Are PPI’s responsible for increased dementia in the elderly?

by Flora Bessey, PharmD, CGP

There has been much discussion lately regarding the use, or overuse, of proton pump inhibitors (PPI) in our patient population, especially given the recent article in the Journal of the American Medical Association (JAMA February 15th, 2016 issue, “Association of Proton Pump Inhibitors with Dementia; a Pharmacoepidemiological Claims Data Analysis”). This article seems to point to at least a correlation between the use of PPI and dementia. But as we all know, “correlation” is not the same as “causation.” So, given this new data, as well as everything we have learned about this class of medicines, what do we need to focus upon as we attempt to provide the best care for our very vulnerable residents?

The data in the article are compelling, but it is difficult to fully control for other factors in large studies like this. In the study, only those 75 years of age or older are included, and the participants are noted to be “free” of dementia at baseline. But data analysis is only over five months (August through November 2015). Is it realistic that someone “free” of dementia would develop this disorder in this time frame? Also, our patients (and presumably, many of the patients in this study) already suffer, and have suffered for many decades, from many of the correlative factors that may hasten dementia, i.e. poor diet, lack of exercise/sedentary lifestyle, coronary artery disease, etc. 

The unfortunate reality for our residents is that many suffer from gastro-esophageal reflux disorder (GERD). Also, many have been in out of the hospital several times, and it is routine for hospitals to prescribe PPI prophylactically while in the inpatient setting. Therefore, the majority of our residents end up on PPI at one time or another, or on a continuing basis. PPI are very effective in treating the symptoms of GERD, but what else do we need to know about them? First of all, they have been implicated in an increase of infections like C. diff and UTI. Also, they make it more difficult for our residents to absorb minerals from their diets, like iron, calcium and vitamin D. As mentioned above, our residents already have had poor diets much of their lives, and despite the best efforts of our dietary staffs, continue to have a poor diet in our facilities. This would lead to greater risk of anemia and osteoporosis, as well as other disorders. Risk/benefit analysis is vital for the IDT; the prescriber, nursing staff, and consultant pharmacist must determine whether these very real risks are mitigated by the obvious benefits of PPI use.

What alternative do we have to PPI use? There is ample evidence that H2 antagonists are nearly as effective as PPI in the treatment of GERD. Obviously these medications have their own risks that must be acknowledged; as always, the IDT must come together to find the best balance between symptom relief and mitigation of side effects.

In conclusion, PPI are very effective medications that come with a bit of baggage. The data regarding PPI use and correlative dementia are intriguing, but there are plenty of other reason causative reasons for taking another look at the use, or overuse, of PPI in the LTC setting.  If you are going to discontinue a PPI be sure to titrate off slowly and monitor for symptoms. Consider an alternate even on PRN basis to avoid uncomfortable withdrawal symptoms.