Research into the treatment of vascular dementia in China using traditional therapies

Age and Ageing 1998; 27: 247-250

LETTER FROM...CHINA

Research into the treatment of vascular dementia in China using traditional therapies

By JlNZHOU TlAN

Department of Geriatrics, Beijing University of Chinese Medicine and Pharmacology, Beijing Dongzhimen Hospital, 5 Haiyuncang Street Beijing 100700, China. Fax: (+86) 10 6401 0817

The prevalence of dementia in those aged 65 years or over in China is 3.9%, of which vascular dementia accounted for 69% in 1989 [1]. A subsequent study has confirmed that multi-infarct dementia occurs more frequently than primary degenerative dementia, with a ratio of 3:2 [2].
Apart from a few individual case studies, there were few reports of attempts to investigate the treatment of vascular dementia until the early 1990s [3], when a clinical research programme to explore the use of Chinese herbal medicine for this condition was started at Beijing Dongzhimen Hospital.
In 1991, the Internal Medicine Committee of the Chinese Society of Traditional Medicine developed criteria for the diagnosis of, and differentiation between, the syndromes responsible for dementia (including vascular dementia) and also the evaluation of treatment using the Chinese herbal approach [4]. After a further 4 years, a validation study of the criteria for differentiating syndromes was completed [5].
Acupuncture is another form of traditional Chinese medicine that has been investigated for the treatment of multi-infarct dementia, especially with regard to its effect on the electroencephalogram in patients with this condition [6].

Criteria for the diagnosis of vascular dementia, differentiating different syndromes and evaluating treatment

Diagnostic criteria for dementia

The Hasegawa Dementia Scale (HDS-R, Chinese version) and the Mini-Mental State Examination have been evaluated in China in this context [3, 7-9]- A score of 295 on the HDS-R was identified as a suitable cut-off point for dementia, with a specificity of 0.9 [7]. The Chinese version of the Mini-Mental State Examination was evaluated in a Chinese clinical sample, and found to have a sensitivity of 1.0 and a specificity of 0.98 [3, 8, 9] for a cut-off score of £23. It has also been shown that in the Chinese population, as in Western civilizations, the HDS-R and the Mini-Mental State Examination scores are influenced by educational background [9, 10].

Diagnostic criteria for vascular dementia

Once a diagnosis of dementia has been made [11, 12], the criteria of the American Psychiatric Association Diagnostic and Statistical Manual, third edition, revised (DSM-m-R) [13, 14] and/or the Hachinski ischaemia scale [15] are used in China to identify people whose dementia has a vascular basis. The same scoring system is used in China as in the West. Evidence of ischaemic change on computed tomography or magnetic resonance imaging of the brain is sought, wherever possible.

Treatment of vascular dementia with traditional Chinese therapy

A three-phase procedure is employed: (i) the diagnostic criteria for vascular dementia are used to screen out subjects; (ii) syndromes are differentiated according to established criteria; and (iii) intervention is performed using appropriate treatment. This procedure is called 'differentiation of syndrome and rendering treatment', which is conceptually very different from Western medicine.
The differentiation of syndromes is a process of determining the nature, cause and location of the illness through overall analysis of symptoms, signs, relevant factors of the illness and the patient's physical condition according to the basic theories of traditional Chinese medicine. The nature includes deficiency of energy or excess of pathological causes in body. The causes include heat, phlegm, blood stasis or clot and wind. The location of the illness includes different organs such as brain, heart, liver, spleen, lungs, and kidneys. According to the criteria for differentiating syndromes, for example, a red tongue with yellow coating, constipation, vexation, yellow urine, a rapid pulse and a dry mouth with a bitter taste belong to the heat syndrome category; while phlegm or phlegmatic sound in the throat, listlessness or apathy, fat, heaviness in the head, moist greasy fur on the tongue and an enlarged tongue belong to the phlegm syndrome category; and a dark or purplish tongue, headache, cyanotic lips, and string pulse are features of the blood stasis syndrome.

Traditional herbal treatment of vascular dementia

Studies have suggested that the most frequent causes of dementia associated with stroke are the heat, the phlegm and the blood stasis syndromes [5, 16-18].
Treatment is considered to be a process of re-establishing the energy balance by removing these causes, and hence improving the patient by allowing the functions of the different organs to recover. As an example, the syndromes of phlegm and heat would be treated by injection of Qingkailing (QKL, extracts from Chinese cow-bezoar, scutellaria root, honeysuckle flower, isatis root, pittosporum) as a means of resolving phlegm and clearing heat. Blood stasis syndrome, on the other hand, would be treated by a method promoting blood flow that involved the injection of Chuanxiong piperazine (an extract of Chuanxiong) [16].
Two studies will serve as an example of this approach: in one, at Dongzhimen Hospital, 10 cases of heat and phlegm syndrome in dementia following stroke were identified, and the patients treated using an intravenous infusion of QKL (product number BWZ 80: 804) administered on a daily basis for 30 successive days. At the same time, a herbal tea (pinellia tuber, grassleaved sweetflag, dahurian angelica root, bighead atractylodes, pseudostellaria root) was prescribed twice daily. The patients were followed for the duration of their treatment and, on subsequent assessment, five were judged to be considerably improved intellectually, increasing their score by 10 points on HDS-R.
Three cases improved, but to a lesser degree, 5 or less on the HDS-R, whilst the remaining two subjects did not benefit from the treatment [7, 17].
In a study at Beijing Xiyuan Hospital, 15 cases of the syndromes of heat and phlegm in vascular dementia were evaluated in a treatment programme. In this particular study a modified HDS-R was used, which allowed the level of education to be taken into account when making the diagnosis of dementia. Ten of these subjects with vascular dementia were given an intravenous infusion of QKL once a day for 14 successive days, in a randomized double-blind design, in -which the control group were given an infusion of Chuanxiong piperazine.
Again, there was marked benefit in the QKL group, with a significant improvement on the HDS-R. After the treatment, the QKL group increased their score from 12.4 to a mean of 22.8, whilst the control group increased their score only to a mean of 18.5 from 13-6.
Seven of those receiving QKL were judged to be significantly improved intellectually, and increased their score by at least 20 points on the HDS-R, whilst a further two improved, although to a lesser extent (between 15 and 20 points). One person failed to gain any intellectual improvement [18].
These studies suggest that QKL is of benefit in some patients who have vascular dementia, as long as an appropriate and careful differentiation of syndromes is undertaken before deciding which herbs or herbal extracts should be used. Chuanxiong piperazine has an effect on promoting blood flow, but cannot resolve phlegm and clear heat. It is therefore considered to be unsuitable for treating heat and phlegm syndromes, hence the lesser degree of improvement in the group receiving this treatment.
Other studies show that QKL may have 'anti-platelet stickiness' properties and also promote the absorption of thrombus and necrotic tissue in the brain. This can be helpful in patients with vascular brain damage, as are its putative abilities of improving cellular metabolism and maintaining survival of neurons after vascular damage [19].

Acupuncture treatment for vascular dementia

Acupuncture begins with a diagnosis of the individual's energy imbalance. The energy of the body, mind and spirit is distributed through 12 main energy pathways (sometimes called meridians). Each pathway is associated with an organ. The chronic over- or underactivity
of any of these pathways will cause organs, including the brain, to work less effectively, resulting in disease. Each organ also has a pulse associated with it that informs the practitioner about the energy of that organ. These signs, together with others, such as focal neuropsychiatric symptoms and signs, form the basis of diagnosis. Treatment is the process of re-establishing the energy balance through the insertion of needles into acupuncture points located on the pathways. As the balance improves, health improves [20].
A study at Shanghai Medical University investigated the effects of acupuncture on 21 elderly subjects with vascular dementia. These all met the DSM-HI-R criteria, and scored >7 on the Hachinski ischaemia scale, <295 HDS-R and >5 on the Functional Activities Questionnaire [21]. They all had evidence of vascular damage on a brain computed tomography or magnetic resonance imaging. In 10 cases the dementia was considered to be mild (22-29.5 on die HDS-R), in seven it was thought to be moderate (10.5-21.5 on the HDS-R) and in four cases the dementia was severe (0-10 on the HDS-R).
The main acupuncture points employed in this study were baihui, qiangjia, naohu, shuigo and shengmen, but at the same time the researchers injected other acupuncture points, including yamen, ganyu, shengyu, dajui, fengchi and zhusanli, using 1 ml of acetyl glutamine, injecting two points at the same time every other day, with longitudinal comparison. Three months later improvement on the HDS-R scale of > 5 -10 was noted. Similarly, statistically significant results were reported for improvement on the Functional Activities Questionnaire. The intelligence disturbance rate dropped from 3946 % before treatment to 22.52%, with high density lipoprotein-c notably raised to normal level.
Another trial was undertaken at Helongjiang College of Chinese Medicine Hospital with 18 inpatients with vascular dementia, diagnosed using the DSM-HIR criteria, the HDS-R and the Hachinski ischaemia scale, together with evidence of infarcts on computed tomography. All patients underwent acupuncture, using shengting, baihui, fengchi, shemen and dazhong as the main points, once daily, for 30 successive days, again with longitudinal assessment. The authors report an improvement in intellectual function in 15 of the 18 subjects, including memory function as measured by the Clinical Memory Questionnaire [22].
There was also evidence of an improvement in the electroencephalogram, especially the a wave pattern [6].
It is considered that the acupuncture points described above are associated with pathways that
penetrate the brain, and the authors of these reports believe that the efficacy of acupuncture is associated with an increasing provision of oxygen to the brain brought about by an improvement in cerebral blood flow [6, 12].
A number of factors make it difficult to evaluate accurately the reliability of the results described above. For example, different criteria were used when evaluating the outcome and some of the trials were not conducted in a randomized double-blind controlled fashion. The findings do, however, indicate that traditional Chinese medicine, especially acupuncture, has something to offer people with vascular dementia. The mechanism by which these improvements are obtained is uncertain, and warrants further investigation.

Acknowledgements

I would like to thank Gordon Wilcock and Judy Haworth at Clinical Research Centre and Memory Disorders Clinic, Department of Care the Elderly, Frenchay Hospital, Bristol, UK, for their supervision and assistance in the modification and preparation of the manuscript.

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