I. Introduction

With increasing age, dogs and cats may develop cognitive impairment or cognitive dysfunction syndrome (CDS), a form of neurodegenerative disorder, which shares some analogies with Alzheimer’s disease in humans.^1-3 Although a declining of learning and memory may begin in dogs as young as 7 years of age, clinical cases of CDS are seldom identified until the age of 11 years or older, when dogs started to show signs of DISHA (Disorientation, Interaction changes, Sleep/wake disturbances, House soiling and Activity changes).^4,5 In a study of 180 dogs aged 11 to 16 years with no identifiable health problems, 28% of dogs aged 11–12 years, and 68% of dogs aged 15–16 years showed at least 1 sign consistent with CDS.⁶ One study reported that 50% of cats older than 15 years of age had possible CDS.⁷ CDS can adversely affect the quality of life in both dogs and their owners. Treatment is aimed at slowing the advancement of neuronal damage and cell death and improving clinical signs. Drugs, diet, and supplements are often used concurrently to improve neurotransmission and reduce oxidative damage and inflammation.¹

Acupuncture and Chinese herbal medicine can be an excellent adjuvant to conventional therapy of CDS patients, as it has been used in animals for thousands of years in China.⁸ Clinical anecdotal evidence indicates acupuncture and Chinese herbals may greatly benefit patients with CDS.^9,10 Acupuncture has shown to significantly improve cognitive impairment and showed to be effective in improving intelligence and ameliorating depression and anxiety in various pathological conditions in humans and lab animals.^9,11,12 Many Chinese herbs or herbal formulas have been found to posses calming effect and are able to enhance/stimulate blood circulation in the brain and to promote adult neurogenesis in the dentate gyrus in animals. Thus, these herbs may be beneficial for patients with CDS.^10,13

II. TCVM Etiology and Pathology

In Traditional Chinese Veterinary Medicine (TCVM), CDS is due to a loss of Shen. The Shen is the Spirit or Mind. Shen rules mental activities, memory and sleep. Shen also refers to the outward appearance of the vital activities of the whole body. It provides an animal with awareness and mental clarity. When Shen is healthy, it produces inner peace. The animal with a healthy Shen will exhibit normal behaviors and will be alert and responsive to environmental stimuli. When Shen is lost, the animal will show poor memory, disorientation, confusion, restlessness, palpitation, anxiety and hyperactivity.

The Shen is housed in the Heart. The Heart Qi plays an important role in mental activities and brain functions. The plaques formed by beta amyloid peptides in the brain are considered Phlegm or local Blood Stagnation. Phlegm is often generated by the abnormal amount of accumulated fluids produced by Spleen Qi Deficiency. Phlegm in the brain tends to mist and block the Mind, leading to a loss of Shen. The Shen also requires nourishment and anchoring from Heart Yin and Blood to remain healthy. When Heart Yin and Blood are Deficient, the Shen lacks anchoring and nourishment, leading to a Shen Disturbance and abnormal behavioral changes. Thus, CDS can be divided into 5 main patterns: the 3 Excess patterns include Phlegm/Phlegm Fire Misting the Mind, Qi-Blood Stagnation, and Liver Qi Stagnation; the 2 Deficiency patterns are Heart and Spleen Qi Deficiency and Heart Yin and Blood Deficiency. Due to that most CDS cases are often already chronic by the first time the owner seeks medical attention, a combination of Excess and Deficiency is not uncommon. The most common combinations are (a) Phlegm Misting the Mind with Heart and Spleen Qi Deficiency, and (b) Heart Yin and Blood Deficiency with Qi-Blood Stagnation.

III. General TCVM Treatment

A. Acupuncture

a) Common points for CDS in animals: PC-5/6, HT-5/7, BL-14/15/43/44, GV-20, CV-15, Da-feng-men, Nao-shu, An-shen, GB-20, LI-4, LIV-3

b) Methods of Stimulation:

• Dry needle for 20–30 minutes
• Electroacupuncture: PC-6 bilateral, BL-15/44 bilateral, BL-23/52 bilateral, GV-20 to Nao-shu, Da-feng-men to Long-hui, 20Hz for 10 min followed by 80–120Hz for 10 min
• Aquapuncture: vitamin B12 injected into 5 acupoints (An-shen, Da-feng-men, GB-20, CV-14, CV-17, ST-40, BL-15/44, BL-23/52), 0.2–0.5 cc per acupoint
• Acupressure or laser acupuncture

B. Tui-na Massage

a) Mo-fa (Touching skin & muscle) or Ca-fa (Rubbing) from Long-hui to GV-15 for 3–5 min

b) Clockwise thumb Rou-fa to stimulate An-shen, GV-20, Nao-shu, GB-20, PC-6, PC-8, BL-15/44, BL-23/52, KID-1, KID-3 and KID-7 for 3–5 minutes

c) Ca-fa (Rubbing) on each ear with the thumb rubbing the midpoint of the inner ear

d) Rou-Fa (Rotary-Kneading) along the back-shu Bladder meridian (BL28 to BL11) from caudal to rostral back and forth 12 times

e) Rou-fa along the Conception Vessel meridian (CV8 to CV2) back and forth 12 times

C. Herbal Medicine

a) If you do not know or cannot figure out the TCVM pattern of your patient, you may always start with Shen Calmer (from Jingtang Herbal Inc.), 0.5 g per 1020 lb body weight BID–TID

b) It is functioning to calm the mind, nourish Heart Yin and Blood, and soothe Liver Qi

IV. Scientific Evidence

A. Acupuncture

a) Acupoints that have been found to be effective in improving cognitive function and reducing stress in human and animal models: ST-36, GV-14, GV-20, HT-7, HT-9, PC-9, CV-6, CV-12, CV-17, SP-10, BL-23, GB-34, LIV-3, KID-1, LU-11, Ex-HN-3, LI-20^11,12,14,15

b) These acupoints improve cognitive function through^11,12,14,15

• Improving cerebral blood flow
• Promoting cholinergic neural transmission
• Facilitating dopaminergic synaptic transmission
• Enhancing neurotrophin signaling and nerve growth factor in the hippocampus
• Protecting cerebral neurons from apoptosis and oxidative damages
• Regulating glucose metabolism
• Reducing the expression of microglia in the hippocampus
• Suppressing acetylcholinesterase in the hippocampus
• Decreasing the levels of extracellular amyloid b (Aβ) proteins in the hippocampus and relevant brain regions

c) In Alzheimer’s human patients, brain fMRI demonstrates that acupuncture stimulation at HT-7, ST-36, ST-40, KID-3, LI-4, and LIV-3 increased in the activity in the temporal lobe (including hippocampus) and prefrontal lobe, which are related to the memory and cognitive function, as well as some regions of parietal lobe, and cerebellum.¹⁴

B. Chinese Herbal Medicine

a) Single Chinese Herb^10,16-18

• Huperzia serrata (Qian Ceng Ta or Jin Bu Huan) is a potent, reversible, selective inhibitor of acetylcholinesterase (AChE). A systematic review and meta-analysis of randomized clinical trials demonstrated that Huperzine A from Huperzia serrata appears to have beneficial effects on improvement of cognitive function, daily living activity, and global clinical assessment in human patients with Alzheimer’s disease.
• Ginseng and Ginkgo biloba increase the uptake of choline in CNS, release acetylcholine from hippocampus, and reduce the level of Aβ.
• Salvia miltiorrhiza (Dan Shen), Herba Erigerontis (Deng Zhan Hua), Radix Morinda Officinalis (Ba Ji Tian), Coptidis Rhizome (Huang Lian), Houttuyniae Herba (Yu Xing Cao), Uncaria rhynchophylla (Gou Teng), and Lycium barbarum (wolfberry; Gou Qi Zi) have been found to protect the brain against Aβ cell toxicity in different types of neuronal cells.
• Wolfberry (wolfberry; Gou Qi Zi) was able to enhance the neuronal differentiation of the hippocampal neurogenesis and reverse the depression-like behavior caused by 50 mg/kg corticosterone injection.

b) Chinese Herbal Formula^16,19,20

• Liu Wei Di Huang Tang/Wan, at a dose of 100 mg/kg, was proven to improve cognitive function by promoting hippocampal neurogenesis in adult rats.
• Jia Wei Wen Dan Tang at a dose of 50 mg/kg improved the cognitive functions via enhancing neurogenesis in the hippocampus of mice treated for 2 weeks.
• Jia Wei Xiao Yao San was able to reverse the impaired neurogenesis in the hippocampus in stressed rats.
• Bu Yang Huan Wu, 5 g per kg per day by mouth for 2 weeks, displayed a stimulating effect on neurogenesis and improved the neurological scores and functional recovery in stroke rats.
• Ba Wei Di Huang Wan, 2 g 3 times a day by mouth for 8 weeks, significantly improved the cognitive function scores in human patients with dementia as compared to the placebo group.
• Yi Gan San, 2.5 g (1.5 g of extract) 3 times a day by mouth for 4 weeks resulted in significant improvement of behavioral and psychological symptoms of dementia and activities of daily living in dementia patients as compared to the control group.

V. Pattern Differentiation & Treatment

1) Phlegm Misting the Mind

• Signs: mental confusion and depression, lethargy, change of voice, vomiting of mucus, dull eyes. Tongue is pale to pink with thick sticky coating, may have swollen with teeth marks or a midline crack reaching the tip. Pulses are slippery with normal strength.
• Treatment strategy: Resolve Phlegm, open the Heart orifice.
• Acupuncture treatment: Common points (PC-5/6, HT-5/7, BL-14/15/44/45, GV-20, CV-15, Da-feng-men, Nao-shu, An-shen, LI-4, LIV-3); Add ST-40, BL-20, SP-6, CV-12 for Phlegm.
• Herbal formula: Di Tan Tang, 0.5 g per 1020 lb body weight BID–TID.

2) Phlegm Fire Misting the Mind

• Signs: Agitation or irritability, rash/manic behavior, aggressive, barking, thirsty, warm to the touch, cool seeking, mental depression, dull eyes. Tongue is red, the tip is redder or has red points, yellow sticky coating, maybe swollen with teeth marks. Pulses are full, rapid, slippery or wiry.
• Treatment strategy: Resolve Phlegm, cool Fire, soothe the Liver.
• Acupuncture treatment: Common points (PC-5/6, HT-5/7, BL-14/15/43/44, GV-20, CV-15, Da-feng-men, Nao- shu, An-shen, GB-20, LI-4, LIV-3); add ST-40, BL-20, SP-6, CV-12 for Phlegm; add PC-7, HT-8, GV-14, LIV-2, Wei-jian, Er-jian to clear Heat/Fire.
• Herbal formula: Wen Dan Tang or Zen Xin San, 0.5 g per 1020 lb body weight BID-TID. Use Zhen Zin San in severe cases.

3) Qi-Blood Stagnation

• Signs: Agitation or irritability, stop social interaction or become less responsive, poor memory, dislike of lying down, weak and cool limbs, wandering through the house, household accidents, getting lost in corners, step over anything, sleep less. Tongue is pale purple, or purple on the sides. Pulses are wiry or choppy.
• Treatment strategy: Move Heart Qi-Blood, eliminate stagnation, open the Heart orifices.
• Acupuncture treatment: Common points (PC-5/6, HT-5/7, BL-14/15/43/44, GV-20, CV-15, Da-feng-men, Nao-shu, An-shen, GB-20, LI-4, LIV-3); add LU-7, LI-4, LIV-3, CV-14, BL-21, LI-10, BL-17, SP-10 to move Qi-Blood and clear stagnation.
• Herbal formula: Stasis in Mansion of Mind or Xue Fu Zhu Yu, 0.5 g per 1020 lb body weight BID–TID. Use Stasis in Mansion of Mind in severe cases.

4) Liver Qi Stagnation

• Signs: Irritability/aggressiveness, depression, fluctuation of mental state, burping, nausea/vomiting, constipation to diarrhea, finicky/poor appetite, thirst, red conjunctiva, dislike to be touched on the thoracic flank region. Tongue is pink to red/lavender or red on the sides. Pulses are wiry, especially on left side.
• Treatment strategy: Soothe Liver Qi, strengthen Spleen/Stomach, calm the mind.
• Acupuncture treatment: Common points (PC-5/6, HT- 5/7, BL-14/15/43/44, GV-20, CV-15, Da-feng-men, Nao-shu, An-shen, GB-20, LI-4, LIV-3); add BL-18/19, LIV- 3/13/14, GB-3 to soothe the Liver Qi, and BL-20/21, LI-10 and ST-36 to strengthen Spleen and Stomach.
• Herbal formula: Yi Gan San, Chai Hu Shu Gan, Liver Happy, or Xiao Yao San, 0.5 g per 1020 lb body weight BID–TID. Use Liver Happy in severe cases; Use Xiao Yao San if patients have digestive problems.

5) Heart and Spleen Qi Deficiency

• Signs: Reduced responsiveness, stop any social interaction or become less responsive, become more aloof or fearful, poor memory, having indoor accidents, decreased appetite, lassitude, a desire to lie down, weakness of the limbs, sleep more, panting due to shortness of breathe, stare blankly at a roof, wall or air, signs often worsen during day time, fail to recognize their owners and friends at the end. Tongue is pale wet. Pulses are deep, weaker in the right side.
• Treatment strategy: Tonify Heart and Spleen Qi, calm the Mind.
• Acupuncture treatment: Common points (PC-5/6, HT-5/7, BL-14/15/43/44, GV-20, CV-15, Da-feng-men, Nao-shu, An-shen, GB-20, LI-4, LIV-3); add CV-6/17, BL-20/21, ST-36, SP-6, LI-10 to strengthen Qi.
• Herbal formula: Yang Xin Tang, 0.5 g per 1020 lb body weight BID–TID. Add Si Jun Zi Tang or Liu Jun Zi Tang if there is decreased appetite.

6) Heart Yin and Blood Deficiency

• Signs: Listlessness, anxiety, poor memory, reduced responsiveness, bark or abnormal behavior at night or late evening, pacing at home at night, sleep less at night, awake at night, having household accidents, cats may howl at night for no reason, signs often worsen during evening. Tongue is red or pale and dry. Pulses are deep and thin, weaker on left side.
• Treatment strategy: Nourish Heart Yin and Blood, calm the Mind.
• Acupuncture treatment: Common points (PC-5/6, HT-5/7, BL-14/15/43/44, GV-20, CV-15, Da-feng-men, Nao-shu, An-shen, GB-20, LI-4, LIV-3); Add CV-4, BL-17, BL-20, SP-10, KID-3/7, SP-6/9 to nourish Yin and Blood.
• Herbal formula: Shen Calmer or Tian Wang Bu Xin Dan, 0.5 g per 1020 lb body weight BID–TID. Use She Calmer in severe cases.

VI. Summary

Acupuncture and herbal medicine could serve as an effective, safe, well-tolerated and inexpensive form of care for dogs with CDS.

References

1.  Landsberg GM, Nichol J, Araujo JA. Cognitive dysfunction syndrome: a disease of canine and feline brain aging. Vet Clin North Am Small Anim Pract. 2012;42(4):749–68.

2.  Cummings BJ, Head E, Afagh AJ, et al. Beta-amyloid accumulation correlates with cognitive dysfunction in the aged canine. Neurobiol Learn Mem. 1996;66:11–23.

3.  Bosch MN, Pugliese M, Gimeno-Bayón J, et al. Dogs with cognitive dysfunction syndrome: a natural model of Alzheimer’s disease. Curr Alzheimer Res. 2012;9:298–314.

4.  Landsberg G. Therapeutic agents for the treatment of cognitive dysfunction syndrome in senior dogs. Prog Neuropsychopharmacol Biol Psychiatry. 2005;29(3): 471–479.

5.  Ruehl WW, Hart BL. Canine cognitive dysfunction. In: Dodman NH, Shuster L, eds. Psychopharmacology of Animal Behavior Disorders. Malden: Blackwell Science; 1998:283–304.

6.  Neilson JC, Hart BL, Cliff KD, Ruehl WW. Prevalence of behavioral changes associated with age-related cognitive impairment in dogs. J Am Vet Med Assoc. 2001;218:1787– 1791.

7.  Head E, Moffat K, Das P, et al. Beta-amyloid deposition and tau phosphorylation in clinically characterized aged cats. Neurobiol Aging. 2005;26:749–763.

8.  Zhongjie Liu, Jianqin Xu, eds. Traditional Chinese Veterinary Medicine. 3rd edition. (In Chinese). Beijing, China: Agricultural Press; 2005.

9.  Liu F, Li ZM, Jiang YJ, Chen LD. A meta-analysis of acupuncture use in the treatment of cognitive impairment after stroke. J Altern Complement Med. 2014 Jun 10.

10.  Fu LM, Li JT. A systemic review of single review Chinese herbs for Alzheimer’s disease treatment. Evid Based Complement Alternat Med. 2011.

11.  Lee MS, Shin BC, Ernst E. Acupuncture for Alzheimer’s disease: a systematic review. Int J Clin Pract. 2009;63:874–879.

12.  Schroer S, Adamson J. Acupuncture for depression: a critique of the evidence base. CNS Neurosci Ther. 2011;17:398–410.

13.  Sun ZK, Yang HQ, Chen SD. Traditional Chinese medicine: a promising candidate for the treatment of Alzheimer’s disease. Transl Neurodegener. 2013;2(1):6.

14.  Zeng BY, Salvage S, Jenner P. Effect and mechanism of acupuncture on Alzheimer’s disease. Int Rev Neurobiol. 2013;111:181–95.

15.  Leung MC, Yip KK, Ho YS, Siu FK, Li WC, Garner B. Mechanisms underlying the effect of acupuncture on cognitive improvement: a systematic review of animal studies. J Neuroimmune Pharmacol. 2014 Jun 6.

16.  Endong Zhang, Jiangang Shen, Kwok Fai So. Chinese Traditional Medicine and adult neurogenesis in the hippocampus. J Tradit Complement Med. 2014;4(2):77–81.

17.  Li-Min Fu, Ju-Tzu Li. A systematic review of single Chinese herbs for Alzheimer’s disease treatment. Evid Based Complement Alternat Med. 2011;2011:640284.

18.  Jinzhou Tian, Jing Shi, Xuekai Zhang, Yongyan Wang. Herbal therapy: a new pathway for the treatment of Alzheimer’s disease. Alzheimer Res Ther. 2010;2(5):30.

19.  Iwasaki K, Kobayashi S, et al. A randomized, double-blind, placebo-controlled clinical trial of the Chinese herbal medicine “ba wei di huang wan” in the treatment of dementia. J Am Geriatr Soc. 2004;52(9):1518–21.

20.  Iwasaki K, Satoh-Nakagawa T, et al. A randomized, observer-blind, controlled trial of the traditional Chinese medicine Yi-Gan San for improvement of behavioral and psychological symptoms and activities of daily living in dementia patients. J Clin Psychiatry. 2005;66(2):248–52.