How to make your practice feline friendly (Proceedings)

There is no question that feline medicine has grown steadily in popularity since the 1970s when the first feline-only practices were established. Today, organizations such as the American Association of Feline Practitioners (AAFP; www.catvets.com), the Cornell Feline Health Center (www.vet.cornell.edu/fhc), the International Society of Feline Medicine (www.isfm.net), the Winn Feline Foundation (www.winnfelinehealth.org) and the Feline Advisory Bureau (www.fabcats.org) provide funding for feline health research and continuing education for veterinarians and cat owners. Cats have now surpassed dogs as the most popular companion animal in many countries. In the United States, there are over 93 million pet cats compared with over 77 million pet dogs. One-third of households own at least 1 cat, and the average number of cats per household is 2.45. Canadians own 8.5 million cats compared with 6 million pet dogs. About 35% of Canadian households own at least 1 cat and the average number of cats per household is 1.76. However, some alarming statistics about feline veterinary care have been published in the United States. In 2006, only 64% of cats visited a veterinarian compared with 83% of dogs. Between 2001 and 2006, the number of feline veterinary visits declined by over 10% despite an increase in the number of owned cats. In addition, pet owners spend half as much on veterinary care for cats compared with dogs.

The reasons for the decline in feline veterinary care are multiple and complex. They include issues such as:

     • Difficulty getting the cat to the veterinary clinic

     • A low level of owner awareness of cats' basic medical needs

     • Difficulty recognizing subtle signs of illness in cats

     • The perception that cats are able to take care of themselves

     • The low perceived value of cats, since most cats are acquired for free

     • Owner discomfort and stress associated with experiences at the veterinary clinic

All veterinarians that treat cats can benefit from an understanding of the unique nature of cats as well as the physiologic and behavioral responses to stress experienced by this species. Cats are bonded to their home environment and seldom leave it by choice. Being forced into a strange environment makes a cat uncertain about its safety and causes anxiety and distress. Cats prefer to avoid danger and confrontation by running away or hiding, strategies that are not easy to employ during veterinary visits. Young kittens rarely experience anxiety at veterinary visits, but it may become apparent as the cat matures. Implementation of approaches to create a cat-friendly practice environment and use of respectful handling techniques will improve welfare and veterinary care for cats as well as make working with cats more rewarding for the veterinary team. In addition, health care tailored to the various feline life stages improves early recognition and treatment of problems, thereby improving feline health and welfare and preserving the human-animal bond.

How to encourage more feline veterinary visits

Reducing the stress associated with veterinary visits starts at home; habituation to the carrier and the car should start early in the cat's life. AAFP has published a position statement on the transport of cats that contains useful information.9 Each cat should travel to the veterinary clinic in its own carrier; it is unsafe to allow a cat to move freely inside an automobile. Placing more than one cat in a carrier is unwise as redirected aggression can occur in fearful situations. Solid sturdy carriers that open at the front and top or with easily removable tops are preferred. Soft-sided carriers can be used as long as they have adequate ventilation; however they collapse easily, are more difficult to clean, offer minimal protection, and are often difficult to get a cat out of. The carrier should provide the cat with an enclosed, safe feeling; coated wire carriers or cage-type carriers should be covered to provide privacy. Feliway can be sprayed on a towel and placed in the carrier about 30 min before the cat is put inside. Other tips that can help desensitize cats to carriers include leaving the carrier out in the home so that it is familiar, feeding the cat in or near the carrier, placing catnip or toys in the carrier, training the cat to enter the carrier on command for a reward, and acclimating the cat to the car and carrier with occasional short trips that are not to the veterinary clinic. Travel should be on an empty stomach; this helps prevent motion sickness and makes the cat more interested in treats while at the clinic. If necessary, medications such as maropitant may be used for motion sickness. Sedatives or tranquilizers should be avoided when possible as the cat may be injured because it is unstable and may not be properly monitored during transportation. If sedation must be used, benzodiazepines such as alprazolam are preferred (1/4 to 1/2 of 0.25 mg tablet BID, start one day before travel).

Once at the clinic, the owner should be welcomed with visible signs that the staff care about cats, such as posters, photos of staff and clients' cats, cat products and cat-specific information. Veterinary staff that interact with cats and their owners should be knowledgeable about general cat care, behavior, handling, medical and surgical needs, and cat breeds. The clinic can hold special educational events or 'clinics' for diabetes education, obesity prevention and treatment, kitten kindergarten, etc. A separate waiting area or even separate appointment times for cats are appreciated. Cat-friendly waiting areas are quiet with softer lighting. Tables or shelves should be provided so that carriers can be placed off the floor. Ideally, owner and cat would be placed into an examination room as soon as possible after arrival. Waiting in this normally quieter environment is preferable to a busy reception area. Minimizing wait times helps reduce stress for both cat and owner.

Once in the examination room, the clinician should spend time taking a history and talking with the owner while allowing the cat to adjust and venture out of the carrier on its own if possible. Remember that cats are very sensitive to sights, sounds (voices, equipment, door bells, etc.), smells (perfumes, disinfectants, alcohol, etc.) and touch so that attention should be paid to these details to reduce anxiety. No rule says all cats must be examined on a stainless steel table; many cats are more comfortable remaining in the carrier (with the top removed), or being examined on a lap, on the floor, on a shelf or even on the scale after being weighed. Cat-friendly exam table surfaces are made of non-slip materials, such as rubber mats. When possible, allow the cat to remain on the towel or bedding that came with the carrier. A Feliway plug-in diffuser should be placed in waiting areas, examination rooms and in areas of the clinic where cats will be housed. Security is important; ensure that any escaped cats cannot get out of doors or windows.

'Understand that most cats are pessimists – they assume the worst will happen. Try not to confirm it for them.' – Kim Kendall

Respectful feline handling is a critical component of successful feline practice.8 Gone are the days when difficult cats are handled with large gloves or 'scruffed.' The key to successful handling is an understanding of feline behavior. Most of the undesirable behaviors exhibited by cats in veterinary clinics are induced by fear. Physical confrontation is the last resort for most cats; their efforts are first focused on avoidance and escape. The more control the cat has during the visit, the less forceful and aggressive the handling, and the more patient the approach, the better the outcome. Many anxious cats can successfully be examined with the use of a towel to cover the head; reducing sight of unfamiliar people and places can reduce fear. Avoid making sounds that mimic hissing, such as 'shushing' sounds. Cats should be approached calmly and talked to quietly. Avoid direct eye contact as 'staring' is considered confrontational. Minimal restraint is the best approach for cat handling; make use of techniques such as allowing the cat to stay in the bottom half of the carrier. Always start with the least invasive procedures and progress to those more likely to be stressful later in the appointment. Owners are more likely to return for regular visits if they feel the veterinarian and clinic staff are skilled and respectful when handling cats.

Caging for cats in the clinic should be in a ward separate from dogs. As well, cages should be placed so that cats cannot see one another. Cage materials should decrease sounds and maintain heat, features that are not found in metal structures. Ideally, vertical space and hiding places should be provided with a shelf, as well as placement of a box or even the cat's own carrier in the cage. The cage should have enough room to place the food and water as far as possible from the litter box. Feliway can be sprayed on towels or bedding 30 minutes before use. Since cats evolved in desert environments, ambient temperatures somewhat above the typical human comfort zone are desirable. Warmth can be provided with bedding for insulation and burrowing.

Feline health care and counseling of cat owners on wellness and prevention varies by life stage.

The AAFP/AAHA guidelines defined 6 life stages with associated health care guidelines:

     1. Kitten: birth to 6 months

     2. Junior: 7 months to 2 years

     3. Prime/Adult: 3-6 years

     4. Mature: 7-10 years

     5. Senior: 11-14 years

     6. Geriatric: 15+ years

Annual health examinations are considered the minimum standard by AAFP and AAHA. More frequent examinations are recommended for senior and geriatric cats as well as those with chronic medical conditions (e.g., diabetes mellitus, chronic renal disease). Changes in health can occur quickly in these patients although the signs may not be readily apparent to owners. Educating owners about the subtle signs of sickness can lead to more frequent visits, better communication and more timely diagnosis and treatment. As well, prevention and earlier detection of disease can save money in the long run. Pet health insurance should be encouraged as it allows for optimal treatment decisions.

The 10 subtle signs of sickness

During examinations, asking questions in an open-ended manner will gather more information. Checklists can be used to ensure no areas of inquiry are missed. The body weight and body condition score or body mass index should be determined and recorded at every opportunity, even if a cat has been presented only for grooming or a nail trim. Percentage change in body weight since the last visit is also useful. Since cats are so good at hiding signs of illness, baseline laboratory testing is valuable and allows for detection of trends at future visits.

The home environment is critically important in wellness and veterinary staff should be trained to ask questions that uncover pertinent information and counsel clients about enriched environments. An indoor-only life style decreases the risks of trauma and infectious diseases, but welfare may be compromised and illness induced by a stressful or sterile environment. Recent research has shown that stressors (e.g., lack of sufficient resources, presence of visitors, changes in diet, changes in routine, conflict with other cats, etc.) can induce physical signs of illness in otherwise healthy cats, such as anorexia, vomiting or diarrhea. Indoor cats need adequate numbers of 'resources' - hiding places, elevated resting places, food and water stations, scratching posts, litter boxes and stimulating toys.

In conclusion, all veterinary clinics can incorporate principles of cat-friendly practice to encourage more frequent feline visits and more satisfied cat owners. As Dr. Barbara Stein famously said, 'Cats are not small dogs. Given the decrease in feline veterinary care, now more than ever veterinary teams must understand the unique nature of cats and their needs.

Resources

Feline Advisory Bureau/International Society of Feline Medicine Cat Friendly Practice:

http://www.isfm.net/catfriendlypractice/publications.html

CATalyst Cat-Friendly Practice:

http://www.catalystcouncil.org/resources/health_welfare/cat_friendly_practices/

References

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Flanigan J, Shepherd AJ, Majchrzak S et al: U.S. pet ownership & demographics sourcebook, Schaumburg, IL, 2007, American Veterinary Medical Association.

Herron ME, Buffington CA: Environmental enrichment for indoor cats, Compend Contin Educ Vet 32, 2010.

Lue TW, Pantenburg DP, Crawford PM: Impact of the owner-pet and client-veterinarian bond on the care that pets receive, J Am Vet Med Assoc 232:531, 2008.

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Rodan I, Folger B. Respectful handling of cats to prevent fear and pain: American Association of Feline Practitioners, http://www.catvets.com/professionals/guidelines/position/, 2009.

Rose C, Rodan I, Levy J et al. Transport of cats: American Association of Feline Practitioners, http://www.catvets.com/professionals/guidelines/position/, 2010.

Stella JL, Lord LK, Buffington CAT: Sickness behaviors in response to unusual external events in healthy cats and cats with feline interstitial cystitis, J Am Vet Med Assoc 238:67, 2011.

Vogt AH, Rodan I, Brown M et al: AAFP-AAHA: Feline life stage guidelines, J Feline Med Surg 12:43, 2010.