Stress During Hospitalization in Dogs and Cats: Consequences and Prevention
World Small Animal Veterinary Association World Congress Proceedings, 2007
Patrick Pageat, DVM, MSc, PhD, ECVBM-CA
Phérosynthèse Research Centre
Le Rieu Neuf, France

Modern and effective veterinary medicine and surgery leads the vet to hospitalize some dogs and cats. This is a stressful event for both the pet and its owners. It is usually possible to control the owners' stress by explaining the oncoming treatment and examination and by showing the place where the pet will be kept and in which condition it will stay. Such arguments are poorly helpful for the dogs and cats that will display different kind of stress-related reactions including physical and behavioral modifications. These reactions will make the medical work more difficult to perform, the nurses and vets will be at risk to be bitten or scratched, the reactions of the animals to different drugs (e.g., anesthetic agents) will be modified, the immune system will be impaired and the pet will remember its stay in hospital as a fearful experience making the future veterinary examination a nightmare. Moreover, it also impairs the recovering of a physiological equilibrium which is the condition to cure the patient, and it will be highly detrimental to the efficacy of the treatment.

Since vets are more and more concerned about distress in hospitalized animals, it makes sense to use the current scientific results about precocious detection and effective prevention of such reactions in both dogs and cats. Because the two species are deeply different, we shall describe separately the medical approach of stress-related reactions in each of those.

Detecting and Preventing Stress in Hospitalized Cats

Cats are easily stressed animals and modifying their surrounding as well as introducing new people or animals are certainly some of the most distressing events a cat can experience. Every vet and every nurse has experienced the difficult management of the hospitalized cats, with its association of anorexia, inhibition and aggression.

The clinical expression of the acute stress in cats is organized around three characteristics:

 Disorganization of the self-oriented behaviors (mainly feeding and self-grooming)

 Disorganization of the way to use the available space (disorganized elimination, inappropriate place to sleep)

 Emotional aggressions: irritative and fear-related aggression

Two associations of symptoms are usually observed. The first one is characterized by an increased self-grooming (the cat licks every part of its body which has been touched during the treatment, or licks the accessible parts of its body if the "touched ones" are inaccessible because of an Elizabethan collar), a tendency to hide under the carpet or the cover, inappropriate elimination and a sub-continuous attitude of irritation (the cat is curled up, the last third of the tail moving spastically when someone tries to approach) and the aggressions occur systematically during the contacts. Such cats, showing a very productive behavior, are usually regarded as very difficult, but their physiological evolution appears to be much more favorable than in the cats of the second type. These cats show an inhibited self-grooming, they do not eat, eliminate and sleep in the litter box and they are rarely aggressive. Easier to manage, their medical evolution is usually poor and their anorexia induces many difficulties. Some cats will show an association of symptoms from those groups.

The disorganization of the way to use the available space (the cage) seems to be the first symptom to appear. Whatever the type of disorder, it can be regarded as a precocious sign of distress and we must propose some adapted strategy, as described hereunder.

The causes of this distress are now well identified and two main causes have to be known because observed in all the cats. The first one is the loss of the territory. Each cat organizes its surrounding by marking it with different odorant secretions including pheromones associated with some visual signals. Facial marking with the pheromone F3 is used to organize the ways to go from one part of the territory to another one, and it used too to mark every new and not dangerous structure within the territory (e.g., new furniture). Scratching marks, urine marking, and individual marks (odorant secretions and specialized proteins carrying individual signatures) are the other ways to organize the territory and provide appeasing information for the inhabitant. Being hospitalized, the cat looses suddenly this information in a time when it is especially sensitive to stress as a consequence of the disease it is suffering.

The second cause of stress is the contact with novel individuals who are not carrying the allomarking pheromone F4. Such individuals, for a cat experiencing an internal stress (the cat is sick), are considered as possible aggressors and induce distress.

Some additional causes of stress will worsen the disorders induce by the two main: inappropriately organized cages, painful treatments, disturbing neighbors (the other hospitalized animals). The poor organization of some cages is a common distressing element. The lack of real litter box, a food and water bowl placed close to the litter box, the lack of access to the third dimension (something to climb on), are the most common mistakes we still observe in some hospitals.

The ways to prevent are based on the understanding of the inducing causes. The development of the pheromonotherapy has been very helpful in the management of the hospitalized cats. Preparing the cages by spraying F3 on the different corners and on the main elements is effective in preventing the first reactions of stress. During the following days, electric diffusers of F3 will help in providing continuous appeasing information. The use of F4 on the hands of the medical team is another technique which helps in preventing the second main cause of distress. But these techniques do not work if the management of the environment is inappropriate. Each cage must include a litter box which will be on the opposite corner to the food and water, and a resting area on which the cat will climb must be provided as often as possible (except if there is some medical contraindication). The association of different species in the same hospital must be prohibited, and is especially unacceptable for dogs and cats. The control of the pain related to the disease as well as to the treatment itself, is crucial.

Hospitalizing a cat must not be regarded as a routine question. As often as possible, we have to try to treat the cat in its home, but when it is impossible, the hospitalization has to be prepared with professionalism to guarantee the best possible medical result.

Detecting and Preventing Stress in Hospitalized Dogs

Being hospitalized can be a stressful experience in dogs too, but the underlying reasons are different to those described in cats. Dogs are social animals that cannot deal easily with isolation and especially separation to their group. Whatever the quality of the surrounding provided by the veterinary clinic, the dog will display different signs of distress, and vocalizing is probably one of the most commonly observed. Pain, related to the medical problem that has led to hospitalization or to the treatment or examination, is a major inducer of distress. If some dogs display fear aggression or irritative aggression as a response to pain, some others can get inhibited, showing typical signs of learned helplessness. Most of those dog will cope with this situation, especially when the vet team behaves in an appropriate way, providing appeasing stimuli, avoiding any kind of excessive or fearful punishment and treating pain.

The situation gets much more difficult when hospitalizing a dog that displays clinical signs of anxiety with its owners and moreover with those suffering of over-attachment, sensorial deprivation or any kind of anxiety usually controlled in presence of the owners or any kind of well-known person, animal or surrounding. In such cases, the dog will display the famous symptoms of separation anxiety that will be emphasized by the novelty of the situation and the fear induced by the fear reactions of the other hospitalized dogs: in dogs, fear is contagious!

In order to detect and prevent distress in hospitalized dogs, it is crucial to use a questionnaire to diagnose the previous signs of anxiety and the possible over-attachment. Some questions like "how does your dog react when you let it home alone?", "when you, or someone within the family, is home with the dog, does the dog follow you or this person everywhere?", "does your dog display any sign of fear when it is in presence of a novel stimulus (humans, animals, things, ...)?", "does your dog growl or bite if you try to provide it any kind of medical treatment?", are easy to ask and can help in detecting the dogs that will be especially difficult to hospitalize. If there is any doubt regarding its reactions when getting separated to the owners, it is easy and useful to test in asking the owners (one by one) to leave the room where the dog stays with the other family members and some people from the vet team. If the dog only reacts to the absence of a precise person, it underlines a specific bond that could be over-attachment. Such a dog will need to be managed in a special way in order to control its anxiety.

In dogs, the symptoms of distress include physical signs (autonomic signs like salivation, vomiting, diarrhea, tachypnea), which can be associated with inhibition (anorexia, hiding in a corner of the crate, shaking) or overactivity (scratching the walls, panting, jumping, barking and sometime aggression, direct or re-directed. Different studies have also shown the numerous biological modifications related to distress in this species: increased hematocrit, cortisol, neutrophil/lymphocyte rate, prolactinaemia. Some between these modifications could be regarded as detrimental to the effectiveness of the treatment of many physical problems since most of them are correlated with impaired immune reactions.

On the contrary to the cat, the topographic organization of the cage is poorly effective in controlling the possible distress. The management of the physical relationships between the dog and the medical team is much more effective. Walking the dog on the leash, grooming it, petting it, may help. The prescription of psychotropic drugs is poorly interesting since it can create problems of interactions with the drugs specifically used for the treatment of the physical problem. In dogs showing signs of anorexia, the use of an alpha-2-antagonist, mianserin, is interesting to stimulate food intake and spontaneous motor activity.

Different authors have described some cases of successful treatment using alternative medication or techniques like aromatherapy, homeopathy or acupuncture.

Different controlled clinical trials, against placebo or reference products, have shown that pheromonotherapy using the synthetic analogue of the Dog Appeasing Pheromone, is effective to reduce the clinical signs of separation-related anxiety and controlling fear reactions. The anticipation of the stress by treating the dog with the pheromone during the day before the hospitalization is very effective to increase the efficacy of this treatment.

The hospitalization is sometime a good opportunity to convince the owners to pay attention to the anxiety of their dog and especially to the over-attachment. Assuming that separation-related disorders are one the most common causes for euthanasia and relinquishment, early detection and treatment of this problem is a major issue from a welfare point of view.


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Speaker Information
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Patrick Pageat, DVM, MSc, PhD, ECVBM-CA
Pherosynthese Research Centre/University of Torino

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