Yeah, so this, this session is probably going to be quite interactive, so it's basically a Q&A about cognitive dysfunction in, in cats and dogs. So you can probably chat put your questions in the chat box or in the, in the Q&A box and Otherwise, we can probably just start discussing a bit the similarities and differences between between cats and dogs and as you said, then maybe we could start with with clinical signs, perhaps that's a good, a good start. So maybe Natalie, you want to start explaining the clinical signs, what, what would these cats present with really and then I can follow up with maybe differences with dogs.

Yeah, no, that sounds like a good plan and we can keep an eye out for questions coming through. With my screen set up if Ben's able to flag any interesting questions that come along, that would be great. So I am I'm preferring for this, obviously I knew a lot of the clinical signs of cognitive dysfunction in cats, but I needed to just double check and make sure there wasn't anything new that had come out and that I'd missed.

And one of the things and and doing my bit of research was I came across a really nice an acronym which I hadn't learned before. So I thought that was quite a nice one to start with. I think it's one.

As as we'll come through in this discussion, every time Florence will say something, I'll be like, yeah, there's not much information in cats compared to dogs. And I think this, this particular acronym was probably developed for dogs, but it is still relevant for cats. And it's Dha is what what it is said as.

So the D stands for disorientation. The I is altered social interactions, and that can be with people or with other pets. The S is for altered sleep wake cycles.

The H is for house soiling, but also a loss of learned behaviour. And in cats, the actual use of a litter tray is an innate behaviour, it's not a learned behaviour. But knowing where to find the litter tray is probably a learned behaviour.

So it may be that that loss of, of not knowing where the litter tray is, that may be the reason why house soiling, especially in cats, is seen associated with cognitive dysfunction. And then the two A's at the end of this, the first one stands for alterations and activity levels, and then the second one is increased anxiety. However, nothing is ever simple with cats, and we, we know, and it's some work that I've found within my own PhD research work, but also, there's been some lovely work published out of.

From a couple of quite large studies, showing that there's quite a lot of sort of age-related behaviour changes that do occur with cats, which may relate to some of the disease conditions that they get, but may also be part of, of their natural ageing. And the ones that are most commonly reported are increased vocalisation, which can be both day and night. .

Increased sociability with people and other pets. Again, increased incidence of house soiling, and then a decline in things like appetite, grooming behaviour, and willingness to go outside. Within those sort of behaviours and cognitive dysfunction, the, the kind of changes in cats that are especially more associated with cognitive dysfunctioning are definitely that sort of spatial disorientation and confus With altered social relationships, it's more often aggression, which may be due to the anxiety or some irritability that they're feeling.

The vocalisation tends to be more inappropriate. And I think the classic one that many of us that work with cats would recognise is that night calling behaviour. And there's been a nice paper published recently showing that that really As the result, at least from the owner's perspective, of either the cat being disorientated, getting a bit confused and not knowing where they were in the middle of the night, or sort of attention seeking, so potentially they were feeling anxious, and needed some reassurance from their, their owner as well.

Other things that are sort of associated specifically with cognitive dysfunction in cats, Decreased responsiveness, changing in their sleeping patterns, a loss of learning and memory. And then their activity changes tend to be more a sort of aimlessness, pacing, wandering type change to to their activity and increased lethargy as well. We also see things like a altered interest in food, decrease in grooming.

Behaviour and just general forgetfulness as well. However, as I read through all of those, I'm sure most people recognise that they are often symptoms of many other illnesses, especially ones that we see in older cats. So we do have to remember, especially because cognitive dysfunction in cats is very much a diagnosis of exclusion, a thorough workup is definitely required to rule out other causes because there is a lot of corresponding clinical signs that may also indicate another problem going on.

So I'll hand over to you, Florence, and, and how dogs are a bit different, but I'm sure there are similarities as well. Yeah, there are many similarities and, and I like what you said that this clinical signs you can find them with many other conditions. So that's where the challenge is and the other big challenge I think is that for many owners it's actually, they look at it as if it was a normal.

Thing for these pets to just act a bit differently, so they may not even report these clinical signs to start with. So there is a nice study looking at the prevalence of these clinical signs and how often is it reported to the to the to the vet and they did a study on dogs above 10 years old and when they asked the question that would point towards thinking that the dog may have canine cognitive dysfunction, the pet owner reported that. Yes, there may be some cognitive dysfunction actually in 75% of the cases, but only 20% discussed that with their vets.

And if you look at vet records, only 2% of the vet actually recorded on the notes that the pet may have cognitive dysfunction. So it's really clinical signs are considered as normal in in pet owners, but actually they are not normal and that I'd like to discuss this a bit further later just to not normalise the cognitive dysfunction of these ageing pets. In dogs it's a bit the same as in cats for the clinical signs.

We also have this this nemonic. So, as you said, this, this stands for disorientation and that's often something that pet owners would, dog owners would, or dog pet parent, dog parent would, who would describe is that their dog is lost in the house or tries to go through a door, but via the hinge of the door instead of going through the normal opening of the door so you can see that. The, the space orientation is lost a little bit there.

And as you said, I stands for social interaction and once again, maybe dogs will be different than cats there because maybe the owner would realise a bit of a different behaviour, different interaction with the dog earlier than they would with a cat. And also because anything that has been learned like simple orders like sit or come here or the simple communication, you would see that the dog doesn't get it when actually the dog has been sitting well for the past 12 years when you give them a little treat. For example, this time they just seem to not understand and this sort of interaction.

Problem you can see that quite early when you have these, these dogs with cognitive dysfunction. Loss of house training, as you said, same a dog would just urinate in the corner of a room when he has never done this since he was a puppy, and change in sleep wake cycle, that's a big one because that's often what has a heavy impact not only on the dog, quite quality of life, but on the owner quality of life. So if you have a dog that is pacing the whole night and vocalising that can affect the relationship and, and can increase the frustration of the, of the dog owner and, and it can be quite distressful actually having this, this dog howling in the middle of the night.

So. Yeah, I think it's quite similar to cats in terms of clinical signs, but maybe the, the, the dog owner would recognise them earlier because the subtle changes may reflect earlier in the relationship between the, between the dog, and, and the owner, but yeah, really it's, it's, that was quite shocking for me to see that many pet owners see the this sign, but none of, many of them don't report them to the vet and I guess it's the same in, in cats as well. I think so and yeah, I think you're right, the, the interaction between cat owners and and dog owners with their pet is sometimes quite different.

So I think probably, I don't think we know for sure, but I think in cats, potentially the owners aren't necessarily picking up on some of these changes until they are more advanced compared to, to the dogs, I think. I think that would be fair to say that we've still got a long way to go with raising awareness about perhaps even disease conditions that are a bit more obvious. And yeah, cognitive dysfunction is, is a little bit less overt perhaps in cats until it may be more advanced.

So do you have an idea, you've sort of mentioned the study that had some prevalence. Are there any other studies to really indicate in dogs how Common cognitive dysfunction is. Yeah, so as you can imagine studies they give very different numbers, but overall if you look across the literature, if you look at dogs older than 8 years old, then it's between 10 and 30% of dogs would have cognitive dysfunction.

If you look at dogs above 14 years old, then it's up to 70%. So it's a huge population of these dogs that would have this cognitive dysfunction, and Actually, there are some nice questionnaires and at the end of the session, I can give a link into the chat box to have access to one of the questions that was developed in dogs to, to assess this patient and know if you can put them in the canine cognitive dysfunction suspected case or or if actually they look OK from this point of view because And it can be also difficult for the vets to know is that normal ageing or is that a cognitive dysfunction. So this, this question are quite nice and actually the, the, the, this prevalent studies are based on these questionnaires, for example, one is the CAGES, I don't know how they pronounce it, probablyAES, which is the canine dementia scale.

And you have, I think it's a set of 20 questions that really help you understand in all the area where this dog is at risk or if the dog has developed cognitive dysfunction. I, I guess in cats maybe the prevalence is a bit less known or are there any, any studies, it, it definitely, is, I think realistically underreported, but there's not, I haven't come across any large epidemiological studies using sort of practise data as such that look into it. But I did, in my noting there was a study from quite a number of Years ago from Professor Gunmore at Edinburgh University.

And I, I found this quite interesting because it actually was higher than I thought it probably would be. In her study, looking at cats over 11 years of age, so a little bit older than the dog studies, they found overall a prevalence of 35%, in cats of that age range. And then when they broke it down into Been two subgroups.

So the first one, between 11 and 15 years of age, was 28% of cats, but then increased up to 50% of cats over 15 years of age. So I think that, that to me really highlights the importance of us starting to, to make sure we're asking questions, of our owners, especially, our cat owners when they're coming in with their, their animals up. Obviously, dogs over 8 years of age, and then our cats probably over 10 years of age to, to really just start to ask the questions about what changes they've observed, because definitely that study to me really highlighted that we need to be, we need to be asking owners, prompting them more, rather than just relying on them coming to us, and, and saying what they've seen in terms of the changes with their cats.

Yes, definitely. I don't know if you have any, questions. There's none in the chat but I loads thousands of them.

Here we go. The one thing that I'm fascinated by, and obviously my backgrounds aside to veterinary is in tech, and, and obviously there's been this huge upsurge over the recent years in, in the sort of adoption of, you know, sorts of pet activity trackers and, you know, things that tell you which neighbours feeding your cat cake, and, you know, all of these sorts of things, and I just wonder is there. Presumably there's a, a sort of bright future, and where did you guys see the benefits of the sort of tech, developments coming into that sort of early identifiers for sort of this cognitive change, because presumably, especially with our cats, we're going to see sort of changes in their roaming patterns and stuff like that as well.

I just wondered whether you guys both had any insights as to, you know, where those sorts of bits of tech might be useful or, or perhaps where they're a hindrance. Definitely on, on cat side of things, I think they, they are really, really interesting, especially that sort of activity monitor, wearable type tech. We're still getting there with cats, in terms of the size of them, so the wearability really, as it were.

I, I, my research project for my PhD had a specific focus on feline osteoarthritis. And so there's been a fair amount of research using Especially with regards to, to helping aid the diagnosis of, of osteoarthritis. They don't always give you the answers you would expect them to do.

And that I think is the tricky part. I think probably my conclusion, out of having reviewed that literature, specifically looking at, at osteoarthritis diagnosis, is you need to be following the individual cat over time. So it's harder to look at patterns across.

Cats, it's probably better to look at the individual cats changes over time because there's just far too much into cat variation to be able to get really clear patterns, at least at this point. I think as these things maybe become more readily available, the the wearability of them improves, and you get larger data sets, you probably will start to see some clearer patterns. But as they stand at the moment, I don't think we're quite there yet with them for cats anyway.

I think for dogs maybe things have gone a bit further with all the activity monitor that we can have for dogs, and when we have an app on your phone telling you how many steps your dog took or these sort of things. I guess maybe not for the detection of the disease, but for monitoring once you've started treatment, that would be great because the sleep wake and cycle, disturbance is one of the big problem with these diseases. So maybe you would be able to monitor how, how long are the awake, how long is your dog awake, awake during the night, for example, and you could help manage the condition like this and see if you need to adjust the drug that you're using to manage this cognitive dysfunction.

I guess that would be a nice way of following up these cases. And, and I guess obviously, you know, sort of one of the other big areas is looking at the correlation between diseases, and for me one of the fascinating areas are, are there any sort of diseases that, that we feel actually sort of advance and hasten the development of cognitive dysfunction? And certainly from, you know, again, anecdotally I look at my, my, my dear old nna before she passed away and, you know.

As she slowed down and as her mobility slowed down, she was doing less, she was, you know, I can say, utilising her brain a bit less. And actually has that, is there any evidential sort of relation between the relationship between the two of them, or, or is it actually just that a lot of things start going wrong at the same time and it's just coincidence that we have all of these changes alongside one another? I think, definitely on the cat side, I don't think that evidence is there, in terms of showing strong relationships, you know, that if X happens at this stage in your life, you're more likely to get Y.

But definitely, a lot of the other conditions that we get in older cats, I mean, They get a lot of multiple morbidities and I think that, I think dogs do as well really too. Definitely they, a lot of those conditions could, could worsen the symptoms of cognitive dysfunction. I think if we take high blood pressure as example, potentially something like that will be exacerbating, some of these the symptoms of cognitive dysfunction, because the symptoms are often, there's a lot of, double up.

So it's really hard to be able to say what is caused by high blood pressure. What is caused by cognitive dysfunction, until you're fully addressed and treated the high blood pressure. And likewise, I think in people, things like urinary tract infections can often exacerbate some of the the, the signs of, of the sort of senility dementia type symptoms.

And definitely, anecdotally we do see the same in cats as well. I don't know if Florence, if that you see the same in dogs, but definitely things just as simple as a urinary tract infection can, can make things appear worse. Yeah, I think that there are many comorbidities that can, yeah, enhance the clinical signs and also in dogs and in people actually, we've started to understand some predisposing factors that would make this cognitive dysfunction, .

Either develop faster or happen earlier and there is one, a big one that has been seen in human and in dog and it's epilepsy. So it's been shown that they started to look at this in human and they realised that people with a certain type of epilepsy and that were put on. Certain drugs were having learning difficulties and so they extrapolated that to see actually what is happening there and then they found the RVC actually studied that they found that dogs with idiopathic epilepsy had some degree of cognitive dysfunction earlier than other dogs.

And then they looked into is it the epilepsy or is it the treatment of the epilepsy, and they have identified that the epilepsy on its own is associated with earlier onset of cognitive dysfunction in dogs, but also some drugs. So if the dog is on several drugs and potassium bromide, then you have earlier chances to develop a cognitive dysfunction, which is quite interesting. And and diet as well has been proven to increase or reduce the chance of cognitive dysfunction in humans, so probably we think that the same probably happens in dogs and cats.

And in humans, things like red meat, processed food, and refined sugar in the food have been associated with earlier decline of cognitive function, which is quite interesting, and vegetarian diets in humans have been proven to actually increase the cognitive function on the longer term. Oh, that's fascinating. I think it's, again, it's something that's becoming increasingly common where we're having, pet owners, pet parents, pet guardians.

I too suffer with knowing exactly what to call people nowadays. Florence, so no, I can, you have my full empathy for what you were referring to earlier. It's fascinating because I'm certainly having more and more conversations with people coming to me about, you know, insect-based diet.

And, vegan diets and vegetarian diets, and I have to say, invariably I'm kind of sat there like a bit like a rabbit in headlights kind of going. We don't know because a lot of these concepts are incredibly new in our pets. And yeah, I think that's, it is, you know, diet plays such a key factor in, in everyone's lives.

I think, you know, there has to be some degree of, of association. With with something and you know, it's gonna be an interesting sort of decade of discovery really when it comes to the nutritional impact on that, sort of cognitive longevity. If people have got any more questions, please do, fire them into either the chat or the Q and A, and I think, you know, sort of, we, as I say, we are seeing more and more older patients and, and, you know, for me it's.

It's a really interesting geriatric medicine is, is such a, an interesting area. So, I mean, looking at, for instance, you know, the dogs and cats that you guys are dealing with, is there anything, I, I kind of suppose that over the years we've always looked at it and kind of gone, well, they're just getting old, we'll support them with this and that and the other, and obviously you've alluded to medical management of things earlier. Realistically, when we're having conversations as first opinion GP vets in practise, what, what kind of things can we be suggesting, to, to, you know, to the different client demographics, to the cat owners, to the dog owners, and saying to them, look, you can do this.

It, it, because I find now I'm sat there kind of going, you can do this, it might help, it might not help. And certainly that's something where, where my personal knowledge is lacking. Yeah, I'm, I'm, I'm happy to start and probably Natalie will have more input in the environmental management side of things because that really helps in, in, in cats and dogs as well.

And I'm happy to start with sort of more medical management. So if you, let's say you, you're first opinion vet and you're facing, can you hear me well, by the way? Is it better?

Yes. So let's say your first opinion vet and you have a a dog owner there. And because it's an old dog, you start asking questions about does he get lost in the house and does he walk around in, in the night, which he didn't used to do, or you bring up the question and, and you feel like there is some degree of cognitive dysfunction there.

Then the first thing to do is that, you can actually do a test in practise. So that has been described where you can actually, in the consultation room. Do some tests to assess the cognitive function of the dog.

So I've discussed with some neurologists. Some said that, yeah, it's reliable. Some others say that it's not reliable.

So it's just an idea that I can get out there. There is a paper that described this food search, yeah, food search basically. When you're in the, in the practise with the dog, you show them a little treat.

So you show them that. Have the treat in your hand and you put that in in the corner of the room so you don't let them follow you. You just show to them, look, I'm putting the treat in this corner.

Then you ask the pet owner to go out of the consultation room with the dog for 10 seconds or 15 seconds, then they come back in and they let the dog off the leash. And the dog with a normal cognitive function would remember where you put the treat and would go straight there. And a dog with some degree of cognitive dysfunction could put, for example, remember that there is food somewhere, but he doesn't remember where, so he would just look in every corner, for example, before finding the food.

And a dog with advanced cognitive dysfunction would completely forget that you've put any food there and would just come in as if nothing had happened. And then that's a test that has been proven quite reliable and more than 70% of dogs without cognitive dysfunction would just go straight to the food. And more than 70% of dogs with cognitive dysfunction would actually not even look for the food.

So it's a nice way of assessing the short term memory and problem solving abilities in this pets. So that's the bad thing to do is try to put out the questionnaire and do these simple tasks to see if the dog really has this issue. And then you have, if you feel that the dog has K and cognitive dysfunction, either you need to do your medical tests to Rule out basically other conditions that could cause this disorientation.

So you would run your blood work to rule out kidney disease, liver disease. You would do your neurological examination to rule out any other neurological condition. For example, a brain tumour sometimes can cause this degree of behaviour.

So that's the big thing to rule out. So you would do a basic examination and blood work. If you feel that there is nothing major and you think it's cognitive dysfunction.

Then there are 3 things that you can do. One is drug, one is diet, and one is environment. So, starting with the drug, the only medication that is recognised or approved, I should say, for use in canine cognitive dysfunction is elleline.

So the cellgian I think it's called, so this one would would it's, it's, let's say it's approved to be used for can and cognitive dysfunction, although some people start thinking that actually what it does, it's just that it's Makes the pet a bit more hyperactive, a bit brighter, but actually doesn't help at all with the cognitive function. So it may look like the dog feels better because it promotes what they call a low grade hyperactivity, so it's a bit more reactive. But actually if you do a cognitive function test, the dog is not better in terms of cognitive function.

So you could try elleoline and see how that affects the pets, but I would say if after 6 weeks this hasn't changed anything, then it means that in this particular case it's not going to work. There is another drug that has been looked into a lot in human and a little bit less, but still a little bit in dog. It's levetiracetam, which is an anti-convulsive drug, so the Keppra.

And this, this, drug actually enhanced cognitive function. So, again, you can try levetiracetam, which is a very safe drug. The biggest side effect is sleepiness.

So if you see that this happened, you can reduce the dose or play a bit with the dose. But these are the two drugs that are looked into at the moment for canine cognitive dysfunction. Then diet, there is more and more evidence that diet can help slow down the process of canine cognitive dysfunction.

The big one that probably everyone agrees on is antioxidants, because a lot of the damage that happening in the brain are linked to oxidative damage and ageing process. And what happens is that with the oxidative damage, you have a lot of betayloid protein. Which deposit everywhere in the brain and in the vessels, and that's what basically prevents your neurons to communicate between them and to work together.

So if you go strong on antioxidants, you slow down this oxidative damage and this toxicity of this betayloid protein. So a diet with antioxidants is important. Then another part that is quite important is medium chain triglycerides.

I don't know if you've heard of that. It, it's talked about a lot. Some diets have them directly inside.

Sometimes you can just add actually coconut oil, for example, contain these MCTs, and NCTs alongside antioxidants seems to help as well, cognitive function. So they can prevent cognitive decline and they can slow down the cognitive decline when it's there. So that's quite interesting.

And environment and Natalie will talk a bit more about that also can help. So it has been proven that if you take big girls around 8 years of age and you provide a lot of stimulation, game, you teach them new tricks, you take them out regularly, so a lot of mental stimulation, you actually slow down the decline of the of the cognitive function and you slow down the deposition of this beta amyloid protein. And it's, it's all to do with the idea of cognitive reserve.

So people think that if actually you create a lot of connection between your neurons by learning new tricks, going out, having a routine with your own, all these things, actually, even when the proteins develop and prevent some Synapse between neuron into work because you have so many synapses created and actually you're able to cope better and then the message just goes in another way but still gets there in the brain. So these are the three big things drug, diet, and and environment and maybe Natalie, you want to go a bit further with the environment on the on the cat's point of view. Yeah, definitely.

Yeah, just to follow on what you said around sort of the nutraceuticals and the drugs, basically in the cat side of things, it's really extrapolated from the dog side of things. Again, there's just very little additional research to support any benefits. The other thing that Florence mentioned was around the beta, the amyloid beta amyloid build up.

And in cats, it's still not clear how significant that is as a cause. Of cognitive dysfunction. So, they do get it, but they get a different pattern distribution from people and dogs.

So we don't know for sure if the the pathophysiology of the, the process of cognitive dysfunction in cats probably has some overlap with what we see in dogs and with people, but may not necessarily be the same disease. So, I think that also probably has a bit of an impact about we just don't have enough evidence of exactly what's going on to then say, What specific nutraceuticals and drugs may also benefit. But at this stage, it is very much following on from what's done in dogs, and everything in cats is pretty much off licence or has very little evidence to support it, apart from the diet side of things, as, as Florence said, that the sort of cocktail of antioxidant type things is, is probably the way to go in cats.

When we're managing, cats, really, we We need to do some modification and enrichment of their environment. I think still encouraging learning and play is important, so using things like puzzle feeders, and engaging in some form of or enabling the cat to engage in some form of play behaviour is also important to just try and keep them stimulated, keep those pathways active. It's sort of a use it or lose it type situation, I suspect with, with this.

So I think It's it's important to, you know, even if it's more gentle play to still be engaging in it. Definitely, obviously do your full workup, find any actual diseases and conditions that we can treat. And to me and cats, really trying to assess and recognise any chronic pain that may be there, associated with dental disease or musculoskeletal disease is really important, because that may be exacerbating, some of the, the decline associated with.

The cognitive dysfunction. In terms of modifying their environment with cats, it's really making sure that they have easy access to all their key resources, and you don't go moving them around that often. So making sure that their, their food, their water, their sleeping places are all still easy for them to access.

So that may mean moving furniture if their sleeping places are up high, making some adjustments to allow them to access. And also making sure that they have a really secure, safe place that they can hide in or sleep in, especially if anxiety is a big part of, a part of the disease process that is occurring with them. It's just making sure that they've got somewhere where they can feel secure to help manage that anxiety.

If previously they used a toilet outside, you may need to start providing litter trays inside for them as well. I find as well with some of these cats that that anxiety does result in the need that they really do need probably more companionship and emotional support than maybe what they did previously as young cats. Cats are notoriously quite independent, although I say this with a giant ball of ginger fluff sitting next to me.

He made his crossing earlier, but now he's gone to sleep, fortunately. And he's definitely quite a needy cat, even though he's only 2 or 3. Whereas, yeah, I found with with my, my own pets, it's the old ones that really do need more support from you, more time, more companionship, and making, making considerations for that, I think is important if people work long hours and just seeing if there's additional friends or family that could provide some support for the cat, I think would be helpful.

I've mentioned that sort of enrichment as well. And the other thing is to consider the, the importance of a sense of smell for cats as well, and perhaps a slightly different. It's obviously very important for dogs and communication, but for cats, it also plays a big role in making them feel secure.

So encouraging owners that may be exceedingly hot on their cleaning, maybe to not be washing the cat's beard as regular, to just try and preserve that sort of familiar sense of smell and some of their safe and secure places. And also the use of feline pheromones as well. So historically, we would have talked about using feelway Classic plug-ins.

But the new felaway optimum, I think potentially might be quite interesting in these cases, because it activates the similar sort of pheromone targets as the, the feelway classic, but also, the, the sort of targets which are more the appeasing pheromone for, for kittens. And, and I do wonder if that potentially is helpful around some of the anxiety that we see with with these cats. And the other thing to consider is Also, with, with your owners perhaps talking to them about whether or not they also consult with a, a, a feline qualified behaviourist as well, to provide that additional support.

And I think it'll be the same with dogs as well, to just help structure maybe some of their routines a little bit more and to help them engage in some appropriate activities around play, around puzzle feeding, that helps just keep them engaged as well and create that more sort of supportive environment. That's, yeah, that's awesome, guys. That's, yeah, lots and lots of insights certainly for all of us there, and I think a really fascinating quote from Charlotte and it's something that has has been going on in my head for the last 5 minutes.

She's got a 15 year old Yorkie that's had a new lease of life since they've rehomed their 2-year-old Jack Russell. And I think it's interesting, isn't it? I, I kind of always see.

The introduction of a new younger pet is going one of two directions, and, and very little in between. But, but have you guys, have you seen anything, by way of sort of, you know, correlation by, by multi-pet households? Does that have any potential impact on, on delaying the onset or, or improving the clinical presentation, of, of sort of these cognitive dysfunction cases?

At least what I've heard very often from owners in dogs, it's a bit the opposite, but actually proves that companionship probably helps with that. Often people would say, since my second dog died, the other dog is really not interacting, just. The whole time and it's just declining, meaning that probably having this interaction between them keep keeps them busy and keeps them mentally active, I think.

So I don't have this type of experience, but the opposite is definitely true. When you lose one pet, the other pet is probably less stimulated, I would say, especially in dogs. Yeah, I think cats are probably too much of a variable picture because their social their sociability with other, other cats and other pets is very individual.

So sorry, definitely in some, I think it might, that sort of stimulation might be a positive thing. And for others, I think it would be a massively negative thing. So yeah, it's, it's probably too variable to, to really give clear advice on that.

A lot of that individual. Really encouraging question from from Harriet, I think 10 points to your practise, Harriet, because they're still hoping to start senior clinics in practise. And this is that awkward question, is it, when we think about it in humans, what age would you recommend starting them in dogs and cats?

It's that thing, isn't it, like, at what age do I become old? But, but yeah, obviously we'll start with a more gentle transition into our pets before we consider it for ourselves. I think the definition of, of, of, of this in cats is probably much more, much clearer than in dogs because all cats are ageing at the same pace probably.

So I think Natalie probably has a bit a clearer idea than we have for dogs. Yes, let's say there's a lot of breed variation in dogs. I think, yeah, you'd have to look at large breed, medium breed and small breed in dogs because of, because of those different and definitely.

In cats, things are clearer. So in terms of, of really starting to recognise age-related diseases, you need to be encouraging them from 1011 years of age. But my personal feeling, and again, I think slightly supported by my PhD research, we were assessing middle-aged cats, mature cats.

So we were doing, essentially senior clinics in terms of their composition from 7 years of age. And I would argue. There's value actually starting then.

We don't see truly age age related diseases in that, that sort of age range, but we see an awful lot of dental disease. We were seeing an awful lot where we're just starting to get a suspicion that musculoskeletal disease may be developing. And it also really gives you a really good opportunity to get them very comfortable with having blood pressure performed regularly.

So, so in cats, I would be encouraging a senior style. Clinic, whether you fully call it a senior clinic, or you may call it the mature cat clinic to start with. But from 7 years of age, it's really worth getting them in at least on an annual basis.

If not, to be honest, an annual basis with the vet and every 6 months or the nurse, especially around monitoring their weight. I think the cats is really useful. Yeah, large for dogs.

When do they truly start getting older? I think, I think in dogs, what you can say is that Dogs are ageing or senior for the last third of their life. That's a nice way of looking at it.

So if you look at big breeds like a Great Dane, you could really start doing a senior checks from 5 years old, probably. If you look at smaller breed, it's probably more around 8 to 10 years old. So, yeah, I'd say between 6 and 10 years old, depending on the size, then I would like to have this senior check.

Maybe 6 months, as you said. But before that, it's great as it is in cats to probably start earlier just to have a baseline about what is the normal renal value for this pets, for example. So start annually for all their life, but then senior chicks probably around, yeah, 6 to 8 years old.

Yeah. And and definitely starting earlier, you are able to pick up a lot earlier as well. So we found that with our project that we were because we were regularly testing.

Thyroid. We didn't get a huge number of cats under 10 with hyperthyroidism, but we had a few. And you're starting to pick them up when really their thyroid level is only just outside of the reference range.

And there's not huge overt clinical signs of hyperthyroidism. There's not the dramatic weight loss, the tachycardia, but they're starting to move in that direction. So you're really able to get them under control before it really affects their, their physiology and their health, which I think is a good thing.

Yeah, and I think it is, it's interesting, isn't it, because I think much as though we, we look at, you know, individuals when they come into us presented with a problem, how much easier would our jobs be if actually we could turn around to, to our owners and say, or, or parents, and say to them, you know, actually, well, we have seen a change, you know, compared to the the Bloods when they were normal, you know, in inverted commas normal, and it's finding what's normal. For that particular individual, and I think, of course, you know, the vast majority of our of our job is based around, you know, population averages. And of course, there is such individual variation, that, you know, what is, what's abnormal for one cat could well be normal for another cat.

And I think that's, for me, that's always one of the most fascinating things about this geriatric sort of change, because, you know, you're looking at stuff thinking, actually, How early could we intervene and how early could we, prevent, and I know certainly, you know, in my business ventures, that's one of the, the sort of, very much the, the linchpins of, of what our business is built on. For me, one of the interesting things is, is looking at the sort of, the right age to start doing bloods and also then what we would look at, because of course, you know, generally speaking, We associate just cognitive change with just a degenerative change, but do you see any, you know, we're, you know, we're looking for chronic liver disease or kidney disease. There's obvious parameters that we're measuring, but is there something that we could be keeping an eye out for on, you know, annual geriatric bloods as maybe, you know, an early indicator of, of something that may be going wrong, or, or are we not at that point yet?

For cognitive dysfunction, you mean, you know, so there are some in experimental settings they've proven that you could potentially measure this betamiloid protein that is going in the brain. You could measure it in the blood, and there is some degree of correlation between this and the accumulation of this protein in the brain, but that's really experimental. Even in human medicine, there is no blood test to evaluate, for example, Alzheimer's disease.

And canine cognitive dysfunction is really, really similar to Alzheimer's disease. So it's actually dogs are the model for, for human studies for this disease. So it's really complex and unless you actually do histopathology of the brain which has to be postmortem, you can't detect it apart from looking at the clinical signs.

Having said that, it's really important to do blood work every year to assess your kidney, your liver and all that, but you can't assess with blood, the, the, the cognitive function. Yeah, I, I agree. Unfortunately, with cats, we're still not even super clear on the pathophysiology of what's causing the disease, let alone a, a biomarker for it.

. I, I do think, and definitely I would encourage people when they're doing their senior clinics, in addition to to measuring the blood pressure, do also get in the habit of doing a retinal exam and having a look at the back as well. I don't know if that's going to help us with diagnosing cognitive dysfunction, but I think it's a useful thing to get into the, to the habit of doing. Yeah, that, that would be really the main things and definitely to me and cats.

The key thing around cognitive dysfunction is just recognising what other morbidities are also going on, because especially with it 1516 year old cats, there'll be other things happening. It's an exceedingly lucky cat if there's no other disease processes going on. And so, recognising those, and a lot of them at least have treatment or, or, you know, management options that, that hopefully improve the, the overall quality of life and welfare of the cat, which I think is important to do.

Definitely, I would be strongly advocating annual bloods at least in cats over 10. And if, if you're in the situation where your, your client base can afford to do them on an annual basis between 7 to 10, I think it's definitely useful, to get that baseline. And as I said, you can start picking up some earlier changes there as well.

Collecting urine from the cats, ideally every year as well, but that's a lot easier said than done, unfortunately. Nothing like fishing around a litter tray, hey. I really, and this is definitely one for you, Natalie, a really great question from Sylvia.

Does indoors or outdoors by a way of life, have an effect on the prevalence of cognitive dysfunction in cats? Unfortunately, I don't think we've got the answer to that, but I think that is a really interesting thing to look at. When we were talking about diet earlier, the other thing we need to remember with outdoor cats is some of them are also doing some of their own seeking of food, and it's not just what they're eating when they catch it, but it's actually that behaviour of catching it.

I mean, that's quite complex in terms of the, the neuro pathways that are being stimulated to catch a mouse. And I, it would be really interesting, not just indoor outdoor, but hunting outdoor cats, and whether or not there's a difference in, in prevalence as well. I think in the UK we're probably reasonably well placed for that type of study because we don't necessarily have some of the societal pressure around keeping our cats inside, and we don't have fortunately, a large, you know, coyotes and things like that that they have in the state.

Which is a good reason why you don't let your cat outside in certain areas because the risk of your cat not living long enough to ever develop cognitive dysfunctions quite high. So I think that would be a really interesting study to look at. The problem is you'd need a very large population because there would be so much variation, not just indoor, outdoor that you'd have to look at.

So it would be a very complex study, but it would be super interesting. Yeah, I think it, it is, it, it's really interesting is that I have to say when you look at cats being safe in the UK, I think any to try and cross the threshold in our garden, have a springer spaniel flying after them. So probably not as effective a hunter as a coyote, but certainly keeps them on their toes.

Definitely. Another, another interesting one from Georgia, for clients who, and this is all too common, of course, in GP practise, for clients who've left it a little too long in regards to the, the increase in symptoms, both in severity and number of symptoms, how do you manage a patient with quite severe symptoms and obviously in both categories? I think that, so the first thing to say is that it's, it's nice probably for the, for the, for the vets to compare the cognitive dysfunction to Alzheimer's disease.

I think it can help them relate and understand. But it's also nice to for for the pet owner to understand that usually in dogs, at least, it doesn't go as far as Alzheimer's disease and you can really Give a good quality of life with some tricks because the pet doesn't need to be so involved in the society as a human do. So it's really OK to say, OK, you, the cognitive dysfunction is quite advanced, but we can really make a difference there.

So it's a bit like Alzheimer's disease, but it's a bit less. Yes. So let's see what we can do.

And I would say the most important thing is to focus on the quality of life. So ask the, the pet owner what is the thing that affects the quality of life the most. And in my experience, most of the time it is that the pet is sleeping in the day and awake in the night and barking and this sort of thing.

That's what is really disturbing for them. So I'm discussing with an anaesthetist that was doing a lot of anxiety management, and I guess you could speak with a behaviourist as well, but they were not against the idea to actually giving medication to the dog to help them sleep in the night. For example, trazodone was was mentioned to me, so it's medication that you give to manage anxiety in sometimes hospitalised dogs, for example, when they can't cope being in a kennel.

So if a pet owner would be on the edge and say to me, I'm going to utilise this dog because really the quality of life is not there. He barks the whole night. I can't cope, he can't cope, then I would just medicate the dog because we have some drugs that can really help.

And then once you've started the medication, you can see what you can do to help with the environment and with the diet, and then little by little maybe step back with the medication. And help with the environment, but I think that it's really worth trying one of these medications that we are discussing, either levetiracetam or elegiline, and if needed to manage the anxiety, maybe trazodone. I've read in the Q&A some questions about levitonin and probenzophyin, I think.

So I'm just going to answer this now. There is no evidence that this would would help because actually what it does is that it creates some degree of vasodilation. The brain, so it's supposed to bring more oxygen to your brain and make your brain work better.

But the problem in canine cognitive dysfunction is that there are these amyloid deposition everywhere. So actually it doesn't matter if you really vasodilate the vessels in the brain. It's not really going to help.

There is no evidence behind the use of levitonin for canine cognitive dysfunction. So if you look at any of the review paper, there isn't anyone really recommending it. Not to say that it won't help for sure, but that wouldn't be my first choice.

Yeah, definitely, anecdotally, there are some reports that it is beneficial in some cat cases, but I think again, because it may vary with what the actual underlying pathophysiology of the disease in that particular cat is, I have used it once many years ago in a cat case with some benefit, but you know, sample size of one, so . I think, yeah, I think you're right. There's better, better options out there.

And yeah, following on from what you've said, definitely, with cats with huge amounts of anxiety, gabapentin is, is probably an appropriate choice for them as well. And the additional advantage of that is because I'm always suspicious. Some underlying degree of discomfort from osteoarthritis in these cases as well, potentially if that's causing neuropathic pain, that potentially will also be of assistance, both as an anti-anxiety slash sedative type medication, but also potentially the neuropathic pain component as well.

Yeah, I think certainly having been, having been prescribed gabapentin in, in my past, it's great. It's nothing, nothing better than to chill you out of an evening. And I think it's great because of course, I graduated in 2008, and you know, the go to at that point was, you know, have some bit of tone and it's going to increase your oxygen flow.

And even when you're giving out, you're kind of going, yeah, this is probably not gonna work, but good luck to you. And it's great to see the advancement in our understanding and also our ability to just offer that, you know, sort of various different options to people. I kind of feel like, you know, in, in so many aspects.

Of veterinary medicine now we have multiple options for people. And of course, you know, this sort of geriatric, care from a, from a cognitive perspective was sort of left behind and lacking previously, and it's great to see that sort of coming forward and us being able to present those those options to people, . I think from the looks of things we've gone through everybody's questions.

If everybody has got any more questions, then, then please do fire them into the chat or into the Q&A session over that we've got about 5 minutes left in this session. I see that your cat has woken up in the background there, Natalie. And the other one's now I'm like, I was gonna say that's definitely not a ginger cat.

No, this is the other one now, so I'm likely to get 2 of them in a moment. Which, yeah, just helping my cat created, it really is. Yeah, if I was to ask you, you know, obviously you're both experts in your field, you both deliver this, this information on a high level on a daily basis.

You have the, the benefits, I dare say, of time in your individual endeavours. Life in first opinion practise, busy, ever more pressure, especially with the increasing pet numbers and sort of, you know, the way we work presently. If you were to be able to give people one piece of advice for engaging with owners in, in, you know, both the canine and the feline spheres, for, for, you know, really bringing them into that journey and getting us as veterinary professionals involved in that sort of long term process, what would you, what would you say to people listening?

Which one of us wants to go first? Should I go? To me, especially around geriatric medicine, I think there's a really strong argument for us as veterinary professionals to stop referring to annual appointments as annual vaccinations, and start reframing them as an annual healthcare appointment and trying to give them the time that they deserve.

I, I, I think fortunately that Well, I'm hoping the days of the 5-minute consult have ended. Definitely the 10 minute was still very prevalent, when I last worked in general normal GP practise, before I moved into shelter medicine. But dipping back in as a locum, the 15 minutes seems to be a bit more longer.

I think there's a strong argument to give these these animals half an hour at least on an annual basis and really Give it the time to do that thorough health check. Yes, talk about whether or not a vaccine is appropriate this year or not, and what vaccines are, are needed and what aren't, but really make it the focus on it's that healthcare appointment, it's the wellness appointment. We're looking at so much more than just giving them an injection once a year, and I think it's just reframing it as, as probably a really good way of communicating to owners.

I, I think, yeah, I totally, I'm totally aligned with that and, and what I, the, the takeaway message that I would like to give around canine cognitive dysfunction on, on my side, it's, it's really actually three messages. One is that it is, it's not normal for an old dogs to have an inappropriate. Behaviour.

It's not normal. No one should have to cope with that and just wait until it goes. So it's not normal.

It's super common, but it's not normal. And the second thing is that we can help. So there are loads of paper that show that drugs help, diet help, enrichment of the environment helps, so we just need to talk about it because we can actually make a difference.

And the third thing that I wanted to, to really focus on is the empathy with the pet owner because it's very easy for the vet, I think, to be a bit judgmental sometimes and be like, come on, this poor old pet, why do you want to euthanize him? You know, we can be in this sort of judgmental way when actually we don't see the nightmare that it could be at home for the pet and for the pet owner. And so I think something that I found quite nice in practise is that try to connect the pet owner with someone else that had the same issue.

And talking about canine cognitive dysfunction, there is a great website that is called pet dementia or dog dementia, I think.com. It's not made by a vet, it's made by a lady that had a dog with canine cognitive dysfunction, and she just explained her journey and how she made amendments and how she felt and how the dog improved and these sort of things, just to go back to the level of the pet owner and give them simple.

Advice. So often I would refer people to this website actually. So I say it's not written by a vet, but look at this lady, she had a dog with the same condition and she did great for years.

So it's really just making the effort of moving one step towards the vet and putting yourself in their in their shoes, really. No, that's fantastic, and I think, I think that's such an important thing is that, as you say, it's so easy for us to be judgmental. And you know, I hold my hands up I've been guilty of it myself and passing.

What's wrong, you know, and you sit there and you think, actually they then show you the videos of the house, which is of course much more, commonplace now that people have smartphones and you sit there thinking, yeah, OK, fair enough. You know, we have, we have. 15 minutes with most of these people once a year, they're with these pets all day every day, and I think, you know, that's, it's stressful, like, you know, I think that's, you know, it's something that we have to be, you know, accepting of, I think, and, you know, sort of in terms of quality of life, I think actually the owners are becoming begrudging and sort of, you know, really sort of.

Disengaged with their pets and frustrated by them at this stage, then actually you have to look at the quality of life and go, well, potentially, euthanasia is the best option in these circumstances, and of course it's a controversial topic. I'm sure we could have a whole day on it ourselves, but, but the reality is we do have to have quality of life and health and welfare very much at the epicentre of what we do. So, good afternoon.

It's a pleasure to be with you today and to show you a really innovative tool that we have developed using artificial intelligence to help detect in just one visit cats at risk of developing chronic kidney disease. Artificial intelligence is absolutely everywhere. We may not realise this, but we use it constantly.

It predicts the weather forecast you saw this morning on TV. It is in all our cell phones with auto-completing texts, and it is also determining how expensive your car insurance might be. It's obviously a gold mine for healthcare, and it can now make us augmented beds, so making the invisible visible, enabling us to predict if the senior feline patient on the table without any clinical diseases may develop a renal disease in the next 12 months.

But before going into further details with renal detect, I'd like to take a moment to discuss how digital transformation can make our life easier. It is everywhere impacting our daily life, and it is making health and veterinary care evolve pretty fast. It's obviously accelerated by the COVID crisis, and it can become a great opportunity to add value to your consultations.

And at we believe we have a role to play in this transformation using digital platforms to make each and every vet a nutritional expert who can positively impact the life of their patients through health nutrition. And to support this, we have created a range of digital applications dedicated to vets to make their nutritional recommendation easier. We know that you are overloaded by admin work, but we also know that pet owners expect a nutritional recommendation from their vets.

So we have created this range of services to allow vets to define which nutritional solution is best adapted for each pet. And this is particularly tricky, and we will see in a few minutes for chronic kidney disease patients, for which the nutritional management has to be really tailored to the stage of the disease. Our ambition is that a simple tool that can facilitate the prescription of the most adapted diet will help enrich the nutritional discussion with pet owners to reinforce your vet experts image.

Also to build trust with the patroners. We also help improve patron's commitment and compliance with a personalised prescription and follow-up. And make you gain time by simplifying your recommendation process.

It is also a way to drive footfall to the practise, and there will be a clear recommendation for monitoring each patient. But without further ado, I'd like to share with you a little video. There we go.

Chronic kidney disease, or CKD is very common in inside a cat. An estimated 30% of the feline population over 10 is affected. The earlier the diagnosis of CTD, the earlier we can intervene medically and nutritionally to better maintain quality of life.

Unfortunately, because cats show clinical signs very late in the process of the disease, when 75% of the nephrine are already affected, it is very difficult to identify early. At Royal Cannon, with veterinary nephrologist of the Royal Vet College in London, we ask ourselves, how can we help practitioner to identify those cated risk of CKD as early as possible. We retrieve historical data from over 3500 cats collected before and after a diagnosis of CTD totaling more than 10,000 consultations.

This data was then used with artificial intelligence tools to create a reliable predictive algorithm. Real the tech was born. Realdetech is a digital application which can predict with 88% accuracy if a cat over 7 is at risk of developing azotemia in the next 12 months.

To predict CD using RealTech, you just need to enter serum creatine, serum urea, and you specific gravity into the application. In a single visit and in less than one minute, we only adds value to the seorial check by calculating if a cat is at risk or not to develop CTD during the year. This I will give you a follow-up and nutritional advice.

If at risk, a catch should be followed closely with regular kidney panels with creatinine, SDMA, and urine specific rabbits. And as a precautionary measure, we also recommend a diet moderately restricted in phosphorus and enrich in omega 3 fatty acid and antioxidant. Identifying patients at risk of sick early allows better management and maintenance of quality of life as well as honour reassurance.

Developed by veterinarian for veterinarians, we detect achieve healthier life for senior cats. So, you all know that chronic kidney disease is a very common problem in senior cats. And as we saw in the video, it's affecting an estimated 30 to 40% of cats over than 10 years.

And it's actually the second cause of death of cats. It is a progressive and irreversible disease, and it is well known that the earlier we can intervene in CKD, the better for the cat's quality of life and longevity. But early diagnosis of CKD is quite challenging, as there is often no clinical signs until the disease has already progressed to high risk stage 2 or 3, so when more than 75% of the nephronnes are already affected.

There are minimal to new clinical signs in the early stages of CKD, so when we are in high risk stage 1 or early stage 2. And the most common test used to indicate kidney function, so creatinine, does not increase. Above reference range until quite late in stage 2, so when most of the kidney function is already lost.

Diagnosis is not a simple process, and even measurements such as creatinine and ADMA need to be repeated multiple times to have a proper diagnosis. Urinalysis as well can be indicative, but unfortunately, it can be influenced by many factors and it's often not done at routine checks. So for all these reasons, in most first opinion practises, CKD will be actually diagnosed at stage 3, so when more than 2/3 of the nephrons are damaged.

Internist and nephrologists, they may spot the disease earlier, but we are still missing a diagnosis that would allow the detection of Stage one patient, that would be the dream. And the issue we have with the tests available even in the recent ones is that they are not very sensitive at very early stages of the disease. So this is why a few years ago, we have started a project to try to do better, and our discover team had the idea to use artificial intelligence to try and predict which cat would get chronic kidney disease.

And thanks to a long term partnership with the Royal Vet College in London, we had access to a database of senior cats, followed over time, and which some of them eventually developed CKD. So those data were analysed by mathematicians to create a neural network. When working with artificial intelligence, the first thing is training in this first stage.

Clinical data, so from a bit more than 200 cats from the feline RBC kidney clinic and their corresponding renal health status over time. We entered in the system to train the computer how to distinguish between healthy cats and those with CKD so from their clinical data. And the result was this initial model or algorithm.

Then, this algorithm was tested and validated using new sets of data. So coming from Bandfield Pet Hospital, which is a big chain of clinics in North America. This data was used to stretch the performance of the model and ensure its robustness.

This time, the clinical data is entered to test if the algorithm is correctly distinguishing which cats develop renal disease over time and which do not. And from the 16 clinical input variables we had available for each of the consultations. The 3 most useful variables that allowed for the most predictive model.

So urea, creatinine, and urines specific gravity was selected. So along with the most useful time point for prediction, which was 12 months. So, if we recap, the renal detect algorithm was built using 20 years of clinical data from healthCATs and CKDCATs.

Then it analysed data from more than 3500 cats and more than 10,000 consultations. And for each consultation, we had 16 clinical inputs, so biochemistry parameters, but also age parameters from the clinical exam, etc. And this resulted in an algorithm that is capable of predicting the risk of a feline patient over 7 years of age to develop azotemic CKD in the next 12 months from 3 bits of information, so urea, creatinine, and urine specific gravity.

It may feel quite basic parameters, but what's really important to realise is that this algorithm does not look at data individually and compare it to the reference range. It's actually a neural network that is using those data in combination. Doing complex mathematical equations on them to provide a prognosis and assess if the cat will develop CKD in the next 12 months.

And the reliability of this model was assessed throughout the validation process. And actually all results have been published in the Journal of Veterinary Internal Medicine back in 2019. The accuracy of the model to predict if a cat is going to develop as a CD in the next 12 months is actually pretty good, so 88%.

That means that 88% of the time the algorithm will provide the right answer. Then we have the negative predictive value. So it means that if the test is positive, the likelihood of the cat to develop CKD within 1 year is 92%.

And Positive predictive value. Means that if a cat is detected. At risk, then he has 53% of chance, so more than one chance out of 2, to develop CKD in the next 12 months.

We also have assessed classic parameters of any test, like sensitivity, which is 87%, and specificity, which is 70%. So, in summary, after a single visit, this model will be able to tell you once you'll feel creatinine, urea and USG value. If a cat over 7 years of age is either so at risk.

Of CKD in the next 12 months, which means that this cat has more than 50% chance to develop a stage 2, asoamic CKD within a year. Or not at risk, which means that this cat has less than 10% of chance to develop a stage 2 CKD within the next 12 months. What's important to remember here is that this tool gives a prediction and not a diagnosis.

With this prediction, you will be able to adjust the nutrition and better plan and tailor the frequency of your follow-up visits. For cats not at risk of CKD, a senior diet can be recommended, and a checkup can be planned in 12 months. For cat at risk of developing CKD, we would recommend an early renal diet and organise a recheck in the next 4 to 6 months to reassess the patient.

And it's frozen, but OK. So, what is The rationale behind this nutritional recommendation for a cat, so more than 7 years old. Predicted not at risk of CKD.

We would suggest a senior diet, which will address the first stage of maturity of the cat. So in the current right and range, this is mature consult, which is supplemented with an antioxidant coffee to fight the accumulation of oxidative stress with age. It's enriched with EPA and DHA for their inflam anti-inflammatory effects.

And it's supplemented with control protectors to support ageing joints. Protein in this range is slightly higher than the corresponding adult diet to help maintain muscle mass through ageing. For cats predicted at risk of CKD within 1 year, so by the renal detector, as these cats may already be in CKD stage 1 or will likely turn stage one in the coming months.

We would suggest to feed an early renal diet, so the same diet as we recommend currently for CKD stage one patients. This diet is more directly restricted in phosphorus and protein. And for a cat which creatinine and USD were already indicative of CKD stage 2 or over.

From the Irish guidelines. If the repeated measures confirm these values, then the cat should be fed a renal diet, which is further reduced in phosphorescent protein to help control hyperphosphateemia and uremic signs. So now let's try to see how Renal detect works in practise and imagine you received today, so strike.

The slide is wrong actually. That would be a feline patient of 9 years for a senior health check. So you've done your blood work, your biochemistry and urinalysis, and all parameters are within the reference range.

And here I will need to change my settings to show you this little video. So you're on the renaltech tool, and you will enter the value of your cat. So blood creatinine.

You can enter Any of the different units and the tool will do the conversion. It is also telling you when the value you may enter is not in the current reference range. Then you can enter a log urea.

And urine specific gravity. Then you click and the algorithm is working. So this cat actually was found at risk of developing a chronic kidney disease in the next 12 months.

So, the tool also gives you some links to go on the Iris International recommendation. And you can then Apply for the best nutritional solution. So here, to better tailor the rationing and the daily aggregation, we will ask you to enter the pet profile.

So the name of the pets, the sex, the neutral status, the date of birth, the current weights, and the activity level. The algorithm will also tell you if the cat is less than 7 years old because the algorithm is only working for cats over than 7 years. Right?

Then you can select the appropriate diet. So in this case, it could be early enough, dry or wet. And the tool will be giving you the appropriate daily allocation.

So here in this case in mix feeding, that you can at every stage, tailor. Yourself. And you can print.

The recommendation, and then you have A full recap for the pet owner. That you can also personalise with, for instance, your clinic logo and other observations that you've made during the consultation. And if the owner wishes, you can also send.

The full recap by email. This is how the recap looks like. And from one video to another, you will be also able to track weights.

And all the different parameters. So What kind of protocols can we recommend? So you see your senior patients, so I insist on that, more than 7 years of age, and do your blood and urine tests.

In case the cat is already out of the reference ranges. You may confirm the CKD diagnosis using the Iri guidelines and. A renal diet.

And then you have your classical CKD management protocol. If nothing is apparently abnormal, then you may run the renal detection. If the cat is detected, not at risk.

Sorry, that's right. OK. The cancer is detected not at risk on top of the senior diet.

You may recommend a normal follow-up protocol with yearly assessments. In case the cat is detected at risk to develop CKD, you may recommend an early renal diet with a closer follow-up with 4 to 6 month visits. So what's the rationale behind suggesting this early renowned diet?

Well, we know that classical therapeutic renal diets are widely recognised for their beneficial effects in pets with asulteic so stage 2 and late stage 2 CKD. The question was here, how should we extrapolate that to stage 1 patients? If we look at the different nutritional levels we have in a classical renal diet, the main point is the low phosphorus content.

We can also have additional phosphorus binders, and this is really to fight hyperphosphatemia and hyperparathyroidism. We can also have EP and DHA supplementation that aims at reducing the inflammation and therefore the kidney lesions. Those diets are supplemented in antioxidants to fight oxidative stress and kidney lesions as well.

And they usually have moderate protein content to lower uremic signs, potassium supplementation to fight hypokalemia, and alkalinizing substance to fight metabolic acidosis. So, behind that, what we target is either A compensatory mechanism. So we Low phosphorus diet, for instance, or causing processes.

So with kidney lesions, inflammation oxidative stress, or clinical signs. So what do we need to keep for those stage one cats that are at risk? The clinic and signs are not there, but we want to address the causing process.

And to some extent the compensatory mechanisms. As in early stages of CKAD, cats need a lower level of phosphate restriction, notably to limit a risk of hypercalcemia. And the evidence behind this strategy was shown in this study, so I put the reference here that was presented at the 2019 ECVIM Congress that suggested a positive effect of diets more directly restricted in phosphorus.

On calcium phosphorus homeostasis in nonazoic senior cat. So in those cats, you start lowering phosphoric intake, but you don't want to reach the level of restriction that is needed in a later stage patients. That's really also highlighted by Iris in a note that is explaining that for early stages patients, especially if there is a development of hypercalcemia, we want to have a moderately restricted phosphorus level.

So what's the efficacy of this tool on the field? So before the launch, this tool has been assessed on the field with a pilot study involving 10 clinics and in France and 72 cats, all from 7 years of their age, which undergone a vet consultation, a blood and urine sample. We are taking all those cats and run through the algorithm.

We had also 61 owners that were asked to provide feedback, and 8 veterinarians who really participated to an extensive interview process to really give their insights and feedback on the usage of the tool. And the results showed that vets found renal detect quite fitting to their daily routine, and they found it was a real opportunity for them to give a nutritional recommendation. In fact, 83% of cats at risk received a nutritional prescription after running the renal detect tool.

On their end, pet owner felt quite engaged and reassured. So 93% of them had a positive feelings after the visit, and regardless if their cat was found at risk or not. And 65% of cats not at risk would come back.

The following year and pay for another visit, which was an interesting finding. And another interesting insight is that 95% of owners found that the cystocentesis was worth it, even though quite a lot of them were initially stressed by this procedure. So that's quite interesting as vets often feel uncomfortable performing a cystosynthesis during a routine check, but Actually, the, the patroners thought it was worth it.

So what was the results among those cats? So among those 72 apparently healthy cats. Actually, 11% of them were predicted at risk, so quite likely already in stage one, and 15% of them were already out of the reference ranges, so they could benefit from an earlier intervention.

So with this tool, we believe we are creating value for the full ecosystem. So the veterinarian, the patient, obviously, and the pet owner. For, for vets, Real detect brings more value to your senior routine checks for the same cost.

It's also providing some earlier insights so that you can deliver a better, more targeted preventative medicine. And really value your expertise as a vet. And it can also help strengthen your relation with pet owners because they will be entering in a monitoring process.

So coming back on a yearly basis if the cat is not at risk or more frequently if the cat is found at risk. For cats, obviously, it provides an earlier care thanks to an earlier detection of cats at risk. And therefore we can help limit the progression of the visit by the right intervention.

And for the pet owners it's really providing a peace of mind in both cases actually. So either the cat is not at risk, obviously the pet owner is relieved. But even if the cat is detected at risk, he will have a proper care, a close follow-up, and will be taken care of as early as possible to limit future damages and and preserve the quality of life of the cats.

So we've reached the end of this presentation. I'm really I really want to thank you for, for your attention. And if you want to know more about this tool, I can invite you to review the the publication, so from the Journal of Veterinary Internal Medicine that explains the concepts and all the validation process.

And you can also in this platform, review some existing webinars. So we have one with Vincent Bourges, our scientific director, and also one with Jonathan Elio from the Royal Veterinary College about the early detection of chronic kidney disease in cats. So thanks very much and have a great afternoon.