Growing a feline-friendly practice (Sponsored by Nestlé Purina)

February 1, 2012

Margie Scherk, DVM, DABVP (feline practice)

Article

While the number of cats being kept as companions in North American homes is increasing, the number of feline visits to clinics has been declining since 2001.

While the number of cats being kept as companions in North American homes is increasing, the number of feline visits to clinics has been declining since 2001. Based on the AVMA's 2007 pet ownership and demographics survey, there are 13% more cats than dogs, yet cats fail to receive the same amount of veterinary attention. In small-animal practices, dogs represented 59% of office visits, cats only 39%. The recent 2011 Bayer Brakke study further noted three client-driven factors that limited the number of feline visits.

1. Inadequate understanding of the need for regular preventive health visits other than for vaccination.

2. Resistance to bringing a cat to the clinic because of the distress caused by placing a cat into a carrier and making the trip to the clinic. This factor was reflected dramatically by the fact that 40% of cats had not been to a veterinarian within the past year, compared with only 15% of dogs.

3. The cost of veterinary care, in particular the frequency and size of price increases.

The goal of this presentation is to look at these reasons, so we can start reversing this trend, in order to benefit cats, their human companions, and clinic growth.

Specifically feline

A cat is a prey animal that lives on its own. With no support network to fall back on for protection or food, cats need to continue taking care of themselves until they are too ill to do so. Cats are subtle and hide their signs of illness or pain extremely well. Many people believe that cats are self-sufficient and low-maintenance. As a consequence, by the time a client notices clinical signs and decides that a clinic visit is warranted, the patient may already be sicker than it looks. Thus, it is important to educate clients to recognize the subtle signs of sickness and pain. Earlier intervention will benefit all.

Ten subtle signs that a cat is sick

Our feline patients will benefit if we focus on educating clients so that they know what to look for and are aware of how significant minor changes in a cat's behavior, interactions, and physical appearance can be. These 10 signs are explained in greater detail at the website www.healthycatsforlife.com.

1. Inappropriate (and changes in) elimination

2. Changes in interaction with people, other animals, or the environment

3. Changes in activity, either a decrease or an increase

4. Changes in sleeping habits

5. Changes in food and water consumption, in quantity as well as behaviors associated with eating and drinking

6. Unexplained weight loss or gain

7. Changes in grooming, a lack of, or excess in, grooming

8. Signs of stress, such as hiding, chewing on nonfood items, a flicking tail, ears placed farther back than normal

9. Changes in vocalization

10. Bad breath

Getting cats to your clinic

It is no fun taking a cat to a veterinary clinic (for the owner or the cat)! All veterinary team members can teach clients how to make the trip less stressful, starting at home, during transit, and once they arrive at the clinic.

The frightening experience begins at home. Imagine the scenario from the cat's point of view: The carrier comes out. Your caregiver is nervous, and she (or he) chases you around and tries to force you into the carrier. You resist and may resort to self-defense. There are smells of human sweat, fear, maybe even blood. You may feel so anxious that you soil yourself! Eventually you are in the carrier. Everyone is exhausted.

Then you are carried to a "car" that moves without you moving. You may feel a bit nauseated; certainly, you are scared. You cry out repeatedly. You may vomit or soil yourself. Then the "car" stops and you get carried on a noisy and unfamiliar street and into a place with overwhelming smells and sounds! Help! And you are already aroused and anxious....look out!

We can reduce the stressors that a cat encounters or, in the case of a new cat, prevent the stressors from occurring, by teaching or habituating the cat to associate positive experiences with the carrier, the car, and even the clinic. By leaving the carrier out or using a Hide, Perch & Go™ box/carrier Figures 1A & 1B) so that the cat sees it routinely and enters it for treats or other rewards, we dampen the initial tension and fight. Taking the cat on short car rides that are unassociated with the clinic helps recondition the cat's negative associations with the car. Finally, taking the kitty to the clinic to be fussed over or only to be given a treat will help teach the cat that the clinic isn't necessarily a horrible place. Clicker training can be used to help create positive associations. The Catalyst Council (www.catalystcouncil.org) has created excellent videos that clinic teams and clients can watch to facilitate learning.

Improving a cat's clinic experiences

In many clinics, some veterinarians and other team members do not enjoy working with cats because of an underlying fear of getting hurt. The whole experience can be improved by understanding why cats feel that they need to defend themselves, learning to identify their cues, managing the interactions in a positive manner, and making relatively minor changes in what the cat is exposed to.

The basis for working cooperatively with cats is being empathic to their nature and behaviors and trying to imagine what their experience is like. Cats are a species with a completely different social structure than ours.

We need to look at cats differently and adjust our interactions as well as the physical space to reduce the strangeness and threats that cats experience in the veterinary clinic.

Relying on the "fight or flight" response, cats attempt to escape situations they view as dangerous.

From a cat's perspective, who humans are and what we do is dangerous. As a result, we see frightened and defensive cats every day. Cats try to avoid physical confrontation through the use of intimidating sounds and posture. This small creature feels more threatened than we do, so we need to slow down and avoid becoming frightened ourselves.

Reading and understanding the cues and signals that cats use is important to reducing their fear. It also allows us to respond respectfully. We can then avoid using signals that are hostile (e.g. scruffing, making shushing or hissing sounds, looking directly into a cat's face).

Examples of practical applications

1. If a cat is uncooperative, a comprehensive physical examination can usually be done using just a towel as a protective barrier. Facing the cat away from you is less threatening for the patient. Confining the cat between your legs as you sit on the floor provides adequate persistent firm restraint that is reassuring rather than frightening.

2. Blood and urine can be collected by "burrito-ing" the forelimbs, torso, and possibly the head of a defensive cat in a towel, then using the medial saphenous vein and a lateral approach for cystocentesis. This vein is also a superb choice for catheter placement and administration of intravenous medications. If the cat is allowed to have its front end in a sternal position while the back end is positioned laterally, it may struggle less.

3. Allow the client to be with the cat as much as, and whenever, possible.

4. Recognize that a persistently elevated systolic value above 170 or180 mm Hg probably represents true hypertension rather than the stress response. If in doubt, repeat the measurement later during the visit.

5. Feliway® (Ceva Animal Health), a synthetic analog of a feline facial pheromone, generally has a calming effect on cats. Spray it into kennels and carriers and even on your clothing before handling an anxious cat. Let the carrier substance evaporate for a few minutes before placing the cat into the sprayed space. Plug Feliway diffusers into treatment and hospitalization areas as well as reception and consultation rooms to help patients relax. (www.feliway.com)

6. Elevated blood glucose and glucosuria may be a result of persistent stress. A diagnosis of diabetes, therefore, should be confirmed by finding an elevated serum fructosamine.

In the wild, the number of feral cats living together depends on the availability of resources: food, water, privacy and safety, latrine availability, and sexual partners. This results in little competition and a social structure that does not require sharing or taking turns. Stress is minimal unless there is a lack of resources. Thus, communication and aggression are largely developed to keep distance between individuals and prevent contact with outsiders. The natural grouping, if there are enough resources, is a colony of related female cats with their young, that they jointly defend and nurse. Males are relegated to the periphery and vie for the prime breeding spot; usually only one tom lives with the group.

Feline signaling: Reading their cues

Tactile sense

Touch is very important to cats. Social rubbing may consist of rubbing a head, a flank, or a tail against another cat (allorubbing), person, or object. Whether a full-body rub or rubbing with a flank, tail, cheek, or other body part, this is believed to be an affiliative behavior and is seen between members of the same social group. Additionally, rubbing is not only tactile but is also a means of depositing scent. Cats often rub against us; unfortunately, we often misinterpret it as a request to be fed.

Allogrooming (mutual grooming) may precede a playful attack or follow a stressful interaction. It may appear to be conciliatory or may simply be grooming. Kneading and treading occurs in adults either as a kitten-regressive behavior or as a component of sexual interaction.

The neck bite/scruffing is a signal that is used in three contexts: for the transportation of a young kitten, as part of sexual mounting, and as a means for dominating another cat in a fight. Our use of scruffing fits most closely with the last and probably does not belong in a conciliatory, respectful cooperative setting.

Olfactory cues

The role of smell and scent in feline communication is something we human beings are ill-equipped to appreciate. It has been estimated that the size of the olfactory epithelium in cats can be up to 20 cm2, whereas people have only 2 to 4 cm2 of olfactory epithelium. Signals may be left by several methods. The one that is most problematic for people is urine spraying. This is a potent communication method that we fail to appreciate. Other forms of olfactory messaging are cheek marking an object or individual, scratching to leave scent from glands below the footpads, and midden (i.e., leaving a deposit of feces uncovered in a strategic place).

All of these signals have several advantages over visual cues. The message persists over time and in the absence of the sender, allowing for remote communication without risking the potential for conflict that direct interaction provides. This is especially useful in areas with poor visibility and at night. In this way, these signals help cats spread out over space as well as time-share territory. The disadvantage of this form of communication is that the sender cannot change the message once it has been deposited; it cannot be altered or removed and no adjustments can be made in response to the recipient's reaction. So urine marking in the home is an attempt to signal to the other cats when "I was here" and to establish a routine so that the cats can keep a distance by time-sharing the same space without needing to see each other. Every time we remove the urine, we interfere with this communication!

Because of our less-developed olfactory sense, we fail to "read" the cues patients may be giving us and are unable to fathom the overwhelming olfactory messages that the clinic experience must present to them.

Visual cues: Body language (posture, face, tail)

Body language and facial expression are extremely effective at maintaining or increasing distance between hostile individuals. Visual cues require an unobstructed view, adequate ambient light, and, unlike olfactory cues, that the two individuals occupy the same space together. Body posture gives the big picture of relaxation or fear (Figure 2), but facial expression (eyes, ears, whiskers, mouth, visibility of teeth) changes more rapidly and provides the finer details. Thus, in a clinic setting, for us to understand the mental or emotional state of an individual to avoid provoking the cat and getting hurt, it is extremely important to watch and interpret facial changes.

As a species that generally leads a solitary existence, survival depends on speed, stealth, self-reliance, and outsmarting others. As a consequence, cats may "bluff." When they act aggressively, they are generally hiding fear: "stoicism" hides vulnerability. Subtle changes in behavior mask significant illness. Body postures communicate confidence and physical prowess that may not be present. Keeping a threat at a distance may eliminate the need for a physical confrontation. The arched-back "Halloween cat" typifies this façade of confidence. Making oneself smaller, on the other hand, to minimize threat and evade attention is portrayed by a crouch and withdrawal. In these postures, the weight remains on all four paws so that flight or chase remains possible. A cat feeling less fearful does not need to be on its feet. However, an extremely fearful threatened cat may roll, exposing its abdomen with all four feet ready for self-defense. This cat will also be showing all of its weapons (nails and teeth) and be screaming.

Cats have extremely mobile ears (Figure 3). When the ears are forward, a cat is listening and is generally relaxed or alert but not emotionally aroused. Turned down and laterally, fl at "airplane ears" indicate that the cat is more fearful or feels threatened. When ears are back and tight to the head, the cat is feeling very threatened and frightened. This cat will have a partially or fully open mouth and be hissing, spitting, yowling, or screaming. The cat will protect itself if we fail to reduce the perceived threat level. Ears turned laterally but erect indicate the most reactive and aggressive state. In this case, the mouth will be closed and the cat will be emitting a low growl with or without swallowing. This is the cat that will attack you.

Vocalization

This form of communication requires that the recipient be present; it has the benefit of being easy to adjust from moment to moment. As with other signaling, cats have a well-developed repertoire of sounds to convey a need or wish to increase the distance between individuals. The sounds made for encouraging socialization are a trill or chirrup, purr, puffing, prusten, chatter, miaow, and sexual calling. The cat that is open-mouth reaming is highly aroused but is probably less aggressive than the cat that is close-mouth growl/wah-wah/mowling.

Cats use a combination of these different signals in any situation. We have to learn to look for all of them and interpret them together.

From a cat's point of view: Reducing threats in your clinic

In our clinics, we need to reduce exposure to predators (dogs, people, other cats) and other perceived threats. Looking over our clinic or hospital, what can we do to reduce the stress and threat level of the physical and social environment? What things or events assault the five senses of a cat? How can we make positive changes to these? Table 1 shows a chart that can be completed to evaluate your clinic.

Handling (examination, hospitalization, diagnostics,and treatments)

The goal is to handle our patients respectfully and provide an appeasing environment to build positive, long-term relationships. This is achieved by reducing threat and, thus, the cat's need to react defensively. Avoid doing things in a way that uses threatening feline body language or tone. The aggressive cat is upright, stiff-legged, large: sit down to examine the cat.

Never look a frightened cat directly in the eyes: Examine cats from behind, and other than for ophthalmic evaluation, avoid direct facial viewing. Look at the cat's face using a sideways glance with hooded eyelids. A slow blink is a reassuring signal to a cat, similar to a smile.

The aggressive cat growls and uses low tones; use light, upper-register tones, perhaps chirruping as cats do with conspecifics when they are relaxed. "Shushing" a cat to try to calm it as we might a child is the equivalent to hissing at the cat. Short repetitive sounds should also be avoided, since these may resemble spitting rhythms. Purrs, chuffing, trills, and chirrups are welcoming sounds.

When cats feel secure and safe, even just able to hide their faces in an elbow or a towel, they allow most procedures. Try to keep all four paws on the floor (or table) and avoid changing a cat's body position as much as possible. A comprehensive examination, blood and urine collection, body temperature measurement, and blood pressure evaluation can all be done without changing the cat's position. Examine the cat in the base of its own carrier if the lid can be removed. Don't hang a cat's forelimbs over the edge of a table for jugular venipuncture. For an already frightened cat, additional lack of support under the paws is not reassuring.

When you reach into a kennel to bring out a patient, you block the light and appear as a looming frightening stranger. Approach the opening of a kennel from the side so that some light still enters. Do not block every chance for escape; if the possibility to have some control over the environment and situation exists, the cat will be much more cooperative. Because cats rely on flight and fight for survival and are not reliant on others, when it comes to restraint, LESS IS MORE!

Cats inherently resist intimate handling and restraint. By restraining them, we take away their sense of control and cause them to react. It is very easy to condition negative emotional responses. Scruffing is strongly discouraged as it is an act of dominance that cats may resent. Cat bags, masks, and gloves all carry the scents of similarly terrified patients plus other sundry smells (anal gland secretion, pus, blood, halitosis, etc.). A towel is all that is needed to wrap a cat in, in order to protect the handler. Remember, a cat would rather flee than attack.

Other considerations

As cats age, they tolerate less time in the clinic. Siamese cats are especially prone to becoming depressed.

Three days is about as long as a cat can stand the indignities and anxieties of hospitalization, even with daily visits from the owner. Consider capping intravenous catheters and sending patients home and then having them return for day care. Even for in-hospital care, capping off fluid lines overnight prevents alarms from going off, keeping patients awake, and allows cats greater ease of movement. In either case, administer the overnight fluid volume subcutaneously.

Because cats "see" the world in "overlapping clouds of smells," we should try to provide familiar smells and reduce foreign, medicinal smells. Client-worn shirts are helpful in cages. Because cats' sense of hearing is tuned more finely than ours, it helps to provide as quiet and reassuring an environment as possible. Cats should not be exposed to the sounds of predators, including barking dogs. Try to reduce noise, especially when using certain induction agents that enhance hearing (e.g. ketamine).

Avoid changing a cat's diet during hospitalization, as that is likely to result in inappetence and possibly the development of an aversion. If a change in diet is required for therapeutic reasons, try to make the change gradually at home.

History taking is especially important given cats' tendency to hide illness. Listening carefully to clients and their concerns is extremely important. Often clients sense changes that represent real problems. I believe this situation is more common than the client who is blissfully unaware of significant health problems. By asking open-ended questions, we elicit a more detailed history than using only specific questions. For example, asking, "Have you noticed any changes in the contents of the litter box?" will probably evoke a yes or no answer. Asking something like, "What does his stool look like? Would you describe it as hard pellets, moist logs, a cow pie, or colored water? When did you first notice this?" will probably provide more useful answers. "Is there anything else?" is a valuable question.

Schedule recheck appointments to evaluate the effect of any medical or nutritional therapy. Reassessing important variables (e.g. body weight, body condition score, previously abnormal laboratory results) and updating the patient history allows us to provide better care for our feline patients. Care of the client is essential to providing complete patient care. It is only through hearing, educating, and working with the client that we are able to offer the best veterinary care.

Facilitating finances

The Bayer study showed that clients want costs spread out over time. Fear of large bills is another significant factor preventing owners from bringing their cats to the clinic. Many practices have wellness plans. Clinics interested in investigating the idea can have a look at an income-generating, customizable program called Partners in Wellness (www.partners-n-wellness.com). Additionally, directing clients toward pet health insurance for both preventive care and accident and illness coverage before their cats need it is sound medical advice. This could save lives otherwise lost because the owner hesitated to seek care or decided to euthanize the pet because of financial concerns.

Margie Scherk, DVM, DABVP (feline practice)

catsINK

Vancouver, British Columbia, Canada