Effects of sodium valproate on behavioral disturbances in elderly outpatients with dementia

Differential Expression of Multiple Disease-Related Protein Groups Induced by Valproic Acid in Human SH-SY5Y Neuroblastoma Cells

Valproic acid (VPA) is a multifunctional medication used for the treatment of epilepsy, mania associated with bipolar disorder, and migraine. The pharmacological effects of VPA involve a variety of neurotransmitter and cell signaling systems, but the molecular mechanisms underlying its clinical efficacy is to date largely unknown. In this study, we used the isobaric tags for relative and absolute quantitation shotgun proteomic analysis to screen differentially expressed proteins in VPA-treated SH-SY5Y cells. We identified changes in the expression levels of multiple proteins involved in Alzheimer’s disease, Parkinson’s disease, chromatin remodeling, controlling gene expression via the vitamin D receptor, ribosome biogenesis, ubiquitin-mediated proteolysis, and the mitochondrial oxidative phosphorylation and electron transport chain. Our data indicate that VPA may modulate the differential expression of proteins involved in mitochondrial function and vitamin D receptor-mediated chromatin transcriptional regulation and proteins implicated in the pathogenesis of neurodegenerative diseases.

Valproic Acid for Treatment of Hyperactive or Mixed Delirium: Rationale and Literature Review

BACKGROUND

Delirium is the most often encountered psychiatric diagnosis in the general hospital, with an incidence of up to 82% in the intensive care unit setting and with significant detrimental effects on patients' morbidity and mortality. Antipsychotics are often considered the first-line pharmacological treatment of delirium, but their use may be limited by lack of efficacy, existing contraindications (e.g., prolonged QTc intervals), or resulting side effects (e.g., akathisia). Valproic acid (VPA) is a potential alternative or adjunct treatment. It has multiple mechanisms of action, including effects on neurotransmitter modulation, neuroinflammation, oxidative stress, and transcription, all of which are implicated in the pathophysiology of delirium. Yet, data on the use of this agent in delirium are limited.

OBJECTIVE/METHODS

In this article, we discuss postulated mechanisms of VPA action that provide a theoretical basis for its use in the treatment of hyperactive and mixed type delirium, based on the known and theorized pathophysiology of delirium. We also discuss potential side effects and considerations with use of VPA.

CONCLUSIONS

VPA has multiple modulatory effects on neurotransmitter systems, inflammation, oxidative stress, and transcriptional changes implicated in pathophysiology of delirium. When carefully chosen, VPA can be an effective and well-tolerated treatment option for the management of hyperactive and mixed type delirium. Randomized controlled trials are needed to establish tolerability and efficacy of VPA for treatment of delirium.

Principles and management of neuropsychiatric symptoms in Alzheimer's dementia

Neuropsychiatric symptoms of Alzheimer's disease (NPS-AD) are highly prevalent and lead to poor medical and functional outcomes. In spite of the burdensome nature of NPS-AD, we are continuing to refine the nosology and only beginning to understand the underlying pathophysiology. Cluster analyses have frequently identified three to five subsyndromes of NPS-AD: behavioral dysfunction (for example, agitation/aggressiveness), psychosis (for example, delusions and hallucinations), and mood disturbance (for example, depression or apathy). Recent neurobiological studies have used new neuroimaging techniques to elucidate behaviorally relevant circuits and networks associated with these subsyndromes. Several fronto-subcortical circuits, cortico-cortical networks, and neurotransmitter systems have been proposed as regions and mechanisms underlying NPS-AD. Common to most of these subsyndromes is the broad overlap of regions associated with the salience network (anterior cingulate and insula), mood regulation (amygdala), and motivated behavior (frontal cortex). Treatment strategies for dysregulated mood syndromes (depression and apathy) have primarily targeted serotonergic mechanisms with antidepressants or dopaminergic mechanisms with psychostimulants. Psychotic symptoms have largely been targeted with anti-psychotic medications despite controversial risk/benefit tradeoffs. Management of behavioral dyscontrol, including agitation and aggression in AD, has encompassed a wide range of psychoactive medications as well as non-pharmacological approaches. Developing rational therapeutic approaches for NPS-AD will require a firmer understanding of the underlying etiology in order to improve nosology as well as provide the empirical evidence necessary to overcome regulatory and funding challenges to further study these debilitating symptoms.

Dosing of valproate in an elderly population with dementia: Evaluation of discontinuations and dose reductions

It is estimated that more than half of elderly patients with dementia will develop some degree of behavioral and psychological symptoms of dementia (BPSD). BPSD is associated with significant morbidity, rapid functional decline, and psychiatric hospitalization, and there are currently no medications approved by the Food and Drug Administration (FDA) for its treatment. One treatment option that has been evaluated is the antiepileptic drug valproate. This retrospective medical record review evaluated the tolerability of valproate in elderly patients with dementia. A total of 62 patients met inclusion criteria for this review, which sought to determine whether there was an association either between the initial valproate dose and discontinuation or dose reduction (DCDR) or the maximum valproate dose achieved and DCDR. Both the total daily dose and total daily dose in mg/kg were assessed. For both the maximum daily dose (OR 1.0; 95% CI 0.99, 1.01) and maximum daily mg/kg dose (OR =1.15; 95% CI 0.92, 1.49) there was also no association with DCDR. There was no associated risk of DCDR when evaluating initial daily doses (OR: 1.0; 95% CI: 0.99 – 1.01). However, an association between DCDR and initial daily mg/kg dose was found (OR: 1.92; 95% CI: 1.11–4.02). For both the initial dose and initial mg/kg dose model, African Americans were associated with the need for DCDR (OR 20.75; 95% CI: 1.77–660). Results from this study suggest that higher initial starting doses based on weight may lead to higher rates of side effects necessitating a discontinuation or dose reduction; however, large trials are needed to confirm these results.