 GMT

[quote user="Michael Woodhouse"]These 'screening' tests for well animals don't sit terribly comfortably with me. [/quote]

I agree up to a certain point with you Michael. However, giving my own cat as an example, 1y6m (at the time of 1st sample) MN DLH rescue, I did a pre-GA haem and biochem before GA for scaling teeth, flagged up renal insufficiency cysto showed UP:C high. He had no clinical signs at all. Just shows you they are out there! So I've been lucky enough to be able to help his kindeys out before they give up.

I think it is a good idea to check older cats for renal disease so you can get in early with renal diet to prevent the vicious cycle that renal disease brings. So a U+ dipstick and SG is a cheap, non-invasive (unless need cysto) place to start. Blood pressure measurement is also very useful in senior cat as hypertension is often only picked up because the cat has gone blind. As for full blood screens I think they have their place where indicated but wouldn't do as a routine for every cat over 8y.

Louise

Re: Suggested geriatric screening parameters

Alan Tevendale — Sat, 07 May 2011 19:19:36 GMT

[quote user="Michael Woodhouse"]

[/quote]

I'm certainly no fan of doing unnecessary tests on animals but just for argument do we not have to remember that a large proportion of cat owners will not pick up on the early signs of many diseases? Is it not possible that these screening schemes will make a few people think more about their pet's health? I'm sure that some people that come in for these screenings would not come in otherwise and therefore would never been through a thorough clinical exam and history.

Re: Suggested geriatric screening parameters

Michael Woodhouse — Sat, 07 May 2011 19:10:12 GMT

[quote user="amanda nicholls"] am currently recommending an annual urine test for all adult cats (which has had a fairly poor uptake unless we are able to cysto in the surgery)[/quote]

Just squeeze the bladder and collect urine into a kidney dish. No need for an invasive cysto for a dipstick.

These 'screening' tests for well animals don't sit terribly comfortably with me. Just some basic statistics; remember the standard reference ranges are usually plotted from a standard distribution curve taking the middle 95% as 'normal'. Therefore for every 20 times you do a test one result will be outside the normal range, yet from a healthy animal. If you come up with a profile for old cats with 10 tests roughly 1 in 2 cats will have an 'abnormal' result.

[quote user="amanda nicholls"]n cats over 8 (total 43 cats) 40% had abnormalities. In cats over 12 (total 19 cats) 47% had abnormalities.[/quote]

What are you calling 'abnormal'? The Merck Vet Manual has a feline Creatinine reference range of 49-165mmol/l are you taking 170 as abnormal?

In humans they don't do routine pre-anaesthetic bloods.

[quote user="Anthony Todd"]as a T2 diabetic 6 month bloods, annual retinal screening and annual foot-stroking, for peripheral neuropathy[/quote]

Not really fair to throw in testing for already diagnosed disease! You could almost argue than 6 monthly bloods would be less than many diabetic animals would get! I know for certain that 'elderly' people on the NHS receive no annual blood sample.

Re: Suggested geriatric screening parameters

Sheila Kerr — Sat, 07 May 2011 17:34:49 GMT

Our practice is also looking at asking cat owners to bring in urine samples at their boosters and free Blood Pressure checks with the nurses. (Over 10 years was our current thinking) .Maybe offering free urine collection kits? Various older pet clinics have ground to a halt before now! Even just picking up dilute urine would be very useful for early pick upof renal disease.

Re: Suggested geriatric screening parameters

Amanda Nicholls — Sat, 07 May 2011 17:14:24 GMT

Hi Anthony,

I have been looking at exactly these stats for my practice this week in preparation for a mail shot to owners of senior cats encouraging them to book their cat in for a senior health check with a VN. I am currently recommending an annual urine test for all adult cats (which has had a fairly poor uptake unless we are able to cysto in the surgery); annual blood pressure measurement and senior health screen bloods (+ urine) for all cats over 8.

I have looked at the results for cats over 8 and over 12 that were presented for a 'wellness screen' and have excluded any cats that were brought in for a non routine consult or if during a routine consult / vaccination the vet examining the cat found any abnormalities (heart murmur, enlarged thyroid gland etc).

In cats over 8 (total 43 cats) 40% had abnormalities. In cats over 12 (total 19 cats) 47% had abnormalities. As I am still a fairly new practice I don't have lots of data to analyse so I'm not sure how my results would hold up if analysed using a statistical test, however I am happy to continue recommending annual screens for cats over 8 based on these findings.

I would be very interested to hear what other vets are currently recommending and what data they have. I think we can make a huge difference for our senior patients, if only we could get it across to all the owners!

What are you recommending currently and do you have any data Anthony?

Amanda

Re: Suggested geriatric screening parameters

Julian Earl — Sat, 07 May 2011 16:53:36 GMT

I'm not exactly answering your question but I am now of the view that owners may well be wasting their money vaccinating their cat for leukaemia and enteritis once above maybe twelve years of age, and would be better spending that on blood testing for T4,/urea/creatinine/maybe liver, and a urine test.

I have yet to have the courage to instigate this however.