Risk factors for dementia diagnosis in German primary care practices

Gastroesophageal reflux disease in Sri Lanka: An island-wide epidemiological survey assessing the prevalence and associated factors

Gastroesophageal reflux disease (GERD) is commonly encountered in clinical practice in Sri Lanka. However, its prevalence in Sri Lanka is unknown. Our objective was to study the island-wide prevalence of GERD symptoms in Sri Lanka and its associated factors. A total of 1200 individuals aged 18-70 years (male: female 1: 1.16, mean age 42.7 years [SD 14.4 years]). were recruited from all 25 districts of the country, using stratified random sampling. An interviewer-administered, country-validated questionnaire was used to assess the GERD symptom prevalence and associated factors. Weight, height, waist, and hip circumference were measured. Heartburn and/or regurgitation at least once a week, an internationally used criterion for probable GERD was used to diagnose GERD. In this study, GERD symptom prevalence was 25.3% (male 42.1% and female 57.9%). Factors independently associated with GERD were inadequate sleep, snacking at midnight, sleeping within two hours of consuming a meal, skipping breakfast, increased mental stress, and certain medications used such as statins, and antihypertensive medications (p<0.001, univariate and logistic regression analysis). 38.4% of the study population have been using medication for heartburn and regurgitation in the past 3 months and 19.8% were on proton pump inhibitors. To conclude, the prevalence of GERD symptoms in Sri Lanka (25.3%) is higher than its estimated global prevalence of 13.8%. Several meal-related lifestyle habits, mental stress, and the use of some medications are significantly associated with GERD, indicating the importance of lifestyle modification and stress reduction in its management.

Association between proton pump inhibitor use and neurological or psychiatric disorders: a systematic review protocol

OBJECTIVE

The objective of this review is to examine the association between proton pump inhibitors (PPIs) and neurological and/or psychiatric disorders in adults.

INTRODUCTION

The association between PPIs and neurological and/or psychiatric disorders remains unclear, despite the widespread use of the medications. A systematic review is required to investigate the risk of developing neurological and/or psychiatric disorders following the use of PPIs.

INCLUSION CRITERIA

Studies including participants aged ≥18 years and using any PPIs, including participants with comorbid conditions or using other medications, will be considered for inclusion. Randomized controlled trials, quasi-experimental studies, and observational studies examining the association of neurological and/or psychiatric disorders with the use of PPIs among adults will be included.

METHODS

MEDLINE, Embase, PsycINFO, CINAHL, and Cochrane CENTRAL databases will be searched from inception until the present. Two authors will independently screen and review the titles, abstracts, and full texts. The methodological quality of included studies will be assessed using the JBI critical appraisal checklists. Study characteristics, populations, type and duration of PPI usage, status of existing neurological and/or psychiatric disorders, comorbidity conditions, use of other medications, identification of neurological and/or psychiatric disorders (International Classification of Diseases codes vs others), and estimation of the associated neurological and/or psychiatric disorders will be extracted. Studies will be pooled using statistical meta-analysis where available; otherwise, the findings will be presented in narrative format. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach for grading the certainty of evidence will be followed.

REVIEW REGISTRATION

PROSPERO CRD42022355543.

Should evidence of an autolysosomal de-acidification defect in Alzheimer and Parkinson diseases call for caution in prescribing chronic PPI and DMARD?

Nearly fifty million older people suffer from neurodegenerative diseases, including Alzheimer (AD) and Parkinson (PD) disease, a global burden expected to triple by 2050. Such an imminent "neurological pandemic" urges the identification of environmental risk factors that are hopefully avoided to fight the disease. In 2022, strong evidence in mouse models incriminated defective lysosomal acidification and impairment of the autophagy pathway as modifiable risk factors for dementia. To date, the most prescribed lysosomotropic drugs are proton pump inhibitors (PPIs), chloroquine (CQ), and the related hydroxychloroquine (HCQ), which belong to the group of disease-modifying antirheumatic drugs (DMARDs). This commentary aims to open the discussion on the possible mechanisms connecting the long-term prescribing of these drugs to the elderly and the incidence of neurodegenerative diseases.Abbreviations: AD: Alzheimer disease; APP-βCTF: amyloid beta precursor protein-C-terminal fragment; BACE1: beta-secretase 1; BBB: brain blood barrier; CHX: Ca2+/H+ exchanger; CMI: cognitive mild impairment; CQ: chloroquine; DMARD: disease-modifying antirheumatic drugs; GBA1: glucosylceramidase beta 1; HCQ: hydroxychloroquine; HPLC: high-performance liquid chromatography; LAMP: lysosomal associated membrane protein; MAPK/JNK: mitogen-activated protein kinase; MAPT: microtubule associated protein tau; MCOLN1/TRPML1: mucolipin TRP cation channel 1; NFE2L2/NRF2: NFE2 like bZIP transcription factor 2; NRBF2: nuclear receptor binding factor 2; PANTHOS: poisonous flower; PD: Parkinson disease; PIK3C3: phosphatIdylinositol 3-kinase catalytic subunit type 3; PPI: proton pump inhibitor; PSEN1: presenilin 1, RUBCN: rubicon autophagy regulator; RUBCNL: rubicon like autophagy enhancer; SQSTM1: sequestosome 1; TMEM175: transmembrane protein 175; TPCN2: two pore segment channel 2; VATPase: vacuolar-type H+-translocating ATPase; VPS13C: vacuolar protein sorting ortholog 13 homolog C; VPS35: VPS35 retromer complex component; WDFY3: WD repeat and FYVE domain containing 3; ZFYVE1: zinc finger FYVE-type containing 1.

Proton Pump Inhibitor Use and Cognitive Function in the Boston Puerto Rican Health Study

BACKGROUND

There is a lack of consensus among studies on the association between proton pump inhibitor (PPI) use and cognitive impairment. This association is not well studied among minority populations, including among Puerto Ricans. Therefore, we sought to examine this association among Boston-area Puerto Ricans.

METHODS

The Boston Puerto Rican Health Study is an ongoing longitudinal cohort that enrolled 1499 Boston-area Puerto Rican adults, aged 45-75 years at baseline. Complete outcome and exposure data was available for 1290 baseline participants. Covariate-adjusted linear regression and linear mixed effects models were used to examine the association between PPI use, and global cognition, executive function, and memory cross-sectionally and longitudinally over ~12.7 years of follow-up. Furthermore, we examined the cross-sectional association between long-term PPI use (continuous use of ~6.2 years) and global cognition, executive function, and memory.

RESULTS

Among 1 290 participants at baseline, 313 (24.3%) self-reported PPI use. Baseline PPI use was not associated with baseline global cognition, executive function, or memory. Baseline PPI use also did not alter the trajectory of global cognition, executive function, or memory over ~12.7 years of follow-up. Long-term PPI use was not associated with global cognition, executive function, or memory over ~12.7 years of follow-up.

CONCLUSION

In this study of Boston-area Puerto Ricans, we did not observe an association between PPI use and global cognition, executive function, or memory either cross-sectionally or over 12.7 years of follow-up.

Proton pump inhibitors and dementia: what association?

Several recent studies have suggested an association between proton pump inhibitors and the development of cognitive changes.

Objective

To assess the existence of this association.

Methods

A comprehensive literature search was conducted including guidelines, meta-analyses, systematic reviews, observational and experimental studies published between February 2011 and February 2021.

Results

The initial research identified 393 articles, 28 of which were included: 8 systematic reviews, 1 clinical trial, 15 observational studies, 3 case-control studies, and 1 cross-sectional observational study.

Conclusions

Most studies classified with the highest level of evidence found no statistically significant association between the use of proton pump inhibitors and the development of cognitive impairment or dementia.

Time-Varying Use of Proton Pump Inhibitors and Cognitive Impairment and Dementia: A Real-World Analysis from Germany

BACKGROUND

Cumulative evidence of dementia risk in patients taking proton pump inhibitors (PPIs) is still inconclusive, probably due to a variety of study designs.

OBJECTIVE

This study aimed to compare how the association between dementia risk and use of PPIs differs by different outcome and exposure definitions.

METHODS

We conceptualized a target trial using claims data with 7,696,127 individuals aged 40 years or older without previous dementia or mild cognitive impairment (MCI) from the Association of Statutory Health Insurance Physicians in Bavaria. Dementia was defined as either including or excluding MCI to compare how the results alter by different outcome definitions. We used weighted Cox models to estimate the PPI initiation effect on dementia risk and weighted pooled logistic regression to assess the effect of time-varying use versus non-use during 9 years of study period, including 1 year of wash-out period (2009-2018). The median follow-up time of PPI initiators and non-initiators was 5.4 and 5.8 years, respectively. We also evaluated the association between each PPI agent (omeprazole, pantoprazole, lansoprazole, esomeprazole, and combined use) and dementia risk.

RESULTS

A total of 105,220 (3.6%) PPI initiators and 74,697 (2.6%) non-initiators were diagnosed with dementia. Comparing PPI initiation with no initiation, the hazard ratio (HR) for dementia was 1.04 [95% confidence interval (CI) 1.03-1.05]. The HR for time-varying PPI use versus non-use was 1.85 (1.80-1.90). When MCI was included in the outcome, the number of outcomes increased to 121,922 in PPI initiators and 86,954 in non-initiators, but HRs remained similar, showing 1.04 (1.03-1.05) and 1.82 (1.77-1.86), respectively. Pantoprazole was the most frequently used PPI agent. Although the estimated HRs for the time-varying use effect of each PPI showed different ranges, all agents were associated with an increased dementia risk. A total of 105,220 (3.6%) PPI initiators and 74,697 (2.6%) non-initiators were diagnosed with dementia. Comparing PPI initiation with no initiation, the hazard ratio (HR) for dementia was 1.04 [95% confidence interval (CI) 1.03-1.05]. The HR for time-varying PPI use versus non-use was 1.85 (1.80-1.90). When MCI was included in the outcome, the number of outcomes increased to 121,922 in PPI initiators and 86,954 in non-initiators, but HRs remained similar, showing 1.04 (1.03-1.05) and 1.82 (1.77-1.86), respectively. Pantoprazole was the most frequently used PPI agent. Although the estimated HRs for the time-varying use effect of each PPI showed different ranges, all agents were associated with an increased dementia risk.A total of 105,220 (3.6%) PPI initiators and 74,697 (2.6%) non-initiators were diagnosed with dementia. Comparing PPI initiation with no initiation, the hazard ratio (HR) for dementia was 1.04 [95% confidence interval (CI) 1.03-1.05]. The HR for time-varying PPI use versus non-use was 1.85 (1.80-1.90). When MCI was included in the outcome, the number of outcomes increased to 121,922 in PPI initiators and 86,954 in non-initiators, but HRs remained similar, showing 1.04 (1.03-1.05) and 1.82 (1.77-1.86), respectively. Pantoprazole was the most frequently used PPI agent. Although the estimated HRs for the time-varying use effect of each PPI showed different ranges, all agents were associated with an increased dementia risk.A total of 105,220 (3.6%) PPI initiators and 74,697 (2.6%) non-initiators were diagnosed with dementia. Comparing PPI initiation with no initiation, the hazard ratio (HR) for dementia was 1.04 [95% confidence interval (CI) 1.03-1.05]. The HR for time-varying PPI use versus non-use was 1.85 (1.80-1.90). When MCI was included in the outcome, the number of outcomes increased to 121,922 in PPI initiators and 86,954 in non-initiators, but HRs remained similar, showing 1.04 (1.03-1.05) and 1.82 (1.77-1.86), respectively. Pantoprazole was the most frequently used PPI agent. Although the estimated HRs for the time-varying use effect of each PPI showed different ranges, all agents were associated with an increased dementia risk.A total of 105,220 (3.6%) PPI initiators and 74,697 (2.6%) non-initiators were diagnosed with dementia. Comparing PPI initiation with no initiation, the hazard ratio (HR) for dementia was 1.04 [95% confidence interval (CI) 1.03-1.05]. The HR for time-varying PPI use versus non-use was 1.85 (1.80-1.90). When MCI was included in the outcome, the number of outcomes increased to 121,922 in PPI initiators and 86,954 in non-initiators, but HRs remained similar, showing 1.04 (1.03-1.05) and 1.82 (1.77-1.86), respectively. Pantoprazole was the most frequently used PPI agent. Although the estimated HRs for the time-varying use effect of each PPI showed different ranges, all agents were associated with an increased dementia risk.A total of 105,220 (3.6%) PPI initiators and 74,697 (2.6%) non-initiators were diagnosed with dementia. Comparing PPI initiation with no initiation, the hazard ratio (HR) for dementia was 1.04 [95% confidence interval (CI) 1.03-1.05]. The HR for time-varying PPI use versus non-use was 1.85 (1.80-1.90). When MCI was included in the outcome, the number of outcomes increased to 121,922 in PPI initiators and 86,954 in non-initiators, but HRs remained similar, showing 1.04 (1.03-1.05) and 1.82 (1.77-1.86), respectively. Pantoprazole was the most frequently used PPI agent. Although the estimated HRs for the time-varying use effect of each PPI showed different ranges, all agents were associated with an increased dementia risk.A total of 105,220 (3.6%) PPI initiators and 74,697 (2.6%) non-initiators were diagnosed with dementia. Comparing PPI initiation with no initiation, the hazard ratio (HR) for dementia was 1.04 [95% confidence interval (CI) 1.03-1.05]. The HR for time-varying PPI use versus non-use was 1.85 (1.80-1.90). When MCI was included in the outcome, the number of outcomes increased to 121,922 in PPI initiators and 86,954 in non-initiators, but HRs remained similar, showing 1.04 (1.03-1.05) and 1.82 (1.77-1.86), respectively. Pantoprazole was the most frequently used PPI agent. Although the estimated HRs for the time-varying use effect of each PPI showed different ranges, all agents were associated with an increased dementia risk.A total of 105,220 (3.6%) PPI initiators and 74,697 (2.6%) non-initiators were diagnosed with dementia. Comparing PPI initiation with no initiation, the hazard ratio (HR) for dementia was 1.04 [95% confidence interval (CI) 1.03-1.05]. The HR for time-varying PPI use versus non-use was 1.85 (1.80-1.90). When MCI was included in the outcome, the number of outcomes increased to 121,922 in PPI initiators and 86,954 in non-initiators, but HRs remained similar, showing 1.04 (1.03-1.05) and 1.82 (1.77-1.86), respectively. Pantoprazole was the most frequently used PPI agent. Although the estimated HRs for the time-varying use effect of each PPI showed different ranges, all agents were associated with an increased dementia risk.A total of 105,220 (3.6%) PPI initiators and 74,697 (2.6%) non-initiators were diagnosed with dementia. Comparing PPI initiation with no initiation, the hazard ratio (HR) for dementia was 1.04 [95% confidence interval (CI) 1.03-1.05]. The HR for time-varying PPI use versus non-use was 1.85 (1.80-1.90). When MCI was included in the outcome, the number of outcomes increased to 121,922 in PPI initiators and 86,954 in non-initiators, but HRs remained similar, showing 1.04 (1.03-1.05) and 1.82 (1.77-1.86), respectively. Pantoprazole was the most frequently used PPI agent. Although the estimated HRs for the time-varying use effect of each PPI showed different ranges, all agents were associated with an increased dementia risk.

CONCLUSION

Our large study supports existing evidence that PPI use is related to an increased risk of dementia.

Do proton pump inhibitors increase the risk of dementia? A systematic review, meta-analysis and bias analysis

AIM

Previous studies on the association between proton pump inhibitor (PPI) intake and the increased risk of dementia has shown discrepancies in their conclusions. We aimed to provide updated evidence based on extensive bias assessments and quantitative sensitivity analyses.

METHODS

We searched the databases PubMed, EMBASE, SCOPUS, CENTRAL and clinicaltrials.gov for prospective studies that examined an association between PPI use and dementia, up to February 2022. Each study was assessed using the Cochrane risk of bias assessment tools for non-randomized studies of interventions (ROBINS-I) or randomized trials (RoB2). Pooled risk ratios (RRs) and 95% prediction intervals were computed using random-effects models. Sensitivity analyses were adjusted for small-study bias.

RESULTS

We included nine observational studies with 204 108 dementia cases in the primary analysis on the association between PPI use vs. non-use and dementia, and the RR was 1.16 (95% CI = 1.00; 1.35). After adjusting for small-study bias by Copas selection model and Rücker's shrinkage procedure, the RR was 1.16 (1.02; 1.32) and 1.15 (1.13; 1.17), respectively. A subgroup analysis of PPI use vs. non-use regarding Alzheimer's disease risk yielded an RR of 1.15 (0.89; 1.50). The secondary analysis on the risk of dementia by use of PPI vs. histamine-2 receptor antagonist showed an RR of 1.03 (0.66; 1.62).

CONCLUSION

This meta-analysis provided no clear evidence for an association between PPI intake and the risk of dementia. Due to discrepancies in sensitivity analyses, however, some risk of dementia by PPI use cannot be ruled out. Since an unequivocal conclusion is still pending, further research is warranted.

Signal and Noise: Proton Pump Inhibitors and the Risk of Dementia?

The association between proton pump inhibitor (PPI) use and dementia remains controversial. This cohort study re-examines this issue, addressing shortcomings identified in previous publications using a population-based and a high-dimension propensity-score matched cohort to follow patients for up to 22 years. Cox regression models using baseline characteristics, a lag period, and time-varying variables were used to examine the risk of dementia by cumulative PPI exposure. High-dose PPI users (> 180 days of use) had significantly higher risk of dementia in crude Cox models. After adjustment for medical diagnoses and prescription drug use, these associations disappeared. Among high-dose users starting PPI therapy between 46 and 55 years old, the unadjusted hazard ratio (HR) was 1.55 (95% confidence interval (CI) 1.14, 2.10); the adjusted hazard ratio (aHR) was 1.10 (95% CI 0.80, 1.51). For high-dose users starting therapy between 56 and 65 years, HR = 1.22 (95% CI1.03, 1.44); aHR = 0.99 (95% CI 0.83, 1.17). High-dose users between the ages of 66 and 75 years had no association with the risk of dementia. The use of lag models or time-varying parameters similarly found some association with dementia in crude, but not multivariable Cox models. Although high-dose PPI users were more likely to develop dementia, they were more likely to be diagnosed with dementia risk factors, such as diabetes and cardiovascular disease, which are risk factors for dementia. Controlling for these conditions using multivariable models or a propensity-score matched cohort eliminated this association.

Associations between proton pump inhibitors and Alzheimer’s disease: a nested case–control study using a Korean nationwide health screening cohort

Background

Safety concerns against the use of proton pump inhibitors (PPIs) based on the risk of dementia, especially Alzheimer’s disease (AD), remain controversial. Here, we investigated the likelihood of AD depending on previous PPI exposure, use duration, and PPI generation.

Methods

This nested case–control study comprised 17,225 AD patients who were 1:4 matched with 68,900 controls for age, sex, income, and region of residence from Korean National Health Insurance Service-Health Screening Cohort data between 2002 and 2015 using propensity-score matching method. Conditional and unconditional logistic regression analyses were used to evaluate the effects of previous PPI use on AD adjusting for multiple covariates.

Results

Prior PPI use increased likelihood for AD in current and past PPI users (adjusted odds ratio 1.36 [95% confidence interval (CI) = 1.26–1.46] and 1.11 [95% CI = 1.04–1.18], respectively). Participants with either < 30 days, 30–90 days, or > 90 days of PPI prescription showed higher odds for AD (1.13 [95% CI = 1.07–1.19]; 1.18 [95% CI = 1.10–1.27]; 1.26 [95% CI = 1.16–1.36], respectively). Participants with either 1st-generation or 2nd-generation PPIs demonstrated higher incidences of AD in those with < 30 days (1.14 [95% CI = 1.07–1.22] and 1.13 [95% CI = 1.05–1.22], respectively), 30–90 days (1.19 [95% CI = 1.09–1.30] and 1.17 [95% CI = 1.05–1.29], respectively), or > 90 days (1.18 [95% CI = 1.07–1.30] and 1.27 [95% CI = 1.14–1.43], respectively) of prescription.

Conclusions

Prior PPI use, regardless of current or past exposure, duration of use, or use of 1st- or 2nd-generation PPIs, may increase likelihood of AD, providing supportive evidence of previous pharmacoepidemiologic studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13195-022-01032-5.

Suppression of vacuolar-type ATPase and induction of endoplasmic reticulum stress by proton pump inhibitors

BACKGROUND

Proton pump inhibitors (PPIs), such as esomeprazole, pantoprazole, dexlansoprazole, and rabeprazole, are one of the most commonly prescribed medications. Several studies have linked the long-term use of PPIs to a potentially increased risk of gastric cancer. Therefore, this study aimed to determine the underlying mechanism of PPI-mediated gastric cancer.

METHODS

Lysosomes were isolated using immunoprecipitation. The inhibition of vacuolar-type ATPase (V-ATPase) by PPIs was assayed using a PiColorLock Gold Phosphate Detection System. PPI-induced lysosomal stress was analyzed using transcription factor EB (TFEB) nuclear translocation. PPI-induced endoplasmic reticulum (ER) stress was analyzed using the expression of protein kinase RNA-like endoplasmic reticulum kinase (PERK), inositol-requiring enzyme 1 (IRE1), and activating transcription factor 6 (ATF6). Finally, reactive oxygen species (ROS) removal was determined using the activity of superoxide dismutase (SOD).

RESULTS

PPIs caused a 70% inhibition of V-ATPase activity at 20 μM, leading to lysosomal stress through TFEB nuclear translocation; ER stress by inducing the expression of PERK, IRE1, and ATF6; and enhanced SOD activity for ROS removal.

CONCLUSION

The long-term use of PPIs inhibits lysosomal V-ATPase, leading to ER stress and ROS accumulation, which may result in an increased risk of gastric cancer. Because lysosomes and the ER are common organelles in cells, physicians prescribing PPIs for gastroesophageal reflux and peptic ulcer diseases should pay more attention to the general effects of these agents on the human body.

Regular proton pump inhibitor use and incident dementia: population-based cohort study

BACKGROUND

To examine the association between regular use of proton pump inhibitors and the risk of incident dementia, including dementia subtypes, and whether the association differs between APOE genotypes.

METHODS

Based on a prospective analysis of data from the UK Biobank, 501,002 individuals (female, 54.4%) aged between 40 and 70 years, who had no prevalent dementia at baseline, were enrolled between 2006 and 2010 and followed up to 2018. We compared all-cause dementia, Alzheimer's disease (AD), and vascular dementia (VaD) incidence rates between proton pump inhibitor users and non-users by the Cox proportional hazard model.

RESULTS

During 4,438,839 person-years of follow-up (median length of follow-up, 9.0 years), there were 2505 incident cases of all-cause dementia, including 932 cases of AD and 524 cases of VaD. The incident rate of all-cause dementia among proton pump inhibitor users was 1.06 events per 1000 person-years, compared with 0.51 events per 1000 person-years among non-users. After adjustment for multiple confounders and indications, the hazard ratios (HRs) of the proton pump inhibitor users were 1.20 (95% CI, 1.07-1.35) for incident all-cause dementia, 1.23 (95% CI, 1.02-1.49) for incident AD, and 1.32 (95% CI, 1.05-1.67) for incident VaD. In addition, the association between proton pump inhibitor use and all-cause dementia differed by APOE genotype (P for interaction = 0.048). Among APOE ε4 heterozygotes, the fully adjusted HR of proton pump inhibitor use was 1.46 (95% CI, 1.22-1.75) and 1.68 (95% CI, 1.36-2.07), especially for individuals aged 65 years and older.

CONCLUSIONS

The finding of this large population-based cohort study indicates that the use of proton pump inhibitors is associated with an increased risk of incident dementia, particularly among APOE ε4 heterozygotes.

Development and validation of a risk model for cognitive impairment in the older Chinese inpatients: An analysis based on a 5-year database

Early diagnosis of cognitive impairment is important but difficult. Prediction models may work as an efficient way to identify high risk individuals for this disease. This study aimed to develop a simple and convenient model to identify high-risk individuals of cognitive impairment in the older Chinese inpatients. We enrolled 1300 inpatients aged 60 years or above from the department of geriatrics of the First Affiliated Hospital of Chongqing Medical University during 2013 to 2017. The model for cognitive impairment was established in the developing cohort of 1100 participants and tested in another validating cohort of 200 participants. Logistic regression analyses were used to identify the candidate variables of cognitive impairment. Receiver operating curve was adopted to validate the model. Logistic regression analyses showed that increasing age, diabetes, depression and low educational level were independently associated with cognitive impairment. The model was generated in the following way: P_model = e^y/(1 + e^y), where y = -6.874 + 0.088 * age + 0.317 * diabetes + 0.647 * depression + 0.345 * education level. The value of P_model indicates the probability of cognitive impairment for each patient. The present model proved to be a reliable marker for identifying people at high risk of cognitive impairment (area under curve = 0.790, 95% CI = 0.728-0.852, p < 0.001). It had a high sensitivity (86.2%) but a relatively low specificity (59.4%). It may be helpful to "recognize" those at high risk of cognitive impairment rather than "rule out" those at low risk of this disease.

Chronic omeprazole use in the elderly is associated with decreased risk of dementia and cognitive decline

BACKGROUND

The association between proton pump inhibitor (PPI) use and increased risk of dementia is controversial.

AIM

Investigating this issue in a large population of community-dwelling elders.

METHODS

Our database was retrospectively searched for all community-dwelling patients aged ≥65 years who newly diagnosed with dementia/cognitive decline (DCD) between January 2002 - December 2012. Receiving ≥11 prescriptions of PPIs/year was categorized as PPI users. Clinical data were collected from the medical files. Risk of DCD in PPI users was analyzed by Cox regression models.

RESULTS

Included 48,632 elders of whom 8,848 were diagnosed with DCD (18.2%). PPI use was documented in 10,507, of whom 1,959 were subsequently diagnosed with DCD (18.6%). Among 38,125 non-PPI users, 6,889 (18.1%) were diagnosed with DCD. The hazard ratio for occurrence of DCD in PPI users compared to non-users was 0.85 (95% CI: 0.81-0.89, P <0.001) in an un-adjusted Cox regression model and 0.83 in a Cox regression model adjusted for age and sex (95% CI: 0.79-0.87, P <0.001). Multivariate Cox regression accounting for background diseases, marital status, and socioeconomic state yielded a hazard ratio of 0.77 (95% CI: 0.73-0.81, P <0.001).

CONCLUSION

PPI use wasn't associated with DCD development in chronic PPI users.

Higher Dementia Risk in People With Gastroesophageal Reflux Disease: A Real-World Evidence

Background

Whether or not patients with gastroesophageal reflux disease (GERD) have a higher risk of developing subsequent dementia remains unknown, and no observational evidence from population-based data is available. This study was to determine whether patients with GERD have a higher future risk of developing dementia.

Methods

For the period 2000–2012, datasets from the Longitudinal Health Insurance Database (LHID, subset of National Health Insurance Research Database in Taiwan) were analyzed. Definition of GERD was based on ICD-9-CM codes 530.11 and 530.81 and prescriptions for PPIs. After matching gender, age, index year, and comorbidities, each GERD patient was matched with four control patients without GERD. Future risk of dementia was evaluated, and sensitivity analysis of subgroups was conducted to clarify the potential association.

Results

In the present study, 13,570 patients were included in the GERD cohort and 54,280 patients were included in the control cohort. Patients with GERD showed higher risk developing dementia than control group, with an aHR of 1.34 (95% C.I., 1.07, 1.67). In GERD patients between above 70 years old, the risk of developing dementia was higher than that of the control groups (aHR = 1.34; 95% C.I., 1.01, 1.77).

Conclusion

Patients with GERD showed higher incidence of dementia, and elder patients had the highest risk of developing dementia. Clinicians should be concern of the association between GERD and dementia and should develop strategies to prevent dementia while managing patients with GERD.

Emulating a target trial of proton pump inhibitors and dementia risk using claims data

BACKGROUND

Understanding the adverse effects of proton pump inhibitors (PPIs) is important due to their widespread use, but the available evidence for an increased dementia risk among patients taking PPIs is inconclusive. The present study aimed to estimate the causal effect of PPIs on the risk of dementia by target trial emulation and time-varying exposure modeling.

METHODS

Using claims data of 2,698,176 insured people of a large German statutory health insurer, we conceptualized a target trial in which individuals aged 40 years and older were classified as PPI initiators or non-initiators between 2008 and 2018, and followed until diagnosis of dementia, death, loss to follow-up or end of study. Incidence of dementia (ICD-10 codes F00, F01, F03, F05.1, G30, G31.0, G31.1, G31.9, and F02.8+G31.82) was defined applying a 1-year lag window. We used weighted Cox models to estimate the effect of PPI initiation vs. non-initiation on dementia risk and weighted pooled logistic regression to estimate the effect of time-varying use vs. non-use.

RESULTS

29,746 PPI initiators (4.4%) and 26,830 non-initiators (1.3%) were diagnosed with dementia. Comparing PPI initiation with no initiation, the hazard ratio (HR) for dementia was 1.54 (95% confidence interval [CI]: 1.51-1.58). The HR for time-dependent PPI use vs. non-use was 1.56 (95% CI: 1.50-1.63). Differentiated subtypes, including unspecified dementia, Alzheimer's disease (AD), and vascular dementia (VaD), showed increased risk by PPI initiation and time-varying PPI use.

CONCLUSIONS

This study suggests that PPI initiation and time-varying PPI use may increase overall dementia risk.

Gastric acid suppressants and cognitive decline in people with or without cognitive impairment

INTRODUCTION

Studies suggest associations between proton pump inhibitors (PPIs) and dementia risk; however, many neither considered histamine-2 receptor antagonists (H2RAs) nor baseline cognitive status.

METHODS

Participants (National Alzheimer's Coordinating Center Database; 2005-2021) using a PPI or H2RA were compared. Covariate-adjusted Cox regression was used to estimate hazard ratios (HR) for progression from normal cognition to mild cognitive impairment (MCI), and from MCI to dementia over 5 years. In a propensity-score-matched subsample of mild-moderate Alzheimer's disease (AD), mixed-effects negative binomial regression was used to estimate decline in delayed recall memory.

RESULTS

Compared to PPI, H2RA use was associated with earlier progression from MCI to dementia (HR = 1.40 [1.09-1.81]; n = 1701), and with faster memory decline in AD over time (rate ratio = 0.76 [0.64-0.92]; n = 628), but not with progression from normal cognition to MCI (HR = 0.94 [0.71-1.24]; n = 2784).

DISCUSSION

Compared to PPIs, H2RAs were associated with cognitive decline, specifically among people with pre-existing cognitive impairment.

Association Between Ginkgo Biloba Extract Prescriptions and Dementia Incidence in Outpatients with Mild Cognitive Impairment in Germany: A Retrospective Cohort Study

Background:

Clinical trials have demonstrated a significant effectiveness of Ginkgo biloba therapy versus placebo in patients with dementia.

Objective:

The present study aims to analyze the impact of Ginkgo biloba drug prescriptions on dementia incidence in patients with mild cognitive impairment (MCI) in a real-world setting.

Methods:

This retrospective study was based on the IQVIA Disease Analyzer database and included patients aged 65 or older with a first diagnosis of MCI from January 2000 to December 2019. Each patient was followed for up to 20 years after MCI diagnosis until February 2021. Date of the first diagnosis of dementia or loss to follow-up, whichever occurred first, was noted. To estimate the association between Ginkgo biloba prescriptions during the follow-up and dementia incidence, a multivariable Cox regression analysis was performed, adjusted for age, sex, health insurance, documented co-diagnoses, and prescription of cholinesterase inhibitors.

Results:

Overall, 24,483 MCI patients (mean age: 77.0 years, 56.3% women) were included. It was found that > 2 prescriptions of Ginkgo biloba were significantly associated with a reduced dementia incidence (HR: 0.71 (95% CI: 0.55–0.91), p = 0.007), as compared with no Ginkgo biloba prescription. The effect of receiving > 3 Ginkgo biloba prescriptions was even stronger, with an HR of 0.64 (95% CI: 0.48–0.86), p = 0.003), while for > 4 prescriptions the HR was 0.58 (95% CI: 0.41–0.82) (p = 0.002).

Conclusion:

All-cause dementia incidence decreased with higher numbers of Ginkgo biloba prescriptions in MCI patients.

Statin use and risk of dementia or Alzheimer's disease: a systematic review and meta-analysis of observational studies

AIMS

As the potential impact of statins on cognitive decline and dementia is still debated, we conducted a meta-analysis of observational studies to examine the effect of statin use on the risk of Alzheimer's disease (AD) and dementia.

METHODS AND RESULTS

PubMed, Cochrane, and EMBASE were searched since inception to January 2021. Inclusion criteria were: (i) cohort or case-control studies; (ii) statin users compared to non-users; and (iii) AD and/or dementia risk as outcome. Estimates from original studies were pooled using restricted maximum-likelihood random-effect model. Measure of effects were reported as odds ratio (OR) and 95% confidence intervals (CIs). In the pooled analyses, statins were associated with a decreased risk of dementia [36 studies, OR 0.80 (CI 0.75-0.86)] and of AD [21 studies, OR 0.68 (CI 0.56-0.81)]. In the stratified analysis by sex, no difference was observed in the risk reduction of dementia between men [OR 0.86 (CI 0.81-0.92)] and women [OR 0.86 (CI 0.81-0.92)]. Similar risks were observed for lipophilic and hydrophilic statins for both dementia and AD, while high-potency statins showed a 20% reduction of dementia risk compared with a 16% risk reduction associated with low-potency statins, suggesting a greater efficacy of the former, although a borderline statistical significance (P = 0.05) for the heterogeneity between estimates.

CONCLUSION

These results confirm the absence of a neurocognitive risk associated with statin treatment and suggest a potential favourable role of statins. Randomized clinical trials with an ad hoc design are needed to explore this potential neuroprotective effect.

No association between acid suppressant use and risk of dementia: an updated meta-analysis

PURPOSE

Findings from large observational studies on whether the use of acid suppressants increases the risk of dementia have been inconsistent. Since proton pump inhibitors (PPI) and histamine-2 receptor antagonists (H2RA) are the most commonly used acid suppressants in clinical practice, we performed a meta-analysis to examine the influence of PPI and H2RA on the risk of dementia.

METHODS

A systematic search was performed on the PubMed, EMBASE, and Cochrane Library databases to identify studies published up to April, 2021. Studies that reported adjusted hazard ratio (HR) with 95% confidence intervals (CI) for the associations of interest were included. Data in the included studies were pooled using the random-effects model for meta-analysis. Statistical analysis was performed using Stata version 12.0 software.

RESULTS

Seventeen studies involving 1,251,562 participants were included. It was found that PPI users were not likely to develop dementia compared with those not taking PPI (HR = 0.98, 95% CI: 0.85-1.13). Subgroup analysis based on publication year, location, mean age, duration of PPI use, and female proportion also revealed no association between PPI use and dementia risk. Similarly, H2RA use was not associated with the risk of dementia, as indicated by the pooled HR of 1.20 (95% CI: 0.98-1.47).

CONCLUSION

Results of this meta-analysis suggest that PPI and H2RA do not increase the risk of dementia. These results may be used to inform the clinical application of acid suppressants. However, further randomized controlled trials are needed to confirm the present conclusions.

The Janus-like Association between Proton Pump Inhibitors and Dementia

Early pharmacoepidemiological studies suggested that Proton Pump Inhibitors (PPIs) might increase the risk of Alzheimer’s Disease (AD) and non-AD related dementias. These findings were supported by preclinical studies, specifically stressing the proamyloidogenic and indirect anticholinergic effects of PPIs. However, further large-scale pharmacoepidemiological studies showed inconsistent results on the association between PPIs and dementia. Pharmacodynamically, these findings might be related to the LXR/RXR-mediated amyloid clearance effect and anti-inflammatory action of PPIs. Further aspects that influence PPI effects on AD are related to patient-specific pharmacokinetic and pharmacogenomic characteristics. In conclusion, a personalized (individualized) medicinal approach is necessary to model and predict the potential harmful or beneficial effects of PPIs in AD and non-AD-related dementias in the future.

The inappropriate use of proton pump inhibitors and its associated factors among community-dwelling older adults

Objectives

Little is known about the inappropriate use of proton pump inhibitors (PPIs) and how mild cognitive impairment (MCI) and high comorbid burden relate to the inappropriate prescribing of PPIs. Therefore, the current study aimed to examine these associations among community-dwelling older adults in Jordan.

Method

This cross-sectional study was conducted on 215 community-dwelling older adults from three local healthcare centers located in Irbid, Jordan. Data about PPI use, including the name of medication, dose, frequency, duration, and indication, were collected retrospectively from a review of the participating older adults’ medication cards for November and December 2019. The collected data were evaluated based on the Food and Drug Administration (FDA) guidelines. MCI was measured using the Arabic version of the Montreal Cognitive Assessment, and comorbid burden was measured using the Cumulative Illness Rating Scale for Geriatrics.

Results

Forty-seven percent of the participants were found to have taken a PPI, with 68 % having taken one for a longer period than recommended by the FDA. Older adults with MCI or high comorbid burden were found to be more susceptible than other older adults to the long-term use of PPIs. The logistic regression revealed that MCI is a statistically significant predictor of inappropriate PPI use (p < 0.001).

Conclusion

Inappropriate PPI use is common among community-dwelling older adults in Jordan, with a significantly higher prevalence of inappropriate PPI use in people with MCI than in people with normal cognitive abilities. Future intervention studies are highly recommended to encourage optimal prescribing of PPIs for community-dwelling older adults.

Lack of association between proton pump inhibitor use and decline in cognitive performance in the ELSA-Brasil cohort

OBJECTIVE

The study aims to investigate the longitudinal association of use and time of use of proton pump inhibitors (PPIs) with decreased performance in three cognitive tests.

METHODS

Prospective cohort study included 7115 participants with mean age of 58.9 years at baseline (2008-2010) who participated in the second wave (2012-2014) of ELSA-Brasil (average interval between visits = 3.9 years (range: 1.7 to 6.0 years)). Cognitive performance was assessed by tests of memory, phonemic and semantic verbal fluency, and the trail making test, applied to both waves. Associations with the use and time of use of PPIs at baseline were investigated using linear models with mixed effects after adjusting for confounding factors.

RESULTS

At baseline, 7.4% (529) of the participants used PPIs on a regular basis. After all adjustments, the interaction term use of PPI × age was not statistically significant for the cognitive tests evaluated, indicating that the use of PPI at baseline was not associated with a more accelerated decline in cognitive performance between waves. The interaction term PPI use × age was not statistically significant, in any of the categories of medication use time, any of the cognitive function tests evaluated, indicating that PPI use time is not associated with decrease in cognitive scores as the time interval between visits increases.

CONCLUSION

In this cohort middle-aged and elderly adults, after average interval of 3.9 years (relatively short time to detect cognitive decline in a young cohort), the use and time of use of PPIs at the beginning of the study were not associated with a decline in cognitive performance in these tests between visits.

Drugs in Focus: Proton Pump Inhibitors

Proton pump inhibitors (PPIs) are amongst the most commonly prescribed drugs in infants and children with the last decades witnessing a dramatic rise in their utilization. Although PPIs are clearly effective when used appropriately and have been regarded as safe drugs, there is growing evidence regarding their potential adverse effects. Although, largely based on adult data it is clear that many of these are also relevant to pediatrics. PPI use potentially affects gastrointestinal microbiota composition and function, decreases defence against pathogens resulting in increased risk for infections, interferes with absorption of minerals and vitamins leading to specific deficiencies and increased risk for bone fractures as well as interferes with protein digestion resulting in increased risk of sensitization to allergens and development of allergic diseases and eosinophilic esophagitis. An association with gastric, liver and pancreatic cancer has also been inferred from adult data but is tenuous and causation is not proven. Overall, evidence for these adverse events is patchy and not always compelling. Overall, the use of PPIs, for selected indications with a good evidence base, has significant potential benefit but carries more caution in infants and children. Pediatricians should be aware of the concerns regarding the potential adverse events associated with their use.

The effects of proton pump inhibitors on neuropsychological functioning

OBJECTIVE

The current study investigated the effects of proton pump inhibitor use and apolipoprotein ε4 carrier status on changes in neuropsychological functioning in healthy adults with familial risk factors for dementia.

METHODS

As part of the Wisconsin Registry for Alzheimer's Prevention study, 1,573 subjects were administered questionnaires on their medical history, gave blood samples, and were administered neuropsychological assessments during four visits over a 10-15 year period. Linear mixed models assessed if non-users, subjects who stopped, started, or consistently used proton pump inhibitors differed in changes in working memory, verbal memory, psychomotor speed, and cognitive flexibility.

RESULTS

The models did not yield significant main effects for proton pump inhibitor use or interaction effects between proton pump inhibitor use and apolipoprotein ε4 carrier status on a decline in memory or processing speed. An interaction effect suggested stopping a proton pump inhibitor may be protective against declines in cognitive flexibility among non-carriers.

CONCLUSIONS

Although stopping a proton pump inhibitor use may have mild protective effects on executive functioning for non-apolipoprotein ε4 carriers, proton pump inhibitor use was not associated with memory decline in a sample of subjects with familial risk factors for dementia.

Promoting Successful Cognitive Aging: A Ten-Year Update

A decade has passed since we published a comprehensive review in this journal addressing the topic of promoting successful cognitive aging, making this a good time to take stock of the field. Because there have been limited large-scale, randomized controlled trials, especially following individuals from middle age to late life, some experts have questioned whether recommendations can be legitimately offered about reducing the risk of cognitive decline and dementia. Despite uncertainties, clinicians often need to at least make provisional recommendations to patients based on the highest quality data available. Converging lines of evidence from epidemiological/cohort studies, animal/basic science studies, human proof-of-concept studies, and human intervention studies can provide guidance, highlighting strategies for enhancing cognitive reserve and preventing loss of cognitive capacity. Many of the suggestions made in 2010 have been supported by additional research. Importantly, there is a growing consensus among major health organizations about recommendations to mitigate cognitive decline and promote healthy cognitive aging. Regular physical activity and treatment of cardiovascular risk factors have been supported by all of these organizations. Most organizations have also embraced cognitively stimulating activities, a heart-healthy diet, smoking cessation, and countering metabolic syndrome. Other behaviors like regular social engagement, limiting alcohol use, stress management, getting adequate sleep, avoiding anticholinergic medications, addressing sensory deficits, and protecting the brain against physical and toxic damage also have been endorsed, although less consistently. In this update, we review the evidence for each of these recommendations and offer practical advice about behavior-change techniques to help patients adopt brain-healthy behaviors.

Glia-Driven Neuroinflammation and Systemic Inflammation in Alzheimer's Disease

The neuroinflammatory hypothesis of Alzheimer's disease (AD) was proposed more than 30 years ago. The involvement of the two main types of glial cells microglia and astrocytes, in neuroinflammation, was suggested early on. In this review, we highlight that the exact contributions of reactive glia to AD pathogenesis remain difficult to define, likely due to the heterogeneity of glia populations and alterations in their activation states through the stages of AD progression. In the case of microglia, it is becoming apparent that both beneficially and adversely activated cell populations can be identified at various stages of AD, which could be selectively targeted to either limit their damaging actions or enhance beneficial functions. In the case of astrocytes, less information is available about potential subpopulations of reactive cells; it also remains elusive whether astrocytes contribute to the neuropathology of AD by mainly gaining neurotoxic functions or losing their ability to support neurons due to astrocyte damage. We identify L-type calcium channel blocker, nimodipine, as a candidate drug for AD, which potentially targets both astrocytes and microglia. It has already shown consistent beneficial effects in basic experimental and clinical studies. We also highlight the recent evidence linking peripheral inflammation and neuroinflammation. Several chronic systemic inflammatory diseases, such as obesity, type 2 diabetes mellitus, and periodontitis, can cause immune priming or adverse activation of glia, thus exacerbating neuroinflammation and increasing risk or facilitating the progression of AD. Therefore, reducing peripheral inflammation is a potentially effective strategy for lowering AD prevalence.

Acid suppressants use and the risk of dementia: A population-based propensity score-matched cohort study

In this population-based propensity score matched (PSM) cohort study, we aimed to investigate the risk of developing dementia with the use of acid suppressants, including proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2 antagonists). Cohorts of PPI users (n = 2,778), H2 antagonist users (n = 6,165), and non-users (n = 86,238) were selected from a dataset covering the years 2000 to 2010 in Taiwan’s National Health Insurance Research Database. Patients in the three groups were PSM at a ratio of 1:1 within each comparison cohort (CC). Three CCs were created: (1) PPI users compared to non-users (CC1, n = 2,583 pairs); (2) H2 antagonist users compared to non-users (CC2, n = 5,955 pairs); and (3) PPI users compared to H2 antagonist users (CC3, n = 2,765 pairs). A multivariable robust Cox proportional hazard model was used to estimate the adjusted hazard ratio (aHR) and the 95% confidence interval (CI) for the risk of developing dementia. The multivariable analysis results show that the aHR of developing dementia during the follow-up period was 0.72 (CC1: 95% CI = 0.51–1.03, P = 0.07) for PPI users and 0.95 (CC2: 95% CI = 0.74–1.22, P = 0.69) for H2 antagonist users, when compared to non-users. Between the patients using acid suppressants, there was no difference between PPI and H2 antagonist users in the risk of developing dementia (CC3: aHR = 0.82, 95% CI = 0.58–1.17, P = 0.28). In conclusion, no association was observed between the use of acid suppressants and the risk of developing dementia in any of the three CCs. Further, randomized controlled trials are warranted to confirm this relationship.

Risk of dementia in patients with periodontitis and related protective factors: A nationwide retrospective cohort study

AIM

We aimed to evaluate the long-term risk of dementia in patients with periodontitis and its associated factors.

MATERIALS AND METHODS

Using Taiwan's National Health Insurance Database, we identified 56,018 patients aged ≥50 years with newly diagnosed periodontitis in 2000-2008. A cohort of 56,018 adults without periodontitis was selected for comparison, with matching by age and sex. Both cohorts were followed from 2000 to the end of 2013, and incident dementia was identified during the follow-up period. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of dementia associated with periodontitis were calculated in the multivariate regressions.

RESULTS

Periodontitis was associated with dementia risk (HR: 1.79, 95% CI: 1.67-1.93), and the association between periodontitis and dementia risk was significant in men, women, and people aged more than 60 years. Among patients with periodontitis, the use of statins (HR: 0.78, 95% CI: 0.71-0.87), metformin (HR: 0.53, 95% CI: 0.44-0.62), and influenza vaccination (HR: 0.67, 95% CI: 0.61-0.74) were associated with a reduced risk of dementia, while diabetes, mental disorders, and stroke were major significant risk factors.

CONCLUSIONS

Periodontitis was a risk factor for dementia, while the use of statins and metformin may reduce the risk of dementia.

Clinical Use of Acid Suppressants and Risk of Dementia in the Elderly: A Pharmaco-Epidemiological Cohort Study

BACKGROUND

Results of studies regarding the potential link between acid suppressant use and dementia risk are inconsistent. This study aimed to evaluate the association of cumulative exposure to histamine 2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) with dementia risk in an Asian older cohort aged ≥65 years.

METHODS

Patients initiating H2RA (the H2RA user cohort, n = 21,449) or PPI (the PPI user cohort, n = 6584) and those without prescription for H2RA (the H2RA non-user cohort, n = 21,449) or PPI (the PPI non-user cohort, n = 6584) between 1 January 2000 and 31 December 2005 without a prior history of dementia were identified from Taiwan's National Health Insurance Research Database (NHIRD). The outcome of interest was all-cause dementia. Patients' exposure to H2RAs or PPIs was followed-up from dates of initial prescription to the earliest outcome of incident dementia, death, or the end of 2013. Potential associations between acid suppressant use and dementia risk were analyzed using time-dependent Cox regression estimated hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

After mutual adjustment for H2RA and PPI use and other potential confounders, patients with H2RA use had significantly higher risk of developing dementia as compared to those not treated with H2RAs (adjusted HR, 1.84; 95% CI, 1.49-2.20). Likewise, PPI users had significantly elevated risk of dementia compared to PPI non-users (adjusted HR, 1.42; 95% CI, 1.07-1.84).

CONCLUSIONS

Our results indicate that exposures to H2RAs and PPIs are associated with increased dementia risk.

Cognitive impairment in a primary healthcare population: a cross-sectional study on the island of Crete, Greece

OBJECTIVES

Cognitive impairment is known to have a significant impact on the quality of life of individuals and their caregivers, yet it is often underdiagnosed. The objective of this study is to assess the extent of cognitive impairment among elders visiting primary healthcare (PHC) practice settings, to explore associated risk factors and discuss current care challenges for PHC providers.

DESIGN

A cross-sectional study was conducted between March 2013 and May 2014.

SETTING

Fourteen PHC units located in rural and urban areas of the Heraklion district in Crete, Greece.

PARTICIPANTS

Consecutive visitors aged at least 60 years attending selected PHC practices.

PRIMARY AND SECONDARY OUTCOME MEASURES

The Mini-Mental State Examination (MMSE) was used to indicate cognitive status. Associations of low MMSE scores (≤23/24, adjusted for education level) with 12 socio-demographic factors, comorbidities and lifestyle factors were assessed.

RESULTS

A total of 3140 PHC patients met inclusion criteria (43.2% male; mean age 73.7±7.8 years). The average MMSE score was 26.0±3.8; 26.7±3.5 in male and 25.4±3.9 in female participants (p<0.0001). Low MMSE scores were detected in 20.2% of participants; 25.9% for females vs 12.8% for males; p<0.0001. Female gender (adjusted OR (AOR)=2.72; 95% CI 2.31 to 3.47), age (AOR=1.11; 95% CI 1.10 to 1.13), having received only primary or no formal education (AOR=2.87; 95% CI 2.26 to 3.65), alcohol intake (AOR=1.19; 95% CI 1.03 to 1.37), reporting one or more sleep complaints (AOR 1.63; 95% CI 1.14 to 2.32), dyslipidaemia (AOR=0.80; 95% CI 0.65 to 0.98) and history of depression (AOR=1.90; 95% CI 1.43 to 2.52) were associated with low MMSE scores.

CONCLUSIONS

This study identified a relatively high prevalence of low MMSE scores among persons attending PHC practices in a southern European community setting and associations with several known risk factors.

Proton pump inhibitors and dementia risk: Evidence from a cohort study using linked routinely collected national health data in Wales, UK

OBJECTIVES

Proton pump inhibitors (PPIs) are commonly prescribed for prevention and treatment of gastrointestinal conditions or for gastroprotection from other drugs. Research suggests they are linked to increased dementia risk. We use linked national health data to examine the association between PPI use and the development of incident dementia.

METHODS AND FINDINGS

A population-based study using electronic health-data from the Secure Anonymised Information Linkage (SAIL) Databank, Wales (UK) from 1999 to 2015. Of data available on 3,765,744 individuals, a cohort who had ever been prescribed a PPI was developed (n = 183,968) for people aged 55 years and over and compared to non-PPI exposed individuals (131,110). Those with prior dementia, mild-cognitive-impairment or delirium codes were excluded. Confounding factors included comorbidities and/or drugs associated with them. Comorbidities might include head injury and some examples of medications include antidepressants, antiplatelets and anticoagulants. These commonly prescribed drugs were investigated as it was not feasible to explore all drugs in this study. The main outcome was a diagnosis of incident dementia. Cox proportional hazard regression modelling was used to calculate the Hazard ratio (HR) of developing dementia in PPI-exposed compared to unexposed individuals while controlling for potential confounders. The mean age of the PPI exposed individuals was 69.9 years and 39.8% male while the mean age of the unexposed individuals was 72.1 years and 41.1% male. The rate of PPI usage was 58.4% (183,968) and incident dementia rate was 11.8% (37,148/315,078). PPI use was associated with decreased dementia risk (HR: 0.67, 95% CI: 0.65 to 0.67, p<0.01).

CONCLUSIONS

This study, using large-scale, multi-centre health-data was unable to confirm an association between PPI use and increased dementia risk. Previously reported links may be associated with confounders of people using PPI's, such as increased risk of cardiovascular disease and/or depression and their associated medications which may be responsible for any increased risk of developing dementia.

Potential proton pump inhibitor-related adverse effects

Proton pump inhibitors (PPIs) are one of the most common medications taken by patients worldwide. PPIs are used to treat acid-related disorders, including gastroesophageal reflux disease, peptic ulcer disease, Helicobacter pylori infection, and nonsteroidal anti-inflammatory drug/stress ulceration. For some of these diseases, long-term treatment is necessary. With such prolonged use, concern and investigation into potential adverse effects has increased. In addition, data are available regarding potential anticancer effects of PPIs, especially regarding solid tumors. The aim of this review is to assess the literature on PPIs with regard to common concerns, such as drug-drug interactions, the intestinal microbiome, dementia and central nervous system disease, and osteoporosis, as well as to highlight potential negative and positive impacts of the drug in cancer.

Possible dementia risk of proton pump inhibitors and H2 receptor blockers use in the treatment of Helicobacter pylori: A meta-analysis study

INTRODUCTION

The risk of dementia when using proton-pump-inhibitors (PPIs) and H2-receptor-blockers as a treatment of Helicobacter-pylori have a lot of controversial-research with different results; however, no final recommendation was deduced from all these researches. A meta-analysis study was performed to evaluate the relationship between PPIs and H2-receptor-blockers use and dementia.

METHODS

Through a systematic literature search up to December-2019, 10-studies with 371951-subjects of them 71021Helicobacter-pylori-positive subjects using either PPIs or H2-receptor-blockers or both were identified reporting-relationships between PPIs and H2-receptor-blockers uses and dementia (10-studies contained PPIS, 4-contained H2-receptor-blockers). Odd-ratio (OR) with 95% confidence-intervals (CIs) was calculated comparing PPIs and H2-receptor-blockers users and to non-user subjects on the bases of dementia using the dichotomous-method with a random-effect-model.

RESULTS

No significant difference was found between PPIs-users or non-user (OR, 0.87; 95% CI, 0.62-1.22) or between H2-receptor blockers-users and non-users (OR, 1.21; 95% CI, 0.91-1.59) as a risk of dementia. The extent of increases in dementia with H2-receptor-blockers was higher than that with PPIs. The impact of PPIs and H2-receptor-blockers was similar in all populations.

CONCLUSIONS

Based on this meta-analysis, the contentious use of PPIs or H2-receptor-blockers may not have an independent-relationship to dementia. This suggests that using PPIs or H2-receptor-blockers is not related to dementia. However, we still have to recommend careful use of PPIs and H2-receptor-blockers when treating Helicobacter-pylori and sticking to the dose and length of treatment and not to extend it to avoid any possible risk.

No Association Linking Short-Term Proton Pump Inhibitor Use to Dementia: Systematic Review and Meta-analysis of Observational Studies

INTRODUCTION

Long-term use of proton pump inhibitors (PPIs) has been associated with a wide variety of potentially serious adverse effects including a possible increased risk of dementia. Studies evaluating this association have reached divergent conclusions. We aimed to evaluate this proposed association further and to assess the quality of the evidence in its support.

METHODS

We searched MEDLINE, EMBASE, ISI Web of Science, and Cochrane databases for studies examining a link between PPI use and dementia, up to February 2019. Studies reporting summary results as hazard ratio (HR) or odds ratio (OR) were pooled using the DerSimonian and Laird random-effects model for meta-analyses. Methodological quality of individual observational studies was assessed using the Newcastle-Ottawa scale and the overall quality of evidence rated as per the GRADE approach.

RESULTS

We identified and included 11 observational studies comprising 642,949 subjects; 64% were women. Most studies were short-term ranging from 5 to 10 years. There were 158,954 PPI users and 483,995 nonusers. For studies summarizing data as adjusted HR, pooled HR for all causes of dementia was 1.10 (0.88-1.37); for Alzheimer dementia only, it was 1.06 (0.72-1.55). For studies summarizing data as adjusted OR, pooled OR for all causes of dementia was 1.03 (0.84-1.25) and for Alzheimer dementia only 0.96 (0.82-1.11). Per Newcastle-Ottawa scale assessment, 10 studies were of high quality and 1 was of moderate quality. By applying GRADE methodology, quality of evidence for both outcomes was very low.

DISCUSSION

We found no evidence to support the proposed association between PPI use and an increased risk of dementia. PPI use among patients who have a valid indication for it, should not be curtailed because of concerns about dementia risk.

The Relationship of Coronary Artery Calcium and Clinical Coronary Artery Disease with Cognitive Function: A Systematic Review and Meta-Analysis

AIM

Coronary artery disease (CAD) and cognitive impairment are common in the elderly, with evidence for shared risk factors and pathophysiological processes. The coronary artery calcium (CAC) score is a marker of subclinical CAD, which may allow early detection of individuals prone to cognitive decline. Prior studies on associations of CAC and clinical CAD with cognitive impairment had discrepant results. This systematic review aims to evaluate the association of (sub)clinical CAD with cognitive function, cognitive decline, and diagnosis of mild cognitive impairment (MCI) or dementia.

METHODS

A systematic search was conducted in MEDLINE, Embase, and Web of Science until February 2019, supplemented with citations tracking. Two reviewers independently screened studies and extracted information including odds ratios (ORs) and hazard ratios (HRs).

RESULTS

Forty-six studies, 10 on CAC and 36 on clinical CAD, comprising 1,248,908 participants were included in the systematic review. Studies about associations of (sub)clinical CAD with cognitive function and cognitive decline had heterogeneous methodology and inconsistent findings. Two population-based studies investigated the association between CAC and risk of dementia over 6-12.2 years using different CAC scoring methods. Both found a tendency toward higher risk of dementia as CAC severity increased. Meta-analysis in 15 studies (663,250 individuals) showed an association between CAD and MCI/dementia (pooled OR 1.32, 95%CI 1.17-1.48) with substantial heterogeneity (I²=87.0%, p＜0.001). Pooled HR of CAD for incident MCI/dementia over 3.2-25.5 years in six longitudinal studies (70,060 individuals) was 1.51 (95%CI 1.24-1.85), with low heterogeneity (I²=14.1%, p=0.32). Sensitivity analysis did not detect any study that was of particular influence on the pooled OR or HR.

CONCLUSIONS

Limited evidence suggests the CAC score is associated with risk of dementia. In clinical CAD, risk of MCI and dementia is increased by 50%, as supported by stronger evidence.

No association between proton pump inhibitor use and risk of dementia: Evidence from a meta-analysis

BACKGROUND AND AIM

A growing body of literature suggests the association between dementia risk and proton pump inhibitor (PPI) use. Therefore, we aimed to investigate the association between PPI use and dementia risk.

METHODS

An extensive literature search was performed in PubMed, Embase, and Cochrane till March 31, 2019. All the studies (cohort and case-control) assessing the association between PPI use and dementia risk were eligible for inclusion. Articles were selected based on the screening of title and abstract, data were extracted, and risk of bias was assessed using Newcastle-Ottawa scale. The primary outcome was pooled risk of dementia among PPI user as compared with non-PPI user. Secondary outcomes include dementia risk based on subgroups. Statistical analysis was performed using review manager software.

RESULTS

Twelve studies (eight cohort and four case-control) were found to be eligible for inclusion. Majority of the studies were of high quality. Dementia was diagnosed based on International Classification of Diseases 9/10 codes in majority of the included studies. PPI use was not associated with the dementia risk, with a pooled relative risk (RR) of 1.05 (95% confidence interval [CI]: 0.96-1.15), P = 0.31. Subgroup analysis based on study design (cohort: P = 0.14; case-control: P = 0.14), sex (RR 1.25 [95% CI: 0.97-1.60], P = 0.08), histamine 2 receptor antagonist blockers (P = 0.93), and Alzheimer's disease (RR 1.00 [95% CI: 0.91-1.09], P = 0.93) revealed no significant association between PPI use and dementia risk.

CONCLUSION

We found no significant association between PPI use and the risk of dementia or Alzheimer's disease.

Beyond uncertainty: Negative findings for the association between the use of proton pump inhibitors and risk of dementia

OBJECTIVES

We investigated the risk of dementia associated with the use of proton pump inhibitors (PPIs) as compared with the use of histamine-2 receptor antagonist (H2RA).

METHODS

We conducted retrospective propensity score-matched cohort study using the National Health Insurance Service-National Sample Cohort. Subjects were defined as the patients newly prescribed with PPI or H2RA between 2003 and 2013 without prior prescriptions of PPI/H2RA or diagnosis of dementia from their history within the past 1 year. We followed up participants until dementia occurrence, death, or the end of the study, whichever occurred first, with an intention-to-treat approach. A 1-year lag time between exposure and outcome measure was used to reduce protopathic bias. The incidence rate per 1000 person-years was estimated. The incidence rate of PPI was compared with that of H2RA, defined as incidence rate ratio (IRR), calculated with a 95% confidence interval. To control for potential confounds, propensity score matching at a 1:1 ratio was conducted, and the crude IRR was adjusted by risk factors.

RESULTS

Our propensity score-matched cohort included 87 562 patients on PPIs and 87 562 patients on H2RAs. The IRR was 1.01 (95% confidence interval 0.96-1.06) with 1-year lag time. IRR showed the decreased trend as the longer lag time. Also, no treatment duration or dose-response relationship was observed.

CONCLUSIONS

Our finding demonstrated that PPIs did not associate with dementia more strongly than did H2RA. On this basis, we suggest that the previously reported risk for dementia associated with PPI may have been overestimated.

The Clinician's Guide to Proton Pump Inhibitor Related Adverse Events

A substantial volume of literature exists linking proton pump inhibitor (PPI) use with a multitude of serious adverse events. There is uncertainty, however, over whether these associations are clinically important. Excessive concern about PPI-related adverse events may leave patients at risk of harm by leaving acid-related upper gastrointestinal disease untreated. Conversely, the risk of treatments may outweigh the benefits if any of the purported adverse events are directly caused by PPI use; this is of particular concern where indications for PPI use are not present. In this paper, we review the studies which have reported associations between adverse events and PPI use, discuss the proposed mechanisms of action, grade the confidence in whether these associations are truly causal, and provide advice regarding balancing the benefits of PPI use against their possible harms.

Proton-pump inhibitor use is associated with a broad spectrum of neurological adverse events including impaired hearing, vision, and memory

Proton-pump inhibitors, PPIs, are considered effective therapy for stomach acid suppression due to their irreversible inhibition of the hydrogen/potassium pump in the gastric parietal cells. They are widely prescribed and are considered safe for over-the-counter use. Recent studies have shown an association between PPI use and Alzheimer dementia, while others have disputed that connection. We analyzed over ten million United States Food and Drug Administration Adverse Event Reporting System reports, including over forty thousand reports containing PPIs, and provided evidence of increased propensity for memory impairment among PPI reports when compared to histamine-2 receptor antagonist control group. Furthermore, we found significant associations of PPI use with a wide range of neurological adverse reactions including, migraine, several peripheral neuropathies, and visual and auditory neurosensory abnormalities.

Proton pump inhibitors use and dementia risk: a meta-analysis of cohort studies

PURPOSE

The aim of this study was to explore the relationship between proton pump inhibitors use and the risk of dementia.

METHODS

A comprehensive literature search was conducted in English and Chinese databases from origination to December 2018. The pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated with a random-effects model. Subgroup analyses and sensitivity analyses were also conducted. Cochran's Q test and the I² statistic were used to evaluate the heterogeneity. Publication bias was assessed by Begg's test and Egger's test.

RESULTS

Six studies were included, which contained a total of 166,146 participants. The overall result demonstrated a significant increase in dementia risk with proton pump inhibitors use (HR = 1.29, 95% CI = 1.12-1.49). In subgroup analyses, a significant association was detected between proton pump inhibitors use and the risk of dementia in Europe (HR = 1.46, 95% CI = 1.23-1.73) and among participants aged ≥ 65 years (HR = 1.39, 95% CI = 1.17-1.65). For the factor follow-up time ≥ 5 years, the pooled HR was 1.28 (95% CI = 1.12-1.46), demonstrating a 1.28-fold increase in the risk of dementia among proton pump inhibitors users. In the case of regional impact, participants from Europe showed an overall pooled HR estimate of 1.46 (95% CI = 1.23-1.73). There was no evidence of publication bias.

CONCLUSIONS

The overall result of this meta-analysis supports the hypothesis that proton pump inhibitors increase the risk of dementia. Furthermore, high-quality cohort studies are needed to confirm these findings.

Association Between the Use of Antihyperglycemic Drugs and Dementia Risk: A Case-Control Study

BACKGROUND

There is a conflicting literature on the association between the use of antihyperglycemic drugs and dementia risk.

OBJECTIVE

The goal of this case-control study was to analyze the association between the use of antihyperglycemic drugs and dementia risk in patients followed in general practices in Germany.

METHODS

This study included patients with type 2 diabetes mellitus who had received a first dementia diagnosis in 972 general practices in Germany between January 2013 and December 2017 (index date). Controls without dementia were matched (1:1) to cases by age, gender, index year, and physician. Two multivariate regression models were used to study the association between the use of antihyperglycemic drugs and dementia risk. Model 1 included all antihyperglycemic drugs prescribed to patients regardless of the prescription duration, whereas Model 2 only included the longest therapy prescribed to each patient.

RESULTS

There were 8,276 diabetes patients with dementia and 8,276 diabetes patients without dementia included in this study. In Model 1, glitazones were associated with a decreased dementia risk (odds ratio [OR] = 0.80), whereas insulin was associated with an increased risk of developing the condition (OR = 1.34). In Model 2, metformin, prescribed as monotherapy (OR = 0.71) or as dual therapy with sulfonylureas (OR = 0.90), was associated with a decrease in the likelihood of subsequently being diagnosed with dementia. By contrast, the combination of basal insulin and bolus insulin (OR = 1.47) and premix insulin (OR = 1.33) were risk factors for dementia.

CONCLUSION

Metformin and glitazones were negatively associated with dementia, while insulin was positively associated with dementia.

Drug interactions with dementia-related pathophysiological pathways worsen or prevent dementia

Many risk factors are known to induce or precipitate dementia. Drugs acting via different mechanisms can modulate cognitive performance and exert either beneficial or deleterious effects on cognition through functional or neuropathological mechanisms. This review discusses the association between several classes of drugs and cognitive impairment and dementia risk. These drugs can be divided into drugs targeting CNS disorders (e.g., anticholinergic drugs, antiepileptics, antipsychotics, benzodiazepines, and opioids) and drugs targeting non‐CNS disorders (e.g., antidiabetics, antihypertensives, proton pump inhibitors, and statins). Furthermore, we sought to highlight the pharmacological mechanisms underlying their possible detrimental or beneficial effects on cognition. Anticholinergic and antiepileptic drugs were excluded from this review because their effects on cognition are well known. Studies investigating benzodiazepines have revealed an increased risk of dementia. Conclusions on dementia risk or cognitive impairment regarding opioids and antipsychotic drugs are difficult to draw. These different classes appear to impair cognition not by a single clear mechanism of action specific to each class but by several relatively interdependent and interconnected mechanisms (e.g., impaired neurotransmission, neuroinflammation, neuronal death, oxidative stress, or interactions with dementia‐related pathways). The dementia risk initially associated with the use of proton pump inhibitors might have been overestimated. In contrast, statins, antihypertensive medications, and antidiabetics could potentially decrease the risk of dementia and cognitive impairment by acting in ways opposite to the mechanisms cited above.

Linked Articles

This article is part of a themed section on Therapeutics for Dementia and Alzheimer's Disease: New Directions for Precision Medicine. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v176.18/issuetoc

Proton pump inhibitor use does not increase dementia and Alzheimer's disease risk: An updated meta-analysis of published studies involving 642305 patients

Recent studies have indicated an increased risk of dementia and Alzheimer’s disease (AD) among people who consume proton pump inhibitors (PPIs), but the results of those studies are inconsistent. This meta-analysis aimed to explore the correction risk of dementia and AD among PPI users. The literature search for relevant studies was conducted in PubMed, Web of Science, EMBase and ScienceDirect. Pooled hazard ratio (HR) and 95% confidence intervals (CIs) were used to assess the relationship between the PPIs and risk of dementia and AD. Ten independent studies that involved 642305 participants were included in this meta-analysis. PPI users were unassociated with dementia (HR = 1.04, 95% CI 0.92–1.15; I² = 95.6%, p < 0.001) and AD (HR = 0.96, 95% CI 0.83–1.09; I² = 80.7%, p <0 .001). No evidence of publication bias was detected by Begg’s and Egger’s test. Sensitivity analyses showed no important differences in the estimates of effects. The current evidence indicates that PPI use does not increase dementia and AD risk. The remarkable heterogeneity among the studies warrants a further review of our findings.

Does Long-Term Proton Pump Inhibitor Use Increase Risk of Dementia? Not Really! Results of the Group-Based Trajectory Analysis

Conflicting data of the potential association between proton pump inhibitors (PPIs) and risk of dementia have been reported. This study aimed to examine the subsequent risk of incident dementia in older adults by categorizing subjects into different trajectories of longitudinal PPI use. A group-based trajectory modeling was used to identify distinct groups with regard to longitudinal PPI use over 3 years and to further examine the association between the trajectories of PPI use and dementia in a 5-year follow-up. Among 10,533 older adults who initiated PPIs, three distinct trajectories of longitudinal PPI use were identified: short-term (n = 7,406, 70.3%), intermittent (n = 1,528, 14.5%), and long-term users (n = 1,599, 15.2%). Long-term (hazard ratio (HR) = 0.99 (95% confidence interval (CI), 0.93-1.17)) and intermittent PPI users (HR = 0.91 (95% CI, 0.76-1.09)) were not associated with an increased risk of incident dementia compared with short-term users. Regardless of pattern of use, PPIs did not appear to significantly increase the risk of dementia over a mean follow-up period of 4 years.

Diagnosing dementia and cognitive dysfunction in the elderly in primary health care: A systematic review

Dementia is a public health issue making the screening and diagnosing of dementia and its prodromal phases in all health settings imperative.

OBJECTIVE

using PRISMA, this systematic review aimed to identify how low-, middle-, and high-income countries establish dementia and cognitive dysfunction diagnoses in primary health care.

METHODS

studies from the past five years in English, Spanish, and Portuguese were retrieved from Scopus, PubMed, Embase, Lilacs, Scielo, and Web of Science. Of 1987 articles, 33 were selected for analysis.

RESULTS

only three articles were from middle-income countries and there were no studies from low-income countries. The most used instrument was the Mini-Mental State Examination (MMSE). Mild Cognitive Impairment (MCI) and dementia criteria were based on experts' recommendation as well as on the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD-10), respectively.

CONCLUSION

differences between these criteria among high- and middle-income countries were observed.

PPI Long Term Use: Risk of Neurological Adverse Events?

The purpose of this review study is to reveal a potential threat of one type of such widely used and freely distributed drugs, which are proton pump inhibitors that might be the cause of the onset of both dementia and depression. The authors performed a literature review of available studies on the research topic describing the adverse effect of proton pum inhibitors (PPIs) (omeprazole, esomeprazole, lansoprazole, dexlansoprazole, rabeprazole, pantoprazole, dexrabeprazole, ilaprazole). For a long time, PPIs were considered to be completely safe drug substances for both short and long-term use. In recent years, there have been a few contradictory studis of absolute safety, especially in patients, who have long been using PPIs. At this time when depression and dementia are rising in the population, this is a very worrying fact that needs to be highlighted, and which needs to be carefully studied and evaluated, ideally trying to prevent it. The findings of most research studies described in this review indicate that there is a direct association between the onset of dementia and depression on one side and the long-term use of PPIs on the other.

A Nationwide Population-Based Cohort Study of Dementia Risk Among Acid Suppressant Users

OBJECTIVE

Data regarding the potential link between acid suppressant use and dementia are inconsistent. This study assessed the association between cumulative exposure to proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) and dementia risk among Korean adults.

DESIGN AND METHODS

A population-based longitudinal study was conducted using the Korean National Health Insurance Corporation claims database merged with national health examination data for 2002-2013. The study cohort included 70,529 subjects who were dementia-free in 2007. Incident dementia was assessed throughout follow-up until 2013. Exposure to acid suppressants prior to 2007 was assessed using a standardized defined daily dose system. Potential associations between acid suppressant use and dementia risk were analyzed using time-dependent Cox regression estimated hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

There were 1,297 cases of dementia during the study period. Multivariate analyses identified several factors associated with dementia risk: old age, female, current smoker, Type 2 diabetes, comorbidities, and use of nonaspirin nonsteroidal anti-inflammatory drugs. H2RA users had a significantly increased risk of dementia compared with non-H2RA users (HR 1.31, 95% CI 1.13-1.51), whereas PPI use was not associated with increased risk.

CONCLUSION

Our results indicate that exposure to H2RAs (but not PPIs) is associated with increased dementia risk. Further randomized controlled trials and basic research examining the underlying mechanism are needed to confirm this association.