Old Dogs and New Tricks? – Improving Detection and Management of Canine Cognitive DysfunctionSummary:

Geriatric care is becoming more recognised as an important part of dealing with patients in the veterinary profession, especially as patient life is extending. More support is needed from veterinary professionals in order for the pet and owner to deal with what can be a difficult stage of life. Geriatric clinics have an important role in that they can be used to detect the effects of ageing. These changes are commonly considered as organ failure but in fact the central nervous system (CNS) is also affected by the ageing process E.g. changes in neurotransmitter levels, alterations in membrane permeability and increased production of free radicals. These changes are a normal process of ageing but issues arise when these changes influence the normal interactions and behaviour of the animal. This is known as canine cognitive dysfunction syndrome (CCDS) and has four main categories of recognition – Disorientation, changes in social and environmental interactions, changes in the sleep/wake cycle and loss of learned behaviours. It must be considered when looking at elderly patients whether the presenting signs are due to medical issues arising from organ failure alone, behavioural changes related to the ageing CNS or CCDS, or a mixture of both. Recognising the behavioural signs of CCDS early in the disease process is important to prolong good, quality life by intervention of the disease. Therefore, it’s paramount to ask the right questions during clinics to identify CCDS patients, while there’s still the chance to make a valued difference to the patient’s life. Management of CCDS comes by first ruling out any differentials, supporting the patient nutritionally with essential fatty acids and antioxidants, dietary supplementation with products such as Senilife and Aktivait, treatment with drugs to promote brain function, for example, increasing cerebral blood flow (Vivitonin) or slowing down cell damage (Selgian) and finally supporting the patient with behavioural modification and re-training. In instances of disorientation and anxiousness, it may be necessary to modify the animals’ environment by increasing accessibility and maximising environmental predictability.

Key Points:

Ageing of the central nervous system is becoming a more recognised part of veterinary medicine.

The differentiation between the normal ageing central nervous system and CCDS is important in terms of management.

Some behavioural changes may be attributable to medical conditions which must be ruled out before CCDS is considered.

The four main categories of CCDS diagnosis are: Disorientation, differences in social and environmental interaction, disturbances in the sleep/wake cycle and loss of learned behaviours.

Management is achieved through nutrition, promotion of brain function with drugs and behavioural and environmental modification.

Geriatric clinics and regular elderly patient check-ups are integral in detection of CCDS in the early stages of the disease which ultimately leads to a better prognosis in terms of prolongation of good, quality life.

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Key Words:

Geriatric Ageing Detection Management Behaviour Interaction Distress CNS Cognitive Dysfunction

Thank you ever so much Anthony, it is nice to know where people are listening from and what backgrounds people are coming from, so thank you very much for being here this evening and I hope you enjoyed the puppy and kitten one if you were listening last week. We are going to be looking, as Anthony said, at the other end of the lifespan now.

I’m going to start off by putting it in context really, that in contrast to human medicine which has been in recognising the importance of healthcare in its broadest terms, both in terms of its mental and its physical components in humans for a very long time, in contrast our profession has only really very relatively recently started thinking seriously about geriatric care and we still don’t really talk about it as a separate discipline as they do in some places in terms of human medicine, but definitely there is more of a recognition now that we have to have a slightly more specialised attitude towards the older pets that we are dealing with. Although as I say, in human medicine the importance of quality of life to people has been thought about for longer, we are all very aware from the news that that doesn’t always happen in the way that perhaps it should, so it’s not that the veterinary profession is way behind the medical profession but I think there are things we can learn from them certainly and there are definite similarities between caring for elderly humans and caring for elderly animals.

So the change in demographics has led to this changing emphasis in veterinary care and really if you’re in first opinion practice a support service (and I would call it a support service rather than a sort of treatment service because what we are dealing with is both supporting the animal and their owners through what can be a difficult stage of life, from both angles as we will see as we go through the presentation), providing full support to the geriatric animal is now seen as important for those of us now working in first opinion practice.

So first, to just start off by looking at canine life expectancy and I am going to mention cats just once this evening when we look at life expectancy, just to contrast the two species before then concentrating on the dog. So with dogs, considerable variation as we know in life expectancy, often related to breed with smaller dogs generally living longer, so in the picture here we have got an Irish Wolfhound only going to live for around seven to eight years whereas generally Jack Russell Terriers may reach fifteen, may even go into its twenties and those of us who have particular breeds that we own, I’m a flat coat owner so I am used to the slightly shorter duration of life that’s expected, sadly with the dogs that I share my life with. But crossbreeds and mongrels are often well ahead of course in the longevity stakes and I thought it would be interesting just to look at some records in terms of longevity in dogs.

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For the UK, it’s actually a Welsh Collie called Taffy who has the record of being the oldest recorded dog in the UK, he died in 1980 so quite recently, or certainly feels quite recently to me, and lived for 27 years and 317 days which is fairly impressive. But that’s not the oldest dog in the world.

The oldest dog recorded in the Guinness Book of Records is actually 29 years and five months and that was an Australian Cattle dog called Bluey and that was a lot longer ago too. So we tend to think about longevity in dogs being part of our prowess in terms of our veterinary profession in that we have extended life and that now we are so good at our jobs that they are living longer but this is back in 1910. A man called Less Hall in Victoria, Australia got Bluey as a puppy and he worked that dog with his cattle and sheep for nearly 20 years but unfortunately had to put him to sleep and that happened November 14, 1939, at the grand old age of 29 years and five months, so pretty impressive.

If we just contrast that with cats, cats have got much less longevity variation, they usually live into their mid to late teens obviously with exceptions like there always are but there is little breed variation and life expectancy for cats is quite like a much of a muchness across the board and not affected in the same way by breed.

Looking at some records for cats, an American cat called Crème Puff (Yes really), died when she was 38 years and three days, she is the oldest cat ever recorded and that’s according to the Guinness Book of World records and again, you can see there, August 6th, 2005 so fairly recently.

And the oldest feline recorded in the UK, well that goes to a cat in Devon, or does it, because this cat, born in 1903 owned by somebody in Devon, died one day after his 36th birthday but there is a little bit of an argument as to whether this is actually authentic.

So if you’re actually looking for the most reliably oldest recorded cat in the UK, it goes to this female tabby named Ma, who was again owned in England and was put to sleep on November 5 th 1957 at the age of 34. That’s just some interesting statistics about life expectancy and our pets.

As I say, maybe not all down to modern veterinary care. So the veterinary profession can’t offer any cure for ageing. We know that ageing is an inevitable process but if we understand this ageing process and we actually think about the ways in which diet and drugs and lifestyle can affect it, we can certainly increase the quality of the life of our ageing pet population and that is very much the aim of our profession, quality of life – We make a vow when we qualify about the welfare of the animals committed to our care, being our prime concern. So, quality of life is very important.

In the UK, we have got lots of veterinary practice now offering regular health checks for senior or geriatric pets and that’s been really brought about by the focus on early detection of organ failure. What we need to remember, yes of course heart, kidneys, liver, we do need to be looking at these systems and we do need early detection for organ failure in our older pets but age doesn’t only take its toll on the organs that we think about perhaps more traditionally but also have an effect on the central nervous system.

So it’s changes in that CNS from the ageing process which are an important consideration for our geriatric patients and we have all sorts of changes, changes in your transmitter levels, alteration in membrane permeability, of course increased production of free radicals, are leading to the onset of age related behavioural changes in this population of pets.

Of course when we are thinking about treating these animals or what interventions we may be thinking of using when managing this process, (treatment probably isn’t the right word because of

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the fact that it is an inevitable process, we are not actually stopping it, we are just helping to improve quality of life during the ageing process) as it takes its effect on the heart and the brain to major ones associated with the slowing down type symptoms that owners report, we do need to differentiate between those that are simply slowing down because of the fact that all of their organs are basically coming to the end of their lives and have been used a lot, or whether we are actually dealing with an animal finding it difficult to interact at a social level. So when we are talking about canine cognitive dysfunction as a condition then true brain ageing at that level actually influences the animal interactions with the world that it is living in at more of a social level.

Normal ageing of course takes place in every single dog that’s coming into its geriatric years. When there are no signs of cognitive dysfunction, that doesn’t mean they don’t have a problem. We still need to support our elderly patients in terms of maximising their quality of life, we are going to be thinking about maybe changes in nutrition, we want to support their digestive system, we will also think about any ageing dog and in supporting their brain function as they go into older age. Also alterations in the physical environment may also be necessary because of mobility issues or sensory compromise in any dog that’s ageing, even If there are no signs of cognitive dysfunction. So it is important not to think of only diseases of the Canine Cognitive Dysfunction Syndrome (CCDS) sufferers as being the ones to think about.

I am going to focus a little bit on cognitive dysfunction as that the topic of the webinar tonight. So cognitive dysfunction is a medical condition and that’s really important, so they are medical changes that need treatment or need management and there is a lack of recognisable clinical symptoms, so when you’re looking at detecting cognitive dysfunction the signs that are going to get you to your diagnosis are almost entirely behavioural and that is going to necessitate a slightly different approach perhaps in general practice from what we are used to doing on a daily basis.

There are four main categories assigned to the presenting signs of CCDS and you may have heard these referred to with all sorts of acronyms, while here we are going to use more of a descriptive approach so disorientation is the first one, changes in social and environmental interaction, changes in sleep/wake cycle and loss of learned behaviours. Now each of those categories could have symptoms in them which are indicative of organic disease or of CCDS alone and this is where it is really important to have an over-arching view on elderly patients and look at this inter-play which is possible between physical and brain related behavioural disease.

The signs need to be present really from a range of those categories. If we only had symptoms from only one of those categories, I really would be looking for whether there was a medical cause for that rather than jumping to the conclusion of cognitive dysfunction, but if you have signs from each of the categories and most importantly from the two that are about social interaction and interaction with the environment, so disorientation and changes in social interaction, a diagnosis of cognitive dysfunction certainly needs to be considered.

How many dogs are affected is something that is perhaps of interest to us as a profession because I think we overlook this population very definitely, they are underdiagnosed and we will go on to some of the reasons for that. As many as 48% in a market study in the US of dogs over eight years of age were shown to have signs of cognitive dysfunction and when there was a study done on dogs older, between 11 and 16 years of age, 62% of those dogs were shown to have signs of CCDS and it’s also shown in these studies, the number of finds is also found to increase with age, so you are more likely as you get older to have more signs and from more categories. That is a lot of dogs potentially out there with a condition and yes, we can’t cure it, we can’t treat it, but we can help to manage it and we can certainly improve quality of life and this is something that really is underutilised in the

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veterinary profession, there is a population of dogs out there that aren’t getting the best possible care in these later years.

So what are we looking at when we are doing out health checks for our geriatric patients then? Well of course we need to remember that maybe the individual in front of us has entirely medical issues and we are much more proficient perhaps at looking at it from that perspective, there may also be in that population in front of us of geriatrics, those that have entirely behavioural age related changes but their medical conditions are none so they are perfectly physically well, but there are changes in a behavioural sense. More commonly, it is the result of a combined effect of the ageing process of learning on the pets’ physical and mental health that presents in these geriatrics.

So the ageing process is both progressive and irreversible and rarely is one system going to be affected by the ageing process, it is much more likely that the animal is going to be showing signs of deterioration in a number of organ systems that we more traditionally think of, such as, the heart, liver and kidneys, but also the brain and the central nervous system.

So let’s just recap on those medical signs of ageing, and I’m going to look at how some of these need to be thought about as a differential diagnosis as we go through our examination and our care of elderly patients, certainly of course sensory compromise, orthopaedic changes, we may very readily think about that in some of our older dogs (although that’s an another subject which we need to be looking at providing the best possible care because we see an awful lot of patients coming through the behavioural route, especially when they get older, with behavioural changes where actually they are orthopaedic changes causing mobility issues with chronic pain etc which is affecting their behaviour, but of course it is also in its own right a medical sign of ageing which needs to be treated), depletion of muscle and nerve cells and changes in skin and coat condition would be expected in an ageing patient as well as alteration in the function of its major body systems, but from a behavioural point of view, the other thing that happens as you get older is a decrease in the ability to cope with stress. The part of the body, the HPA axis (Hypothalamic – pituitary – adrenal axis) is becoming less efficient with its working as you get older, but it’s also an inherent increase in anxiety with increasing age, and anxiety being the emotion which predicts the possibility of a negative outcome. So there is more of a tendency as one gets older to anticipate that something may have a negative outcome and have an anxious reaction to that, and not being able to cope with the changes or unpredictability that the environment can through at you. So things that a younger dog can take in its stride, an older dog just through the ageing process, may find it more difficult to cope with and may start to show as a result of that behavioural changes, things like sensitivity to noises for example, as they get older. A combination of sensory compromise and a decreased ability to cope with stress leads to an increase in the presentation of sound related problems, until you get to the point of course when the hearing becomes impaired and so sound related problems start to plummet. When we are looking at these dogs, we have to be thinking in this very holistic approach, thinking of all the possible contributing factors which may be affecting that patient that is standing in front of us in this consultation.

Behavioural signs of ageing, again there are a bunch of behavioural signs in the ageing process which are not necessarily related to canine cognitive dysfunction. Changes in sleep patterns and alterations in exercise requirements as well as slowing down of reactions and of learning are part of ageing, it becomes more difficult and as you get older (and some of us may testify), to learn things, to change things to accept the onset of new possibilities because of the fact that we are ageing, and that may be totally separate from a situation of dementia. We can’t link CCDS to all changes associated with ageing. There are some behavioural signs that happen, whether or not you have actual dementia signs. Ageing is not an illness, ageing is a process, it is not something which is abnormal. CCDS is an illness and an abnormal form of ageing, which has specific behavioural consequences.

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So when we’re doing our health checks for geriatrics, I think we are probably quite good at suggesting to our owners that they report health deterioration and there is regular increasing physical examinations being suggested for our elderly pets. We also need to be thinking about those changes in behaviour and also thinking about behavioural examination or at least asking the right sorts of questions to detect the more behavioural aspects of the ageing process and to determine or not whether that is within normal boundaries or whether we are actually encroaching into the territory of cognitive dysfunction.

Differentiating between normal ageing and the onset of CCDS relies on looking at the connection between behaviour and the context and that is the classic sign of dementia or as we tend to call it in the veterinary world, cognitive dysfunction. And many owners will actually talk to you about this disconnection, about the fact that this animals behaviour is odd, is strange in a context which doesn’t seem to make sense in the way that they are seeing it. Then we have the owners that describe the dog as seeming like a stranger in its own home, they are disconnected not only from the physical environment but disconnected from their social environment, maybe with their owners or other dogs and we can see quite marked changes in reactions or interactions and relationships between dogs within the household if one of them is beginning to suffer with cognitive dysfunction. We may even see deterioration in the relationships such that we get inter-dog aggression and onset within that household. Sometimes it can be the individual that does not have the cognitive dysfunction who is showing the signs of so called aggression or repelling behaviour, a behaviour which is designed to get rid of a perceived threat, because for the dog that is not in the ageing process, or doesn’t have dementia if they are ageing, for them the behaviour of their housemate suffering from cognitive dysfunction is going to appear out of context, is going to appear odd or strange, and that can lead to an emotional response as well in the other dog. So, another thing to think about when we are looking at these elderly patients is considering not only that individual that is in front of you at that time but, also thinking about the household, asking about other pets, asking about the relationship with the other pets and whether owners had noticed any change in that.

In cases of cognitive dysfunction, it has been post-mortems that have given most of the evidence to the processes that are involved and first identify that the neuropathological lesions that are seen in CCDS are similar, if not the same in some situations, to those seen in people with Alzheimer’s disease and you will hear people refer to CCDS as canine Alzheimer’s. That’s not quite strictly true, which is why we use a slightly different name for it but certainly there are enormous similarities. So the physical changes associated with ageing are primarily going to be detected at post-mortem, so obviously then can’t be used diagnostically, but it is useful to have this post-mortem evidence, because from it we can learn about the physical processes that happen during the onset of this kind of dysfunction and then develop treatment or management strategies going forward. It has been useful to have post mortem information though obviously not useful for that individual it’s useful for the dogs that follow.

So what physical changes are associated with canine cognitive dysfunction? Well here you can see the brain of a young dog and the brain of an old dog, and you can see that decrease in brain mass quite clearly as well as the increase in ventricle size, so that is probably the main features if you like, if you look at the brain of a dog that is suffering from cognitive dysfunction, there will be a smaller brain mass and an increase in ventricle size. If the decrease in mass is coming from an internal increase in the vacuolation and increase in ventricle size rather than the brain shrinking away from the outside, which is a good job otherwise their brains would be rattling. Anyway, an increase in oxidative stress is also going to be important of course in cognitive dysfunction, and what happens then through the extra free-radicals is vacuolation of parts of the brain as we know, and a decrease in essential fatty acids, DHA and EPA, that will lead to changes in the density and therefore the

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effectiveness of the myelin sheaths and that of course is going to change the rapidity of the neurological signal transfer that’s happening. We are all very familiar with old age in our changes in ability to quickly recognise incoming neuronal messages, such as when we need to go to the toilet, having less warning between a full bladder and a really desperate need to evacuate it is related to lipo-oxidation, the changes in DHA and EPA and the effectiveness of myelin sheaths. When you look at these patients with cognitive dysfunction, it is one of the tell-tale physical signs.

We also have laying down of beta-amyloid plaques, if you look at the pictures here, the A and C on the left hand side are form an ageing dog brain with canine cognitive dysfunction, whilst the images on the right hand side (B and D) are from an ageing human brain suffering from Alzheimer’s, you can see very similar changes, so laying down of beta amyloid plaques in the hippocampus and the cortex primarily is a really consistent feature. There is also evidence of hypoxia leading to CNS function changes and alterations in neurotransmitter levels. Primarily dopamine and serotonin decreasing due to the increased level of monaminooxidase-B, therefore if you hold that thought, when we come to think about drug interventions later, you’ll make sense of the drugs that we’re likely to use.

The most important thing that we know that we can identify obviously in terms of physical changes, but too late for that individual, what we are looking at is trying to identify it on the behavioural signs because it’s the behavioural signs that are going to be able to give us the early detection, the early intervention which is so important in the success of treatment/management. If we are going to have the best prognosis possibly in terms of extension of good quality life, so that’s not an extension of life, we aren’t changing life expectancy necessarily, but we are changing the quality of the life that that pet can have. Those pets that exhibit symptoms of old age are suffering from a medical condition. As I said, normal ageing is not an illness but CCDS very definitely is, and it requires appropriate veterinary attention but really importantly it requires prompt veterinary attention. The sooner we can identify these individuals the more successful our intervention can be.

Early detection relies on noticing these behavioural signs of cognitive dysfunction. The most effective way of doing that is to actually be proactive, we’ll see in a minute that owners are often quite reluctant to raise these issues with us, so including a behavioural question in routine either geriatric clinics or actually booster appointments for elderly dogs as well, can be a very useful way of actually getting this information. In this little picture, we have got some examples of the sorts of things we might be thinking about. ‘Doesn’t wag like it used to’ – so not showing the same level of pleasurable interaction with its environment, either the physical environment or the social environment. ‘Accidents indoors’ – is referring to here, the house soiling changes. Now the house soiling changes in cognitive dysfunction are actually part of the loss of learned behaviour category, so what happens is, the behaviours that learnt through association earlier in life start to be lost and that’s when you get house soiling problems. ‘Lack of exercise’ Or being less active and ‘sleeping more’ – now those obviously are related in a CCDS dog because the sleep has actually become different, there is actually a change in the way the animal sleeps, yes they appear to be sleeping more and they seem to be less active, but actually it’s the pattern of sleeping that is important and we need to look at it in relation to the pattern that is normal for that individual, so it’s changes in sleep pattern for that individual. ‘Gets confused’, ‘doesn’t recognise you’ or ‘barks at night for no reason’ – Certainly vocalisation at night is more characteristic of feline cognitive dysfunction than canine but certainly getting confused and not recognising people is very important as a sign of disorientation and also the change in social interactions. ‘Turning away when someone pets them’ – So not being interested in that social interaction, ‘wandering’ – being disorientated and ‘doesn’t run to greet the kids’ – basically doesn’t engage in pleasurable behaviours that it traditionally has and that could be a variety of different behaviours, doesn’t run to chase the rabbit would be another one. So it doesn’t necessarily have to be interacting with children but this diagram is quite a nice representation of

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some of the sorts of things that owners might need to be thinking about. Then we go to the human side of it.

Remember that owners judge the quality of their pets’ life in a different way that we as veterinary practice staff judge quality of life. There is one really important component of quality of life for owners that we are often not very aware of.

That is the relationship between the owner and their pet. As far as the owner is concerned, that relationship is a very fundamental part of the quality of the life for that dog and behaviour is one of the major indicators of the strength of the relationship as well as one of the most significant sources of strain upon it, in terms of when the animals behaviour changes, the relationship with their owner is put under considerable strain. This relationship element of quality of life is going to be really important when we think about how we are going to find out about early signs of CCDS and not be waiting for the signs to be brought to us often at quite an end stage position when our intervention is going to have minimal effect.

So really quality of life, again from the owners’ perspective, what is the owner going to think about these changes in behaviour that we are talking about. So the changes in sleep pattern and breakdowns in house training are often things that owners consider an inconvenience associated with having an older dog. I mention that because the owners don’t see that as a reason to come and talk to a vet. In fact, changed in sleep pattern and breakdown in house training, they see it as inevitable, part of having an older dog, a dog which they have loved and cherished for a long period of time, that’s very definitely a family member, they don’t see the right to complain or ask for advice about these areas, they see it as something that as owners of elderly dogs, they should just put up with, that it is just something that is inconvenient but it is part of the part of having an older pet. We also look at the other two categories though, the changes in social interaction and the signs of disorientation. It’s far more likely that clients are going to interpret these behavioural changes as indicators of the animal being distressed. These are the one that are far more likely to talk to you about it readily. It’s the sleep patterns and the house training changes that are less likely to be brought to your attention, because of the fact that the owner worries what you will say.

Clients are reluctant to talk to us because if they just talk to us about changes in sleep or house soiling, they are frightened that you are going to suggest that it is time to say goodbye. In many cases owners do see the signs of CCDS, particularly those of sleep patterns and house soiling as inevitable of pets growing old but they don’t think anything can be done and they are worried to talk to you as a veterinary practice that you are going to see it as the time to say goodbye. Even with the disorientation and changes in the social interaction even when they are more likely to consider those to be potentially medical in origin, they worry that in that stage of life, the advice they are going to be given is that we shouldn’t go forward with any treatment and it is just something that we expect is old age and therefore consider putting the dog to sleep.

Now in order to understand this better we need to remember that human society, certainly in our culture frowns upon the concept of euthanasia. So euthanasia, rightly or wrongly, wrongly in my opinion, is something human society doesn’t usually accept as being a sensible alternative and the only way of justifying it in a veterinary context is that it’s used to stop physical suffering and it is very important in many peoples’ minds that it is physical suffering. Putting to sleep because of changes in behaviour is something that many owners see as being done for their convenience so, you know, it’s not very nice being woken at nice and having toileting problems in the house and then having the dog put to sleep can make my life easier and that makes me feel guilty. Lots of owners are very reluctant to come to the vet, thinking that they are going to be told that euthanasia is something that they should consider, but feeling guilty that in their eyes the dog is just being a bit of an

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inconvenience rather than being a dog that they can see is actually suffering at the moment. An early diagnosis is therefore inhibited by under-reporting and this is something that we really need to be thinking about how do we pro-actively approach owners, discuss the issues of ageing, normal ageing and canine cognitive dysfunction, in a way that enables those owners to come forward to tell us about these problems as early as possible.

It’s down to really asking the right questions and asking at the right time. Some of the important things to think about are questions about interaction with the environment and also with social behaviour that would include both social behaviour at home, the interaction with housemates, pets, maybe other dogs, maybe other species and humans. Not only the owners but familiar visitors as well and visitors of course that are unfamiliar and out on walks, again we will be thinking about potential interaction with people but also interaction with other dogs. We are also going to want to have information about sleep patterns, how much sleep is there but also what sort of quality of sleep. Are they deeply asleep, are they easily disturbed? Where do they sleep, have they changed their sleeping location as well as the pattern or duration of their sleeping. Toileting habits we have touched on already, we are going to be asking about whether there are accidents, so when do they happen? And then we have got changes in any other previously learned behaviour, where toileting breakdown is a loss of a previously learned behaviour. So asking the right questions is important but we also want to make sure that we are asking the questions in a way that maximises the owners’ likelihood of responding accurately to them. I talked earlier about having a behavioural questionnaire that you use in routine geriatric clinics, appointments or booster appointments and the importance of that is that, if you start asking these questions when the animal is about eight years of age, which is usually when people begin to consider the animal is going into its senior and geriatric years, if you start with routinely asking these questions at that age it is very likely that at that age there will be no problem, therefore the owner is used to the fact that you ask those questions, realises that these changes are something that they should be looking for, something that they should be bringing to your attention and then knowing that they are bringing it to your attention in order to have some sort of intervention, not necessarily in order to put it to sleep. So if you start asking the questions before you begin to get the answers that necessitate the discussion of CCDS, the more likely you are to get honest and predictable answers that are useful to those questions going forward. The owners are going to realise it is routine to be asked these questions in booster appointments so they aren’t going to clam up about the information and wanting to know why you’re asking for it.

Again, the four categories: Disorientation – That’s to do with not recognising places, that’s things like dogs turning down the wrong driveway at the end of a walk, they used to always run down the right driveway, now they are running down next-doors. Disorientation within walks for example, dogs often have very regular walk routines and not recognising where they are or where they are going for a walk or appearing to be worried or anxious in locations that should be very familiar.Changes in social interaction – Which is likely to be primarily with the owner because that tends to be where the owner focuses the emphasis is in their social interactions with their dog but don’t forget the other pets in the household as well, particularly other dogs but also other species.Alterations in sleep wake cycles – We have mentioned that a few times, so yes it is about where the dog is sleeping, how the dog is sleeping, what duration of sleep there is, how disturbed they are during that sleeping, also how long does it take for them to go to sleep, do they have lots of pacing and padding around after they have shut the door at night or possibly the change in location, have we now got a dog that is unable to sleep on its own, that is craving being with the owner in order to sleep, which is perhaps something different to what the owner had experienced in the earlier parts of the dog’s life. Alterations in previously conditions responses such as house training – but very certainly not limited to house training.

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In all of those categories, remember there are a number of medical differentials, so we do need to remember that we are not going to look at CCDS in isolation, CCDS can often co-exist with a number of medical conditions. First of all, having these signs doesn’t rule out medical conditions and even if you have got CCDS and you are sure that is what you have got, you still want to look at the possibility of co-existing medical conditions which will need to be addressed at the same time.The main sorts of medical differentials that we are considering is of course sensory deficits, particularly if you have got disorientation or changes in social interaction and changes in sleep/wake cycle, so sensory deficit really is at the top of your list in terms of the medical differential. A dog that is not fully aware of its surroundings through a lack of sensory input can often look like an animal with cognitive dysfunction. Neurological disorders can also resemble disorientation, certainly standing in corners, being unable to reverse, not being able to seem like they recognise where they are, that could be neurological in root as well as being CCDS. And of course house soiling issues could be influenced by neurological changes in an elderly animal. Pain, very important to think about in any case where there is a behavioural presentation, whether it is an old dog or a young dog, but in an older dog, activity levels and social interaction, sleep patterns and house soiling, they can all be affected by the presence of chronic pain or unmanaged acute pain. It is very important to look at these categories when you are looking at these differentials.

Cardiovascular disorders will influence levels of interaction and activity as well, and can have an effect on the sleep/wake cycle. We also know that cardiovascular disorders are linked to changes in mood and changes in emotional state as well, again, something important to look at particularly in your elderly patients. Metabolic disease and endocrine disorders that lead to any kind of polyuria/polydipsia type presentation could obviously be a differential if you have got a house soiling problem and endocrine disorders also lead to irritability, very commonly reported and also the disorientation. If we go back to our presentation of disorientation, sleep/wake cycle and social interaction, you can see how these medical differentials may present signs that are similar and would fit though categories that there is a definite attribution there to an actual medical condition.

Where there is a breakdown in house training being the major presenting sign, then think about any medical conditions which are affecting the urinary tract, gastro-intestinal tract if it is faecal rather than urinary and of course changes in metabolism, that would be important as well, for example we need to be looking at diet if we have got changes in frequency of gastro-intestinal movement and passing of faeces, and that could affect the house training for that elderly patient.

Cases of CCDS do need a clinical approach, so you do need a clinical examination which you will be doing, particularly blood samples which will rule out things like endocrine disorders, determining the physical state of health in terms of their orthopaedic examination; is there any evidence of pain? Only when you have been through this list of differentials would you then be considering cognitive dysfunction and again, not thinking that these are mutually exclusive situations and that it is very likely that there is organ failure and cognitive dysfunction coinciding with each other.

When we get to managing the cognitive dysfunction element of the problem some things apply. First of all it is really important to treat any underlying or associated disease or pain. So the first thing is to make sure we have identified if there are contributory or just coincidental physical disease changes, they must be treated and particularly chronic pain, and I do say that as an area of the veterinary profession we need to look hard at. Treat the medical condition of CCDS, so we are going to look at the physiological and physical disease changes, changes in neurotransmitter levels, changes in the brain function and think about how we can apply nutritional and pharmacological intervention. And of course we will need behaviour modification too, particularly for dogs who have got other medical conditions as well, but we do need behavioural modification and probably behavioural modification in terms of the environment and I have put there, ‘particularly for dogs’, behavioural modification as

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we modify the environment perhaps more in cats, than with dogs perhaps more active behavioural modification. But the environment will also need to be altered for some of these dogs.

So starting with nutritional support, we know from the medical research that there are benefits from dietary supplementation, particularly with antioxidants and with essential fatty acids for cognitive dysfunction, which I’m sure you have heard lots about how you should be protecting your central nervous system in the ageing process by your diet and particularly a lot of emphasis on anti-oxidants and essential fatty acids. And the recent research in the veterinary field that has shown that the diet that supplemented in this way is beneficial of course for dogs and cats as well, and there is quite a lot of evidence now for a dietary approach.

There are a variety of supplemented diets, old dog diets are fortified with anti-oxidants and fatty acids. Having life-stage diets (as they are often referred to) where we are actually feeding diets that are specifically created and composed for the elderly patient, is something that can be very useful. Sometimes though in old age, owners can be very reluctant to change diets, so we may have at our disposal a very good senior diet, that we are sure has got very good fortification with anti-oxidants and fatty acids, but if the client has a reluctance to actually change the diet because perhaps, of a gastro-intestinal history which was difficult to stabilise and they therefore don’t want to go down the route of changing the diet, then we can use nutritional supplements instead. There are a couple on the market in the UK, Aktivait and Senilife, very little to choose between these products so work very much in the same way with the same sort of ingredients and what has been shown in these supplements and in the diets as well, appears to be the synergy between the components which is so important, so it’s the way they are put together and which anti-oxidants and fatty acids are working together synergistically that will give the best effect. Certainly with Aktivait, that product does have a placebo control trail behind it and obviously we are always trying to look for reliable evidence to make our profession more evidence-based, so something that has a placebo controlled trial behind it is something to be sought after. Senilife does have trial work behind it but not placebo controlled, as far as I’m aware, but does have field trials.

An alternative approach to tackling the ageing process is to think about the central nervous system in terms of glucose metabolism and medium chain triglycerides found particularly for example in coconut oil are among the most saturated of the fatty acids. They are more easily digested than other fats and they can be a direct energy source. So although they are fats, they act like carbohydrates in that they supply energy to the brain, so there are also some products that are based on this approach in terms of increasing the effectiveness or efficiency of central nervous system metabolism

What about drugs? Well there are several approaches when we think about drugs. We can approach the ageing process, not necessarily cognitive dysfunction, just the general ageing process in terms of increasing cerebral blood flow and there are products on the market which help with this, for example, Vivitonin or there are others which are available as well, and also we might want to think about having some other effects as well as cerebral blood flow, looking at the process of cell damage and increasing the level of free radical scavengers. Free radical scavenging it’s a superoxide dismutase action for example, that’s going to be promoted, the drug here Selgian (selegiline hydrochloride), promotes the actions of superoxide dismutase and can be useful in the process of slowing down that cell damage and having better free radical scavenging. Acting as glial cell modulators will also be useful in combating the issues at the mitochondrial level and Vivitonin can be very useful for that and drugs that alter neurotransmitter levels, particularly dopamine, so Selgian comes into its own there and Selgian, which is the UK tradename for selegiline hydrochloride, doesn’t have a license specifically for cognitive dysfunction in the UK whereas in the US, anapril, which is the US tradename for selegiline hydrochloride, so the same product, has a licence for the

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treatment of cognitive dysfunction. So Selgian is the drug of choice along with Vivitonin which has that added increase in cerebral blood flow effecting glial cell modulation. Those sorts of things together can be very useful, so a combined drug approach is probably the way to go with cognitive dysfunction.

What about behavioural modification then? So for dogs, actually actively supporting their learning is going to be important, remember that as they go through the process of cognitive dysfunction they lose a lot of their previously learnt behaviours. Classical conditioning techniques are going to be used for something like house soiling, so for that you are going to be sure that the dog is in the right place at the right time, just the same as you would have done originally for that dog when it was a puppy. So a lot of going back to basic puppy training rules. Instrumental training, so re-establishing commands or cues as we more accurately call them these days. If you are using cues remember that dogs only realise what they are through associative learning and if that associative learning is compromised by having CCDS, then the loss of those commands or cues or knowledge of those words, needs to be re-established. We often need to think about these dogs in terms of providing mental stimulation, which is important, but doing it through frequent and shorter excursions from home rather than longer ones. So if a dog has disorientation issues then actually leaving the house and being out for an extended period of time, so being out for maybe an hour at a time, could be more than that dog is able to cope with in terms of disorientation, particularly if you are thinking of going to new places of different places. It may be easier for the dog to cope with a shorter excursion away from home and then coming back to the security of somewhere that’s more familiar. I hope that those people listening have not have experience of Alzhiemer’s or vascular dementia but I know that many of us have through those that are close to us and we will never know that for all those sufferers of those conditions that actually the house, or the home, or the familiarity is incredibly important and going away from that environment, does increase the disorientation signs of the condition. We need to think about that as well when we are dealing with our dogs that are suffering from cognitive dysfunction.

There are limitations of course to this behavioural treatment because the dog is old, so as well as having the cognitive dysfunction, the animal may also be ageing in other ways. Responses to stimuli will be slower in old age because of the demyelination or the oxidation processes. So every older animal is going to have slower responses to stimuli but in addition, they may have sensory deficits, impaired sight or hearing, which is going to limit behavioural modification, in fact also the work you put in is going to have less effect. Also mobility can be incredibly important. Being unable to get around the environment may be difficult in terms of behavioural modification. You may need to modify the physical environment just to make it easier for that animal to get around because of mobility issues. Of course those two things may also be combined. The picture here of the cat with the dog is taken from a site which talks about seeing eye cats, so this cat is this dogs guide cat, who is used to be able to guide the dog around the home environment, the dog follows the cat around, so has a guide cat instead of a guide dog.

Environmental modification of course is going to be thinking about ease of access. Routine and predictability is going to be very important, maximising the ability to make associative learning, it depends on having routines and having predictable outcomes. Increasing the accessibility, that might be within the car, as you can see here, step ups to the car and ramps can be extremely useful, as well as in the home. So thinking about environmental modification and making it easier for this older animal to gain access, particularly to resources, so where do we put food bowls and water bowls? It is important for an older animal in making sure that it is somewhere that is easily accessible and limiting physical changes. This is going to be important for those that have sensory perception problems, but it is also going to be important for an animal suffering from CCDS because of the disorientation components. So unless you can change the physical environment, moving the

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furniture around, moving the dog bed and putting it in a different place, all of those things are going to complicate the disorientation component of the CCDS signs. So we are going to encourage the owners to keep their homes with as little physical change as possible when their pet is suffering from this condition.

So the onset of old age is inevitable, there is only one certain thing in life and that is going to get to the end of life, to go through the ageing process and signs of the disorientation and confusion of the ageing process can make it really difficult for owners. Owners find it hard to be with their pets who physically look the same but in terms of behaviour, is behaving like a different dog. So they say that a dog may appear like a stranger in their own home, some owners might make the comment that they don’t recognise him, he is just not the dog he used to be and I’m sure as you’re looking at this, thinking about these words, you are making comparisons with vascular dementia and Alzheimer’s in people. Cruel conditions, which change the behavioural identity of the individual, sometimes in conjunction with medical problems at the same time, sometimes with an animal or person who is very physically fit but is not able to orientate or feel safe within their home environment. Changes in social interactions can make brain ageing very distressing for the owner especially if you get a lack of recognition, if the dog is not greeting in the way that it used to in the past, its slow to recognise the owner when the owner comes home and so dealing with the cases is important to remember that human element, remember the fact that owners struggle with this condition, remember they may be reluctant to tell you about it. Maximising their comfort with discussing issues of cognitive dysfunction with you is a very important part of being in veterinary practice. Sometimes in things like putting posters up, the poster that I showed you of the Jack Russell before where it has the arrows of the different things to look out for, something like that on the wall of the waiting room, can give the owner the confidence that if they were to discuss it and you were going to take it seriously, they are going to think of it as something you are going to do something about or something that you can certainly assist with, you can use that kind of indirect delivery of information to your clients in the waiting room as a way of making it safer for the owner to approach you and to discuss these things with you.

Detecting at the earliest opportunity is crucial. It will enable geriatric pets to get the appropriate care and it will maximise the benefits in both quality and potentially the duration of life. We really do need to incorporate a programme for early detection of canine cognitive dysfunction into everyday general practice, preferably by asking the right questions but asking them first of all ahead of time, so the owner is more comfortable about answering those questions when the time actually comes.

So thank you very much for listening, I hope that has given you a bit of an increase in understanding of the issues facing our elderly dog population and also increased your level of compassion for them and their owners and imposed you to have a more proactive geriatric care service within your practice.

Question and Answer Session:

Q: Is Vitamin E worth using as a nutritional supplement as well as EFAs?A: Yes definitely, and as I said when we are looking at supplementation, it is the synergy that is important, so when you look at the products like Aktivait and Senilife and these specifically fortified diets, you are going to see a combination of vitamins and of course vitamins that have antioxidant properties are very important and there is a whole range of ingredients that are important in these products. Some, like Aktivait and Senilife are very similar in many ways, they are just little tweaks in different interactions that are having a very similar effect, just the difference in the controlled trial. But yes, absolutely, I didn’t list all of the antioxidants that are useful, vitamin E is certainly one of

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them and if you look on these products, then you will get the information about the individual ingredients of each of those products and the synergy is what is important.

Q: What is the scheduled dosage of using essential fatty acids, is there a dosage regime for that?A: The products that we are talking about there incorporate EFA in them, and they recommend daily dosing and what we are talking about is starting as early as possible, so although we are talking about those being important in animals that have CCDS, there is an argument for starting nutritional supplementation from about eight years of age in all dogs, in order to support the ageing process and support the metabolism of the central nervous system as it starts going into the ageing process. So I don’t think the nutritional supplements are only for use in a situation where canine cognitive dysfunction has been confirmed, I think of them more as an additional nutritional supplement for our animals entering old age. Whereas when we think about the drugs vivitonin and selgian, you are talking about treating the condition of CCDS. As I said, being old is not an illness but they all need support. Those who are the wrong side of 50 will be eating more fruit for example, and increasing our fresh fruit and veg intake.

Q: If you are using the essential fatty acid and antioxidant approach and you are using non-commercial products, you mentioned feeding coconut oil as an EFA but what do you feed to dogs as an antioxidant, also what can you feed to cats and what else can you feed to dogs as an EFAs?A: I understand that many people would want to feed from scratch themselves, I think the difficulty in doing that is as I say, the synergy between the products that is important, between the different ingredients that’s important so I think getting that right is going to be quite difficult to do from scratch. The coconut oil by the way was for MCTs for changing or boosting the glucose metabolism within the brain so it’s one aspect of helping with the ageing brain but can you do it yourself? Yes, probably you can, I must admit I don’t know any recipes of exactly what you need of any ingredients in order to make it work more effectively. I have tended to use the proprietary product or diet to achieve that because of the fact that I know from the research that it is not just the individual things you use but it is the synergy between them that is so important. But I wouldn’t say that it’s not possible to do it yourself if you want to, it would be a lot harder and would need a lot of research to be sure that you are supplementing the right combination of things, not just the right things. I think if you are going to do it yourself it is hard work, you would need to do a lot of research, I don’t have that information at my fingertips to be able to suggest any way of doing it for people that want to do it themselves. I’m not saying it’s not possible, I’m just saying that if you wanted to do it, it would be hard to do it and you would need to research it well to make sure the ratios of these things are right.

Q: Who supplies the Jack Russell Terrier poster?A: That is just one that I have found on the internet, so there isn’t a poster as such of that one, it is just an image that I have found when I was doing some research on the internet about the subject, but you can make your own and it would be better as a practice to make your own because it has that individual theme to it and the practice can draw attention to the things that you think are important for your clients. What I was really trying to say was, some of the owners like visual things and it’s good to do it indirectly so that you’re not the one actually raising the subject in the consulting room where the owner is likely to clam up potentially, worried that what you are saying is that their dog is at the end of the road. It is better to get the idea into the clients mind, making use of a questionnaire before the problem is so useful, and it just gets the owner to think about these issues and the questions that are worth considering.

Q: If money is a factor for treating an animal with CCDS, would you use Selgian, Vivitonin, nutritional supplements or diets as a first line of treatment, how would you approach that?

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A: It would depend for me on the stage, or the severity of the signs. I think if you have actually got CCDS, not ageing, you’ve actually crossed that boundary into a situation where it is an abnormal stage of ageing then Selgian I would go for. Vivitonin and nutraceuticals I would certainly use those, certainly in those animals that I am not yet convinced it is CCDS but they are of an age where that could be happening and they are starting to show mild signs I might then do a more nutraceutical approach with some Vivitonin, but I think Selgian plus Vivitonin certainly, I don’t think using Selgian exclusively is necessarily enough because of the cerebral blood flow effect of the Vivitonin does seem to be very useful, so ideally you do want to be using a pronged approach, rather than just using one approach, you want to be using different angles. I understand with cost, and certainly you might be deterred by that and in which case what you might start with will depend on the severity. I l know that’s not an overly clear answer but that would be my thought process really.

Q: Is panting ever a sign?A: Not on its own, no. On its own I would obviously think of other potential differentials such as cardiac disease and pulmonary disease to start with but certainly it can be part of the animal being distressed. If you have got an animal that is disorientated then you may also see increased panting because of the fact the animal is distressed so again you would need to look at these things in combination with each other rather than in isolation. I think panting alone is not something I would immediately think of cognitive dysfunction.

Thanks to Pedigree for sponsorship for this webinar.

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