Setting the stage for owners when senior pets develop behavior problems – American Veterinary Medical Association

With people spending more time at home during the pandemic, they have taken greater notice of the behavior of their pets. That very much includes senior pets, who are more apt to display behavioral issues for a number of reasons, mostly related to their higher risk for developing various medical conditions.
Before pets even get to the geriatric stage, however, experts recommend veterinarians help owners understand what to expect and look for because any sudden change in behavior merits a review of the pet’s physical status. Senior pets are likely to develop chronic, multifactoral conditions that typically require ongoing treatment. But these conditions can improve with a multifaceted approach that addresses medical, behavioral, and environmental management and includes—when indicated—drug treatment, with the goal of optimizing quality of life and interactions for both owners and pets while maintaining the human-animal bond.
It is well known that as humans age, the body changes, and pain becomes more commonplace.
“We don’t fully appreciate how senior pets are different, even if they do not necessarily have severe pathologies,” said Dr. Carlo Siracusa, associate professor of clinical behavior medicine at the University of Pennsylvania School of Veterinary Medicine and president of the American College of Veterinary Behaviorists.
Normal aging changes in pets can add up to decreased coping abilities as a result of conditions such as sensory impairment, decreased immune or gastrointestinal function, or changes in microbiota, said Dr. Ilona Rodan, owner of Cat Behavior Solutions and the former owner of Cat Care Clinic in Madison, Wisconsin.
Behavior observations are a noninvasive way for veterinarians to assess these medical issues in old age. At the same time, Dr. Rodan acknowledged how challenging it can be for practitioners to parse what is behind behavior changes in senior pets given that there are so many potential causes.
“When talking about senior cats, you’re talking about comorbid conditions. You could have chronic kidney disease going on with osteoarthritis, urine marking, soiling, and a myriad of intercat conflicts,” she said during her talk “Senior Cat Behavior” for the Morris Animal Foundation’s Feline Behavior Lecture Series 2021. “With senior cats, no doubt about it, they have more behavior changes, and they have more behavior problems.”
A recent survey of cat owners showed that about 28% of cats aged 11-14 years develop signs of behavioral issues and cognitive decline, with prevalence increasing to over 50% in cats 15 or older.
Dr. Rodan also cited a 2012 study of 100 cats aged 12-22 years with behavior problems. The study found 61% of the cats vocalized excessively, of which 31% did so at night. In addition, 27% of cats had urine soiling or marking, 22% had disorientation, 19% had aimless wandering, and 18% had restlessness.
Among senior cats, osteoarthritis is the most common medical condition causing behavior changes. A 2010 study of 100 cats between 6 months and 20 years found that 92% had radiographic evidence of degenerative joint disease. For each year increase in cat age, the expected total DJD score increases by an estimated 13.6%. Dr. Rodan noted that cats with OA often have chronic kidney disease, saying 68.8% of cats with one condition have the other concurrently. Behavior changes or problems in cats with OA include inactivity, changes in relationships, and house soiling.
“The pain may lead to a breakdown of the social bond with another companion animal or the owner,” she said. “It’s tragic for owners, and we see it all the time.”
Other common medical issues that cause behavior issues for senior cats are hypertension, hyperthyroidism, and diabetes mellitus, while less common causes are GI disease, other endocrine disorders, hepatic disease, neoplasia, and neurologic disease.
Dr. Bonnie Wright, a diplomate of the American College of Veterinary Anesthesia and Analgesia, says new behavior issues, especially in senior cats, are often related to pain. She mentioned several sources of pain that can lead to litter box issues, such as arthritis making it difficult to get in and out of the box or pelvic pain that relates to urinary issues. Cats can also become less friendly with other cats in the household as they try to protect themselves from painful interactions.
“Anything that develops in elderly cats should be looked at through the lens of pain and medical conditions,” Dr. Wright said.
Fear and anxiety are often coupled with pain, Dr. Rodan said in her talk. When evaluating senior behavior issues, she advised, first rule out illness, pain, and sensory decline. Then think about emotional distress, including frustration, fear and anxiety, and unmet needs. Cognitive dysfunction is a diagnosis of exclusion.
“If you take away one thing from this talk, senior cats have decreased coping ability, and that can lead to fear and anxiety,” Dr. Rodan said.
Cognitive dysfunction is a potentially underdiagnosed condition in senior cats. The condition has been estimated to affect 28-36% of cats aged 7-14 years, 50% aged 15 years or older, and 88% aged 16-19 years, according to a 2007 study in the Journal of Small Animal Practitioners.
Behavioral changes related to CD in cats are spelled out with the acronym VISHDAAL: inappropriate vocalization, especially at night; altered social interaction with the family or other pets; changes in sleep patterns; house soiling; spatial and temporal disorientation, such as forgetting the location of the litter box or that they have been fed; changes in activity, such as aimless wandering; anxiety; and learning and memory deficits. The 2007 study found excessive vocalization and aimless activity to be the most commonly reported problems in the oldest age group.
“We don’t know much about CD, about its etiology, or how to diagnose it,” Dr. Rodan said. “It’s a real problem.”
A study that came out last year looked at owner perception of the causes of increased vocalization in cats with cognitive dysfunction and what impact it had on the cat’s household. Owners reported that the main cause of their cat’s vocalization appeared to be disorientation (40.5%) or attention seeking (40.5%). When owners were asked how stressful they found their cat’s increased vocalization to be, 40.5% scored it as stressful to significantly stressful.
“Owners tend to note a lot what causes a change in their routine and their quality of life,” especially waking up at night or elimination issues, and not necessarily the more subtle behavior changes, Dr. Siracusa said.
He has also noticed that it’s dog owners who more often come to see him than cat owners. “Not that it (behavior change) doesn’t happen in cats, but cat owners tend to be much more tolerant of changes,” Dr. Siracusa said.
Plus, cats, while they’ve learned to live with humans, don’t communicate as frequently or expansively as dogs do with their owners, he said.
In senior dogs, the most common sources of pain and discomfort are musculoskeletal and gastrointestinal disease, said Dr. Marsha R. Reich, owner of Maryland-Virginia Veterinary Behavioral Consulting, a behavioral house call practice based out of Silver Spring, Maryland. She gave the talk “Behavior Problems of Senior Dogs and Cats” at the AVMA Virtual Convention 2020.
With musculoskeletal disease in dogs, the source of pain usually is arthritis, muscle aches, or another joint disease. With GI disorders, pain sources include inflammatory bowel disease, food intolerance or allergy, or dietary indiscretion facilitated by owners. With neurologic disease, the source of pain usually is spinal cord issues, disk issues, or lumbosacral compression.
“The pet can have a combination of problems, and, unfortunately, weight gain from any cause, including tumors, can exacerbate musculoskeletal disease,” Dr. Reich said.
Some dogs age in a way that may not directly affect their day-to-day activities or relationship with their owners, while for others, their declining performance may compromise these things. A 2011 study in the Journal of Veterinary Behavior reported that some old dogs—those 8 years or older and of various breeds—even if aging normally, might encounter rapid age-related deterioration in activity, play, and responses to commands and an increase in fears and phobias within a six-month period.
Another study that appeared in 2001 in JAVMA reported that 28% of dogs aged 11-12 years had impairments in one or more of the following categories: disorientation, interaction changes, sleep or wake disturbances, house soiling and activity changes, anxiety and sense of smell, and learning and memory. Further, 10% of them had impairments in two or more categories. In contrast, 68% of dogs aged 15-16 years had impairments in one or more categories, and 35% of them had impairments in two or more categories.
When thinking about behavior problems in senior pets, Dr. Reich divides them into three categories: primary, which often are seen at a younger age; secondary to a medical issue; and cognitive dysfunction.
“If the behavior problem is secondary, it will be difficult to resolve it unless the medical problem is addressed,” she said. “The possibility of CDS (cognitive dysfunction syndrome) maybe looms in the background, but it is a diagnosis of exclusion.”
The clinical signs for CDS in dogs can be summarized by the acronym DISHAA, which refers to disorientation, a decrease in social interactions, changes in sleep-wake cycles, a loss of prior house training, increased anxiety, and changes in level of activity. A decrease in the ability to find dropped food has also been reported for dogs in which CDS has been diagnosed.
“Interestingly, it is rather unclear to what extent the pet dog population is affected by CDS,” according to the 2018 scientific article “Cognitive Aging in Dogs” that appeared in Gerontology. “This is partly due to the high degree of variability in how dogs age and to the lack of systematic CDS evaluation criteria.”
In 2011, Dr. Hannah E. Salvin and others developed a CDS rating scale for the diagnosis of cognitive dysfunction in dogs and reported the prevalence to be 14.2% in pet dogs over 8 years old, in contrast to the diagnosis rate of 1.9%. Overall, when including different studies, the prevalence of CDS in the population of dogs 8 years or older is estimated to range from 14.2%-22.5% and to increase exponentially with increasing age.
For all of these medical conditions in senior pets, Dr. Siracusa says, simply having a good yearly examination, complete blood count, and laboratory tests as well as a urinalysis every six months should be enough to catch them.
“You don’t need to look for very strange things; just be consistent and be a good observer,” he said.
In human medicine, when patients reach a certain age, they are screened for certain changes or conditions. Dr. Siracusa would like to see the same thing for veterinary patients.
“I don’t wait for the owner to report because when it becomes so visible for the owner to report, it’s probably at an advanced stage,” Dr. Siracusa said.
He recommends veterinarians research the many available questionnaires and pain scales available and modify them to what works best for their clinic.
When asking owners questions, he said, “You have to give very specific examples. You can’t ask if their pet is OK or if they’ve seen anything strange because they’ll say it’s OK. It’s partly on the owner, but a great deal of responsibility is on veterinarians.
“I think it’s important for veterinarians to be trained to recognize the signs, but not everybody is trained to recognize dog or cat behavior. If we want to use behavior as a health marker, then we have to be trained to read these markers.”
Dr. Rodan emphasized the need to eliminate fear in veterinary practices and to handle senior cats as if they are potentially painful because so many are. For example, during the physical examination, she recommends gently handling cats instead of using full-body restraint, clipnosis, or scruffing. Gentle handling has proven to be more efficient and safer. When measuring blood pressure, Dr. Rodan said, realize that cats don’t like their feet being held tightly. It is good to come from behind the humerus and move forward.
Dr. Wright recommends that senior cats have a physical examination, thyroid evaluation, abdominal palpation, and assessment for chronic kidney disease as well as a myofascial examination. “You can tell a lot about pain and some of the internal structures that share neurologic wiring,” she said.
The American Association of Feline Practitioners will release the 2021 AAFP Senior Care Guidelines and associated supplemental resources in the July issue of the Journal of Feline Medicine and Surgery, which will have a section on what to include when performing a physical examination on senior cats.
Dr. Reich likes to watch dogs as they are walking so she can see if the rear end is swaying from side to side or if there is a head bob. She’ll also perform an orthopedic examination, if the dog’s temperament allows it. Client videos of dogs on different surfaces and in different situations can help, too, for dogs that don’t like smooth flooring or whose feet slide, which means they likely have orthopedic disease.
“There needs to be detective work to determine whether a medical problem is going on, but I don’t let those turn into fishing expeditions,” Dr. Reich said. “You can’t run every test, and it can be frustrating.”
Dr. Siracusa and Dr. Federica Pirrone, a research fellow at the University of Milan, are studying how chronic inflammation affects cognition, behavior, and the overall health of senior cats. The two researchers and their teams will study 100 client-owned cats that are 7 years of age or older. First they will perform a routine veterinary examination on each cat to look for signs of chronic inflammation, including specific blood markers and physical changes. Then they will assess the cats’ behavior, their living environment, and their cognitive abilities using validated questionnaires and behavioral tests.
“Ideally, this study could lead to development of innovative tools for early detection and monitoring of chronic inflammation that affects the long-term well-being of feline patients,” said Dr. Janet Patterson-Kane, chief scientific officer of the Morris Animal Foundation, which awarded a grant for the study to Dr. Siracusa.
Treatment for senior pets will often be multimodal, with nonsteroidal anti-inflammatory drugs as the medication of choice for musculoskeletal conditions. Gabapentin can be useful for neuropathic pain, Dr. Rodan said, especially because 25% of cats with OA have neuropathic pain. She personally recommends using Greenies pill pockets or Royal Canin’s Pill Assist, which allow owners to hide medication inside cat treats, or gel capsules, which allow owners to put multiple medications together in each capsule to reduce the number of pills.
Something to keep in mind is that caregiver burden is a real concern, said Dr. Bonnie Wright, an integrative pain management specialist.
“As you get cats with multiple conditions, there is not only a financial implication to that but also a relationship implication,” Dr. Wright said. “The more time you ask them (caregivers) to get medications in cats, that can degrade relations.
“You have to be sensitive to that issue and keep it in the conversation. I try to be sure I’m not just adding drugs, but I’m helping them with weight reduction and movement and exercise and other physical approaches to pain, not just purely pharmacologically focused. There’s a lot they can do that is positive with the cat that is managing other lifestyle things, such as how the house is set up or their favorite perching area is set up, that can improve the relationship.”
Recognizing that physical activity is analgesic, being more active is a form of pain relief, Dr. Wright said. Environmental modification can help pets be more active around the house. For example, she’ll have owners feed cats or have cats find food in different places, which can help those that are more food motivated. This also serves to keep the brain active, which helps with cognitive dysfunction.
“Physical games are also mind games. It’s important to keep the body and brain active” in senior pets, she said.
Dr. Rodan referenced the importance of the five pillars of a healthy feline environment from the American Association of Feline Practitioners and the International Society of Feline Medicine:
“Regardless of cognitive dysfunction, senior cats have more difficulty coping with change, and routine is very important,” Dr. Rodan said.
Environmental modification for arthritic dogs may involve soft resting areas or ramps to facilitate getting on and off beds or sofas; traction aids on stairs; and carpet runners over smooth flooring.
If GI disease is suspected, working up the disease and treating it should help the problem. Nonspecific treatments include anti-nausea medications, prebiotics, probiotics, appetite stimulants, and limited-ingredient or hydrolyzed-protein diets, Dr. Reich said.
Complaints related to house soiling can be a result of renal disease, lower urinary tract disease, hyperadrenocorticism, diabetes mellitus, and liver disease, among others.
“Some problems are not easily resolved. The dog may need to be taken out more frequently, and sometimes dogs will have urgency to defecate, and the owner may miss signaling that the dog needs to go out,” Dr. Reich said. “One of the really big things about house soiling is the owner needs to be present to make sure the dog eliminates outside. They can’t just stand at the door and assume the dog is going and wait until it comes in.”
Dr. Reich said special diets—pointing out Hill’s Prescription Diet b/d or Purina One Vibrant Maturity 7+ as examples—or medications and supplements can improve signs and slow the progress of CDS in senior dogs. Making gradual changes to the dog’s household or routine can also help it adapt better.
“We can’t stop aging, but we can help signs of it become less problematic,” Dr. Reich said.
The AVMA offers answers to frequently asked questions from pet owners about the care of senior pets.
United Kingdom–based International Cat Care provides a guide (PDF) on how to feed cats, advising cat owners to divide their cat’s daily food ration into five portions to mimic cats’ natural feeding habit of eating little and often.
The American Association of Feline Practitioners provides client resources on senior cats and information for veterinarians, including details about the AAFP’s Cat Friendly Practice program.
Get information from the Purina Institute, which promotes global collaboration and knowledge exchange about nutritional science for pets, and Hill’s Pet Nutrition offers a checklist for owners of senior pets.
The Dog Aging Project aims to enroll 10,000 dogs in a longitudinal study, funded by the National Institute on Aging, to identify the genetic and environmental factors that influence healthy aging. Dog owners can visit the website or more information.
Dr. Ilona Rodan, owner of Cat Behavior Solutions and a past president of the American Association of Feline Practitioners, shows in this video how owners can help cats understand what it’s like to be examined at the veterinary clinic so they are more comfortable when they come in. (Courtesy of Dr. Rodan)
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