Proton Pump Inhibitors in Geriatric and Hospice Populations: Balancing Benefit and Burden

Proton pump inhibitors (PPIs) are among the most commonly prescribed medications worldwide. While their short-term efficacy in managing acid-related disorders is well established, their long-term use—especially in older adults and hospice patients—raises important concerns about safety, necessity, and alignment with patient-centered goals of care. As palliative and hospice professionals, we are uniquely positioned to critically evaluate the role of PPIs in these vulnerable populations and lead deprescribing efforts when appropriate.

The Perils of Chronic PPI Use

PPIs are often started during hospitalizations or after transient episodes of dyspepsia, reflux, or gastrointestinal bleeding. However, these prescriptions are frequently continued indefinitely, even when the initial indication has resolved. This practice contributes to chronic use in populations least equipped to bear the long-term risks.

In older adults, extended use of PPIs has been linked to a range of adverse outcomes:

- Nutritional deficiencies, including vitamin B12, magnesium, calcium, and iron, stemming from impaired absorption due to reduced gastric acidity.

- Bone fractures, particularly of the hip, wrist, and spine, attributed to impaired calcium metabolism and potential direct effects on bone density.

- Infectious complications, such as Clostridioides difficile and community-acquired pneumonia, due to suppression of gastric acid's natural antimicrobial properties.

- Kidney disease, including acute interstitial nephritis and increased risk of chronic kidney disease, often unrecognized until irreversible damage has occurred.

- Potential cognitive decline, as some observational studies have suggested a link between long-term PPI use and dementia—though causality remains unproven.

These risks are particularly significant in frail, poly-medicated older adults who may not have a strong ongoing indication for acid suppression therapy. As a result, organizations such as the American Geriatrics Society have included chronic PPI use without clear indication in the Beers Criteria for potentially inappropriate medications in older adults.

Rational Use in Geriatric Care

In geriatric patients, PPI prescriptions should be regularly reviewed with a focus on the original indication and whether continued use is justified. For example:

- Uncomplicated GERD or dyspepsia typically requires only 4–8 weeks of therapy.

- NSAID-induced ulcer prophylaxis is only needed during concurrent NSAID use in high-risk patients.

- H. pylori eradication regimens require PPIs for no more than 14 days.

Maintenance therapy may be appropriate for select high-risk conditions, such as erosive esophagitis, Barrett’s esophagus, or severe GERD refractory to step-down therapy. However, even in these cases, the lowest effective dose should be used, and the necessity of therapy should be revisited periodically.

When deprescribing, tapering may be advisable to prevent rebound acid hypersecretion. This can include dose reduction followed by transition to H2 blockers or antacids as needed.

Hospice Considerations: Comfort Over Prevention

In the hospice setting, medication decisions should be rooted in the patient’s symptom burden and goals of care. Preventive and maintenance medications should be discontinued unless they directly contribute to comfort or dignity in dying.

PPIs may have a role in hospice if a patient is experiencing:

- Painful esophagitis or gastritis

- Refractory nausea or vomiting due to acid reflux

- Gastric acid-related complications of malignancy or treatment (e.g., gastric outlet obstruction, gastroparesis)

In these scenarios, PPIs can improve quality of life. However, if the patient is asymptomatic, has discontinued high-risk medications like NSAIDs or steroids, or is approaching end of life with no active GI distress, PPIs can and often should be discontinued.

Hospice professionals are also challenged by pill burden and polypharmacy, particularly in patients with dysphagia or cognitive impairment. Every additional medication increases the risk of adverse events, non-adherence, and caregiver burden. Streamlining regimens by stopping non-essential drugs—including PPIs when appropriate—can significantly enhance the patient’s comfort and autonomy.

A Practical Approach to Deprescribing

Deprescribing PPIs in geriatric and hospice patients involves several key steps:

1. Identify the original indication for PPI use. If unclear or resolved, this supports discontinuation.

2. Assess for ongoing symptoms. If the patient is asymptomatic, consider a trial of tapering or discontinuation.

3. Discuss risks and benefits with patients, families, or surrogate decision-makers. Emphasize the goal of simplifying care and enhancing comfort.

4. Monitor for symptom recurrence. In some cases, symptoms may rebound transiently but can often be managed with H2 blockers or lifestyle adjustments.

5. Collaborate with the interdisciplinary team. Nurses, pharmacists, and other providers can support medication review, education, and follow-up.

Conclusion

Proton pump inhibitors, while effective, are not benign. In older adults and patients receiving hospice care, the potential harms of chronic use—nutritional deficiencies, bone fractures, kidney injury, and infections—often outweigh the benefits when no active GI pathology is present. Palliative and hospice professionals play a pivotal role in aligning medication use with individualized goals, prioritizing symptom management, and advocating for deprescribing when appropriate.

By carefully evaluating PPI use, initiating conversations about deprescribing, and monitoring for symptoms, we can ensure that these medications serve their purpose: to relieve suffering, not to prolong risk or burden at the end of life.

References

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