Objective: 1)To determine the prevalence of concomitant use of divalproex (DVP) and antipsychotics (AP) to treat agitation in elderly nursing home (NH) residents; 2)to determine whether patient characteristics are predictive of AP treatment alone v. concomitant therapy with DVP; 3)to compare baseline AP dosage differences between the two treatment groups; 4)to determine whether concomitant therapy is used for at least 6 months; 5)to examine differential effects of these two treatments on follow-up antipsychotic drug doses and costs.
Design: Retrospective Chart Review of residents in 2 nursing homes: 1 VA and 1 community
Materials and Methods: Inclusion criteria are age >60, diagnosis of dementia and associated behavioral disturbances. Medical and pharmacy records were reviewed to determine the earliest use of at least one antipsychotic medication or divalproex for more than 30 consecutive days during the study period. Patients on DVP to treat seizure disorder or neuropathic pain were excluded. Records were then reviewed 6 months post earliest documented use to determine whether any changes had occurred in psychotropic medication management. Subjects were classified in 3 groups: AP alone, AP+DVP, neither AP or DVP. Differences in demographic characteristics were evaluated using ANOVA and Chi-square procedures. Paired t-test analyses were conducted between the AP only and AP+ divalproex groups to examine differences in cost and dose of antipsychotic medication at baseline and 6 months.
Results: Preliminary analysis of the first 220 records revealed 146 residents with dementia. 59 subjects were treated with AP, of whom 18 (30.5%) were on concomitant therapy with DVP. There were no differences between groups on demographics, presence of underlying psychiatric condition, or baseline AP dose. There was a difference in median antipsychotic dose between the 2 groups at 6 months: 59 mg/d DVP group v. 132 mg/d CPZ eq in the AP alone group(p<0.003). IN 70% of subjects on concomitant therapy, the dose of AP was either decreased or discontinued within 6 months of addition of DVP.
Conclusion: Concomitant DVP and AP medication to treat behavioral disturbances associated with dementia is fairly prevalent in the nursing home, occurring in 14% of SNF residents with dementia and in 1 of 3 such residents taking an antipsychotic. Divalproex is typically added when there has been an inadequate response to antipsychotics alone. Doses of antipsychotics were reduced in both treatment groups, but almost halved in the divalproex group, consistent with one previous small study. As a result, there was a trend towards a decrease in the costs associated with antipsychotics in the divalproex group. Of the patients on concomitant therapy, 35% were on divalproex alone at 6 months. The AP was tapered and discontinued and this accounted for most of the cost differences in this group.
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