Top 5 Ways to Manage Patient Stress During Boarding or Hospitalization
Elizabeth Berliner, DVM, DABVP (Shelter Medicine Practice; Canine & Feline Practice), Cornell University
Physiologic, immunologic, and behavioral impacts of stress on dogs and cats are well-documented. In dogs, stress induced by novel environments can alter appetite, delay wound healing, exacerbate cardiovascular and respiratory conditions, result in gastroenteritis and colitis, and contribute to compulsive, anxious, and aggressive behaviors.1,2 In cats, stress is associated with increased incidence of upper respiratory tract disease, anorexia, GI upset, feline interstitial cystitis, aggression, and poor grooming.3
Although hospital and boarding stays are generally short, the severity of environmental stressors combined with individual variation in temperament and coping mechanisms can significantly compromise patient welfare. In addition, physiologic and behavioral markers of stress can be complicated to measure or interpret. There are many ways of reducing stress in hospitalized or boarded patients.
Following are the author’s top 5 methods of managing stress in these patients.
1. Environmental Mitigation & Monitoring
Patients in hospital and boarding facilities commonly demonstrate different behaviors than in the home.4 Broad and sustainable stress management in boarding and hospital settings should begin with a systematic review of the environment and should include monitoring systems to recognize and address stress. Noises, strange smells, busy human traffic patterns, disruptions of natural light cycles, and presence of other species (particularly cohousing of cats and dogs in the same ward) can contribute to increased stress levels.
Barking dogs can have a serious impact on the welfare and auditory health of humans and animals; decibel levels correlate with facility design.5,6 A reduced number of animals housed in rooms, installation of acoustic panels, and proactive management of stressed and barking dogs can lower stress for all patients in the facility. Formal observation of activities and patient responses can often reveal quick points of intervention, including adjustment of music or conversation at disruptive levels; alteration of cleaning, feeding, or clinical traffic patterns; provision of quiet times when activities are minimized; and reduced points of contact (eg, visual, auditory, olfactory) among patients. Stress scores, pain scales, and body language guides can be used to aid in recognition of observational indicators of stress, pain, and/or compromised welfare.7-10
2. Low-Stress Enclosures that Support Normal Behaviors
Cats and dogs can benefit from double-sided enclosures, choice and control in daily activities, and enriched enclosures (Figure 1).11-13 In a laboratory setting, dogs housed in smaller enclosures demonstrated lower activity levels and had a higher tendency toward stereotypies (eg, compulsively circling inside the cage).11 Provision of separate feeding and sleeping areas from elimination areas is correlated with appropriate use of these areas, mimicking housetraining behaviors.12 Larger (>9 square feet) and/or divided cat enclosures (Figure 2) and decreased transfer between enclosures were correlated with less stress-induced illnesses (eg, upper respiratory tract infections) in cats.13
Although not all facilities can be renovated or updated, those with single-sided cages or runs may be able to retrofit traditional cage banks with aftermarket portals or guillotine doors.14 Room housing with home-like provisions in boarding facilities can provide a more familiar environment and should include elements such as furniture or elevated platform beds for dogs (Figure 3) and vertical spaces for cats. Cats use windows as a reliable source of enrichment, especially when birds or wildlife are in sight.15
Simple changes can include installing quiet latches and hinges on cages to prevent slamming of doors and providing cage covers as visual barriers. In-cage hide boxes can be simple and cost-effective (eg, paper bag, cardboard box) and allow frightened or less social cats to avoid being seen (Figure 4).16 For dogs, travel crates can be placed in the enclosure to provide sleeping and hiding options.
FIGURE 1
Enriched basic dog kennel. Although the enclosure is older and contains chain link fence, this traditional double-sided run allows for separation during elimination, sleeping, and feeding activities and is enriched with soft elevated bedding and toys. Image courtesy of Sarah E. Nickerson, Cornell University
3. Human–Animal Interactions
Because clinical treatment, feeding, and cleaning are necessary points of contact that can be unpleasant, protocols should account for function and duration of the stressor and reduce negative impacts through gentle handing, positive reinforcement, and clinical efficiency.
For clinical procedures or treatments performed on conscious patients, timing and duration of a stressful event should mitigate patient stressors. For example, all necessary supplies and staff should be prepared in advance of engaging the patient so the task can be accomplished efficiently with as short a duration as possible. For repetitive points of stress (eg, feeding, cleaning), a predictable schedule can help long-term patients.
Daily activities that incorporate positive human interactions (eg, petting, playing, exercise) apart from husbandry and clinical care can help more social patients. In-kennel training activities reward desirable behaviors and provide mental enrichment.
Spot-cleaning techniques and use of double-sided enclosures to minimize handling can reduce stress during cleaning, risk for infectious disease transmission, and chance of injury to staff. Minimal restraint and low-stress handling techniques, starting from the point of entry and continuing through the patient’s stay, are essential for individual patient welfare.17,18 These can also result in a safer, more pleasant working environment for staff.
4. Enrichment Options
Cohousing, interaction with conspecifics, and daily grooming can help relieve stress in dogs in stable laboratory settings19; however, time spent in hospital and boarding facilities is usually short, which can prohibit regular use of these methods. For patients eating well, puzzle feeders can enhance mealtimes and provide mental stimulation (Figure 5). For cats that are cage housed for extended periods, disposable scratch pads can provide the ability to stretch and scratch. The effect of toys depends on individual preference. Novel items are typically preferable; thus, maintaining a scheduled rotation of enrichment experiences can be engaging (Figure 6).
Although there have been several studies on the effect music, audiobooks, and talk radio have on dogs and cats, the overall benefits remain unclear20,21; if these are offered, the volume should be well-controlled, and extended quiet times should be provided for natural sleep cycles. Olfactory stimulation with desirable fragrances can also provide mental stimulation (Figure 7). These can be intermittently sprayed in housing areas but never directly on patients.
Activities for which patients express a preference (including walking paths, exercise modalities, human interactions, play items, and food choices) should be recognized and provided, given they are appropriate based on other treatment and husbandry parameters.19,22,23 It is ideal to incorporate the stimulation of multiple senses (eg, olfactory, auditory, tactile) when designing enrichment strategies. Another key concept for enrichment programs is that the patient must engage positively with the item offered. It is not enough to simply offer a variety of options; responses should be monitored to assess if the item provokes an active, positive response.
FIGURE 5A
Tools for feeding enrichment. Stuffing hollow toys with food/treats and using puzzle feeders can provide mental stimulation and mimic natural hunting or play activities. Images courtesy of Sarah E. Nickerson, Cornell University
5. Behavioral Pharmaceuticals
Medication is not a comprehensive approach to stress management but can be an important adjunctive therapy. Trazodone, a serotonin-receptor antagonist and reuptake inhibitor, has been shown to reduce stress-related behaviors in dogs given 4-10 mg/kg PO every 8 to 12 hours in clinic and shelter settings and in cats given 50 mg/cat (NOT mg/kg) PO being transported to the veterinary clinic.24-26 Gabapentin (13-30 mg/kg PO) has been used successfully in cats to reduce stress during veterinary examinations and handling.27 When available capsules are used, gabapentin is often administered at 100 mg/cat (NOT mg/kg) PO and repeated every 8 to 12 hours.28 Trazodone and gabapentin are commonly used in shelters for treatment of situational anxiety. These are controlled substances in some states, and even when logging is not required, facilities should consider limiting access to these medications and maintaining records of administration. Benzodiazepines (eg, diazepam [0.5-2 mg/kg PO] and alprazolam [0.02-0.1 mg/kg PO]) have been used for treatment of situational anxiety in dogs but can have adverse effects (eg, profound lethargy, paradoxical stimulatory effects).29 Acepromazine, a phenothiazine tranquilizer, is not recommended for treatment of anxiety because, although it effectively produces sedation, it is not anxiolytic and may result in an increased and unpredictable fear response.
Other behavioral pharmaceuticals (eg, tricyclic antidepressants, selective serotonin reuptake inhibitors) have demonstrated successful management of generalized anxiety-related disorders in dogs and cats; however, because these drugs have longer periods to reach steady state, they are typically more appropriate for long-term use rather than for situational anxiety. Efficacy of pheromone use remains unclear, as results vary; however, they are considered safe and likely effective for some patients with situational anxiety.30 Evidence for routine use of nutraceuticals (eg, L-theanine, α casozepine) and other supplements is also varied, particularly for short-term boarding. Prescription medications should only be dispensed by a clinician and with consent from the pet owner. Use of pharmaceuticals may be contraindicated in some patients.
Conclusion
Hospitals and boarding facilities can be inherently stressful, but environmental modifications and protocols that address physical and behavioral health can help promote well-being in these settings. Training resources for stress management in patients in hospital and boarding facilities are widely available.17,18,31,32 It can be beneficial to identify key staff members with an interest in behavioral welfare and enrichment to engage in evaluating current practices, creating new protocols, and enacting stress management strategies.