Gait Set
Feru-guard
Rivastigmine
＋
Donepezil must be stopped.
みなさん、ここで歩行セットを覚えてください。
Feru-guardと rivestigmineが、歩行を改善する可能性が高い組み合わせです。
There is another KONO METHOD set, called “Gait Set”.
Feru-guard and rivestigmine are the combinations
that are most likely to improve gait.
39
PSP + NPH
Gait and mood was improved with Gait Set and Pick Set
74y.o. male progressive supranuclear palsy + normal pressure hydrocephalus HDS-R score 9/30
Rivastigmine 4.5mg
Feru-guard 100M
×
3packsChlorpromazine 8mg Pick Set Gait Set
40
彼は、進行性核上性麻痺と正常圧水頭症の患者です。フェルガードとリバスチグミン は、歩行を改善させる最良の組み合わせで、私は歩行セットと呼んでいます。PSPは、
カーテイス先生がピックコンプレックスと呼ぶように、患者の怒りはピックセットが合い ます。このように患者に必要なセットを組み合わせればよりよく改善します。
He is a patient with progressive supranuclear palsy and normal pressure hydrocephalus.
“Gait Set” was applied and his gait improved.
PSP which is included in the “Pick complex”
coined by Dr Kertez tends to show symptoms like Pick’s disease.
So “Pick Set” did well for his irritable mood.
40
63 y.o. male myotonic dystrophy with semantic dementia
１ month
Myotonic Dystrophy
Gait and mood were improved with Pi
ｃ
k Set and Gait SetRivastigmine 4.5mg
Feru-guard 100M
×
2packs Chlorpromazine 8mgFeru-guardが筋強直性ジストロフィーの歩行を改善させたのも私には驚きでした。パーキンソ ン病治療薬以外で歩行を改善する薬はあまりありません。
I was amazed to learn that Feru-guard improved the gait of myotonic dystrophy.
His daughter and grandchild already have developed the same disease.
There are not many medications to improve
ambulation other than Parkinson's disease therapeutic drugs.
41
Patients have mild consciousness disturbance when they don’t look at you.
Dementia with Lewy Bodies
認知症の２０％がレビー小体型認知症です。
彼らに幻覚が出るのは、意識障害があるためと理解すれば、シチコリン1000mgの点滴で幻覚 が消える理由もわかるでしょう。ハロペリドール内服で
パーキンソニズムを悪化させる機会が減ります。
20% of dementia are “Dementia with Lewy Bodies”.
Their characteristic hallucinations may be from their cloudiness of consciousness.
Citicoline 1000mg injection clears their
consciousness and causes hallucinations to disappear.
.
42
20days
Consciousness was restored with Citicoline 500mg IV therapy
Citicoline
シチコリン注射を先に打てば、ハロペリドール内服でパーキンソニズムを悪化させる機会が減りま す。
Drug induced Parkinsonism by haloperidol will decrease
if citicoline injection can clear away hallucinations.
43
1 day 3 months
She became mute in two weeks.
She can climb a 2,700m mountain
three months later.
She started to talk a day after starting IV therapy
Dementia with Lewy Bodies
Condition improved dramatically with citicoline IV therapy
Citicoline
44
DLB患者は、そもそも脳萎縮は軽いので、急激にADLが下がっても、意識障害を治せば 元の生活に戻れます。彼女は2週間で何もできなくなり、シチコリン注射のおかげで3か 月後には趣味の登山を散開したのです。その後4年間元気です。
Brain atrophy of DLB patients are usually mild.
ADL of DLB patients may suddenly fall, but they can come back if their consciousness disturbance is
cleared.
This lady became mute in two weeks and citicoline injection was started.
In 3 months, she can enjoy mountain climbing and she continues to do well the next 4 years.
44
2008 Oct 28 2009 Jan 23 2009 Feb 20
donepezil 1mg 1.67mg 0
Deterioration of Dementia with Lewy Bodies when donepezil was increased
DLB患者は薬剤過敏なので、ドネペジルも少なく投与してください。彼女は、1.67mgでも薬剤 性パーキンソニズムとなりました。これは規定量の1/3です。薬の説明書通りに処方しても患 者はよくなりません。
DLB patients have hypersensitivity to drugs.
She became drug induced Parkinsonism even with donepezil 1.67 mg which is only 1/3 of regular
minimum dosage.
Dementia patient may not improve even if we prescribe drugs just as drug manual instructs.
45
Understanding of Dementia by NTM classification
NTM classification
Acetylcholine(Ach) depletion
Dopamine(DOA) depletion
Dopamine excess Ach and DOA
depletion
Ach depletion and DOA fluctuation
Alzheimer’s disease
Parkinson’s disease
Dementia with Lewy bodies Pick’s disease
and schizophrenia Lewy-Pick
complex(KONO)
みなさんが知っている認知症の種類というのは病理学的診断のことであり生化学的には、
神経伝達物質の不足という観点から薬が作られていると思います。KONO METHD では NTM分類で処方を考えます。ピック病がドパミン過剰である証拠はありませんが、ドパミン 阻害薬で改善するので、そう理解します。Lewy-Pick complexは私が考案した診断名で、あ とで説明します。
Dementias can be classified according to the
neurotransmitters which are depleted, exceeded or fluctuated.
KONO METHOD designs the combination of drugs depending on the condition of neurotransmitters.
There is no evidence that Pick's disease is from excess of dopamine, but the fact that dopamine inhibitors work well suggests so.
“Lewy-Pick complex” is the name that I devised and will be explained later.
46
Vitality classification
Energy classification
Awake
patient Gait
disturbance
positive core
Mental cloudiness
negative
NTM
classification
KONO METHOD classification guiding to effective treatment
Ach depletion Ach
＆
DOAdepletion DOA excess
Ach depletion DOA fluctuation DOA depletion
KONO METHOD recommends these 3 types of classifications of dementia patients.
Treatment of dementia for individual patient should be designed by reference to these
classifications.
コウノメソッドでは、これらの３種類の分類を勧めています。各人の状態や症状を、これら に分類し、一人一人への処方の種類や量は、これらの分類結果を細かく検討した上で決 定がなされます。
47
acetylcholine dopamine serotonin
donepezil from nature
●Galanthamine
●Feru-guard
●Oriental medicine
In a place where various neurotransmitters keep
balance, it is unnatural to increase only acetylcholine like donepezil.
Only 30 % of patients can keep balance after taking donepezil.
脳内ではneurotransmitterどおしでバランスが保たれているので、アセチルコリンだけを賦 活しても問題が起きないのは若い患者だけです。
患者が高齢ならdonepezilは低用量しか処方してはいけません。野球で言えば、donepezilは 速球です。当たれば痛い。
Because neurotransmitters in the brain needs to be in balance of each other, it is important to maintain that balance.
In a young patient that balance is maintained even if only acetylcholine is supplied.
When patients are old, donepezil should be
prescribed only in very small dose not to disturb this balance.
For example, donepezil is the fastball、its effective but It hurts if it hit the batter.
48
acetylcholine
dopamine
Dopepezil excessive dose
parkinsonism
Memory Gait
When excessive donepzilA
（
5㎎）
is given to DLB patient49
DLB患者は、アセチルコリンもドパミンも低下しているのでアセチルコリンだけを賦活してはいけ ないのです。ドネペジル少量ならバランスはくずれません。DLBに限らず高齢者は神経伝達物質 のバランスを考えましょう。そうなるとカクテル処方になるはずです。
Because both acetylcholine and dopamine decrease in DLB patients, only acetylcholine should not be supplemented.
If small amount of donepezil, which increase acetylcholine, is given, this balance won’t be disturbed.
When donepezil is prescribed to elderly patients, this balance of nerotransmitters must always be considered.
This is why prescriptions should be cocktail of small doses of various medications.
49
Core
symptoms Positive symptoms
Negative symptoms
antidepressant
Antidepressants should not be used as the first
treatment option for depressive state of dementia patients
また、認知症のうつ状態に抗うつ薬は合いません。この場合、acetylcholineを補充してから
Serotoninを賦活しないと元気になりません。
Antidepressants do not fit to depressed mental state of dementia.
In this case acetylcholine must be replenished first then serotonin can be supplemented.
Otherwise patients won’t get better.
50
Lewy score
symptoms Full
points
Drug hypersensitivity 2
Visual hallucination（２）, Delusion（１） 2
Syncope 1
Shout in somniloquy（２）, Sleep talking（１）
２
Dysphagia 1
Morbid seriousness that does not have any hobby 1 Lethargic or naps more than 1 hour 2
Resting tremor 1
Cog-wheel rigidity(2), “First rigid” phenomenon*(1) 2 Lateral body slant(2), mild degree(1) 2 16 Physical
exam.
History
total
Over 3 points indicates Dementia with Lewy Bodies with approximately 90% of probability.
*Cog-wheel rigidity is felt only the first time when the elbow joint is bent and stretched
これがレビースコアです。薬剤過敏、幻視、REM睡眠行動障害をチェックします。３点以上 なら９０％レビー小体型認知症です。家族でも診断できます。
This is the chart of “Lewy Score” developed in KONO METHOD.
Drug hypersensitivity, visual hallucination, REM sleep behavior disorder are characteristics.
Over 3 points indicates that patient has “Dementia with Lewy Bodies” with 90% probability.
Diagnosis can be done even by family members not trained in medicine using this chart.
51
Alzheimer score
Lewy score Cut off point 2.5
Lewy score > 3 points
ATD=3%, DLB=98%
レビースコアが３点以上なら、レビー小体型認知症の可能性が高い。
仮に病理基盤がアルツハイマー病だとしても、レビーセットの処方で副作用は出ない。レビー セットは、リバスチグミン、抑肝散とフェルガード100Mです。
Patient is very likely to have “Dementia with Lewy Bodies”
if his score is more than 3.
“Lewy Set” will be effective even if pathological base may be Alzheimer's disease.
“Lewy Set” of KONO METHOD is the combination of rivestigmine, Yokukansan and Feru-guard 100M.
52
1 2 3
Young patient Depression ＝ serotonin deficiency
acetylcholine serotonin
dopamine
Depletion of both acetylcholine and dopamine may participate in causing depressive state
Neurotransmitters related to the depressive state of Dementia
Senile patient Depressive state
若いうつ病は、セロトニン欠乏で説明がつきますが、うつ状態の高齢者は、アセチルコリン やドパミンも影響してる可能性があり、セロトニン賦活だけするとバランスを崩します。
The young patient with depression is explicable only by serotonin depletion, but the elderly patient with a depressed mental state may also be affected by
acetylcholine and dopamine decrease,
so supplementing with only serotonin may break this balance.
53
Donepezil 2.5mg
Sinemet 100mg
Serthraline 25mg 12.5mg
72 y.o. male dementia with Lewy bodies HDS-R score 19.5/30
citicholine glutathion
New Feru-guard LA ×１ ×２
Critically ill DLB patient recovered
by stopping donepezil and adding serotonin & dopamin
Apathy & no appetite He gained 7 kg He can walk 5th year 54
DLB患者が、まったく食べられなくなった時に、私は長年処方していたドネペジルを中止して、
シネメットとセルトラリンを投与して著しく改善しました。ドパミンとセロトニンを補充したのです。
彼はその後5年間元気です。
When this DLB patient became unable to eat,
donepezil was stopped. and Sinemet and Sertraline were started.
His condition improved remarkably, as
neurotransmitters of dopamine and serotonin were supplemented.
He continued to do well for the next five years.
54
9weeks
HDS-R 11.5 HDS-R 24.5
3.5years
78y.o. 82y.o.
Severe depressive state was fully recovered by adding acetylcholine, serotonin and dopamine
Acetylcholine donepezil 1.67mg Rivastigmine 4.5mg dopamine Sinemet 25mg
×
2 Serotonin Sertraline 25mg55
コウノメソッドは長期にわたって患者のベストコンデイションを保てる治療 戦略です。
5年間絶好調の
DLB患者ですが、途中でひどいうつ状態になり、
薬をアセチルコリン、セロトニン、ドパミンのすべてをそろえることで
1週間 で復活しました。薬の用量は常用量より少なくしています。
Kono Method is the treatment strategy that keeps patients in excellent condition for a long time.
This DLB patient who had been in good condition for the last five years, but a severe depressive state came to her.
All of acetylcholine, serotonin and dopamine were supplemented and she recovered in 1 week.
As you can see, dosage of these three medications are fairly small.
55
Pick Score 1/2
situation Patient’s behavior point
refusal, bad humor, afraid of drawn blood, childish 1 arrogance, fold arms and cross legs in front of doctor 1 does not sit in a consultation room,
Leaves the room suddenly without permission
1 cannot understand instructions to tap the right
shoulder with the left hand .
(ask 3 additional questions about proverbs)
2
cannot understand words.
repeats other people’s words.
2 steals other people’s things.
whistles or hums in silent place.
becomes upset in crowd.
2
HDS-R score is less than 7/30 1
manner
medical examination
ピック病患者は、横柄で、子供っぽく、言語理解がわるいです。医師がその特徴を知って いればアルツハイマー型認知症ではないとわかります。
This is the Pick Score chart.
If you know arrogance,
childishness and difficulty in understanding words are characteristics of Pick’s disease,
you can tell that the patient is different from those with Alzheimer's disease.
56
Pick score
Eats other people’s food shoplifting
1 eats only sweets, eat inedible things, overeating,
parorexia, bolt, sexually sthenic
1
gets angry suddenly,
shadowing, afraid of being left alone 1
brain atrophy with the laterality 1 strong atrophy of temporal lobe and/or the frontal
lobe
1
History
CT
findings
2/2
他には、万引き、甘いもの好き、急に怒ること、を家族から聞き出します。CT検査ができ なくても、ここまでで４点以上なら前頭側頭葉変性症（FTLD）が疑われます。
Among others, asking family about shoplifting, carboholic, and irritability, scores are further checked.
If score is over 4, it suggests that the patient has frontotemporal lobe degeneration including Pick’s disease and/or semantic dementia.
57
Pick score distribution in three groups of dementia
0 1 2 3 4 5 6
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29
系列1
0 2 4 6 8 10 12
1 3 5 7 9 11 13 15 17 19 21 23
系列1
0 1 2 3 4 5 6 7 8 9 10
1 3 5 7 9
系列1
0~5 1.5~9 5~11
10.3% 70.0% 100%
90.9%
Frontotemporal Lobe Degeneration semantic dementia Pick’s disease other dementia
The ratio that patients got more than 4 points