## 4 Discussion
Increasing BDNF expression is one of the emerging therapeutic strategies for dementia [54]. In this respect, a botanical extract that increases BDNF may be a plausible solution to delay the progression in older adults with predementia. Previous studies have revealed that compounds present in sage may increase BDNF expression [55]. The botanical blend also contributed to increased AChE inhibition in hippocampal cells, which is a potential biomarker for dementia. One of the suggested hypotheses for Alzheimer's disease onset is due to the low levels of neurotransmitters such as acetylcholine, which causes memory loss and cognitive decline [56]. Acetylcholinesteraseerase (AChE) breaks down cholines and subsequently inhibits neurotransmission in cholinergic neurons. There are numerous natural botanicals that could potentially contribute to improving Alzheimer's disease progress by inhibiting AChE [57]. There are several studies suggesting that components present in _Salvia officinalis_ may help lower AChE activity [58; 59; 60; 61]. This includes in vitro and animal studies, and several components, including rosmarinic acid, have been identified to be involved in this AChE inhibition. This inhibiting effect has been clinically shown to help improve memory, anxiety and mood in older adults [34; 36]. However, the studies demonstrated the short-term effect of the extract in the few hours after consumption, while a longer exposure to the extract was not assessed. Once the final formula was defined, a clinical trial in healthy older adults was conducted using two different doses, 250 mg and 400 mg, and compared to a placebo. Two questionnaires were conducted in the clinical study: MoCA and ADAS-Cog. The results of the MoCA test revealed significant improvements with the 400 mg dose when comparing the intermediate measurement (week 6) with the end of the study (week 12). Whenanalyzing the seven individual categories, both doses contribute to improving short-term memory recall, while abstract reasoning seemed to improve only in the 400 mg dose. As for the ADAS-Cog test, the results revealed that both doses significantly improved the global score after 12 weeks of intake compared to the placebo. Intragroup analysis revealed significant improvements only in the experimental product, with earlier significant results observed at the higher dose. Regarding the types of memory, both doses seem to significantly improve language (at week 12) and praxis (at week 6) compared to the placebo. As for the analysis of the individual items, both doses contributed to improving word recall and commands compared to both baseline values and the placebo, with improvements in word recognition also detected in the 250 mg dose only when compared to baseline. We postulate that the effect of the combination of sage and rutin is contributing to the significant improvement observed in the study through the mechanisms observed in the previous preclinical assessment. Specifically, the increase in BDNF observed with the combination may be one of the major mechanisms for this improvement. The most relevant significant improvements observed were those related to memory, such as short-term memory recall, word recognition and other similar factors. As previously mentioned, BDNF is considered to be one of the most important factors related to memory, and increasing BDNF levels is one of the possible strategies to prevent and/or treat dementia [52, 54]. However, we cannot rule out that there are other contributing factors, which may include the increased expression of additional factors (NGF, VEGF, etc.) and the antioxidant effect of the blend. In the end, it is very plausible that there are several contributing factors behind the observed effects. Interestingly, in many sections of the questionnaires, there was an overall significant improvement at week 6 of the study compared to baseline values, including the placebo group. We hypothesized that this could be due to a learning process of the tests, which results in better scores in all the subjects.