On Friday, we saw an 81-year-old male for a consult on his memory problems and depression. PMHx is significant for DM and COPD, among other conditions. He is on many medications, including paroxetine 40 mg.
His mood has been “terrible” and that he is “always thinking of bad stuff.” He has been waking up three times per night. He is worried about household chores, his wife’s health, and his son. He always feels guilty, and he has difficulty concentrating. He denied anhedonia and suicidal ideation. The PHQ-9 and GAD-7 questionnaires demonstrated severe depression and anxiety, respectively.
His memory is declining. He had gotten lost in a store recently, his wife will not let him drive, and he is unable to help with household chores such as cooking. Upon administration of the Montreal Cognitive Assessment (MOCA), the patient scored 19/30. This falls in between the mean for Mild Cognitive Impairment (22.1) and Alzheimer’s Disease (16.2). He had difficulty with recall, short-term memory, and visuospatial skills. He could not correctly identify the current month or year.
During our A+P conversation, we considered if he could benefit from a medication adjustment. The patient has been taking paroxetine for decades. We could increase his dose to 50 mg, which is the maximum. Another option is vortioxetine, a newer antidepressant that was FDA-approved in 2013. This medication is also believed to possess pro-cognitive effects.
Vortioxetine is an SSRI and a serotonin receptor modulator (SERT). It inhibits 5-HT reuptake and acts as a 5-HT1A receptor agonist and a 5-HT receptor antagonist. The precise mechanism is unknown. It has an efficacy comparable to older antidepressants. “Vortioxetine appears to be effective for treating symptoms of MDD in the elderly,” according to a 2015 article I reviewed. Since then, ongoing studies have demonstrated favorable tolerability profiles in the elderly. The most notable side effect is nausea in the first weeks of dosing.
There have also been studies on vortioxetine in the treatment of cognitive decline. It has shown a beneficial effect on cognition and mood in elderly AD patients. According to one Toronto psychiatrist: “Right now, vortioxetine is the only medication with strong evidence for its direct effects on cognition in MDD.” There may be an association between vortioxetine and increased short-term episodic memory.
In conclusion, this patient may benefit from a switch to vortioxetine. However, it is likely that the anti-depressant effects will be comparable to paroxetine. Potential pro-cognitive effects may not be observable, as he is already in significant decline. Also, Trintellix (vortioxetine) is not yet generic. It costs $451 for a 30-day supply, versus $25 for paroxetine. This could be prohibitive. It was also recommended that the patient participate in psychotherapy. He said he would be willing to try it.
Sources:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4542474/
https://www.ajgponline.org/article/S1064-7481(13)00602-7/pdf
https://clinicaltrials.gov/ct2/show/NCT03779789
Benjamin Samuel Young 