Cognitive impairment during therapeutic total VPA concentration 6 143 Figure 1: VPA dosage, total and free VPA plasma concentration, albumin concentration and cognitive impairment. VPA dosage is increased to 4000mg resulting in (sub)therapeutic total VPA concentrations after which cognitive impairment becomes visible. Albumin levels are continuously below the reference range with a drop around day 120. Free concentration of VPA is measured on day 113 and 126; both values are far above the reference range. While the total VPA concentrations were (sub)therapeutic, the free concentrations were toxic. On day 66 and day 70 a decline in cognitive function can be seen due to the concurrent deliria due to infection and urinary retention. Cognitive impairment was not measured continuously but by interval with the MoCA at that time, and determined afterwards on a Global Deterioration Scale. Cognitive impairment: 1 = No Cognitive Decline, 2 = Very Mild Cognitive Decline, 3 = Mild Cognitive Decline, 4 = Moderate Cognitive Decline, 5 = Moderate Severe Cognitive Decline, 6 = Severe Cognitive Decline, 7 = Very Severe Cognitive Decline.
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