Effectiveness of Yi-Zhi-An-Shen Granules on cognition and sleep quality in older adults with amnestic mild cognitive impairment: protocol for a randomized, double-blind, placebo-controlled trial

Effectiveness of Yi-Zhi-An-Shen Granules on cognition and sleep quality in older adults with amnestic mild cognitive impairment: protocol for a randomized, double-blind, placebo-controlled trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Study protocol Effectiveness of Yi-Zhi-An-Shen Granules on cognition and sleep quality in older adults with amnestic mild cognitive impairment: protocol for a randomized, double-blind, placebo-controlled trial Shengnan Yue, Ting He, Baiyang Li, Yanqin Qu, Hongmei Peng, Jinxin Chen, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.2.249/v3 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Aug, 2019 Read the published version in Trials → Version 3 posted 4 You are reading this latest preprint version Show more versions Abstract Background Amnestic mild cognitive impairment (aMCI) is a syndrome characterized by significant forgetfulness that does not meet the criteria of dementia. Individuals with aMCI are at a bigger risk of progressing to dementia. Current studies suggest good sleep quality is linked with preserved cognition in the elderly, and sleep complaints are common among the elderly with amnesia. Therefore, improving their sleep may be helpful for maintaining and improving their cognitive capacity. According to the theory of traditional Chinese medicine, Yi-Zhi-An-Shen is an herbal compound which may ameliorate forgetfulness and sleep disorders. As growing evidence indicates that gut microbiome is associated with major mental symptoms, a hypothesis was proposed that Yi-Zhi-An-Shen Granules (YZASG) might work by alternating microbial abundance and diversity. In this study, the investigators intend to assess the efficacy of YZASG on global cognition in the elderly suffering from aMCI, and evaluate its safety as well as its potential mechanisms via sleep quality, fecal microbial 16SrDNA and metagenomics analyses, and serum markers. Methods/design This is a randomized, double-blind, placebo-controlled clinical trial. A total of 80 patients (aged 60~85 years) will be recruited and allocated randomly to a treatment group and a placebo group in a 1:1 ratio, then will be administered YZASG or isodose placebo three times a day. The intervention course is 16 weeks, with an 18-month follow-up. The primary outcome is Alzheimer Disease Assessment Scale-Cognitive subscale (ADAS-cog11). Secondary outcome measures are mini-mental state examination (MMSE), Montreal cognitive assessment (MoCA), Pittsburgh Sleep Quality Index (PSQI), serum concentrations of immunological factors and inflammatory cytokines, fecal microbiota. Fecal microbiota will only be collected at the baseline and endpoint of the intervention. Discussion The results of this trial will be conducive to assessing the safety and effectiveness on cognition of YZASG in intervening aMCI among the elderly and determining if it takes effect via the improvement of sleep quality, regulation of gut microbita, concentration of certain serum markers. General Medicine Amnestic Mild cognitive impairment (aMCI) Sleep Gut microbiome Older adults Figures Figure 1 Background Alzheimer’s disease (AD), one common type of dementia worldwide, is a neurodegenerative disease characterized by insidious onset and progressive cognitive decline [1]. It cannot only detrimentally affect physical condition and quality of life in patients, but also bring a huge burden on both family and society [2]. The prevalence of AD was 3.21% reportedly among the old in China [3]. It is proposed recently that research strategies of AD should focus on the preclinical stages – preclinical AD and mild cognitive impairment (MCI) due to AD, which are relatively ideal for intervention [4]. Patients with MCI always suffer cognitive decline severer than expected for an individual’s age and education level, but which does not obviously affect daily function [5]. And the elderly with MCI are at a high risk of developing to dementia [6]. As the main subtype of MCI, nearly 90% of older adults with amnestic MCI (aMCI), MCI with memory complaints, reportedly progress to AD, and share similar pathophysiological characteristics with AD [7]. Nowadays, standard clinical management of MCI includes managing its risk factors, there’re still limited pharmaceutical options for treating MCI from the NIA-AA working group guidelines [8]. Thus effective drugs and other interventions are expected to be discovered to reduce the rate of progression from MCI to dementia. Brain areas and systems of neurotransmitters involving regulation of sleep-wake cycle relate to memory and cognition mostly [9-11]. Individuals with various types of cognitive impairment generally have sleep disturbance [9, 12-14], and the study also suggested that the severity of these sleep disorders closely relates to that of cognitive decline [14]. Moreover, older adults with bad sleep quality always suffer poor cognitive performance [15-16], which might be related to higher level of AD-associated amyloid-β in brain [17]. Structural imaging data indicated that insomnia is associated with decreased volume of brain tissue, including hippocampus, as well [18].The disorder of circadian rhythm often accompanies with high risk of cognitive decline and affects negatively cognition in multiple ways. Therefore, sleep problem is one risk factor of impaired cognitive function. Several studies suggested that besides improving the cognitive performance and ability of daily living in individuals with AD, acetylcholinesterase inhibitors (ChEIs), like donepezil, galantamine and rivastigmine, also improved mental behavioral symptoms and sleep quality of these patients [19-21]. Furthermore, some trials indicated that melatonin could improve cognitive symptoms in patients with MCI and might delay their conversion to dementia [22-23]. As sleep disturbance appears to be linked with both aging and cognitive decline, strengthening sleep quality of the elderly might be an effective therapeutic target to slow the deterioration or improve cognitive impairment. According to recent studies on MCI or AD, which involved donepezil [7], galantamine [24], memantine [25] and Solanezumab [26], pharmaceutical interventions showed poor amelioration of cognitive deficits. It might be the single pharmacological target of these drugs that did not adequately address the specific multiple pathophysiological characteristics. However, traditional Chinese medicine (TCM) is known for its multi-target, which could be used to address the complicated pathophysiological changes. In the light of theory of TCM, kidney deficiency is the basis of amnesia and other cognitive deficits, while phlegm and blood stasis are significant pathological factors. For this reason, amounts of experiments and trials have been carried out and shown specific effects against cognitive decline, which involve Alpiniae oxyphyllae fructus [27], Ligusticum wallichii [28-30], curcuma [31-32], Fructus gardenia [33-34], Radix notoginseng [35-36]. Meanwhile, an herbal formula named Yi-Zhi-An-Shen (YZAS) Granules has been composed of Lophatherum gracile and medical herbs mentioned above, which is designed for aiding the treatment of cognitive deficits. Table 1 details the pharmacological targets that the components in YZAS, which could be involved in the management of MCI. There have been preclinical researches contributing to the standardization of YZAS [37] and the mechanisms of its potential actions in animal experiments [38]. And some indications also manifested its safety and efficacy for improving cognitive function in clinical practice without causing daytime dysfunction. Based on the theory of TCM, the actions of YZAS include soothing the nerves, that is to say, making someone calm down and helping sleep. Besides, as the emerging hypothesis of brain-gut axis, plenty of studies has shown changes of gut microbiome and the metabolite exert of gut microbiome exert an influence on cognition impairment [39-41]. Because of being administrated orally, it should be noticed that the mechanism of action of YZAS might be via the gut microbiota. Consequently, a clinical trial with rigorous design is needed to confirm its safety in old individuals with MCI, efficacy on cognitive performance, and explore its potential mechanisms. Methods 1. Objectives The primary objective of this study is to evaluate the efficacy of Yi-Zhi-An-Shen Granules (YZASG) in optimizing cognitive performance over time in elderly individuals with aMCI. Secondly, the investigators intend to assess whether YZASG can improve sleep quality among aMCI patients, this herbal formula’s safety will also be assessed. Finally, participants’ serum samples and fecal genomic DNA will be extracted to analyze the differences of the indices of metabolism, cellular immune function, and gut microbiota between old individuals with aMCI and ones with normal cognition. 2. Design This study is a randomized, double-blind, placebo-controlled trial with 16-week intervention and 18-month follow-up assessment. The current protocol (version v1.1) met the principles of the Declaration of Helsinki, and was in accordance of with Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) (see Additional file 1) and was approved by the Medical Ethics Committee of Teaching Hospital of Chengdu University of TCM. Then signed informed consents will be obtained from participants. And during the consent process, the caregiver or informant of the potential participants own should be present. The participants will be recruited from the communities, outpatient clinics of Teaching Hospital of Chengdu University of TCM and Welfare Institution of Emei Civil Administration in Sichuan Province, China. The Medical Ethics Committee has thoroughly reviewed this study, and then the ethical approval covers all these study sites. The enrolled participants will be randomly assigned into the YZAS group or the placebo group with the allocation ratio of 1:1 using the statistical package. Allocation was concealed using batch numbers generated with SAS 9.2 software (Cary, NC, USA) by a statistician. The unique code will be assigned to each newly enrolled participant and preserved in the trial management board. The statistician expert who acts as the coder will be shielded from subject recruitment and statistical analysis, which will be performed by another statistician independent of the study group. Both participants and the research team are blinded to allocation. There will be six measurement sessions during this whole study, including the intervention period and the 18-month period (Figure 1). Any changes to the study protocol will be communicated with the study investigative team and the approving ethics committee. 3. Methods 3.1 Participants The investigators anticipate recruiting 80 participants from Teaching hospital of Chengdu University of TCM, communities, and Welfare Institution of Emei Civil Administration. All patients will undergo standard medical examination and neuropsychological testing to ensure correct diagnosis of aMCI. The inclusion criteria are: (1) subject has assigned informed consent to participate in the study and continues to give willing consent for participation with (2) age from 60 to 85 years with a diagnosis of aMCI (3) educational level of at least 6 years (4) availability of a caregiver or informant who can assist in completing rating scales for the duration of the study (5) cognitive complaints reported by the subject and confirmed by the caregiver or informant (6) Clinical Dementia Rating (CDR) global score of 0.5, and memory item score of 0.5 (7) Mini-mental state examination (MMSE) score of 24-30 (for the participant with educational level of 6 years, MMSE score of 20-30) (8) Diagnostic and Statistical Manual of Mental Disorders, Version 5 (DSM-V) criteria of dementia not fulfilled A patient will be excluded when he or she: (1) has been previously enrolled in this study and received the investigational product (2) has received an investigational product within 30 days prior to screening (3) has received disease-modifying therapy in the past 6 months (e.g., donepezil, rivastigmine, galantamine, memantine, and any other existing drugs that are declared to have the function of improving cognition) (4) has a known allergy to the study drug or any of its constituents; (5) has a history of alcohol abuse or alcohol dependency in the 3 years prior to study entry, or is an alcoholic or drug addict, as determined by the investigator (6) has ongoing clinically significant (as judged by the investigator), metabolic or any other disease that could currently cause impaired memory (e.g., untreated thyroid disease, vitamin or other nutritional deficiencies, chronic kidney, or liver disease) (7) has memory impairments that can be attributed to a disease or condition other than an early phase neurodegenerative syndrome (8) has a parkinsonian movement disorder (9) uses psychoactive medications that would affect the subject's ability to reliably perform neurocognitive testing or create uncertainty in distinguishing between the effects of the psychoactive medication and the subject's underlying cognitive impairment (e.g., benzodiazepines, sedatives, antipsychotics) (10) has a history of major recurrent depressive disorder (DSM-V) within the last 5 years prior to screening (11) has a brain tumor or other intracranial lesion, a disturbance of cerebral spinal fluid circulation (e.g., normal pressure hydrocephalus), and/or a significant history of head trauma or brain surgery (12) has signs of major cerebrovascular disease, with score of modified Hachinski Ischemia Score (mHIS) at more than 4, or as verified by medical history and/or brain MRI or CT (13) has severe visual or hearing impairments that cannot cooperate with examinations (14) has severe digestive system diseases (15) has received antibiotics within 60 days prior to screening. Handling of withdrawal and dropout: (1) Voluntarily withdrawal, (2) loss of follow-up, (3) poor compliance and presence of severe adverse effects, (4) revealing and uncovering blind in urgency, (5) misdiagnosis, (6) using forbidden drugs or treatments in the course of the trial, (7) taking no medication during the trial, (8) no evaluable records after medication. Reasons for withdrawing participants will be recorded in case report forms (CRFs), and the last data will be included in data analysis. All these criteria will be ascertained by the supervisor of this study. 3.2 Interventions All the participants will receive the same basic treatment, including health education, moderate aerobic exercise (30-60 minutes per day) and general nutritional support. The participants assigned to the YZAS group will take Yi-Zhi-An-Shen granule, which is composed of YiZhiRen ( Alpinia oxyphylla Miq. ) - 5g, SanQi ( Panax notoginseng ) - 3g, ChuanXiong ( Ligusticum chuanxiong hort ) - 10g, ZhiZi ( Gardenia jasminoides Ellis ) - 10g, YuJin ( Curcuma longa L. ) - 10g, DanZhuYe ( Lophatherum gracile ) - 10g, while ones in the placebo group will take placebo made from starch which appears the same shape, color, smell, taste, texture package and Lot Number. Participants will be instructed to dissolve granules into 100ml of boiled water and to take the solution orally between 30℃ to 37 ℃ three times daily for 16 weeks. Each granule is prepared by Sichuan Neo-green Pharmaceutical Technology Development Co., Ltd, Sichuan China according to the standards of Good Manufactory Practice (GMP). During the whole study period, relevant health care and treatment for medical needs will be permitted without adverse reactions with YZASG or hindering the study process. 80% to 120% of drug usages are eligible for protocol plan. The package, drug name, function and indication, usage and dosage, storage condition, valid period and name of the manufacturer will be marked and a tag indicating ‘trial use’ will be attached. Drugs must be kept in the appropriate temperature in a dry, cool and shady place. Drug administrators should take back unused drugs to estimate participant compliance and record these in the CRFs. 3.3 Outcomes 3.3.1 Primary outcome Cognitive decline is measured using the Chinese version of the Alzheimer Disease Assessment Scale-Cognitive subscale (ADAS-cog11). It was also chosen to calculate the sample size, for a 4-point change in it as the measure of clinical significance [42].The total score is 70. A score increase indicates greater severity of impairment. The specific hypothesis is that the increase from baseline to endpoint will be significantly less at least 2.5 points than that for placebo, which will be considered effective in this study. The ADAS-cog will be assessed at baseline (before intervention), at 16 weeks (the end of intervention) and 6, 12, and 18 months after intervention. 3.3.2 Secondary outcome Secondary measures include the MMSE, Montreal Cognitive Assessment (MoCA, Changsha Version), CDR, Pittsburgh sleep quality index (PSQI), activity of daily living (ADL), gut microbiome, and serum markers. The MMSE is an 11-question measure that tests five areas of cognitive function (orientation, registration, attention and calculation, recall, and language). The maximum score is 30 and a score below 24 is considered abnormal for dementia screening. The MoCA (Changsha Version) will also be used to evaluate general cognitive function, as it contains visuospatial processing and organizational capability which can make up for the shortcoming of the MMSE. The total score for it is 30, with a higher number indicating a more intact cognitive function. Meanwhile, the MoCA has been shown to be a promising tool to detect MCI and early AD. The CDR will be used as an assistant evaluation for patients’ dementia severity, which scored 0-3, with higher scores indicating more severity. It is a semi-structured interview performed with the patient and caregiver (informant), characterizing six domains of cognitive and functional performance. The CDR sum of boxes (CDR-SB) scored 0-18, will also be applied to assess patients’ cognitive status, with higher scores indicating worse functioning. The PSQI will be used to assess participants’ comprehensive quality of sleep, which involves sleep quality, sleep duration, sleep efficiency, sleep disorders, daytime dysfunction, sleeping aids, etc. The total score for it is 21, with a higher score indicating a worse sleep quality. ADL will be assessed including basic activities of daily living (BADL) and instrumental activities of daily living (IADL). An individual's BADL will be evaluated mainly by the subjects' performance from the perspectives of bathing, dressing, grooming, initiation, toileting and feeding, with six items and a sum of scores ranging from 0 (normal) to 24 (complete dependence on others). And modified Lawton Instrumental Activities of Daily Living Scale will be used to measure the IADL of a subject, with eight items and a sum of scores ranging from 0 (normal) to 32 (complete dependence on others). These clinical tests will be administrated by a trained, certified clinician or rater experienced in the assessment of patients with cognitive deficits. And the rater who will conduct the CDR for a patient cannot complete any other rating scales for the same patient, and will be blinded to the results of all other neuropsychological scales. Scales mentioned above will be assessed at baseline (before intervention), at 8 and 16 weeks (during intervention) and 6, 12, and 18 months after intervention. Blood samples will be collected from all participants for further assessing the mechanisms of YZASG via changes in serum metabolic, inflammatory, and immunologic markers. All these tests will be entrusted to the laboratory medicine of Sichuan Academy of Medical Science & Sichuan Provincial People’s Hospital for conduction. Fecal genomic DNA will be extracted from frozen stools using QIAamp DNA mini stool kit (Qiagen, Hiden, Germany), obtained from the patients with aMCI and 15-20 participants with normal cognition at baseline and the end of the intervention. After PCR amplification, DNA fragments will be sequenced on an Illumina HiSeq 2500 instrument and an Illumina HiSeq X instrument for 16SrDNA and metagenomics analyses (which will be chosen from some representative samples in the results of 16SrDNA analysis) respectively at Biomarker Technologies Co, Ltd (Beijing, China) to analyze the differences in gut microbiome between patients with aMCI and individuals with normal cognition. When it is available, the investigators will also assess the changes in gut microbiome between the treatment group and the placebo group after the intervention of YZASG in the same way. 3.3.3 Safety outcomes To assess the safety of YZASG compared to placebo in subjects with aMCI, the investigators will record the incidence and severity of treatment-emergent adverse events (TEAEs), and clinically important changes in safety assessment results. These safety indicators, including vital signs, weight, clinical laboratory tests, physical and neurological exams, ECGs, and CTs/MRIs, will gather at the baseline and the end of 16th week. 4. Statistical considerations and data management 4.1 Sample size Using pre-intervention and post-intervention scores obtained from Miao et al. [43], on the basis of non-inferiority trial principle, one-sided test, at α = 0.05, then at least 33 patients are needed for inclusion in the treatment group who will be administrated with YZASG to achieve a prospective power of 90% (ie. β=0.1) and detect a minimum clinical between-group difference of 1.30 on ADAS-cog [43] at 16 weeks. Allowing for a maximum dropout rate of 20%, the number of subjects in the treatment group has been set to 40 patients with aMCI. With the allocation ratio of 1:1, 80 subjects are required. 4.2 Statistic analysis Analysis will be conducted by another statistician of the National Clinical Trial Center of Chinese Medicine (Chengdu, China), who will be also blinded to the whole trial, using SAS 9.2 software (Cary, NC, USA) and SPSS 21.0 software (IBM, NY, USA). The analysis data set will consist of a modified intention-to-treat data set, a per protocol (PP) set, and a safety data set. All mechanism and efficacy analyses will be conducted according to the modified intention-to-treat (mITT) principle. The mITT data set will include the participants who have completed at least one observation since the intervention begins. The PP population will only include participants who adhered to the trial protocol and completed the clinical trial. And the minimum compliance rate for participants taking the investigational drugs in the PP data set is 80%. Besides, the safety analysis will be conducted according to the safety data set, which will include any participants who were assigned to randomly and took at least one dose of the investigational drug. Missing values will be replaced by the last observation carried forward (LOCF) method. ADAS-cog (including its monomial item) changes from baseline and the secondary outcomes will be assessed using an analysis of covariance with treatment groups as factors and baseline values as covariates. Mean differences will be used to express effect sizes. The baseline homogeneity of the baseline characteristics and differences between the two groups will be analyzed with Fisher’s exact test, or 2 test for categorical measures and with the t test or Wilcoxon rank-sum test for continuous measures. The statistical significance is defined as a one-sided P-value of <0.05 and 90% confidence interval. For the gut microbial 16SrDNA analysis, sequenced data will be interpreted using the bioinformatics tools programmed in the Ion Reporter software. Based on the specified similarity, QIIME algorithms will be used to classify operational taxonomic units (OTU) and statistically analyze biological information, and then to understand the diversity and abundance of the flora community, and further to determine the bacterial diversity within a sample (α diversity) and among all the samples (β diversity). Alpha diversity includes four indicators that represent total number, richness, phylogenetic diversity, and dispersible uniformity of species and community abundance. These four algorithms, including binary jaccard, bray curtis, weighted unifrac, and unweighted unifrac, will be performed to analyze β diversity to compare the similarity of different samples in species diversity. According to the above data, principal component analysis will be conducted to observe the differences between floras. Additionally, multivariate data analysis with principal component analysis on the diversity indexes and comparisons of genus and species level data will be performed to reveal differences in the microbial composition between individuals with normal cognition and ones with aMCI. Metastats software will be used to perform t test on the species abundance data between two groups, and p value will be obtained, then by correcting p value q value will also be obtained. Subsequently, according to p or q value, species that cause the differences in the microbial composition of the two sets will be screened out. Significant analyses between two groups will be performed at the level of classification of the gate, class, subject, family, genera and species, respectively. Sparcc algorithm will be used to conduct correlation analysis (including positive and negative correlation) and statistical tests. Next, a co-expression analysis network map will be drawn using python. The subsequent statistical analyses will be performed with the R Programming Language 3.0.1 (NZL). When it comes to metagenomics analysis, after getting Clean Reads, taxonomic analysis will be conducted to measure species composition and abundance information of samples. After the significance test of difference has been performed, p value will be obtained. Then by correcting the p value, false discovery rate (FDR) will be obtained. The Benjamini Hochberg false discovery rate adjustment will be used to account for the number of taxa tested in each comparison. 4.3 Data management All data will be stored on a secure server with two back-up copies on external hard drives. Paper-based forms will be digitized and the original copies stored in locked filing cabinets in the archives room of Good Clinical Practice (GCP) in Department of Geriatrics, and managed by a department staff member who is external to the research team. All participants are de-identified upon randomization and referred to on all forms with a participant ID. A password-protected spreadsheet stored on the secure server links participant names to ID codes to all for re-identification to occur if required. As this is a relatively small investigator-initiated trial, a data monitoring committee and auditing process are not required. 5. Quality control and monitoring Each trial center has a project manager who takes charge of the quality of research. All investigators were qualified and trained before. After the baseline measurement, the 16 weeks of intervention will be dispensed. Participants will be required to return any unused medication at every 2 weeks, which will be used for determining compliance. The number of returned granules will be counted by a department member who is external to the study team. During the whole course, attentive follow-up will also be conducted every 2 weeks. Participants who exit the study early will be contacted via telephone and requested to complete the exit interview. To monitor safety, participants will be referred to the Teaching Hospital of Chengdu University of TCM and the local cooperating hospital of Welfare Institution of Emei Civil Administration, which is next to the institution. Standard blood safety tests (full blood count, blood coagulation function, liver and renal function tests) and ECGs will be carried out at the baseline and the end of the 1st and 16th weeks of intervention, while brain CTs/MRIs will be done at the baseline and the end of 16th week. And the reports of annual physical checkup of participants are also encouraged to share with the investigators in this study. Adverse events will be closely monitored and recorded throughout the whole course of the study. Once a serious adverse event happens, if the study drug is suspected to be a potential cause and receiving appropriate medical care is identified to be essential for the participant, then unblinding of that participant will occur and at least two persons should present. After treated, that participant will be stopped from the subsequent investigation and regarded as the dropout case. Anyway, the investigators will also visit that participant regularly and record his/her reactions and treatments of the adverse events until the endpoint of this study. And this will be performed by the department member external to this study team. A development update safety report must be submitted annually to the Medical Ethics Committee of Teaching Hospital of Chengdu University of TCM. The random code and allocation information will be kept concealed from the study team and participants by the end of this study when all statistical analyses have been finished. Discussion YZAS has shown effectiveness in improving cognitive performance and neuroinflammation in animal experiments. Provided that it can also be proved to address cognitive deficits in this clinical trial, it may act via multiple mechanisms involved in the pathology of aMCI, which will be determined in the study. Supposing that old individuals with aMCI almost experience poor sleep, this study may provide an evidence-based medical approach to improving sleep quality and then maintaining cognition among these patients. However, in terms of testing specifically the differences of fecal microbiome between the old with normal cognition and those with aMCI, this project has a relatively small sample size, which is calculated according to the primary outcome. Owing to the number and the length of the tasks, participants’ burden is a bit high, breaks will be scheduled during each period of follow-up assessments. The results of this randomized controlled trial will inform the development of future interventional studies to prevent or delay the cognitive decline among patients with MCI or dementia. Trial Status This trial (protocol version: v1.1, Dec. 18th, 2017) began recruitment on 21 April 2018 and is currently ongoing. The recruitment will be approximately completed by the end of April in 2019. Declarations Additional file: SPIRIT 2013 checklist: recommended items to address in a clinical trial protocol and related documents. Acknowledgements We sincerely appreciate Dr. Jieping Zeng, who works at the Center of Good Clinical Practice of Teaching Hospital of Chengdu University of Traditional Chinese Medicine, for her assistance in statistical analysis. We also appreciate Mrz. Xitao Ma, a colleague of Dr. Zeng, for her assistance in randomization making. We appreciate truly Prof. Yong Tang for his recommendations for study design as well. We feel grateful to all the health care workers involved in this study for their help. We also express special gratitude to all the participants in this study. Funding This study is funded by State Administration of Traditional Chinese Medicine of the People’s Republic of China (JDZX2015298), Benefiting the Public Program of Chengdu Science and Technology Bureau (2015-HM01-00467-SF), Cadres Health Care Research Program of Sichuan Province (2017-501, 2018-504). Part of the costs concerning drugs in this study are financially supported by Sichuan Neo-Green Pharmaceutical Technology Development Co., Ltd., Chengdu, China. These funding agencies and the company has had and will have no role in study design, data collection, management, analysis, interpretation of data, or in writing this manuscript. Availability of data and materials The datasets used and/or analyzed during this study are available from the corresponding author on reasonable requests. Consent for publication Not Applicable. Authors’ contributions WBW, the lead principal investigator, contributed to the study design and the development of this trial with SNY. 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Cooke JR, Loredo JS, Liu L, et al. Acetylcholinesterase inhibitors and sleep architecture in patients with Alzheimer's disease. Drugs Aging 2006;23:503-511. 22. Cardinali DP, Furio AM, Brusco LI. Clinical Aspects of Melatonin Intervention in Alzheimer’s Disease Progression. Current Neuropharmacology 2010;8:218. 23. Cardinali DP1, Vigo DE, Olivar N, Vidal MF, Furio AM, Brusco LI. Therapeutic application of melatonin in mild cognitive impairment. American Journal of Neurodegenerative Disease 2012;1:280. 24. Winblad B, Gauthier S, Scinto L et al. Safety and efficacy of galantamine in subjects with mild cognitive impairment. Neurology 2008;70:2024-35. 25. Peters O, Lorenz D, Fesche A et al. A combination of galantamine and memantine modifies cognitive function in subjects with amnestic MCI. J Nutr Health Aging 2012;16:544-8. 26. Honig LS, Vellas B, Woodward M et al. Trial of Solanezumab for Mild Dementia Due to Alzheimer's Disease. N Engl J Med 2018;378:321-330. 27. He B, Xu F, Xiao F et al. Neuroprotective effects of nootkatone from Alpiniae oxyphyllae Fructus against amyloid-beta-induced cognitive impairment. Metab Brain Dis 2018;33:251-259. 28. Liu ZK, Ng CF, Shiu HT et al. Neuroprotective effect of Da Chuanxiong Formula against cognitive and motor deficits in a rat controlled cortical impact model of traumatic brain injury. J Ethnopharmacol 2018;217:11-22. 29. Guan D, Su Y, Li Y et al. Tetramethylpyrazine inhibits CoCl2 -induced neurotoxicity through enhancement of Nrf2/GCLc/GSH and suppression of HIF1alpha/NOX2/ROS pathways. J Neurochem 2015;134:551-65. 30. Michel HE, Tadros MG, Esmat A, Khalifa AE, Abdel-Tawab AM. Tetramethylpyrazine Ameliorates Rotenone-Induced Parkinson's Disease in Rats: Involvement of Its Anti-Inflammatory and Anti-Apoptotic Actions. Mol Neurobiol 2017;54:4866-4878. 31. Ringman JM, Frautschy SA, Teng E et al. Oral curcumin for Alzheimer's disease: tolerability and efficacy in a 24-week randomized, double blind, placebo-controlled study. Alzheimers Res Ther 2012;4:43. 32. Vidal B, Vazquez-Roque RA, Gnecco D et al. Curcuma treatment prevents cognitive deficit and alteration of neuronal morphology in the limbic system of aging rats. Synapse 2017;71. 33. Zhao C, Zhang H, Li H et al. Geniposide ameliorates cognitive deficits by attenuating the cholinergic defect and amyloidosis in middle-aged Alzheimer model mice. Neuropharmacology 2017;116:18-29. 34. Zang CX, Bao XQ, Li L et al. The Protective Effects of Gardenia jasminoides (Fructus Gardenia) on Amyloid-beta-Induced Mouse Cognitive Impairment and Neurotoxicity. Am J Chin Med 2018;46:389-405. 35. Zheng M, Qu L, Lou Y. Effects of icariin combined with Panax notoginseng saponins on ischemia reperfusion-induced cognitive impairments related with oxidative stress and CA1 of hippocampal neurons in rat. Phytother Res 2008;22:597-604. 36. Huang JL, Feng YQ, Bai LR et al. Fraction n-Butanol of Radix Notoginseng Protects PC12 Cells from Abeta25-35-Induced Cytotoxicity and Alleviates Cognitive Deficits in SAMP8 Mice by Attenuating Oxidative Stress and Abeta Accumulation. Evid Based Complement Alternat Med 2017;2017:8469754 37. Wu WB, Xie SL, Lei M, Zhang TM, Zhang WW. Research on extraction process of Yizhi Anshen oral liquid. Pharmacy and Clinics of Chinese Materia Medica 2016;7:27-30. (In simplified Chinese) 38. Yang K, Xie SL, Zhang X, Lei M, Wu WB. Effects of Xiangshao capsules on hormone and 5-HT receptors in older female rats. Pharmacology and Clinics of Chinese Materia Medica 2015;31:207-210. (In simplified Chinese) 39. Frohlich EE, Farzi A, Mayerhofer R et al. Cognitive impairment by antibiotic-induced gut dysbiosis: Analysis of gut microbiota-brain communication. Brain Behav Immun 2016;56:140-55. 40. Cattaneo A, Cattane N, Galluzzi S et al. Association of brain amyloidosis with pro-inflammatory gut bacterial taxa and peripheral inflammation markers in cognitively impaired elderly. Neurobiol Aging 2017;49:60-68. 41. MahmoudianDehkordi S, Arnold M, Nho K et al. Altered bile acid profile associates with cognitive impairment in Alzheimer's disease-An emerging role for gut microbiome. Alzheimers Dement 2018. 42. Molnar FJ, Man-Son-Hing M, Fergusson, Systematic review of measures of clinical significance employed in randomized controlled trials of drugs for dementia. J Am Geriatr Soc 2009;57;536-546. 43. Miao YC, Tian JZ, Shi J, Mao M. Effects of Chinese medicine for tonifying the kidney and resolving phlegm and blood stasis in treating patients with amnestic mild cognitive impairment: a randomized, double-blind and parallel-controlled trial. Zhong Xi Yi Jie He Xue Bao 2012;10:390-7. Tables Due to technical limitations, Table 1 has been placed in the supplementary files section. Supplementary Files supplement2.doc supplement2.jpg Cite Share Download PDF Status: Published Journal Publication published 20 Aug, 2019 Read the published version in Trials → Version 3 posted Editorial decision: Accept 20 Jul, 2019 Reviewers invited by journal 21 Jun, 2019 Submission checks completed at journal 18 Jun, 2019 Editor assigned by journal 18 Jun, 2019 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-249","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Study protocol","associatedPublications":[],"authors":[{"id":99053,"identity":"efeca890-7ab3-4854-b682-8620358d324f","order_by":1,"name":"Shengnan Yue","email":"","orcid":"https://orcid.org/0000-0002-0879-850X","institution":"Chengdu University of Traditional Chinese Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shengnan","middleName":"","lastName":"Yue","suffix":""},{"id":99054,"identity":"95201619-257a-47bd-aaea-d0fc8a0bbe6b","order_by":2,"name":"Ting He","email":"","orcid":"","institution":"Chengdu University of Traditional Chinese Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ting","middleName":"","lastName":"He","suffix":""},{"id":99055,"identity":"89d6dc6f-eb8f-4975-971d-376ae105f327","order_by":3,"name":"Baiyang Li","email":"","orcid":"","institution":"Chengdu University of Traditional Chinese Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Baiyang","middleName":"","lastName":"Li","suffix":""},{"id":99056,"identity":"af642cd2-a2c4-4128-b5ff-5eda1d5527be","order_by":4,"name":"Yanqin Qu","email":"","orcid":"","institution":"Chengdu University of Traditional Chinese Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yanqin","middleName":"","lastName":"Qu","suffix":""},{"id":99057,"identity":"14deccdd-5b74-4ccc-9cf1-de56add90f01","order_by":5,"name":"Hongmei Peng","email":"","orcid":"","institution":"Chengdu University of Traditional Chinese Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hongmei","middleName":"","lastName":"Peng","suffix":""},{"id":99058,"identity":"e7d0be00-47db-4a61-91d9-74987f3a2174","order_by":6,"name":"Jinxin Chen","email":"","orcid":"","institution":"Chengdu University of Traditional Chinese Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jinxin","middleName":"","lastName":"Chen","suffix":""},{"id":99059,"identity":"ac582931-e977-4a54-aebb-633e235ecdb4","order_by":7,"name":"Ming Lei","email":"","orcid":"","institution":"Chengdu University of Traditional Chinese Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ming","middleName":"","lastName":"Lei","suffix":""},{"id":99060,"identity":"799a7581-15ba-4765-86f5-9d77309eccff","order_by":8,"name":"Chongli Chen","email":"","orcid":"","institution":"Chengdu University of Traditional Chinese Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Chongli","middleName":"","lastName":"Chen","suffix":""},{"id":99061,"identity":"a60a44f6-b5c3-42de-9bb0-ca430caaf108","order_by":9,"name":"Wenbin Wu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYFACHoYDHwwk5BiYQRwD4rQwHpxRYWFMkhbmwzxnKhIbiHaWwY3cAwd42yTSNxznPcD4o+COPAP74aMb8GvJSzgg2SaRu+EwXwIzj8EzwwaetLQb+LSY3c4xOGAI1DKzmceAmcHgMGODBI8ZYS2JQIdJArUw/jA4bE+clgNnJBL4ga5i4DE4nEhQi/39dwkHGyokDPuZ+RIOA7UktxHyi2TP2cOf/xjUybPxnz348Mefw7b97IeP4dWCBIDJAESxEakcomUUjIJRMApGAVYAAJ87S+5i7IfIAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0001-8784-6137","institution":"","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Wenbin","middleName":"","lastName":"Wu","suffix":""}],"badges":[],"createdAt":"2019-01-22 22:51:34","currentVersionCode":3,"declarations":"","doi":"10.21203/rs.2.249/v3","doiUrl":"https://doi.org/10.21203/rs.2.249/v3","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13063-019-3607-x","type":"published","date":"2019-08-20T12:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":2614727,"identity":"873bee16-e30e-4cd7-9c84-a9737db19c45","added_by":"b0e95e7b-bbe0-4bfd-bf12-a325b7db0c3e","created_at":"2020-09-25 20:54:26","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":92497,"visible":true,"origin":"","legend":"Schedule of interventions and assessments. Abbreviation: ADAS-cog, Alzheimer disease assessment scale-cognitive subscale; MMSE, mini-mental state examination; MoCA, Montreal Cognitive Assessment; CDR, clinical dementia rating; PSQI, Pittsburgh sleep quality index; ADL, activity of daily living; 16SrDNA: 16S ribosomal deoxyribonucleic acid; ECG, electrocardiogram; CT, computed tomography; MRI, magnetic resonance imaging. \nAnd vital signs include individual’s temperature, breath and pulse per minute, and blood pressure.","description":"","filename":"figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-249/v3/figure_1.jpg"},{"id":13467461,"identity":"9868b8ee-ef4f-437e-81ea-1b72d0823da9","added_by":"auto","created_at":"2021-09-16 20:55:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":440200,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-249/v3/c1019e5a-0cc0-4a8a-8de7-fa01689ba6b0.pdf"},{"id":2610395,"identity":"1f34466e-8d2a-46f5-8fba-b2da993397f2","added_by":"b0e95e7b-bbe0-4bfd-bf12-a325b7db0c3e","created_at":"2020-09-25 20:51:37","extension":"doc","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":142336,"visible":true,"origin":"","legend":"","description":"","filename":"supplement2.doc","url":"https://assets-eu.researchsquare.com/files/rs-249/v3/supplement_2.doc"},{"id":2610397,"identity":"1ffc13fc-8f2b-44ff-aca6-e6a118c18b8a","added_by":"dbe1c910-fa3f-4a3a-a5c6-af99624d3e99","created_at":"2020-09-25 20:51:37","extension":"jpg","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":1221828,"visible":true,"origin":"","legend":"","description":"","filename":"supplement2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-249/v3/supplement_2.jpg"}],"financialInterests":"","formattedTitle":"Effectiveness of Yi-Zhi-An-Shen Granules on cognition and sleep quality in older adults with amnestic mild cognitive impairment: protocol for a randomized, double-blind, placebo-controlled trial","fulltext":[{"header":"Background","content":"\u003cp\u003eAlzheimer’s disease (AD), one common type of dementia worldwide, is a neurodegenerative\n disease characterized by insidious onset and progressive cognitive decline [1]. It\n cannot only detrimentally affect physical condition and quality of life in patients,\n but also bring a huge burden on both family and society [2]. The prevalence of AD\n was 3.21% reportedly among the old in China [3]. It is proposed recently that research\n strategies of AD should focus on the preclinical stages – preclinical AD and mild\n cognitive impairment (MCI) due to AD, which are relatively ideal for intervention\n [4]. \u003c/p\u003e\n \n\u003cp\u003e Patients with MCI always suffer cognitive decline severer than expected for an individual’s\n age and education level, but which does not obviously affect daily function [5]. And\n the elderly with MCI are at a high risk of developing to dementia [6]. As the main\n subtype of MCI, nearly 90% of older adults with amnestic MCI (aMCI), MCI with memory\n complaints, reportedly progress to AD, and share similar pathophysiological characteristics\n with AD [7]. Nowadays, standard clinical management of MCI includes managing its risk\n factors, there’re still limited pharmaceutical options for treating MCI from the NIA-AA\n working group guidelines [8]. Thus effective drugs and other interventions are expected\n to be discovered to reduce the rate of progression from MCI to dementia.\u003c/p\u003e\n \n\u003cp\u003eBrain areas and systems of neurotransmitters involving regulation of sleep-wake cycle\n relate to memory and cognition mostly [9-11]. Individuals with various types of cognitive\n impairment generally have sleep disturbance [9, 12-14], and the study also suggested\n that the severity of these sleep disorders closely relates to that of cognitive decline\n [14]. Moreover, older adults with bad sleep quality always suffer poor cognitive performance\n [15-16], which might be related to higher level of AD-associated amyloid-β in brain\n [17]. Structural imaging data indicated that insomnia is associated with decreased\n volume of brain tissue, including hippocampus, as well [18].The disorder of circadian\n rhythm often accompanies with high risk of cognitive decline and affects negatively\n cognition in multiple ways. Therefore, sleep problem is one risk factor of impaired\n cognitive function. \u003c/p\u003e\n \n\u003cp\u003eSeveral studies suggested that besides improving the cognitive performance and ability\n of daily living in individuals with AD, acetylcholinesterase inhibitors (ChEIs), like\n donepezil, galantamine and rivastigmine, also improved mental behavioral symptoms\n and sleep quality of these patients [19-21]. Furthermore, some trials indicated that\n melatonin could improve cognitive symptoms in patients with MCI and might delay their\n conversion to dementia [22-23]. As sleep disturbance appears to be linked with both\n aging and cognitive decline, strengthening sleep quality of the elderly might be an\n effective therapeutic target to slow the deterioration or improve cognitive impairment.\u003c/p\u003e\n \n\u003cp\u003eAccording to recent studies on MCI or AD, which involved donepezil [7], galantamine\n [24], memantine [25] and Solanezumab [26], pharmaceutical interventions showed poor\n amelioration of cognitive deficits. It might be the single pharmacological target\n of these drugs that did not adequately address the specific multiple pathophysiological\n characteristics. However, traditional Chinese medicine (TCM) is known for its multi-target,\n which could be used to address the complicated pathophysiological changes.\u003c/p\u003e\n \n\u003cp\u003eIn the light of theory of TCM, kidney deficiency is the basis of amnesia and other\n cognitive deficits, while phlegm and blood stasis are significant pathological factors.\n For this reason, amounts of experiments and trials have been carried out and shown\n specific effects against cognitive decline, which involve \u003cem\u003eAlpiniae oxyphyllae fructus \u003c/em\u003e[27], \u003cem\u003eLigusticum wallichii \u003c/em\u003e[28-30], \u003cem\u003ecurcuma \u003c/em\u003e[31-32], \u003cem\u003eFructus gardenia \u003c/em\u003e[33-34], \u003cem\u003eRadix notoginseng \u003c/em\u003e[35-36]. Meanwhile, an herbal formula named Yi-Zhi-An-Shen (YZAS) Granules has been\n composed of \u003cem\u003eLophatherum gracile\u003c/em\u003e and medical herbs mentioned above, which is designed for aiding the treatment of\n cognitive deficits. Table 1 details the pharmacological targets that the components\n in YZAS, which could be involved in the management of MCI. There have been preclinical\n researches contributing to the standardization of YZAS [37] and the mechanisms of\n its potential actions in animal experiments [38]. And some indications also manifested\n its safety and efficacy for improving cognitive function in clinical practice without\n causing daytime dysfunction. \u003c/p\u003e\n \n\u003cp\u003eBased on the theory of TCM, the actions of YZAS include soothing the nerves, that\n is to say, making someone calm down and helping sleep. Besides, as the emerging hypothesis\n of brain-gut axis, plenty of studies has shown changes of gut microbiome and the metabolite\n exert of gut microbiome exert an influence on cognition impairment [39-41]. Because\n of being administrated orally, it should be noticed that the mechanism of action of\n YZAS might be via the gut microbiota. Consequently, a clinical trial with rigorous\n design is needed to confirm its safety in old individuals with MCI, efficacy on cognitive\n performance, and explore its potential mechanisms.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003e1. Objectives\u003c/h2\u003e\n \n\u003cp\u003eThe primary objective of this study is to evaluate the efficacy of Yi-Zhi-An-Shen\n Granules (YZASG) in optimizing cognitive performance over time in elderly individuals\n with aMCI. Secondly, the investigators intend to assess whether YZASG can improve\n sleep quality among aMCI patients, this herbal formula’s safety will also be assessed.\n Finally, participants’ serum samples and fecal genomic DNA will be extracted to analyze\n the differences of the indices of metabolism, cellular immune function, and gut microbiota\n between old individuals with aMCI and ones with normal cognition.\u003c/p\u003e\n \n\n \n\u003ch2\u003e2. Design\u003c/h2\u003e\n \n\u003cp\u003eThis study is a randomized, double-blind, placebo-controlled trial with 16-week intervention\n and 18-month follow-up assessment. The current protocol (version v1.1) met the principles\n of the Declaration of Helsinki, and was in accordance of with Standard Protocol Items:\n Recommendations for Interventional Trials (SPIRIT) (see Additional file 1) and was\n approved by the Medical Ethics Committee of Teaching Hospital of Chengdu University\n of TCM. Then signed informed consents will be obtained from participants. And during\n the consent process, the caregiver or informant of the potential participants own\n should be present. The participants will be recruited from the communities, outpatient\n clinics of Teaching Hospital of Chengdu University of TCM and Welfare Institution\n of Emei Civil Administration in Sichuan Province, China. The Medical Ethics Committee\n has thoroughly reviewed this study, and then the ethical approval covers all these\n study sites.\u003c/p\u003e\n \n\u003cp\u003eThe enrolled participants will be randomly assigned into the YZAS group or the placebo\n group with the allocation ratio of 1:1 using the statistical package. Allocation was\n concealed using batch numbers generated with SAS 9.2 software (Cary, NC, USA) by a\n statistician. The unique code will be assigned to each newly enrolled participant\n and preserved in the trial management board. The statistician expert who acts as the\n coder will be shielded from subject recruitment and statistical analysis, which will\n be performed by another statistician independent of the study group. Both participants\n and the research team are blinded to allocation. There will be six measurement sessions\n during this whole study, including the intervention period and the 18-month period\n (Figure 1). Any changes to the study protocol will be communicated with the study\n investigative team and the approving ethics committee.\u003c/p\u003e\n \n\n \n\u003ch2\u003e3. Methods\u003c/h2\u003e\n \n\u003ch2\u003e3.1 Participants\u003c/h2\u003e\n \n\u003cp\u003eThe investigators anticipate recruiting 80 participants from Teaching hospital of\n Chengdu University of TCM, communities, and Welfare Institution of Emei Civil Administration.\n All patients will undergo standard medical examination and neuropsychological testing\n to ensure correct diagnosis of aMCI. \u003c/p\u003e\n \n\u003cp\u003eThe inclusion criteria are: \u003c/p\u003e\n \n\u003cp\u003e(1) subject has assigned informed consent to participate in the study and continues\n to give willing consent for participation with\u003c/p\u003e\n \n\u003cp\u003e(2) age from 60 to 85 years with a diagnosis of aMCI\u003c/p\u003e\n \n\u003cp\u003e(3) educational level of at least 6 years\u003c/p\u003e\n \n\u003cp\u003e(4) availability of a caregiver or informant who can assist in completing rating scales\n for the duration of the study\u003c/p\u003e\n \n\u003cp\u003e(5) cognitive complaints reported by the subject and confirmed by the caregiver or\n informant\u003c/p\u003e\n \n\u003cp\u003e(6) Clinical Dementia Rating (CDR) global score of 0.5, and memory item score of 0.5\u003c/p\u003e\n \n\u003cp\u003e(7) Mini-mental state examination (MMSE) score of 24-30 (for the participant with\n educational level of 6 years, MMSE score of 20-30) \u003c/p\u003e\n \n\u003cp\u003e(8) Diagnostic and Statistical Manual of Mental Disorders, Version 5 (DSM-V) criteria\n of dementia not fulfilled\u003c/p\u003e\n \n\u003cp\u003eA patient will be excluded when he or she: \u003c/p\u003e\n \n\u003cp\u003e(1) has been previously enrolled in this study and received the investigational product\u003c/p\u003e\n \n\u003cp\u003e(2) has received an investigational product within 30 days prior to screening\u003c/p\u003e\n \n\u003cp\u003e(3) has received disease-modifying therapy in the past 6 months (e.g., donepezil,\n rivastigmine, galantamine, memantine, and any other existing drugs that are declared\n to have the function of improving cognition)\u003c/p\u003e\n \n\u003cp\u003e(4) has a known allergy to the study drug or any of its constituents; \u003c/p\u003e\n \n\u003cp\u003e(5) has a history of alcohol abuse or alcohol dependency in the 3 years prior to study\n entry, or is an alcoholic or drug addict, as determined by the investigator\u003c/p\u003e\n \n\u003cp\u003e(6) has ongoing clinically significant (as judged by the investigator), metabolic\n or any other disease that could currently cause impaired memory (e.g., untreated thyroid\n disease, vitamin or other nutritional deficiencies, chronic kidney, or liver disease)\u003c/p\u003e\n \n\u003cp\u003e(7) has memory impairments that can be attributed to a disease or condition other\n than an early phase neurodegenerative syndrome\u003c/p\u003e\n \n\u003cp\u003e(8) has a parkinsonian movement disorder\u003c/p\u003e\n \n\u003cp\u003e(9) uses psychoactive medications that would affect the subject's ability to reliably\n perform neurocognitive testing or create uncertainty in distinguishing between the\n effects of the psychoactive medication and the subject's underlying cognitive impairment\n (e.g., benzodiazepines, sedatives, antipsychotics)\u003c/p\u003e\n \n\u003cp\u003e(10) has a history of major recurrent depressive disorder (DSM-V) within the last\n 5 years prior to screening\u003c/p\u003e\n \n\u003cp\u003e(11) has a brain tumor or other intracranial lesion, a disturbance of cerebral spinal\n fluid circulation (e.g., normal pressure hydrocephalus), and/or a significant history\n of head trauma or brain surgery\u003c/p\u003e\n \n\u003cp\u003e(12) has signs of major cerebrovascular disease, with score of modified Hachinski\n Ischemia Score (mHIS) at more than 4, or as verified by medical history and/or brain\n MRI or CT\u003c/p\u003e\n \n\u003cp\u003e(13) has severe visual or hearing impairments that cannot cooperate with examinations\u003c/p\u003e\n \n\u003cp\u003e(14) has severe digestive system diseases\u003c/p\u003e\n \n\u003cp\u003e(15) has received antibiotics within 60 days prior to screening.\u003c/p\u003e\n \n\u003cp\u003eHandling of withdrawal and dropout: (1) Voluntarily withdrawal, (2) loss of follow-up,\n (3) poor compliance and presence of severe adverse effects, (4) revealing and uncovering\n blind in urgency, (5) misdiagnosis, (6) using forbidden drugs or treatments in the\n course of the trial, (7) taking no medication during the trial, (8) no evaluable records\n after medication. Reasons for withdrawing participants will be recorded in case report\n forms (CRFs), and the last data will be included in data analysis. All these criteria\n will be ascertained by the supervisor of this study.\u003c/p\u003e\n \n\u003ch2\u003e3.2 Interventions\u003c/h2\u003e\n \n\u003cp\u003eAll the participants will receive the same basic treatment, including health education,\n moderate aerobic exercise (30-60 minutes per day) and general nutritional support.\n The participants assigned to the YZAS group will take Yi-Zhi-An-Shen granule, which\n is composed of YiZhiRen (\u003cem\u003eAlpinia oxyphylla Miq.\u003c/em\u003e) - 5g, SanQi (\u003cem\u003ePanax notoginseng\u003c/em\u003e) - 3g, ChuanXiong (\u003cem\u003eLigusticum chuanxiong hort\u003c/em\u003e) - 10g, ZhiZi (\u003cem\u003eGardenia jasminoides Ellis\u003c/em\u003e) - 10g, YuJin (\u003cem\u003eCurcuma longa L.\u003c/em\u003e) - 10g, DanZhuYe (\u003cem\u003eLophatherum gracile\u003c/em\u003e) - 10g, while ones in the placebo group will take placebo made from starch which\n appears the same shape, color, smell, taste, texture package and Lot Number. Participants\n will be instructed to dissolve granules into 100ml of boiled water and to take the\n solution orally between 30℃ to 37 ℃ three times daily for 16 weeks. Each granule is\n prepared by Sichuan Neo-green Pharmaceutical Technology Development Co., Ltd, Sichuan\n China according to the standards of Good Manufactory Practice (GMP). During the whole\n study period, relevant health care and treatment for medical needs will be permitted\n without adverse reactions with YZASG or hindering the study process.\u003c/p\u003e\n \n\u003cp\u003e80% to 120% of drug usages are eligible for protocol plan. The package, drug name,\n function and indication, usage and dosage, storage condition, valid period and name\n of the manufacturer will be marked and a tag indicating ‘trial use’ will be attached.\n Drugs must be kept in the appropriate temperature in a dry, cool and shady place.\n Drug administrators should take back unused drugs to estimate participant compliance\n and record these in the CRFs.\u003c/p\u003e\n \n\u003ch2\u003e3.3 Outcomes\u003c/h2\u003e\n \n\u003ch2\u003e3.3.1 Primary outcome\u003c/h2\u003e\n \n\u003cp\u003eCognitive decline is measured using the Chinese version of the Alzheimer Disease Assessment\n Scale-Cognitive subscale (ADAS-cog11). It was also chosen to calculate the sample\n size, for a 4-point change in it as the measure of clinical significance [42].The\n total score is 70. A score increase indicates greater severity of impairment. The\n specific hypothesis is that the increase from baseline to endpoint will be significantly\n less at least 2.5 points than that for placebo, which will be considered effective\n in this study.\u003c/p\u003e\n \n\u003cp\u003eThe ADAS-cog will be assessed at baseline (before intervention), at 16 weeks (the\n end of intervention) and 6, 12, and 18 months after intervention.\u003c/p\u003e\n \n\u003ch2\u003e3.3.2 Secondary outcome\u003c/h2\u003e\n \n\u003cp\u003eSecondary measures include the MMSE, Montreal Cognitive Assessment (MoCA, Changsha\n Version), CDR, Pittsburgh sleep quality index (PSQI), activity of daily living (ADL),\n gut microbiome, and serum markers.\u003c/p\u003e\n \n\u003cp\u003eThe MMSE is an 11-question measure that tests five areas of cognitive function (orientation,\n registration, attention and calculation, recall, and language). The maximum score\n is 30 and a score below 24 is considered abnormal for dementia screening.\u003c/p\u003e\n \n\u003cp\u003eThe MoCA (Changsha Version) will also be used to evaluate general cognitive function,\n as it contains visuospatial processing and organizational capability which can make\n up for the shortcoming of the MMSE. The total score for it is 30, with a higher number\n indicating a more intact cognitive function. Meanwhile, the MoCA has been shown to\n be a promising tool to detect MCI and early AD.\u003c/p\u003e\n \n\u003cp\u003eThe CDR will be used as an assistant evaluation for patients’ dementia severity, which\n scored 0-3, with higher scores indicating more severity. It is a semi-structured interview\n performed with the patient and caregiver (informant), characterizing six domains of\n cognitive and functional performance. The CDR sum of boxes (CDR-SB) scored 0-18, will\n also be applied to assess patients’ cognitive status, with higher scores indicating\n worse functioning.\u003c/p\u003e\n \n\u003cp\u003eThe PSQI will be used to assess participants’ comprehensive quality of sleep, which\n involves sleep quality, sleep duration, sleep efficiency, sleep disorders, daytime\n dysfunction, sleeping aids, etc. The total score for it is 21, with a higher score\n indicating a worse sleep quality.\u003c/p\u003e\n \n\u003cp\u003eADL will be assessed including basic activities of daily living (BADL) and instrumental\n activities of daily living (IADL). An individual's BADL will be evaluated mainly by\n the subjects' performance from the perspectives of bathing, dressing, grooming, initiation,\n toileting and feeding, with six items and a sum of scores ranging from 0 (normal)\n to 24 (complete dependence on others). And modified Lawton Instrumental Activities\n of Daily Living Scale will be used to measure the IADL of a subject, with eight items\n and a sum of scores ranging from 0 (normal) to 32 (complete dependence on others).\u003c/p\u003e\n \n\u003cp\u003eThese clinical tests will be administrated by a trained, certified clinician or rater\n experienced in the assessment of patients with cognitive deficits. And the rater who\n will conduct the CDR for a patient cannot complete any other rating scales for the\n same patient, and will be blinded to the results of all other neuropsychological scales.\n Scales mentioned above will be assessed at baseline (before intervention), at 8 and\n 16 weeks (during intervention) and 6, 12, and 18 months after intervention.\u003c/p\u003e\n \n\u003cp\u003e Blood samples will be collected from all participants for further assessing the\n mechanisms of YZASG via changes in serum metabolic, inflammatory, and immunologic markers. All these tests will be entrusted\n to the laboratory medicine of Sichuan Academy of Medical Science \u0026amp; Sichuan Provincial\n People’s Hospital for conduction.\u003c/p\u003e\n \n\u003cp\u003eFecal genomic DNA will be extracted from frozen stools using QIAamp DNA mini stool\n kit (Qiagen, Hiden, Germany), obtained from the patients with aMCI and 15-20 participants\n with normal cognition at baseline and the end of the intervention. After PCR amplification,\n DNA fragments will be sequenced on an Illumina HiSeq 2500 instrument and an Illumina\n HiSeq X instrument for 16SrDNA and metagenomics analyses (which will be chosen from\n some representative samples in the results of 16SrDNA analysis) respectively at Biomarker\n Technologies Co, Ltd (Beijing, China) to analyze the differences in gut microbiome\n between patients with aMCI and individuals with normal cognition. When it is available,\n the investigators will also assess the changes in gut microbiome between the treatment\n group and the placebo group after the intervention of YZASG in the same way.\u003c/p\u003e\n \n\u003ch2\u003e3.3.3 Safety outcomes\u003c/h2\u003e\n \n\u003cp\u003eTo assess the safety of YZASG compared to placebo in subjects with aMCI, the investigators\n will record the incidence and severity of treatment-emergent adverse events (TEAEs),\n and clinically important changes in safety assessment results. These safety indicators,\n including vital signs, weight, clinical laboratory tests, physical and neurological\n exams, ECGs, and CTs/MRIs, will gather at the baseline and the end of 16th week. \u003c/p\u003e\n \n\n \n\u003ch2\u003e4. Statistical considerations and data management\u003c/h2\u003e\n \n\u003ch2\u003e4.1 Sample size\u003c/h2\u003e\n \n\u003cp\u003eUsing pre-intervention and post-intervention scores obtained from Miao et al. [43],\n on the basis of non-inferiority trial principle, one-sided test, at α = 0.05, then\n at least 33 patients are needed for inclusion in the treatment group who will be administrated\n with YZASG to achieve a prospective power of 90% (ie. β=0.1) and detect a minimum\n clinical between-group difference of 1.30 on ADAS-cog [43] at 16 weeks. Allowing for\n a maximum dropout rate of 20%, the number of subjects in the treatment group has been\n set to 40 patients with aMCI. With the allocation ratio of 1:1, 80 subjects are required.\u003c/p\u003e\n \n\u003ch2\u003e4.2 Statistic analysis\u003c/h2\u003e\n \n\u003cp\u003eAnalysis will be conducted by another statistician of the National Clinical Trial\n Center of Chinese Medicine (Chengdu, China), who will be also blinded to the whole\n trial, using SAS 9.2 software (Cary, NC, USA) and SPSS 21.0 software (IBM, NY, USA).\n \u003c/p\u003e\n \n\u003cp\u003eThe analysis data set will consist of a modified intention-to-treat data set, a per\n protocol (PP) set, and a safety data set. All mechanism and efficacy analyses will\n be conducted according to the modified intention-to-treat (mITT) principle. The mITT\n data set will include the participants who have completed at least one observation\n since the intervention begins. The PP population will only include participants who\n adhered to the trial protocol and completed the clinical trial. And the minimum compliance\n rate for participants taking the investigational drugs in the PP data set is 80%.\n Besides, the safety analysis will be conducted according to the safety data set, which\n will include any participants who were assigned to randomly and took at least one\n dose of the investigational drug. Missing values will be replaced by the last observation\n carried forward (LOCF) method. ADAS-cog (including its monomial item) changes from\n baseline and the secondary outcomes will be assessed using an analysis of covariance\n with treatment groups as factors and baseline values as covariates. Mean differences\n will be used to express effect sizes. The baseline homogeneity of the baseline characteristics\n and differences between the two groups will be analyzed with Fisher’s exact test,\n or \u003csup\u003e2 \u003c/sup\u003etest for categorical measures and with the \u003cem\u003et\u003c/em\u003e test or Wilcoxon rank-sum test for continuous measures. The statistical significance\n is defined as a one-sided P-value of \u0026lt;0.05 and 90% confidence interval.\u003c/p\u003e\n \n\u003cp\u003eFor the gut microbial 16SrDNA analysis, sequenced data will be interpreted using the\n bioinformatics tools programmed in the Ion Reporter software. Based on the specified\n similarity, QIIME algorithms will be used to classify operational taxonomic units\n (OTU) and statistically analyze biological information, and then to understand the\n diversity and abundance of the flora community, and further to determine the bacterial\n diversity within a sample (α diversity) and among all the samples (β diversity). Alpha\n diversity includes four indicators that represent total number, richness, phylogenetic\n diversity, and dispersible uniformity of species and community abundance. These four\n algorithms, including binary jaccard, bray curtis, weighted unifrac, and unweighted\n unifrac, will be performed to analyze β diversity to compare the similarity of different\n samples in species diversity. According to the above data, principal component analysis\n will be conducted to observe the differences between floras. Additionally, multivariate\n data analysis with principal component analysis on the diversity indexes and comparisons\n of genus and species level data will be performed to reveal differences in the microbial\n composition between individuals with normal cognition and ones with aMCI. Metastats\n software will be used to perform \u003cem\u003et\u003c/em\u003e test on the species abundance data between two groups, and p value will be obtained,\n then by correcting p value q value will also be obtained. Subsequently, according\n to p or q value, species that cause the differences in the microbial composition of\n the two sets will be screened out. Significant analyses between two groups will be\n performed at the level of classification of the gate, class, subject, family, genera\n and species, respectively. Sparcc algorithm will be used to conduct correlation analysis\n (including positive and negative correlation) and statistical tests. Next, a co-expression\n analysis network map will be drawn using python. The subsequent statistical analyses\n will be performed with the R Programming Language 3.0.1 (NZL). \u003c/p\u003e\n \n\u003cp\u003eWhen it comes to metagenomics analysis, after getting Clean Reads, taxonomic analysis\n will be conducted to measure species composition and abundance information of samples.\n After the significance test of difference has been performed, p value will be obtained.\n Then by correcting the p value, false discovery rate (FDR) will be obtained. The Benjamini\n Hochberg false discovery rate adjustment will be used to account for the number of\n taxa tested in each comparison.\u003c/p\u003e\n \n\u003ch2\u003e4.3 Data management\u003c/h2\u003e\n \n\u003cp\u003eAll data will be stored on a secure server with two back-up copies on external hard\n drives. Paper-based forms will be digitized and the original copies stored in locked\n filing cabinets in the archives room of Good Clinical Practice (GCP) in Department\n of Geriatrics, and managed by a department staff member who is external to the research\n team. All participants are de-identified upon randomization and referred to on all\n forms with a participant ID. A password-protected spreadsheet stored on the secure\n server links participant names to ID codes to all for re-identification to occur if\n required. As this is a relatively small investigator-initiated trial, a data monitoring\n committee and auditing process are not required.\u003c/p\u003e\n \n\n \n\u003ch2\u003e5. Quality control and monitoring\u003c/h2\u003e\n \n\u003cp\u003eEach trial center has a project manager who takes charge of the quality of research.\n All investigators were qualified and trained before. After the baseline measurement,\n the 16 weeks of intervention will be dispensed. Participants will be required to return\n any unused medication at every 2 weeks, which will be used for determining compliance.\n The number of returned granules will be counted by a department member who is external\n to the study team. During the whole course, attentive follow-up will also be conducted\n every 2 weeks. Participants who exit the study early will be contacted via telephone\n and requested to complete the exit interview. \u003c/p\u003e\n \n\u003cp\u003eTo monitor safety, participants will be referred to the Teaching Hospital of Chengdu\n University of TCM and the local cooperating hospital of Welfare Institution of Emei\n Civil Administration, which is next to the institution. Standard blood safety tests\n (full blood count, blood coagulation function, liver and renal function tests) and\n ECGs will be carried out at the baseline and the end of the 1st and 16th weeks of\n intervention, while brain CTs/MRIs will be done at the baseline and the end of 16th\n week. And the reports of annual physical checkup of participants are also encouraged\n to share with the investigators in this study.\u003c/p\u003e\n \n\u003cp\u003eAdverse events will be closely monitored and recorded throughout the whole course\n of the study. Once a serious adverse event happens, if the study drug is suspected\n to be a potential cause and receiving appropriate medical care is identified to be\n essential for the participant, then unblinding of that participant will occur and\n at least two persons should present. After treated, that participant will be stopped\n from the subsequent investigation and regarded as the dropout case. Anyway, the investigators\n will also visit that participant regularly and record his/her reactions and treatments\n of the adverse events until the endpoint of this study. And this will be performed\n by the department member external to this study team. A development update safety\n report must be submitted annually to the Medical Ethics Committee of Teaching Hospital\n of Chengdu University of TCM.\u003c/p\u003e\n \n\u003cp\u003e The random code and allocation information will be kept concealed from the study\n team and participants by the end of this study when all statistical analyses have\n been finished.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eYZAS has shown effectiveness in improving cognitive performance and neuroinflammation\n in animal experiments. Provided that it can also be proved to address cognitive deficits\n in this clinical trial, it may act via multiple mechanisms involved in the pathology\n of aMCI, which will be determined in the study. \u003c/p\u003e\n \n\u003cp\u003e Supposing that old individuals with aMCI almost experience poor sleep, this study\n may provide an evidence-based medical approach to improving sleep quality and then\n maintaining cognition among these patients. However, in terms of testing specifically\n the differences of fecal microbiome between the old with normal cognition and those\n with aMCI, this project has a relatively small sample size, which is calculated according\n to the primary outcome. Owing to the number and the length of the tasks, participants’\n burden is a bit high, breaks will be scheduled during each period of follow-up assessments.\n The results of this randomized controlled trial will inform the development of future\n interventional studies to prevent or delay the cognitive decline among patients with\n MCI or dementia. \u003c/p\u003e\n \n\n \n\u003ch2\u003eTrial Status\u003c/h2\u003e\n \n\u003cp\u003eThis trial (protocol version: v1.1, Dec. 18th, 2017) began recruitment on 21 April\n 2018 and is currently ongoing. The recruitment will be approximately completed by\n the end of April in 2019.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAdditional file: \u003c/h2\u003e\n \n\u003cp\u003eSPIRIT 2013 checklist: recommended items to address in a clinical trial protocol and\n related documents.\u003c/p\u003e\n \n\n \n\n \n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n \n\u003cp\u003eWe sincerely appreciate Dr. Jieping Zeng, who works at the Center of Good Clinical\n Practice of Teaching Hospital of Chengdu University of Traditional Chinese Medicine,\n for her assistance in statistical analysis. We also appreciate Mrz. Xitao Ma, a colleague\n of Dr. Zeng, for her assistance in randomization making. We appreciate truly Prof.\n Yong Tang for his recommendations for study design as well. We feel grateful to all\n the health care workers involved in this study for their help. We also express special\n gratitude to all the participants in this study.\u003c/p\u003e\n \n\n \n\u003ch2\u003eFunding\u003c/h2\u003e\n \n\u003cp\u003eThis study is funded by State Administration of Traditional Chinese Medicine of the\n People’s Republic of China (JDZX2015298), Benefiting the Public Program of Chengdu\n Science and Technology Bureau (2015-HM01-00467-SF), Cadres Health Care Research Program\n of Sichuan Province (2017-501, 2018-504). Part of the costs concerning drugs in this\n study are financially supported by Sichuan Neo-Green Pharmaceutical Technology Development\n Co., Ltd., Chengdu, China. These funding agencies and the company has had and will\n have no role in study design, data collection, management, analysis, interpretation\n of data, or in writing this manuscript.\u003c/p\u003e\n \n\n \n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n \n\u003cp\u003eThe datasets used and/or analyzed during this study are available from the corresponding\n author on reasonable requests.\u003c/p\u003e\n \n\n \n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n \n\u003cp\u003eNot Applicable.\u003c/p\u003e\n \n\n \n\u003ch2\u003eAuthors’ contributions\u003c/h2\u003e\n \n\u003cp\u003eWBW, the lead principal investigator, contributed to the study design and the development\n of this trial with SNY. SNY drafted the initial protocol, and WBW provided review.\n TH and BYL participated in the coordination of the trial, and recruited patients with\n YQQ and JXC. HMP assisted with the collection of data. ML and CLC advised on medical\n assessment and clinical issues. CLC also worked as the clinical supervisor. All authors\n reviewed the content and approved the final version.\u003c/p\u003e\n \n\n \n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n \n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n \n\n \n\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n \n\u003cp\u003eEthical approval for this study was provided by the Teaching Hospital of Chengdu University\n of Traditional Chinese Medicine Medical Ethics Committee (2017KL-035, 2017KL-036).\n All participants for this study will provide written informed consent.\u003c/p\u003e"},{"header":"References","content":"\u003cp class=\"list_Paragraph\"\u003e1. Querfurth HW, LaFerla FM. Alzheimer's disease. N Engl J Med 2010;362:329-44.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e2. Alzheimer’s Disease International. World Alzheimer’s Report 2016. 2017.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e3. Jia J, Wang F, Wei C et al. The prevalence of dementia in urban and rural areas of China. Alzheimers Dement 2014;10:1-9.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e4. Silverberg N, Elliott C, Ryan L, Masliah E, Hodes R. NIA commentary on the NIA-AA Research Framework: Towards a biological definition of Alzheimer's disease. Alzheimers Dement 2018;14:576-578.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e5. Magaki S, Mueller C, Dickson C, Kirsch W. Increased production of inflammatory cytokines in mild cognitive impairment. Exp Gerontol 2007;42:233-40.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e6. Petersen RC. Mild cognitive impairment: transition from aging to Alzheimer's disease. In: Iqbal K, Sisodia SS, Winblad B, editors. Alzheimer's Disease: Advances in etiology, pathogenesis and therapeutics. Hoboken;\u003c/p\u003e\n\u003cp\u003e2001. p. 141-51.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e7. Petersen RC, Thomas RG, Grundman M, et al. 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The effect of donepezil on sleep and REM sleep EEG in patients with Alzheimer disease: a double-blind placebo-controlled study. Sleep 2006;29:199-205.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e21. Cooke JR, Loredo JS, Liu L, et al. Acetylcholinesterase inhibitors and sleep architecture in patients with Alzheimer's disease. Drugs Aging 2006;23:503-511.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e22. Cardinali DP, Furio AM, Brusco LI. Clinical Aspects of Melatonin Intervention in Alzheimer’s Disease Progression. Current Neuropharmacology 2010;8:218.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e23. Cardinali DP1, Vigo DE, Olivar N, Vidal MF, Furio AM, Brusco LI. Therapeutic application of melatonin in mild cognitive impairment. American Journal of Neurodegenerative Disease 2012;1:280.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e24. Winblad B, Gauthier S, Scinto L et al. Safety and efficacy of galantamine in subjects with mild cognitive impairment. Neurology 2008;70:2024-35.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e25. Peters O, Lorenz D, Fesche A et al. A combination of galantamine and memantine modifies cognitive function in subjects with amnestic MCI. J Nutr Health Aging 2012;16:544-8.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e26. Honig LS, Vellas B, Woodward M et al. Trial of Solanezumab for Mild Dementia Due to Alzheimer's Disease. N Engl J Med 2018;378:321-330.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e27. He B, Xu F, Xiao F et al. Neuroprotective effects of nootkatone from Alpiniae oxyphyllae Fructus against amyloid-beta-induced cognitive impairment. Metab Brain Dis 2018;33:251-259.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e28. Liu ZK, Ng CF, Shiu HT et al. Neuroprotective effect of Da Chuanxiong Formula against cognitive and motor deficits in a rat controlled cortical impact model of traumatic brain injury. J Ethnopharmacol 2018;217:11-22.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e29. Guan D, Su Y, Li Y et al. Tetramethylpyrazine inhibits CoCl2 -induced neurotoxicity through enhancement of Nrf2/GCLc/GSH and suppression of HIF1alpha/NOX2/ROS pathways. J Neurochem 2015;134:551-65.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e30. Michel HE, Tadros MG, Esmat A, Khalifa AE, Abdel-Tawab AM. Tetramethylpyrazine Ameliorates Rotenone-Induced Parkinson's Disease in Rats: Involvement of Its Anti-Inflammatory and Anti-Apoptotic Actions. Mol Neurobiol 2017;54:4866-4878.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e31. Ringman JM, Frautschy SA, Teng E et al. Oral curcumin for Alzheimer's disease: tolerability and efficacy in a 24-week randomized, double blind, placebo-controlled study. Alzheimers Res Ther 2012;4:43.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e32. Vidal B, Vazquez-Roque RA, Gnecco D et al. 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Huang JL, Feng YQ, Bai LR et al. Fraction n-Butanol of Radix Notoginseng Protects PC12 Cells from Abeta25-35-Induced Cytotoxicity and Alleviates Cognitive Deficits in SAMP8 Mice by Attenuating Oxidative Stress and Abeta Accumulation. Evid Based Complement Alternat Med 2017;2017:8469754\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e37. Wu WB, Xie SL, Lei M, Zhang TM, Zhang WW. Research on extraction process of Yizhi Anshen oral liquid. Pharmacy and Clinics of Chinese Materia Medica 2016;7:27-30. (In simplified Chinese)\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e38. Yang K, Xie SL, Zhang X, Lei M, Wu WB. Effects of Xiangshao capsules on hormone and 5-HT receptors in older female rats. Pharmacology and Clinics of Chinese Materia Medica 2015;31:207-210. (In simplified Chinese)\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e39. Frohlich EE, Farzi A, Mayerhofer R et al. Cognitive impairment by antibiotic-induced gut dysbiosis: Analysis of gut microbiota-brain communication. Brain Behav Immun 2016;56:140-55.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e40. Cattaneo A, Cattane N, Galluzzi S et al. Association of brain amyloidosis with pro-inflammatory gut bacterial taxa and peripheral inflammation markers in cognitively impaired elderly. Neurobiol Aging 2017;49:60-68.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e41. MahmoudianDehkordi S, Arnold M, Nho K et al. Altered bile acid profile associates with cognitive impairment in Alzheimer's disease-An emerging role for gut microbiome. Alzheimers Dement 2018.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e42. Molnar FJ, Man-Son-Hing M, Fergusson, Systematic review of measures of clinical significance employed in randomized controlled trials of drugs for dementia. J Am Geriatr Soc 2009;57;536-546.\u003c/p\u003e\n\u003cp class=\"list_Paragraph\"\u003e43. Miao YC, Tian JZ, Shi J, Mao M. Effects of Chinese medicine for tonifying the kidney and resolving phlegm and blood stasis in treating patients with amnestic mild cognitive impairment: a randomized, double-blind and parallel-controlled trial. Zhong Xi Yi Jie He Xue Bao 2012;10:390-7.\u003c/p\u003e"},{"header":"Tables","content":"Due to technical limitations, Table 1 has been placed in the supplementary files section."}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"trials","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"trls","sideBox":"Learn more about [Trials](http://trialsjournal.biomedcentral.com/)","snPcode":"13063","submissionUrl":"https://www.editorialmanager.com/trls","title":"Trials","twitterHandle":"MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Amnestic Mild cognitive impairment (aMCI), Sleep, Gut microbiome, Older adults","lastPublishedDoi":"10.21203/rs.2.249/v3","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.2.249/v3","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Background\n\nAmnestic mild cognitive impairment (aMCI) is a syndrome characterized by significant forgetfulness that does not meet the criteria of dementia. Individuals with aMCI are at a bigger risk of progressing to dementia. Current studies suggest good sleep quality is linked with preserved cognition in the elderly, and sleep complaints are common among the elderly with amnesia. Therefore, improving their sleep may be helpful for maintaining and improving their cognitive capacity. According to the theory of traditional Chinese medicine, Yi-Zhi-An-Shen is an herbal compound which may ameliorate forgetfulness and sleep disorders. As growing evidence indicates that gut microbiome is associated with major mental symptoms, a hypothesis was proposed that Yi-Zhi-An-Shen Granules (YZASG) might work by alternating microbial abundance and diversity. In this study, the investigators intend to assess the efficacy of YZASG on global cognition in the elderly suffering from aMCI, and evaluate its safety as well as its potential mechanisms via sleep quality, fecal microbial 16SrDNA and metagenomics analyses, and serum markers.\n\nMethods/design\n\nThis is a randomized, double-blind, placebo-controlled clinical trial. A total of 80 patients (aged 60~85 years) will be recruited and allocated randomly to a treatment group and a placebo group in a 1:1 ratio, then will be administered YZASG or isodose placebo three times a day. The intervention course is 16 weeks, with an 18-month follow-up. The primary outcome is Alzheimer Disease Assessment Scale-Cognitive subscale (ADAS-cog11). Secondary outcome measures are mini-mental state examination (MMSE), Montreal cognitive assessment (MoCA), Pittsburgh Sleep Quality Index (PSQI), serum concentrations of immunological factors and inflammatory cytokines, fecal microbiota. Fecal microbiota will only be collected at the baseline and endpoint of the intervention.\n\nDiscussion\n\nThe results of this trial will be conducive to assessing the safety and effectiveness on cognition of YZASG in intervening aMCI among the elderly and determining if it takes effect via the improvement of sleep quality, regulation of gut microbita, concentration of certain serum markers.","manuscriptTitle":"Effectiveness of Yi-Zhi-An-Shen Granules on cognition and sleep quality in older adults with amnestic mild cognitive impairment: protocol for a randomized, double-blind, placebo-controlled trial","msid":"","msnumber":"","nonDraftVersions":[{"code":3,"date":"2019-06-19 18:38:43","doi":"10.21203/rs.2.249/v3","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accept","date":"2019-07-20T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2019-06-21T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2019-06-18T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2019-06-18T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"trials","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"trls","sideBox":"Learn more about [Trials](http://trialsjournal.biomedcentral.com/)","snPcode":"13063","submissionUrl":"https://www.editorialmanager.com/trls","title":"Trials","twitterHandle":"MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":2,"date":"2019-04-01 18:40:37","doi":"10.21203/rs.2.249/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2019-05-19T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2019-04-07T12:00:00+00:00","index":1,"fulltext":"Form responses:\n---\n* Quality of written English\nPlease indicate the quality of language in the manuscript:\tAcceptable: **Quality of figures\nAll images and figures within the manuscript should be genuine i.e. without evidence of manipulation. No specific feature within an image may be enhanced, obscured, moved, removed, or introduced. If you have concerns about the veracity of the figures you should choose the first option below.\tAcceptable**\n"},{"type":"reviewerAgreed","content":"","date":"2019-04-06T12:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2019-04-01T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2019-04-01T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2019-04-01T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"trials","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"trls","sideBox":"Learn more about [Trials](http://trialsjournal.biomedcentral.com/)","snPcode":"13063","submissionUrl":"https://www.editorialmanager.com/trls","title":"Trials","twitterHandle":"MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2019-01-23 19:20:36","doi":"10.21203/rs.2.249/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2019-02-18T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2019-02-16T12:00:00+00:00","index":1,"fulltext":"Form responses:\n---\n* Level of interest: **An article whose findings are important to those with closely related research interests**\n* Quality of written English: **Acceptable**\n* Quality of figures: **Acceptable**\n* Statistical review: **Yes, and I have assessed the statistics in my report**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n\nComments to Author:\n---\nThis is a randomized, double-blind and placebo-controlled trial to evaluate the efficacy and safety of Yizhianshen Granules on cognition and sleep quality. Some methodological issues are still waiting to be resolved.\n\n1. Abstract. Methods/design: the authors mentioned \"a placebo-matched group in a 1:1 ratio\", will this trial use any matching technique when randomization? If so, authors should state which factor(s) was/were used to match.\n2. Design. Para2, L4. The statistician who act as the random coder should be shielded from not only subject recruitment but also statistical analysis.\n3. Primary outcome. The hypothesis is confusing. For ADAS-cog11, if the increased score will indicate greater severity, I think the change from baseline to endpoint (baseline-week16) in treatment group will be supposed larger than that in placebo group. If you regard the difference week16 to baseline (week16-baseline) as the outcome, you'd better to specify the formula direction.\n4. Sample size. As this trial is a RCT, I don't think the pre and post scores are enough to determine the sample size. It will be better for authors to provide specific parameter alongside the formula used.\nIn addition, as the comparator in this trial is placebo, why use non-inferiority principle (this design usually used when comparing with an active drug)?\n5. Statistical analysis, Para2. It's not wise to state FAS, PPS, and SS in a general way. Instead, especially in a protocol, it's important to state clearly the definition of each in your trial (also consider the particular situations may occur in your trial) one by one. And which kind of analysis will be conducted in each population.\n6. Statistical analysis. It said that standardized mean differences will be the effect sizes. Although generally mean differences were more often used, if authors confirm standardized mean differences will be used, it will be better to use it when computing sample size and list references.\n7. Statistical analysis. ANOVAs, I don't think you need ANOVAs to compare two groups. Do you mean ANCOVA?\n8. Statistical analysis. Para2, last line. The probability of CI for one-sided P value of 0.05 is 90% instead of 95%. If this trial aimed to get 95%CI ( the wider one), the one-sided p value should be 0.025 (ie. two-sided p value of 0.05).\n9. In the protocol of a double blinded trial, unblinding procedure, both emergency code broken and final unblinding for analysis should be stated in detail.\n\n"},{"type":"reviewerAgreed","content":"","date":"2019-02-05T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2019-02-04T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2019-01-21T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2019-01-21T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"trials","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"trls","sideBox":"Learn more about [Trials](http://trialsjournal.biomedcentral.com/)","snPcode":"13063","submissionUrl":"https://www.editorialmanager.com/trls","title":"Trials","twitterHandle":"MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"279e3268-06a4-46ad-80e5-06f63498afa2","owner":[],"postedDate":"June 19th, 2019","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":7898,"name":"General Medicine"}],"tags":[],"updatedAt":"","versionOfRecord":{"articleIdentity":"rs-249","link":"https://doi.org/10.1186/s13063-019-3607-x","journal":{"identity":"trials","isVorOnly":false,"title":"Trials"},"publishedOn":"2019-08-20 12:00:00","publishedOnDateReadable":"August 20th, 2019"},"versionCreatedAt":"2019-06-19 18:38:43","video":"","vorDoi":"10.1186/s13063-019-3607-x","vorDoiUrl":"https://doi.org/10.1186/s13063-019-3607-x","workflowStages":[]},"version":"v3","identity":"rs-249","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"identity":"rs-249","version":["v3"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}