ORIGINAL RESEARCH ARTICLE

Management of Cognitive Determinants in Senile Dementiaof Alzheimer’s Type: Therapeutic Potential of a Novel PolyherbalDrug Product

Ananya Sadhu • Prabhat Upadhyay • Aruna Agrawal •

Kaliappan Ilango • Dipankar Karmakar • Gur Prit Inder Singh •

Govind Prasad Dubey

� Springer International Publishing Switzerland 2014

Abstract

Background and Objective The enigmatic etiology of

neurodegenerative diseases poses a challenge for the

development of novel and efficient drugs. The objective of

the present study was to evaluate the efficacy of a polyherbal

(test) formulation on cognitive functions, inflammatory

markers and oxidative stress in healthy elderly as well as

senile dementia of Alzheimer’s type (SDAT) patients.

Method A randomized double-blind placebo- and active-

controlled clinical trial was performed in healthy elderly

subjects and SDAT patients with an age range of

60–75 years. The polyherbal test formulation along with a

placebo was given to healthy elderly subjects while the

SDAT patients received either the test formulation con-

taining extracts of Bacopa monnieri (whole plant), Hip-

pophae rhamnoides (leaves and fruits) and Dioscorea

bulbifera (bulbils) at a dose of 500 mg or donepezil drug

(Aricept) at a dose of 10 mg, twice daily, for a period of

12 months. After every three months, cognitive functions

were assessed by determining the mini mental state

examination (MMSE) score, digital symbol substitution

(DSS; subtest of the Wechsler Adult Intelligence Scale—

Revised), immediate and delayed word recall (digital

memory apparatus—Medicaid systems, Chandigarh,

India), attention span (Attention Span Apparatus—Medic-

aid systems, Chandigarh, India), functional activity ques-

tionnaire (FAQ) and depression (geriatric depression scale)

scores. Further inflammatory markers and level of oxida-

tive stress were analyzed using standard biochemical tests.

Results The trial was performed in 109 healthy subjects

and 123 SDAT patients of whom 97 healthy subjects and

104 SDAT patients completed the study. Administration of

the test formulation for a period of 12 months was effective

in improving cognitive functions in the SDAT patients,

when compared to the donepezil-treated group, as deter-

mined by the DSS (38.984 ± 3.016 vs 35.852 ± 4.906,

P = 0.0001), word recall immediate (3.594 ± 1.003 vs

2.794 ± 0.593, P \ 0.0001) and attention span (4.918 ±

1.239 vs 4.396 ± 0.913, P = 0.0208) scores. A significant

improvement in the FAQ (11.873 ± 2.751 vs

9.801 ± 1.458, P \ 0.0001) and depression (16.387 ±

2.116 vs 21.006 ± 2.778, P \ 0.0001) scores was also

observed, whereas no significant differences were observed

in the MMSE and word recall delayed scores. The level of

inflammation and oxidative stress was markedly reduced in

the SDAT patients treated with the test formulation when

compared to the donepezil-treated group indicating a likely

mechanism of action of the test formulation (homocysteine

30.22 ± 3.87 vs 44.73 ± 7.11 nmol/L, P \ 0.0001;

C-reactive protein [CRP] 4.751 ± 1.149 vs 5.887 ±

1.049 mg/L, P \ 0.0001; tumour necrosis factor alpha

[TNF–a] 1139.45 ± 198.87 vs 1598.77 ± 298.52 pg/ml,

P \ 0.0001; superoxide dismutase [SOD]

A. Sadhu (&) � P. Upadhyay � G. P. Dubey

Collabrative programme, Institute of Medical Science, Banaras

Hindu University, Varanasi, India

e-mail: ananya.s.84@gmail.com

A. Agrawal

Department of Kriya Sharir, Faculty of Ayurveda, IMS, BHU,

Varanasi, India

K. Ilango

Interdisciplinary School of Indian System of Medicine (ISISM),

SRM University, Kattankulathur 603203, Tamil Nadu, India

D. Karmakar

Arvind Remedies Ltd., 190, Poonamallee high road,

Aminjikarai, Chennai 600084, Tamil Nadu, India

G. P. I. Singh

Adesh University, Barnala Road, Bathinda, Punjab, India

Clin Drug Investig

DOI 10.1007/s40261-014-0235-9

1145.92 ± 228.75 vs 1296 ± 225.72 U/g Hb, P = 0.0013;

glutathione peroxidase [GPx] 20.78 ± 3.14 vs 25.99 ±

4.11 U/g Hb, P \ 0.0001; glutathione [GSH] 9.358 ±

2.139 vs 6.831 ± 1.139 U/g Hb, P \ 0.0001; thiobarbitu-

ric acid reactive substances [TBARS] 131.62 ± 29.68 vs

176.40 ± 68.11 nmol/g Hb, P \ 0.0001). Similarly, when

healthy elderly subjects treated with the test formulation

for 12 months were compared to the placebo group, a

significant (P \ 0.001) improvement in cognitive measures

(MMSE, DSS, word recall delayed but not immediate,

attention span, FAQ and depression scores) and a reduction

in inflammation (reduction in homocysteine, CRP, IL-6

and TNF-a levels) and oxidative stress levels (reduction in

SOD, GPx and TBARS and increase in GSH) was

observed. This indicated a protective effect of the test

formulation in managing cognitive decline associated with

the ageing process.

Conclusion The results of this study demonstrate the

therapeutic potential of this novel polyherbal formulation

for the management and treatment of SDAT.

Key Points

Administration of test formulation containing

extracts of Bacopa monnieri (whole plant),

Hippophae rhamnoides (leaves and fruits) and

Dioscorea bulbifera (bulbils) in both normal elderly

subjects and SDAT patients after 12 months of

treatment demonstrated significant improvements in

various cognitive and neuropsychiatric measures like

mini mental state examination (MMSE) score, digital

symbol substitution (DSS; subtest of the Wechsler

adult intelligence scale—revised), immediate and

delayed word recall, attention span, functional

activity questionnaire (FAQ) and depression

(geriatric depression scale) scores.

This was accompanied by a reduction in

inflammation and oxidative stress as determined by

the measurement of various markers such as SOD,

GPx, GSH, TBARS, IL-6, TNF-a, CRP and

homocysteine in the blood plasma.

These findings suggest that the test formulation is a

safe novel polyherbal drug product and has immense

therapeutic potential for the management and

treatment of neurodegenerative disorders. However,

in order to demonstrate the efficacy of the drug,

further studies are needed to analyze the levels of

CNS and brain biomarkers of neurodegeneration

along with Phase III clinical trials to explore and

assess the disease modifying potential of the drug.

1 Introduction

Neurodegeneration is defined by the progressive loss of

structure or function and death of neurons [1]. Neurode-

generative diseases are highly debilitating with a serious

detrimental impact on social, economic, and health con-

ditions, including family life. Such diseases often lead to

severe morbidity and even death. Neurodegeneration can

be found from the molecular to systemic levels of neuronal

circuitry. Defective energy metabolism, excitotoxicity and

oxidative damage have been implicated as crucial factors

for the manifestation of neurodegeneration [2, 3]. These

disorders can either be hereditary or sporadic leading to

progressive nervous system dysfunction. More than 600

disorders severely affect the nervous system, resulting in

the atrophy of central and peripheral structures of the

nervous system. Diseases such as Parkinson’s disease,

Huntington’s disease, Alzheimer’s disease (AD) and other

dementias, brain cancer, degenerative nerve diseases,

encephalitis, epilepsy, genetic brain disorders, head and

brain malformations, prion diseases, and others, occur as a

result of neurodegenerative processes [4].

The advent of modern healthcare facilities in the past

century has contributed towards a longer and healthier

lifespan of people. This has and will result in an increase in

the world’s aged population and consequently in an

increase in the number of people with non-communicable

diseases, including dementia. AD is the most common

form of dementia and has been estimated to contribute

towards 60–70 % of cases [5, 6]. In 2010, it was estimated

that the total number of people suffering from dementia

worldwide was 35.6 million and is projected to nearly

double every 20 years, to 65.7 million in 2030 and 115.4

million in 2050 [7]. The total number of new cases of

dementia each year worldwide is nearly 7.7 million,

implying one new case every four seconds. The greatest

risk for dementia is ageing [8]. Dementia in the population

older than 65 years of age is referred to as senile dementia.

In total, approximately 7 % of the population older than

65 years of age and 30 % of people older than 80 years are

thought to be affected by senile dementia of Alzheimer’s

type (SDAT) [9]. In India, since the population is under-

going a demographic transition, age-related diseases like

dementia are on the rise The Dementia India report in 2010

estimated that the number of people with dementia in India

is around 3.7 million and this number is set to double in the

next 20 years [10]. The disease manifests itself by dis-

turbing multiple higher cortical functions, including

memory, thinking, orientation, comprehension, calculation,

learning capacity, language and judgement [11–13].

The cause and progression of AD is not well understood.

Research identifying modifiable risk factors of dementia is

A. Sadhu et al.

in its infancy. Several studies show that the disease is

associated with plaques and tangles in the brain [14].

Current treatments only help with the symptoms of the

disease and there are no available treatments that can stop

or reverse its progression [15, 16]. As of 2014, more than

1,000 clinical trials have been, or are being, conducted to

test various compounds in AD [17]. In the meantime, pri-

mary prevention is mainly focused on mental stimulation,

exercise and a balanced diet as ways to delay cognitive

symptoms (though not brain pathology) in healthy older

individuals [18]. Since the aged population is increasing,

government, policy-makers and other stakeholders need to

address the impact of dementia as an increasing threat to

global health.

For thousands of years the traditional system of Indian

medicine has promoted the therapeutic potential of several

medicinal plants for the treatment and management of

neurodegenerative diseases such as AD, Parkinson’s,

dementias and other neuronal disorders. In Ayurveda, an

approach for the prevention and treatment of degenerative

diseases is known as Rasayana, and involves the use of

polyherbal preparations as rejuvenators or brain tonic [19].

Very few studies have been done to investigate the mode of

action of such formulations and to utilize ancient wisdom

for the development of novel therapeutics. In this study,

three plants namely, Bacopa monnieri, Hippophae

rhamnoides and Dioscorea bulbifera, with properties that

have a direct effect on learning and memory have been

selected to develop a novel polyherbal formulation for the

treatment and amelioration of neurodegenerative disorders

like SDAT.

B. monnieri Linn or Brahmi, is a plant in the family

Scrophulariaceae. It has been used in the Ayurvedic sys-

tem of medicine for centuries and is claimed to act as a

nerve tonic. Extracts of the plant have been extensively

used for the treatment of various neurological and neuro-

psychiatric diseases [20]. In the present formulation, an

extract of the arial part of the plant, especially stems and

leaves has been used. Bioactive molecules like bacoside

present in the extract act on different receptors responsible

for memory and cognition. Several studies have shown that

B. monnieri acts on the cholinergic system (prevents/slows

down the loss of acetylcholine), and regulates the glu-

tametergic and GABAergic receptors, thereby preventing

cognitive decline [21]. Positive effects of the plant towards

ameliorating neuroinflammation and promoting healthy

brain ageing have also been reported [22–24].

H. rhamnoides, belongs to the family Elaeagnaceae, and

is commonly known as seabuckthorn. An extract of the

leaves and fruit pulp has been used in this polyherbal

formulation. The fruit of H. rhamnoides is rich in different

flavonoids like vitamin P and quercetin, contains water-

and fat-soluble vitamins along with essential amino acids,

folic acid, various fatty acids, phytosterols, alpha tocoph-

erol and phenolic compounds. Studies have shown that the

fruit pulp extract has a potent anti-oxidant property [25],

which helps in protecting neurons from oxidative damage

that occurs for a variety of reasons. The high concentration

of folic acid in this plant can help in reducing elevated

levels of homocysteine, which is a marker for neurode-

generation [25, 26]. H. rhamnoides has also been shown to

target dopaminergic, serotonergic, and noradrenergic

receptors [27, 28].

D. bulbifera is a member of the Dioscoraceae family.

Tubers of Dioscorea have been used throughout the world

as a food and herbal medicine. The extract of the bulbil of

the plant was used in this formulation. D. bulbifera extracts

have shown hypolipidemic, anti-inflammatory, anti-hyper-

glycaemic and anti-obesity properties along with alpha-

glucosidase, amylase and lipase inhibitory effects, which

may help prevent neurodegeneration caused by hyper-

glycaemia, hyperlipoproteinaemia and obesity. The targets

of action are suggested to be pro-inflammatory cytokines-

CRP, TNF-a, IL-6, adipokines, adiponectin, leptin, resistin,

gherlin, and hyperinsulinaemia. Pharmacologically active

components of the Dioscorea species include diosgenin,

which is a steroidal saponin, and dioscin, a form of dios-

genin with sugars attached. Studies suggest that dietary

diosgenin may lower plasma cholesterol levels, reduce

blood sugar and decrease inflammation [29, 30].

The polyherbal formulation described here, an inter-

vention based on the traditional knowledge of Ayurvedic

system of medicine, is an attempt to provide a safe, effi-

cacious and cost-effective herbal drug to target multiple

aspects of neurodegeneration [31]. Although the precise

mechanisms of action of such herbal drugs have yet to be

determined, it is well known that this group of plants

possess strong antioxidant, anti-inflammatory and neuro-

protective properties (Table 1). In order to establish the

efficacy and potency of this novel formulation for the

prevention and treatment of SDAT, a double-blind pla-

cebo- and active-controlled randomized clinical trial was

carried out for a period of 12 months.

2 Subjects and Methods

2.1 Test Formulation Preparation

Film-coated tablets (500 mg) were prepared from an

extract containing a combination of three plants namely, B.

monnieri, H. rhamnoides and D. bulbifera combined with

excipients such as dibasic calcium phosphate and micro-

crystalline cellulose. The dried whole plant of B. monnieri,

dried fruit and leaves of H. rhamnoides and dried tuber of

D. bulbifera were utilized for extraction. The extraction

Management of Cognitive Determinants in Senile Dementia

was performed at a temperature of 70–80 �C. The pH of

the solution was maintained between 7–10. Each tablet

contained the following amount of extracts: 225 mg of B.

monnieri and 125 mg each of H. rhamnoides and D.

bulbifera. The placebo was prepared using dibasic calcium

phosphate and microcrystalline cellulose and replicated the

test drug in appearance, odour, and texture. Packaging and

randomization was performed, and then the trial was

conducted.

2.2 Participants

The study protocol was approved by the institution’s eth-

ical committee and all participants gave their written

informed consent. Each volunteer was requested to com-

plete a medical health questionnaire prior to participation.

All the subjects then underwent extensive medical evalu-

ation to ascertain subject suitability for entering the clinical

trial. The inclusion criteria for the SDAT subjects included

age[60 years, willingness to give informed consent and a

deterioration of memory along with at least three of the

following five complaints: poor orientation, poor judge-

ment and problem solving difficulties, trouble in the

functioning of community affairs, inability to function

independently in home and during hobbies and difficulties

in personal care. Patients were then assigned to the SDAT

group following clinical screening using the dementia rat-

ing scale-II [32]. Subjects suffering from any metabolic

disease, established neuropathy or tuberculosis were

excluded. SDAT patients receiving conventional treatment

were also excluded from the study.

The participants were divided into the following four

groups; Group A: healthy elderly subjects who were given

placebo, Group B: healthy elderly subjects who were given

the test formulation, Group C: SDAT patients who were

treated with a standard drug donepezil (Aricept 10 mg,

twice daily) and Group D: SDAT patients treated with the

test formulation.

2.3 Procedures and Treatments

This study was conducted for 12 months in a double-

blinded placebo- and active-controlled randomized man-

ner. The treatments or placebo were administered twice a

day, during the study period of 12 months. A random list of

numbers was determined by a computer-generated series

with the proper sequence applied to container labels and

supplied to participants in the order enrolled after being

randomly assigned to the various treatment groups. All

participants were assessed for baseline data of memory,

cognitive functions, and biochemical markers like homo-

cysteine, CRP (C-reactive protein), IL-6 (interleukin 6),

TNF-a (tumor necrosis factor alpha), SOD (superoxide

dismutase), GPx (glutathione peroxidase), GSH (glutathi-

one), and TBARS (thiobarbituric acid reactive substances).

The healthy subjects and patients were given the drugs, to

be taken independently at home. After every 3 months they

were assessed according to the above-mentioned parame-

ters, throughout the 12 months of treatment. The code for

study allocation was only broken when the last participant

completed the entire follow-up. The staff involved in the

collection of the study’s endpoints were instructed to fol-

low a rigorous protocol and not to discuss any issues

related to the use of medication. Reviews for compliance

with medication and side effects were performed inde-

pendently by the investigators, who were also blinded to

group allocation. Compliance was determined by the col-

lection of unused tablets at each follow-up. Subjects were

asked to call the study centre if they experienced any

medical problems during the study period. At the end of the

study, they were also asked about adverse events. The

following tests and measurements were drawn at baseline

Table 1 A summary of the medicinal properties of plants used in the test formulation

Plant name Part of the plant used Major bioactive

component

Therapeutic properties/targets References

Bacopa monnieri

Family:

Scrophulariaceae

Whole plant

Dose: 450 mg/day

Bacoside Regulates cholinergic system, antioxidant

and cytoprotective effect, acts on

oxidative stress markers, memory

enhancer and nerve tonic

[20, 22, 23, 50–52]

Hippophae rhamnoides

Family: Elaeagnaceae

Leaves and fruits

Dose: 250 mg/day

Quercetin Anti-inflammatory, anti-oxidant,

immunomodulatory properties,

treatment of hypertension and

hyperlipidemia, anti-radiation,

cardioprotective and anti-atherogenic

property

[25–28, 53–58]

Dioscorea bulbifera

Family: Dioscoraceae

Bulbils

Dose: 250 mg/day

Diosgenin Anti-inflammatory, analgesic,

antihyperlipidemic, antihyperglycemic,

antioxidant and anthelmintic activity

[29, 30, 59–62]

A. Sadhu et al.

and at follow-up visits and compared to see whether any

changes suggested adverse events: physical examination

(height, weight, body mass, ponderal, obesity and waist to

hip ratio index, blood pressure, pulse, fundoscopy), blood

examination (haemoglobin, white blood cell count, differ-

ential count of neutrophils, lymphocytes, eosinophils,

monocytes and basophils, red blood cell count, erythrocyte

sedimentation rate, platelet count, fasting and post-prandial

blood sugar, HbA1c, IL-6, TNF-a, high-sensitivity CRP,

adiponectin, homocysteine, serum alkaline phosphatase,

total protein and serum albumin), urine test (urinary van-

illomandelic acid, 17 ketosteroides and glucocorticoid),

cardiology test (electrocardiography and chest X-ray) and

liver function test (serum glutamic-oxaloacetic transami-

nase, glutamic-pyruvic transaminase, bilirubin and alkaline

phosphatase).

2.4 Analysis of Cognitive Functions

Cognitive function was assessed following structured per-

formance tests, which included mental status, verbal

memory, complex psychomotor skills, and attention/exec-

utive functions. Mini Mental State Examination (MMSE)

was used to assess mental status [33]. Memory scores were

tested using the digital memory apparatus (Medicaid sys-

tems, Chandigarh, India) device for both immediate and

delayed memory performance. Complex psychomotor skill

was examined using the digital symbol substitution (DSS)

test, which is a sub-test of the Wechsler Adult Intelligence

Scale—Revised [34], and has a score range of 0–93.

Attention span scores were obtained using the electronic

device—Attention Span Apparatus (Medicaid systems,

Chandigarh, India). A well-trained psychologist/technical

person administered all four tests in the same order to all

the study patients. Depression was assessed by the Geri-

atric Depression Scale-15 (GDS-15) [35], which is a global

test for depression with scores ranging from 0 to 15.

Functional Activity Questionnaire (FAQ) scores were also

obtained to test cognitive function of the participants [36,

37].

2.5 Analysis of Biochemical Markers

Venous blood was collected in vacutainer tubes and sub-

jected to centrifugation at 1500 g for 15 min; the plasma

from the samples were then collected and stored at -80 �C

until they were assayed. The blood plasma level of

homocysteine was determined by a high-performance

liquid chromatography (HPLC) method. CRP, IL-6 and

TNF-a levels were detected in the blood plasma as markers

for inflammation by the ELISA method using test kits.

SOD and GPx activity, and GSH and TBARS levels were

measured as markers for oxidative stress. SOD activity was

estimated by the method of Misra and Fridovich (1971),

GPx activity was estimated by the method of Rotruck et al.

(1973). GSH levels as well as TBARS levels were detected

in the blood by colorimetric assays [38–43].

2.6 Statistical Analysis

All data are expressed as mean ± SD. The unpaired stu-

dent t test was performed to compare the results obtained

from the different groups. All statistical analysis was done

using the Graph pad prism ver. 2.0. Per-protocol analysis

was performed and statistical significance was regarded at

P \ 0.05. All data available from the follow-up studies

were included in the analysis, irrespective of whether the

participant attended all the follow-up visits.

3 Results

3.1 Demographic Data of Subjects for Clinical

Complaints

A total of 109 healthy elderly volunteers and 123 SDAT

patients with an age range of 60–75 years were recruited,

out of whom 97 healthy subjects and 104 SDAT patients

completed the study. The baseline demographic data of the

subjects for clinical complaints are presented in Table 2.

When percentages of participants with complaints or the

mean score in each of these parameters were compared

among the healthy elderly group and within the SDAT

group, no significant differences were observed. However,

the SDAT subjects showed significant differences in these

parameters compared to the healthy elderly subjects. These

included elevated levels of homocysteine, CRP, IL-6, TNF-

a and higher percentage of aggression, sleep disturbance,

communicate difficulty, depression and psychotic features.

The drop-out rates were lower in the test formulation

groups when compared to the corresponding placebo or

donepezil group, All of the drop-outs were lost to follow-

up.

3.2 Effect of the Test Formulation

on Neuropsychological Parameters

The effects of the test formulation on several neuropsycho-

logical parameters like memory, mental status, complex

psychomotor skills, and attention/executive functions are

shown in Table 3. After 12 months of treatment, results from

the healthy elderly group who received the test formulation

were compared to the group which only received the placebo.

Statistical analysis revealed that the test formulation-treated

group showed significant improvements over the placebo-

treated group in their MMSE score (P = 0.0003), DSS score

Management of Cognitive Determinants in Senile Dementia

(P = 0.0008), delayed word recall score (P \ 0.0001),

attention span (P \ 0.0001), FAQ score (P = 0.001) and

depression score (P \ 0.0001). However, word recall

immediate score showed no significant changes (P\0.1500)

(Table 3). These results demonstrate the potential of the test

formulation to augment the cognitive deficits due to aging.

Similarly, results from the SDAT group treated with the test

formulation for 12 months were compared to the SDAT

group treated with donepezil. Analysis showed that the test

formulation treatment was either similar or significantly

better in the improvement of neuropsychological parameters

such as their MMSE (P = 0.9375), DSS (P = 0.0001), word

recall immediate (P \ 0.0001) word recall delayed

(P = 0.052), attention span (P = 0.0208), FAQ (P \0.0001) and depression (P\0.0001) scores (Table 3). These

results indicate a beneficial role of the novel herbal test

formulation for the treatment of SDAT.

3.3 Effect of the Test Formulation on Biochemical

and Inflammatory Markers

In this study the levels of inflammatory cytokines, TNF-aand IL-6, were measured in healthy elderly subjects and

SDAT patients before and after 12 months of treatment

(Table 4). Statistical analysis revealed a significant reduc-

tion in the levels of both TNF-a (P \ 0.0001) and IL-6

(P \ 0.0001) in the healthy elderly subjects following

treatment with the test formulation for 12 months when

compared to the placebo group. Similar analysis done on

SDAT patients treated either with donepezil or the test

formulation showed a significant reduction in the levels of

TNF-a (P \ 0.0001) in the test formulation group. The

levels of IL-6 was lowered in both groups following

treatment and although lower levels were observed in the

test formulation group when compared to the donepezil

group, the result was not found to be significant

(P = 0.2052). A significant decrease in the levels of

another inflammatory marker, CRP (P \ 0.0001), was

observed in the healthy elderly subjects after 12 months of

treatment with the test formulation, when compared to

placebo treated group (Table 4). A similar decrease in the

CRP (P \ 0.0001) levels was observed in SDAT patients

treated with the test formulation when compared to do-

nepezil. Moreover, it is well documented that the elevated

levels of homocysteine are associated with neurodegener-

ative disorders [43]. In the current study, treatment with the

test formulation resulted in a significant decrease in the

levels of homocysteine (P \ 0.0001) in both the healthy

elderly and SDAT participants after 12 months of treat-

ment with the test formulation (Table 4) when compared to

the corresponding control groups (placebo/donepezil).

3.4 Effect of the Test Formulation on Oxidative Stress

In the present study the effects of the test formulation on

antioxidants like SOD, GPx, GSH and TBARS were also

studied (Table 5). A comparison between the plasma

antioxidant activity of the test formulation and placebo-

treated healthy elderly groups showed a significant reduc-

tion in the SOD (P \ 0.0001) and GPx activity (P \0.0001) in the test formulation group. In addition to this,

lower TBARS (P\0.0001) and higher GSH (P\0.0001)

levels were also observed in the test formulation group

indicating a reduction in reactive oxygen species.

Table 2 Demographic data of study subjects

Characteristics Group A ? B (N = 109) Group C ? D (N = 123)

Number of subject recruited 109 123

Number of subjects completed trial 97 104

Aggression (%) 24 62

Sleep disturbance (%) 20 71

Communication difficulty (%) None reported 79

Depression (%) 25 68

Psychotic features (%) 9 67

Homocysteine (nmol/L) 21.99 ± 2.85 38.42 ± 4.16

CRP (mg/L) 2.38 ± 0.76 6.23 ± 1.09

IL-6 (pg/ml) 2.23 ± 0.41 4.12 ± 1.06

TNF-a (pg/ml) 483.80 ± 85.64 1124.06 ± 105.87

Values are expressed as mean ± SD unless specified otherwise

The number of subjects: 109 healthy subjects and 123 patients were recruited, of whom 97 healthy subjects and 104 patients completed the study.

Group A ? B (N = 109) were healthy elderly subjects and were treated with either placebo or test formulation, while group C ? D (N = 123)

were SDAT patients treated with donepezil or test formulation. Data for aggression, sleep disturbance, communication difficulties, depression

scores and psychotic features are presented as the percentage of subjects with these clinical complaints

CRP C-reactive protein, IL-6 interleukin 6, TNF-a tumor necrosis factor alpha

A. Sadhu et al.

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Management of Cognitive Determinants in Senile Dementia

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s

Management of Cognitive Determinants in Senile Dementia

Similarly, when the SDAT group treated with donepezil

was compared to the test formulation treated group, a

marked reduction in SOD activity (P \ 0.0013), GPx

activity (P \ 0.0001) and TBARS levels (P \ 0.0001),

along with an increase in GSH levels (P \ 0.0001) was

observed in the latter (Table 5). These results demonstrate

the ability of the test formulation to reduce oxidative stress

in both healthy elderly subjects as well as SDAT patients.

3.5 Safety and Adverse Events

The percentage of trial subjects completing the study

were placebo, 80.3 %, test formulation, 96.5 % for

healthy subjects, donepezil (10 mg twice daily), 74.1 %,

and test formulation, 93.8 % for SDAT patients. The

percentage of patients who discontinued the study were

placebo, 19.6 %, test formulation, 3.4 % for healthy

subjects, donepezil (10 mg twice daily), 24.8 %, and test

formulation, 6.15 % for SDAT patients (Fig. 1). All drop-

outs were lost to follow-up. The drop-out rates for the test

formulation-treated groups were lower than the corre-

sponding placebo or donepezil groups indicating that the

test formulation is safe and well tolerated among trial

subjects. Adverse events reported in the trial included

nausea, constipation and/or drowsiness were transient and

mild in severity.

Fig. 1 Flow chart of the

subjects who participated in the

clinical trial

A. Sadhu et al.

4 Discussion

The pharmaceutical industry is facing a serious challenge

in the drug discovery and development process for neuro-

degenerative diseases [44]. Drugs are becoming extremely

expensive, riskier and inefficient; a shift from the pre-

dominant single-target approach towards a multi-target one

could help address this. In recent years the Ayurvedic

system of medicine in India has gathered increasing rec-

ognition as a potential mode of treatment for diseases. This

system of medicine is based on reverse pharmacology and

thus provides an efficient platform for drug development

[45, 46].

Several medicinal plants have been extensively used in

Ayurvedic medicines as rejuvenators (which prevent dis-

eases), that have been shown to slow the process of

ageing and related disorders. For centuries, Ayurvedic

therapeutics have been prescribed for neurodegenerative

diseases, including dementias, and there are extensive

data available on the history of human use from both a

safety and efficacy perspective [47, 48]. Studies on

mechanisms of action of such therapeutics have demon-

strated their ability to increase levels of nerve growth

factors, neurotrophic factors and to reduce inflammation

and oxidative damage [31].

The present study demonstrates the potential of a

polyherbal formulation for the treatment and prevention of

neurodegenerative disorders with special reference to

SDAT. This test formulation is a combination of three

plants, namely B. monnieri, H. rhamnoides and D. bulbif-

era. These plants were selected based on their potential to

target multiple factors associated with the onset and pro-

gression of neurodegeneration, including oxidative stress,

inflammation and hyperhomocysteinaemia [21, 24, 30].

These plants contain several bioactive molecules such as

bacoside, quercetin, diosgenin and folic acid which provide

neuroprotective effects by acting on multiple targets like

glutamatergic, GABAergic, dopaminergic, noradrenergic

and serotonergic receptors along with oxidative stress

markers, pro-inflammatory cytokines: TNF-a, IL-6, CRP

and homocysteine [22, 26, 27, 29]. In this exploratory

double–blind placebo- and active-controlled study,

administration of the test drug in healthy elderly subjects

led to significant improvements in cognitive functions and

a reduction in markers for inflammation and oxidative

stress. Consequently, SDAT patients treated with the test

formulation also showed a significant improvement and

amelioration of their symptoms. In order to further

understand the effect of this drug, in depth molecular and

pharmacological studies in animals and humans are nee-

ded, to corroborate the mechanism of action that could

extend beyond its anti-inflammatory and anti-oxidant

effects. The effect of this formulation on the levels of

b-amyloid and tau (including phospho tau) in the brain or

CSF as well as on the accumulation of plaques and tangles

in the brain that are commonly associated with Alzheimer’s

disease warrants investigation in order to assess the dis-

ease-modifying potential of this drug [49]. In this direction,

multicentric (Phase III) clinical trials need to be performed

for a longer period of time to substantiate the therapeutic

potential of the test formulation.

5 Conclusion

Administration of a polyherbal formulation containing

extracts of B. monnieri (whole plant), H. rhamnoides

(leaves and fruits) and D. bulbifera (bulbils) for a period of

12 months resulted in significant improvement of cognitive

functions as well as reduction in inflammation and oxida-

tive stress related to neurodegeneration in healthy elderly

subjects in comparison to placebo and in SDAT patients in

comparison to donepezil.

Acknowledgments This study was supported in part by UGC Grant

No. Dev./D/CPBM/2015, AYUSH and DST India. Additional support

was provided by SRM University, Chennai and Adesh University

Punjab. The tablets were manufactured by Varanasi Bioresearch at no

cost. The clinical study was performed at Banaras Hindu University,

Varanasi, SRM University, Chennai and Adesh University, Punjab,

India. Thanks to the clinical investigators Prof. V N Mishra and Prof.

Malvin George for their help and support in conducting the clinical

trial. No competing financial interests exist for any authors. All

authors declare no conflicts of interest. The clinical trial titled ‘‘Pre-

vention and management of age related neurodegenerative disorders-

an Ayurvedic intervention’’, was registered (No. K.11022/10/2009-

DCC) with Dept. of AYUSH (Ministry of health and family welfare,

Govt. of India).

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