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Neuroscience Letters xxx (2009) xxx–xxx 1

Contents lists available at ScienceDirect

Neuroscience Letters

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Ki Young Shin a,1 , Jun-Young Lee b,1 , Beom Young Won a , Hee Yeon Jung b , Keun-A. Chang a , Sushruta Koppula a , Yoo-Hun Suh a,∗

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BT-11 is effective for enhancing cognitive functions in the elderly humans

a Department of Pharmacology, College of Medicine, National Creative Research Initiative Center for Alzheimer’s Dementia and Neuroscience Research Institute, MRC, Seoul National University, 28 Yeongeon-dong, Jongno-gu, Seoul 110-799, Republic of Korea b Department of Psychiatry, Seoul National University Boramae Hospital, Seoul, Republic of Korea

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Article history: Received 11 June 2009 Received in revised form 13 August 2009 Accepted 13 August 2009

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It has been reported that a major risk factor of cognitive decline is aging in the elderly humans, even in the absence of neurodegenerative diseases such as Alzheimer’s and Parkinson’s diseases [2,4]. The cognitive decline in aging arises from multiple, distinct age-associated processes [3]. The cognitive impairments also were characterized in many patients with mild cognitive impairment, Alzheimer’s and Parkinson’s diseases [10]. Although it is different between the therapeutic approaches for the cognitive decline of the normal elderly and the patients with psychiatric disorders, the need for the development of nutraceuticals is remarkably noticed in many countries including USA [9]. The nutraceuticals are commonly defined as any substance that is considered as a food, a part of a food, or an herb that provides health benefits, including disease prevention and/or treatment, and they were first identified in 1989 [14]. Especially, the market for nutraceuticals is booming in USA on purpose to enhance and maintain memory function before the onset of memory impairments [9]. Roots of Polygala tenuifolia Willdenow have been used in humans for centuries because of its sedative effects on insomnia, palpitation with anxiety, restlessness and disorientation in humans [8]. We previously reported that BT-11 was extracted from roots of P. tenuifolia Willdenow which were used in oriental medicine

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Keywords: BT-11 CERAD-K Cognition MMSE Polygala tenuifolia

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Roots of Polygala tenuifolia Willdenow have been used in humans for centuries because of its sedative effects. We previously reported that BT-11, extracted from the roots of the plant, improved memory impairments in rats, enhanced memory in normal humans, and inhibited acetylcholinesterase activities in vitro. The present study was a randomized, double-blind, placebo-controlled comparison study to investigate whether BT-11 could enhance memory in the elderly humans. We used the Consortium to Establish a Registry for Alzheimer’s Disease Assessment Packet (CERAD) and the Mini-Mental State Examination (MMSE). In the elderly, the total CERAD scores were much more significantly increased in the BT-11-treated group (n = 28) than in the placebo-treated group (n = 25). Especially, the mean scores of word list recognition, constructional recall and praxis, and modified Boston naming test were markedly improved in BT-11-treated group than in placebo-treated group. In conclusion, BT-11 could enhance some cognitive functions including memory in the elderly humans and therefore may be used as nutraceuticals that provide health benefits, including disease prevention and/or treatment. © 2009 Published by Elsevier Ireland Ltd.

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journal homepage: www.elsevier.com/locate/neulet

∗ Corresponding author. Tel.: +82 2 740 8285; fax: +82 2 745 7996. E-mail address: yhsuh@snu.ac.kr (Y.-H. Suh). 1 These authors contributed equally to this work.

for centuries, improved memory impairments induced by scopolamine [15] and stress [18] in rats, and enhanced memory in normal humans [13]. BT-11 also inhibited acetylcholinesterase activities and prevented neuronal cells against many toxins in vitro [15]. In the present study, we investigated whether BT-11 could enhance cognitive functions including memory of the elderly after 8 weeks of administration. For measuring cognitive functions of the humans, we used the Consortium to Establish a Registry for Alzheimer’s Disease Assessment Packet (CERAD) and the MiniMental State Examination (MMSE). Participants aged 60 and over were recruited from among elderly outpatients registered at Seoul National University Boramae Hospital and community residents around there. To determine the dose in healthy human, the NOAEL (no observed adverse effect levels) was applied to this study as recommended in the “Guidance for Industry: Estimating the Maximum Safe Starting Dose in Initial Clinical Trials for Therapeutics in Adult Healthy Volunteers” published by the U.S. FDA CDER (U.S. Department of Health and Human Services Food and Drug Administration Center for Drug Evaluation and Research). BT-11 was proven safe at doses up to 0.6 g/kg in preclinical toxicity tests in rats. If the dose of drug was extrapolated to healthy people (60 kg), the maximum human dose was calculated using a safety factor of 100 as follows: 0.6 times 60 divided by 100 gives 360. Thus, the 300 mg dose per person was determined based on the maximum human dose, 360 mg. This was a randomized, double-blind, placebo-controlled comparison study of one oral dose of BT-11 (300 mg/person/day) given during 8 weeks.

0304-3940/$ – see front matter © 2009 Published by Elsevier Ireland Ltd. doi:10.1016/j.neulet.2009.08.033

Please cite this article in press as: K.Y. Shin, et al., BT-11 is effective for enhancing cognitive functions in the elderly humans, Neurosci. Lett. (2009), doi:10.1016/j.neulet.2009.08.033

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BT-11 (n = 28)

Placebo (n = 25)

P value

Age (years) Female (%) Education (years) MMSE score CERAD score

67.57 ± 6.36 22 (78.6) 6.54 ± 3.6 24.11 ± 3.11 61.39 ± 9.30

69.92 ± 5.81 23 (91.7) 5.46 ± 3.6 23.24 ± 2.68 60.56 ± 8.04

0.417 0.256 0.441 0.759 0.150

Values represent number (%) or mean ± standard deviation. CERAD: Korean version of Consortium to Establish a Registry for Alzheimer’s Disease Assessment Packet. MMSE: Korean version of Mini-Mental State Examination.

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age was 68 years (BT-11 = 67.57 ± 6.36 vs. placebo = 69.92 ± 5.81, n.s.) and 85% were female (BT-11 = 78.6% vs. placebo = 91.7%, n.s.). The mean education years were 6 years (BT-11 = 6.54 ± 3.6 vs. placebo = 5.46 ± 3.6, n.s.). The mean scores of MMSE (BT11 = 24.11 ± 3.11 vs. placebo = 23.24 ± 2.68, n.s.) and CREAD (BT11 = 61.39 ± 9.30 vs. placebo = 60.56 ± 8.04, n.s.) at baseline were similar between the two groups. In Table 2, the results about the mean changes of total CERAD and the subtests from baseline to week 8 were shown. Primary efficacy was measured by total CERAD scores. The total CERAD scores at the end point supported the effectiveness of BT-11 on cognition (baseline = 24.11 ± 3.11 vs. changes at week 8 = 25.25 ± 2.81, P = 0.001). Fixed factors are groups (BT11-treated and placebo-treated group) and time (Pre and Post). Dependent variable is each cognitive score. Interactions between time and groups are observed in word list learning, constructional recall and praxis, and Boston naming test. In BT-11-treated group, postscore is better than prescore, but not in placebo-treated group. In the subtests of CERAD, the mean scores of word list learning (BT-11 = 2.82 ± 2.96 vs. placebo = 0.00 ± 2.08, P = 0.035), constructional recall (BT-11 = 0.64 ± 1.57 vs. placebo = −1.04 ± 2.48, P = 0.004) and praxis (BT-11 = 0.18 ± 1.81 vs. placebo = −0.8 ± 1.50, P = 0.047), and modified Boston naming test (BT-11 = 1.00 ± 1.61 vs. placebo = 0.00 ± 1.83, P = 0.047) were much more improved in the BT-11-treated group than in the placebo-treated group. But, the mean scores of the MMSE, word list recall, word list recognition, verbal fluency and trail making tests A and B were not significantly different between two groups. Therefore, BT-11 could enhance some cognitive functions of the elderly humans. It has been known that the roots of P. tenuifolia Willdenow exhibit sedative effects in oriental medicine [8] and we first demonstrated that BT-11 extracted from those roots improved scopolamine-induced [15] and stress-induced [18] memory deficits in rats and enhanced memory in normal humans [13]. As shown in Table 2, the results supported the effectiveness of BT-11 on cognition. In the subtests of CERAD, word list learning (verbal memory), constructional recall (visuospatial memory) and praxis (visuospatial ability), and modified Boston naming test (language ability) were much more enhanced in the BT-11-treated group than in the placebo-treated group. These results strongly suggest BT-11 can enhance memory, visuospatial ability, and language ability in humans. This means that BT-11 enhances cognitive functions. Therefore, BT-11 can be used as nutraceuticals such as Brain Energy, Brain Gum, Brain Pep that are claimed to enhance cognitive functions and are readily accessible in local pharmacies and food markets [9]. Additionally, we previously investigated that BT-11, known as an anti-acetylcholinesterase agent, improves stress-induced memory impairments through increment of glucose utilization in PET studies on rat brains [18]. Cholinomimetics, such as acetylcholine precursors and acetylcholinesterase inhibitors, were developed as potential memory-enhancing drugs. There is some evidence that the enhancement of cholinergic functions in healthy humans may improve cognitive processes, including memory [5,7,16]. If we succeed in isolating a major component of BT-11 that plays an important role in antipsychotic and antidementic

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Table 1 Baseline characteristics of the BT-11-treated and placebo-treated group.

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All participants received BT-11 or placebo using three matched capsules (100 mg/capsule). The review board of the institution (IRB) of Seoul National University Hospital approved the study protocol. Eligibility criteria were as follows: (1) age 60 years or over, (2) having subjective memory complaints, (3) no use of other cognitive enhancers for least 2 weeks and (4) no known history of neurological disease, head trauma, stroke, dementia, severe depression or any other physical illness affecting cognitive functions. Dementia subjects were excluded by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria [1]. One trained psychologist evaluated the cognitive functions of the subjects using the Korean versions of the Consortium to Establish a Registry for Alzheimer’s Disease Assessment Packet (CERAD) and the Mini-Mental State Examination (MMSE) at baseline and at week 8. The primary efficacy variables were total CERAD scores. In addition, MMSE and seven subtests of CERAD are compared between groups. Compliance and safety were also checked at weeks 4 and 8. The safety and tolerability of BT-11 were assessed by physical examinations, measurement of vital signs, electrocardiography, laboratory tests (hematologic tests, blood chemical values, and urinalysis), and recording of adverse events. The test was used to detect dementia by CERAD [19]. It tests five areas of cognition: memory (word list learning, word list recall, word list recognition, constructional recall), visuospatial ability (constructional praxis), executive function (verbal fluency, trail making test B), language ability (modified Boston naming test), and attention (trail making test A). Total CERAD score is comprised of following item scores: word list learning, word list recall, word list recognition, constructional praxis, verbal fluency and modified Boston naming test [4]. It scores from 0 to 100; higher scores indicate better cognition. High scores of all subjects except trail making test indicate better cognition. Trail making test scores mean the time to complete tests, therefore low scores indicate better cognition. The CERAD neuropsychological test is commonly used worldwide in studies of AD and other dementias of the elderly. It was well validated in Korean elderly [12]. The MMSE is a neurocognitive test designed to screen memory impairments [6]. It scores from 0 to 30; higher scores indicate better cognition. It can be administered in 5–10 min. The Korean version of MMSE is composed of orientation (10 points), shortterm memory registration and recall (6 points), attention (5 points), naming (2 points), following verbal commands (4 points), judgment (2 points), and copying a double pentagon (1 point). The MMSE was well validated in Korean elderly [6,11]. In the results, the main efficacy analysis was based on the randomized patients who completed the study. Analysis of safety was performed on all patients who received at least one dose of study medication and who provided any post-baseline follow-up data. Changes from baseline were compared between BT-11-treated and placebo-treated group using a two-way model analysis of variance. SPSS for Windows (release 11.0) was used for the data analyses. P values below 0.05 were considered statistically significant throughout the analysis. Sixty were enrolled. They were randomly assigned to one of the two groups taking 300 mg/day of BT-11 (n = 30) or placebo (n = 30). Fifty-three subjects completed an 8-week, randomized, double-blind, placebo-controlled trial (BT-11 group = 28, placebo group = 25). Premature discontinuations were due to the patient’s refusal of ongoing participation (2 patients receiving BT-11 [7%] and 3 patients receiving placebo [10%]), drug noncompliance (2 patients receiving placebo [7%]). There were no serious adverse effects in both groups. Seven subjects (23%) from BT-11-treated group and 1 subject (3%) from placebo-treated group had only mild dyspepsia and totally disappeared during 1 month. As shown in Table 1, the baseline characteristics were similar between the two groups. Of the randomized patients, the mean

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Table 2 Mean of baseline scores and changes at week 8 in BT-11-treated and placebo-treated group. Baseline

Change from baseline

24.11 61.39 15.25 4.68 8.61 5.21 9.26 13.11 10.46 79.98 267.46

± ± ± ± ± ± ± ± ± ± ±

3.11 9.30 3.01 1.66 1.60 2.81 1.72 3.40 2.33 38.63 108.05

Placebo (n = 25) 23.24 60.56 13.84 4.52 8.68 5.72 9.64 13.48 10.40 104.80 296.48

± ± ± ± ± ± ± ± ± ± ±

BT-11 (n = 28)

2.68 8.04 4.11 1.64 1.28 2.88 1.66 3.28 2.84 94.27 87.90

1.14 7.68 2.82 1.07 0.79 0.64 0.18 1.82 1.00 −6.23 −0.53

± ± ± ± ± ± ± ± ± ± ±

2.34 7.41 2.96 1.39 1.37 1.57 1.81 4.12 1.61 27.84 86.74

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BT-11 (n = 28) MMSE score CERAD total score** Word list learning* Word list recall Word list recognition Constructional recall** Constructional praxis* Verbal fluency Modified Boston naming test* Trail making test A Trail making test B

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P value Placebo (n = 25) 0.00 1.64 1.16 1.04 0.16 −1.04 −0.8 0.00 0.00 9.88 17.28

± ± ± ± ± ± ± ± ± ± ±

2.08 4.93 2.17 1.40 1.40 2.48 1.50 2.77 1.83 34.29 103.39

0.052 0.001 0.035 0.855 0.065 0.004 0.047 0.068 0.049 0.071 0.498

Values represent number (%) or mean ± standard deviation. CERAD: Korean version of Consortium to Establish a Registry for Alzheimer’s Disease Assessment Packet. MMSE: Korean version of Mini-Mental State Examination. * P < 0.05 compared with placebo-treated group. ** P < 0.01 compared with placebo-treated group.

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[17]. Acknowledgements

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This study was supported by a National Creative Research Initiative Grant (2003–2009) from the Ministry of Science and Technology, the Republic of Korea and in part by BK21 Human Life Sciences, the Republic of Korea and by Braintropia Co., Ltd., the Republic of Korea.

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effects, it is possible that the single component of BT-11 can be used as a therapeutic candidate for Alzheimer’s disease. In conclusion, BT-11 has beneficial effects on cognitive functions including memory of the elderly. Therefore, BT-11 may be used as nutraceuticals that provide health benefits, including disease prevention and/or treatment.

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