Integrative assessment and Integrative assessment and treatment of cognitive impairmenttreatment of cognitive impairment

2005 U.S. Psychiatric Congress2005 U.S. Psychiatric Congress

James Lake M.D.James Lake M.D.www.IntegrativeMentalHealth.netwww.IntegrativeMentalHealth.net

Pacific Grove, CA.Pacific Grove, CA.Adjunct clinical facultyAdjunct clinical faculty

StanfordStanford

View BibliographyView Bibliography

Integrative mental health careIntegrative mental health care——foundations foundations

!! Brief overview of stepsBrief overview of steps!! History/assessment to formulation to Rx. Plan History/assessment to formulation to Rx. Plan

to assessment and so on until to assessment and so on until sxsx resolve and/or resolve and/or Rx exhaustedRx exhausted

!! Takes into account Takes into account indivindiv preferences, values and preferences, values and resources, costs, etc. resources, costs, etc.

Severe impairment: differential Severe impairment: differential diagnosisdiagnosis

!! DeliriumDelirium——transient, normal baseline, global transient, normal baseline, global deficits, identified medical cause or acute deficits, identified medical cause or acute substance intoxicationsubstance intoxication

!! DementiaDementia——progressive deteriorating course, progressive deteriorating course, global deficits, no identified medical causeglobal deficits, no identified medical cause

!! TBI or TBI or cerebrovascularcerebrovascular accident (Stroke) accident (Stroke) !! AmnesticAmnestic syndromesyndrome——transient deficit in transient deficit in

capacity to learn or recall new informationcapacity to learn or recall new information

Mild cognitive impairmentMild cognitive impairment

!! Possible causes includePossible causes include!! Normal agingNormal aging!! Chronic nutritional deficienciesChronic nutritional deficiencies!! Less severe stroke injuryLess severe stroke injury!! Chronic narcotic abuseChronic narcotic abuse!! Adverse effects of prescribed drugsAdverse effects of prescribed drugs!! Social isolationSocial isolation

Severe cognitive impairmentSevere cognitive impairment

!! TBI most common cause. 2 million new cases TBI most common cause. 2 million new cases each year costing $48Beach year costing $48B

!! Dementia is second most common cause and Dementia is second most common cause and Alzheimer’s accounts for 60 to 70% of all Alzheimer’s accounts for 60 to 70% of all dementia at annual cost of $100Bdementia at annual cost of $100B

!! Stroke is the third most common cause at Stroke is the third most common cause at 500,000 new cases each year costing $43B500,000 new cases each year costing $43B

Conventional assessment methodsConventional assessment methods

!! Careful history establishes course and symptomsCareful history establishes course and symptoms!! Laboratory workup if indicated Laboratory workup if indicated !! Functional brain imaging if evidence of CVA, Functional brain imaging if evidence of CVA,

TBI or infectionTBI or infection!! MiniMini--mental state exam in dementia but not mild mental state exam in dementia but not mild

or moderate casesor moderate cases!! CoCo--morbid psychiatric symptoms and historymorbid psychiatric symptoms and history

Limitations of conventional Limitations of conventional assessment methodsassessment methods

!! Rigorous medical workRigorous medical work--ups often not doneups often not done!! Comprehensive medicalComprehensive medical--psychiatric history psychiatric history

seldom doneseldom done!! Insurance coverage limits workInsurance coverage limits work--upsups!! Patients and relatives do not advocate for more Patients and relatives do not advocate for more

extensive evaluationextensive evaluation!! Consequences include missed or Consequences include missed or mismis--diagnosis, diagnosis,

no or inadequate treatment, and reduced no or inadequate treatment, and reduced treatment treatment costcost--effectivenesseffectiveness

The integrative assessment of The integrative assessment of cognitive impairmentcognitive impairment

!! Starts with a conventional medical, psychiatric, Starts with a conventional medical, psychiatric, social and cultural history, MMSE, and social and cultural history, MMSE, and appropriate laboratory studiesappropriate laboratory studies

!! Includes nonIncludes non--conventional approaches that conventional approaches that potentially yield specific accurate information potentially yield specific accurate information about causes of dysfunctionabout causes of dysfunction

!! Takes into account Takes into account relativerelative evidence for different evidence for different approaches, cost, availability, and patient approaches, cost, availability, and patient preferencespreferences

Rating evidence of nonRating evidence of non--conventional conventional assessment and treatment approachesassessment and treatment approaches

!! Based on modified EBM criteriaBased on modified EBM criteria!! Four levels of evidenceFour levels of evidence

!! SubstantiatedSubstantiated——compelling evidencecompelling evidence!! ProvisionalProvisional——good evidencegood evidence!! Possibly effective/specificPossibly effective/specific——inconsistent findingsinconsistent findings!! RefutedRefuted——consistent negative findings consistent negative findings

NonNon--conventional assessment conventional assessment approachesapproaches

!! SubstantiatedSubstantiated!! QEEG and QEEG and neurometricneurometric brain mapping to evaluate brain mapping to evaluate

cognitive impairment in TBI, postcognitive impairment in TBI, post--stroke and stroke and dementiadementia

!! ProvisionalProvisional!! QEEG mapping with VEP or AER in dementia and QEEG mapping with VEP or AER in dementia and

mild cognitive impairmentmild cognitive impairment!! Virtual reality testing environmentsVirtual reality testing environments!! Serum zinc and magnesium levelsSerum zinc and magnesium levels

Substantiated Substantiated assessment approachesassessment approaches

QEEG Brain mappingQEEG Brain mapping

!! QEEG measures include power, leftQEEG measures include power, left--right interright inter--hemispheric symmetry, and phase coherence of hemispheric symmetry, and phase coherence of electrical brain activity in homologous regions in electrical brain activity in homologous regions in both hemisphere (both hemisphere (SenfSenf 1988) 1988)

!! Shows correlations between cognitive Shows correlations between cognitive impairment related to dementia or stroke (CVA) impairment related to dementia or stroke (CVA) and diminished activity in the alpha and beta and diminished activity in the alpha and beta rangesranges

QEEG brain mappingQEEG brain mapping

!! Provides useful information when planning EEG Provides useful information when planning EEG biofeedback protocols addressing cognitive impairmentbiofeedback protocols addressing cognitive impairment

!! Shows changes at different stages of Alzheimer’s Shows changes at different stages of Alzheimer’s disease and other syndromes of severe cognitive disease and other syndromes of severe cognitive impairment which are frequently not apparent in impairment which are frequently not apparent in conventional CT or MRI imaging studies (conventional CT or MRI imaging studies (PasseroPassero1992) 1992)

!! Can be used to evaluate response to both conventional Can be used to evaluate response to both conventional and nonand non--conventional cognitive enhancing treatments conventional cognitive enhancing treatments

NeurometricNeurometric Brain mappingBrain mapping

!! Specialized QEEG approach that compares Specialized QEEG approach that compares EEG characteristics of the individual being EEG characteristics of the individual being evaluated with normative databases for the same evaluated with normative databases for the same age.age.

!! Helps to clarify functional brain correlates of Helps to clarify functional brain correlates of cognitive impairment, and yields information cognitive impairment, and yields information that is useful for planning EEG biofeedback that is useful for planning EEG biofeedback protocols addressing specific kinds of protocols addressing specific kinds of dysfunctiondysfunction

NeurometricNeurometric brain mappingbrain mapping

!! NeurometricNeurometric brain mapping is an evolving brain mapping is an evolving diagnostic tool which is increasingly used in diagnostic tool which is increasingly used in clinical settings to differentiate cognitive clinical settings to differentiate cognitive impairments that are due to head injuries, impairments that are due to head injuries, medical disorders, progressive dementia, alcohol medical disorders, progressive dementia, alcohol or substance abuse, depressed mood, learning or substance abuse, depressed mood, learning disorders or other underlying biological causes. disorders or other underlying biological causes.

QEEG brain mappingQEEG brain mapping

!! The rate of deterioration in normal theta (3.5 to The rate of deterioration in normal theta (3.5 to 7.5 Hz) activity in the early stages of dementia is 7.5 Hz) activity in the early stages of dementia is highly predictive of longhighly predictive of long--term clinical outcomes term clinical outcomes (Rodriguez 1996) (Rodriguez 1996)

!! Abnormal decreases in slowAbnormal decreases in slow--wave delta activity wave delta activity (1.5 to 3.5 Hz) take place after normal theta (1.5 to 3.5 Hz) take place after normal theta activity has deteriorated, and correspond to activity has deteriorated, and correspond to severe dementia severe dementia

Provisional assessment Provisional assessment approachesapproaches

Serum zincSerum zinc

!! Alzheimer’s risk may Alzheimer’s risk may possiblypossibly be associated with chronic be associated with chronic low blood levels of zinc and magnesiumlow blood levels of zinc and magnesium——findings findings inconsistent. inconsistent.

!! High zinc levels are High zinc levels are neurotoxicneurotoxic and may promote and may promote formation of formation of amyloidamyloid plaques, however histopathology plaques, however histopathology studies of the brains of Alzheimer’s patients reveal studies of the brains of Alzheimer’s patients reveal deficient zinc (deficient zinc (CuajungcoCuajungco 1997)1997)

!! Low plasma levels of zinc bound to Low plasma levels of zinc bound to thymulinthymulin in in Alzheimer’s patients suggests that impaired zinc Alzheimer’s patients suggests that impaired zinc metabolism contributes to pathogenesis (metabolism contributes to pathogenesis (CuajungcoCuajungco1997). 1997).

Serum magnesium Serum magnesium

!! DysregulationDysregulation of magnesium transport into of magnesium transport into neurons may be a metabolic abnormality of neurons may be a metabolic abnormality of Alzheimer’s disease in spite of adequate Alzheimer’s disease in spite of adequate magnesium intake in the diet (Glick 1990)magnesium intake in the diet (Glick 1990)

!! Checking serum magnesium levels does Checking serum magnesium levels does notnotprovide useful information and magnesium provide useful information and magnesium supplementation is probably supplementation is probably notnot an effective an effective interventionintervention

QEEG brain mapping in TBI, postQEEG brain mapping in TBI, post--stroke and dementiastroke and dementia

!! Emerging research findings suggest that Emerging research findings suggest that quantitative EEG and EEG (auditory or visual) quantitative EEG and EEG (auditory or visual) evoked potentials are useful assessment toolsevoked potentials are useful assessment tools for for the evaluation of the evaluation of mildmild cognitive impairment, cognitive impairment, earlyearlystages of Alzheimer’s disease, and symptoms of stages of Alzheimer’s disease, and symptoms of inattention and cognitive slowing following inattention and cognitive slowing following stroke or traumatic brain injury. stroke or traumatic brain injury.

QEEG with evoked potentialsQEEG with evoked potentials

!! Visual evoked potentials (VEP) may Visual evoked potentials (VEP) may reliably differentiatereliably differentiate patients patients with mild cognitive impairment (MCI) or frank Alzheimer’s with mild cognitive impairment (MCI) or frank Alzheimer’s disease from intact subjects (disease from intact subjects (BenvenutoBenvenuto 2002). 2002).

!! Abnormal auditory evoked potentials (Abnormal auditory evoked potentials (AEP’sAEP’s) provide specific ) provide specific markers of milder forms of cognitive impairment. markers of milder forms of cognitive impairment.

!! Slowing of global alpha activity below 8 Hz, increased theta Slowing of global alpha activity below 8 Hz, increased theta activity, and a decrease in the alpha to theta ratio are typicalactivity, and a decrease in the alpha to theta ratio are typicalfindings in Alzheimer’s disease. findings in Alzheimer’s disease.

!! Vascular dementia is associated with normal EEG activity Vascular dementia is associated with normal EEG activity interspersed with regions of focal slowing. interspersed with regions of focal slowing.

QEEG brain mapping with VEP and AER in QEEG brain mapping with VEP and AER in dementia and mild cognitive impairmentdementia and mild cognitive impairment

!! PrePre--frontal cortical frontal cortical disdis--inhibition is a typical inhibition is a typical finding in AD and other forms of dementia finding in AD and other forms of dementia

!! A significant percentage of mildly cognitively A significant percentage of mildly cognitively impaired adults eventually progress to frank impaired adults eventually progress to frank dementia dementia

!! Early QEEG evaluation of atEarly QEEG evaluation of at--risk risk individuals may facilitate early aggressive individuals may facilitate early aggressive treatmenttreatment

Virtual reality testing environmentsVirtual reality testing environments

!! Virtual reality tools may enhance the diagnostic Virtual reality tools may enhance the diagnostic accuracy of conventional neuropsychological accuracy of conventional neuropsychological assessment methods used to evaluate cognitive assessment methods used to evaluate cognitive impairment in degenerative neurological disorders, impairment in degenerative neurological disorders, stroke, developmental disorders and traumatic brain stroke, developmental disorders and traumatic brain injury (TBI) (Rizzo 2000). injury (TBI) (Rizzo 2000).

!! Virtual performance testing environments will lead Virtual performance testing environments will lead to the development of novel methods for earlier to the development of novel methods for earlier and more accurate assessment of cognitive and more accurate assessment of cognitive impairment.impairment.

VR testing environmentsVR testing environments

!! Prototype VR environments have yielded promising results for Prototype VR environments have yielded promising results for assessment of memory, attention, executive functioning, assessment of memory, attention, executive functioning, sensorimotorsensorimotor integration, and activities of daily living. integration, and activities of daily living.

!! Combining VR technology with Combining VR technology with fMRIfMRI and other functional brain and other functional brain imaging technologies is adding to our understanding of the imaging technologies is adding to our understanding of the causes of moderate and severe forms of cognitive impairment. causes of moderate and severe forms of cognitive impairment.

!! The use of VR environments to assess neuropsychological The use of VR environments to assess neuropsychological functioning will lead to individualized rehabilitation functioning will lead to individualized rehabilitation strategies that strategies that more effectivelymore effectively address performance address performance deficits on a case by case basis.deficits on a case by case basis.

Possibly specificPossibly specificassessment approachesassessment approaches

Serum vitamin levelsSerum vitamin levels!! Malnutrition due to Malnutrition due to malabsorptionmalabsorption of essential dietary of essential dietary

factors may play a significant causative role in dementia. factors may play a significant causative role in dementia. !! Chronic brain deficiencies of vitamins and certain trace Chronic brain deficiencies of vitamins and certain trace

elements may be causes of elements may be causes of neurofibrillaryneurofibrillary tangles and tangles and other other neuropathologicalneuropathological changes that manifest as changes that manifest as Alzheimer’s Disease or other degenerative disorders Alzheimer’s Disease or other degenerative disorders (Evans 1987). (Evans 1987).

!! Clear correlations have not been established between Clear correlations have not been established between the risk of developing AD and abnormal low serum the risk of developing AD and abnormal low serum levels of vitamins or trace elements (levels of vitamins or trace elements (ScileppiScileppi 1984). 1984).

Serum DHA levelsSerum DHA levels

!! Case studies Case studies suggestsuggest that abnormal low levels of serum that abnormal low levels of serum DHA (an OmegaDHA (an Omega--3 fatty acid) may be correlated with 3 fatty acid) may be correlated with the severity of cognitive impairment in demented the severity of cognitive impairment in demented patients (Tully 2003). patients (Tully 2003).

!! Other studies contradict this finding (Other studies contradict this finding (LaurinLaurin 2003). 2003). !! Testing serum DHA levels in demented patients should Testing serum DHA levels in demented patients should

is is notnot a specific assessment approach pending more a specific assessment approach pending more conclusive findings conclusive findings

Integrative formulation Integrative formulation

!! Includes:Includes: biological, psychological, psychobiological, psychological, psycho--social, mindsocial, mind--body, and possible energybody, and possible energy--information causes or meanings of cognitive information causes or meanings of cognitive impairmentimpairment

!! Suggests integrative treatment plan including Suggests integrative treatment plan including biological, psychological, mindbiological, psychological, mind--body and energybody and energy--information treatments addressing identified information treatments addressing identified causes or meaningscauses or meanings

Conventional treatments of cognitive Conventional treatments of cognitive impairmentimpairment

!! AcetylcholinesteraseAcetylcholinesterase inhibitorsinhibitors!! MAOIsMAOIs!! Estrogen replacement therapyEstrogen replacement therapy!! NaloxoneNaloxone!! OnOn--going research: going research: neuropeptidesneuropeptides——

somatostatinsomatostatin, vasopressin; vaccines, , vasopressin; vaccines, secretasesecretaseinhibitors, NSAIDS, inhibitors, NSAIDS, statinsstatins

NonNon--biological conventional biological conventional treatmentstreatments

!! Address behavioral and cognitive symptoms of Address behavioral and cognitive symptoms of dementia, TBI and strokedementia, TBI and stroke!! Behavioral interventionsBehavioral interventions!! Environmental enrichmentEnvironmental enrichment!! Social supportSocial support

Limitations of conventional Limitations of conventional treatmentstreatments

!! AcetylcholinesteraseAcetylcholinesterase inhibitors are the only FDA inhibitors are the only FDA approved treatmentsapproved treatments!! Limited clinical benefits generally in early and Limited clinical benefits generally in early and

moderate AD onlymoderate AD only!! Few or no demonstrated benefits in other forms of Few or no demonstrated benefits in other forms of

severe cognitive impairmentsevere cognitive impairment!! Toxicities and adverse effectsToxicities and adverse effects!! High cost and limited availabilityHigh cost and limited availability

Substantiated nonSubstantiated non--conventional conventional treatmentstreatments

!! Dietary changesDietary changes!! Regular exerciseRegular exercise!! Ginkgo Ginkgo bilobabiloba!! HuperzineHuperzine AA!! PhosphatidylPhosphatidyl serineserine!! CDPCDP--cholinecholine!! IdebenoneIdebenone

Dietary modificationDietary modification

!! Moderate wine consumption, reduced saturated fats, Moderate wine consumption, reduced saturated fats, and reduced total caloric intake are correlated with and reduced total caloric intake are correlated with reduced risk of developing Alzheimer’s reduced risk of developing Alzheimer’s

!! Excess caloric intake and high fat intake promote Excess caloric intake and high fat intake promote formation of damaging free radicals that cause many formation of damaging free radicals that cause many neuropathologicalneuropathological changes in the brain changes in the brain

!! A metaA meta--analysis of findings from 18 communityanalysis of findings from 18 community--wide wide studies concluded that the risk of Alzheimer’s disease studies concluded that the risk of Alzheimer’s disease increased linearly at a rate of 0.3% with every 100 increased linearly at a rate of 0.3% with every 100 calorie increase in daily intake (Grant 1997). calorie increase in daily intake (Grant 1997).

Dietary modificationDietary modification

!! Average daily fat consumption was highly correlated Average daily fat consumption was highly correlated with increased risk of developing dementia. with increased risk of developing dementia.

!! Fish consumption was the Fish consumption was the only specific dietaryonly specific dietary factorfactorassociated with a measurable reduction in the risk of associated with a measurable reduction in the risk of developing Alzheimer’s disease. developing Alzheimer’s disease.

!! Caution:Caution: Consuming over 2Consuming over 2--4 glasses/day increases 4 glasses/day increases the risk of dementiathe risk of dementia

!! Caution:Caution: Elderly people should be cautioned about Elderly people should be cautioned about excessive alcohol consumptionexcessive alcohol consumption

Exercise Exercise

!! Regular physical exercise in healthy elderly individuals Regular physical exercise in healthy elderly individuals significantly reduces the risk of all categories of significantly reduces the risk of all categories of dementia dementia

!! Note: Note: exercise is probably not an effective intervention exercise is probably not an effective intervention after the onset of dementiaafter the onset of dementia

!! Caution:Caution: individuals who have been sedentary or who individuals who have been sedentary or who have a chronic pain syndrome or a major medical illness have a chronic pain syndrome or a major medical illness should be evaluated by a physician before starting a should be evaluated by a physician before starting a rigorous exercise program rigorous exercise program

Exercise Exercise

!! Physical exercise increases levels of brainPhysical exercise increases levels of brain--derived derived neurotrophicneurotrophic factor (BDNF), probably enhancing factor (BDNF), probably enhancing neural plasticity and new synapse formation (neural plasticity and new synapse formation (CotmanCotman2000). 2000).

!! Over 2,000 physically nonOver 2,000 physically non--impaired men aged 71 to 93 impaired men aged 71 to 93 years were followed with routine neurological years were followed with routine neurological assessments at two year intervals starting in 1991 assessments at two year intervals starting in 1991 (Abbott 2004). At the end of the study period, men (Abbott 2004). At the end of the study period, men who walked less than a quarter of a mile daily had an who walked less than a quarter of a mile daily had an almost twoalmost two--fold greater probability of being diagnosed fold greater probability of being diagnosed with any category of dementia compared with men who with any category of dementia compared with men who walked at least two miles each day. walked at least two miles each day.

Exercise Exercise

!! BiBi--annual mailed surveys over ten years showed that annual mailed surveys over ten years showed that elderly women aged 70 to 81 years who engaged in elderly women aged 70 to 81 years who engaged in regular vigorous physical activity were significantly less regular vigorous physical activity were significantly less likely to have been diagnosed with dementia compared likely to have been diagnosed with dementia compared to women with more sedentary lifestyles (to women with more sedentary lifestyles (WeuveWeuve 2004). 2004).

!! A randomized controlled trial showed that regular daily A randomized controlled trial showed that regular daily exercise in moderately demented individuals receiving exercise in moderately demented individuals receiving inin--home care reduces depressed mood, but does home care reduces depressed mood, but does not not improve cognitive functioning (Teri 2003). improve cognitive functioning (Teri 2003).

Ginkgo Ginkgo bilobabiloba

!! Standardized extracts ofStandardized extracts of Ginkgo Ginkgo bilobabiloba are are effective treatments of mild to moderate effective treatments of mild to moderate symptoms of Alzheimer’s disease and symptoms of Alzheimer’s disease and vascular dementiavascular dementia

!! Most commercially available Ginkgo Most commercially available Ginkgo preparations are standardized to two bioactive preparations are standardized to two bioactive constituents: 24% constituents: 24% flavoneflavone glycosides, and 6% glycosides, and 6% terpenoidsterpenoids. .

Ginkgo Ginkgo bilobabiloba

!! The The flavonoidflavonoid constituent functions as a strong anticonstituent functions as a strong anti--oxidant and is believed to have a general oxidant and is believed to have a general neuroprotectiveneuroprotective effect (effect (SeifSeif--ElEl--NasrNasr 1995). 1995).

!! Animal studies have confirmed that the Animal studies have confirmed that the terpenoidterpenoidfraction antagonizes platelet activating factor (PAF), fraction antagonizes platelet activating factor (PAF), facilitating postfacilitating post--stroke recovery through vascular restroke recovery through vascular re--perfusion by decreasing thrombosis and nerve cell perfusion by decreasing thrombosis and nerve cell death associated with cerebral ischemia (Smith 1996). death associated with cerebral ischemia (Smith 1996).

Ginkgo Ginkgo bilobabiloba

!! Therapeutic doses range from 40mg three times Therapeutic doses range from 40mg three times daily up to 600mg/day in divided doses, and daily up to 600mg/day in divided doses, and sustained improvement in cognitive functioning sustained improvement in cognitive functioning is usually observed following three month of is usually observed following three month of treatment. treatment.

Ginkgo Ginkgo bilobabiloba——safety issuessafety issues!! Informed consent should be documented in the patient’s Informed consent should be documented in the patient’s

chart at the time of the consultation when chart at the time of the consultation when G. G. bilobabiloba is is discussed.discussed.

!! Because of its strong antiBecause of its strong anti--platelet aggregation factor (PAF) platelet aggregation factor (PAF) profile, profile, G. G. bilobabiloba extract increases the risk of bleeding, and extract increases the risk of bleeding, and concurrent use should be avoided in patients taking aspirin, concurrent use should be avoided in patients taking aspirin, warfarinwarfarin, heparin or other medications that interfere with platelet , heparin or other medications that interfere with platelet activity and increase bleeding timeactivity and increase bleeding time

!! G. G. bilobabiloba preparations should be discontinued at least two weeks preparations should be discontinued at least two weeks prior to surgery. prior to surgery.

!! G. G. bilobabiloba preparations have been reported to result in elevation preparations have been reported to result in elevation of hepatic enzymesof hepatic enzymes

!! case reports of case reports of possiblepossible serotonin syndrome when serotonin syndrome when G. G. bilobabiloba is is taken with taken with SSRIsSSRIs. .

!! Mild transient adverse effects include upset stomach, dizziness Mild transient adverse effects include upset stomach, dizziness and headaches.and headaches.

Ginkgo Ginkgo bilobabiloba!! Systematic reviews and metaSystematic reviews and meta--analyses of double blind analyses of double blind

studies show that standardized preparations of studies show that standardized preparations of Ginkgo Ginkgo bilobabiloba in doses between 120 and 600mg/day taken over in doses between 120 and 600mg/day taken over durations of several weeks to one year result in durations of several weeks to one year result in consistent modest improvements in memory, general consistent modest improvements in memory, general cognitive functioning, and activities of daily living in cognitive functioning, and activities of daily living in mild to moderate cases of both Alzheimer’s dementia mild to moderate cases of both Alzheimer’s dementia and multiand multi--infarct dementia that are equivalent to infarct dementia that are equivalent to improvements seen with improvements seen with donepezildonepezil ™, a conventional ™, a conventional cholinesterase inhibitor (Wong 1998; Ernst 1999; cholinesterase inhibitor (Wong 1998; Ernst 1999; KanowskiKanowski 1997; 1997; OkenOken 1998; Le Bars 1997).1998; Le Bars 1997).

Ginkgo Ginkgo bilobabiloba

!! a more recent metaa more recent meta--analysis pointed out analysis pointed out inconsistent findings of three trials based on inconsistent findings of three trials based on more rigorous methodologies and commented more rigorous methodologies and commented on research design problems in those studies on research design problems in those studies and earlier trials including the absence of and earlier trials including the absence of standardized preparations and the use of standardized preparations and the use of different dementia rating scales across studies different dementia rating scales across studies ((BirksBirks 2004). 2004).

HuperzineHuperzine--AA

!! HuperzineHuperzine--A (A (HuperziaHuperzia serrataserrata) may be more ) may be more effective than conventional cholinesterase effective than conventional cholinesterase inhibitors for ageinhibitors for age--related memory loss and related memory loss and dementiadementia

!! Important ingredient of many compound herbal Important ingredient of many compound herbal formulas used in Chinese medicine to treat formulas used in Chinese medicine to treat cognitive impairment related to normal aging cognitive impairment related to normal aging

HuperzineHuperzine--AA

!! HuperzineHuperzine--A reversibly inhibits A reversibly inhibits acetylcholinesteraseacetylcholinesterase, , and may also slow production of nitric oxide in the and may also slow production of nitric oxide in the brain, reducing agebrain, reducing age--related related neurotoxicityneurotoxicity (Zhao 2002). (Zhao 2002).

!! Findings from animal studies suggest that Findings from animal studies suggest that HuperzineHuperzine--A A may be a more potent and more specific inhibitor of may be a more potent and more specific inhibitor of acetylcholinesteraseacetylcholinesterase compared to available conventional compared to available conventional cholinesterase inhibitors. cholinesterase inhibitors.

HuperzineHuperzine--AA

!! Controlled trials show consistent beneficial Controlled trials show consistent beneficial effects in both ageeffects in both age--related memory loss (related memory loss (ieiebenign senescent forgetfulness) and Alzheimer’s benign senescent forgetfulness) and Alzheimer’s disease at doses between 200 and 400 disease at doses between 200 and 400 micrograms/day (Wang 1994; micrograms/day (Wang 1994; ZuckerZucker 1999). 1999).

!! Infrequent adverse effects include transient Infrequent adverse effects include transient dizziness, nausea and diarrhea. dizziness, nausea and diarrhea.

PhosphatidylPhosphatidyl serineserine

!! PhosphatidylPhosphatidyl serine is beneficial for ageserine is beneficial for age--related related cognitive decline and Alzheimer’s diseasecognitive decline and Alzheimer’s disease

!! PhosphatidylPhosphatidyl serine is one of the most important serine is one of the most important phospholipids in the brain and is an essential phospholipids in the brain and is an essential component of nerve cell membranes. component of nerve cell membranes.

!! Believed to enhanced fluidity of nerve cell membranes, Believed to enhanced fluidity of nerve cell membranes, indirectly increasing brain levels of many important indirectly increasing brain levels of many important neurotransmitters (neurotransmitters (PepeuPepeu 1996). 1996).

PhosphatidylPhosphatidyl serineserine

!! The findings of many large doubleThe findings of many large double--blind blind placeboplacebo--controlled studies confirm improved controlled studies confirm improved global functioning and memory in Alzheimer’s global functioning and memory in Alzheimer’s disease and agedisease and age--related cognitive decline at related cognitive decline at typical doses of 300mg/day (typical doses of 300mg/day (CenacchiCenacchi 1993; 1993; Crook 1991; Crook 1991; VillarditaVillardita 1987; 1987; PalmieriPalmieri 1987; 1987; AmaducciAmaducci 1988). 1988).

PhosphatidylPhosphatidyl serineserine——sources and sources and safety safety

!! BrainBrain--derived derived phosphatidylphosphatidyl serine is probably serine is probably more effective than the soymore effective than the soy--derived product derived product ((HibbelnHibbeln and Salem, 1995) possibly due to the and Salem, 1995) possibly due to the higher content in DHA, an Omegahigher content in DHA, an Omega--3 fatty acid3 fatty acid

!! HoweverHowever, recent concerns have been raised over , recent concerns have been raised over the risk of slow viruses in infected bovine tissue. the risk of slow viruses in infected bovine tissue.

CDPCDP--cholinecholine

!! CytidinediphosphocholineCytidinediphosphocholine (CDP(CDP--cholinecholine) has ) has beneficial effects on memory and behavior in postbeneficial effects on memory and behavior in post--stroke patients and possibly also in TBI and stroke patients and possibly also in TBI and Alzheimer’s diseaseAlzheimer’s disease

!! Like AcetylLike Acetyl--LL--carnitinecarnitine, CDP, CDP--cholinecholine increases increases mitochondrial energy production and in many mitochondrial energy production and in many parts of the world is used to treat cognitive parts of the world is used to treat cognitive impairments resulting from neurodegenerative impairments resulting from neurodegenerative diseasesdiseases

CDPCDP--cholinecholine

!! CDPCDP--cholinecholine 500mg to 1000mg/day improves overall 500mg to 1000mg/day improves overall energy metabolism in the brain, increases dopamine and energy metabolism in the brain, increases dopamine and norepinephrinenorepinephrine ((SecadesSecades 1995) and enhances short1995) and enhances short--term memory in Alzheimer’s patients (Alvarez 1997).term memory in Alzheimer’s patients (Alvarez 1997).

!! Two Cochrane systematic reviews concluded that CDPTwo Cochrane systematic reviews concluded that CDP--cholinecholine has consistent positive effects on the rate of has consistent positive effects on the rate of recovery in postrecovery in post--Stroke patients, and in elderly Stroke patients, and in elderly individuals who are cognitively impaired due to individuals who are cognitively impaired due to cerebrovascularcerebrovascular disease (disease (MitkaMitka 2002; 2002; FioravantiFioravanti 2004). 2004).

CDPCDP--cholinecholine

!! There is preliminary but promising evidence of a There is preliminary but promising evidence of a beneficial effect following traumatic brain injury beneficial effect following traumatic brain injury ((SpiersSpiers 1999). 1999).

!! The findings of one small study suggest a The findings of one small study suggest a possible effect of CDPpossible effect of CDP--cholinecholine 1000mg/day in 1000mg/day in the early stages of Alzheimer’s disease (Alvarez the early stages of Alzheimer’s disease (Alvarez 1999). 1999).

IdebenoneIdebenone!! IdebenoneIdebenone may be more effective than may be more effective than

conventional treatments of Alzheimer’s disease conventional treatments of Alzheimer’s disease !! Naturally occurring substance that is related to Naturally occurring substance that is related to

ubiquinoneubiquinone (coenzyme Q10), and like Co(coenzyme Q10), and like Co--Q10 also Q10 also increases intraincreases intra--cellular energy production in cellular energy production in mitochondria. mitochondria.

!! IdebenoneIdebenone 360mg/day may be more effective than 360mg/day may be more effective than tacrinetacrine ((GutzmannGutzmann 2002) and possibly other 2002) and possibly other cholinesterase inhibitors for cognitive impairment in cholinesterase inhibitors for cognitive impairment in mild to moderate cases of Alzheimer’s dementia mild to moderate cases of Alzheimer’s dementia ((GutzmannGutzmann 1998). 1998).

!! Preliminary evidence from animal studies suggests that Preliminary evidence from animal studies suggests that combining combining IdebenoneIdebenone with with vinpocetinevinpocetine accelerates accelerates recovery following Stroke (Ishihara 1989).recovery following Stroke (Ishihara 1989).

Provisional nonProvisional non--conventional treatmentsconventional treatments

!! Dietary modificationDietary modification!! AcetylAcetyl--LL--carnitinecarnitine!! KamiKami--untanuntan--toto (KUT)(KUT)!! RhodiolaRhodiola rosearosea!! ChotoChoto--sansan!! DHEADHEA!! B vitaminsB vitamins

Dietary modificationDietary modification

!! Evidence from epidemiologic studies suggests Evidence from epidemiologic studies suggests that regular intake of foods rich in Omegathat regular intake of foods rich in Omega--3 3 fatty acids may be inversely related to cognitive fatty acids may be inversely related to cognitive impairment or the rate of overimpairment or the rate of over--all cognitive all cognitive decline in nondecline in non--demented elderly individuals.demented elderly individuals.However, findings to date are inconclusive.However, findings to date are inconclusive.

!! Life style choices confound findingsLife style choices confound findings

AcetylAcetyl--LL--carnitinecarnitine

!! AcetylAcetyl--LL--carnitinecarnitine (ALC) occurs naturally in the brain (ALC) occurs naturally in the brain and liver. and liver.

!! ALC may stabilize nerve cell membranes, stimulate ALC may stabilize nerve cell membranes, stimulate synthesis of acetylcholine, and increase the efficiency of synthesis of acetylcholine, and increase the efficiency of mitochondrial energy production. mitochondrial energy production.

!! Commonly used to treat cognitive impairments related Commonly used to treat cognitive impairments related to dementia or other neurodegenerative diseases, to dementia or other neurodegenerative diseases,

!! Findings of human clinical trials are inconsistent Findings of human clinical trials are inconsistent ((PettegrewPettegrew 2000). 2000).

KamiKami--UntanUntan--toto (KUT)(KUT)

!! KamiKami--UntanUntan--toto (KUT) is probably an effective treatment of (KUT) is probably an effective treatment of ageage--related cognitive decline and early or mild Alzheimer’s related cognitive decline and early or mild Alzheimer’s diseasedisease

!! Compound herbal formula consisting of 13 different herbs used Compound herbal formula consisting of 13 different herbs used in Japanese traditional healing (in Japanese traditional healing (KampoKampo) to treat cognitive ) to treat cognitive impairment and frank dementia, as well as other psychiatric impairment and frank dementia, as well as other psychiatric symptoms. symptoms.

!! KUT increases brain levels of both nerve growth factor (NGF) KUT increases brain levels of both nerve growth factor (NGF) and and cholinecholine acetyltransferaseacetyltransferase ((ChATChAT), the enzyme that makes ), the enzyme that makes acetylcholine (Yabe 1996; Yabe 1996/1997). acetylcholine (Yabe 1996; Yabe 1996/1997).

!! KUT protects against cognitive impairment due to thiamin KUT protects against cognitive impairment due to thiamin deficiency in mice suggesting possible beneficial effects in deficiency in mice suggesting possible beneficial effects in delirium tremens and other syndromes of cognitive impairment delirium tremens and other syndromes of cognitive impairment related to thiamin deficiency (related to thiamin deficiency (NakagawasaiNakagawasai 2004). 2004).

RhodiolaRhodiola rosearosea

!! Golden RootGolden Root ((RhodiolaRhodiola rosearosea)) may enhance may enhance memory in healthy adults and speed up recovery memory in healthy adults and speed up recovery following traumatic brain injuryfollowing traumatic brain injury

!! Subject of intense research interest in the former Subject of intense research interest in the former Soviet Union because of its use as an Soviet Union because of its use as an adaptogenadaptogenor performance enhancer in athletes, soldiers or performance enhancer in athletes, soldiers and cosmonauts. and cosmonauts.

RhodiolaRhodiola rosearosea

!! Psychiatric benefits are probably related to increased Psychiatric benefits are probably related to increased dopamine, serotonin and dopamine, serotonin and norepinephrinenorepinephrine ((PetkovPetkov1990), and include improved memory, increased mental 1990), and include improved memory, increased mental stamina, and a general calming effect. stamina, and a general calming effect.

!! Results from open studies suggest that Golden root Results from open studies suggest that Golden root 500mg improves overall mental performance and 500mg improves overall mental performance and stamina in normal individuals (stamina in normal individuals (SpasovSpasov 2000), and may 2000), and may accelerate return to normal cognitive functioning accelerate return to normal cognitive functioning following traumatic brain injury. following traumatic brain injury.

ChotoChoto--sansan!! ChotoChoto--san, a san, a KampoKampo herbal formula, may be herbal formula, may be

beneficial for vascular dementiabeneficial for vascular dementia!! ChotoChoto--san is a san is a kampokampo herbal formula used to treat herbal formula used to treat

symptoms associated with symptoms associated with cerebrocerebro--vascular disease. vascular disease. !! Putative mechanisms of action include activating effects Putative mechanisms of action include activating effects

at serotonin and dopamine receptors, and strong antiat serotonin and dopamine receptors, and strong anti--oxidant effects. oxidant effects.

!! Two controlled doubleTwo controlled double--blind studies showed consistent blind studies showed consistent beneficial effects in the treatment of vascular dementia, beneficial effects in the treatment of vascular dementia, including improved global functioning, improved sleep, including improved global functioning, improved sleep, reduced psychotic symptoms, and improved cognitive reduced psychotic symptoms, and improved cognitive functioning (functioning (TerasawaTerasawa 1997; Shimada 1994).1997; Shimada 1994).

DHEADHEA

!! DHEA is a precursor of testosterone and other DHEA is a precursor of testosterone and other hormones. hormones.

!! Widely used in Europe and NorthWidely used in Europe and North America to America to selfself--treat declines in cognitive functioning treat declines in cognitive functioning associated with normal aging. associated with normal aging.

!! Binds to both GABA receptors and NMDA Binds to both GABA receptors and NMDA receptors but it is unclear whether these receptor receptors but it is unclear whether these receptor affinities are related to its putative cognitive affinities are related to its putative cognitive enhancing role (enhancing role (FriessFriess 1995). 1995).

DHEADHEA!! Preliminary evidence from anecdotal reports and pilot Preliminary evidence from anecdotal reports and pilot

studies suggests that DHEA 25studies suggests that DHEA 25--50mg/day improves 50mg/day improves memory and enhances general cognitive functioning in memory and enhances general cognitive functioning in healthy adults (healthy adults (WolkowitzWolkowitz 1997). 1997).

!! Research findings are inconsistent, and negative Research findings are inconsistent, and negative findings have been reported at doses lower than findings have been reported at doses lower than 90mg/day (Wolf 1997). 90mg/day (Wolf 1997).

!! DHEA 200mg/day may improve symptoms of DHEA 200mg/day may improve symptoms of cognitive impairment in multicognitive impairment in multi--infarct dementia (Azuma infarct dementia (Azuma 1999). 1999).

!! Mild insomnia is an infrequent side effect of DHEA. Mild insomnia is an infrequent side effect of DHEA. There is no evidence that DHEA replacement doses of There is no evidence that DHEA replacement doses of 25 to 50mg/day increase the risk of prostate cancer in 25 to 50mg/day increase the risk of prostate cancer in middle aged men.middle aged men.

B vitaminsB vitamins

!! Folic acid, BFolic acid, B--12 and thiamin improve cognitive functioning 12 and thiamin improve cognitive functioning in some cases of dementiain some cases of dementia

!! Many B vitamins are essential enzyme coMany B vitamins are essential enzyme co--factors in the synthesis factors in the synthesis of neurotransmitters. of neurotransmitters.

!! Low serum levels of folic acid, niacin and thiamin are associateLow serum levels of folic acid, niacin and thiamin are associated d with cognitive impairment in general (with cognitive impairment in general (HassingHassing 1999). 1999).

!! A diet low in folic acid and B12 leads to elevated blood levels A diet low in folic acid and B12 leads to elevated blood levels of of homocysteinehomocysteine and decreased synthesis of Sand decreased synthesis of S--adenosyladenosyl methioninemethionine((SAMeSAMe), resulting in reduced synthesis of several ), resulting in reduced synthesis of several neurotransmitters critical for normal cognitive functioning. neurotransmitters critical for normal cognitive functioning.

B vitaminsB vitamins

!! Chronic dietary deficiencies of Chronic dietary deficiencies of folatefolate and Band B--12 12 ultimately manifest in moderate to severe ultimately manifest in moderate to severe degrees of cognitive impairment.degrees of cognitive impairment.

!! Clinical trials results suggest that healthy adults Clinical trials results suggest that healthy adults who take a B vitamin supplement experience who take a B vitamin supplement experience improvements in overall cognitive functioning improvements in overall cognitive functioning (Benton 1997). (Benton 1997).

B vitaminsB vitamins

!! A daily B vitamin supplement may slow deterioration of A daily B vitamin supplement may slow deterioration of cognitive functioning in mild to moderate dementia cognitive functioning in mild to moderate dementia ((PelkaPelka 1995). 1995).

!! Findings from case studies and controlled trials suggest Findings from case studies and controlled trials suggest that a large daily dose of folic acid reduces the severity that a large daily dose of folic acid reduces the severity of dementia in some cases.of dementia in some cases.

!! In a doubleIn a double--blind placeboblind placebo--controlled study depressed controlled study depressed demented patients treated with 5demented patients treated with 5--MTHF (a form of MTHF (a form of folatefolate) 50mg/day experienced significant improvements ) 50mg/day experienced significant improvements in both mood and memory after four weeks of therapy in both mood and memory after four weeks of therapy ((PasseriPasseri 1993). 1993).

Possibly effectivePossibly effective treatmentstreatments

!! AshwagondhaAshwagondha!! Lemon balm (Lemon balm (Melissa Melissa

officinalisofficinalis))!! Common sage (Common sage (Salvia Salvia

officinalisofficinalis) ) !! GinsengGinseng!! AlphaAlpha--lipoiclipoic acidacid!! CentrophenoxineCentrophenoxine (CPH)

!! TrasinaTrasina™ and ™ and MentatMentat™™!! DHEDDHED!! Regular massage therapyRegular massage therapy!! Bright light exposureBright light exposure!! EEG biofeedbackEEG biofeedback!! QigongQigong

(CPH)

AshwagondhaAshwagondha

!! AshwagondhaAshwagondha 50mg/kg may improve short 50mg/kg may improve short term memory, long term memory and executive term memory, long term memory and executive functioning in cognitively impaired individuals functioning in cognitively impaired individuals (Bhattacharya 1995) (Bhattacharya 1995)

!! Note:Note: few human trials on few human trials on AshwagondhaAshwagondha have have been publishedbeen published

Lemon balm and SageLemon balm and Sage

!! Extracts of Lemon balm and Common sage (60 Extracts of Lemon balm and Common sage (60 drops/day) may slow the rate of decline in drops/day) may slow the rate of decline in Alzheimer’s disease (Alzheimer’s disease (AkhondzadehAkhondzadeh 2003) 2003)

!! Teas made of both herbs are traditionally used Teas made of both herbs are traditionally used to enhance general cognitive functioning and to to enhance general cognitive functioning and to treat dementia treat dementia

PanaxPanax ginsengginseng

!! Ginseng may enhance memory and overall Ginseng may enhance memory and overall cognitive performance in healthy adults cognitive performance in healthy adults (Sorensen 1996; (Sorensen 1996; VoglerVogler 1999)1999)

!! Note:Note: some negative trials with Ginseng, and at some negative trials with Ginseng, and at least one reported case of mania inductionleast one reported case of mania induction

AlphaAlpha--lipoiclipoic acid (ALA)acid (ALA)

!! Animal studies suggest that ALA may enhance Animal studies suggest that ALA may enhance recovery following stroke Human case reports recovery following stroke Human case reports suggest that ALA may accelerate return of suggest that ALA may accelerate return of cognitive function after traumatic brain injurycognitive function after traumatic brain injury

!! Note:Note: a 2004 Cochrane review identified no a 2004 Cochrane review identified no controlled trials; findings on ALA in dementia controlled trials; findings on ALA in dementia are largely from case studies (Sauer 2004)are largely from case studies (Sauer 2004)

CentrophenoxineCentrophenoxine

!! CPH may improve global functioning and CPH may improve global functioning and cognitive performance in Alzheimer’s disease cognitive performance in Alzheimer’s disease ((PekPek 1989) 1989)

!! Benefits of CPH are possibly enhanced when Benefits of CPH are possibly enhanced when combined with vitamins. combined with vitamins.

!! Note:Note: beneficial findings for CPH in dementia beneficial findings for CPH in dementia are still very preliminary are still very preliminary

TrasinaTrasina™ and ™ and MentatMentat™™

!! TrasinaTrasina ™ and ™ and MentatMentat ™ are compound herbal ™ are compound herbal formulas used in formulas used in AyurvedicAyurvedic medicine to treat medicine to treat symptoms that resemble Alzheimer’s disease and symptoms that resemble Alzheimer’s disease and ageage--related cognitive impairment (related cognitive impairment (BattacharyaBattacharya1995, 1997).1995, 1997).

!! TrasinaTrasina has beneficial effects on experimental has beneficial effects on experimental animal models of Alzheimer’s disease animal models of Alzheimer’s disease (Bhattacharya 1997). (Bhattacharya 1997).

DehydroevodiamineDehydroevodiamine (DHED)(DHED)

!! DehydroevodiamineDehydroevodiamine (DHED) may be more effective (DHED) may be more effective than cholinesterase inhibitors in Alzheimer’s disease than cholinesterase inhibitors in Alzheimer’s disease

!! DHED is a biologically active constituent of DHED is a biologically active constituent of EvodiaEvodiarutaecarparutaecarpa, a plant used in traditional Korean medicine, , a plant used in traditional Korean medicine, and may prove to be more effective in the treatment of and may prove to be more effective in the treatment of ageage--related cognitive decline and Alzheimer’s disease related cognitive decline and Alzheimer’s disease than cholinesterase inhibitors (Park 1996) than cholinesterase inhibitors (Park 1996)

Massage therapyMassage therapy

!! Regular massage therapy may reduce agitated Regular massage therapy may reduce agitated behavior in demented individuals behavior in demented individuals

!! Skilled nursing homes frequently provide regular Skilled nursing homes frequently provide regular massage therapy to demented residents. massage therapy to demented residents.

!! Anecdotal evidence of calming effects and reduced Anecdotal evidence of calming effects and reduced agitation following massage. agitation following massage.

!! Findings from open trials suggest that massage Findings from open trials suggest that massage decreases agitated behavior in demented individuals decreases agitated behavior in demented individuals (Snyder 1995; Fraser 1993). (Snyder 1995; Fraser 1993).

Bright light exposure therapyBright light exposure therapy

!! Regular exposure to bright light may improve Regular exposure to bright light may improve sleep and reduce sunsleep and reduce sun--downing in demented downing in demented patientspatients

!! Bright light exposure may improve sleep and reduce Bright light exposure may improve sleep and reduce sunsun--downing in Alzheimer’s patients (downing in Alzheimer’s patients (SatlinSatlin 19921992). ).

!! HoweverHowever, findings of a Cochrane meta, findings of a Cochrane meta--analysis of analysis of studies on bright light therapy in the management of studies on bright light therapy in the management of sleep, behavior and mood in demented individuals were sleep, behavior and mood in demented individuals were inconclusive (Forbes 2004). inconclusive (Forbes 2004).

EEG biofeedbackEEG biofeedback

!! EEG biofeedback training may enhance EEG biofeedback training may enhance recovery following stroke and traumatic recovery following stroke and traumatic brain injurybrain injury

!! EEG biofeedback training, also called EEG biofeedback training, also called neurotherapyneurotherapy, employs light or sound as , employs light or sound as feedback with the goal of entraining changes in feedback with the goal of entraining changes in brain electrical activity that result in improved brain electrical activity that result in improved cognitive functioning. cognitive functioning.

EEG biofeedbackEEG biofeedback

!! Findings of a case report suggest that EEG Findings of a case report suggest that EEG biofeedback training improves the speed of biofeedback training improves the speed of cognitive rehabilitation following stroke, cognitive rehabilitation following stroke, including enhanced word finding, attention, including enhanced word finding, attention, speech and concentration (speech and concentration (RozelleRozelle 1995). 1995).

!! Findings from one small open study suggest that Findings from one small open study suggest that EEG biofeedback training may improve EEG biofeedback training may improve memory following traumatic brain injury (TBI) memory following traumatic brain injury (TBI) (Thornton 2000).(Thornton 2000).

QigongQigong

!! Regular Regular QiGongQiGong practice may normalize practice may normalize EEG activity and slow the rate of cognitive EEG activity and slow the rate of cognitive decline in Alzheimer’s diseasedecline in Alzheimer’s disease

!! 33--dimensional positron emission tomography dimensional positron emission tomography (PET) and EEG were used to examine (PET) and EEG were used to examine relationships between brain electrical activity relationships between brain electrical activity and changes in regional cerebral blood flow in a and changes in regional cerebral blood flow in a qigong practitioner (Manabu 1996). qigong practitioner (Manabu 1996).

QigongQigong

!! Findings included significant increases in high Findings included significant increases in high frequency (alpha and beta) EEG domains and frequency (alpha and beta) EEG domains and reduced slow frequency (delta) activity following reduced slow frequency (delta) activity following qigong. qigong.

!! Enhanced beta activity in the frontal lobes Enhanced beta activity in the frontal lobes following qigong practice was correlated with following qigong practice was correlated with increased cerebral blood flow in the same region increased cerebral blood flow in the same region and relatively decreased regional blood flow in and relatively decreased regional blood flow in posterior brain regionsposterior brain regions..

SummarySummary

!! PreliminaryPreliminary findings suggest that many nonfindings suggest that many non--conventional biological and energyconventional biological and energy--information information therapies reduce the severity or rate of cognitive therapies reduce the severity or rate of cognitive decline, and improve global functioning in decline, and improve global functioning in dementia, postdementia, post--stroke recovery and traumatic stroke recovery and traumatic brain injurybrain injury

!! Larger and better studies are needed to further Larger and better studies are needed to further substantiate efficacy claimssubstantiate efficacy claims

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!! A Clinical Manual of Complementary and A Clinical Manual of Complementary and Alternative Treatments in Mental HealthAlternative Treatments in Mental Health, eds. Lake , eds. Lake and Spiegel, American Psychiatric Press, Inc., expected and Spiegel, American Psychiatric Press, Inc., expected publication date Spring, 2006.publication date Spring, 2006.

!! Textbook of Integrative Mental Health Care: Textbook of Integrative Mental Health Care: Foundations and Clinical Applications,Foundations and Clinical Applications, Lake, Lake, ThiemeThieme Medical Publishers, expected publication date Medical Publishers, expected publication date Spring, 2006Spring, 2006

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