Nakamura Masamichi, et al.. Japanese Acupuncture and Moxibustion; 2017; Vol.13(1): 9-15

Original Research

Effects of acupuncture on dementia-A case series with a novel Sanjiao Acupuncture methodNAKAMURA Masamichi1), HYODO Akira2), HAN Jingxing3), KAWANAMI Oichi4)1）Tokyo Therapeutic Institute/ Department of Clinical Acupuncture and Moxibustion,
Meiji University of Integrative Medicine
2）GOTO College Traditional Chinese Medicine Institute3）Ex-director, First Teaching Hospital of Tianjin University, China
4）President, Gerontology Research Association Japan/ Director, Shinjuku-Kampo Clinic
Abstract[Objective] This study was aimed to explore the efficacy and usefulness of acupuncture which was technically defined by consistent manipulation on 9 needles at 6 acupoints in the body (Sanjiao method). The acupuncture treatment was done for patients with Alzhemier’s disease (AD) or vascular dementia (VaD), and the identical treatment
was performed on a group of the elderly who had lifestyle related disease (LS-D) with no detectable dementia.
[Methods] Totally 56 patients agreed to participate in the study, including 18 with AD, 12 with VaD, and 26 with
LS-D with no obvious dementia. Sanjiao acupuncture treatment was done once a week for 3 months totaling 12
times. The treatment effect was assessed by scores of mini-mental state examination (MMSE) and Nishimura Scaleof Activities of Daily Living (N-ADL). Their posttreatment scores were statistically compared to their pretreatment
ones. Text dwelling analysis was made by the key words collected by interviews done at occasions of acupuncture.
[Results] In total 56 patients, the mean scores of MMSE before the treatment (21.4±7.3) was significantly increasedin the posttreatment (22.3±7.0) (p<0.01). Particularly, significant improvement was shown in patients with VaD(p<0.05) and LS-D (p<0.01), although the improvement tended to be limited in patients with AD and patients who
required higher nursing care levels (≧3). The mean N-ADL scores in pretreatment stage (34.7±13.1) differed significantly from the mean posttreatment score (34.9±13.0) (p<0.01), showing favorable changes of the 56 patients.
Physical, behavioral and psychological activities (BPSD) demonstrated by the text dwelling analysis were very well
improved in each patient’s group after the treatments of the acupuncture.
[Conclusion] The novel acupuncture treatment showed significant improvement of N-ADL and amelioration of
BPSD, which would contribute to have a higher quality of daily lives of the patients and would bring better QOL tothe family and care-givers as well. It would be possible to delay or even prevent the transition of LS-D into dementia.
Thus, this acupuncture method would help curtail excessive medical expense in the ageing society.
Key words: Sanjiao acupuncture , Dementia, Lifestyle related disease, MMSE, N-ADL

I. Introduction
Oral drugs and percutaneous medications are now
widely used for the treatment of dementia. Various nondrug therapies have been tested for preventing dementia
as well. However, these trials have not been evidenced
to a substantial level. In these days lifestyle relateddisease (LS-D) which adults and the elderly tend tosuffer from, is believed to be one of the most potential

precursors in the occurrence of dementia, including
Alzheimer’s disease (AD) and vascular dementia (VaD).
Thus, prevention and treatment of LS-D would suppress
the process of transition into dementia. Patients with LSD and/or dementia are in frequent association with othercomplaints defined as geriatric syndrome, like headache,constipation, incontinence, lumbago and frailty.
Dementia and geriatric syndrome certainly induce anapparent decrease or loss of the quality of life (QOL) in

Corresponding author: Nakamura Masamichi, Tokyo Therapeutic Institute, 1-55 Yoyogi Shibuya,Tokyo,151-0053, Japan

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individual life. It is well known that acupuncture
treatment based upon the yin-yang balance theory has
been providing improvement and cure of complaints due
to geriatric syndrome in the long history. Acupuncture
treatment is recommended as a tool of integrated
medicine by the World Health Organization.
In China dementia therapy with acupuncture has been
extensively studied in both basic science and clinicalfields1-9). However, such studies have been hardly foundin Japan. Here, we report systemic studies taken by agroup of well-trained acupuncturists, emphasizing
efficiency and usefulness of a novel acupuncture method(Sanjiao) which had been developed by one of thepresent authors (HJ).
Ⅱ．Methods
1. Subjects
Total 56 patients (17 male and 39 female; mean age,
83±10, ranging 60–100 years) were enrolled as subjects
following acceptance by the patients and theirfamilies/caregivers of the informed consent to participate
the clinical studies. Eighteen patients had AD, 12
patients VaD, and 26 patients LS-D with no signs ofdementia.
2. Diagnosis
Diagnosis of the subjects was established by attending
doctors at nursery homes and one of the present authors(OK) as well. Patients in the LS-D group were sufferingfrom a large variety of geriatric syndrome including
hypertension, dyslipidemia, osteoporosis, diabetes
mellitus and/or others. However, they never showedexcessive cognitive loss or behavioral psychologicalsymptoms of dementia (BPSD).
3. Treatment method
Twenty-two acupuncturists who had been qualified as
masters of Sanjiao acupuncture method for dementia
after the graduation of Education and Training Course(Gold-QPD) held by Gerontology Research Association
Japan. They had followed a specific training course forthe acupuncture technique described as Sanjiao
acupuncture, and learned general medical knowledge ofTable1. Sanjiao acupuncture Method

dementia and basic technique of nursing care for theelderly. Sanjiao acupuncture was originally described asanti-aging procedure by delaying aging processes by oneof the present authors (HJ). Before and after theacupuncture treatments, they recorded scores of MMSE
(mini-mental state examination) and checked living
conditions of patients with N-ADL (activities of dailyliving after Nishimura). The standard procedure of theacupuncture was performed once a week for 3 months intotal 12 times. We used total 9 needles (disposable
stainless-steel M3; 0.2 mm diameter and 50 mm length,
SEIRIN Co. Ltd.). Six acupuncture points were selectedin the upper (heart and lungs), the middle (spleen andstomach), and the lower (liver and kidneys) energizers.
They were Danzhong; CV17, Zhongwan; CV12, Qihai;
CV6, Waiguan; TE5, Xuehai; SP10, and Zusanli; ST36.
Specific manipulations on 9 needles are described in the
Table 1, which was less stressful for the elderly andquite easy to perform as conducted in the supine position.
4. Evaluation method
To evaluate cognitive ability, MMSE was applied atoccasions before the practice of acupuncture, and after
the completion of 12 times’ treatment. To reveal dailyliving skills, N-ADL which included 5 conditions, suchas walking/sitting, dressing/undressing, bathing, eating
and defecation with 10 points’ scores each in total 50,
was applied. The scores 10~9 points were considered
normal, 8~7 borderline, 6~5 mild, 4~3 moderate and 2~
0 severe degrees of burden. To notify behavioral
changes of patients, interview/hearing was made fromfamily or caregivers in relation to several items,
including conversation, smile, and violated behavior due
to loss of temper and others. Physical changes ofpatients were also written down about general pain, joint
pain, tremor, headache, walking and so on. In addition,
the conditions of nursing-care were defined as nursing
care levels 1, 2, 3, 4 and 5 according to supports given
by professional care-givers.
5. Statistical analysis
The means and standard deviations of the scores of
MMSE and N-ADL scales were calculated.
And their scores before the treatment were compared11
Nakamura Masamichi, et al.. Japanese Acupuncture and Moxibustion; 2017; Vol.13(1): 9-15

to those after 3 months’ (12 times) treatments with apaired t-test. Assessment of MMSE was also done in 2
groups of the patients: one group with MMSE scores≦
21 points (28 patients) and the other with scores≧22 (28patients). The nursing-care levels of 41 patients weredivided into 2 groups: 12 patients were nursing-carelevels≧3 (implying that they need someone's help totake care of their surroundings), and the remaining 29
nursing-care levels≦2 indicating that they can live alone
without particular help of care-givers. Moreover,correlations among age, and scores of MMSE, N-ADL
and nursing-care levels were assessed by SPSS Statistics
17.0.
At the time of acupuncture treatments, language dataof interviews were recorded and analyzed using the
SPSS Text Analytics for Surveys (software for text
mining). This statistical analysis was expected to reveal
behavioral and psychological (BPSD) alterations ofpatients undetectable by the scores of MMSE, N-ADL or
nursery care levels. Text mining is a method ofanalyzing a large amount of text data freely written at
the interview of patients. We decompose the text into
phrases and words (morphological analysis) and see how
many phrases and words appear and how theircorrelation (co-occurrence network) and change in thetime series are like. In this study, on the basis of positive
and negative findings of both physical and mental
aspects, we made estimation of the concept of sensitivity
analysis for the purpose of understanding the patient
image．

Ⅲ．Results
1. MMSE changes after Sanjiao acupuncture
treatment
In all the 56 patients, the mean pretreatment MMSE
score was 21.4 and their posttreatment score was 22.7.
The difference between the two scores was significant (p< 0.01). Among the AD group, the mean MMSE scorebefore the treatment was 17.6, and the posttreatment
score was 18.3, in which no significant difference
existed. The mean pretreatment scores of MMSE in VaD
and LS-D groups were 17.1 and 26.0 respectively. Thoseafter the treatments were 19.2 and 27.3, respectively.
Significantly increased were the scores of VaD (p <0.05) and LS-D (p < 0.01) groups, compared to theirpretreatment scores.
Among all the patients, the MMSE scores of patientswith MMSE scores≦21 (average 15.3) increased to 17.0
in average after the treatments (p < 0.01) . The patientswith MMSE scores≧22 showed a significant increase of
the scores from 27.4 to 28.4 in average (p < 0.01). In thepatients with nursing-care levels≧3, the pretreatment
mean score of MMSE was 15.8 and the posttreatment
score was 16.5 in average, which was insignificant(Table 2).
However, the MMSE score in the patients withnursing-care levels≦2 was 23.9 in average and theirposttreatment score became 25.0, indicating statisticalsignificance between the two scores (p < 0.01) (Table 2).

Table 2. MMSE changes after the treatments

The scores of MMSE before and after the treatment are shown in Table 2.
All; all the patients examined, AD; Alzheimer’s Dementia
VaD; Vascular Dementia, LS-D; Lifestyle related disease

12Nakamura Masamichi, et al.. Japanese Acupuncture and Moxibustion; 2017; Vol.13(1): 9-15

2. N-ADL changes after Sanjiao acupuncture
treatment
The mean N-ADL score in whole 56 patients was 34.7
before the treatment. After 3 months treatments, thescore became 34.9, indicating significant differences (p< 0.01). In the patients with AD, pretreatment mean NADL scores 32.2 tended to increase to 32.3 after thetreatment. N-ADL scores of VaD patients changed from27.3 to 27.7, and those of LS-D raised from 39.8 to 40.1,
respectively. However, they were not statisticallysignificant.
In patients with MMSE scores≦21, the pretreatment
mean N-ADL score 28.3 was increased to 28.7 after thetreatment, which indicates a significant difference (p <0.01). However, in patients with MMSE scores ≧ 22
points, these scores changed from 41.1 to 41.2,
indicating no significance.
In patients with nursing-care levels ≧ 3, thepretreatment mean N-ADL scores was 25.7 and theposttreatment 26.0, respectively. In patients withnursing-care levels≦2, the pretreatment mean N-ADL
score was 39.1 and posttreatment 39.3, respectively.
There was no significant difference (Table 3).
3. Correlations between the categories
Spearman's rank-correlation coefficientswereevaluated for age, category of nursing-care level, MMSE,
and N-ADL scores before the treatment. Significant
negative correlations (-0.43) was found between
category of nursing-care levels and MMSE scores. Also,
significant negative correlation (-0.67) was foundbetween category of nursing-care levels and N-ADL
scores.

4. Physical, behavioral and psychological changes
after Sanjiao acupuncture treatment
Categories of physical findings are shown by SPSS
Text Analytics for Surveys (Figure1). After theacupuncture treatment, as shown in vertical axis, thepositive and favorable improvement was found inphysical attitudes with regard to “pain”, "stiff lower
limbs”, "lower back pain”, "complaints in eyes, fingers
and back, and abnormal tension" and so on. Negativechanges were observed in physical conditions of "foot”,"supine position”, and "muscle tension”. And "pruritus”
was worsened when the body temperature was raised bysuch as in gymnastics. The horizontal axis indicates real
number of patients claimed above.
The categories of psychological and behavioral
findings are similarly shown in Figure2. After thetreatment, psychological conditions were well improvedin relation to "communication with care-givers”, "smile
to family members”, ”willingness to do something”,"smooth expression of their intension and good
impression to the others” and "mental tension andconfidence”. Negative attitudes of patients were found in
the categories such as verbal abuse (shouting) andanxiety during communications and others.
Ⅳ．Discussion
1. Changes in MMSE and N-ADL after the treatment
Following the acupuncture treatment the mean scoresof MMSE and N-ADL were significantly increased
compared to those before the treatment among whole 56
patients. In patients with VaD or LS-D, theposttreatment MMSE scores were significantly increased,in contrast, MMSE increase was increased to a limited
range among patients with AD.

Table 3. N-ADL changes after the treatments

The scores of N-ADL before and after the treatment are shown in Table 3.

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Figure 1. Physical findings
The categories of physical findings are shown in Figure 1 (see the text).

Figure 2. Psychological findings
The categories of psychological findings are similarly shown in Figure 2 (see the text).

According to Sato et al.10-14), mechanical skin irritation
stimulates Meynert nuclei leading to the activation ofneurons which results in acetylcholine release from thecerebral cortex. This process in turn increases cerebral
cortex-blood flow where the brain function such as
thinking and judgment in memory function is involved.
The cerebral cortex and the hippocampus are very
sensitive to a decrease of blood-flow. It is known thatneurons results in death after a short period ofischemia15,16). The physical stimulation of acupunctureleads to cholinergic vasodilatation in the brain, whichcauses an increase of blood flow in the cerebral cortex
and hippocampus. This may prevent neuronal death due
to ischemia17,18), which may be consistent with clinicalimprovement of the patients with Sanjiao acupuncture
treatment as shown in the improvement of MMSE scoresand physical and psychological activities.
One of the present authors (HJ) showed a 20%
increase of lifespan in the senescence accelerated mouse.

These mice apparently showed cognitive improvements
in Morris water maze test, including functions likespatial memory, relearning, thinking and analytical
judgment abilities. Their neuropathological study
indicated that acupuncture inhibits withdrawal ofhippocampal neurons, suppresses reactive proliferationof glial cells while maintaining a neuronal/glia cellbalance. Following acupuncture treatment done for AD
and VaD patients, activities of daily living were
improved significantly compared to those of the patients
who received anti-cholinesterase medication. Memory
retention, orientation, and calculating ability became
apparently better in the VaD group than in the control
group prescribed with Hydergine. Marked and sustained
therapeutic effects were maintained especially in thepatients with mild levels of VaD. This is in good accord
with the present study of Sanjiao acupuncture therapy
for dementia patients.

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There was no good correlation between age, MMSE
and/or N-ADL. No significant changes were observed in
MMSE in the patients with nursing-care levels ≧ 3,
while a significant improvement of MMSE was found in
those with nursing-care levels ≦ 2. These results
implicate that the Sanjiao acupuncture therapy shows
significant help in maintaining and improving memory
for patients who required lesser levels of nursing care.
Yamazaki et al.19) conducted a study of 12-weeks
acupuncture for patients with memory loss. One groupof patients was given a guidance advice for lifestyle
improvement alone and the other received acupuncture
treatment with advices to their lifestyle as well. The
patients’ group with combined treatments of acupuncture
and lifestyle advices showed a better improvement in
MMSE scores and obtained a good sleep rest. Although
the MMSE scores after the treatment were insignificant,improvement was expected to a limited range in patientswith AD or in patients with nursing-care levels≧3 in thepresent study. These results imply that the acupuncture
treatment may prevent an unexpected rapid decline ofcognitive function as frequently seen among AD patients.
2. Physical, behavioral and psychological changes
after the treatment
With acupuncture treatment for 3 months, Guo et al.20)
reported appreciable improvements of BPSD in thepatients with AD, including insomnia, anxiety,frustration,
disturbancein
expression
andcommunication with the caregivers. However, no
therapeutic effects were present on the patients'
cognitive function like memory and calculating ability.
These results are in good accord with the present study,
in which symptoms of physical pain and other geriatricsyndrome were alleviated, and communication withcaregivers and family members was drastically improved.
Acupuncture treatment is an effective way of treatment
for common complaints of the elderly, which in fact had
been well appreciated in a long history andrecommended by WHO in these days. Thus, the novel
acupuncture method will contribute to improve BPSD
and improve quality of life of patients with dementia andtheir family members.
3. Future issue
The present study showed rational effectivities ofacupuncture treatment for patients with dementia and/or
lifestyle disease21). As the number of patients examined
is limited, we might need to add further experience.
Cochran Review for acupuncture treatment might
request to conduct a randomized controlled trial22) infuture. Excessive anxiety and irritabilities shown in
BPSD of the dementia patients may lead to instant denialor discontinuation of the treatment. It is cardinal to keepthem relaxed for the treatment and to give them and theircare-givers trustful information of the treatment.
Acknowledgments
The authors thank Gold-QPD acupuncturists for theircontribution in this study (Harumi AOKI,Hiroshi ARUGA, Takeshi EBISAWA, Masashi EBINA,
Chieko OISHI, Hiroshi KAMIGAICHI,
Isao KAWAKUBO, Yukiko TAKAGI,
Shinichi TAKEDA, Takeharu TAJIMA,
Kazuko TANABE, Masamitsu HANAMURA,
Yoshimi HANAWA, Masaki HARA, Jota HORI,
Yasuyuki MIYAMOTO, Kenzo MURAHASHI,
Tsukasa YANO, Tatsumasa YAMAMOTO,
Natsuko YAMAGUCHI, Ayumi YOKOO. (青木春美、有賀広、海老澤武士、海老名雅志、大石知絵子、上垣内敬司、川久保勳、高木由起子、武田伸一、田嶋健晴、田辺和子、花村将光、花輪貴美、原正輝、堀丈太、宮本泰之、村橋健三、矢野司、山本竜正、山口夏子、横尾亜由美)；

Conflict of interest
There is no conflict of interest.
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