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A marked decline apparently becomes particularly prevalent after around age Dietary omega-3 fatty acid supplementation in the form of fish oil can have beneficial effects in reducing GCP. These physical changes can explain why someone of an older age might not be getting the nutrition they need. The dosage for krill oil which is made from crustaceans rather than fish is mg per day. You do not want to feed an extremely low level of protein so your cat suffers weight loss and malnutrition; but nor do you want to be loading your cat's body with unnecessarily high levels of protein which contribute to your cat feeling ill.

Challenges in the Management of Type 1 Diabetes in Older Adults

Zinc deficiency

It also discusses other nutritional issues, such as the importance of weight and muscle maintenance. If you're feeling overwhelmed and just want some ideas on what to feed your cat, skip this page for now and read the Which Foods to Feed and P ersuading Your Cat To Eat pages instead. Physiological Needs of Cats. Cats are not small dogs.

They have unique physiological needs. When you are dealing with CKD, you need to meet these basic needs but also cater as far as possible for their CKD-related needs.

There are many different opinions about the best food for cats, and the debate can get quite heated. I don't wish to focus on that here, but rather to explain the basic needs of cats from a scientific perspective.

Cats are obligate carnivores. This does not mean they can only eat meat. It means that, unlike other species, such as humans and dogs, they cannot manufacture certain amino acids essential to life themselves.

In order to obtain these amino acids, they must eat food which contains them, and ideally that means they must eat meat, though they may also be able to obtain them from other sources for example, corn gluten meal, the protein part of corn, actually contains all the amino acids which cats need.

It is a myth that our domestic cats are miniature versions of the big cats such as lions. Big cats are part of a pride, and hunt together. Domestic cats, in contrast, are solitary predators, and if they are living in their own version of the wild, they only eat what they can catch.

They catch mice, insects, whatever passes by or what they can hunt. This means they have evolved to eat little and often. They eat very little plant material or carbohydrate, only what would be found in a mouse's stomach, though they may sometimes also eat small amounts of grass.

Originally cats were desert animals, so they evolved to not want to drink much. Therefore ideally cats also need to eat foods containing a reasonable amount of water. So to summarise, healthy cats need foods containing a large percentage of meat-based protein, with limited vegetables and grains. It becomes a little more complicated when you add CKD to the mix. You still want to feed a diet that meets your cat's basic physiological needs, as outlined above, but if possible you also want to feed a diet that can help with the CKD.

There are two main concerns with diet in CKD cats:. It is essential to keep your cat eating, and to maintain weight and muscle as much as possible. Below I discuss the importance of weight management and calorie intake in CKD cats, followed by an explanation of the main components of the feline diet, such as protein and phosphorus, and how they impact on CKD.

The protein section includes information about the pros and cons of a reduced protein diet. I recommend that ideally you read this page so you can understand the main components of feline diets. Then you can read the Which Foods to Feed page, which discusses food choices including therapeutic kidney diets, and what to do if your cat refuses to eat them. Remember, the most important thing is that your cat eats. I cannot emphasise this enough.

If you're struggling to get any food at all into your cat, check the P ersuading Your Cat To Eat page. Maintaining weight and muscle is extremely important.

Anorexic cats cats who have stopped eating and cachexic cats cats who have lost a lot of muscle have a worse prognosis than cats of a normal weight, so it is essential to monitor your cat's weight and body condition closely, and above all to keep your cat eating. The World Small Animal Veterinary Association has a body condition diagram showing how to gauge your cat's physical condition, as does Purina.

If you are lucky enough to have an slightly overweight CKD cat, rejoice, and personally I would not put him or her on a diet, because as the CKD progresses, your cat will almost certainly lose weight anyway. Older cats over the age of ten are prone to weight loss, even if they have no underlying health problems. It is not known exactly why older cats lose weight, but it is thought it may be at least in part because their bodies become less able to digest nutrients, particularly fat and protein.

Low protein digestibility also seems to affect mature and geriatric cats. The incidence of low fat and protein digestibility tends to occur in the same cats.

A marked decline apparently becomes particularly prevalent after around age Whatever the precise reason, weight loss in older cats is not good news. Emaciated cats had a significantly higher risk of death compared with cats in optimal body condition.

Perez-Camargo et al demonstrated that body weight, lean body mass, and fat mass decline in cats over the age of 12 years, particularly in the last 1 to 2 years of life. Even in younger cats, low body weight can be a concern. Mechanisms causing loss of lean body mass in kidney disease Mitch WE The American Journal of Clinical Nutrition 67 pp explains more about this problem in humans.

It is therefore extremely important to monitor your cat's weight and to keep him or her eating. I recommend weighing your cat at least weekly. There are links on buying scales suitable for weighing cats here. Muscle wasting is also common in CKD cats. This is partly because most CKD cats are elderly and the elderly are prone to sarcopaenia, which is the age-related loss of muscle.

CKD cats may also suffer from cachexia. Cachexia is defined as a metabolic syndrome in which inflammation is the key feature and so cachexia can be an underlying condition of sarcopenia. Recently, cachexia has been defined as 'a complex metabolic syndrome associated with underlying illness and characterized by loss of muscle mass with or without loss of fat mass. The prominent clinical feature of cachexia is weight loss in adults.

CKD is one such underlying illness. Although the prevalence of cachexia in dogs and cats with CKD has not specifically been measured, it appears to be relatively high and likely has negative clinical effects.

Since creatinine , one of the measures of kidney function, is a by-product of muscle, cats who lose a lot of muscle may have reduced creatinine levels, because they cannot produce as much creatinine.

The Merck Veterinary Manual states "Serum creatinine levels can be falsely lowered in patients with severe muscle wasting. Over months cats can down regulate their protein needs and switch to use other pathways, but in the short and intermediate term, muscle will be catabolized.

The resulting muscle wasting and decreased mass reduces the serum level of creatinine Cr measured. You may therefore think your cat's CKD is improving because the creatinine is falling, when in fact this is not the case. Cats with hyperthyroidism also tend to lose a lot of muscle, which is an additional headache if your cat has both CKD and hyperthyroidism. Dietary omega-3 fatty acid supplementation increases the rate of muscle protein synthesis in older adults: It concluded "Omega-3 fatty acids stimulate muscle protein synthesis in older adults and may be useful for the prevention and treatment of sarcopenia.

When considering a food for their CKD cats, many people focus on its phosphorus and protein levels, but it is also important to consider the calorie content, especially if you want your cat to keep on or gain weight and muscle. A healthy cat needs approximately calories per day per pound of body weight, or possibly more if the cat is particularly active. The National Research Council states that a lean adult cat weighing 5 lbs needs around calories a day, and a lean adult cat weighing 10 pounds needs around calories a day.

The World Small Animal Veterinary Association Global Nutrition Committee makes similar recommendations for the average healthy adult cat at a healthy weight. This level of intake is unlikely to be sufficient for older cats. In Feeding older cats - an update in new nutritional therapies Sparkes A Topics in Companion Animal Medicine 26 1 pp, Dr Sparkes states that older cats need more calories than younger cats, preferably in the form of protein. He adds that older cats also seem to do better when fed a diet containing prebiotics , antioxidants and essential fatty acids.

Many sources, including the National Research Council, also believe that chronically sick cats need more calories, possibly as many as twice the number of calories as healthy cats. So obviously, feeding a teaspoonful of food a day is not going to be enough to maintain your CKD cat's weight, let alone increase it if your cat is too thin. Another thing to consider is the water content of the food. Although increased fluid content can be helpful for CKD cats, who are at risk of dehydration, the downside is that such foods may make the cat feel relatively full while providing insufficient calories for the cat's needs.

This is often the case with simple foods that consist largely of meat or fish. Lower fat foods may also contain fewer calories. Therapeutic kidney diets are more calorie dense than standard maintenance diets.

You can check the calorie content of some US foods here canned and here dry. I am working on adding the calorie content to the UK food data tables. Stanley Marks discusses feline dietary and calorie needs in Diagnostic and therapeutic approach to the anorectic cat , Presentation to the World Small Animal Veterinary Association World Congress The ins and outs of managing feline chronic kidney disease Codi M Today's Veterinary Technician has a formula Box 1 for calculating the daily energy requirement for neutered CKD cats.

PetSci has a calorie calculator. Some manufacturers provide data about the metabolisable energy ME of their foods. With a higher ME, your pet's body will receive more energy from a smaller amount of food. This can be helpful for CKD cats who tend not to have much appetite. Food Composition and Requirements. The usual guidelines for CKD cats are to feed a diet which has added potassium and essential fatty acids but which has reduced levels of protein, phosphorus and sodium. It is helpful to understand the reasoning behind these recommendations.

If you asked most people what was the main nutritional step to take for a cat with kidney disease, they would probably say "feed low protein. This section discusses the role of protein in kidney disease and if and when to reduce the levels of protein which you feed. Protein is a molecular structure made up of a number of amino acids which are essential for the body to repair and maintain itself.

Cats have a higher need for protein than many other species because, unlike dogs or humans, they cannot manufacture certain of these amino acids e. These missing amino acids are only found in meat and corn gluten meal , and therefore cats must ideally eat meat in order to obtain these amino acids. This is why cats are known as obligate carnivores.

When people feed a cat a vegetarian diet which I definitely do not recommend for any cat , they provide these amino acids in the form of supplements, but cats are optimally designed to obtain them from meat. The National Research Council NRC guidelines indicate a minimum daily protein requirement and a recommended daily protein allowance of 2.

Let's crunch some numbers based on these recommendations:. These levels sounded low to me, and research indicates they probably are. The study states that " approximately 1. This study provides evidence that nitrogen balance studies are inadequate for determining optimum protein requirements.

Animals, including cats, can adapt to low protein intake and maintain nitrogen balance while depleting LBM. Loss of LBM and an associated reduction in protein turnover can result in compromised immune function and increased morbidity. The minimum daily protein requirement for adult cats appears to be at least 5. Further research is needed to determine the effect, if any, of body condition, age and gender on protein requirements.

On this basis, a 10lb 4. To complicate matters, older cats may have higher protein requirements. Pet Education has an overview of protein requirements in cats. Studies performed on humans and rats with CKD found that feeding reduced levels of protein appeared to be beneficial and might help prolong life.

Therefore researchers wondered if a lower protein intake might have a similar beneficial effect for cats. In many of the early studies in cats, the cats had a large percentage of their kidneys surgically removed in order to induce kidney failure; this is not the way kidney disease tends to develop in most cats, who usually have chronic kidney disease rather than acute kidney injury. Even so, the results were not necessarily what might have been expected. Some of the cats fed the high protein diet did develop transient hypokalaemia low potassium levels , which might have been because the low protein diet contained more potassium.

No real differences were seen after a year, and there was no change in GFR in any group. A vet from Ohio State University College of Veterinary Medicine stated with regard to this study "recent findings in cats with induced renal insufficiency suggest that feeding diets restricted in protein may not be necessary for this species.

In Effects of dietary p rotein intake on re nal f unction Supplement to Compendium on Continuing Education for the Practising Veterinarian 21 Dr Finco stated "the negative results from the second study indicate that protein restriction in cats with renal disease remains to be proven as an effective maneuver for ameliorating progression of renal disease". These studies seem to indicate that a reduced protein intake is not necessarily of any real benefit to CKD cats.

However, there are also some studies into the use of therapeutic kidney diets , which have reduced protein levels rather than extremely low protein levels along with other attributes ; and more sensibly, research began to focus on cats with naturally occurring CKD. In Survival of cats with naturally occurring chronic renal failure: Some of the cats presumably in both groups were also given phosphorus binders.

The cats fed the therapeutic kidney diet survived longer than the other cats, but it is not clear whether this was due to the reduction in phosphorus intake rather than the reduction in protein intake.

This is the first prospective dietary study involving naturally occurring feline CKD cases where survival from first diagnosis has been assessed. The studies described above were focusing on whether a reduced protein intake might slow the progression of kidney disease and help the cat live longer. The other issue is whether feeding reduced protein might help the cat feel better. This study found that feeding a therapeutic kidney diet helped to keep BUN levels lower and appeared to help prevent metabolic acidosis in cats with more advanced CKD.

Thus in this study the therapeutic kidney diet not only appeared to reduce the number of deaths, but the cats also exhibited fewer signs of illness.

This is because, during the breakdown of dietary protein in the digestive process, waste substances are created which are filtered out of the blood by the kidneys and excreted via urination.

This is sometimes referred to as the removal of nitrogenous wastes. Contrary to popular opinion, BUN and creatinine are not toxins themselves. However, BUN levels correlate with uraemic toxin levels, i. If you feed a reduced protein diet, this reduces the amount of nitrogenous wastes that must be processed by the kidneys.

This usually leads to a reduction in BUN levels and in turn the cat will often feel and act better. These clinical signs, that are often referred to as uremia, can be caused by an accumulation of the breakdown products of protein metabolism sometimes referred to as nitrogenous waste products.

This protein comes from both the protein in your animal's diet, as well as mobilization and degradation of their own body's protein stores. Consumption of protein in amounts greater than what your animal needs to maintain normal bodily functions can exacerbate these clinical signs. Anemia enhances the weakness and reluctance to eat in animals with renal failure.

Anemia can occur for several reasons with renal disease, but one factor that is believed to make it worse is excessive dietary protein. Nitrogenous waste products are believed to contribute to anemia by reducing the life span of red blood cells. The waste products may also enhance blood loss by leading to the formation of gastrointestinal ulcers and a reduction in blood clotting ability. It must also be remembered that when vets recommend therapeutic kidney diets, they are not only recommending reduced protein levels.

Therapeutic kidney diets have other attributes, for example reduced protein diets also tend to contain less phosphorus, and phosphorus control is extremely important in CKD cats. These foods also contain additional levels of potassium and essential fatty acids see below.

You can read more about the attributes of therapeutic kidney diets on the Which Foods to Feed page. Of course, nothing is ever simple when it comes to cats, so there are also potential downsides with reduced protein intake.

One common problem with reduced protein for cats, as you might expect, is weight loss. One study using healthy cats, Determining protein requirements: In study one, percent weight loss increased in a linear manner with decreasing protein intake. Feeding cats with different nutritional needs: As a result, there may or may not be weight loss, but there will be muscle wasting as well as a deterioration in the hair coat quality.

Because protein is component in antibodies, immune function may be compromised; anemia may be exacerbated due to the lack of building blocks for hemoglobin; albumin levels may decrease and tissue healing will be affected. Protein is a preferred flavour, so if a cat is already inappetant, restricting protein may result in inadequate intake of all nutrients, and the protein intake may fall below that required for normal function.

Slowing the progression of chronic renal failure Grauer GF states "There are, however, potential undesirable effects associated with dietary protein reduction. Reduced protein diets are also of concern for cats with metabolic acidosis, because, according to Nutrition and renal function in cats and dogs: Sufficient, High Quality Protein.

As discussed previously, during the breakdown of dietary protein in the digestive process, waste substances are created which are filtered out of the blood by the kidneys and excrete d via urination. Unfortunately damaged kidneys find it harder to do this, which is why your CKD cat may feel poorly.

You will note the reference to not feeding more protein than your cat's body needs to maintain normal function. This is the crux of the matter. You do not want to feed an extremely low level of protein so your cat suffers weight loss and malnutrition; but nor do you want to be loading your cat's body with unnecessarily high levels of protein which contribute to your cat feeling ill.

The goal in CKD is not to feed low protein or high protein. The goal is to feed sufficient protein with the correct balance and number of amino acids to maintain the cat's health and body weight, but in a form which needs as little breaking down as possible. When talking about CKD, that is what we mean by "high quality protein", not reaching for organic, high quality meat. In addition to the amount of protein, patients with CKD should receive protein of high biologic value.

For most people, the easiest way to achieve this is to feed a therapeutic kidney diet because these diets have a protein level in this range. This does not mean they are low protein foods. If you find your cat starts to exhibit weight or muscle loss, you could consider trying one of the therapeutic kidney diets with protein at the higher end of the suggested range.

A good choice would be egg whites. If you cannot persuade your cat to eat a therapeutic kidney diet see Which Foods to Feed for tips on how to do this , you can also check the food data tables to find other foods which are relatively low in protein; but don't forget the therapeutic kidney diets have other important attributes, and the protein they do contain is good quality from the CKD perspective, something which is not always easy to replicate with non-therapeutic kidney foods.

When To Feed Reduced Protein. IRIS Stages 1 and 2. Because of the potential downsides of protein restriction, it is not necessarily a good idea to feed reduced protein food in all cases.

However for cats with proteinuria , it states "feed a renal clinical diet" regardless of the stage the cat is in.

The study concludes "Our results suggest that cats with early renal insufficiency fed a test food designed to promote healthy aging, over a 6 month period, were more likely to have stable renal function evidenced by stable serum SDMA concentrations compared with cats fed owner's-choice foods.

It is also difficult to compare the effect of the therapeutic kidney diet because not enough is known about the alternative foods that were fed. Other vets believe that it is better to wait until the disease is more advanced before starting a therapeutic kidney diet. M anaging chronic diseases in cats Veterinary Medicine Little S states "Don't restrict dietary protein for cats experiencing mild to moderate chronic renal insufficiency creatinine 1.

These cats require adequate protein and calories to maintain body weight and to avoid muscle wasting and anemia. If your cat also has hyperthyroidism, it can be even more of a concern since hyperthyroid cats are prone to weight loss and muscle wasting.

Diet and nutritional management for hyperthyroid cats Peterson ME the man who discovered hyperthyroidism in cats states that "The major problem that I have with some of the prescription kidney diets is that they restrict protein to the point that some cats — especially those with concurrent hyperthyroidism —will continue to catabolize their own muscle mass despite adequate control of the thyroid condition.

Unfortunately, it can often be easier to switch a cat to a reduced protein diet when the cat is stable with lower numbers. Treatment recommendations for CKD in cats International Renal Interest Society says that introducing a therapeutic diet "may be accomplished more easily early in the course of CKD, before inappetance develops.

If you are concerned, consider adding foods with high biologic value but minimal nitrogenous waste to your cat's therapeutic kidney diet. If you decide not to feed reduced protein to your CKD cat, please do ensure that your cat has a low phosphorus intake and an increased essential fatty acids intake.

IRIS Stages 3 and 4. Cats who are in Stages 3 and 4 would therefore also be advised to eat a therapeutic kidney diet. Another factor to consider is your cat's BUN level. Since BUN is influenced by protein intake, it does often help the cat feel better if you restrict protein intake as your cat's BUN levels rise.

In Slowing the progression of chronic renal failure Dr GF Grauer states that "As the renal failure progresses, additional dietary protein reduction will likely be necessary. You may panic if you cannot get your cat to eat a reduced protein food. Take a deep breath. M anaging chronic diseases in cats Veterinary Medicine Little S states "Never try to force an anorexic patient with chronic renal insufficiency to eat a protein-restricted diet.

Instead, concentrate on encouraging anorexic patients to eat. See the Which Foods to Feed page for more tips on getting your cat to eat the therapeutic kidney diet and what to do if you can't succeed. Consider feeding tube intervention e. See the Persuading Your Cat To Eat page for more information on feeding tubes and tips on getting your cat to eat. Whatever you do, monitor your cat's weight and muscle status closely. Controlling phosphorus levels is extremely important for CKD cats, because high phosphorus levels are very damaging to their health and can make the disease progress more quickly.

This is such an important topic that I have an entire page devoted to phosphorus control. Please read it and do everything you can to keep your cat's phosphorus levels low - it can make all the difference to your cat's wellbeing and can also prolong survival. Just as cats need a diet relatively high in protein, so they also need relatively high levels of fat compared to a human or dog.

Older cats may process fat less efficiently than younger cats, which may be a factor in weight loss. Fat does not result in a lot of waste products like protein, so processing it is not a strain on the kidneys; plus cholesterol is not an issue for cats the way it is for humans.

Studies indicate that cat foods containing even higher amounts of fat are safe. In most therapeutic kidney foods, the fat content is increased to compensate for the lower protein levels. Some senior cat foods also have relatively high levels of fat and relatively low levels of protein; as a bonus, they often also have low phosphorus levels. Therefore, if your cat won't eat a therapeutic kidney diet, it is worth considering senior foods, although do check the protein level is not too low.

The kidneys cannot process sodium as effectively in CKD, which increases the risk of hypertension high blood pressure in humans. It used to be thought that the same applied to cats, and it was therefore recommended that sodium intake should be restricted. Research in Applied Veterinary Medicine 7 4 pp found that sodium intake appeared to have no effect on in blood pressure in CKD cats, but that levels of BUN, creatinine and phosphorus were higher in the cats eating a high sodium diet compared to those eating a low sodium diet.

Even in cats with creatinine over 1. These results are consistent with the majority of other studies evaluating sodium intake in cats, as well as with the National Research Council's assessment, all of which indicate that sodium at 1. Effects of dietary salt intake on renal function: The study concludes "The results of this 2 year study do not support the suggestion that chronic increases in dietary salt intake are harmful to renal function in older cats.

Increased dietary sodium increases urine output and may decrease the risk of forming calcium oxalate uroliths due to the decrease in relative supersaturation of solutes. However, caution should be used in increasing the sodium intake of patients with renal disease as increased dietary sodium may have a negative effect on the kidneys independent of any effect on blood pressure.

So should you restrict sodium intake or not? Treatment recommendations for CKD in cats International Renal Interest Society states on page 5 that there is no evidence that reducing sodium intake is helpful for CKD cats, and that it should certainly not take the place of medication for hypertension , but if you do opt to reduce your cat's sodium intake, you should do it gradually.

The food data tables provide information about the sodium content of many cat foods available in the USA and UK. This occurs because potassium is easily lost through increased urination and vomiting.

Therapeutic kidney diets contain extra potassium all cat foods need some potassium , and this is usually in the form of potassium citrate, because potassium citrate may help with a problem seen in some CKD cats called metabolic acidosis.

If your cat refuses to eat a therapeutic diet, your vet can give you a potassium supplement instead, if appropriate; some cats need a potassium supplement whether or not they eat the therapeutic kidney diet. Many commercial cat foods are acidified in order to reduce the risk of FLUTD feline lower urinary tract disease.

These foods often say that they are designed to maintain urinary tract health; or they may contain cranberries or additional Vitamin C. However, these foods which are actually designed to treat a different kind of problem to CKD may have the effect of increasing the amounts of potassium lost in the urine, which is bad for CKD cats. It is therefore best not to feed acidified foods to CKD cats, who tend to have quite high acid levels anyway.

Please see the Potassium page for more information about potassium. It also states "Our analysis indicates that cats have a ceiling for carbohydrate intake, which limits ingestion and constrains them to deficits in protein and fat intake relative to their target on high-carbohydrate foods. In The carnivore connection to nutrition in cats Zoran D Journal of the American Veterinary Medical Association pp, Dr Zoran writes "It is clear that cats have a greater need than dogs or other omnivores for protein in their diet.

Cats also have several physiologic adaptations that reflect their expected low CHO [carbohydrate] intake These specific differences do not mean cats cannot use starch. In fact, cats are extremely efficient in their use of simple sugars. However, it does underscore their development as carnivores and the expected low amounts of grain in their typical diet. These digestive differences may mean that high amounts of CHO in diets may have untoward effects on cats. Therefore, if you are trying to reduce your CKD cat's protein intake, I would recommend increasing the fat in the diet see above rather than the carbohydrates.

If you are feeding a therapeutic kidney diet, this will often be done automatically - many of these diets increase the fat content rather than the carbohydrates in order to offset the reduced protein content. Pet Education has an interesting article about carbohydrates in the feline diet. Fibre is the non-digestible component of complex carbohydrate. It is important for good digestive health. Increased fibre may help with elevated calcium levels in the body hypercalcaemia , although one type of fibre, fructooligosaccharides or FOS, may actually increase calcium levels in the body see below.

It may also assist with two commonly seen CKD problems, toxin reduction and the control of constipation. There are a number of ways of categorising fibre types, but one way is to divide it into fermentable and non-fermentable. Which fibres are fermentable depends upon the species of bacteria eating the fibre in the cat's gastrointestinal tract.

Diet and large intestinal disease in dogs and cats JW Simpson The Journal of Nutrition SS has a table showing soluble and fermentable fibres. In terms of general health, you do not necessarily want the most fermentable fibres. Dietary fiber for cats: It concludes that the diet "which contained the most fermentable fibers, severely decreased nutrient digestibility and resulted in poor stool characteristics.

Diets that contain moderately fermentable fiber provide fermentation end products that may be important in maintaining the health of the gastrointestinal tract of the cat.

There has long been interest in whether other bodily mechanisms might be useful for relieving the load on damaged CKD kidneys. Bowel as a substitute in renal failure EA Friedman American Journal of Kidney Diseases 28 6 pp states "Extraction, modification, or recycling of nitrogenous wastes by the gastrointestinal tract is a potentially low-cost means of substituting for missing renal function.

Multiple approaches to the bowel as a substitute kidney have been attempted. One way of doing this may be via increased fibre intake in the form of fermentable fibre prebiotics. Fermentable fibre provides a source of carbohydrate for the bacteria in the gut. These bacteria, which are essential to health, increase in number when provided with additional fermentable fibre, and the more bacteria there are, the more nitrogen is excreted in the faeces.

This increased faecal excretion may help to reduce the load on the kidneys by diverting the excretion of urea from the kidneys. You can read more about this in the Treatments chapter. Non-fermentable fibre can be helpful for CKD cats because it reduces the risk of constipation, a common problem in CKD cats, by holding water in the stool.

Thus, when organ failure develops, several agents will have to be titrated or discontinued. For the dying patient, most agents for type 2 diabetes may be removed. There is, however, no consensus for the management of type 1 diabetes in this scenario 23 , Although hyperglycemia control may be important in older individuals with diabetes, greater reductions in morbidity and mortality are likely to result from control of other cardiovascular risk factors rather than from tight glycemic control alone.

There is strong evidence from clinical trials of the value of treating hypertension in older adults 25 , There is less evidence for lipid-lowering therapy and aspirin therapy, although the benefits of these interventions for primary prevention and secondary intervention are likely to apply to older adults whose life expectancies equal or exceed the time frames of the clinical trials.

Special care is required in prescribing and monitoring pharmacologic therapies in older adults Cost may be an important consideration, especially as older adults tend to be on many medications. Metformin is the first-line agent for older adults with type 2 diabetes.

However, it is contraindicated in patients with advanced renal insufficiency or significant heart failure. Metformin may be temporarily discontinued before procedures, during hospitalizations, and when acute illness may compromise renal or liver function. Thiazolidinediones, if used at all, should be used very cautiously in those with, or at risk for, congestive heart failure and those at risk for falls or fractures.

Sulfonylureas and other insulin secretagogues are associated with hypoglycemia and should be used with caution. If used, shorter-duration sulfonylureas such as glipizide are preferred. Glyburide is a longer-duration sulfonylurea and contraindicated in older adults Oral dipeptidyl peptidase 4 inhibitors have few side effects and minimal hypoglycemia, but their costs may be a barrier to some older patients.

A systematic review concluded that incretin-based agents do not increase major adverse cardiovascular events Glucagon-like peptide 1 receptor agonists are injectable agents, which require visual, motor, and cognitive skills. They may be associated with nausea, vomiting, and diarrhea.

Also, weight loss with GLP-1 receptor agonists may not be desirable in some older patients, particularly those with cachexia. Sodium—glucose cotransporter 2 inhibitors offer an oral route, which may be convenient for older adults with diabetes; however, long-term experience is limited despite the initial efficacy and safety data reported with these agents.

The use of insulin therapy requires that patients or their caregivers have good visual and motor skills and cognitive ability. Insulin therapy relies on the ability of the older patient to administer insulin on their own or with the assistance of a caregiver. Insulin doses should be titrated to meet individualized glycemic targets and to avoid hypoglycemia.

Once-daily basal insulin injection therapy is associated with minimal side effects and may be a reasonable option in many older patients. Multiple daily injections of insulin may be too complex for the older patient with advanced diabetes complications, life-limiting comorbid illnesses, or limited functional status. The needs of older adults with diabetes and their caregivers should be evaluated to construct a tailored care plan.

Social difficulties may impair their quality of life and increase the risk of functional dependency Social and instrumental support networks e.

Older adults in assisted living facilities may not have support to administer their own medications, whereas those living in a nursing home community living centers may rely completely on the care plan and nursing support.

Those receiving palliative care with or without hospice may require an approach that emphasizes comfort and symptom management, while deemphasizing strict metabolic and blood pressure control. Management of diabetes in the long-term care LTC setting i. Individualization of health care is important in all patients; however, practical guidance is needed for medical providers as well as the LTC staff and caregivers The American Medical Directors Association guidelines offer a step program for staff This training includes diabetes detection and institutional quality assessment.

The guidelines also recommend that LTC facilities develop their own policies and procedures for prevention and management of hypoglycemia. Staff of LTC facilities should receive appropriate diabetes education to improve the management of older adults with diabetes. Treatments for each patient should be individualized. Special management considerations include the need to avoid both hypoglycemia and the metabolic complications of diabetes and the need to provide adequate diabetes training to LTC staff 3 , An older adult residing in an LTC facility may have irregular and unpredictable meal consumption, undernutrition, anorexia, and impaired swallowing.

Furthermore, therapeutic diets may inadvertently lead to decreased food intake and contribute to unintentional weight loss and undernutrition. Older adults with diabetes in LTC are especially vulnerable to hypoglycemia. They have a disproportionately high number of clinical complications and comorbidities that can increase hypoglycemia risk: Another consideration for the LTC setting is that unlike the hospital setting, medical providers are not required to evaluate the patients daily.

According to federal guidelines, assessments should be done at least every 30 days for the first 90 days after admission and then at least once every 60 days. Although in practice the patients may actually be seen more frequently, the concern is that patients may have uncontrolled glucose levels or wide excursions without the practitioner being notified. Providers may make adjustments to treatment regimens by telephone, fax, or order directly at the LTC facilities provided they are given timely notification from a standardized alert system.

Low finger-stick blood glucose values should be confirmed by laboratory glucose measurement. Call as soon as possible: The management of the older adult at the end of life receiving palliative medicine or hospice care is a unique situation.

Overall, palliative medicine promotes comfort, symptom control and prevention pain, hypoglycemia, hyperglycemia, and dehydration and preservation of dignity and quality-of-life in patients with limited life expectancy 34 , A patient has the right to refuse testing and treatment, whereas providers may consider withdrawing treatment and limiting diagnostic testing, including a reduction in the frequency of finger-stick testing Glucose targets should aim to prevent hypoglycemia and hyperglycemia.

Treatment interventions need to be mindful of quality of life. Careful monitoring of oral intake is warranted. The decision process may need to involve the patient, family, and caregivers, leading to a care plan that is both convenient and effective for the goals of care The pharmacologic therapy may include oral agents as first line, followed by a simplified insulin regimen. If needed, basal insulin can be implemented, accompanied by oral agents and without rapid-acting insulin.

Agents that can cause gastrointestinal symptoms such as nausea or excess weight loss may not be good choices in this setting. As symptoms progress, some agents may be slowly tapered and discontinued. Strata have been proposed for diabetes management in those with advanced disease There is very little role for A1C monitoring and lowering.

A patient with organ failure: Dehydration must be prevented and treated. In people with type 1 diabetes, insulin administration may be reduced as the oral intake of food decreases but should not be stopped. For those with type 2 diabetes, agents that may cause hypoglycemia should be titrated. The main goal is to avoid hypoglycemia, allowing for glucose values in the upper level of the desired target range. In patients with type 1 diabetes, there is no consensus, but a small amount of basal insulin may maintain glucose levels and prevent acute hyperglycemic complications.

In Standards of Medical Care in Diabetes— Diabetes Care ;40 Suppl. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at http: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail.

We do not capture any email address. Skip to main content. Diabetes Care Jan; 40 Supplement 1: Recommendations Consider the assessment of medical, mental, functional, and social geriatric domains in older adults to provide a framework to determine targets and therapeutic approaches for diabetes management. C Screening for geriatric syndromes may be appropriate in older adults experiencing limitations in their basic and instrumental activities of daily living, as they may affect diabetes self-management and be related to health-related quality of life.

C Annual screening for early detection of mild cognitive impairment or dementia is indicated for adults 65 years of age or older. B Hypoglycemia should be avoided in older adults with diabetes. B Older adults who are cognitively and functionally intact and have significant life expectancy may receive diabetes care with goals similar to those developed for younger adults.

C Glycemic goals for some older adults might reasonably be relaxed using individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients.

C Screening for diabetes complications should be individualized in older adults. C Treatment of hypertension to individualized target levels is indicated in most older adults. C Treatment of other cardiovascular risk factors should be individualized in older adults considering the time frame of benefit.

E When palliative care is needed in older adults with diabetes, strict blood pressure control may not be necessary, and withdrawal of therapy may be appropriate. E Consider diabetes education for the staff of long-term care facilities to improve the management of older adults with diabetes. E Patients with diabetes residing in long-term care facilities need careful assessment to establish glycemic goals and to make appropriate choices of glucose-lowering agents based on their clinical and functional status.

E Overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity are primary goals for diabetes management at the end of life. E Diabetes is an important health condition for the aging population; approximately one-quarter of people over the age of 65 years have diabetes 1 , and this proportion is expected to increase rapidly in the coming decades.

View inline View popup. Healthy Patients With Good Functional Status There are few long-term studies in older adults demonstrating the benefits of intensive glycemic, blood pressure, and lipid control. Patients With Complications and Reduced Functionality For patients with advanced diabetes complications, life-limiting comorbid illnesses, or substantial cognitive or functional impairments, it is reasonable to set less intensive glycemic goals. Vulnerable Patients at the End of Life For patients receiving palliative care and end-of-life care, the focus should be to avoid symptoms and complications from glycemic management.

Beyond Glycemic Control Although hyperglycemia control may be important in older individuals with diabetes, greater reductions in morbidity and mortality are likely to result from control of other cardiovascular risk factors rather than from tight glycemic control alone. Metformin Metformin is the first-line agent for older adults with type 2 diabetes. Thiazolidinediones Thiazolidinediones, if used at all, should be used very cautiously in those with, or at risk for, congestive heart failure and those at risk for falls or fractures.

Insulin Secretagogues Sulfonylureas and other insulin secretagogues are associated with hypoglycemia and should be used with caution. Incretin-Based Therapies Oral dipeptidyl peptidase 4 inhibitors have few side effects and minimal hypoglycemia, but their costs may be a barrier to some older patients. Sodium—Glucose Cotransporter 2 Inhibitors Sodium—glucose cotransporter 2 inhibitors offer an oral route, which may be convenient for older adults with diabetes; however, long-term experience is limited despite the initial efficacy and safety data reported with these agents.

Insulin Therapy The use of insulin therapy requires that patients or their caregivers have good visual and motor skills and cognitive ability. Other Factors to Consider The needs of older adults with diabetes and their caregivers should be evaluated to construct a tailored care plan. Resources Staff of LTC facilities should receive appropriate diabetes education to improve the management of older adults with diabetes. Nutritional Considerations An older adult residing in an LTC facility may have irregular and unpredictable meal consumption, undernutrition, anorexia, and impaired swallowing.

Hypoglycemia Older adults with diabetes in LTC are especially vulnerable to hypoglycemia. The following alert strategy could be considered: National diabetes statistics report: Accessed 21 November Depression and all-cause mortality in persons with diabetes mellitus: J Am Geriatr Soc ; Diabetes in older adults. Diabetes Care ; Cognitive decline and dementia in diabetes--systematic overview of prospective observational studies. Diabetologia ; Association of type 2 diabetes with brain atrophy and cognitive impairment.

Neurology ; Drug Des Devel Ther ; 7: Intranasal insulin therapy for Alzheimer disease and amnestic mild cognitive impairment:

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