Treating Dementia with Chinese Herbs

Transcription

1 Treating Dementia with Chinese Herbs Sheng Fang L.Ac Mentor: Dr. Liu, Guohui L.Ac Oregon College of Oriental Medicine Doctor of Acupuncture and Oriental Medicine Class of 2013 Sheng Fang L.Ac All Rights Reserved. 1

2 ACKNOWLEDGEMENTS I thank the Oregon College of Oriental Medicine for enrolling me into this wonderful DAOM program. Thanks are due to all the teachers at the college, special thanks are due to Dr. Beth Burch, Dr. Zhao-xue Lv, Dr. Cui-hua Lai for their great working. I thank my mentor, Dr. Guo-hui Liu for his great patience, promptness, and insightful thoughts that guided me to finish this project. I thank Dr. Robert Kaneko for his help. Thanks are due to Valerie Razutis for her insightful suggestions and her helping with the proof reading. Thanks are due to David Klath for his help with the proof reading. Thanks are due to Forrest Cooper for his help. I especially thank all my family members. I won t be able to finish this program without their full support. Sheng Fang L.Ac All Rights Reserved. 2

3 CONTENTS P 5 P 5 P 6 P 7 P 8 P 10 P Western Medicine Aspect. 1.1 Introduction. 1.2 Types of Dementia. 1.3 Diagnosis. 1.4 Differential Diagnosis. 1.5 Treatment. 1.6 Prognosis. P Traditional Chinese Medicine: Introduction and Diagnosis P 11 P 12 P 14 P 17 P TCM Introduction. 2.2 Disease Location. 2.3 Etiology and Pathology. 2.4 Diagnosis. 2.5 Differential Diagnosis. P 19 P 19 P 20 P Traditional Chinese Medicine: Treatment and Prevention. 3.1 Treatment Goal. 3.2 Treatment Principles. 3.3 Commonly used herbs. Sheng Fang L.Ac All Rights Reserved. 3

4 P 22 P 25 P 27 P 28 P 29 P 31 P 31 P 33 P 35 P 37 P39 P 41 P 43 P The nourishing herb group The Qi and blood moving group The phlegm and dampness transforming herb group The orifice opening herb group The heat toxin clearing group. 3.4 Common patterns, analysis and treatment methods Liver Kidney deficiency: Liu Wei Di Huang Wan Heart Spleen deficiency: Gui Pi Tang Qi and Yang deficiency: Huan Shao Dan Qi and Blood stagnation: Tong Qiao Huo Xue Tang Phlegm Stagnation: Di Tan Tang Heat toxin: Huang Lian Jie Du Tang. 3.5 Prevention. 3.6 Prognosis. P Discussion. P 46 Reference Sheng Fang L.Ac All Rights Reserved. 4

5 Treating Dementia with Chinese Herbs 1.0 Western Medicine Aspect. 1.1 Introduction Dementia is an acquired impairment in intellectual function, including loss of short term memory and deficits in at least one other area, including aphasia, apraxia, loss of cognitive function, or a disturbance in executive functioning. The impairment usually is persistent and progressive and the patient usually experiences a significant function decline that is severe enough to influence work or social activities. The onset of dementia usually is the age of 60. The risk of dementia doubles every 5 years in the older population. At age 85, 30-50% population has dementia. Risk factors include; stroke, family history of dementia or Alzheimer disease, lower education level, hypertension, smoking, atrial fibrillation, diabetes mellitus, female gender, hyperlipidemia. The most commonly seen clinical symptom of dementia is the memory impairment usually starting with subtle short-term memory loss. The patient has difficulty remembering things that happened hours ago or days ago. Symptoms worsen gradually until long-term memory is also affected. Other symptoms may include language impairment, starting with word finding, then difficulty following a conversation and finally the patient will no longer be able to talk. Along the way, small losses occur regularly, such as being unable to recognize the names of items, unable to accomplish Sheng Fang L.Ac All Rights Reserved. 5

6 daily little tasks like peeling fruit; loss of simple mathematical skills, getting lost easily, becoming unable to recognize the correct directions or find the patient s own home. Personality changes can be particularly difficult to manage. The patient may became more selfish, angry or depressed; show poor executive function, or display confusion, poor attention, poor mental flexibility, poor planning and poor judgment. The dementia is caused by the degeneration or damage of the brain cells, commonly seen risk factors include Alzheimer's, Parkinson's, Huntington's, stroke, chronic alcohol toxic and head injury. The exact cause of dementia is unknown. 1.2 Types of Dementia The Alzheimer disease type: This is the most common dementia. The incidence of Alzheimer doubles every 5 years after age 60. Short-term memory impairment is the most commonly seen clinical symptom. Other symptoms include different deficits of executive function, visuospatial (to recognize shapes and the size of items or recognize the distance) function and language ability. Diagnostic imaging and post-mortem studies of Alzheimer brains show the presence of beta amyloid plaques outside neurons and neurofibrillary tangles inside neurons. The exact role of these two findings in the disease in not well understood. The blood vascular type: This is the second most common type of dementia after Alzheimer's disease. The damage to the brain caused by stroke will lead to stepwise or progressive accumulation of cognitive deficits. Symptoms may vary depends on the exact Sheng Fang L.Ac All Rights Reserved. 6

7 location of the stroke and the neurological functions controlled by that area of the brain. The dementia with Lewy bodies: Lewy body dementia affects about 20 percent of people diagnosed. The clinic symptoms include fluctuations between confusion and clear mind, fluctuating delirium, visuospatial and executive deficits (the patient has problem to regulate, control, and manage other cognitive processes), anxiety, visual hallucinations and Parkinson's-like signs such as tremor and rigidity. A-synuclein-containing Lewy bodies (Lewy bodies are the abnormal aggregates of protein that develop inside nerve cells) occur in the brainstem, midbrain, olfactory bulb, and neocortex. The exact role of Lewy bodies in the disease in not well understood. Alzheimer s and Parkinson's pathology may coexist in this type of dementia. The frontotemporal dementia: This is a less common type of dementia that tends to occur at a younger age, seen as early as age 40. The clinical symptoms include socially inappropriate behaviors, loss of mental flexibility, language problems, and difficulty with thinking and concentration. It is caused by the degeneration of nerve cells in the frontal and temporal lobes of the brain. Neuropathology is variable and defined by different types of proteins. For example, the build-up of tau proteins in neurons was observed in the progressive frontotemporal dementia caused by Pick's disease (Pick s disease is a rare neurodegenerative disease). 1.3 Diagnosis The diagnosis of dementia is mainly depends on the clinic symptoms. If the patient Sheng Fang L.Ac All Rights Reserved. 7

8 has the dementia syndromes and the symptoms have a gradual onset and continuing decline and they are not due to an identifiable physical, neurological, or psychiatric condition or medications it may be considered as dementia. The mini mental status examination (MMSE) is widely used in helping with the screening and evaluation of dementia. MMSE is 30-points questionnaire cognitive test. A score from 18 to 23 may suggest a mild cognitive impairment; a score from 0 to 17 may suggest a severe cognitive impairment. The score could be affected by educational attainment, age and other mental disorders. The test can be used to monitor the progress of dementia if it is taken at regular intervals. The brain-imaging test such as MRI and CT scans can help to assess the brain for evidence of acute trauma or stroke, signs of Lewy bodies, or brain atrophy as seen in Alzheimer. Lab test can also help to detect the cholesterol and blood sugar level and to rule out the thyroid disorders, vitamin deficiencies and adrenal disorders which may cause memory loss, confusion and fatigue. 1.4 Differential Diagnosis Mild cognitive impairment is defined as mild memory problems. Patients may demonstrate mild deficits on formal testing, but do not meet the standard for dementia. More than half of people with mild cognitive impairment will see it develop into dementia within five years. Sheng Fang L.Ac All Rights Reserved. 8

9 Delirium and dementia may coexist, it is difficult to determine how much of the impairment is from delirium and how much is from dementia. Delirium has an acute onset, fluctuating course, and deficits often in attention instead of memory. Dementia usually has a much longer onset term and manifest as memory damage. Electrolyte imbalances and glucose abnormalities: The abnormal glucose and electrolyte level can cause different symptoms. For example, the high blood sugar level can cause brain damage and the low levels of sodium and potassium can cause confusion, paralysis and muscle spasm. Lab test for electrolyte and glucose can help to check it out. Pharmaceutical side effects: Some drugs used to treat depression, Parkinson s disease and allergies may cause the symptoms of poor memory, drowsy, cognitive impairment. Check the medicine history helps to differentiate this. Drug and alcohol use: Long term drug and alcohol usage can impair the brain s function and cause the symptoms of dementia. Drug and alcohol use is also a risk factor for dementia. Verify the drug and alcohol using history can help to differentiate. Brain trauma: Brain trauma can lead to interbrain bleeding or swollen, which can cause oxygen deprivation phenomena such as long-term, low grade carbon monoxide poisoning and damage the brain s function and cause headache, poor memory, cognitive impairments. Brain injury may be a risk factor for dementia. The injury history can help the differentiation. Brain tumor: The growing of brain tumor may cause the oxygen deprivation phenomena too and impair the cognitive ability. Brain imagine such as MRI can help to Sheng Fang L.Ac All Rights Reserved. 9

10 locate the tumor. Normal pressure hydrocephaly: Due to the abnormal accumulation of cerebrospinal fluid, the intracranial pressure may increase to a high normal level and the ventricles are enlarged. This will put increased pressure on the nearby cortical tissue and cause clinic symptoms like mental decline and urinary incontinence. Brain imagining such as MRI and CT can help to rule out the enlarged ventricles as well as mass lesions in the brain. 1.5 Treatment The treatment goal of dementia is to control symptoms and delay the disease progress. Commonly used medicines for the cognitive impairment are the following: 1. Acetylcholinesterase inhibitors such as donepezil, galantamine, rivastigmine. These drugs may help to improve cognitive function. Currently there is no evidence showing they can delay the disease progress. Side effects may include nausea, vomiting, lose of appetite, joint pain, fainting, bleeding and seizures. 2. Memantine (Brand name Namenda).This medicine may benefit more advanced disease. Additional studies are needed to evaluate its long-term and meaningful functional outcomes. Side effects may include fatigue, headache, dizziness, constipation, vomiting, body pain, coughing, shortness of breath and hallucination. 3. Rivastigmine. (Brand name Exelon) This medicine may help to improve the patient s behavior symptoms. There is no strong evidence showing that other anti-psychotic agents maybe helpful to the behavior symptoms. Side effects may include nausea, vomiting, Sheng Fang L.Ac All Rights Reserved. 10

11 weakness, loss of appetite, joint pain, fainting, aggressive behavior, anxiety, hallucination, bleeding and seizures. General non-pharmacologic approaches are very important to behavioral problems. If the patient s behavioral problems are caused by delirium, pain, urinary obstruction, constipation or other physical problems, then the physical conditions need to be addressed first. General speaking, if the patient is disturbed by a behavioral problem; the care giver can use simple language, simple component tasks, distraction strategies to redirect the patient. Family and social emotional support, memory training, easy physical tasks training may also helpful with behavioral problems. 1.6 Prognosis The prognosis of dementia is fair. The survival period after a diagnosis of dementia is usually 3-15 years. Lewy body dementia may have a more rapid decline. Currently, the treatment goal of dementia is to control symptoms, develop coping mechanisms, and delay the disease progress. 2.0 Traditional Chinese Medicine: Introduction and Diagnosis 2.1 Chinese Medicine Introduction: In tradition Chinese medicine, dementia is called as Chi Dai. The term Chi Dai was first briefly recorded in The Secret Book of Hua Tuo (Hua, Probably 230) says: The Sheng Fang L.Ac All Rights Reserved. 11

12 patient who suffers from Chi Dai often has the depression and anger may also cause Chi Dai. The Book From Jing Yue (Zhang 1624) also discussed the Chi Dai disease: There was no obvious previous phlegm syndromes in Chi Dai; the stagnation, over thinking or frightening gradually will cause Chi Dai ; the symptoms of Chi Dai include manic speeches, crazy activities, profuse sweating, over thinking or depression and all types of other weird symptoms. This is due to the Heart Qi reversion or Liver, Gallbladder Qi is not clear. While the clinical symptoms of dementia were observed and recorded much earlier, most of those symptoms were recorded under different diseases names such as Jian Wang (Poor memory), Yu Zheng (Stagnation and Depression), Dian Kuang (Manic). The earliest recorded description of dementia symptoms were from Ling Shu ( Anonymous, probably 50) Chapter 33 Hai Lun. It pointed out that the Kidney dominating the bone and generating marrow to nourish the brain, and if the marrow is insufficient then there is dizziness, tinnitus, decreased vision, fatigue and sleepiness. 2.2 Disease Location: Dementai is a disease that is located in the brain, with involvement of the Kidneys, Heart, liver, and Spleen. The brain controls the normal daily activities. As stated in LingShu. Chapter 33 Hai Lun: Sheng Fang L.Ac All Rights Reserved. 12

13 The brain is the sea of marrow, when the brain is well nourished; the person s action is swift and strong. The head (brain) is also the meeting spot of the Yang meridians, the body s Yang Qi gathers in the brain, and Yang Qi directly support the clear spirit and mind. In Huang Di Nei Jing. Tai Shu (Yang 618) stated that the head is the house of the spirit and mind, so if the head (the brain) is sick, there will be mental and spiritual disorders. In Shu Wen ( Anonymous, probably 50) Chapter 17 Mai Yao Jing Wei Lun pointed out that the head is the house of spirit and alertness, a dropped head with sunken eyes predicts the spirit will leave. This suggests that the head is very closely related with the spirit and mental activities. Later Chinese medicine practitioners also recognized that the head (brain) is the center of the mental and spirit activities and the brain controls the memory. For example, Dr Wang, Qingren explained in his book Yi Lin Gai Cuo(1830): The food and water were transferred into Qi and Blood, nourish the body and flesh, the clear part of the essence became the marrow (to nourish the brain); the spirit, mental activities, alertness and memory are controlled by the brain instead of by the heart. The main symptoms of dementia are memory impairment, mental activities ability impairment and loss of executive function. The brain controls all of these aspects, so disease location is in the brain. The Heart, Liver, Spleen and Kidney are also closely related with the onset and the progressing of dementia. In Shu Wen, Chapter 8 Ling Lan Mi Dian Lun pointed out that Sheng Fang L.Ac All Rights Reserved. 13

14 the Heart is the emperor and controls the spirit. The disharmony of the Heart may lead to the spirit disturbance, which is one of the dementia s chief symptoms. The liver controls the Qi s movement. If the Qi can not move smoothly, it will lead to the stagnation and cause dementia. The Spleen controls the transforming and transporting of food water essence. If the Spleen failed to do so, the brain can not get nourished and phlegm stagnation will be formed and cause dementia. The Kidney stores the essence to support the marrow and the brain. The Kidney also controls the motor function. If the essence is deficient, the brain cannot be nourished, and memory falters. In Su Wen, Chapter 8 Ling Lan Mi Dian Lun stated that the Kidney is the officer of action and controls actions and skills. Motor dysfunction is also one of the chief clinic symptoms of dementia. 2.3 Etiology and Pathology: Qi and essence deficiency: For the senile patient, the Kidney essence is gradually exhausted and eventually cannot support the brain. If the Spleen and Stomach are weak they cannot transform and transport the food and water essence to nourish the body and support the normal functions of the brain. The deficient Yang Qi can not distribute or move the essence to nourish the brain. These disharmonies may all lead to dementia. In Shu Wen Chapter 1 Shang Gu Tian Zhen Lun, the physiological and pathological changes related with aging were discussed: For the female, at the age of 35, the Yangming meridian is starting to become deficient, the face starts to become lusterless, hair starts to fall out. At the age of 42, all three yang meridian become deficient, the Sheng Fang L.Ac All Rights Reserved. 14

15 whole face becomes lusterless, and the hair starts to turn gray. At the age of 49, the Ren and Chong meridians are deficient. TianKui (explain this term) is exhausted and the woman cannot give birth. For the male, at the age of 40, the Kidney Qi starts to become deficient, hair starts to fall out and teeth are poorly nourished. At the age of 48, Yang Qi is further declined from the upper Jiao, the whole face becomes lusterless, and the hair starts to turn gray. At the age of 56, Liver Qi is deficient, meaning the tendons cannot support movement. TianKui and essence are exhausted, the Kidneys are deficient, and the whole body is exhausted. At the age of 64, the teeth and hair are gone. This suggests that the deficiency of Yang Qi, Chong and Ren meridians and TianKui will cause the aging of the female while the deficiency of Yang Qi, TianKui, essence, Liver, and Kidney may contribute to the aging of the male, and the aging process will contribute to dementia. In Shu Wen Chapter 5 Yin Yang Yin Xiang Da Lun also mentioned that the patient s Yin is half consumed in the forties and the patient starts to became slow. In the fifties the patient starts to feel heavy, has blurred eyesight and declining hearing. In the sixties, the Yin is totally exhausted and the Qi is severely consumed, so the patient s nine orifices are stagnated, and he has deficiency in the lower body with excess in the upper body, nasal discharge and tears. Low intelligence is due to deficiency while high intelligence results from excessive essence. With excessive essence people will have bright eyes and sharp hearing, a strong body, and they stay strong in senior years. This statement suggests that the Qi and essence deficiency is the direct cause of the dementia and the deficiency is the Sheng Fang L.Ac All Rights Reserved. 15

16 cause of the stagnation. Other ancient Chinese medicine books have made similar statements. Qian Jin Yi Fang (Sun 800) from Tang dynasty points out: After fifties, the Yang Qi becomes deficient, when the deficiency is severe, the heart is affected and the patient will suffer from poor memory, lose interest in daily life and become slow. Ben Cao Bei Yao (Wang 1664) from Qing dynasty mentions: The memory is controlled by brain; poor memory in a child is due to the underdevelopment of the brain; senility in older people is due to the deficiency of the brain. Yi Lin Gai Cuo from Qing dynasty also stated the similar ideas. The Brain is a special Fu Organ, the normal function of the brain is the foundation of normal spirit activities. If the brain is not nourished due to different types of deficiency, the clear spirit then can not function and dementia will develop. This makes it clear that deficiency is the key cause of dementia. Blood, Qi and phlegm stagnation: The stagnation of Blood, Qi and phlegm may block the meridians and vessels. In this case, the Qi, Blood and essence can not reach the upper body to nourish the head; the brain will gradually lose its function gradually to that malnourishment. Some ancient Chinese medicine books recorded dementia related symptoms caused by stagnation. Sheng Fang L.Ac All Rights Reserved. 16

17 In the Su Wen Chapter 62 Tiao Jing Lun states: Blood stagnated in the lower body and Qi stagnated in the upper body, the disharmony causes the poor memory. Further, in Ling Shu Chapter 80 Da Huo Lun states: The Qi in upper Jiao is deficient and the Qi in Lower Jiao is excess, that is the deficiency in Heart and Lung and stagnation in Stomach and Intestine, so the Yin and Wei Qi will be stagnated in the lower body and can not nourish the upper body on time, this will cause the poor memory. In Shang Han Lun (Zhang 220) line 237 notes that if the patient easily forgets things, there must be blood stagnation. In Shi Shi Mi Lu (Chen 1687) writes: When there is severe phlegm stagnation, there is severe dementia; there is no special method to treat dementia, to treat phlegm is to treat dementia. These statements suggest that Qi, Blood and phlegm stagnation play a very import role in causing dementia. Trauma or toxin: Trauma or toxin may damage the normal movement of Qi and Blood as well as cause stagnation in meridians and vessels. This will lead to the malnourishment of the brain and cause dementia. The trauma or toxin may also directly damage the brain s function and cause dementia. 2.4 Diagnosis: Sheng Fang L.Ac All Rights Reserved. 17

18 Just as in Western medicine, the diagnosis of dementia is primarily determined by evaluation of clinical symptoms, including tongue and pulse information. For a thorough assessment, the practitioner of Oriental medicine must also use Western medical diagnostic methods such as the mini mental status exam (MMSE) and where appropriate, collaborate with allopathic practitioners. 2.5 Differential Diagnosis: The differential diagnosis of dementia is primarily confined to three manifestations of mental disorders: Yu Zheng (depression and anxiety disorders), Dian Bing (depression and bipolar disorders), and Jian Wang (memory disorders). Yu Zheng (Depression, Anxiety): The main clinic symptoms of Yu Zheng are emotional symptoms such as depression, grief, crying, irritability, or anger. Some patients may also have chest/hypochondriac distention or pain, and the sensation of phlegm stagnation in the throat. Yu Zheng is mainly caused by Liver Qi stagnation and does not feature memory impairment, cognitive function impairment, or motor function impairment. Dian Bing (Depression, Bipolar disorder): The main clinical symptoms of Dian Bing are emotional symptoms and abnormal behavior. Symptoms include depression, sadness, moving slowly, low interest in daily life, patients may sit or lay quietly or make meaningless talk. It may be due to stagnation of Qi, Blood and/or phlegm. The pathology of Dian Bing is similar to the Chi Dai s pathology with common symptoms. In Dian Bing Sheng Fang L.Ac All Rights Reserved. 18

19 pattern, there is less progressive cognitive impairment. Also, the slow-moving or lack of movement in Dian Bing are due to lack of interest, while in dementia, these symptoms are due to the impairment of motor function. Towards the late stage of Dian Bing, due to the long term of stagnation, the patient may develop Chi Dai. Jian Wang (poor memory): The main clinical symptom of Jian Wang is poor memory, making this condition closest to true dementia. The patient cannot remember things while all other mental abilities are normal. The patient has no problem with calculation, direction and understanding. The patient does not have motor impairment. The causes of Jian Wang include stagnation of Blood, Essence deficiency or Blood and phlegm stagnation. Since these causes are also the causes of dementia, Jian Wang (poor memory) could be one of the early manifestations of dementia. 3.0 Traditional Chinese Medicine: Treatment and Prevention. 3.1 Treatment Goal: The goal of the treatment is to stabilize the disease, delay the progress of dementia, and improve quality of life. It is very difficult to reverse brain impairment and bring the patient back to a completely normal condition. So the treatment should focus on improving the symptoms. If the dementia can be stabilized and progress halted, the patient will be able to maintain part of their memory, intelligence, and motor ability to live a better life. The Chinese medicine treatment can help to improve the whole body s condition and balance, which will also be helpful to the overall health condition for the Sheng Fang L.Ac All Rights Reserved. 19

20 patient. 3.2 Treatment Principles: Start treatment as early as possible, emphasizing prevention. The general development of disease progresses from mild to severe, from simple to complicated. Treating the disease early usually can bring better results. Preventing the occurrence of disease whenever possible is the best way. Therefore, practitioners should consider family history when developing a treatment plan for a patient at risk of dementia. This principle was clearly stated in both Su Wen and Ling Shu. In Shu Wen chapter 2 Si Qi Tiao Shen Da Lun mentioned that the best doctor treats the patient before the patient gets sick, harmonizes the body before it goes out of balance. In Ling Shu chapter 55 Ni Shun also stated the same idea. Nourish the deficiency and disperse the excess. The deficiency and excess are the basic pathologies of dementia. The deficiency is usually related to the Qi, Blood and Essence. For these patterns the treatment plan is to nourish and restore the deficient aspect to normal levels. The excess in dementia is usually Qi, Blood and/or Phlegm stagnations. For these patterns the treatment plan is to remove the stagnation and open the orifices. There may be a combination of deficiency and excess at the same time. For these combination patterns, the treatment plan needs to be well balanced between nourishing and dispersing. In classic Ling Shu chapter 5 Gen Jie advised to disperse the excess and Sheng Fang L.Ac All Rights Reserved. 20

21 nourish the deficiency as a basic rule in treating diseases. Pay attention to the branch (Biao), root (Ben), lesser urgency (Huan) and urgency (Ji). The root (Ben) is the major pathology cause of the disease; the branch (Biao) is an additional pathology that contributes to the disease and the clinical symptoms. For dementia, the essence deficiency is the root while the blood and phlegm stagnations are the branch. The essence is the material foundation of Qi; deficiency of essence will lead to Qi deficiency. Essence and Blood share the same source, therefore deficiency of essence will also lead to blood deficiency and then blood stagnation. Deficient essence cannot nourish the Shen (spirit), so the spirit is restlessness and scattered. The importance of differentiating branch and root while maintaining the Shen (spirit) was described in Shu Wen Chapter 13 Yi Jing Bian Qi Lun: If the doctor fails to differentiate the branch and root and treats the patient in the wrong way, the patient will lose the spirit. With the spirit, the patient has a good prognosis, without the spirit, the patient has a bad prognosis. With this statement, it is clear that treatment plans should always try to focus on the root (Ben) and treat it when treating dementia. But if the branch (Biao) is in an urgent state (Ji), then consider treating the branch (Biao) first. For example, if a patient has severe phlegm stagnation (the branch) due to Spleen Qi deficiency (the root), transform phlegm first then strengthen Spleen Qi. Treat the disease according to its current stage. Dementia is a chronic disease that steadily progresses. It usually has several stages and practitioners should choose the Sheng Fang L.Ac All Rights Reserved. 21

22 treatment plan according the the current stage of disease for the specific patient. For example, in the early stage of dementia due to blood stagnation, the treatment strategy should be moving Qi and Blood to resolve stagnation. If the dementia progresses and the stagnation is causing Qi and essence deficiency, then the treatment strategy should be moving Qi and Blood while nourishing Qi and essence at the same time. Choose specific treatments and caring methods based on the pattern differentiation. In TCM, a disease may result from different patterns due to the cause of the disease and the patient s constitution. For example, the dementia could be due to Kidney essence deficiency pattern or phlegm stagnation pattern. It is very important to have the correct pattern diagnosis before beginning treatment. For example, for the Kidney deficiency pattern, the treatment principle is to nourish the Kidney essence to support the brain. For the phlegm stagnation pattern, the correct treatment plan is to support the Spleen and transform the phlegm to open the orifices. 3.3 Commonly used herbs: Commonly used herbs for dementia include the nourishing herb group, the Qi and Blood moving herb group, the phlegm and dampness transforming herb group, the orifice opening herb group and the heat toxin clearing group Nourishing herb group: The herbs in this group have the ability to nourish essence, Yin, Qi, or Blood to support normal brain function. Commonly used essence and Yin nourishing herbs include Shu Di Huang, Tu Si Zi, Sheng Fang L.Ac All Rights Reserved. 22

23 Gou Qi Zi, Huang Jing, Rou Cong Rong, Sang Shen, Gui Ban, Du Zhong, Lu Jiao Jiao, Zi He Che, Mai Men Dong, and Nv Zhen Zi. Commonly used Qi nourishing herbs include Ren Shen, Huang Qi, Gan Cao, Bai Zhu, Shan Yao, and Dang Shen. Commonly used Blood nourishing herbs include Dang Gui, He Shou Wu, Bai Shao, E Jiao, Ji Xue Teng, and Suan Zao Ren. Some of the herbs in this group can nourish more than one aspect. For example, Shu Di Huang can nourish essence, Yin, and Blood; Lu Jiao Jiao can nourish essence and Qi. Introduction to the key herbs in the nourishing group: Shu Di Huang has a sweet flavor and slightly warm temperature and it goes to the Liver and Kidney channel. It can nourish the Kidney Yin and nourish essence. Shu Di Huang has been used as a nourishing and anti-aging herb for a long time in China. In Shen Nong Ben Cao Jing(Divine Husbandman s Classic of the Materia Medica) (Anonymous, porbably 50), it states that Shu Di Huang can remove Blood stagnation, nourish essence and marrow, generate flesh, and increase longevity if taken long term. In Ben Cao Gang Mu(Comprehensive Outline of the Materia Medica) (Li, 1590), it mentions that Shu Di Huang is a great herb to nourish essence and marrow, to generate blood and flesh, and to nourish the internal deficiency for all five Zangs. Shen (2007) reported that Shu Di Huang can improve the learning ability and memory of mice with Sheng Fang L.Ac All Rights Reserved. 23

24 dementia. The possible mechanism is by reducing brain cholinesterase activity, inhibiting the accumulation of aluminium ions in the brain, maintaining the normal level of Glu/GaBA, and protecting brain function. Cui (2003) reported that Shu Di Huang can improve the learning ability and memory of mice with dementia, decrease the number of mistakes and prolong the incubation period in step down tasks, and shorten the incubation period of seeking the platform in Morris water maze tasks. Ren Shen has a sweet and slightly bitter flavor and a slightly warm temperature and it goes to the Spleen, Lung, and Heart. Ren Shen is a very good Qi nourishing herb. In Shen Nong Ben Cao Jing, it states that Ren Shen can nourish the five Zangs, calm the spirit and mind, open the Heart orifice and improve intelligence, and that long term use of Ren Shen can increase longevity. But the temperature of Ren Shen was described as slightly cool. In Ben Cao Gang Mu, it mentions that Ren Shen can treat all types of deficiencies. Lu (2012) reported that Compound Ginseng Brain Tonic Liquid (Ren Shen is the main ingredient) has a preventive effect on cerebral ischemia-reperfusion injury, can decrease lipid peroxide content and oxygen consumption levels, and can increase reduced glutathione content levels. Shao (2005) reported that Ren Shen can improve the learning ability and memory of mice with dementia. Huang Qi has a sweet flavor and a slightly warm temperature and it goes to the Spleen and Liver, Lung and Kidney. Huang Qi can nourish Qi, generate flesh and heal sores, and drain dampness. In Shen Nong Ben Cao Jing, it states that Huang Qi can treat sores and carbuncles, especially chronic ones, nourish deficiency, and treat different Sheng Fang L.Ac All Rights Reserved. 24

25 pediatric diseases. Nei (2004) reported that Huang Qi can influence the expression of certain proteins and prevent the apoptosis of hypoxic neurons in primary cultured cerebral cortical neurons. Gan Cao has a sweet flavor and a neutral temperature and it goes to the Spleen and Stomach and Lung. It can balance Yin and Yang, nourish Qi and Blood, and remove toxins. In Shen Nong Ben Cao Jing, it states that Gan Cao can treat cold or heat evil attacks in Zang and Fu, strengthen bone and flesh, remove toxins, and treat carbuncles and wounds. Taking Gan Cao for a long time can also increase longevity. Ben Cao Gang Mu emphasizes that Gan Cao can treat heat toxin. Li (2010) reported that Gan Cao has an anti-oxidative effect which could delay the aging process. Dang Gui has an acrid, sweet and bitter flavor and a warm temperature and it goes to the Spleen, Liver and Heart. Dang Gui can nourish and move Blood. In Shen Nong Ben Cao Jing, it states that Dang Gui can treat Qi uprisings and cough, female menstrual disorders, trauma, and carbuncles. In Ben Cao Gang Mu, it mentions that Dang Gui can treat different types of Blood related diseases. Wu (2013) reported that a large dose of Dang Gui can help to improve learning ability and memory, improve the activity of cholinergic neurotransmitters, and protect nerve cells in the brain tissue. Sun (2011) reported that many active components of Dang Gui have pharmacological effects to treat Alzheimer's disease Qi and Blood moving group: The herbs in this group have the ability to move Qi Sheng Fang L.Ac All Rights Reserved. 25

26 and Blood stagnation and improve the circulation to better nourish the brain. Commonly used herbs include Chuan Xiong, Dan Shen, Ge Gen, Shui Zhi, Tu Bie Chong, Wu Gong, Quan Xie, Di Long, Yu Jin, Tao Ren, Hong Hua, Shui Zhi, Chi Shao, Jiang Huang, Niu Xi, San Qi, and Yin Xing Ye. Introduction to the key herbs in the Qi and Blood moving group: Chuan Xiong has an acrid flavor and warm temperature and it goes to the Liver, Gallbladder and Pericardium. Chuan Xiong can move Qi and Blood and disperse wind. The acrid flavor helps it to go upward and reach the head area. In Shen Nong Ben Cao Jing, it states that Chuan Xiong can treat a headache caused by wind invasion and it can also treat trauma. In Ben Cao Gang Mu, it mentions that Chuan Xiong can dry dampness and remove Qi stagnation. Li(2003) reported that Chuan Xiong can regulate arginine vasopressin(avp) levels in the central nervous system and improve the symptoms of vascular dementia.zhao(2008) reported that the herb combination of Tian Ma and Chuan Xiong can improve the learning ability and memory of mice with vascular dementia. Dan Shen has a bitter flavor and slightly cool temperature and it goes to the Liver and Heart. In Shen Nong Ben Cao Jing, it states that Dan Shen can treat diseases of the Heart and abdomen, remove cold and heat stagnation, disperse Qi and Blood stagnation, calm the spirit and nourish Qi. In Ben Cao Gang Mu, it mentions that Dan Shen can move the Blood stagnation, open the pericardium, and treat hernias. Li (2010) reported that Dan Shen might be able to protect cholinergic nerves in the brain, decrease inducible nitric oxide synthase (inos) expression in the hippocampus, and improve learning and Sheng Fang L.Ac All Rights Reserved. 26

27 memory impairment in dementia model rats. Ge Gen has an acrid, sweet flavor and a neutral temperature and it goes to the Spleen and Stomach. Ge Gen can release the exterior, clear heat, generate fluid, vent rash, raise clear Yang and stop diarrhea. In Shen Nong Ben Cao Jing, it states that Ge Gen can treat Xiao Ke disease (Diabetes), heat disease, raise the Yin fluid, and de-toxify. In Ben Cao Gang Mu, it mentions that Ge Gen can disperse the stagnated fire. Zhu (2010) reported that Ge Gen extract can prevent and cure vascular dementia to some extent. Chen (2006) reported that Ge Gen extract can improve the learning ability and memory of Alzheimer type dementia patients Phlegm and dampness transforming herb group: The herbs in this group have the ability to remove dampness. Dampness and phlegm are important pathology factors causing dementia. Commonly used herbs include Fu Ling, Ze Xie, Zhu Ru, Cang Zhu, Chen Pi, Ban Xia, Dan Nan Xing, Bei Mu, Hou Po, Sha Ren, and Huo Xiang. Introduction to the key herb in the phlegm and dampness transforming group: Fu Ling has a sweet and blank flavor and a neutral temperature. It goes to the Heart, Spleen, Kidney and Lung. Fu Ling can drain Spleen dampness, remove phlegm and support Shan Yao to nourish the Spleen; it can also calm the spirit. Fu Ling also has been used as a nourishing and anti-aging herb in Chinese medicine. In Shen Nong Ben Cao Jing, it states that taking Fu Ling for a long period of time can calm and nourish the spirit; a person will feel less hungry and have increased longevity. Hou (2004) reported Sheng Fang L.Ac All Rights Reserved. 27

28 that Fu Ling extract has an anti-aging effect on mice Orifice opening herb group: The herbs in this group have the ability to open orifices and awaken the spirit. They can help the patient to improve memory and learning ability. Commonly used herbs include Shi Chang Pu, Yuan Zhi, Bing Pian, She Xiang, and Niu Huang. Introduction to the key herbs in the orifice opening group: Shi Chang Pu has a bitter and acrid flavor, a warm temperature and it goes to the Heart and Stomach. Shi Chang Pu can awaken the Stomach and transform the phlegm, open the orifices and improve intelligence. It has been used as an orifice herb for a long time in Chinese medicine. In Shen Nong Ben Cao Jing, it states that Shi Chang Pu can nourish the five Zangs, open nine orifices, benefit the eyes and ears, and improve slurred speech. In Ben Cao Gang Mu, it mentions that Shi Chang Pu can treat stroke and other brain related diseases. Jing (2002) reported that Shi Chang Pu can improve the learning ability and memory of mice with dementia. Yuan Zhi has a bitter, acrid flavor, slightly warm temperature and it goes to the Heart, Kidney, and Lung. Yuan Zhi can calm the spirit and improve intelligence, transform phlegm, and improve sleep. It also has been used as an anti-aging herb in Chinese Medicine since ancient times. In Shen Nong Ben Cao Jing, it states that Yuan Zhi can open nine orifices and improve intelligence, benefit eyes and ears, improve the memory, and strengthen will power and muscle power. In Ben Cao Gang Mu, it mentions Sheng Fang L.Ac All Rights Reserved. 28

29 that Yuan Zhi especially goes into the Kidney instead of the Heart and it can strongly nourish essence, strengthen will power and treat poor memory. Mu (2007) reported that Yuan Zhi can decrease cerebral acetylcholinesterase (AchE) activity and improve the learning ability and memory of dementia model rats. Yu (2011) reported that the herb combination of Yuan Zhi, Ren Shen and Fu Zi may improve learning ability and memory, and increase levels of SOD,GSH Px,and reduce MDA in the brain tissue of model dementia mice. Bing Pian has a bitter acrid flavor, cold temperature and it goes to the Heart, Liver and Lung. Bing Pian was introduced into China from abroad during the Tang dynasty (about AD 610) and it has been used to open the orifices and awaken the spirit for a long time. Bing Pian can also disperse heat toxin. In Ben Cao Gang Mu, it mentions that Bing Pian can treat headache, open all orifices and disperse fire stagnation. Wu (2001) reported that Bing Pian can increase blood circulation in the brain. Yang (2010) reported that Bing Pian has an anti-thrombosis effect Heat toxin clearing group: The herbs in this group have the ability to clear heat and de-toxify. They can also calm the spirit. Commonly used herbs include Huang Lian, Huang Qin, Huang Bai, Zhi Zi, and Da Huang. Introduction to the key herb in the heat toxin clearing group: Huang Lian has a bitter flavor, cold temperature and it goes to the Heart, Stomach, Spleen, Gallbladder, and Liver. Huang Lian can clear heat toxin and drain dampness. In Sheng Fang L.Ac All Rights Reserved. 29

30 Shen Nong Ben Cao Jing, it states that Huang Lian can treat heat disease, eye pain, and diarrhea. Taking Huang Lian for a long time can improve the memory. Gou (2011) reported that Huang Lian displays an anti-anxiety effect in the elevated plus-maze test and light-dark transitions test. Huang Lian can increase the content of gama-aminobutyric acid (GABA) in the brains of mice. Lan (2001) reported that Huang Lian can increase blood circulation in the brain and improve learning ability. Some statistical research work on the anti-dementia herbs has been done. Lin (2012) et al. checked 27 ancient TCM books and found 236 formulas for improving cognitive function. They identified 139 herbs from those 236 formulas. The ten herbs (of the 139) used most frequently are: Fu Ling (used 182 times); Ren Shen (used 169 times); Yuan Zhi (used 139 times); Gan Cao (used 100 times); Dang Gui (used 84 times); Shi Cang Pu (used 80 times); Suan Zao Ren (used 79 times); Shu Di Huang (used 62 times); Mai Men Dong (also used 62 times); and Sheng Jiang (used 53 times). Zhou (2005) et al. collected 1232 formulas that had been published from 1979 to 2004 in more than 160 TCM journals and modern TCM books. There are a total of 426 herbs included in those 1232 formulas. The ten single herbs used most frequently in those formulas are: Shi Cang Pu (used 764 times); Chuan Xiong (used 495 times); Yuan Zhi (used 486 times); Dan Shen (used 431 times); Shu Di Huang (used 401 times); Dang Gui (used 395 times); Gou Qi (used 389 times); Fu Ling (used 385 times); Huang Qi (used 370 times); and Shan Zhu Yu (used 311 times). The top five herb groups are the nourishing herb group (used 4339 times); the Blood moving group (used 2167 times); the Sheng Fang L.Ac All Rights Reserved. 30

31 phlegm transforming group(used 1351 times); the dampness draining group (used 993 times); and the orifice opening group (used 935 times). These two research projects indicate that nourishing the brain, removing blood and phlegm stagnation, and opening the orifices could be the main treatment methods for dementia. 3.4 Common patterns, analysis and treatment methods: Liver Kidney Essence (Yin) deficiency: The main clinical symptoms include poor memory, especially decreased short term memory, decreased calculating ability, lack of spirit in the eyes, dizziness or tinnitus, weakness or soreness in the lower back or knees, an unstable walk or difficulty walking, numbness in the limbs, a dark red tongue with a thin white coating or peeled coating, and a deep thin weak pulse. The Liver Yin and Kidney essence are consumed due to advanced age, overuse, or internal heat. Ling Shu (Hai Lun) mentions: the brain is the sea of marrow. The Yin and essence are the material foundation for the marrow. When there is not enough Yin or essence going upward to nourish the brain, the marrow in the brain will become vacant and the patient will have decreased memory and calculating ability. Liu Wei Di Huang Wan is the basic formula for the Liver Kidney Yin deficiency pattern. This formula is from Dr Qian, Yi s book Xiao Er Yao Zheng Zhi Jue (Craft of Medicines and Patterns for Children), compiled by Dr. Qian s student Yan Ji Zhong. Dr. Qian lived during the Song Dynasty (about AD 1119) and he was the number one pediatric specialist Sheng Fang L.Ac All Rights Reserved. 31

32 at that time. He preferred to use gentle formulas and a Yin nourishing strategy. He modified Dr. Zhang, Zhong Jing s Jin Gui Shen Qi Wan and removed the Fu Zi and Gui Zhi. He named the new formula Di Huang Wan and used it to treat the mal-development of children due to Kidney,,Liver Yin and essence deficiency. Now we call it Liu Wei Di Huang Wan. Liu Wei Di Huang Wan focuses on nourishing the Kidney, Liver Yin and essence to support the marrow. The ingredients and daily dosage are the following: (bulk herbs) Shu Di Huang 24g to benefit the Liver Shan Zhu Yu 12g to nourish Liver, Kidney Yin Shan Yao 12g to nourish Spleen and Kidney Yin Mu Dan Pi 9g to clear deficient heat and move Blood Fu Ling 9g to nourish the Spleen, drain dampness and phlegm Ze Xie 9g to drain Kidney dampness Modification and analysis: add in Ren Shen 9g, Shi Chang Pu 12g, Yuan Zhi 9g, Chuan Xiong 6g, and Ge Gen 6g to move Blood stagnation and transform phlegm to open the orifices and also to nourish Qi and raise the clear Yang Qi and essence to nourish the brain. For severe essence deficiency case, some animal agents such as Lu Rong, Hai Shen and Dan Cai can be added to strongly strengthen the essence. In Shu Wen chapter 5 Yin Yang Ying Xiang Da Lun, it mentions: for essence deficiency, should nourish it with (heavy) flavor (the Yin, Blood, essence nourishing herbs). So for the Liver, Kidney essence deficiency pattern, Liu Wei Di Huang Wan is a great formula. And for dementia, Sheng Fang L.Ac All Rights Reserved. 32

33 there are different patterns and the key is the deficiency in brain essence with Blood stagnation or phlegm stagnation. So promoting blood circulation and transforming the phlegm to open the orifices is very important. After opening the orifices, the herbs or essence can reach the brain and nourish the brain. Zhang (2012) reported that the Liu Wei Di Huang Wan patent can improve the learning and motor abilities of dementia patients. Qin (2007) reported that the patent Liu Wei Di Huang Wan can delay the progress of dementia and improve the learning ability and memory of dementia patients Heart Blood Spleen Qi deficiency: The main clinical symptoms include forgetfulness, poor memory, difficulty in concentrating, a lack of spirit in the face, palpitations, insomnia with profuse dreams, fatigue, poor appetite, abdominal distention, loose stool, pale tongue with a thin white coating, and a weak and thin pulse. In this pattern, the deficient Spleen Qi is unable to transform food and water into essence and Blood to nourish the body. The Heart cannot get nourished so there is a memory problem and insomnia. Gradually, the chronic mal-nourishment leads to essence deficiency in the brain and causes dementia. Gui Pi Tang is the basic formula for the Spleen Qi and Heart Blood deficiency pattern. The Gui Pi Tang, recorded in Zheng Ti Lei Yao (Categorized Essentials for Normalizing the Structure), is a modified edition from Ji Sheng Fang. Dr. Xue, Ji, who lived during the Ming dynasty (about AD 1529) added Dang Gui and Yuan Zhi to nourish Blood and calm the spirit. Dr. Xue was a great Chinese medicine practitioner and he served as an imperial Sheng Fang L.Ac All Rights Reserved. 33

34 doctor at that time. He preferred to warm, nourish, and strengthen the Spleen. He was also a specialist in treating trauma so he listed the first function of Gui Pi Tang as treating falls and trauma. Based on Zheng Ti Lei Yao, Gui Pi Tang can treat Qi and Blood related diseases such as insomnia, fatigue, sleepiness, trauma, Qi and Blood stagnation, and bleeding. The ingredients and daily dosage are the following: (bulk herbs) Dang Gui 6g to nourish Blood and move Blood Bai Zhu 9g to nourish the spleen Qi Huang Qi(Chao) 15g to nourish the spleen Qi Ren Shen 6g to nourish the spleen Qi Fu Ling 9g to support the Spleen and drain dampness Yuan Zhi 9g to nourish essence and calm the spirit Suan Zao Ren(Chao) 6g to nourish Blood and calm the spirit Long Yan Rou 6g to nourish Blood and calm the spirit Mu Xiang 3g to move Qi Zhi Gan Cao 3g to nourish the spleen Qi Da Zao Sheng Jiang 1 piece to nourish Qi and Blood 3 pieces to drain the dampness and move Qi Modification and analysis: add in Shi Chang Pu 12g, Chuan Xiong 6g, Ge Gen 6g, Sha Ren 6g. Shi Cang Pu transforms dampness and opens the orifices; Chuan Xiong moves Blood and opens the orifices; Gen Gen raises the clear Yang to nourish the brain; and Sha Sheng Fang L.Ac All Rights Reserved. 34

35 Ren moves Qi and promotes digestion. Ling Shu Chapter 28 Kou Wen states: When there is not enough Qi in the upper body (to nourish), then there is deficient brain, tinnitus, dropped head and blurred eye-sights. This suggests that lifting the Qi up from middle Jiao to nourish the upper body especially the head is very important in the treating of dementia. A large does of Huang Qi was used in the formula. For this pattern, the deficiency of Spleen Qi and Heart Blood is the root cause, so the main treatment strategy is to nourish the Qi and Blood So the Gui Pi Tang is a suitable formula for this pattern. But the moving and opening ability of Gui Pi Tang is weak, so in the modification, moving and opening herbs are introduced. Li (2012) reported a case in which modified Gui Pi Tang was used with great effect to treat Heart Spleen deficiency dementia Spleen Qi and Kidney Yang deficiency: The main clinical symptoms include dizziness, decreased short term memory, shortness of breath, reluctance to speak, vacant face, fatigue and weakness, drowsiness and lack of alertness, cold body or cold hands and feet, profuse urination, increased night urination, loose stool or constipation due to the lack of strength to make a bowel movement, edema, pale tongue with a white coating, and a deep, thin, weak pulse. In this pattern, the deficient Spleen Qi and Kidney Yang are unable to warm the body and transform the water. So there are cold symptoms and cold dampness retention symptoms. There is not enough Qi and Yang to keep the spirit awakened, so the patient is drowsy and lacks alertness. The deficient Qi and Yang are unable to carry out the moving Sheng Fang L.Ac All Rights Reserved. 35