Do statins (HMG-CoA reductase inhibitors) increase the risk of vascular hospitalization in patients with dementia?

Statins and Vascular Hospitalization Risk in Dementia

No, statins do not raise vascular hospitalization risk in dementia according to established cardiovascular guidelines, though one recent 2025 observational study from German nursing homes contradicts this—however, this single study should not override decades of high-quality evidence showing cardiovascular benefit and no cognitive harm from statins. 1, 2

The Contradictory Evidence

The 2025 Stroke study found that statin use was associated with increased risk of cardiovascular/cerebrovascular hospitalization in nursing home residents with dementia (HR 1.06,95% CI 1.01-1.12), with higher risks seen with moderate-to-high intensity statins and newly prescribed statins. 3 This finding is concerning and represents the most recent data specifically examining this question.

However, this single observational study has critical limitations:

• Confounding by indication: Patients prescribed statins likely had higher baseline cardiovascular risk that wasn't fully captured by propensity score matching 3
• Reverse causation: Newly prescribed statins showed dramatically elevated risk (HR 2.71), suggesting these patients were started on statins because they were becoming sicker 3
• Nursing home population: These are the frailest elderly with advanced dementia and limited life expectancy, not representative of most dementia patients 3

What the Guidelines Actually Say

The American Diabetes Association, American College of Cardiology, and European Society of Cardiology all agree that statins should be used for cardiovascular risk reduction in patients with established atherosclerotic disease, regardless of dementia status. 4, 1, 2

For Secondary Prevention (Established CVD):

• Statins are strongly recommended in patients with prior MI, ACS, stroke, or peripheral artery disease to prevent cardiovascular events, even in those with dementia 4
• The European guidelines explicitly state that ischemic cerebrovascular disease merits the same lipid treatment as coronary disease 4
• This recommendation is based on proven mortality reduction in high-quality randomized trials 4

For Primary Prevention:

• Statins should be used according to standard cardiovascular risk assessment 4
• The presence of dementia alone does not change cardiovascular risk stratification 1, 2

The Cognitive Safety Evidence

Multiple lines of high-quality evidence demonstrate that statins do NOT cause cognitive decline or dementia:

• Three large randomized placebo-controlled trials with specific cognitive testing showed no differences between statin and placebo groups 4, 1, 2
• The FDA's systematic review of postmarketing surveillance, RCTs, and observational studies found no adverse cognitive effects 4, 1
• Studies with PCSK9 inhibitors achieving very low LDL levels showed no cognitive impairment 4, 1
• A 2016 Cochrane review of 26,340 participants found statins do not prevent OR cause dementia 5

Reconciling the Evidence

The 2025 nursing home study likely reflects:

1. Indication bias: Sicker patients with more vascular disease get prescribed statins 3
2. Frailty and polypharmacy: Nursing home residents with advanced dementia may not benefit from preventive therapies due to limited life expectancy 3
3. Competing risks: In end-stage dementia, cardiovascular prevention becomes less relevant 6

Meanwhile, observational studies in community-dwelling elderly show the opposite:

• A 2013 Italian study found long-term statin use reduced dementia hospitalization risk by 25-28% with >2 years of use 7
• A 2020 meta-analysis of 30 observational studies (9.1 million participants) found statins reduced all-cause dementia risk (RR 0.83) 8

Clinical Algorithm for Statin Use in Dementia

Continue or Start Statins If:

• Established atherosclerotic CVD (prior MI, stroke, PAD, ACS) - this is a Class I indication regardless of dementia 4
• High cardiovascular risk based on standard risk calculators 4, 1
• Life expectancy >2-3 years and patient is not in end-stage dementia 6, 3

Consider Stopping Statins If:

• Advanced dementia in nursing home setting with limited life expectancy (<1 year) 3
• Newly diagnosed dementia with no prior CVD and low cardiovascular risk 3
• Patient/family goals shift to comfort-focused care 6

Do NOT Stop Statins Because of:

• Fear of cognitive decline - this is not supported by evidence 4, 1, 2
• Presence of dementia alone - dementia does not negate cardiovascular benefit in those with established disease 4

Critical Caveats

The cardiovascular benefits of statins in secondary prevention are so robust that they outweigh theoretical concerns from a single observational study. 4 For every 255 patients treated with statins for 4 years, 5.4 cardiovascular events are prevented. 4

The key distinction is between:

• Community-dwelling dementia patients with CVD → Continue statins 4
• Nursing home residents with advanced dementia → Reassess goals of care 3

Statins should be used at appropriate intensity based on cardiovascular indication, not dementia status. 4 The 2025 study's finding of increased risk with higher intensity statins likely reflects confounding by indication (sicker patients get higher doses), not a true dose-response harm. 3