Comparison of Safety and Effectiveness Between Direct Oral Anticoagulants and Vitamin K Antagonists in Dementia Patients with Atrial Fibrillation: A Systematic Review and Meta-Analysis

<b>Background/Objectives</b>: The question of whether the benefits of anticoagulation outweigh the risks of bleeding in patients with dementia and atrial fibrillation (AF) remains unresolved. This study aimed to evaluate the effectiveness of oral anticoagulation (OAC) and to compare the safety and effectiveness of direct oral anticoagulants (DOACs) with vitamin K antagonists (VKAs) within this at-risk population. <b>Methods</b>: This meta-analysis was conducted following the PRISMA guidelines and was registered in PROSPERO. Data were extracted from MEDLINE, Web of Science, and Cochrane Library. The Newcastle-Ottawa Scale was used to assess the risk of bias. The outcomes were analyzed using the Comprehensive Meta-Analysis software, with odds ratios (ORs) and 95% confidence intervals (CIs) calculated for dichotomous variables. <b>Results</b>: Eight retrospective studies were included, with sample sizes of up to 40,350 participants. The primary outcome was mortality incidence, while secondary outcomes included ischemic stroke, major bleeding, and intracranial hemorrhage (ICH). DOACs significantly reduced ICH events compared to VKAs (OR 0.38, 95% CI 0.17-0.84; I² = 87.3%) but showed no significant difference in major bleeding (OR 0.48, 95% CI 0.22-1.03; I² = 88%). Mortality and ischemic stroke rates were similar between the DOAC and VKA groups. OAC use reduced mortality by 29% compared to no OAC (OR 0.71, 95% CI 0.57-0.88; I² = 81.3%) but increased major bleeding risk (OR 1.19, 95% CI 1.08-1.3; I² = 0%). <b>Conclusions</b>: DOACs offer a safer profile regarding ICH in dementia patients with AF compared to VKAs, with no significant differences in mortality or ischemic stroke rates. This study highlights the need for careful anticoagulant selection in this vulnerable population.