Postoperative cognitive dysfunction remains a significant concern for surgical patients, particularly among older adults and individuals with preexisting vulnerabilities. Although its mechanisms are multifactorial and not fully understood, growing evidence suggests that inflammation, anesthetic effects, perioperative hemodynamic instability, and patient-specific factors all contribute to the condition. Reducing the risk of postoperative cognitive dysfunction requires a coordinated approach that begins in the preoperative period and extends through intraoperative management and postoperative recovery, emphasizing prevention, early detection, and tailored intervention.
In the preoperative period, identifying patients with baseline cognitive impairment, frailty, sleep disorders, depression, or polypharmacy provides an opportunity to address modifiable contributors before surgery. Optimizing chronic medical conditions, particularly cardiovascular and metabolic diseases, can help stabilize cerebral perfusion and reduce susceptibility to perioperative insults. Prehabilitation strategies, including exercise, nutritional optimization, and cognitive engagement, are increasingly recognized for their potential to improve physiologic reserve and lessen postoperative cognitive decline. Informed conversations about expectations and risks also allow clinicians to tailor anesthetic and surgical plans to the patient’s neurologic vulnerability.
Intraoperative management helps reduce the risk of postoperative cognitive dysfunction. Avoidance of excessive depth of anesthesia, guided by brain function monitoring when appropriate, may reduce exposure to unnecessarily high concentrations of anesthetic agents. Maintaining stable hemodynamics is essential, as hypotension can compromise cerebral perfusion, particularly in patients with impaired autoregulation. Attention to oxygenation, ventilation, and glucose control further supports neurologic stability. The choice of anesthetic technique may influence postoperative cognition, although evidence remains mixed. Some patients may benefit from regional anesthesia, lighter sedation, or multimodal analgesia when clinically appropriate. Equally important is minimizing exposure to deliriogenic medications such as benzodiazepines and anticholinergics, especially in older adults.
Postoperative care focuses on early recognition of cognitive changes and aggressive prevention of delirium, which is strongly associated with longer-term cognitive impairment. Regular cognitive assessments can help establish recovery trajectories and identify deviations that warrant intervention. Multimodal nonpharmacologic strategies remain the cornerstone of delirium prevention. Adequate pain control, sleep hygiene, early mobilization, hydration, and frequent orientation reinforce neurologic stability and reduce
the likelihood of confusion or agitation. Involving family members or caregivers as part of reorientation and support strategies can be especially effective. When medications are necessary for severe agitation or safety concerns, the lowest effective dose and shortest duration should be used to avoid exacerbating cognitive impairment.
Because undertreated pain and excessive sedation can worsen cognitive outcomes, pain management should be given adequate attention. Multimodal analgesia tailored to minimize opioid exposure can help maintain cognitive clarity while preventing delirium associated with uncontrolled discomfort. Regional anesthesia and non-opioid analgesics often enable more stable postoperative cognition, although these choices must be individualized to surgical and patient-specific considerations.
Finally, sustained follow-up is important because postoperative cognitive dysfunction can persist for weeks or months. Early outpatient evaluation provides an opportunity to reinforce recovery strategies, monitor for improvement, and initiate referrals to neuropsychology, geriatrics, or rehabilitation services when cognitive symptoms interfere with daily function. Interprofessional collaboration across anesthesiology, surgery, nursing, geriatrics, and rehabilitation medicine strengthens continuity of care and enhances overall outcomes.
Reducing the risk of postoperative cognitive dysfunction hinges on anticipating vulnerability, preventing potentially reversible insults, and responding promptly to early signs of decline. As research continues to refine our understanding of its mechanisms and predictors, comprehensive perioperative strategies rooted in vigilance and individualized care remain the most effective means of protecting cognitive health in surgical patients.