A compassionate approach to feline cognitive dysfunction

When a client casually mentions that their senior cat is getting friendlier and talking a lot, they may be describing the early signs of feline cognitive dysfunction (FCD), a progressive neurodegenerative disease. Vocalization and increased affection are both clinical signs of FCD.

As cats live longer, the ability to discuss this sensitive subject has become an essential part of daily practice. Helping clients to accept and understand this diagnosis, of course, requires clinical knowledge, but empathy is probably the single most important skill.

The need for screening

The disorder is frequently overlooked. Amy Pike, DVM, DACVB, IAABC-CDBC, writer and educator on FCD, co-owner of the Animal Behavior Wellness Center, explains, “It is a very under-diagnosed and under-recognized disorder, and it’s because we’re just not screening for it. Owners are assuming it’s just part of aging, so they oftentimes don’t offer the information to their veterinarian… It’s one of those things that owners don’t necessarily equate with an abnormality. They’re like, ‘Oh, my cat’s old, [they’re] just slowing down.’”

To build trust and encourage further investigation, veterinarians can acknowledge a client’s perspective and share personal experience.

Pike explains her own approach. “So, it is a difficult conversation to navigate with owners. I just try to be very empathetic, and I equate it to my own life. ‘You know, I had a cat once that didn’t like to use the litter box when it got older and these are the things that we had to do.’ And then they’re like, ‘Oh, you also have gone through this, right?’”

Recognizing the signs

The common acronym for diagnosing cognitive decline in dogs is DISHA/DISHAA, which stands for disorientation, interaction changes, sleep/wake cycle disturbances, house soiling, and activity/anxiety.

For cats, the acronym VISHDAAL is more appropriate. Pike breaks it down: “V is vocalization. I is interaction changes. S is sleep-wake cycle disturbances. H is house soiling. D is disorientation. A is anxiety. A is activity. And then L is learning and memory.”

Research confirms these behavioral patterns. A 2020 study of senior cats found that increased vocalization was reported in over 58% of elderly cats during the day and more than 30% at night, 55% experienced new house-soiling issues, and more than a third of cats showed increased affection and dependency on their owners.

Danielle Gunn-Moore, BSc, BVM&S, PhD, FHEA, MACVSc, MRCVS, Professor and RCVS Specialist in Feline Medicine at the University of Edinburgh, Personal Chair of Feline Medicine at The Royal (Dick) School of Veterinary Studies, adds more context. “You’ve got a third [of senior cats] house soiling, you’ve got two thirds hypervocalizing. And yet, in one of our studies, we asked people, how did they feel about their [senior] cat? 96% of owners ticked they love their cat as much or more than they used to.”

So cat caregivers may welcome these behavior changes without realizing they could indicate a problem. “And there, we’re very lucky because the most common change in interaction is to become much more clingy … But the increased affection and the increased need for attention is seen [by clients] as a very positive thing,” he said. The bad news is that this can lead to delays in seeking medical attention, because clients don’t think anything is wrong.

Asking the right questions

Carlo Siracusa DVM, PhD, DACVB, DECAWBM, Associate Professor of Clinical Animal Behavior and Welfare, and Director of the Animal Behavior Service and of the Primary Care Education Section at the School of Veterinary Medicine of the University of Pennsylvania, has done extensive research on FCD. He suggests that the way questions are asked can help a clinician elicit more useful information from a client, especially when they do not recognize that their cat may have a problem.

In other words, avoid general behavior questions, “because people say, ‘Oh, he’s doing fantastic. He looks happier than ever,’” he said. “The point is to ask very specific questions. For example, ‘Did you see any changes in the way in which the cat interacts with you?’ Or then other things like, ‘Do you think your cats sleep less?’ ‘Do you think your cat is more fearful than usual?’ Or sometimes we can even ask, ‘So tell me, when you approach your cat, what does he do?’”

If clients think that slowing down, sleeping more, and becoming chattier are just normal signs of getting old, they may not mention these things to their veterinarian. If they are concerned that age-related symptoms may be indications of something serious, they may try to avoid the conversation altogether, fearing the worst. That’s why it’s important to ask these specific questions in a way that gets the necessary details without putting pet parents on the defensive.

Addressing client concerns

Aside from simply not realizing that such behavior changes could indicate a medical issue, there are other reasons clients may be hesitant to speak to the veterinarian about the changes they are experiencing with their cat. For instance, they might fear that there’s something seriously wrong—and it’s their fault.

Pike points out that owners don’t want to be blamed for behavior changes in their pets. “We don’t want to think that we were the root cause of that,” she said.

Clients who do recognize these changes as a sign that something is wrong with their aging cat may fear that a diagnosis will lead immediately to euthanasia. This can cause them to hide symptoms or become upset. Veterinarians can reassure clients that these fears are normal and that their goal is to support them to help the cat have the best quality of life possible.

Communicating effectively

Using relatable language can make communication easier.

Gunn-Moore states, “First thing I do is I never call it feline cognitive dysfunction. We need to call it feline dementia [when talking to clients] because everybody has somebody who’s been affected by dementia …. So, you’re immediately all on the same page.”

This comparison has a biological basis. A 2021 study on the similarities between FCD and Alzheimer’s disease showed that elderly cats with FCD develop brain changes that are structurally very similar to the early stages of Alzheimer’s disease in humans, including the buildup of the same toxic proteins.

Because so many people have seen human loved ones impacted by dementia, it’s crucial that these discussions are approached with compassion. This conversation may require additional sensitivity with senior clients who may be facing their own health challenges and feeling vulnerable when it comes to the health of their cat.

In these instances, especially, providing written instructions and gently suggesting they bring a family member or friend to future appointments, if appropriate, can increase the likelihood that the care plan is understood and supported.

The challenges of diagnosing FCD

FCD is not always easy to diagnose as it shares symptoms with so many other illnesses. Pike emphasizes, “Behavior is always a rule-out diagnosis, meaning you have to rule out everything medically that could be happening, and then, you sort of get backed into this behavioral corner.”

Because so many medical problems can look like dementia in cats, Gunn-Moore prioritizes the top rule-outs: Pain, high blood pressure, and hyperthyroidism.

Pain

“All older cats have pain. It’s finding, where is that pain? How bad is it?” That’s why Gunn-Moore says  an analgesic trial is really important, “because all of the signs of dementia can go away if you get the analgesia right [if pain is the only cause].”

Pike agrees and says that even when clients think that the symptoms they are seeing are just a normal part of aging, cats do not always make it easy. “Cats mask a lot of things, pain especially … So if you are seeing signs, that probably means that the issue is much bigger.”

That’s why she thinks it is so important to be able to provide the client with evidence. “We oftentimes do a short course of anti-inflammatory [or] gabapentin, which is a common nerve pain medication. And then oftentimes it’s like oh, wow, now they are jumping up on the counters again, so then the owners can actually see. Certainly, we can do x-rays and look for radiographic evidence of joint disease. I have a thermal image camera in my practice and we take pictures looking at areas of heat and cold to see if there’s a difference between the two sides. I like the thermal image camera because it gives that sort of proof to owners,” she explains.

Siracusa agrees that comorbidities are almost inevitable as cats age, noting that “virtually all of them will have degenerative joint disease (DJD), at least radiographically,” which can easily mask or mimic cognitive decline and make diagnosis more complex. “Then what does it mean for their behavior? Are they necessarily suffering from this DJD? Not necessarily, but we have to assume that just for being old, there’s no cat that will be completely healthy.”

High blood pressure

This is a well-documented concern, as hypertension can cause severe and often irreversible damage to the brain, leading to signs like altered mentation, disorientation, and vocalization.

“Since high blood pressure can cause dementia-like clinical signs, it is important to check the blood pressure of elderly cats. If their blood pressure is too high, treat it to get it back to normal, in which case the dementia-like signs will resolve. However, if FCD is the cause of the dementia-like signs, then controlling the BP would not resolve them,” said Gunn-Moore. “We know that high blood pressure can result from damage to the blood vessels in the brain–e.g. similar to strokes in people. As in people, this can lead to a type of dementia in cats that is synonymous with vascular dementia in people.”

Hyperthyroidism

Hyperthyroidism is another critical rule-out, as it is a common condition in senior cats that can cause behavioral changes. As well as restlessness, Pike explains that the hunger associated with hyperthyroidism can lead to symptoms often associated with FCD. “Hyperthyroidism is also obviously common in cats, and they will vocalize for food when they’re experiencing that disorder.” As these signs stem from a treatable hormonal imbalance, managing the thyroid condition often resolves the dementia-like symptoms.

Creating a management plan

While there is no cure, a thorough management plan can slow progression and significantly enhance quality of life. Creating that management plan requires taking an individualized approach that finds the balance between engaging their minds while still providing the comfort of consistency, all while aiming to reduce anything that might cause or increase pain.

Mental stimulation

Pike explains that keeping cats mentally stimulated is an important part of this. “Mental enrichment is giving the cat things to do that stimulate the brain and so just like with us, we’re supposed to do sudoku and crosswords as we get older because it’s use it or lose it. The same is true with our with our kitties.” She suggests simple, cost-effective solutions like feeder toys and even training.

Predictability and pain management

Siracusa, however, feels that there should be an emphasis on stability and predictability for the cat. That doesn’t mean eliminating stimulation or interaction, but, he said, “”let’s say it is to be a very predictable environment, no big changes.”

Practical adjustments are key. These relate to addressing both cognitive changes and pain, as pain can reduce confidence and increase anxiety. Gunn-Moore offers specific tips: “Raising the food bowl, raising the water bowl, ideally keeping them away from the walls so the cats can go behind them, because they tend to get anxious … Raising [bowls] up takes the pressure out of arthritis in the elbows or the neck.” On litterboxes, she advises, “Litterbox needs to be a low front and a high back because you need it low at the front so you can get in.”

Regarding nutritional support, Pike says, “There are some diets that have high levels of medium chain triglycerides have been shown to help with cats and dogs with cognitive dysfunction.” She also mentions several supplement options,

Discussing quality of life

When feline dementia is diagnosed, a conversation about quality of life is inevitable. And euthanasia can be an important aspect of the care plan. Pike frames this sensitively: “It’s the quality of life for the cat, but also the quality of life for the owner.”

Helping clients to understand what quality of life means and how to measure it ensures that the cat is not allowed to suffer and provides clients with a way to recognize when it is time for euthanasia. This is also a vital tool for veterinarians as they are not able to monitor the welfare of cats in real time, as changes are so incremental that they can pass by unnoticed.

While there is a helpful quality of life questionnaire for dogs known as Canine Dementia Scale, a similarly useful diagnostic tool for cats, called SeniCat, is still in development as part of Gunn-Moore’s research funded by Morris Animal Foundation. This will be of great help to veterinarians supporting clients through this difficult time. Some families also seek the support of certified pet death doulas to help navigate this process.

Gunn-Moore believes it is important to start a conversation about euthanasia early so that clients can prepare emotionally and practically. It often comes up at the beginning of this journey—which is when she wants to start talking about it. “I go, ‘No, no, we’re a long way from that. But I want you to be thinking about their quality of life, because ultimately that is what we have to make sure is okay,’” she said.

Framing euthanasia empathetically can make this difficult conversation easier for everyone. She looks at it as, “explaining to owners that this is the last gift of love that they need to give to their cat.” She also emphasizes the importance of a peaceful passing, recommending pre-visit medication and gentle techniques for at-home euthanasia to ensure the cat’s final moments are calm and free of fear.

Supporting clients to the end

A diagnosis of FCD turns the partnership between a veterinarian and their client into a shared journey.

Pike’s final advice is clear. We need to screen for it. “Unfortunately, we do a good job medically for screening, like is the cat eating, drinking, urinating, defecating normally … but we’re not screening for behavior changes. And that is the biggest thing that I can emphasize is make sure that you’re screening every single patient, no matter their age.”

Siracusa echoes this, stating, “We have to get into the habit as veterinarians to monitor for behavior changes the same way in which we monitor for physical changes.”

Vigilant screening, clear communication, and a flexible management plan allows veterinarians to enrich the human-animal bond through supportive care and, when the time comes, they empower the client by making it clear that euthanasia can be a final act of love.

Photo credit: ArtMarie/E+ via Getty Images 

Disclaimer: Trends™ content is meant to inform, educate, and inspire by providing an array of diverse viewpoints. Any content published should not be viewed as an official stance, position, or endorsement by the American Animal Hospital Association (AAHA) or its Board of Directors.