Anticoagulation in Atrial Fibrillation and Dementia

The co-occurrence of atrial fibrillation (AF) and dementia is increasingly common in aging populations. Anticoagulants reduce the risk of thromboembolic events associated with AF, but they introduce an increased risk of severe bleeding, adherence concerns, and questionable net benefit in the very elderly. This narrative review evaluates the existing literature on anticoagulation in the subset of patients with AF and dementia and aims to clarify clinical guidance on managing AF alongside bleeding risk concerns. Observational cohort studies, meta-analyses, and registry data were analyzed. Multiple large cohort studies support anticoagulation in patients with mild-to-moderate dementia. Advanced dementia populations show more mixed outcomes, though most studies still find neutral to modestly beneficial mortality effects. Direct oral anticoagulants may be preferable to warfarin due to ease of use and lower risk of intracranial hemorrhage. Notably, existing randomized controlled trials on the effects of anticoagulation in AF do not include dementia subgroups. In conclusion, anticoagulation appears to offer a net mortality benefit in patients with AF and early-stage dementia, but its use in very elderly patients with advanced dementia requires cautious, individualized consideration of patient goals and risk/benefit profile. Further research, including RCTs with dementia subgroups and quality-of-life endpoints, is urgently needed.