“All of us feel very overwhelmed at this point,” sympathized Marsha L. Heinke, DVM, EA, CPA, CVPM, owner of accounting and consulting firm Veterinary Practice Made Perfect, as she began a webinar on financial matters veterinary practice owners and managers should be focusing on during the COVID-19 pandemic. It may seem like your hospital has a plan at one moment of the day, but even an hour later things change drastically. “It’s like drinking from a firehose during a tsunami,” Dr. Heinke said.

Even with the unpredictability of the pandemic and its effects on daily life, the lifesaving services provided by veterinary hospitals are invaluable to clients and their pets. Presenting on behalf of the Veterinary Hospital Managers Association on March 31, Dr. Heinke provided guidance on money management, employee communication and updated laws to help navigate these uncharted waters.

Dr. Heinke explained that there is no blanket answer regarding which legislative bodies hospitals should reference at this time. Currently, many municipalities and states have regulations that are different, and sometimes stricter, than those of the federal government. Understanding the new regulations as they pertain to where your practice operates is one of the challenges decision-makers have to face.

“Generally, you want to start at the local community level and work your way up from there,” Dr. Heinke said. “If the community is silent on the matter, then go to the next authority, which might be the state government.”

In addition to staying current on new mandates, utilize the business experts in your quiver, Dr. Heinke advised. “It is very important to work closely with professional advisors, but understand that they are also overwhelmed trying to digest all of the changing information,” she said.

With layoffs and furloughs becoming a reality for many businesses, employees should know how their job will be impacted and the temporary changes the hospital may make.

Management needs to remain aware of timely updates and relay that information as it pertains to the practice, such as orders about essential and nonessential workers. “You owe it to your employees to let them know what is happening and what your plans are for the practice,” Dr. Heinke explained.

She also stressed the importance of remaining positive and taking a solutions-based approach to communication. Provide clear direction for how staff should interact with clients, explain proper sanitation protocols to limit exposure and review additional measures being taken to ensure the safety of staff, clients and patients. It is also vital to encourage questions and dialogue. “Remember that everyone is impacted personally and professionally,” she added.

While the government and different agencies are encouraging flexibility in sick leave and paid time-off policies, the 

 enacted on April 2 may impact your decisions on those policies, Dr. Heinke said. Paid FMLA leave and emergency paid sick leave are available to be used in addition to a hospital’s existing paid time-off policies, and some types of leave may run concurrently. Practices may not alter their policies to restrict time off in light of the new laws, she warned.

Additionally, hospital management must understand state and federal unemployment requirements. This includes reduced hours and wages, furloughs, layoffs and terminations. “You also want to be paying attention to unemployment insurance and disability benefits if you are in a state, such as New Jersey, that requires those,” Dr. Heinke explained. You have to think about how state and federal policies integrate with current hospital policies and updated laws.

Many hospitals are reducing hours, while some employees are choosing not to come into the office but may telework. Do you continue to pay the full salary? Are there Department of Labor (DOL) standards that apply? Following are some of the key aspects Dr. Heinke said to consider:

Review existing contracts to see if any applicable details are outlined.

The DOL requires that, to maintain exempt status, employees receive their full guaranteed salary for any week in which work is performed.

Some states’ laws require additional payment obligations.

If setting a new, temporary salary for an employee, it must be at or above federal and state minimums. The federal minimum is currently $648 per week, but many states have higher minimums.

Do not repeatedly reclassify employees as exempt and nonexempt. This could make it possible for salaried employees to put in claims for unpaid overtime hours they previously worked.

Evaluate which benefits your hospital is going to continue to pay for and which may be curtailed.

For nonexempt workers, Dr. Heinke encouraged reducing hours rather than reducing pay rates, but in instances where pay is reduced, hospitals must maintain the minimum applicable federal and state rates. Reduced hourly wages cannot be retroactive, and employees must be given notice.

Regardless of what measures hospitals decide to take, Dr. Heinke said now is not the time to become lax about record keeping. For instance, continue to require a doctor’s note from employees who have been diagnosed with COVID-19. “The reality is, you’re going to need that documentation in your files,” she said. If employees take advantage of the new paid sick leave laws, the hospital will be eligible for payroll tax credits to offset those costs but will need proper proof.

Now more than ever, anyone with cash flow oversight responsibilities needs a clear understanding of the daily break-even point and recent profit-and-loss statements. “You are going to need to be brutal about what you can reasonably cut that you don’t need but are paying for,” Dr. Heinke said.

Remain in contact with vendors and discuss possible payment deferments. If your practice is facing a cash flow shortage, Dr. Heinke said, it is important to prioritize what needs to be paid first, taking into consideration interest rates and penalties. It may also be time to explore other funding sources, she suggested. These include using existing lines of credit, practice owners temporarily forgoing compensation and owners contributing personal funds to maintain the practice.

Assess the loans that might be available through federal COVID-19 relief packages. “Many veterinary hospitals are seeing that this is necessary,” she explained. The CARES (Coronavirus Aid, Relief, and Economic Security) Act will provide small businesses with access to $350 billion in loans, a portion of which will be forgivable. Similarly, Paycheck Protection Program loans through the Small Business Administration are available to businesses with fewer than 500 employees.

While so much continues to change and hospitals must routinely readapt, Dr. Heinke predicted that the veterinary profession will fare well when restrictions are lifted. “We are going to look different, but perhaps much better in certain ways,” she said.

Amanda Carrozza is a freelance writer and editor in New Jersey.

Articles

As veterinary practices continually adjust clinic protocols in the face of COVID-19, they must also manage costs differently, abide by new employment laws, and keep staff calm and informed. Here’s what you need to know.


COVID-19: financial considerations for veterinary practice owners and managers 

Opioids are a large class of natural and synthetic compounds derived from the opium poppy.

 They include pain medications legally prescribed to people and animals, such as morphine and fentanyl, as well as recreational versions—like heroin—that are illegal.

The “black box” warnings opioids carry on their prescription labels point out the dangers and risks of dependency for 

. Although veterinarians prescribe opioids for animals, they should be mindful of the potential for drug diversion—abuse or illegal distribution—on the part of the pet owner.

“Our patients are not the addicts,” said Julie A.L. Adrian, DVM, associate professor in the Department of Pharmacy at the University of Hawaii, Hilo. “But at times, the owners may be, and [prescribed opiates] get diverted to people instead. So, we have to remember to prescribe to safe environments.”

While generally harmless when taken for a short time by the intended patient and via the prescription by a medical doctor, she added, “they produce euphoria or bliss in addition to pain relief, and they can be misused.”

Opiates work at the receptor level within the nervous system (limbic, thalamus, hypothalamus, striatum, midbrain, spinal cord), gastrointestinal and urinary tracts, and smooth muscle throughout the body.

 They modulate several central nervous system (CNS) receptor types:

, found in pain-regulating regions of the brain: Opioids bound to these receptors may produce analgesia, euphoria, respiratory depression, hypothermia, miosis and physical dependence.

 found in deep layers of the cerebral cortex and spinal cord: Opioids bound to these may produce analgesia, sedation and miosis.

 found in the cerebral cortex, olfactory bulb, nuclei of mesencephalon, hypothalamus and Purkinje cells: Opioids bound to these receptors may produce dysphoria, hallucinations, cardiac/respiratory stimulation and mydriasis.

 found in the limbic system: Opioids bound to these may blunt persistent pain and improve depressive emotional states.

 receptors as analgesics, antitussives and sedating agents. But many of their 

 effects, ranging from respiratory depression to emesis to constipation to physical dependence, are potentially dangerous. The secondary effects of opioids, including euphoria and confusion, bradycardia, hypotension, syncope and urinary retention, can be just as crippling.

Dr. Adrian reminded the audience about the contradictory effects of opioids, which are generally species- or agent-dependent. For instance, opioids produce miosis in dogs and horses, and mydriasis in cats. Likewise, while opioids generally cause sedation and constipation, morphine produces excitement in horses, cattle and pigs, and defecation in dogs.

Opioids are controlled substances classified by the U.S. Drug Enforcement Administration (DEA) based on acceptable medical use and abuse or dependency potential

no currently accepted medical use and high potential for abuse; includes heroin, lysergic acid diethylamide (LSD), marijuana and ecstasy.

 high potential for abuse and dependency; includes cocaine, methamphetamine, hydromorphone, combination products containing less than 15 mg hydrocodone/dosage unit, oxycodone, fentanyl and meperidine.

 moderate to low potential for physical and psychological dependence; includes compounds containing less than 90 mg codeine/dosage unit, ketamine, testosterone and anabolic steroids.

 low potential for abuse or dependency; includes tramadol, alprazolam, diazepam and zolpidem.

 lower potential for abuse; includes preparations containing low quantities of certain narcotics and used mainly as antitussives and antidiarrheals.

The schedule II drugs important in veterinary medicine include codeine, fentanyl, hydrocodone, hydromorphone and meperidine. These medications are potentially dangerous because they can cause profound sedation, respiratory depression and death, particularly when combined with other CNS depressants like benzodiazepines and alcohol. They can also induce neonatal opioid withdrawal syndrome.

Veterinarians should use extra caution when prescribing schedule II compounds for a pet that shares a household with children; in some cases, a single dose can kill a child who accidentally ingests one of these medications.

“Many of our patients live with children,” Dr. Adrian said. “So, we need to educate the owners that they need to keep these drugs in a safe place.”

Fentanyl, an opioid used extra-label in small animals, is typically dosed as a transdermal patch for painful pets. It should be used with caution in geriatric and otherwise debilitated patients, as it can cause CNS, respiratory and cardiac depression, as well as urinary retention and constipation. Fatal overdoses can result from increased drug release and rapid absorption in hyperthermic conditions caused by heating pads, warm baths and such. For households with children, this patch is probably too risky.

Hydrocodone bitartrate is a human-labeled opiate agonist used as an antitussive and analgesic for moderate pain in dogs. Immediate-release products are available in combination with homatropine, acetaminophen, ibuprofen and chlorpheniramine. Cautions include excessive sedation, vomiting and constipation, and it is contraindicated in patients taking monoamine oxidase inhibitors and those that are geriatric or have underlying conditions including Addison’s disease, hypothyroidism, renal insufficiency and respiratory disease.

Hydromorphone, an opiate agonist used off-label in animals as a sedative, analgesic and preanesthetic agent, can cause vomiting, defecation, panting, sedation, and CNS, respiratory and cardiac depression in dogs. Cats may experience nausea, ataxia, hyperthermia, hyperesthesia and behavioral changes.

 Both hydromorphone and hydrocodone can produce rapid-release overdosage if tablets are crushed/chewed.

Codeine, an opioid used in cats and dogs to alleviate pain, coughing and diarrhea, causes sedation, constipation and respiratory depression. Cats may experience CNS excitement.

Meperidine hydrochloride, a human-labeled opioid agonist, is used for analgesia but produces histamine release in cats, resulting in gastrointestinal effects and hypersalivation. For cats and other species, including humans, it carries most of the aforementioned opiate risks, contraindications and adverse effects. Both codeine and meperidine are subject to potentially lethal dosing errors due to confusion between milligrams and milliliters.

Of the lower-schedule drugs, Dr. Adrian pointed out three that are commonly used by veterinarians. Buprenorphine hydrochloride, a schedule III opiate partial agonist that is particularly useful in cats, is an injectable or buccal analgesic. Often used as part of a short-term immobilization “cocktail,” it has fewer adverse effects but lower efficacy than morphine and hydromorphone. Its main risk is potentially fatal respiratory depression, and its effects are not completely reversible with naloxone.

Butorphanol tartrate, a schedule IV opiate partial agonist, is used as a premedication, antitussive, antiemetic and analgesic in many species. Contraindicated in patients with liver disease, hypothyroidism, Addison’s disease, renal insufficiency and head trauma, it can trigger sedation, ataxia, anorexia and diarrhea in dogs and cats. A particularly effective analgesic in horses, butorphanol can decrease critical equine gut motility and cause excitement.

Diphenoxylate hydrochloride, a schedule V opiate agonist used in fixed-dose combination with atropine sulfate, is an effective GI motility modifier and antitussive for dogs. It carries cautions for use with certain underlying diseases, and is contraindicated in several diarrheal conditions. Constipation, bloat and sedation are the chief adverse effects. Diphenoxylate must be dosed carefully in small dogs, and it should not be used in young kittens.

Dr. Adrian closed by asking the veterinary audience which scheduled drugs—of those she covered in her lecture—they use most frequently in their patients. Buprenorphine (mainly in cats) was the No. 1 response, followed by a tie between butorphanol and hydromorphone.

I want to change my life. How to overcome anxiety, depression and addiction.

 Toronto, Ontario: Modern Therapies; 2010.

2. Opioid overdose: commonly used terms. Centers for Disease Control and Prevention website. 

. Reviewed February 12, 2019. Accessed February 24, 2020.

3. Opioid resources for veterinarians. AVMA website: 

avma.org/resources/veterinarians-and-public-health/opioid-resources-veterinarians

4. A guide to drug safety terms at FDA. U.S. Food and Drug Administration website. 

fda.gov/downloads/forconsumers/consumerupdates/ucm107976.pdf

. Published November 2012. Accessed February 24, 2020.

5. Plumb DC. Pharmacology of narcotic (opiate) agonist analgesics. In: Plumb DC, ed. 

 7th ed. Stockholm, WI: John Wiley & Sons; 2011:2417-2418.

6. Al-Hasani R, Bruchas MR. Molecular mechanisms of opioid receptor-dependent signaling and behavior.

7. Hayashi T, Su TP. The sigma receptor: evolution of the concept in neuropsychopharmacology. 

8. Pradhan AA, Before K, Nozaki C, et al. The delta opioid receptor: an evolving target for the treatment of brain disorders. 

9. Drug scheduling. U.S. Drug Enforcement Administration website. 

10. Plumb DC. Codeine. In: Plumb DC, ed. 

 9th ed. Stockholm, WI: John Wiley & Sons; 2018:293-295.

11. Plumb DC. Fentanyl transdermal patch. In: Plumb DC, ed. 

 9th ed. Stockholm, WI: John Wiley & Sons; 2018:481-485.

12. Plumb DC. Hydrocodone bitartrate. In: Plumb DC, ed. 

 9th ed. Stockholm, WI: John Wiley & Sons; 2018:574-576.

13. Plumb DC. Hydromorphone. In: Plumb DC, ed. 

 9th ed. Stockholm, WI: John Wiley & Sons; 2018:580-583.

14. Plumb DC. Meperidine HCL. In: Plumb DC, ed. 

 9th ed. Stockholm, WI: John Wiley & Sons; 2018:752-755.

15. Plumb DC. Butorphanol tartrate. In: Plumb DC, ed. 

 9th ed. Stockholm, WI: John Wiley & Sons; 2018:157-163.

. Philadelphia, PA: Wolters Kluwer Health; 2017.

17. Plumb DC. Diphenoxylate HCL + atropine sulfate. In: Plumb DC, ed. 

 9th ed. Stockholm, WI: John Wiley & Sons; 2018:389-390.

Dr. Joan Capuzzi is a small animal veterinarian and journalist based in the Philadelphia area.

Opioids lob their powers against many of the body’s evils, from pain to coughing to diarrhea. But there’s a dark side to opioids, both for the pets prescribed them and for their human caregivers. 


WVC—Opioids in veterinary medicine: panacea and pandemonium

 has drastically changed how your veterinary clinic operates. Whether you’ve had to cut hours, are trying to help patients via telemedicine for the first time, or are offering primarily curb-side care, your work day likely feels far from normal.

No matter what new trials you may be facing, Kristina Guldbrand, CVT, BS, CSP, says taking care of your wellbeing can help reduce anxiety and stress associated with the current state of affairs. One of her main techniques: focusing on what you are thankful for.

“These are the most important times to practice gratitude … I challenge you to find three specific gratitudes every day until this is over,” she says.

Guldbrand also recommends getting out of the clinic and giving yourself a break from the news. Take your pets for a walk or go for a run. “Make sure you get out there, spend some time with your four-legged friends. We all know what the 

Guldbrand details three wellbeing techniques in the video below.

Videos

With COVID-19 interrupting life as we know it, how can veterinary teams remain calm while continuing to offer patient care? Certified leadership and wellness coach Kristina Guldbrand offers some tips.

Keeping calm and carrying on: Wellbeing tips during the COVID-19 pandemic

There are many, many steps that must come before cutting the ribbon on a new veterinary clinic. There’s planning, building, designing and everything in between. But before any of that can even be started, the perfect site needs to be chosen. Whether you have the perfect spot in mind or you’re still looking for that love-at-first-site moment, here are the fundamentals of site investigation.

 in a growing area as far from other veterinary practices as you can get.

 to make sure the site is zoned correctly. Identify any restrictions on that zoning, such as an inability to have outdoor dog runs.

Have a geotechnical report (also called a soils report) done. 

The report should include foundation recommendations. If the soil is bad, you will need to find out if the foundation can be built affordably on that type of soil. Have a survey done of the geotechnical report that identifies easements, wetlands, property lines and any other site restrictions.

f your selected site has water and hasn’t been identified as a wetland,

 this will need to be determined because most states have regulations about building near a wetland and you may not be able to build there.

Discuss with an architect or civil engineer whether the site is flat enough to build on.

 Check to see if you can get utilities to the site and what the cost is to do so. Some sites have access already, but some don’t. You’ll need professional help for this.

Get a sense for any other major site development costs,

 such as turn lanes that will be put in at the road, storm water ponds, etc.

Figure out whether the site has unusual local (often environmental) requirements 

that will restrict its use. For example, in parts of California you aren’t allowed to cut down oak trees, so you have to work around them.

After this has all been done and the site has passed or is passing muster, remember to complete a phase 1 environmental study to ensure there are no environmental hazards on the site. Even if the site looks like it hasn’t been used, it’s still an important step to carry out.

If you're opting for a leasehold space instead of building new, there’s still plenty to keep in mind before you make your final decision:

 You don’t want to be in the dead shopping center.

is as far from other veterinary practices as you can make it.

Check (and double check) that the space is in good shape.

 Look for mold or other common problems. The building should be well taken care of.

Try to find a space without a business above it. 

You can work with a business above you, but it’s much more difficult. Single-story shopping spaces work best. Square or rectangular spaces work better than long, thin ones. A narrow place wastes space (say that five times fast). In the event that you 

choose a small space, look for something no narrower than 25 feet. It is extremely difficult to work in anything narrower than that. You should also avoid irregularly shaped spaces, such as an L-shaped space with a center staircase.

Determine the availability of utilities to the space.

 Ask the building owner whether you can expand utilities if needed. At some point you may need more power to the unit and need to know ahead of time that you will be able to make those changes.

At the end of the day, always be sure to think strategically about your plan. In the future, will you expand or move? If you plan to expand, try not to locate next to something that will be there forever so you have the potential for grow.


From location to soil to utilities, here are the fundamentals for finding that perfect site to build or lease your veterinary hospital space. 


Love at first site: Your location investigation checklist

We all know the story: A dog walks into a bar—ahem—your veterinary practice, and says, “I’m itchy.” You see patchy hair loss and excoriated skin and know that the possibilities are endless. But one rake with a flea comb yields an immediate diagnosis and the news is delivered.

This initial flea diagnosis is where you, super-vet, must sound the alarm. What I tell owners is that in the event of a nuclear war the only survivors will be horseshoe crabs, cockroaches and, you guessed it, fleas! I’m joking, of course, but I want my clients to take the problem seriously because if they don’t act quickly, aggressively and with painstaking rigor, they will be combatting these hardy invaders for a long time. But sometimes clients just don’t get the message the first time around.

and the owner is back in your office because the fleas won’t go away, or the owner “got rid of them and now they are back.” Get real with your client by reviewing with them these facts:

The adult fleas you see on your cat or dog—

 but these buggers are just the tip of the iceberg.

Each female flea lays 10 to 50 eggs a day,

 with a lifetime total of up to several thousand. Fleas reproduce following a blood meal, with a new generation of fleas emerging every few weeks.

The length of flea life stages varies depending on environmental conditions: eggs (3-21 days), larvae (1-2 weeks), pupae (1-3 weeks to one year) and adults (2-7 months).

Your pet’s fleas never really went away. The “new” infestation is likely another generation of the original batch, still thriving because the life cycle was never broken.

You cannot break the flea life cycle without chemicals. Natural remedies (e.g. garlic, coconut oil, borax) won’t put a stop to it.

With rare exception, if one pet in the household has fleas,

 pet has fleas. Surprised because your other pet(s) are not manifesting flea allergy dermatitis and/or pruritus? Don’t be! Flea infestations in some pets are clinically silent.

If your pet has fleas, your home and likely your yard are also infested.

Leaving an infested environment, like a vacation home, does not necessarily make the fleas die. Adult fleas can live for a few months without a food source, and pupae can survive for up to a year in a barren house; adults are triggered to emerge by vibrations, carbon dioxide and warmth.

After reviewing the principles that lay the groundwork for persistent flea infestations, I ask how the initial infestation was managed. Then, together, the client and I identify the smoking guns. The most common oversights are (1) failure treat 

I tell owners, “Let’s turn your pet into a walking exterminator.” By treating the animal immediately with an adulticide, the fleas currently on the pet and those that jump on when the pet goes home will die quickly, before they have a chance to lay eggs. I get an adulticide such as nitenpyram on board before the pet leaves my office, thereby killing any fleas that might leap onto the fur from the cat carrier or the car during the ride home, and bringing the pet immediate relief.

I advise the owner to bathe the pet well, manually removing adult fleas in the process. They can then begin, or resume, using an oral or spot-on insect growth regulator such as lufenuron, methoprene or pyriproxyfen. These must be given monthly—

—in order to dismantle the flea life cycle successfully. At a minimum, they should be continued for at least two months after the last flea is seen, and then ongoing depending on individual risk factors.

 must be treated, right down to the cracks between the floorboards, where flea eggs can drop and safely mature:

Mop floors, then rinse the infected mop immediately under running water so all fleas, larvae and/or eggs are washed down the drain.

Flea eggs, which are dry and fall from the pet’s coat, can sink deeply into carpet. So vacuum all carpets immediately and repeatedly. Put used vacuum bags into sealed bags, and dispose of them in an outdoor trashcan. Then wipe down the bottom of the vacuum cleaner and, for bagless machines, the canister itself with a cloth dampened with water or (even better) an insecticide solution.

Fabric can harbor any of the four flea life stages, particularly pupae, which cling well to fibers. Launder in hot water or dry clean all removable fabric in the home, from pet bedding to human bedding to furniture upholstery to curtains.

Treat hidden spots where fleas can multiply with abandon, such as corners and crevices, beneath furniture, and inside garages and sheds.

Treat your yard, particularly near the entrances to the home.

Vacuum/clean and treat all vehicles and transport devices (i.e. cat carrier) the pet has come in contact with, as fleas in these areas can re-infect treated pets.

Chemical treatment of the home and yard, I tell owners, is sometimes best left to professionals. For a stubborn flea problem, dial an exterminator. Owners wishing to do it DIY-style can use pyrethroid foggers and sprays in home and outdoor areas.

I explain to owners that if all goes according to plan, it will take a couple months to completely eradicate the flea infestation. More commonly, these diehards wax and wane over six to 12 months as adults die and eggs hatch. When my clients are in this position, I help them identify weak links in their flea management plan and assure them that once we revamp the plan the end really will be in sight.

1. Hsu M-H, Hsu T-C, Wu WJ. Distribution of cat fleas (Siphonaptera: Pulicidae) on the cat. 

2. Rinaldi L, Spera G, Musella V, et al. A survey of fleas on dogs in southern Italy.

3. Guzman RF. A survey of cats and dogs for fleas: with particular reference to their role as intermediate hosts of Dipylidium caninum. 

4. Little SE, Starkey LA. Conquering fleas: preventing infestations and limiting disease transmission. 

5. Bowman DD. Arthropods. In: Bowman DD, ed: 

, 9th ed. St. Louis: Saunders Elsevier; 2008:5-83.

Fleas have a supersonic life cycle and fireball breeding power, but many veterinary clients don’t grasp the behemoth problems these arthropodal dynamos can create. That’s where you come in.

Coaching pet owners through unrelenting flea infestations 

Medicating cats regularly for chronic diseases can be very difficult for owners and stressful for pets. For cats with seizures, there may be a better option. A recent study from the University of Wisconsin-Madison College of Veterinary Medicine evaluated the pharmacokinetics of transdermal administration of levetiracetam to healthy cats, and the results show blood concentrations sufficient to warrant clinical usein veterinary patients.

Six healthy cats were enrolled in the study. Levetiracetam was compounded into a 400-mg/mL lipophilic liposomal cream by the University of Wisconsin-Madison Veterinary Pharmacy Hospital. The transdermal dose protocol was 60 mg/kg every 8 hours. Using a gloved finger, the experimenter applied the cream to one or both pinnae and rubbed into the pinnae until the gel was no longer visible. Serum levetiracetam concentrations were measured on day 7 of this dosing regimen, at times 0 (prior to dosing), 0.5, 1, 2, 3 and 4 hours post-dosing.

All six cats completed the study. Median serum concentrations for all six cats at all time points ranged from 14.8 to 17.4 µg/mL. The lowest serum concentration was 6.8 µg/mL and the highest was 39.6 µg/mL. All of these concentrations are higher than the 5-µg/mL lower limit of the human therapeutic range (therapeutic ranges for levetiracetam in cats are not known). Adverse effects were minimal and included sedation in one cat that resolved without dose adjustment and mild crusting on the pinnae of one cat.

Although the small sample size limits reliable extrapolation, based on serum concentrations in this study, transdermal levetiracetam has appropriate pharmacokinetic profiles to warrant clinical use in cats with seizures. Adverse effects were minimal. Drawbacks to transdermal administration primarily include the increased cost ($227 for a 14-day supply for a 4.5-kg cat) and difficulty of administering the medication to cats weighing more than 5 kg due to the volume of cream required for dosing.

Smith C, Barnes-Heller HL, Reif N, et al. Serum levetiracetam concentrations after transdermal levetiracetam administration, 3 times daily, to healthy cats. 

https://europepmc.org/articles/pmc6430925

Dr. Packer is an associate professor of neurology/neurosurgery at Colorado State University College of Veterinary Medicine and Biomedical Sciences in Fort Collins. She is active in clinical and didactic training of veterinary students and residents and has developed a comparative neuro-oncology research program at Colorado State University. 

Transdermal levetiracetam can be a viable alternative to other forms of anticonvulsant medication for cats with seizures.

Skin is in! A better option for treating seizures in cats

Cognitive impairment in cats is tricky-there's just not much information on the topic for veterinary teams. At the 2018 American Association of Feline Practitioners conference, held in Charlotte, North Carolina, Margaret Gruen, DVM, MVPH, PhD, provided clarity on the complex etiology of feline cognitive dysfunction syndrome (fCDS). She also offered tips for veterinarians on diagnosis and management.

What is feline cognitive dysfunction syndrome?

Cognitive changes are common in cats aged 10 years and older. However, many of these signs, including decreased activity and social interaction, are subtle and may be mistaken by owners as a normal part of aging. In fact, according to one study, cat owners reported at least one behavior problem in 28% of cats aged 11 to 14 years and in more than 50% of cats aged 15 and older.1 Many of the reported issues in that study, such as excessive nighttime vocalization and house soiling, were consistent with fCDS, also called “feline dementia.”

Although our understanding of cognitive dysfunction in animals frequently is extracted from human medicine, the exact etiology of neurobehavioral syndromes remains poorly understood. Cognitive dysfunction likely has genetic, nutritional and environmental components.

Dr. Gruen explained that high oxygen demand and lipid content make the brain particularly susceptible to the “cascade of damage” resulting in cognitive dysfunction. Known neuropathologic changes in the brain that lead to cognitive dysfunction include compromised blood flow, chronic inflammation, oxidative damage, and inefficient free radical scavenging. Across species, these processes cause plaques of beta-amyloid protein to surround neurons, ultimately resulting in neuronal dysfunction and death. Another pathologic change, tau protein hyperphosphorylation, is also documented in humans with Alzheimer disease and in cats, although its role in fCDS remains unknown.

Cognitively impaired patients may have reduced production and/or metabolism of neurotransmitters that are responsible for maintaining normal movement, posture, mood, memory, appetite and sleep. Serotonin, gamma-aminobutyric acid (GABA), norepinephrine, dopamine and acetylcholine are most commonly affected.

The role of chronic pain in cognitive impairment

Dr. Gruen explained that chronic pain plays a significant role in many fCDS cases. Common geriatric issues in cats include degenerative joint disease, arthritis, dental pain, interstitial cystitis and neuropathy. These tend to have “multidimensional effects” on all aspects of the patient's life, including behavior, sensation, cognition, social interaction and physiology.

Dr. Gruen recommended using the acronym “DISHA-AL,” adapted from Gary Landsberg, DVM, to remember the main signs of fCDS2:	

Relatively obvious signs of fCDS tend to be those noticed first by the owner, while subtle or early changes may only be revealed through detailed questioning by the veterinarian. These include mild changes in mood, grooming behavior and appetite. Because owners often mistake subtle signs for normal aging processes, Dr. Gruen explained it is the veterinarian's responsibility to learn more. “When we don't ask about these behaviors,” she stated, “we don't find out about them.”

Cats with fCDS often display learning, memory, motor function and spatial-awareness deficits similar to those seen in humans with Alzheimer disease. Overall, the cat owner may notice these slowly progressive changes as a decreased ability to cope with stress and adapt to changes. 

Dr. Gruen admitted that evaluating cognitive function in feline patients isn't easy. She advised veterinarians to “look at changes in the individual cat over time.” Begin screening early to establish patient-specific physical and behavioral baselines. Then, reference baseline information as clinical signs develop. She also emphasized that many signs associated with cognitive dysfunction, such as house soiling, may have medical causes, which is why fCDS should be a diagnosis of exclusion after ruling out other diseases.

The main goal of fCDS management, Dr. Gruen noted, is to delay progression of the condition and improve patient quality of life. Multimodal treatment should include environmental enrichment, dietary modification, pharmaceutical pain management and cognitive function support.

Management of fCDS, Dr. Gruen explained, is most effective when the veterinarian and owner work together. Owners should be encouraged to make a list of activities they perceive as important to their pet's quality of life. These may include perching, playing and grooming. The veterinarian can then maintain the list in the patient's record and discuss changes with the owner on a regular basis. Because many cats are more comfortable in the home than in a hospital environment, Dr. Gruen often asks owners to take pictures and video of behavior at home. She then uses these images to determine management strategies.

Social interaction, mental stimulation and physical exercise are all vital components for cognitive support in aging cats. Dr. Gruen recommended use of heated beds to draw cats toward certain areas of the home, including elevated perches and window ledges. Also, many enrichment tools created for dogs, such as puzzle toys, effectively stimulate mental and physical activity in cats. The team should focus on maintaining adequate nutrition, hydration, grooming and elimination habits.

Dietary supplements and pharmaceutical support

No FDA-approved options exist for treating behavioral disorders in cats, so use is all off label. Several options are available for symptomatic relief, but Dr. Gruen reminded the audience that all should be considered supportive rather than “miracle drugs” for treatment of fCDS. Options include monoamine oxidase inhibitors (MAOIs), omega-3 fatty acids, free radical scavengers and antioxidants, S-adenosyl-L-methionine (SAM-e) and L-theanine. Some commercial therapeutic diets contain one or more of these ingredients.

Among available pharmaceutical options, selegiline (also known as L-deprenyl and marketed by Zoetis as Anipryl) is currently the only FDA-approved drug for treatment of canine cognitive dysfunction syndrome. This MAOI has several documented neuroprotective effects, including improved astrocyte function, increased dopamine production and enhanced free radical scavenging. Clinical improvement is typically observed within 4 to 8 weeks of initiating treatment. A documented treatment for house soiling and reduced activity, selegiline is also particularly useful for regulating sleep patterns when administered in the morning, according to Dr. Gruen. One study also demonstrated improved spatial memory in dogs after selegiline administration.3 Potential side effects include vomiting, diarrhea, restlessness and anorexia, as well as increased stereotypic behavior if administered at high doses.

SAM-e (marked by Virbac as Novifit) has free radical scavenging effects and improves cell membrane function. Feline studies demonstrated optimal benefits in patients with mild to moderate cognitive dysfunction, suggesting that SAM-e is best utilized in the early stages of disease.

Other pharmaceutical options include Senilife (CEVA Animal Health), which contains the antioxidants phosphatidylserine, ginkgo biloba, vitamin E and vitamin B6; and L-theanine (marketed by Virbac as Anxitane), a green tea extract designed to enhance GABA, serotonin and dopamine levels.

Keep in mind precautions associated with administration of certain drugs. For example, selegiline should not be used concurrently with selective serotonin reuptake inhibitors, tricyclic antidepressants or opioids due to the risk of serotonin syndrome. Tricyclic antidepressants may have anticholinergic effects, particularly in older pets, and benzodiazepines have been blamed for exacerbating cognitive decline in human patients with existing cognitive dysfunction, particularly when used after anesthesia.

Dr. Gruen closed by demonstrating how multimodal treatment can be tailored for treatment of specific signs, such as nighttime vocalization. First, she advised identifying and managing any underlying medical causes. Then, incorporate various components of treatment. For example, environmental management of nighttime vocalization may include blocking noises that awaken the cat and owner, use of a heated bed for improved comfort, and adjunctive use of music, aromatherapy and body wraps. To retrain the patient's circadian rhythm, Dr. Gruen advised owners to keep affected cats awake during the day, especially during the morning and evening periods. Finally, anxiolytic pharmaceutical drugs and supplements may provide additional support for particularly severe cases.

Many veterinarians and cat owners find that cognitive impairment issues are relatively complex, which is why it's important to remember the progressive nature of fCDS and set realistic management goals. As veterinarians, the “goal should be to keep patients as healthy and comfortable as possible during their golden years,” said Dr. Gruen. By establishing patient-specific baselines for behavior and physiology, the practitioner and owner can work together to manage clinical signs and prioritize feline patients' quality of life.

1. Moffat KS, Landsberg GM. An investigation of the prevalence of clinical signs of cognitive dysfunction syndrome (CDS) in cats [abstract]. 

2. Landsberg GM, Nichol J, Araujo JA. Cognitive dysfunction syndrome: A disease of canine and feline brain aging. 

3. Head E, Hartley J, Kameka AM, et al. The effects of L-deprenyl on spatial short-term memory in young and aged dogs. 

Prog Neuropsychopharmacol Biol Psychiatry 

Early detection and regular follow-up are important components for managing this slowly progressive condition in catsand helping cat owners understand the difference between feline cognitive dysfunction and ordinary aging.

Vetted May 2020

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