A systematic review and meta-analysis were conducted to assess the association between cognitive impairment and medication non-adherence in stroke patients. Nine studies were included, with varying measures of cognitive impairment (dementia diagnosis, standardized assessments) and medication adherence (self-report, administrative data). The majority of studies had medium risk of bias, with two having low risk. The overall evidence quality was low due to substantial heterogeneity (I² = 90.9%, p < 0.001). When all studies were pooled, there was no significant association between cognitive impairment and medication non-adherence (OR 0.85, 95% CI 0.66–1.03). However, heterogeneity was high, and results were mixed. Sensitivity analyses revealed no consistent association, with some studies suggesting a reduced likelihood of non-adherence with cognitive impairment. The study highlights the need for standardized and objective assessments to clarify the relationship between cognitive impairment and medication adherence in stroke patients. Limitations include small sample sizes, varying study populations, and potential biases. The findings suggest that further research is needed to better understand the impact of cognitive impairment on medication adherence in stroke patients.A systematic review and meta-analysis were conducted to assess the association between cognitive impairment and medication non-adherence in stroke patients. Nine studies were included, with varying measures of cognitive impairment (dementia diagnosis, standardized assessments) and medication adherence (self-report, administrative data). The majority of studies had medium risk of bias, with two having low risk. The overall evidence quality was low due to substantial heterogeneity (I² = 90.9%, p < 0.001). When all studies were pooled, there was no significant association between cognitive impairment and medication non-adherence (OR 0.85, 95% CI 0.66–1.03). However, heterogeneity was high, and results were mixed. Sensitivity analyses revealed no consistent association, with some studies suggesting a reduced likelihood of non-adherence with cognitive impairment. The study highlights the need for standardized and objective assessments to clarify the relationship between cognitive impairment and medication adherence in stroke patients. Limitations include small sample sizes, varying study populations, and potential biases. The findings suggest that further research is needed to better understand the impact of cognitive impairment on medication adherence in stroke patients.