Traditional Chinese Medicine in Geriatrics, Evidences, and the Guideline

The average life span of Japanese is 90 years. So that Japan is an unprecedented super-aging society. However, healthy life span is 10 years shorter than life span. Many spend an average of 10 years in frailty. People become frail, and reached to “geriatric syndrome.”


Geriatric syndrome
Geriatric syndromes include many symptoms caused by aging, such as dementia, depression, delirium, incontinence, vertigo, falls, spontaneous bone fractures, failure to thrive, and neglect and abuse. Geriatric syndromes are associated with reduced life expectancy. To be considered a geriatric syndrome, these conditions must interfere with a person's daily life.
In ancient China, people considered this phenomenon as Qi (気) deficiency in Kidney organ (shen xu, 腎虚). Qi is energy and signaling using energy. Kidney in traditional Chinese medicine (TCM) is very different from Kidney in Western medicine. TCM kidney is somewhat base of life. Human inherits essence of life (jing, 精) from his/her parents and keeps it all his/her life. When jing runs out, people die. TCM kidney is the box keeping jing. When people become old, the jing in TCM kidney decreases, and the function of whole body goes down. This is the reason of aging and geriatric syndrome. These thoughts were written in the famous ancient medical text book Huan di nei jing (黄帝内経), written in BC 2nd ~ 1st century. That is to say, TCM had geriatric medicine in 2000 years ago. How can we keep jing in TCM kidney? People seeked the ways, from unexpected to some herbal drugs, training methods.
Here, we introduce some evidences of TCM for geriatric syndrome and clinical practice guideline from Japan Geriatrics Society. How can we treat geriatric syndrome using traditional Chinese Medicine?

Traditional Chinese medicine for behavioral and psychological symptoms of dementia (BPSD)
Behavioral and psychological symptoms of dementia (BPSD) is the serious clinical problem of dementia. Usually major tranquilizers are used, but they  cause extrapyramidal side effects. We reported that Yigan San (抑肝散) could improve BPSD without extrapyramidal side effects [3]. Mild-to-severe demented patients who had BPSD (18 men and 34 women; age 80.3 ± 9.0 [mean ± SD] years) were investigated. Participants were randomly assigned to the YGS group (n = 27) or control (drug-free) group (n = 25) and treated for 4 weeks. The Neuropsychiatric Inventory (NPI) test for the assessment of BPSD. Meanwhile, cognitive function was estimated by the Mini-Mental State Examination (MMSE), and ADL by the Barthel Index were tested at baseline and the end of the treatment. The frequency of extrapyramidal symptoms (EPS) and other adverse events were recorded. All participants in both groups completed the trial. In the control group, 11 patients required treatment with tiapride hydrochloride because of deterioration of BPSD.
Significant improvements BPSD (from 37.9 ± 16.1 to 19.5 ± 15.6, mean ± SD) ( Figure 3) and Barthel index (from 56.4 ± 34.2 to 62.9 ± 35.2) were observed in the YGS group, but not in the control group. MMSE was not changed in both groups. EPS were not observed in either group, but dizziness and impaired postural sway were observed in 6 patients treated in control group, may be caused by tiapride hydrochloride. At the same time, we also found that Yigan San could improve typical hallucination in Dementia with Lewy Bodies (DLB), as shown in Figure 4 [4].
Yigan San was developed by Xue Ji (薛己) in 16th century. He devised this recipe for emotional liability of children. But this recipe was not widely spread in China, and Japanese doctors in Edo era applied it to adults. They found that it is effective for persons who are easy to anger. I applied it to some demented patients who easily anger. Therefore, I carried out Randomized Control Trial (RCT) described above. Now then, we found 219 papers with key word "yokukansan (Japanese

Aspiration pneumonia
Pneumonia is now the 4th reason of death of Japanese, and most of them are aspiration pneumonia in the elderly. Absence or attenuation of the cough [7] and swallowing [8] reflex in elderly patients causes micro aspiration. We investigated the effects of Banxia Houpu Tang (半夏厚朴湯、BHT), on the swallowing [9] ( Figure 5) and cough [10] (Figure 6) reflexes in elderly stroke patients. Finally, we found that BHT reduced pneumonia risk in the elderly [11]. Elderly participants  who had history of aspiration pneumonia (mean age 84.0, M:F = 28:67) were randomly assigned to the BHT treatment group (n = 47) or the control group (n = 48) and took BHT or placebo for 12 months. The occurrence of pneumonia, mortality due to pneumonia, and the daily amount of self-feeding were measured. As a result, four participants in the BHT group developed pneumonia, and one of them died as a result, while 14 participants in the control group developed pneumonia, and 6 of them died. There was a significant difference between the two groups in pneumonia onset ( (Figure 7, P = .008), and a tendency toward significance in pneumonia-related mortality (P = .05). The relative risk of pneumonia in the BHT group compared with the control group was 0.51 (95% confidence interval (CI 0.27-0.84, P = .008) and that of death from pneumonia was 0.41 (95% CI = 0.10-1.03, P = .06). No adverse events were observed from treatment with BHT. The BHT group was able to maintain self-feeding better than the control group (P = .006). Very recently, the suppressing effect of BHT for aspiration pneumonia was confirmed by double blind RCT [12].  BHT was described in Jin kui Yao lue (金匱要略) by Zhan Zhong jing (張仲景) in 2nd century. It contains Pinelliae Tuber, Hoelen, Magnoliae Cortex, Perillae Herba, and Zingiberis Rhizoma. It is written that when women feel something block her throat, try this recipe. Now it is considered as throat dysesthesia, and BHT is widely applied to neurosis, depression, and psychophysiological disorder.

Chronic constipation
There were over 1.34 million patients suffering from cerebrovascular diseases in 2008 reported by Ministry of Health, Labour and Welfare in Japan. Poststroke patients often cause constipation. Stratified by stroke severity on the National Institutes of Health Stroke Scale, the incidence of constipation in poststroke patients were reported from 38.9% to 88.2% [13]. Poststroke patients with functional constipation, assessed by the Rome III criteria were recruited in a study on the effects of the traditional Chinese medicine Da Jian Zhong Tang (大建中湯) on constipation. Thirty-four patients (17 men and 17 women; mean age: 78.1 ± 11.6 years) were randomly assigned to 2 groups; all patients received conventional therapy for constipation, and patients in the Da Jian Zhong Tang group received 15 g/day of Da Jian Zhong Tang for 4 weeks. We recorded Constipation Scoring System (CSS) points and the Gas Volume Score (GVS) (the measure of the intestinal gas volume calculated from plain abdominal radiographs) before and after a 4-week observation period. The total score on the CSS improved significantly in the Da Jian Zhong Tang group compared to the control (p < 0.01) (Figure 8). In addition, some CSS subcategories (defecation frequency, feeling of incomplete evacuation, and need for enema/disimpaction) significantly improved in the Da Jian Zhong Tang group (p < 0.01, p = 0.049, and p = 0.03, respectively). The GVS was also significantly reduced in the Da Jian Zhong Tang group (Figure 9, p = 0.03) [14]. Da Jian Zhong Tang was also described in Jin kui Yao lue (金匱要略) by Zhan Zhong jing (張仲景) in 2nd century. Zhan Zhong jing wrote that this recipe was effective for patients who felt severe abdominal pain, abdominal coldness and gut sharply moved. It is very

Guideline
Concerning these evidences, Japan Geriatric Society treated traditional medicine as the independent chapter in their guideline 2015 [15]. As a result, Yigan San,  Banxia houpu Tang, Da Jian Zhong Tang, Buzhongyiqi Tang (補中益気湯), and Ma Zi Ren Wan (麻子仁丸) covering by Japanese national insurance, were reviewed and found to have a high Quality of evidence for the elderly ( Table 1). In these 5 recipes, I already explained Yigan San, Banxia houpu Tang, Da Jian Zhong Tang above. Buzhongyiqi Tang was developed by Li Dong yuan (李東垣) in 13th century. He promoted the theory that disease results from the inhibition of digestive functions. In his book Pi wei lun (脾胃論), he wrote as below. Mongolian army attacked his country and closed in the capital many months. At that time, severe infectious disease spread in the capital and many people died. Doctors could not treat the disease. Then he thought that people went down because of food deficiency. Their digestion deteriorated and immune function declined so that infectious disease did not recover. Then he developed Buzhongyiqi Tang and treated many patients. Buzhongyiqi Tang was assessed in two small, open labeled RCTs [16,17], the findings of which suggested that it improved systemic inflammation and nutritional status in elderly patients with chronic obstructive pulmonary disease and reduced systemic inflammation. It represents a unique therapeutic strategy to improve nutritional status and control chronic inflammation, something lacking in Western medicine. Buzhongyiqi Tang contains Astragali radix, Atractylodis Lanceae Rhizoma, Ginseng Radix, Angelicae radix, Bupleuri Radix, Cimicifugae Rhizoma, and Zingiberis Rhizoma. Ma Zi Ren Wan (麻子仁丸) is purgative, very easy to use for the elderly. It was described in 2 books, Jin kui Yao lue and Shang ha lun (傷寒論), both written by Zhang Zhong jin. It contains Rhei Rhizoma, Aurantii Fructus Immaturus, Armeniacae Semen, Magnoliae Cortes, Paeoniae Radix, and Cannabidis Semen. The effect as purgative was proved the double blinded RCT [18].

Conclusion
As mentioned above, evidences of traditional medicine for geriatrics accumulated little by little, and a part of it is accepted modern medical doctors. Systematic education for traditional medicine and medical care needed.
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