AYURVEDA AND GERIATRIC CARE -A BROAD OUTLINE

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1 AYURVEDA AND GERIATRIC CARE -A BROAD OUTLINE 1. Demographic context of Geriatrics and limitations of conventional medicine 1.1. Demographic trends The World population of the elderly is increasing and by the year 2050, adults older than 65 years will comprise 1/5 th of the global population. In India 3.8% of the population are older than 65 years of age. According to an estimate the likely number of elderly people in India by 2016 will be around 113 million Global health scenario in geriatrics The twenty-first century is witnessing a gradual decline in fertility, and with increase in life expectancy, the society will need to grapple with issues of longevity. The cause of morbidity and mortality world over is shifting from communicable diseases a few decades ago to noncommunicable diseases. The leading causes of mortality among aged people comprise respiratory problems, heart diseases, cancer and stroke. Significant causes of morbidity among this group is chronic inflammatory and degenerative conditions such as Arthritis, Diabetes Osteoporosis, Alzheimer s disease, Depression, Psychiatric disorders, Parkinson s disease and age related urinary problems Limitations of conventional medicine in the management of non communicable diseases The stupendous success of conventional medicine in the management of communicable disease especially in the west was owing to the identification of a single cause in the form of a parasite/causative organism for all communicable disease and a systematic plan of action was derived to counter the cause which then cured the disease. However, the biggest challenge with geriatric problem is that in most of the cases the condition cannot be attributed to a single cause or in certain conditions like neuro-psychiatric disorders (Senile dementia, Alzheimer s depression), the structural cause is unknown. In such cases the conventional medical therapy fails to come out with effective management plan and hence is severely compromised. Another challenge with conventional medical therapy is that it does not have 1

2 AYURVEDA AND SIDDHA health promoting agents. Ayurveda on the other hand has interventions those enhance physiological processes that influence metabolic and immunological status (cyavanaprasha, triphala) and such interventions are significant in the context of geriatric care. 2. Ayurvedic clinical experience on geriatrics 2.1. Ayurvedic understanding of geriatrics Ayurveda has a focused branch of medicine called Rasayana (Rejuvenation) which exclusively deals with the problems related to aging and methods to counter the same. Geriatrics or Jara cikitsa or Rasayana in Ayurveda is a method to control / slow down / arrest the aging process in the human being during the degenerative phase of one s life. Rasayana is normally advised during this degenerative phase which starts from around 45 yrs in both male and female. A holistic system like Ayurveda approaches this condition through two-fold methods. One is a radical approach in which it recharges the whole metabolic process of the body by eliminating the toxins from the system by a three to four months rigorous and organized process known as Kutipraveshika Rasayana. However, this process is seldom practiced due to the extreme intricacy of the physiological process involved and the need for utmost care to be taken by the physician and subject including the environment where the treatment is done. Hence this Kutipraveshika remains as a textual marvel of Ayurveda than a practical process of contemporary relevance. The second approach of Ayurveda, which is quite popular today, is called Vataatapika Rasayana which can go along with the normal day to day life. This type of Rasayana is particularly important in the current scenario as it has a relatively easy mode of administration without any restrictive pre-conditions. Apart from this, Rasayana are also classified as: A. Medhya Rasayana: Rasayana that act specifically as brain tonics, eg: Shankhapushpi, Mandukaparni, Yashtimadhu and Guduchi. B. Vardhamana Rasayana: Rasayana given in a gradual step-up dosage from a minimum to a maximum dose followed by a tapering back, eg: Vardhamana Pippali Rasayana. 2 C. Droni-Praveshika Rasayana: A very spectacular form of Rasayana, where in a person is made to consume stomach full of the juice of

3 8 rare herbs and made to lie down in a wooden casket for a period of 6 months (unconscious). This again has no known history of being performed anywhere in the near past, although finds a mention in the text as being one that will enable an old person to completely regain his youth Core areas of strength in Ayurveda Undoubtedly the strength of Ayurveda in the context of Geriatric care is Rasayana therapy, which is unique because of its ability to promote longevity and influence all aspects of health in a positive way. Describing the effects of Rasayana, the classical texts of Ayurveda say that from Rasayana one attains longevity, improved harmony and intelligence, freedom from disorder, youthful vigor, excellence of luster, complexion and voice, optimum strength of physique and senses, command over language, respectability and brilliance. Ayurveda considers the physical structure to be composed of 7 dhatus starting from Rasa (Rasadi Dhatus) and Rasayana is the tool to create premium dhatus (body tissues). The main utility of Rasayana therapy is in functional and degenerative disorders that have a chronic or long standing nature. In such cases, in fact, Rasayana is the only solution from the point of view of effective management in any system of medicine. Rasayana becomes more fruitful and effective if it is preceded with suitable panchakarma (purificatory therapy). The reason we see mixed results in many cases where Rasayana is employed is because of the fact that either this purification is not done or improperly done. Panchakarma is a bio-cleansing regimen comprising of five main procedures that facilitates better bioavailability of the pharmacological therapies, helps to bring about homeostatsis of body-humors, eliminates disease-causing complexes from the body and checks the recurrence and progression of disease. The five fold measures comprehended in this therapy are Vamana (Therapeutic Emesis), Virechana (Therapeutic Purgation), Astapana Vasti (Therapeutic Decoction Enema), Anuvasana Vasti (Therapeutic oil Enema), Nasya Karma (Nasal administration of medicaments). Panchakarma procedures are preceded by Snehana (Therapeutic Oleation) and Swedana (Sudation) applications to make the body system conducive for elimination of bio-toxins and cleansing of channels. This is effective in managing autoimmune, neurological, psychiatric and musculo-skeletal diseases of chronic and metabolic origin. 3

4 AYURVEDA AND SIDDHA Single Rasayana drugs for some specific disease conditions Diseases of Eye: Jyotishmati (Celastrus paniculata), Triphala (Three myrobalans), Satavari (Asparagus racemosus), Yastimadhu (Glycyrrhiza glabra) and Amalaki (Emblica officinalis). Diseases of Heart: Salaparni (Desmodium gangaticum), Arjuna (Terminalia arjuna), Guggulu (Commiphora mukul), Pushkaramula (Inula racemosa) Skin diseases: Bhallataka (Semecarpus anacardium), Vidanga (Embelia ribes) and Bakuchi (Psoralia corylifolia). Rasayana for overall Health: Guduchi (Tinospora cordifolia), Amalaki (Emblica officinalis), Aswagandha (Withania somnifera), Cow s milk and Takra. Asthma: Sirisha (Albezia lebbeck), Agastya (Sesbania grandiflora), Haridra (Curcuma longa), Haritaki (Terminalia chebula). Arthritis: Rasona (Allium sativum), Guggulu (Commiphora mukul), Aswagandha (Withania somnifera) and Shunthi (Zinziber officinale). Neuropathies: Rasona (Allium sativum), Guggulu (Commiphora mukul), Bala (Sida cordifolia), Aswagandha (Withania somnifera). Diabetes: Silajitu (Black bitumen), Amalaki (Emblica officinalis), Haridra (Curcuma longa), Tejpatra (Cinnamomum tamala), Methika (Trigonella foenum graecum). Lipid disorders: Guggulu (Commiphora mukul), Haritaki (Terminalia chebula), Pushkaramoola (Inula racemosa), Vaca (Acorus calamus). Hypertension: Rasona (Allium sativum), Sarpagandha (Rauwolfia serpentina), Aswagandha (Withania somnifera), Jatamansi (Nardostachys jatamansi). Brain and Memory Disorders: Brahmi (Bacopa monnieri), Mandooka parni (Centella asiatica), Jyotishmati (Celastrus paniculata), Kapikachhu (Mecuna pruriens), Tagara (Valeriana wallichii). Some Compound formulations that are available in the market with a multipronged action are being listed below: Chyawanprasha Brahmi Rasayana Aswagandha Lehyam Mahatriphala Ghrita, Triphala Curna 4

5 Aswagandha Curna Narasimha Rasayana Agastya Rasayana Amalaki Rasayana 3. Challenges for contemporary application of Ayurvedic geriatrics 3.1. Contemporary application of Ayurvedic geriatrics Ayurvedic treatment as such is very individualistic and one medicine found to be useful in a condition in a particular person may not work at all in another. Hence, it is a challenge to come out with generalized management solutions for a condition that would suit all. It is difficult to bring out management plans for a particular disease condition and implement the same in a large scale. It is important that we respect both holism (of traditional medicine) as well as reductionism (of modern bio-medicine) because both are ways of looking at nature and depending on the purpose both the views can be extremely useful. Furthermore the whole and the part are certainly related but it is not a one-to-one relationship. The understanding that it is not one-to-one relationship and learning how to relate the whole perspective (the systemic theories of Ayurveda & Yoga) with part (structural theories of western biomedicine) is the outlook that should underline the implementation of trans-disciplinary research projects. Today, nobody in the academic field has all the answers of how to combine and correlate part and whole perspectives in the context of clinical research design, clinical practice, content of courses on Ayurveda and Yoga, in the context of laboratory research in pharmacognosy and product development, and in assessment of community based local health practices. It is important to understand that drug trials for evaluating efficacy of Ayurvedic interventions is a reductionist approach and is an inappropriate design. Instead, clinical trials should evaluate the efficacy of a whole management package which may consist of drugs, diet, Yoga, Panchakarma including differential diagnosis to identify the specific nature of tridoshic imbalance Developing ambitious projects of trans-disciplinary clinical research on key geriatric problems The biggest challenge in the contemporary application of Ayurvedic 5

6 AYURVEDA AND SIDDHA geriatrics would be to come up with protocols to document, diagnose in an integrative frame work and manage geriatric problems. This would require critical investment (the current strategies are subcritical) in establishing advanced research, treatment and teaching centers that have a state of the art facility to deal with geriatrics. 4. The policy issues It is important for policy makers to firstly recognize the fact that geriatric health care has to be managed in a pluralistic way because no single system of medicine has the capacity to address the health care needs of the growing size of the aged population. Policy therefore needs to clearly identify the key areas for support in Ayurvedic geriatrics and make plans and proposals for critical investments in such areas. A range of both Govt. and Non-Govt. institutions with either promising or outstanding leadership need to be identified and encouraged to prepare ambitious proposals commensurate with the magnitude of the social problem of old-age care. Unless generous funding is invoked, it will be like trying to plough a huge field with a stick instead of modern tractors. It is essential that a multi-dimensional intervention be conceived that will involve a) trans-disciplinary research b) advanced treatment centers and c) specialized post graduate education. There is a very urgent need to establish centers in the country that would engage in the kind of transdisciplinary research that we are envisaging in order to take Ayurveda globally and also to bring the clinical services of Ayurveda into the mainstream. This would require a generous funding for undertaking such research and also establishing centers that would provide effective clinical services. There is also a need to support specialized transdisciplinary PG researches in centres where PG in geriatrics is offered. The areas for policy interventions are outlined below: 4.1. The need for generous funding for Ayurvedic Geriatric research and clinical services 4.2. Building treatment capacities in reputed Govt. and Non-Govt. institutes for geriatrics 4.3. Support advanced clinical centers for Geriatric care in reputed institutions in the Govt. and Non-Govt. sectors 4.4. Support specialized trans-disciplinary PG education courses in geriatric care 6

7 RASAYANA - HEALTHY AGING BACKGROUND Aging is a process of physical, psychological and social change in multidimensional aspects. Some dimensions of aging grow & develop with time while others decline. The world population of the elderly is increasing significantly, and by the year 2050, adults older than 65 years will comprise 1 / 5 th of the global population. In India 3.8% population are older than 65 years age. According to an estimate the likely number of elderly people in India by 2016 will be around 113 millions. The aged population in India is mostly in rural than the urban. The other significant feature in the aged population is that number of females is more than males and are residing in pitiable situation in rural India. The Indian traditional culture respects the aged, but the shift to the nuclear family pattern the aged individuals are neglected. The important issues in aged population are many like social, economical etc. but more than these is health. The Ayurveda & Siddha traditional holistic health sciences are very much potential in prevention of diseases by promotion of health & management of metabolic syndromes occurring in old age. Twentieth century has seen gradual decline in fertility, the growth rate of population but with increase in life expectancy. As a result society is grappling with longevity issues. Though worldwide demographic revolution is a social achievement, yet the consequences of longevity inter alia are larger number and proportions of older people that influence financing of health care. The growing number and proportion of elderly persons is placing the increasing demands on Public Health System and on medical and social services. Most of the older people are suffering from at least one chronic disorder and they may be suffering from multiple of disorders. Their quality of life as a result is suffering and also poses a burden on their family and caregivers. The leading causes of illness and death among aged peoples comprise respiratory problems, heart diseases, cancer and stroke. Chronic inflammatory and degenerative conditions such as Arthritis, Diabetes, Osteoporosis, Alzheimer s disease, Depression, Psychiatric disorders, Parkinson s disease and Urinary incontinence diminish the quality of life. 7

8 AYURVEDA AND SIDDHA Although the risks of developing diseases rises with advancing age, but it is not an inevitable consequence of aging. Prevention and management of health problems could help the elderly to improve quality of life and remain independent for their daily activities to certain extent. Ayurveda literatures record vivid information about the concept of aging process and loss or impairment of tissue system/ functions during various decades of life and their management. Ayurveda has broad spectrum of preventing measures for combating the aging process which is in practice in large number of people in our country. National Policy for aged under the Ministry of Social Justice and Empowerment seeks health security of older people and it recognizes special health needs of the older persons to be met through strengthening and reorienting of public health services at Primary Health Care level and creation of health facilities. Some of the well known centers of Ayurveda & Siddha viz Central Research Institute (Ayurveda) (CCRAS),Cheruthuruthy Kerala, National Institute of Ayurveda, Jaipur, Rajasthan, Institute of Post Graduate Teaching & Research in Ayurveda (IPGT&RA), Gujarat Ayurveda University, Jamnagar, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Govt. Ayurveda College, Thiruvananthapuram, Central Research Institute Siddha (CCRAS), as well as National Institute of Siddha, Chennai are catering significant health care services in the field of Geriatrics. A few Societies and NGOs viz. Association of Gerontology, Geriatric Society of India, Parkinson s & Ageing Research Foundation, Helpage India, Age well Foundation etc. are engaged in support activities related to Geriatric Care. Geriatric clinics and M.D. course in Geriatric are functioning at BHU, Varanasi, AIIMS, New Delhi, MGIMS, Wardha and Maulana Azad Medical College, New Delhi and so on. POTENTIAL AND STRENGTH Ayurveda attributes primary importance to preventive and promotive health care and the maintenance of positive health. The major preventive approaches for maintaining and improving the quality of life include individualized specific daily regimen (Dinacharya), seasonal regimen (Ritucharya), behavioral and ethical considerations (Sadvritta). Healthy lifestyle is emphasized as the determinant of longevity of life, which by and large depends on the Prakriti (bio-identity i.e. body-mind constitution) of an 8

9 individual. Proper understanding of Prakriti leads the physician in making right diagnosis, prognosis and treatment plan and in guiding patients as well as healthy individuals, what do s and don ts they need to follow for restoration and maintenance of health. Rasayana therapy is a specialized branch of clinical medicine in Ayurveda aimed at preventing the effects of aging and to improve intelligence, memory, complexion and sensory and motor functions. Numerous single and compound Rasayana medicines possessing diversified actions like immuno-enhancement, free-radical scavenging, adaptogenic or anti-stress and nutritive effects are described in Ayurveda literature for their use in health promotion and management of diseases with improvement in the quality of life. Rasayana Therapy can be advocated at out door level (Vatatapika Rasayana) and with hospitalization also (Kutipraveshika Rasayana) depending upon the need of patients. Panchakarma is a bio-cleansing regimen comprising of five main procedures that facilitates better bioavailability of the pharmacological therapies, helps to bring about homeostasis of body-humors, eliminates disease-causing complexes from the body and checks the recurrence and progression of disease. The five fold measures comprehended in this therapy are Vamana (Therapeutic Emesis), Virechana (Therapeutic Purgation), Astapana Vasti (Therapeutic Decoction Enema), Anuvasana Vasti (Therapeutic oil Enema), Nasya Karma (Nasal administration of medicaments). Panchakarma procedures are preceded by Snehana (Therapeutic Oleation) and Swedana (Sudation) applications to make the body system conducive for elimination of bio-toxins and cleansing of channels. This is effective in managing autoimmune, neurological, psychiatric and musculo-skeletal diseases of chronic and metabolic origin. Ayurveda and Siddha Literatures record numerous single and compound plant based medicines (majority) and herbo-mineral, herbo-metalic (a few) formulations for general good health and disease specific indications relating to Geriatrics. Single Rasayana drugs for some specific Disease conditions Diseases of Eye: Jyotishmati (Celastrus paniculata), Triphala (Three myrobalans), Satavari (Asparagus racemosus), Yastimadhu (Glycyrrhiza glabra) and Amalaki (Emblica officinalis). 9

10 AYURVEDA AND SIDDHA Diseases of Heart: Salaparni (Desmodium gangaticum), Arjuna (Terminalia arjuna), Guggulu (Commiphora mukul), Pushkaramula (Inula racemosa). Skin diseases: Bhallataka (Semecarpus anacardium), Vidanga (Embelia ribes) and Bakuchi (Psoralia corylifolia) Rasayana for overall Health: Guduchi (Tinospora cordifolia), Amalak (Emblica officinalis), Aswagandha (Withania somnifera), Cow s milk and Takra. Asthma: Sirisha (Albezia lebbeck), Agastya (Sesbania grandiflora), Haridra (Curcuma longa), Haritaki (Terminelia chebula). Arthritis: Rasona (Allium sativum), Sallaki (Boswellia serrata), Guggulu (Commiphora mukul), Aswagandha (Withania somnifera) and Sunthi (Zinziber officinale). Neuropathies: Rasona (Allium sativum), Guggulu (Commiphora mukul), Bala (Sida cordifolia), Aswagandha (Withania somnifera). Diabetes: Silajitu (Black bitumen), Amalaki (Emblica officinalis), Haridra (Curcuma longa), Tejpatra (Cinnamomum tamala), Methika (Trigonella foenum graecum). Lipid disorders: Guggulu (Commiphora mukul), Haritaki (Terminalia chebula), Pushkaramoola (Inula racemosa), Vacha (Acorus calamus). Hypertension: Rasona (Allium sativum), Sarpagandha (Rauwolfia serpentina), Aswagandha (Withania somnifera), Jatamansi (Nardostachys jatamansi). Brain and Memory Disorders:- Brahmi (Becopa monnieri), Mandooka parani (Centela asiatica), Jyotishmati (Celastrus paniculata), Kapikachhu (Mecuna pruriens), Tagara (Valeriana wallichii). SOME COMPOUND FORMULATIONS Cyawanprasa Brahmi Rasayana Aswagandha Lehyam Mahatriphala Ghrita, Karisalai Legiyam Triphala Curna 10

11 Aswagandha Curna Pranada Gutika Narasimha Rasayana Agastya Rasayana Amalaki Rasayana Ayajambeera Karpam Bavana Kadukkai Ayabringaraja Karpam AT A GLANCE Multiple actions of Rasayana therapy includes immuno-modulation, antioxidant action (prevents bio-oxidation thereby checking age related disorders, auto immune disorders, degenerative disorders), adaptogenic (anti-stress) affects and so on. Time-tested holistic and comprehensive remedies for on Nature s Laws can address the gaps in health care of old people. Lifestyle modulation (Swathavritta and Sadvritta) remains integral to the treatment. Most cost effective; affordable by all sections of People Well tolerated; no Adverse Drug Reactions AYUSH systems have specialized therapeutic procedures for rejuvenation, health promotion and prevention & management of degenerative health problems. Panchakarma & Yoga are proven to be efficacious in neuro-muscular, musculo-skeletal, psychosomatic, metabolic and many chronic health problems of elderly people. EVIDENCE BASED RESEARCH 1. Brahmi (Bacopa monnieri) in the management of Senile Dementia. Brahmi Vs Placebo: Administration of 1gm. of powdered extract of Brahmi twice a day for 5 years has shown significant reduction in the progression of memory loss in persons suffering from senile dementia. 11

12 AYURVEDA AND SIDDHA 12 Reference: Role of the Ayurvedic Drug Brahmi (Bacopa monnieri) in the management of Senile Dementia. Pharmacopsychologia (1990),3, Butea monosperma root distillate in the management of age related immature Cataract The root distillate drops of Butea monosperma developed as per I.P Standards has shown significant improvement in visual acuity and quality of vision (disturbance in vision viz. haziness, diplopia etc.) in the subjects of age related immature cataract (n=52). Reference: Srikanth N. et al., Butea Monosperma Root distillate eye drops (Palasa Moola Arka) in age related immature cataract: A clinical observation, Journal of Research in Ayurveda and Siddha, Vol.XXVII. No.1-2, (2006) pp Aswagandha (Withania somnifera) on the process of aging Aswagandha Vs Placebo: 3 gm. of root powder of Aswagandha (Withania somnifera) was administered in the dosage of two tablets three times daily with milk for one year showed statistically significant increase in Haemoglobin, RBC count, hair melanin & seated stature and decrease in serum cholesterol and ESR. Reference: Kuppurajan etal, Effect of Aswagandha (Withania somnifera) on the process of ageing in Human volunteers. Journal of Research in Ayurveda and Siddha. 4. Guggulu (Commiphora wightii) in Hyperlipidaemia Guggulu (Commiphora wightii) Vs Placebo: Cardinal clinical manifestations of disease like precordial pain and dyspnoea were relieved in in most of the cases in a clinical study tried with Guggulu in the dose of 8 gm/day. Substantial fall in lipid fractions like cholesterol 27%, triglycerides 36%, phospholipids 20% and free fatty acids 37% indicated the possibility of regression of atherosclerosis. The reversal of ECG changes substantiated the anti-ischaemic effect of the drug in the treatment of ischemic heart diseases. Reference: Clinical and Experimental trial of Guggulu (Medoroga) Central Council for Research in Ayurveda and Siddha, Janakpuri, New Delhi.

13 5. Sallaki (Boswelia serrata) in Rheumatoid arthritis Sallaki Vs Diclofenac sodium: 600 mg of Sallaki 3 times in a day and 50 mg. of Diclofenac Sodium 3 times in a day was given in treated and control groups respectively for 4 weeks. Efficacy of Sallaki was found to be comparable to that of Diclofenac Sodium in the patients of RA, who demonstrated predisposition for gastric intolerance with antiinflammatory medication. Reference: Bichile, LS et al., Double blind randomized controlled trial of Sallaki Vs Diclofenac in treatment of Rheumatoid arthritis, Select Research Papers on Evidence Based drugs in Ayurveda, Dept of ISM&H, Ministry of Health, Government of India, New Delhi Management of Hemiplegia by Panchakarma therapy Panchakarma Vs Palliative therapy: In a comparative study on 744 hemiplegics revealed that 552 subjects who received Panchakarma therapy showed significant recovery from illness, besides improvement in motor functions and quality of life in comparison to subjects who received shamana therapy (Palliative therapy) alone. Reference: Management of Hemiplegia by Panchakarma therapy, Central Council for Research in Ayurveda and Siddha, Janakpuri, New Delhi Multi-facetted protective role of Cyawanprasa Cyawanprasa showed significant Immunomodulatory activity (Decrease in Ig G, C 3 and C 4 levels in patients of recurrent cough and cold), Cytoprotective action (Cancer patients receiving radiation therapy showed a protective role against radiation induced tissue damage)and Genoprotective action (significant reduction in Mitotic Index (MI) and Chromosomal aberrations (CA)). Reference: NB Brindavanam, N.Bhattacharya, C.K.Katiyar and DBA Narayana Multi-facetted protective Role of Rasayana Therapy: A review of investigations on Cyawanprasa Ayurvedic Conference on Rasayana 2002, Rashtriya Ayurveda Vidyapeeth 8. Anti-anxiety effect of an Ayurvedic compound drug A double blind sequential cross over clinical trial with an Ayurvedic compound containing Mandukaparni (Centella asiatica),yastimadhu 13

14 AYURVEDA AND SIDDHA (Glycyrrhiza glabra) and Jatamansi (Nordostachys jatamansi) as trial drug, diazepam as control and placebo carried out on 12 patients of anxiety neurosis. It was found that Ayurvedic compound formulation is more effective in enhancing the perceptual discrimination and psychomotor performance over placebo and control drug. Reference: K.Kuppurajan et al - Anti-anxiety effect of an Ayurvedic compound drug A cross over trial, Journal of Reserch in Ayurveda & Siddha Vol. XIII No. 3-4, PP Guduchi (Tinospora cordifolia) as immunomodulatory agent Clinical studies of Guduchi (Tinospora cordifolia) have shown significant efficacy in the cases of obstructive jaundice. Dahanukar et al., Immunotherapy with Tinospora cordifolia: A new lead in the management of obstructive jaundice by Tinospora cordifolia, Indian J Gastroenterol, 12 (1993) 5. READING MATERIAL 1. Clinical & Experimental Studies on Rasayana Drugs & Panchakarma Therapy, CCRAS, New Delhi, Management of Hemiplegia by Panchakarma therapy, Central Council for Research in Ayurveda and Siddha, Janakpuri, New Delhi

15 BACKGROUND NEUROLOGICAL DISORDERS (Nadisansthanagata Roga) Neurological disorders need greater attention as the age advances. Many neurological disorders (gait disorders), neurodegenerative disorders (Dementia) and neuromuscular disorders (Paralysis) affect the geriatric population. Atrophy, peripheral sensory neuronal loss are also seen in old age. Marked vascular changes occur with aging. At age 80, brain blood flow decreases by 20-28% and this parallels a decline in a cerebral metabolic rate. In addition, increase in cerebrovascular resistance with cerebral arteriosclerosis, vessel fibrosis and endothelial involution is seen with aging. Decrease in nerve conduction velocity, muscular functions are also seen in elderly individuals due to aging. The functional impairments such as with devastating stroke are threatening to an individual s independence. Stroke is a disease of middle aged and elderly individuals. In U.S.A annual stroke cases are 7, 50,000 and there is occurrence of one stroke in every 53 seconds and one stroke death in every 3.3 minutes. In India exact data is not known, 30% people die in first few days of acute attack and among survivals 25% are suffering with disabilities. Atherosclerosis and uncontrolled HTN are the common causes of Cerebrovascular diseases and the associated risk factors like diabetes, heart disease, hypercholesterolemia, smoking and excessive alcohol intake also play an importance role in the pathogenesis of cerebrovascular diseases. The effect of stroke on the individual can be devastating. The sudden loss of neurological function is unanticipated. Most young and all older patients experience drastic lifestyle changes may never return to employment and may become dependent for even the simplest activity of daily living. Depression is common (up to 5%) following a stroke and interferes with rehabilitation, Insomnia, diminished appetite, poor attention and concentration and a withdrawn feeling are frequently associated with stroke. Pakshaghata (Hemiplegia) is mainly caused by vitiation of Vata causing dryness of sira and snayu and loss of function of one half of body. Ayurveda provides both preventive, curative and rehabilitative 15

16 AYURVEDA AND SIDDHA measures for the management of stroke. Prevention is the best cure. Identification of risk factors and their treatment can prevent the occurrence of stroke. Ayurveda offers various antihypertensive drugs, anticholesterolemic, antistress drugs, practicing of yoga and meditation, lifestyles and dietary regime for the prevention of disease. For curative purpose or to rehabilitate the patients and to treat disability after stroke Ayurveda has Panchakarma treatment and Massage therapy. Various nervine tonics and bulk promoting drugs are available for providing strength. POTENTIAL AND STRENGTH Preventive aspects - Ayurveda offers various herbal formulations to treat the risk factors for stroke. Life style regime as advocated in Ayurvedic literature can help in attaining mental peace. Yoga and meditation are both curative and preventive measures. 1. Antihypertensive drugs Arjuna, Pushkarmoola, Prabhakaravati, Hridyarnava Rasa, Arjunarista, Arjunakshirapaka, Sarpagandhadi Vati 2. Antihypercholesterolemic drugs Arogyavardhini vati, Navakagugglu, Kaisor guggulu, Triphala Curna, Trikatu Curna. 3. Drugs for the management of stress and depression Aswagandha Curna, Brahmi vati, Medhya rasayana, Saraswata Curna etc. Panchakarma Mainly Vasti therapy, Niruha Vasti with Dasamula Kwatha and Anuvasana Vasti with Mahanarayana taila or Bala taila provide strength to neuromuscular system. Massage (Abhyanga) with strengthening oils to provide nutrition to muscles and to prevent atrophy of muscles. Shashtikashali pindasweda. Nervine tonics in Ayurveda 16 Dasamula Kwatha Shilajatu Aswagandha Curna Saraswata Curna Brahmi Ghrita

17 Oils for massage Mahanarayan Taila Bala Taila Prasarini Taila Mahamasha Taila Nirgundi Taila Panchaguna Taila EVIDENCE BASED RESEARCH 1. An Ayurvedic combination therapy in Hemiplegia In a clinical trial, a combination of Ekangaveera rasa 250 mg twice daily, Masha taila for massage and Shastikashali pinda sweda for 45 days were given to the patients of Hemiplegia which showed good response in subjective and objective parameters as power and tone of the muscles in 42% cases. Reference: L.K.sharma et al., A clinical study on pakshaghata (Hemiplegia) with a combination of Ekangaveera rasa, Masha taila and Shashtikashali panda sweda, Journal of Reserch in Ayurveda & Siddha Vol. XXV No. 1-2 pp Hingutriguna taila-role in Hemiplegia In a clinical trial on 35 patients of Pakshaghata, Hingutriguna taila 5ml orally 2-3 times a day with Abhyanga and Pindasweda twice a day is found to be effective within 2 weeks and definite relief has been observed after 4-6 weeks of treatment. Reference: Prem Kishore and M.M.Padhi, Role of Hingutrigunataila in the treatment of Pakshaghata (Hemiplegia). Journal of Reserch in Ayurveda & Siddha Vol. IX No. 1-2 pp Panchakarma treatment in Pakshvadha In a controlled clinical study, 56 patients of hemiplegia were treated with Panchakarma treatment (snehana, sweda, mriduvireka and vasti) with taila and kasaya of Mashadi Yoga (Masha, Atmagupta, Eranda and Bala) and in control group colored taila and Kasaya (of Manjistha) for 17

18 AYURVEDA AND SIDDHA panchakarma treatment had been used. The trial has shown that the treatment sneha, sveda, mriduvireka and vasti are effective but Mashadi compound has only slight effect on this disease. Reference: S.Madhavan Pillai et al., Effect of Panchakarma treatment with Mashadi Yoga on Pakshavadha, Journal of Reserch in Ayurveda & Siddha Vol.I No.2 (1930) pp Sodhana therapy vs Samana therapy in Khanja and Pangu In a control clinical trial Prabhanjanavimardanam taila for internal and external use as samana therapy, for external application only as placebo and for virecana and vastikarma as sodhana therapy were randomly given to patients of Khanja (Monoplegia) and Pangu (Paraplegia). Results were highly encouraging and statistically significant with samana and sodhana therapy and not significant with placebo. Further results in sodhana group was found better in comparison to samana group Reference: P. Ramachandran Nair et.al., Clinical evaluation of Prabhanjanavimardanam taila and Sodhana therapy in the management of Khanja (Monoplegia) and Pangu (Paraplegia), Journal of Reserch in Ayurveda & Siddha Vol. XIII No.1-2 pp READING MATERIAL: 1. CCRAS Research an over view, CCRAS, New Delhi, Clinical & Experimental Studies on Rasayana Drugs & Panchakarma Therapy, CCRAS, New Delhi,

19 MUSCULOSKELETAL DISORDERS (Mamsa-Asthi-Sandhigata Roga) BACKGROUND Musculoskeletal Disorders predominate in the older adults and are major cause for chronic disability and health care utilization in the geriatric age group. Disorders of Musculoskeletal system impair mobility, interfering with activities of daily living and function. These disorders are chronic in nature, not life threatening but affect the quality of life. Due to ageing process, there is a decrease in hydration of cartilage secondary to changes in proteoglycan structure, affecting water binding. There is an increase in crystallization and calcification, decrease in cellularity and probable decrease in the response to growth factor stimulation. All these change in the tissue results into less able to handle the mechanical stress. Fragility fractures have doubled in the last decade. 40% of all women over 50yrs. will suffer an osteoporotic fracture. The number of the hip fractures will rise from about 1.7 million in 1990 to 6.3 million by Common musculoskeletal disorders found in Geriatric group are Osteoarthritis (Sandhivata), Rheumatoid arthritis (Amavata), Spondylosis and Osteoporosis (Asthi soushirya), Back pain (Katisoola), etc. It is found that nearly 20% to 30% of Rheumatoid arthritis patients present after age 60. It is a chronic multi-system disease, which affects mainly the joints. Remissions are less likely in the elderly with established disease, resulting in much discomfort and disability in patients with Rheumatoid arthritis. Osteoporosis is common in older adults and is associated with enormous morbidity from complications. Ayurvedic classics have comprehensive description on the pathophysiology and management of Musculoskeletal disorders like Sandhigata vata, Amavata, Vataroga, etc. Ayurveda also considers these musculoskeletal disorders to be prevalent in elderly persons as the domination of Vata is predominant in old age and it is mentioned that Vata rogas generally occurs in elderly persons. Different procedures like Snehana (oleation), Swedana (sudation), Vasti (medicated enema), Kativasti, Januvasti and a number of single and compound formulations are practised in Ayurveda for the management of these disorders. 19

20 AYURVEDA AND SIDDHA In addition, preventive measures like Rasayana (Rejuvenation), Panchakarma (Bio-cleansing) therapy, dietary regimen and lifestyle practices are also equally practiced for these disorders. POTENTIAL AND STRENGTH Preventive aspects: Specific do s and don ts for the prevention of musculoskeletal disorders are advisable. Use of Rasayana drugs and Panchakarma procedure can prevent the physiological changes in bones and joints occurring due to aging. Special Oleation (Snehana) and Sudation procedures (Swedana) like Kativasti, Januvasti, Grivavasti, Valuka swedana, Nadi swedana and Patrapinda pottali swedana are very effective in the management of these disorders. Some single herbal drugs in musculoskeletal disorders In single drugs following are giving promising results in the musculoskeletal disorders. 1. Bala (Sida cordifolia) 2. Guggulu (Commiphora mukul) 3. Rasna (Pluchea lanceolata) 4. Eranda (Ricinus communis) 5. Bhallataka (Semecarpus anacardium) 6. Laksha (Laccifer lacca) 7. Kupilu (Strychnos nux-vomica) 8. Sunthi (Zinziber officinalis) 9. Aswagandha (Withania somnifera) 10. Nirgundi (Vitex negundo) 11. Guduchi (Tinospora cordifolia) Some compound formulations in musculoskeletal disorders 1. Vaiswanara Curna 2. Aswagandha Curna 20

21 3. Rasna Panchaka Kwatha 4. Maharasnadi Kwatha 5. Dashmoola Kwatha 6. Rasna saptaka Kwatha 7. Yogaraj Guggulu 8. Mahayoga Raja Guggulu 9. Sinhnada Guggulu 10. Sunthi Guggulu 11. Saptavinsati Guggulu 12. Panchatikta Guggulu Ghrita Some medicated oils for massage Narayana Taila Mahanarayana Taila Nirgundi Taila Panchaguna Taila Mahamasha Taila Pinda Taila Kshirabala Taila Dhanwantari Taila EVIDENCE BASED RESEARCH 1. Shunthi & Guggulu in Rheumatoid arthritis A combination of equal parts of powder of Shunthi (Zingiber officinale) and Guggulu (Commiphora mukul) resin at a dose of 2 gm thrice daily with Valuka Sweda (dry fomentation) was studied on 497 patients and very good effect was found in 67% of patients after a course of 6 weeks treatment. Reference: CCRAS Research An Overview,

22 AYURVEDA AND SIDDHA 2. Ayurvedic combination in Rheumatoid arthritis 22 A combination of Mahayogaraja Guggulu (1 gm), Vaiswanara Curna (3 gm) twice daily and Simhanada guggulu ( 1 / 2 gm) at bedtime has been given in 518 patients and was found that, about 60% of the patients have shown improvement. Reference: CCRAS Research An Overview, Ayurvedic combination in Rheumatoid arthritis A combination of Aswagandha curna 3gm thrice daily, Eranda taila 15 ml at bedtime have been administered along with dry fomentation for a total duration of 6 weeks. It was observed that, 57% of the patients have shown improvement with the above therapy. Reference: CCRAS Research An Overview, Sunthi Guggulu and Godanti in Amavata (Rheumatoid arthritis) In a Clinical study of Sunthi Guggulu and Godanti on 80 cases of Rheumatoid arthritis encouraging results are found. Reference: M. Mruthyumjaya Rao et al., Clinical evaluation of efficacy of Sunthi, Guggulu and Godomti in the management of Amavata (RA). Journal of Reserch in Ayurveda & Siddha, Vol. XXVI. No. 3-4 (2005) Page: Shallaki as an Add-on therapy along with NSAID in the management of Osteoarthritis In a clinical trail on patients of Osteoarthritis, Sallaki 400 mg thrice daily for a period of 4 weeks in addition to routinely prescribed NSAID were given. After a period of 4 weeks NSAID was withdrawn and only Sallaki administered for an additional two weeks period. It was observed that the improvement in signs and symptoms was sustained until the sixth week i.e. even after discontinuation of the NSAID therapy. Supplementation of the NSAID with Sallaki resulted in a significant reduction in pain, tenderness, swelling, morning stiffness and functional impairment of the affected joints. Reference: Rajadhyaksha A.Chauhan et.al. Open study to evaluate the efficacy of Sallaki as an Add-on therapy along with NSAID in the management of patients with Osteoarthritis, Selected papers on evidence based Ayurvedic drugs, CCRAS, 2001.

23 6. Vaitaranavasti, Patrapinda Sweda in Inter vertebral disc prolapse Vaitarana Vasti (medicated enema) with prior Patrapinda Sweda (medicated fomentation) has been tried on 72 patients suffering from inter-vertebral disc prolapse with sciatica and other related problems. The overall treatment was found encouraging and good relief is seen in 47% of cases and fair relief in 26% of cases. Reference: P.K.S. Nair et. al. Journal of Reserch in Ayurveda & Siddha, Vol. XXII, 3-4 (2001) Page: Guggulu (Commiphora mukul) in Osteoarthritis In a clinical study on 30 male and female patients each Commiphora mukul in capsule form (500 mg concentrated extract) thrice daily along with food showed significant improvement in both the subjective and objective parameters used for assessment purpose and no side effect was noticed during the trial. Reference : Singh B.B.et.al. The effectiveness of Commiphora mukul for Osteoarthritis of the knee- an outcome study, Altern Ther Health Med May-June 9 (3):74-9 READING MATERIAL: CCRAS Research an over view, CCRAS, NewDelhi

24 AYURVEDA AND SIDDHA BACKGROUND Cardiovascular diseases are the most frequent causes of death in the geriatric age group. Significant physiological changes in the heart and blood vessels occur due to aging (Cardiac mass increases, vascular fibrosis and calcification occurs). Increased collagen deposition, calcification, smooth muscle cell proliferation and elastin breakdown lead to vascular thickness and stiffening. There is also diminished capacity of heart to work. The incidence of congestive heart failure, coronary artery disease, cardiac arrhythmias, valvular abnormalities and hypertension increases with age. Heart failure remains the leading cause of death in geriatric age. The causes of heart failure in the elderly are many. CHD remains the predominant cause. Prevalence of coronary heart disease (CHD) increases in older subjects, 80% of total myocardial infarctions (MI) occur in those more than 65 yrs. Angina pectoris is common presentation. Hypertension is also one of the risk factor and there is a steady rise in average systolic and diastolic blood pressure with advancing age upto 70 years age. Treatment of cardiovascular disorders in elderly is difficult and need prolonged treatment and there is a need for the safer drugs to use them for longer period. Ayurveda offers satisfactory management strategies for cardiovascular disorders through preventive and curative approaches. It provides clinically effective and safe single and compound formulations to control the risk factors like obesity, hyperlipidaemia, hypertension, and diabetes. In addition, these drugs are also helpful as an adjuvant and supportive therapy along with the conventional treatment. The adjuvant effect of Ayurvedic drugs has been established through various studies. POTENTIAL AND STRENGTH Preventive potentials Concept of well-balanced dietary regimen (fresh foods, seasonal fruits, salt restriction, etc.) and advocating exercise, Pranayam, yoga, sufficient sleep, avoiding anxiety, worry and emotional upset, regularly attend natural urges, mantra chanting, positive attitude etc. in regard to heart diseases is elaborately available in the Ayurveda literature. 24 CARDIOVASCULAR DISORDERS (Hridroga)

25 Curative aspects Different effective and proven single and compound formulations to control the risk factors like obesity, hyperlipidaemia, hypertension, diabetes are available in the Ayurveda classics. Some drugs (e.g. Terminalia arjuna) even reduce the hypertrophy of the cardiac muscle. Some single and compound drugs Churna (Powders): (i) Arjuna Curna (Terminalia arjuna), (ii) Pushkaramula Curna (Inula recemosa), (iii) Trivritadi Curna, (iv) Haritakyadi Curna. Vati (Tablets) and Guggulu: (i) Prabhakara Vati, (ii) Nagarjunabhraka ras, (iii) Hridayarnava Rasa, (iv)navaka Guggulu, (v) Puskara Guggulu. Asava & Arishta (Fermented liquids): (i) Arjunarishta, (ii) Punarnavasav, (iii) Dasamularishta, (iv) Chitrakadyarishta. Ksheera paka (Processed milk with herbs): Lasuna Kshirapaka, Arjuna kshirapaka. EVIDENCE BASED RESEARCH 1. Pushkara guggulu as an Antianginal and Hypolipidaemic drug In a clinical trial on 150 patients of Coronary Heart Disease, Pushkarguggulu 6-8 g per day showed highly significant reduction in cholesterol, triglycerides and total lipids. Significant improvement in the symptoms and in ECG changes was observed with remarkable reduction in body weight. Reference: Tripathi S. N. et al., Pushkaraguggulu an antianginal and Hypolipidaemic agent in Coronary Heart Disease, Journal of Reserch in Ayurveda & Siddha, Vol. XII No. 1-2, pp Lekhana Vasti (medicated enema) in Ischemic Heart Disease A clinical trial on 35 cases of essential HTN (mild-moderate) and IHD, Lekhana Vasti with Vaca (Acorus calamus) revealed significant reduction in mean systolic blood pressure, body weight and lipid profile. Reference: P.K.Gupta et al., A study on the effect of Lekhana Vasti in cases of Essential Hypertension and Ischemic Heart Disease, Journal of Reserch in Ayurveda & Siddha, Vol. XVI. No. 3-4 (1995) PP Terminalia Arjuna as an adjuvant in Hypertensives with LVH In a controlled clinical study, with Arjuna Kwatha (25ml twice daily) along with atenolol (50mg daily) in treatment group and atenolol (50mg daily) alone as control was studied on hypertensive LVH patients. Significant 25

26 AYURVEDA AND SIDDHA decrease in LV mass which was seen after 3 months and maintained even for a period of 6 months in treatment group. Whereas in control group, regression in LV mass was insignificant. Reference: B.Chandrashekhar Rao et al., Effect of Terminalia Arjuna W & A on regression of LVH in Hypertensives A clinical study, Journal of Reserch in Ayurveda & Siddha, Vol. XXII No. 3-4 (2001) PP ). 4. Arjunavacadi yoga in Hypertension (HTN) Arjunavacadi yoga a combination of Arjuna (Terminalia arjuna), Brahmi (Centella asiatica), Vaca (Acorus calamus) and Jatamansi (Nordostachys jatamansi) in the form of Ghana (aqueous extract) at the dose of mg thrice daily was given on 182 patients of Vyanbala Vaishamya (HTN) for 3 months. A considerable fall in Blood pressure and improvement in symptoms was observed in this study. Reference: Bharti et.al Evaluation of efficacy of Arjuna Vacadi Yoga in Vyanabala vaisamya (Hypertension) A clinical study Journal of Reserch in Ayurveda & Siddha, Vol. XXVII No. 1-2 (2006) PP Guggulu (Commiphora wightii) in Hyperlipidaemia Guggulu 8gm daily Vs placebo: In a study with Guggulu 8gm/day, cardinal clinical manifestations of disease like precardial pain and dyspnoea were relieved in most of the cases; substantial fall in lipid fractions like cholesterol 27%, triglycerides 36%, phospholipids 20% and free fatty acids 37% indicated the possibility of regression of atherosclerosis. The reversal of ECG changes substantiated the antiischemic effect of the drug in treatment of ischemic heart disease. Reference: Clinical and experimental trial of Guggulu (Medoroga), 1989, CCRAS 6. Guggulu (Commiphora wightii) as Hyper-cholesterolemic agent The clinical studies with crude gum guggulu (Commiphora wightii) showed reduction in serum cholesterol levels in patients with obesity and hypercholesterolemia. Reference: Satyavati G.V. Effect of an indigenous drug on disorders of lipid metabolism w.r.t. to atherosclerosis & obesity, M.D. Thesis BHU, 1966, READING MATERIAL: Clinical and experimental trial of Guggulu (Medoroga), CCRAS, New Delhi, 1989, 26

27 RESPIRATORY DISORDERS (Swasansansthanagata Roga) BACKGROUND Respiratory disorders are among the most common cause of morbidity and mortality in elderly. Pulmonary function progressively decline after 25 years of age. The major changes with aging in lungs include decreased elastic recoil, stiffening of the chest wall and deteriorating respiratory muscle strength. Total lung capacity decreases with age, residual volume increases, due to small airway closure during exhalation resulting in air trapping. Common respiratory disorders like COPD (chronic bronchitis and emphysema), Asthma, Pneumonia and Lung cancer are more likely to develop as the age advances. Chronic Obstructive Pulmonary Disease (COPD) is defined as a disease state characterized by the presence of airflow obstruction due to chronic bronchitis or emphysema. COPD is the fourth leading cause of death in USA and a growing health problem. The prevalence of chronic bronchitis in rural India may be high as 30% in the over 40 years age group where as in urban India the incidence around 10%. Asthma is a chronic inflammatory disorder of the airways. The prevalence rate of asthma in elderly people indicate that it varies from 6.5 to 10% approximately. Asthma manifests itself differently in children, adults and elderly people. In older people, it is not early to differentiate whether it is certainly a case of asthma as cough & breathlessness in this age group is a symptom of other disease also because of poor respiratory function. Treatment of COPD and asthma in older people needs much more attention and care. Corticosteroids can cause softening of bone results in to fracture of fragile bone. Incidence of acquiring Tuberculosis also increases in patients on therapy with of corticosteroids. Injection of adrenaline in status asthmaticus endangers the heart and blood vessels of those who have hypertension and Ischemic Heart Disease. Elderly people are more likely to get pneumonia. Elderly people tend to have diminished cough and gag reflexes and weaker immune system. In elderly people pneumonia can be fatal. It is the common cause of hospitalization and prolonged hospital stay in the elderly. 27