Key result
Dementia was associated with lower oral anticoagulant use and higher bleeding risk, but no difference in embolic events, MI, or death.
Why the study?
Does the prevalence, safety, and effectiveness of oral anticoagulant use differ between people with and without dementia or cognitive impairment?
Systematic Review
Does the prevalence, safety, and effectiveness of oral anticoagulant use differ between people with and without dementia or cognitive impairment?
Patients with dementia are less likely to receive oral anticoagulants and experience higher bleeding risks and poorer anticoagulation control when treated with warfarin compared to those without dementia.
Answers are grounded in this paper and cite their sources.
Does not support withholding anticoagulation in dementia despite higher bleeding; leaves open randomized trials to assess net benefit.
BACKGROUND: Differences in management and outcomes of oral anticoagulant (OAC) use may exist for people with and without dementia or cognitive impairment (CI). OBJECTIVE: To systematically review the prevalence and safety and effectiveness outcomes of OAC use in people with and without dementia or CI. METHODS: MEDLINE, EMBASE, and CINAHL were searched for studies reporting prevalence or safety and effectiveness outcomes of OAC use for people with and without dementia, published between 2000 to September 2017. Study selection, data extraction, and quality assessment were performed by two reviewers. RESULTS: studies met pre-specified inclusion criteria (21 prevalence studies, 6 outcomes studies). People with dementia had 52% lower odds of receiving OAC compared to people without dementia. Mean OAC prevalence was 32% for people with dementia, compared to 48% without dementia. There was no difference in the composite outcome of embolic events, myocardial infarction, and all-cause death between dementia and non-dementia groups (adjusted hazard ratio (HR) 0.72, 95% CI, 0.45-1.14, p = 0.155). Bleeding rate was lower for people without dementia (HR 0.56, 95% CI, 0.37-0.85). Adverse warfarin events were more common for residents of long-term care with dementia (adjusted incidence rate ratio 1.48, 95% CI, 1.20-1.82). Community-dwelling people with dementia treated with warfarin had poorer anticoagulation control than those without dementia (mean time in therapeutic range (TTR) % ±SD, 38±26 (dementia), 61±27 (no dementia), p < 0.0001). CONCLUSION: A lower proportion of people with dementia received oral anticoagulation compared with people without dementia. People with dementia had higher bleeding risk and poorer anticoagulation control when treated with warfarin.
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Fanning et al. (2018) conducted a systematic review in Dementia or cognitive impairment requiring oral anticoagulants. Dementia or cognitive impairment vs. No dementia or cognitive impairment was evaluated on composite outcome of embolic events, myocardial infarction, and all-cause death (HR 0.72, 95% CI 0.45-1.14, p=0.155). Dementia was associated with lower oral anticoagulant use and higher bleeding risk, but no difference in embolic events, MI, or death.
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