From the Guidelines
Depakote is not an appropriate medication for managing impulsivity or preventing falls in geriatric patients due to its significant risks, including increased fall risk, cognitive impairment, sedation, and drug interactions. The American Geriatrics Society Beers Criteria lists valproate and its derivatives as potentially inappropriate medications for older adults, supporting this stance 1. For impulsivity management in geriatric patients, non-pharmacological approaches such as behavioral interventions, environmental modifications, and consistent routines are preferred. If medication is necessary, low-dose atypical antipsychotics with careful monitoring or selective serotonin reuptake inhibitors for certain types of impulsivity may be considered. Fall prevention is better addressed through comprehensive assessment, physical therapy, environmental safety modifications, and treating underlying medical conditions, rather than medications like Depakote, which can increase fall risk through side effects like dizziness, drowsiness, and gait disturbances. The lack of sufficient evidence for single interventions, including medication management, to prevent falls in community-dwelling older adults further supports avoiding Depakote for this purpose 1.
Key considerations in managing geriatric patients include:
- Careful risk-benefit analysis for any medication
- Starting with low doses
- Regular monitoring
- Avoiding potentially inappropriate medications as listed by criteria such as the Beers Criteria
- Focusing on non-pharmacological interventions for impulsivity and fall prevention
- Comprehensive assessment and management of underlying medical conditions to prevent falls.
Given the potential for increased morbidity, mortality, and decreased quality of life associated with Depakote in geriatric patients, especially concerning fall risk and cognitive impairment, its use should be avoided in this population unless absolutely necessary and with careful consideration of alternative options. The most recent and highest quality evidence supports prioritizing patient safety and well-being through the avoidance of potentially inappropriate medications like Depakote in older adults 1.
From the FDA Drug Label
The capacity of elderly patients (age range: 68 to 89 years) to eliminate valproate has been shown to be reduced compared to younger adults (age range: 22 to 26). Intrinsic clearance is reduced by 39%; the free fraction is increased by 44% Accordingly, the initial dosage should be reduced in the elderly. No patients above the age of 65 years were enrolled in double-blind prospective clinical trials of mania associated with bipolar illness A study of elderly patients with dementia revealed drug related somnolence and discontinuation for somnolence
Valproate use in geriatric population: The FDA drug label does not provide direct information on the use of valproate for impulsivity and preventing falls in the geriatric population. However, it does mention that the capacity of elderly patients to eliminate valproate is reduced, and the initial dosage should be reduced in the elderly. Additionally, a study of elderly patients with dementia revealed drug-related somnolence, which may be a concern for patients with impulsivity. It is not possible to draw a conclusion about the appropriateness of valproate for impulsivity and fall prevention in the geriatric population based on the provided information 2, 2, 2.
From the Research
Depakote in Geriatric Population
- Depakote (valproate) is an antiepileptic medication that has been used to treat various conditions, including impulsivity and aggression 3.
- However, its use in the geriatric population to help with impulsivity and prevent falls is not well-established.
- A study published in 2010 found that valproate was effective in reducing aggression and associated impulsivity in certain populations, but the evidence was insufficient to draw firm conclusions about its use in the treatment of aggression and associated impulsivity 3.
- Another study published in 2003 discussed the mechanisms of action of valproate and its clinical uses, but did not specifically address its use in the geriatric population 4.
Safety and Efficacy Concerns
- The use of antiepileptic medications, including valproate, in the geriatric population can be associated with safety and efficacy concerns, such as increased risk of falls, cognitive impairment, and drug interactions 5.
- A study published in 2016 found that the addition of lithium or valproate to second-generation antipsychotics was associated with poorer metabolic outcomes, including lower insulin sensitivity and higher body mass index 5.
- However, the evidence is limited, and more research is needed to fully understand the safety and efficacy of valproate in the geriatric population.
Alternative Treatment Options
- Other treatment options, such as second-generation antipsychotics, have been studied for their efficacy in treating impulsivity and aggression in various populations 6, 7.
- However, the use of these medications in the geriatric population to prevent falls is not well-established, and more research is needed to determine their safety and efficacy in this population.