Article

Tolerability of divalproex sodium in elderly psychiatric patients with mixed diagnoses.

Department of Psychiatry, Veterans Affairs Medical Center, Baylor College of Medicine, Houston, Texas 77030, USA.
Journal of Geriatric Psychiatry and Neurology (Impact Factor: 1.63). 11/1995; 8(4):234-7. DOI: 10.1177/089198879500800407
Source: PubMed

ABSTRACT This study addresses the tolerability of divalproex sodium in elderly psychiatric inpatients with various Axis I diagnoses, using structured assessments. A chart review for a 7-month period on a geropsychiatry inpatient unit identified 13 patients who had been treated with divalproex sodium. All 13 patients received standardized ratings on the Cohen-Mansfield Agitation Inventory (CMAI), Brief Psychiatric Rating Scale (BPRS), Rating Scale for Side Effects (RSSE), and Mini-Mental State Examination (MMSE) on admission and discharge, which were compared using paired t-tests for 12 of the 13 patients. The thirteenth patient was withdrawn from valproate prior to discharge after developing a delirium thought to be secondary to a divalproex-phenytoin interaction. All of the remaining 12 patients tolerated divalproex sodium well with no significant change in MMSE scores (P = .486), CMAI scores (P = .0546), or RSSE scores (P = .124). The change in BPRS score was found to be significant (P = .004). Based on the present study and previously reported case series, divalproex sodium appears to be well tolerated in an elderly psychiatric population.

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    ABSTRACT: Objective: The aim of this study was to assess the efficacy, tolerability, and safety of divalproex sodium in the treatment of elderly patients with dementia who exhibited manic symptoms.Methods: This 6-week, multicenter, randomized, double-blind, placebo-controlled, parallel-group study enrolled elderly nursing home residents with dementia and secondary mania, as distinct from the actual manic episodes that might be associated with bipolar disorder. Patients were randomly assigned to receive placebo or divalproex sodium at a starting dose of 125 mg BID, followed by daily titration in increments of 125 mg/d up to a target dosage of 20 mg/kg/d (maximum dosage of 30 mg/kg/d). Efficacy was assessed using the Bech-Rafaelsen Mania Scale (BRMS), the Cohen-Mansfield Agitation Inventory (CMAI), the Brief Psychiatric Rating Scale (BPRS), and the severity of illness and improvement scales of the Clinical Global Impressions (CGI). Because of a disproportionate number of withdrawals due to somnolence in the active-treatment group, the study was terminated prior to full enrollment.Results: A total of 172 patients were enrolled; 87 received divalproex sodium and 85 received placebo. Forty (46%) divalproex sodium-treated and 60 (71%) placebo-treated patients completed the study. There was no appreciable difference between drug and placebo groups in scores on the BRMS, the primary outcome measure. Scores on the CMAI, however, showed significant improvement in the divalproex sodium-treated group compared with the placebo group (P < 0.05) for the total score and the verbal agitation subscale. There was no drug-placebo difference in scores on the BPRS, whereas the CGI improvement score at the final assessment was significantly better in the placebo group (P = 0.035). Nineteen divalproex sodium—treated patients (22%) and 3 placebo-treated patients (4%) withdrew from the study because of adverse events (P < 0.001), primarily somnolence; this typically occurred at or above daily dosages of ∼15 mg/kg. Lower doses were well tolerated. Somnolence and thrombocytopenia occurred significantly more frequently (P = 0.027 for somnolence; P = 0.029 for thrombocytopenia) with divalproex sodium use than with placebo.Conclusions: Divalproex sodium did not improve signs and symptoms of mania associated with dementia in this sample of nursing-home residents, but did improve symptoms of agitation. Further study of divalproex sodium for agitation, at lower doses and a slower titration rate, is needed to define the optimal regimen for this drug in elderly, medically compromised populations.
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