Could your heartburn medicine be putting you at increased risk for developing dementia, a condition that causes a decline in thinking and learning? A new study suggests a possible relationship between popular heartburn drugs called proton pump inhibitors (PPIs) and cognitive decline in later years.
PPIs and GERD
Gastroesophageal reflux disease, or GERD, is an anatomical abnormality that occurs when the barrier between your stomach and esophagus (the tube that connects the mouth and stomach) doesn't function normally and allows acid to travel back up from your stomach into your esophagus. The main symptom is heartburn.
"This is one of the most common conditions seen by primary care physicians," says Ronnie Fass, MD, Director of Division of Gastroenterology and Hepatology, Head of the Esophageal and Swallowing Center at MetroHealth Medical Center, and Professor at Case Western Reserve University School of Medicine in Cleveland, Ohio. In fact, about 20 percent of Americans today have GERD, according to the National Institutes of Health (NIH) website.
PPIs, which are available both by prescription and over-the-counter, are a common remedy for the symptoms. PPIs work by minimizing the stomach acid secretion and thus reducing its flow upward.
"PPIs are the eighth most commonly prescribed class of drugs," says Joseph Barry, MD, a primary care doctor specializing in geriatrics who owns a private practice affiliated with SignatureMD in the Syracuse, NY, area. In fact, an average of more than 100 million PPI prescriptions are filled every year.
Research Findings on PPIs
A number of recent studies have suggested an association between the use of PPIs and the development of other health issues. Yet most of these studies have not demonstrated any solid cause and effect, Fass stresses.
"What’s unique in all of the studies on PPIs is that they are population-based [studies that look at a particular population] and are not prospective trials [studies that follow patients over a defined period of time to see how certain factors affect outcomes]," he says.
The latest study, published in JAMA Neurology in April 2016, was conducted by German scientists who used an insurance company’s drug prescription database to follow more than 700,000 patients over the age of 75 who had no signs of dementia at the onset. Over the course of a seven-year period, the researchers found that those using PPIs had a significantly increased risk of developing dementia when compared with people who did not use PPIs. After adjusting the numbers for a variety of factors (such as age, health status, and other medications), the risk of dementia was about 52 percent higher in men, and 42 percent higher in women who used PPIs.
Understanding the Findings
The results sound disturbing, but that's not the whole story. "This study shows an association between PPIs and dementia," Barry says, but it does not indicate that PPI use causes the dementia. "Furthermore, it’s anomalous [unusual and unexpected] that the frequency of dementia diagnosis was very low at the start of the study and rose to more than 50 percent at the end of only seven years. This is not usually how fast dementia develops, and may suggest a confounding influence [an uncontrolled variable that can invalidate the study findings] of increased awareness so increased diagnosis," he speculates.
In layman's terms, this means that being aware of the possibility of dementia may have led to more people being diagnosed with the condition—not to more people actually developing it.
And "In addition, all the patients were over 75 years of age, so an increasing diagnosis is very likely, regardless of any medication use," Barry points out. That's because the risk of dementia increases as people age, regardless of medication use. For example, the Alzheimer’s Association reports that one in nine Americans over the age of 65 has Alzheimer's disease (the most common form of dementia), but this number spikes to almost one in every three people 85 or older. So while the study did take age into account, it is difficult to know if dementia in many older people who use PPIs would have occurred even if they did not use the medication.
On the other hand, this is not the first study that has found a connection between PPI use and cognitive ability. "Mice studies suggest that PPIs increase certain proteins in the brain that have been linked to Alzheimer’s, but mice and men are not the same," Barry points out. "One possible relationship is that PPI use is known to affect [vitamin] B12 absorption, and B12 deficiency is a well-known cause of memory loss." Although this form of memory loss isn’t the same as Alzheimer’s memory loss, he notes that both types fall under the heading of "dementia," so there could be some connection worth exploring in future research efforts.
What You Can Do
If you wonder what all of this means for you in practical terms, Fass says patients with severe GERD who are concerned about medication use should weigh the risks of not treating their condition, like frequent discomfort; difficulty sleeping; damage to the esophagus, throat, and gums, and reduced quality of life.
"I always tell patients that if you need these medicines because you’re very symptomatic and the disease affects your quality of life, you should take them," Fass stresses. Furthermore, "The risk of having a problem from PPIs is very low. In fact, a lot of us who treat GERD patients on a regular basis don’t see any of these complications that are found in the trials."
Making Lifestyle Changes
It’s also important for people with heartburn or GERD to make some strategic lifestyle modifications that can minimize symptoms, or perhaps even head them off and prevent the need for medication, Fass says.
Barry adds, "I recommend to all my patients that they take as few medications and supplements of any kind as possible. Too many Americans take PPIs for heartburn when they really should be changing what they eat and how much they eat."
To prevent GERD, you should avoid the following:
- Large meals
- Spicy foods
- Carbonated beverages
- Chocolate
- Citrus juice
- Fresh onions
- Tomato sauce
The following tips can also help you minimize GERD symptoms:
- Avoid wearing tight clothes that put pressure on your stomach area.
- Eat your last meal of the day at least three hours before bed; this will allow you time to digest.
- Sleep on your left side (the right is believed to allow stomach juices to rise).
- Read the labels of other medications to be sure they aren’t triggering reflux.
- Control your blood pressure and your blood sugar by eating regular meals and exercising regularly.
- Avoid smoking.
- Keep alcohol use to a minimum.
- Take your medications as prescribed—use the right dosage for your weight, and take the drug at the right time, for the prescribed period of time.
- Walk. "Exercise increases blood flow to the brain, and I think that’s the best therapy and prevention approach. Evidence is mixed on how protective exercise is for the brain, but it’s still good for the whole body and makes sense for all ages," Barry says.
The Bottom Line
Don't panic! "While such studies generate a lot of hype and media attention," Fass says, findings need to be understood in context. So if you're struggling with GERD, speak to your primary care doctor or gastroenterologist about treatment options. And hopefully "This study should serve as the catalyst for performing proper long-term trials to see if there is any true risk of taking PPIs," he adds.
Ronnie Fass, MD, reviewed this article.
Sources
Barry, Joseph, MD.. Email interview April 5, 2016.
Fass, Ronnie, MD. Phone interview March 25, 2016.
Gomm, Willy, PhD, et al. "Association of Proton Pump Inhibitors with Risk of Dementia." JAMA Neurologist 73, 4 (2016): 410–416. doi:10.1001/jamaneurol.2015.4791.
Bakalar, Nicholas. "Heartburn Drugs Tied to Dementia." The New York Times February 17, 2016.
