Good afternoon. My name is Natalie Delerey, and I am the head of ISFM. Today, I'm going to be talking to you about feline healthy ageing, and specifically around how to support the mature or middle-aged cat.

Some of the work that I'm going to be presenting to you today comes from my work for my PhD at the University of Liverpool, and I'm still working there one day a week as a postdoc on that research project with the feline Healthy ageing Clinic. So we're going to start just by really talking about what is ageing and ageing really is the process of growing older. It's become quite a focus of intense research in recent times, especially within the human field, and we're really starting to develop quite a good understanding of some of the biological processes of ageing and how these can be manipulated as well.

Geriatric medicine really is sort of a focus on the progression and management of age-related diseases, whereas healthy ageing, really is the process of growing older in the absence of some of these age-related diseases. Now, I'm sure many of you are familiar with the IFM feline life stage chart. Previously, we used to refer to all cats over 15 years of age as being geriatrics, but in line with what's happening in the human medical field, there's now a real sort of movement to be referring to healthy cats over 15, as what we've dubbed super seniors, and really reserving the term.

Geriatric, for cats that have started to develop age-related diseases. And whilst these sort of age-related diseases do become more common in cats that fall into the senior and super senior categories, and they really can start to occur from younger age ranges, so from 7 years of age and onwards. The average lifespan currently for a cat in the UK is around sort of 14 years of age.

However, they do have the potential to live up to 30 years of age. So the goal really when we're trying to manage ageing is to be extending the period of, of healthy lifespan. And to do this, the goal is to delay the development of age-related diseases in the first place and then to be slowing down the progression of these age-related diseases.

And if we're able to achieve that, then we, we really have the potential to be extending first the healthy lifespan, which is probably the most important in terms of welfare, but also just to be extending the potential lifespan as well, out past that, that 14 years of age average. And I do suspect that over time in the future, the average lifespan of, of our pet cats in the UK will be extending in line with us. So when we sort of talk about the biology of ageing, I will just give you a sort of quick whistle stop tour into the ageing process and what's going on with that.

This really is sort of coming from a sort of a sort of human research field, but hopefully I'll introduce just some of the points that we do know about feline ageing with regards to that. There was a quite a sort of very well-known paper published in Cell in 2013 around the hallmarks of ageing, and these hallmarks are used now quite commonly because it just helps structure some of the biological ageing processes that are going on. So the first sort of four processes of ageing that we're going to talk about, genomic instability, telomere attrition, epigenetic alterations, and the loss of proteostasis, are considered sort of primary hallmarks of ageing as they really do cause tissue damage.

Genomic instability, really increases the risk of, of cancers forming. And in cats, the most common example really of this, that we recognise in our older cats probably is actually hyperthyroidism. Whilst it's an endocrine disease, it is the result of, usually a benign tumour of the thyroid gland.

So it's in some ways it is quite a good example of, of one of these sort of biological ageing processes that increases the risk of development of, of what we recognise as an age-related disease in cats. Telomere attrition, is also a process that really does contribute to genomic instability. But because it is quite an important process, it's, it's given its own sort of separate hallmark.

Telomeres are the protective caps that sit on the end of chromosomes, and the shown to shorten with age across multiple species to the point that they are actually used as a biological clock within tissues of ageing, and so can create a sort of separate to the chronological age of a species that enables a way for a biological age to also be calculated. And cats with chronic kidney disease have been shown to have telomere attrition. So it's definitely a process that's occurring within our cats, that may also be contributing to some of the, the age-related diseases that we see.

Epigenetic alterations are things that alter how genes are expressed, and they are the result of both external and internal factors. They are heritable, so they can be passed along through generations, but probably the most interesting thing about epigenetic alterations is that they can potentially be reversed. So when we come to the next slide, when I talk just briefly around interventions, epigenetic alterations are a very popular area of research because of this, this ability for them to be reversed.

And then the last one in these, in the sort of first group is loss of proteostasis. And with ageing, proteins can become misfolded and can lead, their accumulation can lead to disease processes in people such as Alzheimer's and Parkinson's, and also cataract formation as well. So some of the, the sort of common age-related diseases that we see.

In people. And cats, we have obviously seen amyloid accumulation in the pancreas associated with diabetes, and also amyloidosis is not uncommon on postmortem in cats with chronic kidney disease as well. So some of these misfolded protein accumulation does also have an impact on feline ageing too.

The next three hallmarks are really antagonistic hallmarks, and their responses to, to the damage that's caused by some of these, these sort of primary hallmarks. Initially, what they are often trying to do is mitigate some of this damage, but over time, they themselves can actually become damaging. And the first one on this list is around deregulated nutrient sensing.

And one of the, the sort of common pathways that gets talked about in this area is the insulin and insulin-like growth factor signalling pathway. It's very well conserved through evolution, and manipulations of this pathway, have really strongly been associated with longevity in other species. The next one on this list is mitochondrial dysfunction, and it has been shown to lead to accelerating ageing in some mammals.

But as, as of this time, improving mitochondrial function has not yet been shown to extend longevity, so there's still quite a lot of research to be done with this particular hallmark. And then the last one on this, this sort of group is cellular senescence, and senescent cells are cells that no longer grow or divide. The accumulation of senescent cells is is occurring through both increased production, so more senescent cells forming, but also through Decreased clearance, and this decreased clearance is often associated with changes that are occurring in the body's immune system.

And the accumulation of senescent cells also leads to a pro-inflammatory state due to markers that the senescent cells are secreting. So they are contributing to some of the pro-inflammatory states that do occur with ageing. And then the final two hallmarks, stem cell exhaustion and altered intracellular communication, really are the end result of all of these other hallmarks, and they are the ones that ultimately lead to functional decline associated with ageing.

So stem cell exhaustion really reduces the regenerative capacity of tissues, and the altered intracellular communication. Leads to this regulation of tissue signalling, and this in turn further exacerbates some of these pro-inflammatory states that are occurring within the body's tissues, and it's also reducing the immuno surveillance ability of the body as well. And I think it's probably quite timely that we're discussing this, given we're in the middle of a, of a pandemic situation, .

And the, the virus that we're currently dealing with around the world is having quite a severe impact on both the ageing population and also people with, with some pre-existing conditions. And some of the reactions that we're seeing around coronavirus really do fit in with potentially some of these changes that have already occurred within the body of ageing people that, that may seem to, to sort of be making them more susceptible due to both the reduced ability in terms of their immune system to be able to clear the environment, but also the, the pro-inflammatory states and cascades that seem to be occurring, within, this particular virus's effect on the body too. So.

Definitely ageing, unfortunately does seem to be making people more susceptible to the effects of, of coronavirus. Really part of the reason why, ageing as a, as a process has become an exceedingly popular area of research. As people are looking for, for the, the mythical fountain of youth, and people are looking at sort of interventions that can be performed, to, to extend lifespan, but also, realistically healthy lifespan is, is really the main thing that we want.

We, we do maybe want to be living longer, but most of us would be choosing, to be living a healthy period of time for longer rather than just length. And the first sort of area that that really has shown the most promise is around loric restriction and dietary energy restriction. And some of these intermittent fasting regimes, also really fit into, into this sort of process as well.

And this sort of area of research, has been shown to increase lifespan across quite a number of model species. It's been shown to improve the deregulated nutrient sensing pathway, improving protein formation. Reducing genomic instability, reducing telomere shortening, improving autophagy, improving insulin sensitivity, reducing oxidative damage to the mitochondria, and also reducing chronic inflammation, by affecting intracellular communication.

So, this sort of area of interventions, really is impacting on a lot of the hallmarks of ageing. And the next one that has also shown huge benefit is around exercise and high intensity training, and that's been shown to reduce mitochondrial dysfunction, improve muscle mass, improve insulin sensitivity, and also reduce chronic inflammatory states that start to occur within the sort of altered intracellular communications. So sadly, diet and exercise, unsurprisingly, in some ways, are really the main things that have been shown to have the best impact on ageing across people, but also across a lot of the model species that are used for ageing studies as well.

So, in, in sort of regards to this, obviously people sometimes aren't the best in terms of, of this sort of caloric restriction and exercise, because we have known for a long time there are benefits around this, but we're not so good sometimes at following through of this. So within the ageing world, they're also really trying to look at interventions that may activate some of these biological pathways without us necessarily having to put the hard work in. And I've sort of grouped these under nutraceuticals, but some of them, they fit the way we use the term nutraceutical in the veterinary world, and some of them are also licenced drugs as well that are used for other things that have been shown to have some benefit for ageing.

The first one on the list is reversatrol, which is a natural product that is found in quite a lot of foods. Blueberries especially are one of the The ones that get sort of marketed in health food shops around being a source of reversatrol. The evidence really is quite inconclusive at this, at this time around its benefits, but there is some evidence that it may help in people around cardiovascular disease.

The next one on the list is Metformin, and it's actually a licenced oral hypoglycemic medication, that's used in people for type 2 diabetes. And there was quite a bit of work around it because initially it was shown to reduce the accumulation of senescent cells, so it showed quite a bit of promise in that area. But to date, the evidence really for its benefits is still quite low.

The third one on the list, rapamycin, is the one where currently there's been quite a bit of interesting research going on. Rappamycin really helps mimic some of the positive aspects of caloric restriction through activating some of the pathway around the insulin insulin-like signalling pathway. And to date there has been a small study in the states using rapamycin in dogs, which has been shown that at least over a short period of time, I think if I remember correctly, it was used for 12 weeks.

It's been shown to improve cardiac output. And there is hopefully now a larger study that was supposed to get underway this year in the States, again, looking at rapamycin and dogs over a longer period of time. I'm not sure how much the impact of coronavirus will have on whether or not the study was able to start.

But hopefully we'll be getting some results coming from that in the coming years, which, which is going to be very interesting to see. The group that's doing that has also done some work with rapamycin in mice. One of the things I found really interesting from their study was around improvement of periodontal bone, so it's sort of loss of periodontal bone with ageing in mice.

Contributes to obviously the dentition and you can picture that poor teeth in mice is obviously going to lead to decline with age. And I, I found that especially interesting because dental disease is often a problem with our older animals as well. So it will be interesting to see whether or not from the dog study we do start to, to get an improvement with periodontal health as well.

And then the final one on the list around nutraceuticals that are showing sort of promising results, is with spermatidine, and a lot of the foods that that fall into the, the Mediterranean diet category of foods are very rich in spermatidine. And again, it's been shown to improve autophagy, and so through that clearance of senescent cells, and again, some of its effects are mimicking some of the pathways that caloric restriction and also improves as well. And there's a bit of evidence out there to show that it does have a beneficial effect in people with cardiovascular disease and also some types of cancer as well.

So that was a bit of a whistle-stop introduction around the biology of ageing, but I'll now move back sort of more into the veterinary world. And when we sort of start to consider cats and their risk of development of age-related diseases, a lot of the disease conditions that we really consider to be sort of more age-related than cats, they start to really be at increased risk of them from sort of 8 to 10 years of age, for the ones that that we sort of think of quite commonly. And then within things like diabetes, the risk starts to increase from about 6 years of age, but as I'm sure many of you know, there are other factors that also increase the risk of diabetes, especially around the weight of the cat.

Likewise, the risk of osteoarthritis and degenerative joint disease starts to increase from about 6 years of age, heart disease from over 9 years of age, and then the risk of cancer, really increases, odds increase with each year of life, basically. So your risk of developing cancer in a cat increases every year that they live up until about 16 years of age, and then the risk sort of plateaus after that. And the final one as well, it's a bit of a contentious debate whether or not obesity is a disease, but I think it is something that we do have to consider.

And the risk of obesity in cats really does start to increase from sort of 7 to 12 years of age. So I think it is important that we do include that. As sort of an age-related disease because it is something that we, we do need to be aware of, and then doing the best that we can, as vets to try and reduce the risk of obesity developing, because once it's developed, it, it's been harder, it's always harder to lose the weight in some ways than it is to prevent gaining it in the first place.

So the, the biological processes that really lead to the physical appearance of ageing and the development of the age-related diseases are really starting to occur from 7 years of age. So whilst the sort of presence and our recognition of these disease states. Tend to be a little bit later.

What's underpinning them is, is really starting to occur from around 7 years of age. So I think that is something that we do have to have to be keeping in our mind when we're, we're sort of organising our regular examinations of our pet cats. Just a little bit further on obesity, this was some work that came out in 2010, but I just think it illustrates quite nicely, this is from a feeding colony of cats that were followed for their life expectancy, and you can see that on their weight, they were sort of really starting to peak with their body weight and that sort of 1910 years of age mark.

But in some ways, more interestingly, around the body condition score, you can see most of them were kind of maintaining a reasonably healthy weight up until around sort of 7 years of age. They were maintaining their body condition score, you know, between 5, which is sort of ideal, and 6, which is getting a little bit heavy. But, but at least they were sort of within what we would consider a healthy weight range.

And then that really started to increase from sort of 8 to 9 years of age, with them sort of becoming overweight between that sort of 7 to 12 age range and then obviously weight loss starting to occur after that with ageing. So in terms of what we can do, really, I think the most important thing for us as vets is to be performing regular physical examinations of our, of our pet cats. And at ISFM we do have a programme called Cat Care for Life.

So the website's up there, it's free to access, and it just gives some, some really good information about frequency of visits and the kind of things that you should be considering with your pet cats, and we really are encouraging that all cats should be seen yearly. And that you should be doing some core sort of measures around them at each of those appointments. And to me, the sort of area to really highlight is this mature category.

So these are the cats. That are middle aged, so they're aged between 7 years up to 11 years. And it's definitely important to, to be seeing them each year and to be including within that examination, a good thorough physical examination, and to be assessing their weight and their body condition score and asking questions about what they're being fed, I think is, is very important to be included in this time range.

The Cat Care for Life programme, is obviously very, very detailed and really sums up if you're able to do everything on those assessments, it really is a gold standard examination for pet cats. I think realistically, most of us do work in practises where we may not have the resources within our practise to be able to provide that gold standard level of care, but we may also be dealing with a client population that may not be invested. In providing that gold standard level of care for their cats, but may just also not have the financial resources to be able to do it as well.

And so, for me, really, the, the key things that we, we do really need to be including, especially at middle age, is just getting them into the clinic on a regular basis for a good thorough physical examination. I think you can tell a lot if you're able to have that time to really examine a cat, make sure you're performing an oral examination and a dental examination. Make sure you're weighing them.

I'm sure Sarah Kaney will have covered this in her lecture, but if you're weighing the cat, please write the weight down. There's nothing more frustrating than having a cat presented for weight loss, and you look back through the records and you know the cat was weighed, but no one's written the weight down. .

And I also do really like to include a body condition score because I think that helps you interpret the weight to the individual cat. Because we all know that there's a, there's a relatively wide range of weights that we see from our pet cats. Some cats are very healthy at 3 kg.

Some cats at 3 kg will be in a very poor physical state. So a body condition score does really help us interpret that and the sort of ratio of the weight and the fat distribution. Of, of the cat, helps us really understand what that weight means.

And in addition to that, I also really like to include some description of muscle condition as well, because I do think this is important for us to be understanding the weight, the distribution of fat, and also the muscle condition, especially at middle age. Because I think it helps us really understand changes that might then be occurring as the cat moves through to the senior age range. The pictures that I've included in this slide actually come from WSAVA, and they are freely available from their website to download.

Body condition scoring, I think is a really useful thing to be including regularly, as I've said. I had to have a little bit of further training in it when I started my PhD project at Liverpool. I, I thought I was reasonably onto it with body condition scoring.

I've worked in shelters for quite a long time, prior to this, where we did body condition score regularly our shelter cats. But actually, I was being too nice. So I was probably underscoring cats that are sort of around the body condition score of 6, especially to be polite to their owners, .

And part of the reason why I, I've included the WSAVA one is that it does go up to 9. I think if you're using a 1 to 5 body condition score, you'll be using a lot of halves and quarters. It's very tricky sometimes not to want to say that a cat has body condition score 6.5, but what I was taught by the, the staff over at the weight management clinic at Liverpool is, if you think a cat is a 6.5, you need to call it a 7.

And so I, I think we do probably need to, to be a little bit firmer, with our owners. We can still be polite, but we probably do need to be firmer with them, around the reality, especially with these middle-aged cats, which I'll come to a little bit later with some of the data from our enrollment into the feline healthy ageing clinic, but it is very important I think to to, to, to be realistic around the weight gain. The reason why I like to include muscle condition score as well is, especially with some of these conditions that we're looking out for, hyperthyroidism being, being one of the more common ones is, especially if you're catching hyperthyroidism early, you may not actually have a very dramatic change in their body weight, but you can start to get some very subtle changes with muscle condition if you're looking out for it.

So. Their, their actual physical weight may have only changed by 200, 300 grammes, so not a huge change, especially for, for some of these cats that are on the, the chunkier side of middle age. But if you're palpating their muscle, you may start to notice just a subtle sort of shift in their muscle condition.

So I do think that's a really useful thing to be looking out for. One of the other things I like to be looking out for with muscle condition score actually relates to the development of osteoarthritis as well. So you will start to sometimes see muscle wastage, especially around the hind limbs, more associated with, with the development of, of OA rather than actual changes, other, other changes that may be related more to, to their weight.

So within these appointments, doing a really thorough physical examination, make sure you're recording the details and then have a discussion around the diet, around vaccination, what's going to be appropriate for this cat at their particular life stage, and also around parasite control as well. It still surprises me the number of cats that come in with fleas, given how advanced we've become in the last, well, during the course of my career actually around our options for flea control, and there's still a lot of fleas out there. So it's important to make sure you're including that in your discussion as well.

But my reasons for sort of going on a little bit about this is, you know, really the biggest resource that you're offering at that point is, is time, so making sure that you're scheduling an appropriate length of, of appointment time on an annual basis, within your, your routine veterinary appointments for, for following up on these cats. Giving the time that you need to be able to examine them is, is really important. And I will come to it a little bit later about also potentially including a six-month check with the nurses.

But I do think that's important, especially with the middle-aged cat, with regards to changes in their weight and their body condition score and also around dental disease as well. I think it's really useful to be factoring in a 6 month checkup with, with the middle-aged cat as well, to just start to get on top of changes around weight again, to be trying to prevent obesity from developing. With regards to, to getting the most out of your appointment, this is just a quick plug around a cat-friendly clinic, which is a programme that we have introduced with ISFM.

As I'm sure many of you know, examining a cat, if the cat does not want to be examined. It can be very unrewarding. So it is important to, to, to really start, start with the best approach.

So cat-friendly clinic is a really useful resource, even if you don't want to go down the accreditation programme with your clinic, please do explore our website. There's some really useful. Some information there about tips that you can do for the owner with regards to them getting the cat into the basket and into the vet clinic in the first place, and some small changes that you can make around your waiting room area to make things as sort of relaxed as possible for the cat so that when you take them first of all into the consult room, you're not dealing with a, a very upset, and scared cat before you've even begun, because if you're already starting at that stage, it's going to be very hard to do a thorough physical examination on a cat if they, if they're already in a state of, sort of anxiety and meltdown, which, for some cats just turns them into a A total trembling wreck and for other cats can create a very upset and assertive cat, shall we say.

So it's really trying to get the best out of your appointment, if you can be as cat-friendly as possible, that puts you on the best footing for being able to perform a thorough physical examination. We do have a, YouTube channel for international cat care as well, and a lot of our handling videos are on there, but also tips for owners as well, around medicating their cats and around getting them trained to be happy in the, in the basket too. So I would encourage you if you haven't already to do explore that resource.

It's it is very helpful. So, the next sort of part of this lecture is, really just presenting some of our findings, from the feline Healthy ageing clinic at Liverpool. And giving you sort of, some, some taste of of what's really happening in middle age and, and hopefully, be encouraging you to, to be performing regular examinations, on the middle-aged cat and starting to, to try and prevent some of these conditions from developing or reacting to them before, before they become established.

So, we have recruited 206 cats into the study. The study began in February 2017 and we closed enrollment in October 2019 for me to start to write my thesis up. Enrollment of cats.

Medium age was 8 years of age, so we were inviting cats aged between 7 and 10 to join the study because we really wanted to be sort of following them through that, that sort of mature middle-aged period, ideally before some of these age-related diseases started to become established. So some of the cats, at enrollment were slightly under 7. We had a couple that were sort of 6 years, 10 months, due to some mistakes and discrepancies between the veterinary record and the records the owners had.

And likewise, we had a few that were over 10, up to about 11, I think, again, due to discrepancies around the veterinary records. It's always interesting when you get veterinary records from, from a couple of different practises as the owners may have moved during the course of the cat's life. When you're relying on the owner at enrollment to actually tell you how old the cat is, you do get quite a variety of ages.

As we were based in Liverpool, and we were requiring the owners to, to physically bring the cat to see us every 6 months at the clinic. Unsurprisingly, most of the cats that we recruited, were from the Liverpool area and in the northwest of the UK. Hopefully, I think they're fairly represented.

Of the UK population in general, but there might be some biases within that population. Definitely, I can say that the, the average cat in Liverpool is black and black and white, that definitely is our sort of street cat stray population. And as most of them, the pet cats that people obtain in Liverpool, come from, come from that group via via rescues or just via cats that decide they want to move in with them.

We do have a lot of black and black and white cats in our study. So this slide comes from their enrollment data. So this is the weight and body condition score that they were at enrollment, and as I said previously, the median age of these cats, was 8 years of age.

So the weight one is probably not that interesting because with regards to when you look across cats, it's probably not surprising that most cats were sort of between 4 kg and 5.5 kgs. That's pretty average for the size of a cat.

But body condition score is probably more useful because that really gives us a bit more information about how their weight actually relates to, to what is a healthy weight for that cat. And as you can see, the, the average was 6, so most of these cats are on that plumper side of, of what they should be at, at enrollment, so at 8 years of age. Generally, the way we've approached things within the clinic is if the cat has body condition score of 6, we tend to be advising the owner that they are at kind of the maximum weight for their age that they, that, that we want them to be.

There was some nice research that came out a few years ago from Australia, that was a retrospective analysis looking at body condition scores across a population of cats from inner city Sydney. And that really showed that once you were reaching a maximum body condition score of, of over, over 6, especially, the 8 and 9 range was, was associated with the shortened longevity and likewise cats had only ever achieved a maximum body condition score of 3, or less was obviously associated with a shortened lifespan as well. But it did sort of give us a feel that probably the heaviest over the course of their life that we'd want a cat to be is probably around a body condition score of 6.

So that's quite, quite useful to know. So generally within the study, once the cats were getting body condition score 78, we were starting to give advice about weight loss. And for a number of the cats, we, we did have a little bit of a referral process, with some of them that we were then, sending them over to the weight management clinic at Leighurst.

We did have a little bit of toing and froing between our, between our clients with that. And some of them weren't able to go to Lee Hurst, but we did refer them to, to, in-house weight management clinics within the university that practise as well. Within the study, we also performed blood pressure at each appointment with the cats, and this is from the enrollment data again.

And as you can see, we, we managed to actually obtain blood pressure measurements from 94% of the cats, which, given that for this population of cats, the vast majority of them, this would have been the first time they ever had a blood pressure measurement performed. It was, it was good and quite heartening to see that we could manage it with most of the cats, which is great. Generally we tried very hard to, to work with the cats and, and do the blood pressure, in positions that they were comfortable in.

So sometimes this means, on the chair next to their owner. Often we had the owners involved, with, with giving them scratches and tickles under the chin. Currently, we're still seeing cats with follow-up appointments and, due to coronavirus, we're not able to have the owners in the consult room with us.

So one of the things we are going to be interested in is just seeing if there's been a difference in blood pressure measurements compared to previous years where we have had the owner in the room, it would just be, be a little bit of an interesting analysis to do on the data that we're currently collecting. Generally, I do prefer to perform blood pressure measurements on the radial artery, but with some of the cats, I do use the tail because they're not amenable to having their head areas and feet attached. So there's a picture there of lovely Ollie, who is is one of our.

Special clients, he has quite an assertive temperament if, if he doesn't like something that you're doing. But fortunately, he can be quite easily distracted with, with being groomed actually. He has a brush that he comes in with and he quite likes having his face brushed and stroked whilst I'm doing things down the other end around measuring his blood pressure.

So at enrollment, we had a few cats that the blood pressure measurement was over 160. We do also aim to perform a retinal examination, on all of our cats, at these appointments as well, to just double check for any signs of retinal hypertension. And none of the cats, with the blood pressure was over 160 had any evidence of retinal hypertension.

So, probably most of these, it was an example of, of white coat hypertension. Some of them, weren't happy with, with having their feet touched and, and the examination being performed. We did have two cats within this, this enrollment cohort that did have evidence of retinal hypertension, and both of these cats were shown to have chronic kidney disease on their blood results, but both of them had blood pressure measurements actually between 100.

50 and 160. So it was likely that probably, the stage of kidney disease and the dehydration that they were experiencing due to the kidney disease, was actually slightly lowering their blood pressure measurements. The next slide is probably the most, not the most attractive, I'm afraid.

It's a little bit of a heat map, but it was one of the ways that I found quite easy to sort of display quite a large amount of data. So on the left-hand side, we have the 106 cats that were enrolled. The white indicates that we didn't diagnose anything with them.

Red indicates that I wasn't able to perform that part of the test or the examination. And green indicates that the, that the state was present. So, the dental disease, was, was very common, and I'll come to that a little bit further in the next slide.

And you can see, if you look closely enough, there is a red line across cat number 17 in this enrollment examination. I was not able to perform much around cat number 17 at all apart from I think I did manage to get her on the scales and do a visual body condition score assessment of it. But she has continued to come and see us regularly.

And now 3 years into the study, we're actually able to, to achieve most of an examination, which is great. Fortunately, she's very amenable to bribery. So we do go through vast quantities of licky licks with each of her visits, but it does enable us to be able to measure her blood pressure and we've even been able to collect blood samples from her over the last year as well through use of food bribery and Mla cream and a lot of time.

But we have gotten there in the end with her, which is great. The next one on the list after dental is heart murmurs, and we found 29% of the cats had a heart murmur present at at the enrollment examination. The next one is, hypertension, so cats that had blood pressure measurements over 160, and we found 5% of our cats had blood pressure measurements over 160.

So technically, we're at least at that time point hypertensive. However, we were only performing one examination at one time point, and with these cats, we did encourage that the owners attend the clinic again to have a follow-up blood pressure measurement. Just to make sure, to, to double-check that that there wasn't persistent hypertension, especially any cats that there was a suspicion of, of early chronic kidney disease, or again, hyperthyroidism as well, a number of the cats that were diagnosed with hyperthyroidism were also hypertension, hypertensive at that time, but we did find the hypertension resolved after treatment for the hyperthyroidism.

So the hyperthyroidism is actually the one on the last bit illustrated in this, in this graph, and 2.7% of the cats were newly diagnosed hyperthyroid at their enrollment appointment. One of the cats was known to be hyperthyroid at enrollment.

And then the middle one, which is also quite green, is MSD which is my shorthand for potential musculoskeletal disease, and I'll go into that in a little bit more detail in one of the latest slides. CKD, 10% of the cats had increased creatinine concentrations at their enrollment appointment. We couldn't confirm, diagnosis of CKD in them, so they kind of found that there was a suspicion of chronic kidney disease.

Two of the cats that also had retinal hypertension, did have very advanced CKD, so I was confident to, to be able to, to make that diagnosis at the time. Some of the cats, I was able to have a urine sample collected on the day, which was able to either rule in or rule out CKD, but for a number of these cats, we, we really just had a single elevated creatinine, and then with some of the subsequent appointments, we were able to confirm. That they were likely to be developing chronic kidney disease, but for others, we just had a raised creatinine on the day, which was potentially just related, especially in summertime to some of the, the warmer weather and possibly a little bit of dehydration.

We did have one non-diabetic, at the time of an enrollment as well into the study, although interestingly at that time that cat was actually in remission, but it has, subsequently come out of remission, is now being managed again on, on insulin. So the next slide really is talking around dental disease, and there was one cat that we weren't able to perform a dental examination on, but out of the other 205 cats, 54% of them had dental disease at their enrollment appointment. And dental disease is obviously a bit of a blanket term, but the, the type of scoring system I was using.

Essentially I've categorised dental diseases as being that early plus stage that's illustrated, in the Royal Cayman slide. So it's the kind of cases that you'd be clinically pointing out to the owner, showing the buildup of tarta, showing the gum reaction, and they'd be the kind of ones that you would be starting to encourage, potentially that they do have a scale and polish and some further investigations. And then hopefully, once that is done, then following up with some preventative care to try and slow down the further development of dental disease.

So as well as, as these sort of gingivitis and accumulations of, of tarta, also quite a proportion of these cats had felaodontoclastic lesions as well. So they were present in 29% of the cats, and then a very small number of them had stomatitis as well. With the cats that we then followed up for subsequent appointments, so 200 of the cats, have come back for at least a further 6 months, a 6 month appointment, and for some of them we've been following for, for 3.5 years now.

. And over time, 82% of the cats have had dental disease recorded at at least one time point. So these are cats, when we look at the longer part of the study, they're aged between 7 years up to, I think the oldest for follow-up appointments are about 12.5 from the start.

So 82% of cats into that age range have signs of dental disease to the point that you would, as a vet, be encouraging some form of an intervention. So it's not the most exciting, I'm afraid, and probably it's just confirming what we, what we as vets have been seeing through the course of our careers, but dental disease is very, very common in the middle-aged cat, so. Part of that, that, reasoning really is, is why I do think it's important that cats are seen twice a year in this age range in the vet clinic, having at least one annual appointment with a vet and ideally actually then a six-month follow-up with the nurses to be monitoring their weight and keeping an eye out for changes in their, in their body weight, but also to be checking their teeth because Some of these early signs of dental disease, you might be encouraging the owner to have a dental performed, but definitely in my clinical experience, it often takes quite a few nudges from you around dental disease before the owner actually commits to booking the cat in for an appointment.

I think when you have more advanced dental disease and you can really be showing the owner infected inflamed, wobbly teeth, they are often more inclined at that point to, to do something about it and to, to book the cat in. Whereas when you're starting to encourage them in these early stages, sometimes that, that motivation from the owner isn't quite there, especially around the cost of dental disease does have an impact when You, when you're asking them to be booking in for a dental procedure under anaesthesia, it does come with, with costs. So I think the nice thing about having regular follow-up appointments with, with your nurses in the at that sort of six-month stage is that it's just reinforcing that message that it's not getting better, it is getting worse, and something does need to be done, which I think is beneficial for the cat's welfare.

And then the next slide is really talking around musculoskeletal disease. So within our cat population, we try and perform an orthopaedic examination at each of the time points. And this is from the enrollment data initially.

As you can see my numbers. Gone to 182 from 206. So there are some cats that are just will reach the point with the examination that you're manipulating all of their joints, it's just something that they're not willing to be amenable to.

But based on the cats that we were able to perform an orthopaedic examination, 58% of them had had findings of reduced range of motion, you know, discomfort or manipulation of the joint or palpation of thickening of the joints on the orthopaedic examination. And now these findings aren't conclusive, of, the presence of, of, osteoarthritis and degenerative joint disease. Unfortunately, within our study design, we just didn't have the ethics to be able to perform a sedation and X-rays on the cats, nor the funds to actually be able to do it as well.

So probably this might be a bit of an overestimation of of orthopaedic dysfunction. Within, within this group of cats. But, I still think it's a very useful thing to be starting to do, especially when, when I looked across, just the enrollment data, cats that I was, I was finding the potential of musculoskeletal disease were all significantly older than the sort of 7 to 8 year old cats were a lot more comfortable with me performing an orthopaedic examination.

And that to me is an indication that there probably is some degree of discomfort then with these older cats, . Definitely, studies have shown that, grumpiness, shall we call it, is, is definitely a sign of, of musculoskeletal disease in cats, and resistance to having orthopaedic examination was correlated with findings of osteoarthritis on X-rays in some of the studies. And we do have now a very Good evidence base around radiographic studies looking at osteoarthritis and degenerative joint disease in cats to really show that it is highly prevalent in older cats.

One of the studies that came out in 2010 from Duncan La Scales, showed up to 100% of older cats, especially had evidence of osteoarthritis, . If you looked hard enough in their joints, and also what that study really showed is the older the cats got, the more number of joints increased, so more joints were, were showing evidence of osteoarthritis and the severity of the disease within those joints also increased with age as well. So it is not surprising that we were seeing more findings on orthopaedic examination within older cats in this enrollment cohort.

And then again, over time, as I followed these cats, for their repeat appointments, 70% of the cats are now in our cohort, have started to show abnormal findings, over, over the course of the study. . And these are cats that on previous years were comfortable with me performing an orthopaedic examination.

So they have become more resistant to this happening, which again fits with, with a sort of suspicion that they are starting to develop musculoskeletal disease as well. So I do think it's important, even if you're not performing a full physical examination with with sort of mind to assessing joints, at least starting to be aware that it might be an issue, try and build it into your, your examinations if you can, and start to do some form of assessment, at least, discussion with the owner about how the cat has been moving at home, I do think would be exceedingly useful. So just a little bit of a summary for you all, some take-home points, especially with regards to, to middle-age appointments.

Please weigh and body condition score the cat at every visit and do record that on their notes, examine their teeth at every visit as well, and, and I think these are lessons for, for vets, but also to be making sure they are included in nurse consultations. Well, to be weighing body condition scoring and doing a dental assessment on a regular basis from 7 years of age and all cats, I think is going to be really important. And I do think it's important to, as I said, to, to start to assess for musculoskeletal disease from middle age, so at least doing a visual assessment and asking a few questions, of the owner, I think is a good place to start.

And if you do have the ability. To be able to build it into your, your consultation process, then I think it's something to really consider. We do have the luxury of time with the appointments that we do at the feline Healthy ageing clinic, but generally the sort of physical examination side I find takes me about half an hour and that includes doing a full physical examination, performing a blood pressure measurement, doing an orthopaedic examination, and collecting a blood sample.

However, I do have the luxury of having a nurse working alongside me. So there are 2 of us performing this examination, and I think that is exceedingly helpful having a trained pair of hands, for, for holding the cat when you are performing the blood pressure measurement, and also collecting the blood sample as well is, is very useful to be able to do that. But it is something for you, you to be considering to be building into your, into your regular examinations.

And then the next one on the list is, is really trying to prevent obesity, so, through monitoring the weight and the body condition score, really starting to recognise when these cats are gaining weight, and starting to try and implement measures to reduce that weight gain before it really starts to occur, . What has been shown in the human world around musculoskeletal disease is that obesity, whilst you've got the, the physical weight on the joints, having an impact on, on movement. Also, obesity does create a pro-inflammatory state within the body, and that is likely to also have an impact on some of the pain experienced around musculoskeletal disease.

And whilst we don't yet fully have that evidence in cats, there is a study showing that cats with osteoarthritis do have increased cytokines on their bloods, and so there is likely to be some inflammatory states associated with muscular. Skeletal disease in cats. How that relates to obesity is still not clear, but I think at least just from the physical weight side of things, preventing weight gain and then treating the weight gain once it's occurred is going to be beneficial for the cat's movement.

And just finally, when you're doing these visits, please be communicating this to the owners as well. Do update them on what the cat's weight is, what their body condition score is, what their weight change and change to the body condition score has been, and make sure they're aware of the teeth status. You know, I always try, it's not always the easiest with some cats.

But I always do try and show them what I'm seeing, show them the, the tar buildup, show them the redness of the gums, show them where the gums are receding and you can see the roots starting to appear. If, if the owners can see it, I think it does help, raise that awareness within them and hopefully motivate them to, to booking the cat and for some preventative measures. And likewise, making them aware around some of the clinical signs of degenerative joint disease in our.

If you've got a a sort of combination of the owners starting to notice some notice some changes in the cats and you're starting to see some findings on your visual assessment and your orthopaedic examination. Then this is really good evidence to then start to consider whether or not you book them in for some X-rays, to investigate further, or you may choose, if especially if cost is an issue, to do a treatment trial with something like meloxicon, for a week or two and get the owners to see if there has been a benefit and how the cat is moving, to do a sort of pain relief treatment trial, around, around joint diseases is something to consider as well. So I'd just like to finish off with saying thank you to Royal Can in UK for inviting me to speak today, but also to Royal Canon International, as they have funded the feline Healthy ageing clinic and my, my PhD posted at Liverpool University and they're continuing to fund my one day a week as a postdoc on this project as well.

Special thank you to Kelly, who is the clinic nurse for the feline Healthy ageing clinic, and has been, very much involved in the collection of the data, that I have presented today, and my supervisors for the project, Alex Ena, Gina, and Carl for all their assistance. And finally to International Cat Care and ISFM for allowing me to, to speak today. I've been doing it on, on their time.

So thank you very much to them. Thank you very much to everyone that's attended and I will end this, this webinar presentation now. That's great.

Thanks, Natalie. I'm sure everybody got a lot of information from that and it's really nice to see your passion coming through for what you do as well. There's a few questions in the Q&A box.

If I open it up here, I'm not sure. Can you see that, Natalie? Yes, I can, thank you.

Can you hear me OK? Yep, I'll just mute myself. Brilliant, thank you.

Now I'm live from my, my living room. So the first question we had from from Susan, I'm just asking about the background of the orthopaedic examination slide and whether or not it was a pressure mat that she could see. It was, it's a tech scan pressure sensitive walkway.

So as part of my PhD project, we've also been collecting Some gait analysis work as well. And I've been processing that. It's probably not been as exciting as I hoped in terms of the data, but we do have quite a bit of interesting information from the cats so far, and I'm hopeful that as we continue to follow the cats from middle age through into older age, we'll get some further information from them too.

But it has been an experience trying to encourage people's pet cats to walk in a steady line and a straight line as well across that pressure mat has been, yeah, it's been some of the fun parts of the last 4 years. So there'll be probably some further information from my work on that coming out over the next year or so. And then we also had a comment from Jane about ocular manifestations of hypertension and sort of saying some of these chronic subtle signs can be a lot more difficult to see and do require a specialist examination.

And I definitely agree the more subtle signs are a lot harder to see. What I've been using in this project is a Welsh Allen panoptic ophthalmoscope, and then we have a little attachment called the eye examiner. Attachment, which enables me to attach my old iPhone to the ophthalmoscope.

And what I tend to do just through a little bit of trial and error is I kind of hit record and take about 100 photos of the back of the cat's eye while I examine it. And then I scroll through those photos and save the ones that were clinically useful. As you can imagine, a lot of them are slightly blurred, have eyelashes and things in the way.

But doing that and being able to click the photos and then look at them as I'm saving the good quality ones has enabled me to pick up some of these more subtle lesions that I do think I would struggle to do, just having a look myself, whereas when you've got that really acute haemorrhage and acute onset blindness, obviously those lesions are very dramatic and a lot easier to see. So I think that is all the question we've had so far. If I think Jenny's asked about interest in the recordings and from what I understand from webinars, they are going to be available for up to 6 months, I think, for people to watch.

So I hopefully people will be able to catch up on them further, but if there aren't any more questions, then I will say goodbye. Wonderful. Thanks, Natty.

Have a good day. And thanks to everyone for listening. So we're gonna have, a short break now until 11 o'clock.

And don't forget to visit the goodie bag page where you can find out more information. The link is in the chat box. Enjoy your break, have a cup of tea, whatever you need to do.

And when we see for the next session, we'll have Professor Jonathan Elliott and he'll be discussing early detection of chronic kidney disease in cats. So we'll see you at 11. Thanks, everyone.