The first two parts of this article covered the various behaviourally-active drugs and how they can be used to treat problem behaviours in dogs and cats. The third part of this article will look more widely at the ways veterinary nurses can support the behavioural welfare of their patients. Nurses are very well placed to do this because, in addition to observing and handling animals in the surgery, they also interact with their owners. This means they are likely to come across animals that might benefit from additional behavioural support, and possibly also behaviourally-active medication. It is therefore important that nurses are able to identify these animals and advise their owners appropriately. This may include giving behavioural first aid advice to ensure safety and reduce the risk of the problem behaviour getting worse in the short-term, arranging an appointment for a veterinary examination and, where appropriate, referral to a suitably-qualified behaviourist. An understanding of the potential effects and side-effects of the various behaviourally-active drugs will also ensure veterinary nurses are able to effectively support owners who are considering the use of behaviourally-active medication for their animals, as well as those whose pets are already receiving it.
Identifying animals that might benefit from behaviourally active medication
Veterinary nurses can play an important role in helping to identify animals that might benefit from behavioural help and, potentially, behaviourally-active medication. They are likely to come across these animals in one of two ways.
Owners may mention concerns about their animal's behaviour during a nurse clinic appointment (Figure 1), at reception or over the telephone (Marshall, 2016). It is important that these concerns are picked up and explored further, as evidence suggests this does not always happen, even during veterinary consultations (Roshier and McBride, 2013). If these conversations suggest that animals are being exposed to triggers or situations that cause them to become anxious or fearful, or to show other problem behaviours in other contexts, they will benefit from behavioural help, potentially including behaviourally-active medication, especially if these triggers are unavoidable.
Veterinary nurses may also observe or experience a problem behaviour directly. For example they may see dogs that are reluctant to enter the surgery, or that appear very stressed in the waiting room. This may present as panting, shaking and drooling, or possibly as barking and lunging at other people or animals. Finally, they may encounter cats and dogs that are difficult to approach or handle when they are in the consulting room or hospital. This not only makes it difficult to give the animal the healthcare it needs, but it also means that veterinary visits are likely to be detrimental to the animal's welfare and also potentially to the safety of the owner and veterinary staff.
Even where problem behaviour is not directly mentioned or observed it is important that veterinary nurses (and other members of the veterinary team) make a point of asking owners about their animal's behaviour as part of any consultation or discussion they have. Owners may not always mention behaviours that may be indicative of compromised welfare, such as those associated with fearfulness or anxiety, possibly because they do not recognise their significance or think that they are relevant to the context of the veterinary consultation (Roshier and McBride, 2013; Marshall, 2016).
Providing first-aid behavioural advice before behaviour referral
As mentioned in Part 1 of this article, unless there is sufficient expertise within the practice to provide ongoing behavioural support, animals with behaviour problems should be referred to a suitably-qualified behaviourist such as those listed on the Animal Behaviour and Training Council (ABTC) Clinical Animal Behaviourist or Veterinary Behaviourist registers. However there may be a delay before an animal can be seen by a behaviourist, and it is important that nurses are able to provide owners with appropriate first aid behavioural advice during this period. This is important in all behaviour cases, not just those that are likely to benefit from behaviourally active medication.
The aims of first aid advice are:
- To ensure the safety of the animal itself, or of people or other animals in the case of animals that are showing aggressive behaviours
- To prevent the behavioural problem getting worse in the time before the animal can be seen and assessed by the behaviourist.
This advice will vary according to the animal, problem behaviours being shown etc, but will include:
- The importance of avoiding triggers and problem situations where possible, and advice on how to achieve this. For example, dogs that are fearful of noises and very reluctant to go out for walks may respond better to staying at home and being provided with opportunities for mental and physical activities in the house and garden until they can be assessed and treated by a behaviourist. Dogs that are worried about and potentially reactive to visitors may be safer, and less stressed, if visitors are discouraged in the short-term, and if this is not possible, the dog should be securely shut away in another room while visitors are in the home.
- The importance of using safety equipment where appropriate, such as a muzzle or keeping a dog on a lead where it is not possible to reliably avoid problem situations or triggers. If introducing something new like a muzzle owners should be shown how to choose and use it, and most importantly, how to introduce it gradually to ensure the animal is comfortable wearing it. See Riemer et al (2021) and the Resources section for more information.
- The importance of avoiding the use of positive punishment. Owners need to understand that using aversive stimuli such as shouting, smacking or jerking the lead to try and stop animals showing unwanted behaviour is likely to be counter-productive and could potentially exacerbate the problem behaviour, especially if the animal is anxious or fearful. There is also a risk that an animal might show aggressive behaviour to their owner in response to feeling threatened.
The Resources section has a link to some articles giving more detailed first aid advice for cats and dogs with various behavioural problems and also to some videos, including one on teaching dogs to be comfortable wearing a muzzle.
Practice gentle, low-stress handling at all times
It is important to remember that animals that are difficult, and potentially dangerous, to examine in the veterinary surgery are likely to be fearful. They may be scared of travelling, of being in an unfamiliar place and/or of being approached and handled by unfamiliar people, and they will be exposed to all of these things in the course of a veterinary visit. In addition, they may also be painful, or will have uncomfortable things done to them, such as injections. Pain will exacerbate fearfulness, and fear can potentially increase pain perception (Mills et al, 2020).
Fearful animals will generally avoid contact with scary people if they can, but if they are unable to do so, for example because they are cornered or restrained, they may either show behavioural inhibition (stay still and appear to accept the interaction) while still feeling very scared or they may show defensive behaviours such as growling, snapping or biting (dogs) or hissing, clawing or biting (cats) in an attempt to repel the person away from them. In either case, the animal is likely to feel more scared the next time they are approached or handled in the veterinary surgery, and if performing the aggressive behaviours helped them to feel safer, they will be quicker to use them in future (Riemer et al, 2021).
The ability to accurately assess an animal's emotional state via observing their behaviour and body language is an essential skill for all veterinary nurses. It is also important that veterinary nurses know how to handle animals in ways that minimise stress, and how to respond to signs of fear or anxiety in order to prevent their escalation (Riemer et al, 2021).
Taking time and using gentle, low-stress handling methods will reduce the risk of animals learning to be fearful of being handled in the veterinary surgery. Gentle, low-stress handling will also often enable a nervous animal to be examined or handled without the need for any restraint or medication (Figure 2) (Ryan, 2018; Riemer et al, 2021).
Even where short-acting medication is used to facilitate handling, the handling should still be done carefully and gently, both to increase the chances of the procedure being successful and to reduce the risk of further exacerbating the animal's fearfulness. See the Resources section for a link to some videos that demonstrate using low-stress handling to teach animals to be more comfortable in the veterinary surgery.
Supporting owners of animals that are on or about to receive longer-term behaviourally-active medication
Veterinary nurses can increase the chances of animals experiencing the welfare-improving benefits of behaviourally-active medication through providing support to owners who are considering the use of behaviourally active medication and to those whose animals have recently started a course of medication. This support can be given via informal chats over the phone or at reception or during scheduled nurse appointments.
Supporting owners when deciding whether or not to use behaviourally active medication
Owners are often concerned that behaviourally-active medication will have adverse effects, both physically and behaviourally, on their pets. From a behavioural perspective, owners tend to be particularly concerned that medication might cause sedation or otherwise adversely alter their animal's personality (van Haaften et al, 2020). This is particularly a concern for owners of animals that might benefit from longer-term medication.
While there are risks of both physical and behavioural side-effects with any behaviourally-active drug, the risk of an animal developing severe side-effects is relatively low and it is important that owners understand this. It will also help to ensure owners are aware of the most likely side effects of the drug(s) their animal will be taking, when they should be concerned about them and what to do if they are (see below).
While some animals starting a course of longer-term medication will experience side effects that can include mild sedation, in most cases this will gradually reduce after a few weeks (van Haaften et al, 2020). Owners should be reassured that their animal may seem a little quieter than normal at first, but that this is likely to wear off over the next few weeks. Most animals on longer-term medication do not demonstrate any major adverse changes in their personalities, and in fact, if the medication helps to reduce stress and negative emotions, they are likely to be generally happier and more relaxed.
Supporting owners of animals that are on behaviourally active medication
Ensure owners are aware of any potential medication side effects and what to do if they occur
While serious side effects associated with behaviourally-active drugs are relatively uncommon it is important that owners are aware of what to look out for, when they should be concerned and what to do if they are. The most common side effects for individual short-and longer-term behaviourally-active drugs are listed in Part 1 Tables 1 and 2 (Warnes, 2022). However, there is also the potential for them to cause less common but potentially more serious side effects, so it is important to check the data sheets for each individual drug. In all cases owners should be asked to contact the practice if they have any concerns at all about their animal's health or behaviour when they are taking behaviourally-active medication.
The most common side effects associated with short-term medications are sedation and ataxia. Some drugs can potentially cause digestive upsets, for example trazodone may cause vomiting. Occasionally drugs such as benzodiazepines and trazodone can have a paradoxical behavioural effect, causing animals to become hyperactive rather than calm. Benzodiazepines and imepitoin (Pexion) have the potential to disinhibit behaviour, including aggressive behaviour, and while this is a relatively uncommon response it is important that owners are aware of this possibility. If a short-acting drug has an adverse effect, this is unlikely to be long-lasting because these drugs will wear off relatively quickly. However, it is important that owners know how to keep the animal safe until the effects do wear off, for example ensuring ataxic animals are confined in an area where they are unlikely to hurt themselves by climbing onto things (cats) or falling down steps or stairs. It would also be sensible to avoid using these drugs in that individual in future.
The most common side-effects associated with longer term medications include digestive problems (appetite reduction, vomiting, diarrhoea) and mild sedation. These are most common in the early weeks after starting the medication, and generally wear off over a few weeks as the animal adjusts to the medication. If the effects are very mild it is usually fine to keep the animal on the same dose of medication, as they will generally resolve in time. However if the animal shows more severe side-effects, such as marked appetite loss, frequent vomiting or diarrhoea it may be necessary to either reduce the dose of medication for a week or so and then try increasing it again or stop giving that particular drug altogether.
Prepare owners for a delay before longer-term medications become effective
A common reason for animals being taken off longer-term behavioural medications too soon is the fact that there can be a relatively long delay between starting the course of medication and seeing any significant improvement in the animal's behaviour. For example, with clomipramine (Clomicalm, Novartis) or fluoxetine (Reconcile, Forte Healthcare), it can take 4–6 weeks before any significant behavioural improvements are seen and potentially 3 months or more before these drugs become fully effective. Selegiline (Selgian, Ceva Animal Health) can take 7–8 weeks to become effective. Owners that are not aware of this may assume the drug is not working and stop giving it before it has any chance of becoming effective. This can be compounded by the fact that any problematic side effects will generally occur in the early weeks, before any behavioural improvement is seen. It is important to ensure that owners are aware of how long it is likely to take before any significant behavioural improvement will be seen, and they may need to be reminded of this if they start to become despondent during the early weeks of treatment.
In some cases a course of a short-acting medication such as benzodiazepines, trazodone or gabapentin can provide behavioural support during the period before the longer-term medication becomes effective. Once the longer term medication does become effective it should be possible to withdraw the short-acting medication. It is important that this withdrawal is done gradually, both to prevent any adverse withdrawal effects such as a rebound increase in anxiety, and also to make it easier to identify any other deterioration in behaviour that might indicate that the short-acting drug was still having a significant beneficial effect on the animal's behaviour. If this is the case it may be possible to continue using a short-acting drug such as trazodone or gabapentin alongside the longer-acting drug, but potentially at a lower dose. Due to their potential to affect memory formation benzodiazepines may be less suited to this role. Alternatively it may be necessary to reassess the choice of longer-term medication.
KEY POINTS
- Veterinary nurses have an important role to play in ensuring those animals experiencing compromised welfare receive appropriate behavioural help, including behaviourally-active medication where appropriate.
- By practicing gentle, low stress handling techniques on their patients, and being able to accurately assess an animal's underlying emotional state, veterinary nurses will ensure they do not cause or exacerbate problems associated with fearfulness of being handled or of the veterinary surgery.
- When talking to owners about their pets, veterinary nurses should always make a point of asking about their behaviour, and any concerns should be explored further. In addition, nurses should observe animals for any signs of stress or other problem behaviours while they are in the surgery.
- When animals are identified that might benefit from additional behavioural support, veterinary nurses should be able to give their owners appropriate behavioural first aid advice and outline the next steps including the need for a thorough veterinary check and referral to a suitably-qualified behaviourist where appropriate.
- A good understanding of the effects and potential side effects of the various behaviourally-active drugs will ensure veterinary nurses can effectively support owners who may be worried about problematic side-effects or lack of efficacy associated with these drugs. This should increase the chances that those animals that would benefit from behaviourally-active medication will actually receive it.
Resources
Fellowship of Animal Behaviour Clinicians (FABC) website: www.fabclinicians.org Vet CPD Webinar and Q&A sessions: https://fabclinicians.org/veterinary-q-and-a-sessions/
- Situational medication: S Penturn and L Notari
- Emergency management of sound sensitivities: E Baker and E Brown
- Long-term management of sound sensitivities: E Baker and E Brown.
Available from the FABC Links for Veterinary Professionals page: https://fabclinicians.org/links-for-veterinary-professionals/
Articles:
- Overview of Behaviour Supplements for Dogs and Cats by Lorella Notari
- Behavioural First Aid advice for dogs
- Behavioural First Aid advice for cats
FABC YouTube Veterinary Playlist: Preparing your pet for the vet. https://fabclinicians.org/links-for-veterinary-professionals/
Many useful videos including:
- Muzzle Training for dogs: Linda Ryan
- Preparing your cat for the vet: Linda Ryan
- Vet training for cats: S Ellis.
International Cat Care website: www.icatcare.org
Resources for helping cats to feel comfortable in a cat carrier:
- https://icatcare.org/advice/putting-your-cat-in-a-cat-carrier-video/
- https://icatcare.org/advice/encouraging-your-cat-to-be-happy-in-a-cat-carrier-video/
Remind owners that medication alone will not resolve problem behaviours
Owners must always be aware that behaviourally-active medication alone will not resolve problem behaviours, and that it needs to be part of a broader behavioural approach. The veterinary nurse can help ensure owners are working with a suitably qualified behaviourist to implement a comprehensive behaviour plan, and that both the owner and behaviourist can liaise with the veterinary practice regarding the animal's progress where required. Owners can often struggle when dealing with problem behaviours and may become discouraged if things are not going well. Veterinary nurses will hopefully be able to provide support and advice, even if this is just to encourage them to continue working with the behaviourist or to remind them that some medication can take time to become effective.
Conclusion
Veterinary nurses can significantly improve the behavioural as well as physical welfare of their patients. By being behaviourally aware at all times when handling animals in the veterinary surgery they will ensure they do not create or exacerbate any fear-related problems associated with handling or the veterinary surgery. Through discussions with owners about their pet's behaviour, and/or through observing their behaviour directly, veterinary nurses are also very well-placed to identify animals that would benefit from additional behavioural support, possibly including behaviourally-active medication. They should be able to advise these owners appropriately, including giving first aid behavioural advice to ensure safety and prevent the problem behaviour getting worse, arranging an appointment for a veterinary check and, where appropriate, referral to an appropriately-qualified behaviourist. An understanding of the various behaviourally-active drugs available, including how they can influence behaviour and their potential side-effects will ensure that veterinary nurses can effectively advise and support those owners who may be considering the use of behaviourally-active drugs for their pets as well as those whose pets have recently started courses of behaviourally-active medication. This will increase the likelihood that those animals that will benefit from behaviourally-active medication will actually receive it.