Hello and welcome to today's webinar on canine cognitive dysfunction. My name's Kelly Drew. I work as a medicine and oncology nurse and training coordinator at the RVC Small Animal Emergency and Referral Hospital, known to many of you as the Queen Mother Hospital for Animals, and also as a teaching fellow on our degree programmes at our centre for Veterinary Nursing, also at the RVC.
And I'm here today to talk to you about canine cognitive dysfunction. And I really hope you enjoy this webinar. So our learning objectives, as you will have seen for today, I sort of kind of summarised into two key points at the top, which is really to just increase awareness of canine cognitive dysfunction.
And as nurses, for you guys to be able to kind of recognise what's our role in this disease, you know, how do we help in the diagnostic process, how do we support owners and clinicians through providing treatment, and how do we support owners in actually caring for their patients in, in all the forms that that might look like. And that kind of broke down to being able to understand the term canine cognitive dysfunction and its prevalence in our patients in practise. To be able to recognise the clinical signs so we can recognise.
Hallmarks of that disease, understand how the disease develops in our aged canines, and be able to feel confident to assist and guide owners in kind of, looking for these signs and signals. To be able to also recognise the benefits of some of the rating scales that we have available to us and, and explore how we might use these, and overall to gain that deeper understanding of the treatment options that are available to us and the overall importance of behaviour modification when it comes to treatment. So first of all then, what is canine cognitive dysfunction?
It seems like a fair place to start. Well, it's a dysfunction causing a loss of knowledge or a loss of learned experiences. We know that it is a degenerative disease, and we see a progressive decline in higher brain function.
And actually we can attribute this or compare this a little bit to Alzheimer's in people in terms of the pathophysiology of the disease, but also the symptoms that present to us. So we have a nice kind of definition here by the CCDS, the canine cognitive dysfunction syndrome working group, back in 2025, and they describe it as a chronic progressive age associated neurodegenerative syndrome characterised by cognitive and behavioural changes that affect daily life to varying degrees. So in terms of signalment then, this is something, as we've kind of already said, that happens in our older animals.
So we usually say a ballpoint of around 10 years plus, but as we know in terms of various breeds, our kind of geriatric descriptors can be quite different. So in our, older, sorry, our larger breeds, we might see it. At an age younger than 10, but still what we consider to be geriatric.
OK? And, the development of this disease can be influenced, we think, by breed, like with a lot of things, but also lifestyle, nutrition, you know, kind of, what I suppose what goes into that dog's, where they live, all these types of things. OK?
And we have some studies that will report that there's an increased risk factor in our females in comparison to males. In our spayed and neutered in in comparison to those that are intact, although as we appreciate our spayed and neutered animals obviously make up a much higher prevalence in many of our studies anyway. Those that have a smaller body size, and largely I attribute this to the fact that the smaller the dog, often the longer that they live.
And also we think that there is an increased risk factor for development of CCD in those that have idiopathic epilepsy, which again makes sense when we consider we're talking about neurodegeneration of the brain. So in terms of disease prevalence, well we know that prevalence of the disease is very high, however, the number of times we diagnose it is not, and that automatically makes us have a little bit of a concern there. So in a study back in 2001, it was found that 28% of dogs aged around 11 to 12 years showed clinical signs of CCD and up to 80, up to 68% of dogs aged 15 to 16 showed clinical signs, so quite high numbers there.
In a more recent study in 2010, the estimated prevalence of CCD was around 14 to 14.2% of our canine population, but only 1.9% had actually received a diagnosis.
So we know that prevalence increases with age. This is a consistently reported thing in all the studies done so we can feel quite sure about this as a risk factor. But what we also know is that our dogs are living longer, OK, with all medical interventions and additional.
Knowledge and resources that we have. So it makes sense that if we're seeing our canine companions live to longer, or higher ages, then we're likely to see an increased prevalence of any age-related, syndromes or diseases. So what do we need to consider then when we think about canine cognitive dysfunction?
Well, kind of the four key things that I've broken down here are free radicals, oxidative stress, beta amyloid plaques, and then the good guys, which are our antioxidants. And we're gonna explore, explore each one of these, in their own right. So our free radicals then?
Well, these are simply atoms that have unpaired electrons. OK, so they're made naturally in the body, they're a normal byproduct of metabolism, but they play an important role in biological processes such as cell division, cell communication. So they're also made though, as much as they're made quite normally, they're also made following exposure to certain toxins or if the body is put under quite high stress load, OK?
And some of the things that we know help to generate free radicals are things like the food and water that their animal eats, OK, medications that are used, also sort of those. Kind of, naughty foods, so fried foods, OK. In humans, we know they're attributed to alcohol consumption and cigarette smoke, but also pesticides and air pollutants.
And this kind of takes us back sometimes to the prevalence of disease in certain areas potentially of the world where we see higher air pollutants or higher use of pesticides. The thing we're interested in when we talk about free radicals is that we must remember that they're a natural and often a helpful byproduct of metabolism, but the problem, like with a lot of things, is when we see them in increased numbers, they start to become harmful. OK, so as we said, they're unpaired electrons, OK, and because they're unpaired, they're more reactive and they're less stable.
OK, they're not kind of bobbing along quite happily with them. Little pair, they actually don't have their pair and therefore it makes them, a little bit more of a wildcard. OK?
Now we know that free radical accumulation in humans is linked to cancer, various cancers, Parkinson's disease, and also Alzheimer's. And again, these are things that we largely, especially the last two, we largely attribute more often than not to the ageing process. So free radicals, they're unpaired electrons, so they're unstable.
So what they're doing as they're going around the body is they're constantly attempting to pair because bearing makes them become stable. So what happens is they then steal an electron from a molecule of another body cell, and that might be a skin cell, it might be a blood cell, etc. But this causes that healthy cell to now become damaged, OK, and this leads to the.
Set of varying disease processes. Once the cells are damaged, they then become a, a free radical because now they are ultimately an atom with an unpaired electron. Someone has taken one of their electrons, OK?
So they're no longer paired. So this is where we see this continuous cycle, of destruction and what this cycle causes is something that we call oxidative stress. So oxidative stress, the second bad guy on that list that we had.
OK, so this describes physiological stress on the body. So what we know about oxidative stress, this physiological stress, is that it impairs mitochondrial function. It leads to a reduction in normal cell metabolism.
It causes damage to the central nervous system and also other parts of the body to a lesser extent. So it leads to brain ageing and therefore the onset of neurodegenerative disease, and it accelerates brain ageing, which increases the risk of cognitive decline occurring. Now we know that free radicals cause accumulation of oxidative stress and the brain reacts to this stress then by producing beta amyloid, and if you remember, beta amyloid is our third bad guy on the list that we shared.
So what is beta amyloid? Well, when we talk about beta amyloid plaques, we're talking about a naturally occurring protein that's produced in the brain. That is there to help assist with growth and repair of our neural brain cells.
Now in the healthy brain, it's able to breakdown and eliminate any sort of unwanted beta amyloid. So if too much is produced, it can kind of breakdown, get rid of it and use what it needs to repair cells. But in the damaged brain, so the elderly brain or the neurodegenerative brain, it's unable to perform this function.
So this means that the beta amyloid plaques, these hard protein plaques accumulate, OK? And they become very hard and they start to stranggulate the healthy brain cells. And again, this contributes to a loss of brain function.
So this brings us on then to the good guys, our antioxidants, a word we'll all be very, very familiar with, quite a buzzword in recent years. So our antioxidants are molecules that are found within cells. They also have an uneven number of electrons, and this is what we particularly like about them, OK?
We also know that antioxidants play an important role in brain. Brain ageing, but they have the ability to neutralise these free radicals, because remember we said, that the free radicals are unpaired and they're looking for a pair. Well, these antioxidants are also unpaired, so they can pair up with them, which stops that free radical from taking an electron from that healthy cell like we talked about before.
So they pair with our free radicals rather than destroying normal cells, and this creates a much more stable environment and it reduces the free radical induced damage to the brain or to our cells. So just to summarise those kind of four key, key things that we've talked about, increasing age, toxic exposure and stress leads to an increased amount of free radicals. These free radicals, sorry, they damage our healthy cells, OK, in a quest to become stable.
So they convert healthy cells into free radicals as well, again, increasing the number of free radicals. An increase in free radicals causes an increase in oxidative stress, and we know that the brain responds to this oxidative stress by producing beta amyloid. OK?
This beta amyloid, there's too much, the brain cannot cope with it, so it starts to strangle the healthy brain cells because it's not removed. And all of this comes together to lead to this loss of brain function. Now our antioxidants can neutralise these free radicals, so they're stopping this process at the earliest stage, OK, and this means that they have the ability to reduce associated damage.
So let's look a little bit now at the pathophysiology of CCD. So we've kind of said that the ageing brain, as we know, faces a combination of issues. So we have an increased level of brain cell damage that's being caused by free radicals.
OK. Now as the dog gets older, it means. Obviously their brain's been around for a longer period of time, so that means there's been a longer period of time for free radical development, OK?
And often there's been an increased time that the animal has been exposed to external toxins. They've lived longer, therefore, they've been exposed for longer periods of time. We also know that we have a decrease in antioxidant production, OK?
And this is, can sometimes in the ageing brain mean that the brain is not producing our antioxidants, our good guys, quite as quickly as it was before, which means they're kind of there at a bit of an insufficient amount considering how many free radicals we've got being produced. And then we have that increased production of beta amyloid plaques that the brain is unable to break down, and all of this helps to build that pathophysiology of disease. So if we take a little look here at the normal brain, we can see in our diagram on the right there or our picture that there is a fixed proportion of grey and white matter.
OK? So our grey matter in the brain allows the passage of information between neurons and the white connects all that grey matter. OK, so on our MRI image, the brain is seen to fill the cranial cavity.
OK? So this is a nice kind of relatively normal looking brain. And there's some small channels that are allowing fluid to be carried around inside the brain, OK, so allowing kind of normal neural processes to be done.
If we now look at an image here of the older brain, what we see is shrinkage away from the cranial cavity. OK, so we see also an enlargement of the fluid carrying channels and we see shrinkage of the hippocampamus, hippocampus, sorry, the memory part of the brain. OK, so we see a notable, noticeable decrease in both grey and white matter.
OK, so it's reasonable to say that we see a decrease in the brain's ability to communicate. And then we start seeing beta amyloid plaques that are spread across the cortex of the brain, which is the control area for many of the patient's higher mental functions. So this is very interesting when we consider disease progression because actually what we see is that the frontal brain is often affected first.
So the rate of plaque formation can be quite variable. The specific location of plaque formation can be variable. It's a very individualised thing with the different patients.
It may be minimal or non-existent in some areas of the brain, OK, but we know that the frontal brain is often affected first. This means that progression of the disease with all of these variables can be quite slow and often one of the biggest challenges we face is that that CCD presents to us, in quite a later stage of development. OK?
Often there's a lot of changes happening. Within the brain before we actually see or recognise the clinical signs that that are attributed to it. OK?
However, we will see changes, on imaging earlier than we see them, you know, presenting clinically. And then continuing our discussion on disease progression, well, as we said, CCD initially affects the frontal area of the brain. So this leads, us to, or leads the patient to having a loss of their previously learned behaviours.
This is a lot of the kind of stored memory area. Loss of house training is one of those behaviours that they often. And seem to, to, to, to lose, and this often is something that triggers the owners to come and speak to us because this, as we know, is, is a behaviour that we value a lot, the fact that our animals are clean inside.
So when this starts to deteriorate and they're having accidents, that often pushes people to come and seek advice and help. Locomotion, so their mobility often becomes affected as the disease progresses as well. So sometimes they start to develop this reluctance to move around, to exercise, to go for walks.
This kind of starts to negatively impact the human, animal bond and relationship. But obviously can often be attributed just to old age. So we kind of rely a lot on our owners, like with a lot of signs of disease, we rely on them noticing something and coming in to see us.
And the issue we have with cognitive decline is kind of that age-old sort of argument of cognitive decline versus accepted old age, and every client will be very different as what they accept as part of a normal ageing process. I suppose it's the same with us in humans as well. And we know that we see many age-related changes, things as deafness, blindness, metabolic disease, pain, debilitation.
These are all things that we attribute with our dogs getting older. OK? And we know that these age-related changes can also affect dogs' behaviour and alter their behaviour, OK?
So owners find these changes when they're attributed to kind of age-related problems, deafness, blindness, they find them much easier to understand. So we know that CCD presents similarly to old age, and we know that oxidated damage is occurring in that ageing brain. So it's really interesting that when medical disease is absent, so there's no medical reason why the animal's behaviour is changing.
This seems to be, research shows us that it's almost harder for owners to detect or maybe harder for them to come in and seek help about. OK, so if they can attribute a behavioural change to a medical condition. Perhaps I hypothesise, but perhaps they feel it's worth coming to see the vet because there's something that can be done.
When they see or notice behavioural changes. But there's no medical problem. A, they don't notice them as rapidly, and B, perhaps they're more accepting of them.
Yeah? Is it that there's just a very gradual onset, so therefore, it goes unnoticed for longer? Is it a case of ignorance is bliss?
They've accepted that, yeah, the dog's getting older, so they're not paying that much attention to these changes or just accepting them as part of old age. Or is it that they actually maybe they have come in, maybe they have spoken to one of the nurses on reception or during a during a geriatric clinic or something like that, but actually their concerns have been kind of discredited or kind of not really picked up on and therefore they're kind of left without pursuing their issue. So in terms of early physical changes, well, there was an interesting study in 2019 which suggested that actually we do see some physical changes in the early stages of canine cognitive disease.
And a lot of this is attributed as well to our human literature as well, whereas we know that in the early onset of Alzheimer's, people do suffer with vision impairment. There are disturbances to, the olfactory senses and, and how, how well, people can smell, which is very much associated with human neurodegenerative disease. Tremors, instability, swaying, something we see in early stage Parkinson's.
And it's also associated to a lesser degree with Alzheimer's. Hepatosis, so dropped head syndrome, this is something we see in central and neuromuscular disease in humans. And whilst we appreciate it's less common in dogs, it certainly is is still something that we may see.
And these things may all present in early stage CCD, so these pre kind of clinical stages, and they can help us aid in early detection. Obviously we need to be quite hot on looking for these things and again we're quite reliant often on what our owners say to us, but also how we lead that conversation to find out what we need to know. So in terms of our patient history then, well we know behavioural consultations can be lengthy, we need to make sure that we have dedicated enough time to them.
We want to take a very detailed clinical and behavioural history and this is really, really key if we're going to stand a chance of making an accurate diagnosis. We want to be able to build that rapport so that we can have really open conversations with owner. We need to consider where.
We having these consults consultations and, and where we're doing our examinations, yeah, what sort of environment are we in? What sort of staff do we have available to us? How well educated in these sort of geriatric issues are the staff members?
What's our approach, cos that might be slightly different depending on your type of owner as well. And like we said at the beginning, how much time have we allocated? So we need to really, as we're talking to owners about their medical history, the dog's clinical history, you know, everything, their environment, we need to always be thinking what may be in the background that's influencing these behavioural changes.
Environmental factors, a change in circumstance, their early life history or their previous experiences, all these things may be things that we need to be thinking about. Their daily routine for both the owners and also the pets. History of any trauma, exposure to a traumatic injury or event, is there anything there that might be leading to give us a reason as to why this dog is now behaving differently?
Are there medical physical conditions, yeah? Do the behavioural changes that we're seeing or or we're finding when we're talking to the owners, do they coincide with the onset of some sort of physical problem? OK.
Have they started any new drugs? OK, are they receiving any drugs from owners, any herbal remedies? Are there any drug related side effects that we may be able to attribute again to to these this onset of new behavioural changes?
What about medical differentials? And there's, there's so many, isn't there? Cardiovascular disease, endocrine disease, metabolic, GI, urinary tract disorders, often changed behaviour, sensory impairment, we've mentioned, we touched upon kind of blindness, deafness, pain.
A huge thing in our aged animals and actually something I think that does still go very under, under detected or undertreated again because it's accepted that they're a bit old, they're a bit creaky, but how much is pain actually contributing to behavioural changes. And then obviously any neurological disorders, any compulsive disorders. So physical and clinical change is very common alongside disease onset.
We know that, OK, and especially in our older animals. But if there's no physical change, yeah, if we're not seeing a sort of physical or clinical component, but we are still seeing these marked behavioural changes or digression in learned behaviours, how frequent is this occurring? How often are we seeing this behaviour?
How intense is that behaviour? OK, is it very mild or actually. Is it very intense?
How long do these behaviours last, these strange behaviours, these changes in behaviour? And what is the context of that behaviour? Does it seem to only happen in the presence of a certain person?
Does it only happen when they're out on walks? Does it only happen when they're excited? Because all these things give us clues into our diagnosis and, and where we're gonna go in.
In terms of our diagnostic journey. OK? Is the owner present to see these behaviours?
And sometimes that can be hard because we don't know what's happening when no one's present. But obviously we do know that some behaviours can be very much attributed to being with the owner as opposed to someone else, say, doggy daycare or the dog walker or other family members. So in canine cognitive disease, what we find is that behaviour that they display, these odd behaviours is often quite out of context.
There's an element of confusion there, yeah. They're often quite exaggerated because there's a a lack of being able to control this behaviour. And they tend to start happening more frequently as that neurogenerative decline continues to happen.
But like we said, physical exam, often unremarkable or relatively unchanged as we go through. So what are the actual clinical signs then of canine cognitive dysfunction? Well, we know that the clinical signs come on gradually, they are progressive, so without any kind of interference, they're going to slowly start to get worse.
We often know from speaking to a lot of owners that these clinical signs that we talk about are often accepted initially, but then they tend to seek, come and look for help. When they become worse and worse, OK? And often it's the behaviours that impact the owner the greatest that they'll come and ask for help with and how soiling is obviously a prime example of that.
So we have an acronym, a very useful acronym that we use to recognise the clinical signs of canine cognitive dysfunction, and that is DISHA. So disorientation, interaction changes, sleep-wake disturbances, house soiling, activity changes, and more more recently added also was anxiety as we recognise that all these things actually cause quite anxiety in our canines. So let's look at each of these individually then.
Well, disorientation, so they tend to wander around aimlessly, they might stare into spaces and have quite a vacant look about them. They often become lost or confused even though they're in very familiar surroundings. OK.
There may be some confusion in their previously learned behaviours. So for them they're, they're going to, they've always gone to the back door to signal that they want to go out to urinate and all of a sudden actually they're going to the the kitchen door that links the kitchen to the hallway. So to them they think they're signalling the behaviour.
But actually they're signal signalling it wrong and therefore we don't recognise it and then that leads them to just urinate because as far as they're concerned, they've asked to go out and they've not been let out. But actually we're not recognising it because there's some confusion in that previously learned behaviour. Sometimes they seem to become stuck in the home.
They'll walk over and they'll kind of be in a corner of the room and it's like they're unable to navigate their way, away, from there. They become unaware of kind of or they lose their spatial awareness, they'll start to try and fit through gaps that they just can't fit through, OK. They'll often stare at walls and sometimes they'll have difficulty finding those resources that they've always just known where they are.
So they always go to their food bowl, but all of a sudden now they're actually can't really find their food bowl or if you throw a treat and it drops on the floor, they can't find it. All of these things often be attributed to age, sometimes they're attributed to deterioration in vision, but they are actually largely indicative of CCD. Interaction changes are next on the list, so they'll often have quite reduced interaction with people and other pets, so they won't come out and initiate kind of contact, they'll shy away from attention.
They seem to have a lack of ability to recognise familiar people and familiar faces. OK, so sometimes this manifests that they used to get up and greet you when you came in. They don't anymore and people say, oh, I think he's gone a bit deaf, I don't think he heard me come in, or I think he's a bit arthritic and he didn't want to get up, or he's just getting old and stubborn.
But actually it can be a real sign of CCD. Sometimes they may may have this misplaced aggression. Towards owners on their return home because again, they're confused, they don't recognise this person.
To them briefly, it's a stranger entering the home. OK? And it might be that actually because they aren't interacting as much, they kind of ignore household disturbances.
So they always used to like bark at the postman, putting a letter through the door. Now they don't do that anymore. And again, often gets attributed to deafness when it may not be.
Often this lack of recognition towards the owner causes quite a lot of emotional upset. So if it happens in that way, they'll often come and, and, and speak to us about it. But it's much less obvious if this kind of lack of recognition is more attributed to slightly less familiar people anyway, so they're not getting excited when friends come round anymore, but they still greet the owner.
Then it tends to not be such a, a big thing, in the owner's mind. Sleep and wake disturbances, they become quite restless at night. They may be pacing around, quite disorientated.
Now, this is something that can be unnoticed for long periods of time, especially if the dogs generally sleep downstairs and they don't sleep upstairs with the owners. Obviously, if the dog sleeps in your room, then you're more likely to notice that they're up pacing around at night because it's gonna disturb you as well. Sometimes they'll vocalise at night, OK?
And this is because they've become disorientated. They may not realise that this is the part Of the day where they should be sleeping, or like we talked about all the other things, they have decided now they need to go outside and toilet or they're getting sort of stuck in, in one room and not able to kind of manoeuvre their way back out. Often this gets attributed as a kind of separation anxiety, or if they're having accidents in the house, people will say, well, they must be urinating more because they're still going out in the day to urinate, but actually maybe they're not urinating when they're going out in the day and they are needing to urinate at night instead.
So often restless nights will lead again to them having reduced energy, which again gets attributed to this kind of lethargy, interaction changes, etc. Sometimes become quite irritable in the day, they can become a little bit snappy because they're really, really tired. OK, so we do have to be careful that sometimes we can see the onset of some aggression, but usually it's attributed to a much bigger reason.
In terms of how soiling then, this is a common problem that we see and often like we kind of talked about, it's because they're not displaying the correct signal to go outside or they are displaying it, but it's completely in the wrong context, so we're not picking up on it, OK? It may be that they have now a failure to associate the, the correct substrate. Always urinated on grass, and now their brain isn't sort of understanding that they're on grass, so they're holding their bladder, etc.
So it's usually caused by confusion. It's not caused by defiance or incontinence. Although we also need to obviously in our history and our discussions, kind of rule those things out.
This is usually noticed really quickly. It's often the first sign that owners come in to seek help for, and usually it's more often a problem with urination than it is with defecation. So it's usually a, a urine being passed in the house more so than faeces.
In terms of activity changes then on our acronym, well, we see reduced mobility, as a very common presentation. This may also be linked to fear and confusion because they are in quite a fearful and confused state. It can be associated with a reduction in memory of what is my normal routine, what are my normal behaviours?
Do I normally get up and do this? Do I normally walk this far? It can also, we know that cognitive decline, sorry, can also lead to.
Ataxia and weakness, knuckling in those limbs, some sort of swaying, some sort of tremors, as are associated with a lot of human neurodegenerative disease processes. Again, many of these things are accepted as age-related change or, taken as being due to some sort of painful element in the animal. And actually, there may well be a painful element in our older animal, but it might not explain all of these changes.
And then lastly, anxiety. We attribute this increasing anxiety that we see in our CCD dogs down to, you know, a reduced cognition. So, you know, they, their brain isn't working as well, they're not understanding the world around them.
They're not able to recognise commonplaces and people. And I think if we all sort of think that like have some empathy, we would say, yeah, that would make us all feel quite anxious. So they have difficulty settling down in familiar areas.
They can't really cope with change very well and they become quite easily startled. OK, and again, people presume that's because they're deaf. They have this increasing fear, so there may be things that we accepted that they were fearful about like fireworks, like thunderstorms, maybe it's the hoover going around the house, but actually that now seems disproportionate.
It's really increased. It's much more extensive than it has been for years. OK, it might be that they had these predisposed fears, that, that, you know, or, or things that you'd worked with before that they'd seem to now be.
Able to cope with and all of a sudden they've lost that coping mechanism. Or it might be that all of a sudden they're fearful to something that they've never been fearful before. And that's because they now can't process this kind of new information.
So they behave in a, in a very erratic, very different way. And that might be to new people coming into the house, things like that where they've always been really accepting and placid before. So if we have a look a bit at consensus guidelines, so in 2025 we had the first ever guidelines developed by the canine cognitive dysfunction syndrome Working Group, and these were developed to help with the diagnosis and monitoring of CCD.
They are. Really interesting read. There is a, their references is later on in our reference pages if you want to have a look.
And they also looked at proposing kind of definitions for how severe the CCD diagnosis was, which is also very useful to us all. So mild CCD we're saying has subtle behavioural changes. It incurs infrequently, has a low severity, and they are ultimately still able to perform most of their normal functions.
In cases of moderate CCD, then our behavioural changes have become more frequent. They're increasing in severity, and they're starting to interfere with their ability to kind of do their normal daily activities. And so we're starting to see that us or the owners are having to make some adjustments or the patients having to make some adjustments to be able to manage life.
And in cases of severe CCD we see these really overt behavioural changes that are becoming really debilitating to the patient. They need to have support now just to perform basic functions, and we need a lot of change to be made to be able to manage their condition. So we know what the clinical signs are, but what do we have to help us to really diagnose CCD because a lot of the clinical signs we've talked about, as you will have recognised, can also be attributed to a lot of other things.
So we know that CCD is largely underdiagnosed. We know that the study we talked about in 2010 said around 14.2% of dogs, but less than 2% of those have been diagnosed by a vet.
So is it that our owners are failing to detect an issue, so they're not coming to us? Is it that they're seeing the issue but accepting it as old age? Are they aware but just not coming to see us anyway?
Or are they coming to see us and we're failing to make that accurate diagnosis? So diagnostic considerations, well, we know that early diagnosis of offers a really much better prognosis, like with many things. We know that imaging such as MRI can assist in our diagnosis, but we do obviously understand that we have cost and anaesthetic risks with those.
As well. History taking and subject matter knowledge, these are really, really essential. The information we extract from our owners and how aware and educated we are on this disease is gonna really make a vast difference when we're talking, OK?
Now what we do know is like many things, there's no definitive diagnostic test for CCD. We're not gonna take some blood and it's gonna come back and say, yep, your patient has this stage of CCD. Unfortunately it's not that easy.
Our diagnostic our diagnosis, sorry, is made from the clinical history and by excluding other causes, like with so many medical conditions, yeah? And our exclusion tests can be quite plentiful considering we're talking about geriatric dogs here. So what's useful to us?
Well, biochemistry, haematology, urinalysis, the key three things. OK, they're going to help us to rule out a lot of medical conditions, OK, or allow us to address these medical conditions alongside the potential for CCD. Diagnostic brain imaging, this can help us to support or exclude a diagnosis.
MRI. Is the only practical modality, but we're aware that CT can help us to exclude other causes. So things like brain tumours may come up on a CT scan and help us like look and go, oh, actually, this looks like it might be the trigger, but MRI is always going to be our kind of gold standard imaging modality in these cases and, and kind of any similar cases where are showing neurodegenerative decline.
And of course we want to have a good neurological exam and we want to make sure that our vets are happy with how we do a really good neurological exam or we may consider referral to a neurologist. What we're looking for really is that absence of other disease processes, absence of other reasons why these behavioural signs are occurring, and they can be, yes, those medical reasons, but also remember we talked about things like changing environments and changing routines, traumas, those sorts of things. So again, kind of builds in these, these kind of testing procedures along with good old conversation.
And then we're looking to see whether our diagnosis of CCD may actually be appropriate for this animal. So in terms of MRI imaging, cos we mentioned it, it can exclude or it can indicate the likelihood of CCD. And the things that we might see are diagnostic findings, they may include shrinking of the brain tissue, so that's cerebral atrophy that we talked about, white matter lesions we may be able to see, microbleeds, both old and new, enlargement of the brain ventricles, so those fluid-filled spaces we.
Talked about. Reduced interthalamic adhesion size, so this is the band of tissue that connects the left and right side of the brain. Often that reduces inside in these kind of cognitive decline cases.
All of these things would be consistent with CCD but not necessarily unique to CCD. Hence, this history and clinical signs, you know, they've got to correlate with what we're seeing on that imaging. We also have the CCDR, which is our canine cognitive cognitive dysfunction Rating Scale.
So this is an online rating scale that was designed, by, Salvin Eal back in 2011. And it was used to grade the severity of cognitive disease, and this is a validated scale for diagnosing CCD. So really, really important to start familiarising yourself with.
Basically there's lots of, questions and the answers to these questions are scored 1 to 5, bit of Er Leichhardt kind of scale. And there's sections for the patient's current behaviour, and there's sections for comparative change, so, you know, comparing their behaviour and how it's changed over the last 6 months. Things like, how often does your dog stare blankly at the walls or floor compared.
6 months ago, does your dog fail to recognise familiar people or pets? So it gets the onus to start thinking about how their dog is now, but also what changes actually have occurred. And then the score is sort of tallied up, you get an overall score, and if it's equal to or above 50, then we say we have a potential diagnosis of CCD.
Obviously we recognise that there's some subjectivity when completed by owners, especially if they're, I suppose, looking for something to be wrong with the patient, and that can be completed by practitioners as well, definitely, but again, that's also gonna be sub subjective, and may lead to some kind of false marks depending on, on what we know. But we can consider how the patient is behaving in that consulting room if it's someone that we see relatively, often. This is just a little picture of that CCD rating scale, so just to kind of show you again a few more of the questions.
And then you have the never once a month, once a week, once a day, more than once a day, and that score is quite simply tallied up along the side there with never being 1, once a month being 2, and so on and so forth. So comparative questions and, questions for the here and now. Other diagnostic aids that we may find useful to use, so we have the Canine Dementia Scale or the CADS, and this is a rating scale to assess cognitive decline in dogs.
It evaluates behaviour and cognitive ability, and it helps to demonstrate really the severity of impairment. So a lot of the time this is something we may undertake after we get that kind of initial diagnosis, but it's good to be aware of the things that we have because like with all of us, we have a certain preference towards certain things that we can't always. And, sort of attributes why, but it's just our, our brain, likes the layout of certain things, more than others.
So obviously this is asking sort of some similar questions. How often does your dog, express aggression, you know, how often does your dog, have a reduced ability, to kind of recognise people. So all these sorts of things and again, it's scored, added up, and then gives you, the kind of if you score this, you're likely to be this severe, etc.
And then we also have the dog impairment in spontaneous Home Activities assessment. Again, DISHA, so using the acronym slightly differently there. And this involves direct observations of the dog in their natural home environment, observing interactions, observing behaviour, and it's just another method to assess cognitive dysfunction.
So this is something that we may undertake or the owners might, in their own home. It's just a slight twist on that kind of cognitive scale. All of these are available online for you to download.
So we've looked at the clinical signs, we've discussed the importance of history taking and kind of correlating everything together. We've talked about, about a bit about imaging modalities and we've looked at the things we kind of have to help support that diagnosis. So once we have that diagnosis, the really important thing then is knowing what we need to do to treat and what the aims of our treatment will be.
So ultimately the biggest aim that we want to delay disease progression. We want to be able to reduce the kind of emotional issues and emotional trauma and anxiety that that patient is experiencing. We want to be able to retrain these previously learned behaviours that now appear to be lost.
We might be able to provide the dog with new coping mechanisms and improve their overall cognition. Overall with all these things, we're ultimately hoping that we're gonna improve their quality of life and be able to restore and improve that pet owner relationship a little bit more as well. So the types of treatment then that we have available, we have nutraceuticals such as Activate or PS as well.
We have anzolytic er therapy, so adapyl, sedatives. We have prescription medications, we have dietary management and we have behaviour and environmental modification. And we're just gonna take a little look at each of these.
So before we do, I think some of the key points we need to remember is that there are a lot of there there's lots and lots of treatment options available out there. All of these have what we call a relatively long lead in time, so they're not gonna bring instantaneous change. It's going to be something that we need to do and we might start to see change in a few weeks' time.
We have to have very committed owners, OK, because it's not as simple as giving a pill, and, and, you know, this condition being treated. They're gonna have to dedicate a lot of time and energy to this. Behaviour modification is key for a successful outcome.
We can go at them with all these drugs and that, but if we don't actually perform some behaviour modification. Won't have any improvement long term. Our medication aims to complement, yeah, and also to enable this behaviour modification to take place.
And as we mentioned, these long lead-in times with a lot of our drugs, it can be up to 6 to 8 weeks. We want to make sure that like we do with all medications, we're monitoring organ function. Hopefully we've had that heme biochemia.
For baseline. OK? And we always want to monitor for any serotonin syndrome if we're using any drugs that increase serotonin levels, OK?
So signs of serotonin syndrome, things like tachypnea, tachycardia, or any sort of changes to neurological, status or, or any development of gastrointestinal abnormalities. So let's look first at our nutraceuticals. So this is a term used to describe non-specific therapies that promote our patient wellbeing.
It combines the words nutrient, which means a nourishing food, and pharmaceuticals, so a medical drug. OK? We, we see many, many, many of them, in practise nowadays, and they're very, well tolerated and well.
Use, they're over the counter, which means they're very accessible to people as well. And often there are more cost effective brands out there for, for kind of humans and in health shops so we can help to advise owners on where they can access these as well because obviously a reduction in cost usually means an increase in compliance or the ability to treat. To activate Vivet Plus, this combines antioxidants, free radical scavengers, and essential fatty acids.
It offers oral dosing as opposed to making a dietary change to include these things, which, you know, if you've got fussy animals, that's a really good thing. It's proven to improve patient behaviour and also the owner. Perception of that behaviour.
Those two things are kind of one and the same, aren't they? It's a complementary therapy, so it can be used alongside behavioural and environmental management. And it can also be used in conjunction in conjunction, sorry, with prescription medications.
So overall, quite a useful addition for our ageing brains. Other nutraceuticals, so PS or phosphatidylserine, I can never say it, it never rolls off the tongue. It's an essential fatty acid, an amino acid derivative compound, and it's naturally found in very high amounts in the normal brain, and it, we know that it contributes to cognitive function.
So it's what we term an. Brain nutrient. So we use it in the management of neurodegenerative processes in humans and in dogs, and again because it's a nutraceutical, it can be used to complement other therapies.
OK. It's also considered to be an effective prophylactic. So actually if you have your clients that are very kind of gung ho on on kind of.
You know, trying to, reduce the likelihood of cognitive decline, then this is something that's, that's really good for them to start taking at a much younger age. PS is present in Activate, and also in some of the specific brain ageing diets as well. Antiolytic treatment, so dap, adaptil, our dog appeasing pheromone would be one that we, all recognise.
Again, a complementary therapy, and this is designed, as it releases synthetic pheromones that mimic kind of natural appeasing pheromones that bitch releases to the young. So it promotes feelings of safety and feelings of security, which can be really useful when we look back to our DA acronym and especially that last kind of. Anxiety component.
So it's also worth considering, if you have some improvement from other therapies just to have some dap diffusers in the house or using it out on walks, those sorts of things to kind of really, help to secure the positive change that's being made. And the nice thing with dap nowadays is that it's available in so many formats. You've got the plug-ins, you've got shoes, you've got collars, you've got diffusers, shirts, sprays, you know, so, so many things.
Sedatives, always an interesting one to discuss. So we know that behaviour modification takes time, OK, we know that a lot of medical therapies have these 6 to 8 week lead-in times. So when we talk about sedation, we're maybe talking about short-term relief from sleep deprivation or nighttime wandering.
And what we're always aiming for is to cause sedation without drowsiness. So things like antihistamines like chlorphenlamine can be really useful to us. Whereas things like asapromazine, diazepam, we know that these are sedatives impair cognitive functions, so they're best avoided.
But actually just using some of these antihistamines last. Thing in the evening just to kind of really help this dog to get some sleep, to stop wandering around, to kind of reduce their ability, I suppose, to, to display these behaviours just means that they have an increased chance of getting rest, which means their brain is going to be more receptive to our behaviour modification that may be coming the following day. In terms of prescription medication, sometimes we find that these are met with quite reluctance from clients, and I think we need to make sure that we're, kind of discussing the aim of using them really openly.
They're not a, a fix all magic pill, we're not going to give this medication and, and we're gonna reverse their cognitive decline. But actually what we're aiming to do is to alleviate these underlying negative emotions, OK, things like fear, anxiety and panic, because if we can. Improve their mental state and improve their emotional wellbeing, we are then going to create an environment where they're able to successfully learn.
OK, so ultimately what we're doing with a lot of these medications is trying to enable their brain to have the opportunity to respond positively to behavioural modification, OK? And that's ultimately what they do. OK, so we're hoping not to use them forever, but.
We might find that if we're just trying behavioural modification, even though it's the gold standard treatment, it might be that that it's not something that we can do with this animal while they're constantly in this emotive state, OK? They are used, these, these drugs with kind of varying success. As I say, I think one of the main reasons is that sometimes people use them as a sole therapy and then the report is they really didn't help.
But actually we know that they're not a sole therapy. We need to use them with behavioural modification and perhaps even with nutraceuticals, anti-anxiolytics, those sorts of things. So we have vivitonin, which is a common one, or Sermion as well.
These are licenced for use in canine brain ageing and with proven efficacy. They ultimately produce vasodilation, so, they also improve cardiac output, and this just means that we get an increased cerebral blood flow and increased flow of oxygen to the brain that reduces confusion. It increases the animal's awareness.
It can help. Them with that increased awareness, it can help improve inappropriate urination or restlessness. And there are a lot of people out there that really advocate the use of these drugs prior to anaesthesia in older dogs, and I mean any older dogs, not those with a diagnosis of CCD but definitely those with a diagnosis of CCD.
And this is because these drugs have been clinically proven to reduce prolonged episodes of hypoxia. And we know that we have some research that has linked general anaesthesia to the onset of CCD, so, using these in our aged canines may actually help act as a preventative to brain ageing. Selegiline, hydrochloride or Selgion, as its brand name is, well, this decreases free radicals in the brain, because it has antioxidant properties.
It's a selective and irreversible inhibitor of monoamine oxidase, so an MAO inhibitor as we often call them, and these are the enzymes that break down neuro, transmitters. So ultimately this drug can. Help to alleviate anxiety and depression by increasing serotonin, norepinephririne, and dopamine levels in the brain.
And what we know is that dopamine in particular plays an important role in memory, in mood, and in attention span. So if we can increase levels safely, yeah, we're gonna be again, opening these doors to behavioural modification, hopefully being more successful. Serotonin, our neurotransmitter, is involved again with mood and cognition, and noradrenaline affects mood, those sleep-wake cycles, and again, the patient's attention span.
So again, all sort of providing ultimately a more positive learning environment. They are only licenced for the treatment of CCD OK, and that is because, they support this learning through behavioural modification, so it is a licenced drug. We also have our SSRIs, so our selective serotonin reuptake inhibitors, so things like fluoxetine, sertraline, citalopram, all things that we largely attribute to, depression in humans.
They're not actually licenced for CCD, they're licenced for separation anxiety. But what they do is inhibit the reuptake of serotonin into the neurons, so they increase the availability for the uptake actually into the brain, OK? And the benefits of.
Their use have been really widely discussed because they help to reduce fear, reduce anxiety, and therefore improve memory and cognition, again, as we've discussed, which is needed for our behavioural modification. We also think that, yes, they may reduce depression like they do in humans, which again, increases the dog's willingness and ability for social interaction and learning. And they again, have been shown to improve, sleep-wake cycles as well.
Now, I always think it's worth just mentioning that there's always lots of things happening, about behind the scenes, isn't there? So there's lots of discussion, lots of research sort of, going on into, to the ageing brain and canine cognitive dysfunction. So Chinese herbal remedies, the use of acupuncture, potentially the use of trazodone moving forward, gabapentin.
And pregabalin, alprazolam, levetiracetam, melatonin, even cannabis. So there's lots of things, there's, there's lots of theories out there and, and, and lots of things that you can kind of, you know, dive a little deeper in, if you want to do a bit of research to yourself. So these may be all things that we start to see come out in, in the future.
OK, so, we're getting close to the end now, but we still need to talk a little bit about dietary changes, and behaviour modification. So in terms of dietary changes as a treatment, if it's indicated, this should be done kind of ASAP. We always say not to do it in the hospital environment, but we don't normally have our CCD dogs hospitalised.
So owners kind of gradually making diet changes at home would be great. Remember that, we talked about free radicals and the fact that they break down fats and proteins. The brain itself has a high fat proportion, OK, which means it's really susceptible to this oxidation that we talked about and amyloid plaque formation.
And as the amyloid plaques increase, the brain function decreases. Well, our i anti sorry oxidant treatment enhances this brain function, fuels and repairs the brain with a good energy source. So a diet that is rich in antioxidants is really essential, as well as we know that they bind and neutralise those free radicals as well.
Now, other things that need to be in our kind of good, brain ageing diets is L-carnitine, so this improves mitochondrial function and energy production. Again, reduces these harmful free radicals, increases the brain's efficiency and increases muscular development as well. We also want to have some medium chain fatty acids to help repair these damaged brain cells.
And really, I think whether you make a dietary change really depends. On the quality of the diet that your patient is already receiving because actually if they are on a high quality diet then often a lot of these things are already in that diet. So they may already be benefiting from this.
But those that are fed on more low quality diets, they may definitely benefit from a change and you know Hill's BD I only put that picture there because it's something that I have experience in using and have definitely seen a positive change. In terms of environmental considerations, it's really important that we manage their environment and that we place appropriate cues to help to support their current brain function, but also reduce stress and anxiety to help improve that cognitive function. So in terms of auditory, well, sound therapy can be a really important thing for the dogs to help reduce phobias or noise and separation anxieties.
Visual things, so lighting to indicate resources, so you know, we tend to turn the kitchen light off at night, but if that's where their food is, maybe we could have a little lamp just on the side that just shows them shines brightly and shows them where that resource is when they're having periods of confusion. Tactile things, so things like rugs on the floor, we, we kind of are slowly transitioning into a world aren't we, where we have quite hard laminate floors downstairs, but placing some rugs down can help just to indicate when they're approaching a wall. That really helps with our kind of aged vision impaired animals as well as those that are suffering with cognitive decline.
Olfactory, so things, certain aromas in the house that aids them to recognise certain areas, diffusers, particular things, obviously making sure they're safe for use, but things like that in the bedroom areas to help them kind of find those areas where rest is, is kind of indicated. And it's really important as well just to recognise that their important resources, so their food, their water, things like that, their toys, things that that that bring them joy should be easily accessible for them and often. During these times, we need to make sure they're duplicated, OK?
Because they may struggle to get to different areas in the house, especially when you're not in. They may have some memory issues as to where their resources are. And sometimes we attribute weight loss to CCD, but I think it's just literally because their brain isn't supporting.
The in finding their food so they have a much reduced intake, OK? And ultimately, let's try and avoid making changes that are gonna make them feel more disorientated. Let's try not to rearrange the furniture, leave things out in the middle of the room, try and keep things very much the same for them.
And then behaviour modification, the most essential element, which I think I've probably said 10 times already, so hopefully, that message has got across. But we want to increase their physical activity, OK, because this increases the blood flow and oxygenation to the brain. We want to increase their mental activity because this stimulates new cell growth, OK, so again, moving away from just giving a pill and hoping for the best, yes, we might need to use.
Use those medications to enable these changes to be successful, but without these changes, we will not have success. OK? We are able with behaviour modifications to returned their lost learned behaviours, so to retrain them.
And as I've mentioned, combination therapy would be really the gold standard. So behavioural modification plus their dietary changes or drug therapy gives us the highest chance of a successful outcome. And our aims are gonna be to reestablish that owner pet bond, to return them to their normal relationship, whatever that was, to encourage play and interaction that both parties can really enjoy.
We want positive reinforcement to enable to retrain their lost behaviour just like we did when they were puppies, OK? We want retraining of our voice commands, we want retraining of appropriate elimination in the home. So in terms of cognitive enrichment, regular exercise for them, and if they are quite aged, which they will be, and they've got a few arthritis problems, mobility issues, then we want to go for those kind of zero load exercises, so swimming, hydrotherapy, use of these underwater treadmills.
We want to increase stimulation through outdoor play and interaction, so encouraging natural exploration, giving them time on walks to stop and sniff, not kind of keep moving them on because we've got to get back for something. So really. Leaving time for this walk to be, you know, one of real exploration and joy.
Take them to new areas, help to stimulate the mind. Don't just do the same routine day in, day out, OK? And these areas that we choose, let's make them stimulating, let's break them from this monotonous routine.
Let's go to a new park, let's go somewhere where we can hear children playing, where I don't know, maybe there's kind of other, other animals or other wildlife to help stimulate them. And let's consider some geriatric socialisation classes. These are things that you guys could be running with great success, yeah?
Helping as a group to retrain those basic commands, stimulating, allowing physical therapy through obstacle courses and play, allowing cognitive therapy through games and puzzles and things like that. Which brings us nicely onto things like food finding games, stimulate their brain while they're eating. Obviously you don't wanna leave these around the house when they're in that real depth of cognitive decline in case they can't use them.
But as you're starting to work on your behaviour modification, hopefully using that drug therapy to enable the ability to learn, these are really great things that you can do together, but ultimately it really stimulates them. Yeah. Increase your visitor.
Interaction. Tell your friends, tell your family what you'd like them to do with the dog when they come in, OK? Not just to walk straight past them, but to interact, yeah?
Play some memory tasks, play some puzzle games. Start going back to that very basic training. Don't just assume they have that kind of memory stored and always, always, always ignore any bad or unwanted behaviour and reward every positive interaction.
So we know that improving cognitive decline takes time. We know that we need the onus to be committed and compliant in what we're trying to achieve, but also we have to communicate that to them really clearly. Dietary changes often take 2 to 4 weeks to see an improvement.
Our selegilines, SSRIs, 6 to 8 weeks. Our adaptors around, 1 to 2 weeks. Consider short-term measures whilst you're waiting.
For some improvements. Yeah. So we talked about kind of sedation to give that, that relief, but make sure that your sedatives aren't causing drowsiness.
OK? Behaviour therapy, it is essential. If people aren't able or willing to put in the time for that, then ultimately you're not likely to see a great outcome, even with the use of certain drugs and diets, and it's really important that the owners understand that.
So our take home messages for today, CCD is a progressive disease. Many signs though are only temporarily reversible. OK, it will continue to progress, but we need to support them through this.
Appropriate treatment can definitely delay progression. Intervention at key points is really important, so if we know there's stressful events coming up, like we talked about the use of vivitonin under general anaesthetic, we can also consider it for things like kenneling, hospitalisation, family gatherings, talk, get, get people to be talking about this. Early diagnosis and treatment really is key, OK, if we can start to reduce the likelihood of decline or the speed of decline at a much earlier stage, then that's gonna be great.
Consider your client education, is this something that you now feel confident that could be nurse led? Is this something that's gonna form part of your geriatric clinics? OK.
Are we using rating scales in them? Shall we start using them? Is this something we're going to start to introduce?
That certain breeds, I don't know, 8th vaccination. Yeah. At the age of 8, this is something that we get every client to try and do and, and kind of get people to be on board with assessing behaviour as such a normal part of their pet owner kind of relationship.
Support them when you're making a diagnosis. Explain to them the process, OK, the need to rule out certain things, the cost that's gonna be implicated here, OK, but the benefits that it may bring, both as giving a full kind of MOT and also looking for that early. Signs of CCD.
Consider their ongoing support needs. It can be quite a lonely journey and people really struggle when their relationship changes with their animal, OK? They need to know that we empathise with that, that we're here to support that, and that ultimately we're a safe space for their thoughts, for their fears.
Be clear on that need for behavioural modification. I know I've said it several times, but there's really no point going down this road if you don't have that compliance. I just wanna say thank you for listening today.
I hope you found the webinar useful and I hope you've left with loads of great ideas as to how you're gonna start looking for these issues and supporting owners that may have pets with these issues in practise. Here's a couple of slides for you with some references that I've used for some further reading. If not, I beg you all a good day.
