Department of Experimental and Clinical Medicine, Faculty of Medicine and Surgery, University Magna Graecia of Catanzaro, Mater Domini University Hospital, Catanzaro, Italy.
Arch Gerontol Geriatr. 2009;49 Suppl 1:113-8. doi: 10.1016/j.archger.2009.09.019.
In this study we report a case of valproate-induced delirium in a patient affected with Alzheimer's disease (AD). A 75-year-old woman with AD presented moderate cognitive impairment associated to behavioral disorders, characterized by aggression, agitation, severe insomnia. She was treated with galantamine, promazine, acetylsalicylic acid and pantoprazole. Since behavioral disorders worsened more and more, home neurological consultation was asked. The neurologist prescribed a mood stabilizer, sodium valproate 500 mg daily for the first week and then, twice a day and stopped promazine. After an apparent initial benefit, about 16 days later, patient suddenly developed hyperactive delirium. It was characterized by worsening of insomnia and agitation, severe confusion, delusions, visual hallucinations alternated to sedation. She became progressively unable to walk and completely dependent in daily living activities. An urgent geriatric consultation was performed at patient's home; physical examination showed mild dehydration, normal blood pressure. Oxygen saturation and electrocardiogram were normal. Sodium valproate was immediately stopped and rehydration was performed. The patient was admitted to a Geriatric Unit, where organic and metabolic damages were excluded. During the hospital stay the patient was agitated, aggressive, confused; intramuscular haloperidol 5mg and saline intravenous infusion 1500 cc daily were performed, they were partly successful. Three days after she was discharged and continued treatment with oral haloperidol 5mg daily. One week later the patient recovered and she is at present healthy. This is a case report of valproate-induced delirium. The Naranjo scale scored 7, classifying this drug-related event as probable. The present case report suggests the need for minimizing the use of psychoactive drugs in elderly demented patients, whether possible; age-related changes in pharmacokinetics and pharmacodynamics suggest the opportunity of a careful evaluation and a slow titration of treatments in these patients.
在这项研究中，我们报告了一例丙戊酸引起的阿尔茨海默病（AD）患者的谵妄病例。一名 75 岁的女性 AD 患者出现中度认知障碍，伴有行为障碍，表现为攻击性、激越、严重失眠。她接受了加兰他敏、奋乃静、乙酰水杨酸和泮托拉唑治疗。由于行为障碍越来越严重，她被转至家庭神经科医生处就诊。神经科医生开了一种心境稳定剂，即丙戊酸钠 500mg，每日一次，持续一周，然后每日两次，停用奋乃静。在最初的症状明显改善后约 16 天后，患者突然出现激越性谵妄。其特征是失眠和激越加重，严重意识混乱、妄想、视幻觉交替出现，同时伴有镇静。她逐渐无法行走，完全依赖日常生活活动。在患者家中进行了紧急老年病会诊；体格检查显示轻度脱水，血压正常。血氧饱和度和心电图正常。立即停用丙戊酸钠并进行补液。患者被收入老年科病房，排除了器官和代谢损伤。在住院期间，患者出现激越、攻击性行为、意识混乱；给予肌肉注射氟哌啶醇 5mg 和每日 1500cc 生理盐水静脉滴注，部分有效。她出院后三天，继续口服氟哌啶醇 5mg，每日一次。一周后，患者恢复健康。这是一例丙戊酸引起的谵妄病例报告。Naranjo 量表评分为 7，将该药物相关事件归类为可能。本病例报告提示需要尽量减少在老年痴呆患者中使用精神活性药物，如有可能；年龄相关的药代动力学和药效学变化表明，在这些患者中，需要仔细评估和缓慢滴定治疗。
