Modified Suanzaoren Tang for Insomnia in the Elderly

Shizhen Guoyi Guoyao (2003, 14.12) once published an experiential formula for treating insomnia in the elderly. It is an augmentation of the "Suanzaoren Tang" (Sour Jujube Seed Decoction) from Jingui Yaolue (Essential Prescriptions from the Golden Cabinet). The formula is: Bulbus Lilii (baihe) 30 g, raw Radix Rehmanniae (sheng dihuang) 20 g, Semen Ziziphi Spinosae (suanzaoren) 15 g, Rhizoma Anemarrhenae (zhimu) 10 g, Poria (fuling) 12 g, Rhizoma Chuanxiong (chuanxiong) 6 g, raw Radix Glycyrrhizae (sheng gancao) 6 g. For those with liver depression transforming into fire, add Radix Gentianae Longhirrhizae (longdancao) 6 g, Radix Bupleuri (chaihu) 10 g, Radix Scutellariae (huangqin) 10 g; for those with phlegm-heat harassing inwardly, add Coptis (huanglian) 3 g, fried Colla Corii Asini珠 (ejiaozhu) 10 g, Semen Platycladi (baiziren) 15 g; for those with dual deficiency of heart and spleen, add raw Radix Astragali (sheng huangqi) 15 g, Radix Codonopsis (dangshen) 15 g, Radix Angelicae Sinensis (danggui) 12 g; for those with heart deficiency and timidity, add Radix Pseudostellariae (taizishen) 15 g, Dragon Bone (duan longgu) 20 g, Poria cum Ligno Hospite (fushen) 15 g. One dose daily, concentrated-decocted to 300 ml, taken in divided doses morning and evening; two weeks is one course. Using this formula to treat 58 elderly insomnia patients, 12 were cured and 46 improved; the cure rate was 20.7% and the total effective rate 100%.

Insomnia is a stubborn problem troubling many elderly people, and it directly affects their quality of life and survival. Suanzaoren Tang from Jingui Yaolue is a classic TCM formula for insomnia, composed of Semen Ziziphi Spinosae, Licorice, Anemarrhena, Poria and Chuanxiong. Semen Ziziphi Spinosae and Poria quiet the spirit and aid sleep; Licorice and Anemarrhena clear the heart and dispel heat; Chuanxiong improves blood circulation. This formula treats both root and manifestation and has a good therapeutic effect on insomnia in the elderly caused by degeneration of brain function.

But plain Suanzaoren Tang often fails when used for elderly insomnia. This formula is in fact a combination of Baihe Dihuang Tang and Suanzaoren Tang. Baihe Dihuang Tang also comes from Jingui Yaolue; it nourishes yin and clears heat, and tonifies the heart and lung, and is a commonly used formula for the heart-lung yin deficiency with internal heat pattern of lily disease (baihe bing). Symptoms include a trance-like spirit, wanting to eat but with poor appetite, sometimes wanting food and sometimes refusing it; taciturn, wanting to lie down but unable, wanting to walk but unable, as if possessed; feeling cold without being cold, feeling hot without being hot, bitter mouth, reddish urine, a red tongue with scant coating, and a fine, faint pulse. The lily disease here is in fact also one of the diseases of declining brain function. So combining Baihe Dihuang Tang with Suanzaoren Tang makes the treatment of elderly insomnia even more powerful.

For those with phlegm-heat harassing inwardly, the formulator further combined and modified it with Huanglian Ejiao Jizihuang Tang (Coptis-Egg-Yolk-E-Jiao Decoction). Huanglian Ejiao Jizihuang Tang comes from Shanghan Lun and is composed of Coptis, E-Jiao and egg yolk; it treats symptoms such as "shao yin illness, more than two or three days after onset, with vexation in the heart and inability to lie down." Its main function is to nourish yin, downbear fire and quiet the spirit, used for vexation and insomnia caused by heart flaming upward, with a red tongue and dry coating and a fine rapid pulse. This formula omits the egg yolk and replaces it with Semen Platycladi, which quiets the spirit and moistens the intestines, making it more suitable for the elderly.

For those with dual deficiency of heart and spleen, it was combined and modified with Guipi Tang (Restore the Spleen Decoction). This shows the formulator was well versed in TCM treatment of insomnia, fusing multiple approaches to treating insomnia.

In addition, elderly insomnia is often influenced by factors such as brain atrophy. In the author's experience, for stubborn insomnia, besides the above formulas, one may also combine the Chinese patent medicine Kongsheng Zhenzhong Dan (Confucius's Heart-Supplementing Pill) to improve brain function. For those with anxiety, it may be combined with Ganmai Dazao Tang and Erzhi Wan.

This formula may also be used to relieve insomnia in patients with post-COVID aftereffects.