January 11, 2019

Reducing Stress in Hospitalized Patients

According to 2 recent article series, stress-management tools benefit patients, pet owners, and veterinary staff.
By Natalie Stilwell, DVM, MS, PhD
https://amvet.s3.amazonaws.com/_media/_image/Reducing%20Stress_AMvet%20Jan%2019%20issue%20_3%20Feature.png?rel=0In 2 recently published article series, Caroline Hewson, MVB, PhD, MRCVS, and Stephanie Almond, RVN, DAVN, provided comprehensive reviews on stress reduction in small animal patients during hospitalization.1-5 The authors detailed studies conducted in both animal shelters and veterinary hospitals and provided tips to incorporate stress reduc­tion methods in the clinical environment. Evidence-based and holistic approaches were described.

RECOGNIZING SIGNS OF STRESS
In her article series, Dr. Hewson offered many phys­iologic and ethologic reasons for stress in small animal patients.1 Hospitalization involves removing the pet from its territory and social group, including the owner; housing it in an unfamiliar environ­ment; and potentially exposing it to pain and fear during treatment.

Stress can elevate certain physiologic parame­ters, including heart rate, respiratory rate, body temperature, and blood pressure. Neutrophilia may reflect stress but is easily mistaken for an inflam­matory response, particularly in an ill or injured patient.6 Results of several studies demonstrate that salivary cortisol level or urinary cortisol-to-creati­nine ratio may increase during kenneling or hospi­talization and correlate with anxious behavior.7-10 Ultimately, impaired immune function impedes the patient's recovery.7

Both investigators emphasized the importance of recognizing behavioral indicators of stress that can complicate handling and treatment.1,4 In dogs, these include salivation, anorexia, shaking, pacing, digging, low tail carriage, hiding, increased aggres­sion, and urination or defecation. Stressed cats often appear fearful and anxious and may attempt to hide in cage accessories, such as a blanket or litter box. If no cage accessories are available, cats may appear depressed and avoid routine behaviors such as feeding, grooming, and elimination. Patients that are unwilling to eat or eliminate may require hand feeding, appetite stimulants, or cystocentesis, poten­tially resulting in additional handling and distress for the patient. In extreme cases, stressed patients may self-mutilate and destroy bandages or sutures, further complicating and prolonging the recovery process.

METHODS TO ALLEVIATE STRESS
Enrivonmental Enrichment
Dr. Hewson explained that many veterinary hospitals are designed purposely as “barren environments” to streamline procedures and reduce costs.3 Cages are typically devoid of environmental enrichment and offer no opportunities to retreat from stimuli, such as loud noises or nearby people and animals. Providing opportunities for normal behaviors can alleviate stress during hospitalization.11

Environmental enrichment encompasses multiple aspects of physical and mental well-being, including housing, feeding, sensory stimulation, exercise and occupation, and social interactions. The investigators recommended addressing as many of these compo­nents as possible for patients during hospitalization.3,5

Veterinary hospitals often consist of unnatural social environments that separate social dogs from each other and place solitary animals, such as cats and exotic species, uncomfortably close to dogs. When possible, Dr. Hewson recommended housing cats and exotics separately from dogs.3,12 She also advised placing feline patients in higher cages where they will feel more secure.

Providing a box for hiding and perching is also particularly useful for anxious cats. An object as simple as a cardboard box or the top or bottom half of a cat carrier allows for hiding, perching, and pheromone marking via facial rubbing. Results from shelter studies show that cats that are g given access to a hiding box show reduced signs of stress; increases in sleep, relaxed body positions, and interest in visitors; and a significantly lower inci­dence of illnesses requiring isolation and euthanasia compared with control cats.13,14 If providing a hide box for feline patients is not feasible, Dr. Hewson advised partially covering the cage door with a towel for increased privacy.3

Canine patients with excess energy may exhibit signs of frustration, such as incessant barking, that disrupt the hospital environment and increase distress in other patients. Bored patients should be provided with items for play and occupation.3 Dogs often benefit from having a chew toy, preferably one from home, or a toy containing kibble or treats. Easy, disposable toys for restless feline patients include a paper bag or a ball of crumpled aluminum foil.15

Treat Each Patient as an Individual
Both investigators emphasized the powerful effect, whether positive or negative, the veterinary team has on a patient’s hospitalization experience. Each patient has a unique temperament and needs, and a few simple measures can encourage cooperation and bonding with veterinary staff.16 Taking a few minutes to brush, groom, or pet a hospitalized patient helps alleviate anxiety and foster trust.3 Results from one study showed that shelter dogs that received positive human interaction had lower sali­vary cortisol levels and demonstrated less anxious behavior compared with control dogs that received no human interaction.17

Dr. Hewson also mentioned that many nervous patients prefer being handled by a single staff member for treatments during hospitalization.3,18 Notes on patient handling and behavior should be included in the medical record to ensure that members of the veteri­nary team provide consistent care during subsequent visits. Providing an individualized approach to patient care helps alleviate owner anxiety and increases trust in the veterinary team.

Compared with humans, dogs and cats have height­ened senses of smell and hearing. In the hustle and bustle of a busy workday, it is easy to overlook poten­tially frightening stimuli, such as loud voices or quick movements.19 Both investigators recommended using gentle patient handling techniques rather than rough handling or rushing.1,5,6 Also avoid actions that may be perceived as confrontational, such as using direct eye contact or approaching the patient from above. Instead, crouch to the patient’s level and provide food and treats during handling to ease fear. Ms. Almond recommended approaching patient care using prin­ciples from the HAPPY mnemonic (Box).19

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HOLISTIC THERAPIES
Dr. Hewson and Ms. Almond explained the increasing popularity of several holistic therapies in human medicine. Three methods in particular were discussed for their potential roles in veterinary care: aromatherapy, pheromones, and music.2,4

Aromatherapy
Although the use of essential oils is becoming increasingly popular, some study results suggest that their primary benefits are psychological rather than physiologic.4,20 Relatively few studies have examined essen­tial oil use in animals. In one study, the use of lavender straw during transport of pigs reduced signs of motion sickness but did not affect salivary cortisol or stress related behaviors.21

Another essential oil, valerian root, report­edly offers anxiolytic benefits by acting on the gamma-aminobutryic acid system. One study found that intraperitoneal dosing of valerian root and its active ingredient, valerenic acid, in rats resulted in significantly reduced anxious behavior compared with rats in the control group.22 However, another study found that the use of a valerian oil plug-in diffuser did not reduce anxious behavior in dogs that were placed in an unfamiliar room.23

Pheromones
Synthetic pheromones, which are commercially available in many forms, are used to mimic natural chemicals released to alter behavior and physiology among members of the same species. Examples include Feliway, a synthetic form of the feline F3 facial pheromone secreted by the vibrissae area and cheeks, and Adaptil, a synthetic form of the dog-ap­peasing pheromone (DAP) produced by lactating dogs in the first few days after whelping.

Two studies examining the use of Feliway spray for hospitalized cats offered insufficient evidence of the product’s efficacy, as multiple other variables existed that may have contributed to results.24,25

In one canine study, use of a DAP diffuser in a hospital setting produced relaxation but did not abate aggressive behavior26; however, another study found that dogs exposed to DAP had fewer signs of separa­tion anxiety, such as lip licking and pacing, compared with dogs that were not exposed to pheromone.27

Several studies have examined use of a DAP pher­omone collar, with variable results. One study found that wearing a pheromone collar for 4 weeks did not reduce stress-related behavior in dogs transitioning from foster homes to a military training environ­ment28; however, another study determined that the use of pheromone collars significantly reduced fear and anxiety in dogs exposed to a simulated recording of a thunderstorm.29

Both investigators believed the existing data offer insufficient evidence of pheromone effectiveness.2,4 Instead, other tactics, such as environmental enrich­ment, are more likely to alleviate stress. As pher­omone production is highly individualized, further research is needed to examine whether commercial formulations and concentrations of synthetic phero­mones are adequate for therapeutic benefit.1-3

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Music
Many human studies have demonstrated the use of music as a mediator of anxiety.5 In one study, students showed reduced anxiety, lowered heart rate and blood pressure, and increased academic performance while listening to music.30 Another study reported decreased pain, anxiety, blood pressure, and heart rate in human patients who listened to music compared with those who did not.31

In a shelter study, dogs barked less and rested more after being exposed to classical music; talk radio and pop music offered no perceived benefit.32 Another study reported that playing classical music in a kennel environment did not affect canine salivary cortisol levels but that study dogs showed decreased physio­logic and psychological signs of stress.33 Many musical recordings are now marketed specifically for pets.3,5

SUMMARY
Several methods of reducing stress in small animal patients, such as environmental enrichment and modi­fied handling techniques, are supported by peer-re­viewed data. Although the benefits of many holistic approaches, such as music and aromatherapy, are subjective, the investigators noted that they cause no apparent harm and, therefore, may be warranted for use especially in fearful or anxious patients.2,4

Both investigators emphasized the rewards gained by alleviating patient stress during hospitalization, including improved welfare, increased immune func­tion, and an easier recovery process.14,15,34,35 Relaxed patients also tend to be less fearful during subsequent visits, making patient care more effective for the veteri­nary team and more enjoyable for the pet and owner.

References
  1. Hewson C. Evidence-based approaches to reducing in-patient stress–part 1: why animals’ sensory capacities make hospitalization stressful to them. Vet Nurs J. 2014;29(4):130-132. doi: 10.1111/vnj.12130.
  2. Hewson C. Evidence-based approaches to reducing in-patient stress–part 2: synthetic pheromone preparations. Vet Nurs J. 2014;29(6):204-206. doi: 10.1111/vnj.12140.
  3. Hewson C. Evidence-based approaches to reducing in-patient stress–part 3: how to reduce in-patient stress. Vet Nurs J. 2014;29(7):234-236. doi: 10.1111/vnj.12156.
  4. Almond S. Reducing stress in canine patients whilst hospitalized in a veterinary practice–a review–a review part 1. Vet Nurs J. 2018;33(2):49-51. doi: 10.1080/17415349.2017.1406318.
  5. Almond S. Reducing stress in canine patients whilst hospitalized in a veterinary practice–a review. Part 2. Vet Nurs J. 2018;33(4):102-104. doi: 10.1080/17415349.2017.1412813.
  6. Williams L. Cat handling and associated stress: a clinical nursing perspective. Vet Nurs J. 2016;31(3):88-93. doi: 10.1080/17415349.2015.1128859
  7. Nicholson SL, Meredith JE. Should stress management be part of the clinical care provided to chronically ill dogs? J Vet Behav. 2015;10(6):489-495. doi: 10.1016/j.jveb.2015.09.002.
  8. Rooney NJ, Gaines SA, Bradshaw JW. Behavioural and glucocorticoid responses of dogs (Canis familiaris) to kennelling: investigating mitigation of stress by prior habituation. Physiol Behav. 2005;92(5):847-854.
  9. Hekman JP, Karas AZ, Dreschel NA. Salivary cortisol concentrations and behavior in a population of healthy dogs hospitalized for elective procedures. Appl Anim Behav Sci. 2012;141(3-4):149-157.
  10. Part CE, Kiddie JL, Hayes WA, et al. Physiological, physical and behavioural changes in dogs (Canis familiaris) when kennelled: testing the validity of stress parameters. Physiol Behav. 2014;133:260-271. doi: 10.1016/j.physbeh.2014.05.018.
  11. Greenfield S. Mental stimulation as a tool to enhance canine patient mental wellbeing. Vet Nurse. 2012;3(9):554-561.
  12. McCobb E, Patronek G, Marder A, Dinnage JD, Stone MS. Assessment of stress levels among cats in four animal shelters. J Am Vet Med Assoc. 2005;226(4):548-555.
  13. Kry K, Casey R. The effect of hiding enrichment on stress levels and behaviour of domestic cats (Felis sylvestris catus) in a shelter setting and the implications for adoption potential. Anim Welfare. 2007;16(3):375-383.
  14. Gourkow N, Fraser D. The effect of housing and handling practices on the welfare, behaviour and selection of domestic cats (Felis sylvestris catus) by adopters in an animal shelter. Anim Welfare. 2006;15(4):371-377.
  15. Wells DL. Sensory stimulation as environmental enrichment for captive animals: a review. Appl Anim Behav Sci. 2009;1(18):1-11. doi: 10.1016/j.applanim.2009.01.002.
  16. Scotney RL. Environmental enrichment in veterinary practice. Vet Nurse. 2010/2011;1(3):140-149. doi: 10.12968/vetn.2010.1.3.140.
  17. Bergamasco L, Osella MC, Savarino P, Re G. Heart rate variability and saliva cortisol assessment in shelter dog: human-animal interaction effects. Appl Anim Behav Sci. 2010;125(1-2):56-68. doi: 10.1016/j.applanim.2010.03.002.
  18. Roden I, Sundahl E, Cariney H, et al. AAFP and ISFM feline-friendly handling guidelines. J Feline Med Surg. 2011;13:364-375. doi: 10.1016/j.jfms.2011.03.012.
  19. Carter C. Reducing patient stress: considerations for nurses. Vet Nurs J. 2014;29(11):362-364. doi: 10.1111/vnj.12192.
  20. Franco L, Blanck TJJ, Dugan K, et al. Both lavender fleur oil and unscented oil aromatherapy reduce preoperative anxiety in breast surgery patients: a randomized trial. J Clin Anesth. 2016;33:243-249. doi: 10.1016/j.jclinane.2016.02.032.
  21. Bradshaw RH, Marchant JN, Meredith MJ, Broom DM. Effects of lavender straw on stress and travel sickness in pigs. J Altern Complement Med. 2008;4(3):271-275. doi: 10.1089/acm.1998.4.3-271.
  22. Murphy K, Kubin ZJ, Shepherd JN, Ettinger RH. Valeriana officinalis root extracts have potent anxiolytic effects in laboratory rats. Phytomedicine. 2010;17(8-9):674-678. doi: 10.1016/j.phymed.2009.10.020.
  23. Taylor S, Madden J. The effect of pet remedy on the behaviour of the domestic dog (Canis familiaris). Animals. 2016;6(11):64. doi: 10.3390/ani6110064.
  24. Griffith CA, Steigerwald ES, Buffington CA. Effects of a synthetic facial pheromone on behavior of cats. J Am Vet Med Assoc. 2000;217:1154-1156.
  25. Kronen PW, Ludders JW, Erb HN, Moon PF, Gleed RD, Koski S. A synthetic fraction of feline facial pheromones calms but does not reduce struggling in cats before venous catheterization. Vet Anesth Analg. 2006;33(4):258-265. doi: 10.1111/j.1467-2995.2005.00265.x.
  26. Mills DS, Ramos D, Estelles MG, Hargrave C. A triple blind placebo-controlled investigation into the assessment of the effect of dog appeasing pheromone (DAP) on anxiety-related behaviour of problem dogs in the veterinary clinic. Appl Anim Behav Sci. 2006;98(1-2):114-126. doi: 10.1016/j.applanim.2005.08.012.
  27. Kim YM, Lee JK, Abdelaty AM, Hwang SH, Lee JH, Lee SM. Efficacy of dog-appeasing pheromone (DAP) for ameliorating separation-related behavioral signs in hospitalized dogs. Can Vet J. 2010;51(4):380-384.
  28. Broach D, Dunham AE. Evaluation of a pheromone collar on canine behaviors during transition from foster homes to a training kennel in juvenile military working dogs. J Vet Behav. 2016;14:41-51. doi: 10.1016/j.jveb.2016.05.001.
  29. Landsberg GM, Beck A, Lopez A, Deniaud M, Araujo
A, Milgram NW. Dog-appeasing pheromone collars reduce sound-induced fear and anxiety in beagle dogs: a placebo-controlled study. Vet Rec. 2015;177(10):260. doi: 10.1136/vr.103172
  30. Gosselin KP, Holland B, Mulcahy A, Williamson S, Widacki A. Music for anxiety and performance enhancement in nursing simulation. Clin Simul Nurs, 2016;12(1):16-23. doi: 10.1016/j.ecns.2015.12.002.
  31. Liu Y, Petrini MA. Effects of music therapy on pain, anxiety, and vital signs in patients after thoracic surgery. Complement Therap Med. 2015;23(5):714-718. doi: 10.1016/j.ctim.2015.08.002.
  32. Wells DL, Graham L, Hepper PG. The influence of auditory stimulation on the behaviour of dogs housed in a rescue shelter. Anim Welfare. 2002;11:385-393.
  33. Bowman A, Scottish SPCA, Dowell FJ, Evans NP. ‘Four Seasons’ in an animal rescue centre; classical music reduces environmental stress in kennelled dogs. Physiol Behav. 2015;143:70-82. doi: 10.1016/j.physbeh.2015.02.035.
  34. Moberg G. The Biology of Animal Stress: Basic Principles and Implications for Welfare. Wallingford, UK: CABI Publishing; 2000.
  35. Dobson H, Tebble JE, Smith RF, Ward WR. Is stress really all that important? Theriogenology. 2001;55:65-73.

Dr. Stilwell received her DVM from Auburn University, followed by an MS in fisheries and aquatic sciences and a PhD in veterinary medical sciences from the University of Florida. She provides freelance medical writing and aquatic veterinary consulting services through her business, Seastar Communications and Consulting.
 

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