Effect of a Standardized Extract of Asparagus officinalis Stem (ETAS®50) on Cognitive Function, Psychological Symptoms, and Behavior in Patients with Dementia: A Randomized Crossover Trial

Dementia is a disease of substantial national concern in a superaging society in Japan. Thus, the treatments targeting this disease are of high priority. However, pharmaceutical treatments are under development and invasive. Hence, many alternative treatments, which are less invasive, are tried, and some of them are supposed to work for dementia symptoms. ETAS®50 is one of these treatments. ETAS®50, a standardized extract of the Asparagus officinalis stem with heat shock protein-inducing activity, is a functional food. ETAS®50 has antistress, autonomic nerve regulation, and sleep quality improvement effects in humans and could contribute to relieving dementia symptoms. This double-blind crossover pilot trial aimed to examine the effects of ETAS®50. A total of 27 patients with mild-to-moderate dementia between October 2018 and February 2020 were included in the trial. ETAS®50 was consumed for 12 weeks and then a placebo for 12 weeks. A significant difference in the mean score of the severity of symptoms in the Neuropsychiatric Inventory Questionnaire (NPI-Q-a) was observed between the ETAS®50 period (0.56 ± 1.72 points) and placebo period (−0.67 ± 2.34 points) (p=0.045). Between-group comparisons with respect to the items of NPI-Q-a also showed a significant decrease in symptoms in the ETAS®50 period compared with the placebo period (p=0.015 for agitation and p=0.045 for depression). In addition, we observed that scores for apathy tended to improve in the ETAS®50 period (p=0.058).


Introduction
Entry into a superaging society is accelerating worldwide due to the medical system's development and increased life expectancy.Te prevalence of dementia among the elderly is increasing along with the number of the elderly.Tus, treatments targeting this disease are of high priority.Eforts to mitigate dementia are being made around the world.Te currently available treatments targeting dementia can delay dementia progression and do not serve as direct interventions [1][2][3].Furthermore, fundamental treatments targeting amyloid beta-peptides or tau protein and the pharmaceutical prevention of dementia onset remain under development.
Besides pharmacological treatments under development, many nonpharmacological treatments, such as exercise or reminiscence, are attempted and supposed to have some efects.Nonpharmacological treatments are less invasive to the body than pharmacological treatments and are easy to use.Functional foods can also be one of the nonpharmaceutical treatments and have the potential for treatment because of their easy way of intake.Tey are very benefcial and easy for the elderly with dementia, who have many hazards in their daily lives, such as executive dysfunction and defect of memory.ETAS ® 50, a standardized extract of the Asparagus of- cinalis stem, is one of the functional foods.It has been shown to enhance heat shock protein 70 (HSP70)-inducing activity and promote antistress efects in mice [4] and autonomic nerve regulation efects in humans [4,5].A human intervention study showed that this treatment improved sleep quality [6][7][8].
Tus, ETAS ® 50 is benefcial for stress, autonomic nerve regulation, and sleep quality and is considered efective in treating dementia, which is a form of brain dysfunction [9].Terefore, we previously conducted a 3-month pilot trial, the prior pilot trial, which is a single-group open-label trial design to verify the clinical efcacy of ETAS ® 50 for treating mild-to-moderate dementia from November 2016.Te results showed that the mean value of the burden scores of the Neuropsychiatric Inventory Questionnaire (NPI-Q-b) ranged from 6.2 ± 5.0 points in the initial point to 3.7 ± 4.1 points in the fnal point, which showed a signifcant difference (p � 0.012).Tese results suggest that ETAS ® 50 is efective to a certain extent in improving cognitive function and is even more efective in reducing behavioral and psychological symptoms of dementia (BPSD).No diference was observed between the sex groups (unpublished data).Terefore, this double-blind crossover pilot trial, the present pilot trial, aimed to further verify these efects and clarify the efcacy of this intervention in ameliorating functionality and symptomology in patients with dementia.To our knowledge, few studies of this type have been conducted on ETAS ® 50 and these efects are verifed.

Materials and Methods
2.1.Methods.Tis trial was a randomized, double-blind, placebo-controlled, crossover comparison pilot trial.We used fve assessment methods, one of which was the Mini-Mental State Examination (MMSE), a 30-point scale for assessing cognitive function [9], which we defned as the primary outcome.Te rest of the assessment methods, which we defned as the secondary outcome, included the following: (1) Clock Drawing Test (CDT), a 15-point scale for assessing frontal lobe function [10]; (2) NPI-Q, a 120-point scale for evaluating BPSD, which is designed to be an inventory for caregivers including family members with two categories (NPI-Q-a: severity of symptoms and NPI-Q-b: burden level); (3) Self-Rating Depression Scale (SDS), a depression self-rating scale; and (4) Quality of Life (QOL) questionnaire, a 12-item questionnaire regarding the condition of body and mind made with reference to the Philadelphia Geriatric Center morale scale.
Te prior pilot trial did not show any diferences between the sex groups.Hence, in the present pilot trial, the participants were divided without regard to sex into two patterns (A and B).Te envelope method was adopted as the allocation method.Accordingly, the envelopes were marked with numbers corresponding to the order of the test foods, after which the envelopes were randomly pulled out for each participant who were then allocated into two patterns.Tis allocation method was administered by the trial staf members.
In the prior pilot trial, NPI-Q-b decreased from 6.2 to 3.7 in patients who received ETAS ® 50.Assuming similar re- sults, the required sample size for each group would be 32, calculated with a standard deviation of 3.5, a two-sided signifcance level of 5%, and a power of 80%.A crossover pilot trial with 36 patients would have sufcient power, despite assuming a 10% dropout rate.Tus, pattern A included 19 participants, and pattern B included 17 participants.Patients took three capsules (100 mg/cps) of ETAS ® 50 or placebo once a day after lunch for 3 months and were then evaluated for functioning and symptomology at the following time points: initial (before the start of intake), intermediate (after 1.5 months of intake), and fnal (after 3 months of intake).
Te intake of ETAS ® 50 and placebo was controlled by care workers or families, and the tests were conducted by experienced therapists.

Test Schedule.
Figure 1 shows the test schedule.In pattern A, the patients received ETAS ® 50 for 12 weeks, followed by 2 weeks washout period, and then the placebo for 12 weeks.Pattern B was the reverse.
Trial staf members fully explained the trial to the participants before providing their informed consent and taking the test foods.Tis procedure included explaining how to answer the questionnaire instruments, MMSE, NPI-Q, CDT, SDS, and QOL questionnaire.Tese implementations were made by the trial staf members.Te participants, caregivers, and trial staf members were blinded to the pattern each participant was in during the trial period.

Test Foods. In this pilot trial, ETAS
® 50 was produced as follows.Te asparagus bases were cut using a machine, and their extracts were obtained in a hot water tank.During the process of natural cooling, cellulase and pectinase (plant cell wall degrading enzymes) were added to break down the residue, and the enzymes were inactivated by reheating.Te solids were then removed, and after undergoing a sterilization process, the product was made into powder by spray drying.
ETAS ® 50 and placebo capsules had the same shape and color (dark caramel) to be indistinguishable.ETAS ® 50 powder was composed of a standardized extract of asparagus extract stem (50 wt% solid content) and dextrin (50 wt%).ETAS ® 50 powder was manufactured by Amino Up Co., Ltd., and the manufacturing process was conducted in accordance with good manufacturing practice standards for dietary supplements and the ISO9001:2015 and ISO22000:2018 health, safety, and quality control criteria.Te placebo powder was composed only of dextrin.

Participants.
A total of 36 patients (30 females and 6 males) with mild-to-moderate dementia diagnosed by their physicians, care levels ranging from support required help level 1 to long-term care level 4, and daily life independence levels of I-M were enrolled [11,12].Support required help and long-term care are Japanese scales for evaluating the care level for the elderly, based on which they get care.Te participants' daily life independence level is also a Japanese scale for evaluating dementia severity.Patients' dementia 2 Evidence-Based Complementary and Alternative Medicine types included cerebrovascular and Alzheimer's diseases.Users and residents of elderly facilities (i.e., those receiving day services, senior houses, nursing homes, and residences with health and welfare services for the elderly) in Sapporo, Japan, were included in this trial.Te exclusion criteria included severe dementia, use of concomitantly banned drugs during the trial period, a history of food allergy, severe liver disease, renal disease, cardiac disease, or hypertension.Tis trial was conducted between October 2018 and February 2020.Te recruitment and follow-up were staggered during the test period.

Statistical Methods.
Descriptive statistics were calculated as means and standard deviations for continuous variables and frequency statistics for categorical variables.Between-group comparisons were performed using the Mann-Whitney U test, and within-group comparisons were performed using the Wilcoxon signed-rank test.A p value <0.05 indicated statistical signifcance.Te p value was used to defne statistical signifcance because diferent tests were used and could, therefore, show signifcant diferences.All statistical tests were conducted using SPSS statistical software (version 24; SPSS, Inc., Chicago, IL, USA).

Ethical Considerations. Tis pilot trial was conducted in accordance with the Declaration of Helsinki and reviewed and approved by the Research Ethics Committee of Japan
Health Care University (approval number 30-13).All participants provided written informed consent before participation.

Results and Discussion
3.1.Results.A total of 36 participants were initially included in the trial.Of the 36 participants, nine were hospitalized or excluded for other reasons as not adverse events (e.g., fractures due to falls or transfer of residence) and had no reference to ETAS ® 50.Tus, a total of 27 participants (mean age: 87.4 ± 11.6 years) were included in the fnal analysis.Of the 27 participants, 13 belonged to care level 1, 7 belonged to care level 2 and 7 belonged to other levels.Te participants' daily life independence levels were Grade IIb (13 patients), Grade I (7 patients), and Grade IIa (6 patients) (Table 1).
Figure 2 shows the fow diagram of the trial participants.Te participants were divided into two patterns (pattern A and B).Te participants in pattern B took ETAS ® 50 for 12 weeks and placebo for 12 weeks, with a washout period of 2 weeks between them, and participants of pattern A followed the same procedure in reverse.Meanwhile, nine participants dropped out.

ETAS ® 50
Improves the Score across Diferent Assessments.
Table 2 shows the score at the initial and fnal assessment and the diference between the periods (n � 27).Regarding the primary outcome, the diference in the MMSE score between the initial point and fnal point was −0.48 ± 2. ® 50 period and 2.07 ± 6.66 points in the placebo period (p � 0.327).Te mean NPI-Q-a score showed a signifcant diference (p � 0.045).However, no signifcant diferences in any other items were observed between the two periods.

Improving for Agitation/Depression in the NPI-Q-a.
Table 3 shows the between-group comparisons of NPI-Qa items because signifcant diferences were observed in NPI-Q-a items.Te between-group comparisons of NPI-Qa items showed signifcant diferences (p � 0.015 for agitation/aggression and p � 0.045 for dysphoria/depression).A marginal trend toward apathy was observed (p � 0.058).
Te within-group comparisons of NPI-Q-a items using Wilcoxon's signed-rank test showed a signifcant diference in agitation in the ETAS ® 50 period (p � 0.046).Te within- group comparisons do not show the result of the doubleblind crossover test but can confrm whether this trial can work or not.
Evidence-Based Complementary and Alternative Medicine 3 a signifcant decrease in symptoms of NPI-Q-a was observed in the ETAS ® 50 period compared with the placebo period (p � 0.015 for agitation, p � 0.045 for depression, and p � 0.058 for apathy).Furthermore, the within-group comparisons between the initial and fnal scores showed that the symptoms in the ETAS ® 50 period signifcantly decreased for agitation (p � 0.046).A marginal trend toward symptom reduction for apathy (p � 0.059) and irritability (p � 0.083) was observed, which suggests that ETAS ® 50 still exerts some efects against dementia.Te cognitive decline in dementia is said to be due to the accumulation of amyloid-β (Aβ) in the brain and  4 Evidence-Based Complementary and Alternative Medicine neurofbrillary tangles caused by tau protein [13][14][15].Aβ forms insoluble Aβ aggregates through the amyloidogenic pathway from its precursor [16].It has been shown that the C-terminus of the tau protein is cleaved by caspase-3 to facilitate its aggregation [17] and that the production of total Aβ and tau increases during apoptosis [18].Pharmacotherapies for dementia include rivastigmine, donepezil, and galantamine, which are cholinesterase inhibitors that suppress the breakdown of acetylcholine in the central nervous system, as well as drugs such as memantine, which suppress the release of excess glutamate so that they do not interfere with memory signals [2].Tese drugs have the potential to slow down dementia progression or improve memory.However, drugs to stop dementia progression and improve prognosis are still under development.Additionally, antipsychotics such as risperidone, atypical antipsychotic, and anxiolytics may be used when BPSD are severe.
Conversely, nonpharmacological therapies, such as exercise therapy, reminiscence, and music therapy, are also used for treating dementia [3].Although there is no defnitive cure for dementia, many attempts have been made to prevent dementia and slow its progress.Tese   [19].Functional foods that utilize ingredients from natural agricultural products are also being implemented as interventions, as a potential alternative or augmentation to drugs that use standard chemical ingredients.For example, the favonol glycosides and terpenoids contained in the Ginkgo biloba extract may be efective in improving memory and brain dysfunction by scavenging active oxygen and improving blood circulation [20][21][22], though this topic remains highly understudied.ETAS ® 50, used in this present pilot trial, has previously shown some efects in the brain of diferent organisms [23].
In animal experiments using mice, it has been confrmed that ETAS ® 50 intake increases HSP70 in the brain and decreases caspase-3, Aβ, and tau proteins [24].Furthermore, it has been confrmed that ETAS-fed mice show a reduction in cognitive decline.Tis efect can be attributed to the fact that Asparaprolin, cyclo(L-leucyl-L-prolyl), cyclo(L-phenylalanyl-L-prolyl), and cyclo (L-tyrosyl-L-prolyl)), in ETAS ® 50 induces HSP70, which is a factor that suppresses the production of Aβ, the aggregation of tau protein, and the accumulation of caspase-3 related to apoptosis.Tese efects may avoid Aβ accumulation and tau protein-induced neurofbrillary tangles in the brain, thus suppressing cognitive decline.
Regarding its efects in humans, the prior pilot trial showed some efects in the NPI-Q-b.Similarly, the present pilot trial also showed some efects and tendency in the NPI-Q-a although this was only a secondary outcome.Hence, it is possibly a new fnding that consuming ETAS ® 50 may, at least in part, improve brain function and help combat dementia.Asparagus is a common and familiar vegetable, and if its ingredients are efective in treating dementia, it could contribute substantially to the fght against this disease [25,26].
Tese results thus suggest that ETAS ® 50, a functional food, has a benefcial efect in improving brain function and BPSD and can help attenuate dementia.In addition, no correlation was observed between the sex of the participants and severity of dementia, perhaps due to the limited number of participants.

Limitation
Dementia mainly occurs in the elderly who often have other concurrent illnesses, such as high blood pressure, heart failure, and back pain.In this trial, many subjects required treatment and medication for these diseases.Further largerscale studies are required to evaluate the efects of ETAS ® 50 on dementia while accounting for the degree of dementia, other diseases, and duration of ETAS ® 50 intake.

Conclusions
Tis pilot trial showed that ETAS ® 50 possibly has a sup- pressive efect on agitation and a suppressive tendency for apathy and irritability in dementia.ETAS ® 50 might help improve BPSD instead of pharmaceutical medicines for people choosing functional foods.Tis trial showed the potential for treating dementia with minimal physical impact and presented a possible approach for achieving such a treatment.
33 points (mean ± standard deviation) in the ETAS ® 50 period and 0.11 ± 2.68 points in the placebo period (p � 0.420).Te MMSE score shows an improvement if the score becomes less.Regarding the secondary outcome, the diference in the CDT score was −0.28 ± 4.23 points in the ETAS ® 50 period and −0.1 ± 2.49 points in the placebo period (p � 0.827).Te CDT score shows an improvement if the score becomes more.Te mean NPI-Q-a score difered signifcantly between the ETAS ® 50 period (0.56 ± 1.72 points) and the placebo period (−0.67 ± 2.34 points) (p � 0.045).Te difference in the NPI-Q-b score was 0.26 ± 1.29 points in the ETAS ® 50 period and −0.44 ± 2.31 points in the placebo period (p � 0.472).Te NPI-Q score shows an improvement if the score becomes less.Te diference in the QOL score was 0.00 ± 3.57 points in the ETAS ® 50 period and −0.19 ± 4.20 points in the placebo period (p � 0.903).Te QOL score shows an improvement if the score becomes more.Te diference in the mean SDS score was 0.37 ± 4.56 points in the ETAS

Figure 2 :
Figure 2: Flow diagram of the trial participants.

Table 1 :
Participants' demographic and medical characteristics.

Table 2 :
Between-group comparisons of the initial and fnal scores and diferences in scores for each assessment method (n � 27).p values <0.05 compared to the initial and fnal scores are considered statistically signifcant. *

Table 3 :
Between-group comparisons of NPI-Q-a items.p values <0.05 compared to the initial and fnal scores are considered statistically signifcant. *