Risk factors for early postoperative cognitive dysfunction after non-coronary bypass surgery in Chinese population

Serum proteomics study on cognitive impairment after cardiac valve replacement surgery: a prospective observational study

Objective

The incidence of perioperative neurocognitive disorders (PND) is high, especially after cardiac surgeries, and the underlying mechanisms remain elusive. Here, we conducted a prospective observational study to observe serum proteomics differences in PND patients after cardiac valve replacement surgery.

Methods

Two hundred and twenty-six patients who underwent cardiac valve surgery were included. They were categorized based on scoring into non-PND group (group non-P) and PND group (group P'). The risk factors associated with PND were analyzed. These patients were further divided into group C and group P by propensity score matching (PSM) to investigate the serum proteome related to the PND by serum proteomics.

Results

The postoperative 6-week incidence of PND was 16.8%. Risk factors for PND include age, chronic illness, sufentanil dosage, and time of cardiopulmonary bypass (CPB). Proteomics identified 31 down-regulated proteins and six up-regulated proteins. Finally, GSTO1, IDH1, CAT, and PFN1 were found to be associated with PND.

Conclusion

The occurrence of PND can impact some oxidative stress proteins. This study provided data for future studies about PND to general anaesthesia and surgeries.

Association of reduced cerebrospinal fluid NPTX2 levels with postoperative delirium in patients undergoing knee/hip replacement: a prospective cohort study

BACKGROUND

Postoperative delirium (POD) is a common complication with poor prognosis in the elderly, but its mechanism has not been fully elucidated. There is evidence that the changes in synaptic activity in the brain are closely related to the occurrence of POD. And neuronal pentraxin 2 (NPTX2) can regulate synaptic activity in vivo.

AIMS

This study aims to explore whether decreased NPTX2 levels affects POD and whether the cerebrospinal fluid (CSF) biomarkers of POD mediate this association.

METHODS

In this prospective cohort study, we interviewed patients with knee/hip replacement 1 day before surgery to collect patient information and assess their cognitive function. CSF was extracted for measuring the CSF levels of NPTX2 and other POD biomarkers on the day of surgery. And postoperative follow-up visits were performed 1-7 days after surgery.

RESULTS

Finally, 560 patients were included in the study. The patients were divided into POD group and NPOD (non-POD) group. The POD group had a median age of 80 years, a female proportion of 45%, a median BMI of 24.1 kg/m2, and a median years of education of 9 years. The Mann-Whitney U test showed that CSF NPTX2 levels were significantly lower in POD group, compared with the NPOD group (P < 0.05). Univariate binary logistic regression analysis showed that reduced CSF levels of NPTX2 protected against POD (crude OR = 0.994, 95% CI 0.993-0.995, P < 0.001). The receiver-operating characteristic (ROC) curve indicated that CSF NPTX2 level had high predictive value for POD. Mediation analyses showed that CSF T-tau (mediating proportion = 21%) and P-tau (mediating proportion = 29%) had significant mediating effects on the association between CSF NPTX2 and POD.

CONCLUSION

CSF NPTX2 levels were associated with the occurrence of POD. Low CSF NPTX2 levels may be an independent protective factor for POD. CSF T-tau and P-tau could mediate the association between CSF NPTX2 and POD occurrence.

CLINICAL TRIAL REGISTRATION

The trial registration number (TRN): ChiCTR2200064740, Date of Registration: 2022-10-15.

Sevoflurane anesthesia reduces the expression of inflammatory response genes and β-site amyloid precursor protein-cleaving enzyme in hippocampi of diabetic mice

Diabetes and inhaled anesthesia are associated with an increased likelihood of developing postoperative cognitive dysfunction in humans and animal models, but the mechanisms are unclear. This study aimed to investigate the effect and mechanism of sevoflurane anesthesia on cognitive function in diabetic (DM) mice. Spontaneously diabetic db/db and control db/m mice were subject to sevoflurane anesthesia or allowed to breathe air, respectively. The Morris water maze test as spatial learning and novel object recognition test as recognition memory were performed. The expression of inflammatory cytokines and neurotoxicity-related genes in the hippocampus of four groups was measured using real-time PCR. The expression level of neurotoxicity and neuroprotection-related proteins in DM mice hippocampus were estimated using Western blot assay. It is found that DM mice developed cognitive impairment; however, the cognitive impairment was not exacerbated in sevoflurane-exposed mice. Sevoflurane anesthesia led to a decrease in mRNA levels of inflammatory cytokines in DM mice hippocampi, including interleukin 17 (IL-17), C-C motif chemokine (CCL20), CCL7 as well as high mobility group box 1 and beta-site amyloid-β cleaving enzyme 1; and no effect was observed on the expression of neurotoxicity genes, including amyloid precursor protein, choline O-acetyltransferase, tumor necrosis factor, alpha-induced protein 1, B-cell lymphoma 2 and estrogen receptor 2. In addition, we observed elevated phosphorylation of cAMP response element-binding protein in DM mice exposed to sevoflurane anesthesia. In conclusion, sevoflurane did not exacerbate DM-associated cognitive impairment.

Postsurgery Subjective Cognitive and Short-Term Memory Impairment Among Middle-Aged Chinese Patients

Importance

Perioperative neurocognitive disorder, particularly postoperative cognitive impairment, is common and associated with multiple medical and social adversities, although data from China are lacking.

Objective

To examine the incidence, trajectory, and risk factors for subjective cognitive and short-term memory impairment after surgery in the Chinese population.

Design, Setting, and Participants

This cohort study used data from the China Surgery and Anesthesia Cohort to assess surgical patients aged 40 to 65 years from 2 medical centers between July 15, 2020, and March 31, 2023, with active follow-up within 1 year after the surgery. Of 11 158 patients who were successfully recruited (response rate, 94.4%), 10 149 participants were eligible and available for analysis. From this population, separate cohorts were constructed for analyzing subjective cognitive impairment (8105 noncardiac and 678 cardiac surgery patients) and short-term memory impairment (5246 noncardiac and 454 cardiac surgery patients).

Exposures

Twenty-four potential risk factors regarding comorbidities, preoperative psychological conditions, anesthesia- or surgery-related factors, and postsurgical events were included.

Main Outcomes and Measures

Outcomes included subjective cognitive function measured by the 8-Item Informant Interview to Differentiate Aging and Dementia (AD8; scores range from 0 to 8, with higher scores indicating more severe cognitive impairment) and short-term memory measured by the 3-Word Recall Test (TRT; scores range from 0 to 3, with lower scores indicating more severe short-term memory impairment) at 1, 3, 6, and 12 months after noncardiac and cardiac surgery. Generalized linear mixed models were used to identify risk factors associated with the presence of AD8 (score ≥2) or TRT (score <3) abnormality as well as the aggressively deteriorative trajectories of those cognitive measurements.

Results

For noncardiac surgery patients, the AD8 analysis included 8105 patients (mean [SD] age, 52.3 [7.1] years; 3378 [41.7%] male), and the TRT analysis included 5246 patients (mean [SD] age, 51.4 [7.0] years; 1969 [37.5%] male). The AD8 abnormality incidence rates after noncardiac surgery increased from 2.2% (175 of 8105) at 7 days to 17.1% (1059 of 6191) at 6 months after surgery, before appearing to decrease. In contrast, the TRT abnormality incidence rates followed a U-shaped pattern, with the most pronounced incidence rates seen at 7 days (38.9% [2040 of 5246]) and 12 months (49.0% [1394 of 2845]). Similar patterns were seen among cardiac surgery patients for the AD8 analysis (678 patients; mean [SD] age, 53.2 [6.3] years; 393 [58.0%] male) and TRT analysis (454 patients; mean [SD] age, 52.4 [6.4] years; 248 [54.6%] male). Among noncardiac surgery patients, the top risk factors for aggressively deteriorative AD8 trajectory and for AD8 abnormality, respectively, after surgery were preoperative sleep disturbances (Pittsburgh Sleep Quality Index ≥16 vs 0-5: odds ratios [ORs], 4.04 [95% CI, 2.20-7.40] and 4.54 [95% CI, 2.40-8.59]), intensive care unit stay of 2 days or longer (ORs, 2.43 [95% CI, 1.26-4.67] and 3.07 [95% CI, 1.67-5.65]), and preoperative depressive symptoms (ORs, 1.76 [95% CI, 1.38-2.24] and 2.23 [95% CI, 1.79-2.77]). Analyses for TRT abnormality and trajectory, as well as the analyses conducted among cardiac surgery patients, found fewer associated factors.

Conclusions and Relevance

This cohort study of middle-aged Chinese surgery patients found subjective cognitive and short-term memory impairment within 12 months after both cardiac and noncardiac surgery, with multiple identified risk factors, underscoring the potential of preoperative psychological interventions and optimized perioperative management for postoperative cognitive impairment prevention.

Safety and efficacy of etomidate in combination with oxycodone in painless gastroscopic procedures in the elderly: A prospective randomized controlled trial study

OBJECTIVE

Etomidate is often combined in rapid succession during induction of anesthesia. However, the effect of pretreatment with oxycodone on recovery of cognitive function and adverse effects has rarely been studied. We conducted a prospective randomized controlled trial to compare etomidate alone with etomidate combined with oxycodone in elderly patients undergoing painless gastroscopy.

METHODS

Hundred elderly patients undergoing painless gastroscopy were divided into a control and an observation group, with 50 cases in each group. The age, gender, height, weight, body mass index and American Society of Anesthesiologists physical status (I/II) of patients in both groups were recorded. The recovery of cognitive function was compared in both groups using the Neurobehavioral Cognitive Status Examination. Adverse events, including somatic motor reactions, hypotension, bradycardia, myocardial tremor, nausea and vomiting, and injection pain, were also recorded in both groups. Moreover, heart rate, peripheral capillary oxygen saturation, systolic blood pressure, and diastolic blood pressure were evaluated in the 2 groups at different time points.

RESULTS

A total of 100 patients were enrolled in this study. The demographic characteristics in the 2 groups were not significantly different (P > .05). Regarding the recovery of cognitive functions, more subjects in the observation group passed the memory, arithmetic and orientation test than in the control group (P < .05). Fewer adverse events such as dynamic body reactions, cardiac tremor, nausea and vomiting, and injection pain occurred in the observation group than in the control group (P < .05). During anesthesia and after awakening, the results of peripheral capillary oxygen saturation, systolic blood pressure and diastolic blood pressure were better in the observation group than in the control group (P < .05).

CONCLUSION

Etomidate in combination with oxycodone for painless gastroscopic operation in the elderly is a safe and effective anesthetic strategy.

Elevated serum alkaline phosphatase correlates with postoperative cognitive dysfunction: A retrospective cohort study based on STROBE statement

Little is known about the association between serum alkaline phosphatase (ALP) levels and postoperative cognitive dysfunction (POCD) after general anesthesia. Thus, we investigated the association of serum ALP levels with POCD in patients who underwent surgery with general anesthesia in a retrospective cohort study. We retrospectively collected data from patients who underwent surgery with general anesthesia between May 2016 and June 2020. Serum ALP activity was detected using a p-nitrophenyl phosphate assay. Pre-and postoperative cognitive function were evaluated using the Chinese version of the Mini-Mental State Examination. Univariate and multivariate logistic regression were used to explore the effect of ALP on cognitive function. The incidence of POCD was 13.5%. Compared with the control group, the POCD group had higher ALP levels. The neuropsychological test results suggested that the scores of most items were lower in the POCD group than in the non-POCD group. Univariate logistic regression indicated that increased ALP levels were significantly associated with cognitive dysfunction (odds ratio = 1.15, 95% confidence interval: 1.13-1.18, P = .000). Multivariate regression showed that elevated ALP was still associated with POCD after adjusting for confounding factors (odds ratio = 1.16, 95% confidence interval: 1.13-1.18, P = .000). The spline regression model indicated the dose-response associations between ALP level and POCD risk (P for nonlinear trend < .001). Our study indicated that elevated serum ALP was an independent predictive factor of POCD at the 3-month follow-up. The occurrence of POCD could be associated with inflammatory status.

Perioperative neurocognitive disorders: A narrative review focusing on diagnosis, prevention, and treatment

Perioperative neurocognitive disorders (NCDs) refer to neurocognitive abnormalities detected during the perioperative periods, including preexisting cognitive impairment, preoperative delirium, delirium occurring up to 7 days after surgery, delayed neurocognitive recovery, and postoperative NCD. The Diagnostic and Statistical Manual of Mental Disorders‐5th edition (DSM‐5) is the golden standard for diagnosing perioperative NCDs. Given the impracticality of using the DSM‐5 by non‐psychiatric practitioners, many diagnostic tools have been developed and validated for different clinical scenarios. The etiology of perioperative NCDs is multifactorial and includes predisposing and precipitating factors. Identifying these risk factors is conducive to preoperative risk stratification and perioperative risk reduction. Prevention for perioperative NCDs should include avoiding possible contributors and implementing nonpharmacologic and pharmacological interventions. The former generally includes avoiding benzodiazepines, anticholinergics, prolonged liquid fasting, deep anesthesia, cerebral oxygen desaturation, and intraoperative hypothermia. Nonpharmacologic measures include preoperative cognitive prehabilitation, comprehensive geriatric assessment, implementing fast‐track surgery, combined use of regional block, and sleep promotion. Pharmacological measures including dexmedetomidine, nonsteroidal anti‐inflammatory drugs, and acetaminophen are found to have beneficial effects. Nonpharmacological treatments are the first‐line measures for established perioperative NCDs. Pharmacological treatments are still limited to severely agitated or distressed patients.

A randomized trial: bispectral-guided anesthesia decreases incidence of delayed neurocognitive recovery and postoperative neurocognitive disorder but not postoperative delirium

BACKGROUND

Postoperative cognitive dysfunction (POCD), also known as delayed neurocognitive recovery (up to 30 days) and postoperative neurocognitive disorder (up to 12 months), is a frequent complication of the neurological system associated with poor outcome. This randomized controlled trial aimed to determine whether bispectral (BIS) monitoring is correlated with delayed neurocognitive recovery, postoperative neurocognitive disorder, or postoperative delirium (POD).

METHODS

Among 197 patients included in the study, 100 were assigned to the BIS group and 97 to the control group. The BIS index was kept at 40-60 in the BIS group, and the depth of anesthesia in the control group was maintained according to anesthetists' clinical experience. Cognitive function was evaluated from the 1^st-7^th day after the operation and the time of discharge, and at 1^st month, 6^th months, and 1 year after the operation.

RESULTS

The incidence of delayed neurocognitive recovery (3% vs. 21.6%, P<0.001, at 7^th day) (3% vs. 21.1%, P<0.001, at 1^st month) and postoperative neurocognitive disorder (6.2% vs. 21.3%, P=0.002, at 6^th month) (4.4% vs. 16.3%, P=0.009, at 1 year) were lower in the BIS group, while there was no significant difference in POD between the two groups (12% vs. 19.6%, P=0.144). The average value of intraoperative BIS was lower in the BIS group (43.75 vs. 50.69, P<0.001). The postoperative hospitalization time (9.99 vs. 12.41, P<0.001) and the mortality (5.4% vs. 14.4%, P=0.042) were significantly decreased, while satisfaction was higher in the BIS group (39% vs. 24.7%, P=0.009).

CONCLUSION

BIS decreases delayed neurocognitive recovery and postoperative neurocognitive disorder; however, it is not associated with POD. BIS monitoring could effectively lessen postoperative hospitalization and mortality and increase patient satisfaction.

Differential Effects of Sevoflurane Exposure on Long-Term Fear Memory in Neonatal and Adult Rats

It remains unclear whether exposure to sevoflurane produces different effects on long-term cognitive function in developing and mature brains. In the present study, Sprague-Dawley neonatal rats at postnatal day (PND) 7 and adult rats (PND 56) were used in all experiments. We performed fear conditioning testing to examine long-term fear memory following 4-h sevoflurane exposure. We assessed hippocampal synapse ultrastructure with a transmission electron microscope. Moreover, we investigated the effect of sevoflurane exposure on the expression of postsynaptic protein 95 (PSD-95) and its binding protein kalirin-7 in the hippocampus. We observed that early exposure to sevoflurane in neonatal rats impairs hippocampus-dependent fear memory, reduces hippocampal synapse density, and dramatically decreases the expressions of PSD-95 and kalirin-7 in the hippocampus of the developing brain. However, sevoflurane exposure in adult rats has no effects on hippocampus-dependent fear memory and hippocampal synapse density, and the expressions of PSD-95 and kalirin-7 in the adult hippocampus are not significantly altered following sevoflurane treatment. Our results indicate that sevoflurane exposure produces differential effects on long-term fear memory in neonatal and adult rats and that PSD-95 signaling may be involved in the molecular mechanism for early sevoflurane exposure-caused long-term fear memory impairment.

An Association Between C-Reactive Protein Levels and the Occurrence of Cognitive Dysfunction After Heart Valve Replacement

Background

Postoperative cognitive dysfunction (POCD) is defined as cognitive dysfunction related to inflammation after surgical procedures, which is common following cardiac surgery. Cognitive deficits are thought to result from a systemic inflammatory response. C-reactive protein (CRP) and other proinflammatory cytokines, which are released in response to inflammation, disrupt the blood–brain barrier and neurotransmission, resulting in POCD. This study aimed to determine the correlation between POCD and increased levels of CRP in patients who had undergone heart valve replacement.

Methods

This study comprised 32 patients with normal cognitive function undergoing heart valve replacement. The CRP levels were measured before surgery and on the second postoperative day, and cognitive function was examined via the Indonesian-adapted Montreal Cognitive Assessment (MOCA-INA) on the third postoperative day. Data were analyzed using Spearman correlation test.

Results

Of the 32 patients, 28 (87.5%) experienced POCD. The median level of CRP was 6.6 mg/dL (interquartile range: 4.0, 8.3 g/dL). According to Spearman correlation test, increased levels of CRP were significantly related to POCD following heart valve replacement (p = 0.003, r = 0.501). The receiver operating characteristic curve indicated that the CRP cutoff level was 3.345 mg/dL, and the sensitivity and specificity were 89.3% and 75%, respectively.

Conclusion

High expression level of CRP was correlated with POCD following heart valve replacement.

Lidocaine Reduces Sevoflurane Consumption and Improves Recovery Profile in Children Undergoing Major Spine Surgery

Background

Intravenous lidocaine administered during surgery improves postoperative outcomes; however, few studies have evaluated the relationship between intravenous lidocaine and volatile anesthetics requirements. This study assessed the effects of lidocaine treatment on sevoflurane consumption and postoperative consciousness disorders in children undergoing major spine surgery.

Material/Methods

Patients were randomly divided into 2 treatment groups: lidocaine and placebo (control). The lidocaine group received lidocaine as a bolus of 1.5 mg/kg over 30 min, followed by a continuous infusion at 1 mg/kg/h to 6 h after surgery. The following data were assessed: end-tidal sevoflurane concentration required to maintain a bispectral index BIS between 40 and 60, intraoperative blood pressure, heart rate, demand for fentanyl, and consciousness level assessed after surgery using the Richmond Agitation-Sedation Scale. Any treatment-related adverse events were recorded.

Results

Compared to the control group, lidocaine treatment reduced by 15% the end-tidal sevoflurane concentration required to maintain the intraoperative hemodynamic stability and appropriate level of anesthesia (P=0.0003). There were no intergroup differences in total dose of fentanyl used, average mean arterial pressure, or heart rate measured intraoperatively. The postoperative level of patient consciousness did not differ during the first 6 h between groups. After 9 h, more patients in the control group were still sleepy (P=0.032), and there were fewer perioperative complications in the lidocaine group.

Conclusions

Lidocaine treatment decreases sevoflurane consumption and improves recovery profiles in children undergoing major spine surgery.

A systematic review: comparative analysis of the effects of propofol and sevoflurane on postoperative cognitive function in elderly patients with lung cancer

Background

The potential risk for cognitive impairment following surgery and anesthesia is a common concern, especially in the elderly and more fragile patients. The risk for various neurocognitive effects is thus an area of importance. The independent impact of surgery and anesthesia is still not known. Likewise, the independent effect of different drugs used during anesthesia is a matter of debate, as is the number and amounts of drugs used and the “depth of anesthesia.” So, understanding the drug-related phenomenon and mechanisms for postoperative cognitive impairment is essential. This meta-analysis aims to compare the effects of propofol and sevoflurane anesthesia on postoperative cognitive function in elderly patients with lung cancer.

Methods

This study is a systematic review and meta-analysis for controlled clinical studies. Public-available online databases were searched to identify eligible randomized placebo-controlled trials or prospective cohort studies concerning the effects of propofol and sevoflurane on postoperative cognitive function. The primary endpoints are postoperative mini-mental state examination (MMSE) scores at various time points; the secondary endpoint is the serum S100beta concentration 24 h after surgery. Standard mean differences (SMDs) along with 95% confidence intervals (CIs) were extracted and analyzed using random or fixed-effects models. Analyses regarding heterogeneity, risk of bias assessment, and sensitivity were performed.

Results

We searched 1626 eligible publications and 14 studies of 1404 patients were included in the final analysis. The majority of included studies had been undertaken in Asian populations. Results suggested that propofol has a greater adverse effect on cognitive function in the elderly patients with lung cancer than sevoflurane. There were significant differences in issues of MMSE 6 h (11 studies; SMD -1.391, 95% CI -2.024, − 0.757; p < 0.001), MMSE 24 h (14 studies; SMD -1.106, 95% CI -1.588, − 0.624; p < 0.001), MMSE 3d (11 studies; SMD -1.065, 95% CI -1.564, − 0.566; p < 0.001), MMSE 7d (10 studies; SMD -0.422, 95% CI -0.549, − 0.295; p < 0.001), and serum S100beta concentration at 1 day after surgery (13 studies; SMD 0.746, 95% CI 0.475, 1.017; p < 0.001).

Conclusion

Propofol has a more significant adverse effect on postoperative cognitive function in elderly patients with lung cancer than sevoflurane.

State of the clinical science of perioperative brain health: report from the American Society of Anesthesiologists Brain Health Initiative Summit 2018

Cognitive recovery after anaesthesia and surgery is a concern for older adults, their families, and caregivers. Reports of patients who were 'never the same' prompted a scientific inquiry into the nature of what patients have experienced. In June 2018, the ASA Brain Health Initiative held a summit to discuss the state of the science on perioperative cognition, and to create an implementation plan for patients and providers leveraging the current evidence. This group included representatives from the AARP (formerly the American Association of Retired Persons), American College of Surgeons, American Heart Association, and Alzheimer's Association Perioperative Cognition and Delirium Professional Interest Area. This paper summarises the state of the relevant clinical science, including risk factors, identification and diagnosis, prognosis, disparities, outcomes, and treatment of perioperative neurocognitive disorders. Finally, we discuss gaps in current knowledge with suggestions for future directions and opportunities for clinical and translational projects.

Perspectives on ethnic and racial disparities in Alzheimer's disease and related dementias: Update and areas of immediate need

Alzheimer's disease and related dementias (ADRDs) are a global crisis facing the aging population and society as a whole. With the numbers of people with ADRDs predicted to rise dramatically across the world, the scientific community can no longer neglect the need for research focusing on ADRDs among underrepresented ethnoracial diverse groups. The Alzheimer's Association International Society to Advance Alzheimer's Research and Treatment (ISTAART; alz.org/ISTAART) comprises a number of professional interest areas (PIAs), each focusing on a major scientific area associated with ADRDs. We leverage the expertise of the existing international cadre of ISTAART scientists and experts to synthesize a cross-PIA white paper that provides both a concise "state-of-the-science" report of ethnoracial factors across PIA foci and updated recommendations to address immediate needs to advance ADRD science across ethnoracial populations.

Ropivacaine for Intercostal Nerve Block Improves Early Postoperative Cognitive Dysfunction in Patients Following Thoracotomy for Esophageal Cancer

BACKGROUND Ropivacaine is commonly used as an intercostal nerve block, but its effects on postoperative cognitive dysfunction (POCD) have not previously been investigated. This study aimed to examine the effects of the use of ropivacaine as an intercostal nerve block on early POCD, postoperative analgesia, and inflammation in patients following thoracotomy for esophageal cancer. MATERIAL AND METHODS One hundred patients with esophageal cancer undergoing thoracotomy were randomly divided into a group with intercostal nerve block (group A) (n=50) and a control group (group B) (n=50). The cognitive function score and visual analog scale (VAS) scores for pain were measured at one hour before surgery (T1), two hours after surgery (T2), 12 hours after surgery (T3), and 24 hours after surgery (T4). Blood samples were collected at each time point, and plasma levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), IL-10, and S100-β were measured using an enzyme-linked immunosorbent assay (ELISA). Cognitive function was determined using the Mini-Mental State Examination (MMSE) scale. RESULTS The VAS scores in group A were significantly lower compared with group B (p<0.05). In the T2, T3, and T4 time points, group A had significantly increased MMSE scores compared with group B (p<0.05). Compared with group B, the levels of IL-6 and TNF-a were significantly decreased in group A at T3 and T4 (p<0.05), while the levels of IL-10 were significantly increased (p<0.05) when compared with group A. CONCLUSIONS The use of the intercostal nerve block, ropivacaine, improved early PCOD in patients following thoracotomy for esophageal cancer.

Dexmedetomidine protects rats from postoperative cognitive dysfunction via regulating the GABAB R-mediated cAMP-PKA-CREB signaling pathway

This work attempts to discuss whether dexmedetomidine (Dex) can protect rats from postoperative cognitive dysfunction (POCD) through regulating the γ-aminobutyric acid-_B receptor (GABA_B R)-mediated cyclic adenosine monophosphate (cAMP) - protein kinase A (PKA) - cAMP-response element binding (cAMP-PKA-CREB) signaling pathway. Sprague-Dawley rats were divided into a non-surgical group (Control), a surgical group (Model), a surgical group treated with Dex (Model + Dex), a surgical group treated with GABA_B R antagonist (Model + CGP 35348) and a surgical group treated with Dex and GABA_B R agonist (Model + Dex + Baclofen). Cognitive and memory functions were evaluated by Y-maze test and open-field test. The neuronal morphology of the hippocampus was observed by hematoxylin and eosin staining and neuronal apoptosis was by terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick-end labeling method. Inflammatory factors and cAMP levels were detected by enzyme-linked immunosorbent assay while expressions of GABA_B R and PKA-CREB pathway-related molecules by Western blot. Compared with control rats, the model rats exhibited reduced alternation rates with a prolonged time spent in the central zone; meanwhile, levels of tumor necrosis factor-α and interleukin-1β and the apoptotic index, as well as GABA_B R1 and GABA_B R2 expressions were increased in the model rats, but the cAMP-PKA-CREB pathway was inhibited (all P < 0.05). When treated with either Dex or CGP 35348, the surgical rats displayed an opposite tendency concerning the above factors as compared to the model rats (all P < 0.05). Furthermore, Baclofen, the agonist of GABA_B R, could reverse the protective effect of Dex against POCD in rats. Dex protects rats from POCD possibly via suppressing GABA_B R to up-regulate the cAMP-PKA-CREB signaling pathway, thereby alleviating the hippocampal inflammation caused by surgical trauma.

Preoperational chronic pain impairs the attention ability before surgery and recovery of attention and memory abilities after surgery in non-elderly patients

PURPOSE

This study aimed to investigate the relationship of preoperative chronic pain and postoperative cognitive dysfunction (POCD) in non-elderly patients who underwent arthroscopic surgery.

MATERIALS AND METHODS

The pain intensity was estimated using visual analog scale, and the cognitive function was assessed by Syndrom Kurz Test. The effects of preoperative chronic pain on the cognitive scales were comparatively studied between the patients of observational group (OG, with chronic pain) and control group (CG, without chronic pain) pre- and postoperatively, and followed up for 3 months.

RESULTS

A total of 57 non-elderly patients completed the study. Twenty-five patients (44%) with preoperative chronic pain were assigned to OG and 32 patients (56%) without chronic pain were assigned to CG. Preoperation chronic pain impaired the attention ability before surgery and caused less recovery of attention and memory abilities from 24 hours to 3 months after the surgery. Surgery procedures improved the attention and memory abilities and impaired the ability of numerical ability in CG patients. A postoperative pain relief in OG patients caused more recovery of cognition in addition to surgery procedure-mediated cognitive recovery. The incidence of POCD was ~3.5% and temporary at 24 hours after surgery, and disappeared at 2 weeks, 6 weeks and 3 months after the surgery.

CONCLUSION

The incidence of POCD in non-elderly population who underwent arthroscopic surgery was low. Surgery improved the abilities of attention and memory, and impaired the ability of counting. The preoperative chronic pain distracted the attention before surgery, and reduced the recovery of attention and memory abilities during the follow-up period after the surgery in non-elderly patients.

The quality of life of patients developed delirium after coronary artery bypass grafting is determined by cognitive function after discharge: A cross-sectional study

AIMS

Postoperative delirium (POD) and declined cognitive function were common in patients (especially elderly patients) who underwent coronary artery bypass grafting (CABG), which may affect quality of life (QoL). The aim of this study was to determine the relationships among age, POD, declined cognitive function, and QoL in patients who underwent CABG.

METHODS

Consecutive patients who underwent first time elective CABG and assessed for POD using Confusion Assessment Method for intensive care unit for 5 postoperative days from November 2013 to March 2015 were recruited. A cross-sectional study was conducted during April 2015 to assess their cognitive function and QoL, using the Telephone Interview for Cognitive Status Scale and Medical Outcomes Study 36-Item Short Form Health Survey. The relationships among age, POD, declined cognitive function, and QoL were tested using path analysis.

RESULTS

Declined cognitive function was associated with poorer QoL. POD was associated with declined cognitive function but was not associated with poorer QoL. Ageing was not associated with QoL but was associated with POD and declined cognitive function.

CONCLUSION

The QoL of patients developed delirium after CABG is determined by cognitive function after discharge. Necessary strategies should be implemented to prevent POD and declined cognitive function, especially in elderly patients.

Hypertension and Risk of Post-Operative Cognitive Dysfunction (POCD): A Systematic Review and Meta-Analysis

Background:

Post-operative cognitive dysfunction (POCD) occurs frequently after major surgery. Hypertension is well-established as a risk factor for age-related cognitive impairment, but it is unclear whether or not it also increases the risk of POCD.

Objective:

To evaluate the role of hypertension in POCD risk in a systematic review and meta-analysis.

Method:

PubMed, Ovid SP and the Cochrane Database of Systematic Reviews were searched for longitudinal studies of adults undergoing surgery with reporting of hypertension, blood pressure and/or anti-hypertensive treatment associations with POCD as relative risks or odds ratios. Fixed-effects meta-analyses were performed using Review Manager (version 5.3).

Results:

Twenty-four studies on 4317 patients (mean age 63 years) were included. None of the studies had set out to assess hypertension as a risk factor for POCD. Hypertension was used as a categorical predictor throughout and only 2 studies adjusted for potential confounders. Across all 24 studies, hypertension was not significantly associated with POCD risk (RR 1.01; 95% CI 0.93, 1.09; p=0.82), though among 8 studies with >75% males, we found hypertension associations with a 27% increased risk of POCD (RR 1.27, 95% CI 1.07, 1.49; p=0.005).

Conclusion:

Our findings do not support the hypothesis that hypertension is a risk factor for POCD. However, since none of the studies included in our analysis were hypothesis-driven and most did not adjust for potential confounders, further systematic investigations are needed to evaluate the role of hypertension in the epidemiology of POCD.

Deferoxamine pre-treatment protects against postoperative cognitive dysfunction of aged rats by depressing microglial activation via ameliorating iron accumulation in hippocampus

Postoperative cognitive dysfunction (POCD) is a common complication of elderly patients after surgery. The mechanisms of POCD have not been clarified. Iron accumulation is a feature of neurodegeneration. Recent reports showed that iron content was increased with impaired cognition induced by surgery. We sought to investigate whether iron chelation would attenuate POCD. In this study, male aged (18 months) Sprague-Dawley rats received 100 mg/kg deferoxamine or saline solution (0.9%) for 6 days before exploratory laparotomy. Cognition was evaluated by Morris water maze before and after surgery. Additional rats received deferoxamine or saline were used to determine hippocampal iron content, iron transport-related proteins (transferrin receptor, divalent metal transporter 1, ferroportin 1 and hepcidin), oxidative stress, microglial activation and brain cell apoptosis. It was found that deferoxamine improved postoperative spatial memory in aged rats. Deferoxamine significantly reduced hippocampal iron concentration and ferritin. Surgery increased divalent metal transporter 1 and hepcidin, decreased transferrin receptor and ferroportin 1, and enhanced ferroportin 1 mRNA. However, deferoxamine reversed the changes of these proteins. Furthermore, deferoxamine sharply reduced the hippocampal reactive oxygen species, malondialdehyde concentration and OX-42 that is a marker of microglia, which might reduce postoperative brain cell apoptosis. This study showed that deferoxamine may improve postoperative cognition of aged rats by ameliorating oxidative stress induced by hippocampal iron accumulation, microglial activation and brain cell apoptosis. This study suggests a potential therapeutic method for reducing POCD.

Assessment of different anesthesia depth under total intravenous anesthesia on postoperative cognitive function in laparoscopic patients

Background:

This study aimed to compare the effects of different depths of sedation during total intravenous anesthesia (TIVA) with remifentanil and propofol given by target-controlled infusion (TCI) on postoperative cognitive function in young and middle-aged patients undergoing gynecological laparoscopic surgery.

Materials and Methods:

A total of 150 American Society of Anesthesiologists physical Status I/II patients scheduled for gynecological laparoscopic operation were randomly divided into three groups. Anesthesia was maintained with intravenous infusion of TCI propofol and remifentanil, intermittent injected intravenously with rocuronium. The infusion concentration of propofol and remifentanil was adjusted to maintain bispectral index (BIS) at 30 < BIS ≤ 40 in the first group, 40 < BIS ≤ 50 in the second group, and 50 < BIS ≤ 60 in the third group. Mini–mental state examination (MMSE) and trail-making test (TMT) were used to assess the cognitive function one day preoperatively and one day postoperatively.

Results:

MMSE scores were > 24 sores on the day before anesthesia and the day after surgery in all three groups. However, the first group had the significantly higher MMSE scores than the other two groups after surgery (P < 0.05). Compared with that before anesthesia, TMT completion time was shorter on the day after surgery in the first group, while prolonged in the third group (P < 0.05). The first group had the significantly lower TMT completion time than the other two groups (P < 0.05).

Conclusion:

The depth of sedation, 30 < BIS value ≤ 40, under TIVA with remifentanil and propofol given by TCI had the minimal influence on postoperative cognitive function.

The effect of sugammadex on postoperative cognitive function and recovery

BACKGROUND AND OBJECTIVE

Sugammadex is the first selective relaxant binding agent. When compared with neostigmine, following sugammadex administration patients wake earlier and have shorter recovery times. In this study, we hypothesized that fast and clear awakening in patients undergoing general anesthesia has positive effects on cognitive functions in the early period after operation.

METHODS

Approved by the local ethical committee, 128 patients were enrolled in this randomized, prospective, controlled, double-blind study. Patients were allocated to either Sugammadex group (Group S) or the Neostigmine group (Group N). The primary outcome of the study was early postoperative cognitive recovery as measured by the Montreal Cognitive Assessment (MoCA) and Mini Mental State Examination (MMSE). After baseline assessment 12-24h before the operation. After the operation, when the Modified Aldrete Recovery Score was ≥9 the MMSE and 1h later the MoCA tests were repeated.

RESULTS

Although there was a reduction in MoCA and MMSE scores in both Group S and Group N between preoperative and postoperative scores, there was no statistically significant difference in the slopes (p>0.05). The time to reach TOF 0.9 was 2.19min in Group S and 6.47min in Group N (p<0.0001). Recovery time was 8.26min in Group S and 16.93min in Group N (p<0.0001).

CONCLUSION

We showed that the surgical procedure and/or accompanying anesthetic procedure may cause a temporary or permanent regression in cognitive function in the early postoperative period. However, better cognitive performance could not be proved in the Sugammadex compared to the Neostigmine.

Extracellular RNAs as a chemical initiator for postoperative cognitive dysfunction

Postoperative cognitive dysfunction (POCD) is a common complication that presents in the postoperative stage, especially in elderly patients. Despite years of considerable progress, the detailed molecular mechanisms of POCD remain largely unknown. Neuroinflammation has been increasingly pointed out as one of the core mechanisms for the pathogenesis of POCD. However, application of anti-inflammatory drugs failed to show consistent beneficial effect in patients with cognitive decline. Hence, it might be of great importance to identify the inflammatory initiators that are involved in the mediation, amplification and perpetuation of postoperative neuroinflammatory reactions. Extracellular RNAs (exRNAs), released from necrotic cells, were demonstrated to initiate the inflammatory responses in various pathological conditions. Recent study has suggested neuroprotective and edema protective effects of ribonuclease (RNase), the counterpart of RNA, in acute stroke. It was theorized that RNase acted against endogenous RNA that was released from tissue damage. Similarly, we have observed significant attenuation of cognitive impairment by RNase in aged mice after unilateral nephrectomy. Damping the systemic initiators at early stages may help to prevent the chain reaction that triggers the central inflammatory or apoptotic response. Therefore, we propose the hypothesis that exRNAs released upon stress, through acting on the peripheral and/or central receptors, may trigger a damaging cascade leading to the development of POCD. Undoubtedly, further study is urgently needed to elucidated the exact signaling mechanisms and confirm the proposed hypothesis.

[The effect of sugammadex on postoperative cognitive function and recovery]

BACKGROUND AND OBJECTIVE

Sugammadex is the first selective relaxant binding agent. When compared with neostigmine, following sugammadex administration patients wake earlier and have shorter recovery times. In this study, we hypothesized that fast and clear awakening in patients undergoing general anesthesia has positive effects on cognitive functions in the early period after operation.

METHODS

Approved by the local ethical committee, 128 patients were enrolled in this randomized, prospective, controlled, double-blind study. Patients were allocated to either Sugammadex group (Group S) or the Neostigmine group (Group N). The primary outcome of the study was early postoperative cognitive recovery as measured by the Montreal Cognitive Assessment (MoCA) and Mini Mental State Examination (MMSE). After baseline assessment 12-24h before the operation. After the operation, when the Modified Aldrete Recovery Score was ≥9 the MMSE and 1h later the MoCA tests were repeated.

RESULTS

Although there was a reduction in MoCA and MMSE scores in both Group S and Group N between preoperative and postoperative scores, there was no statistically significant difference in the slopes (p>0.05). The time to reach TOF 0.9 was 2.19min in Group S and 6.47min in Group N (p<0.0001). Recovery time was 8.26min in Group S and 16.93min in Group N (p<0.0001).

CONCLUSION

We showed that the surgical procedure and/or accompanying anesthetic procedure may cause a temporary or permanent regression in cognitive function in the early postoperative period. However, better cognitive performance could not be proved in the Sugammadex compared to the Neostigmine.

The Prevalence of Undiagnosed Presurgical Cognitive Impairment and Its Postsurgical Clinical Impact in Older Patients Undergoing Lumbar Spine Surgery

Objective

Because elderly patients are undergoing more surgeries, the importance of postoperative cognitive impairment (CI) evaluations is rising, especially for spine surgery, which is related to subjective pain. We investigated the prevalence of undiagnosed CI among elderly patients who underwent spine surgery and the impact of CI on postoperative outcomes.

Methods

The preoperative cognitive statuses of 129 patients over 65 who underwent lumbar spine surgery from 2012 to 2014 were determined with the Mini-Mental State Examination, and patients with scores under 24 were diagnosed with CI. The patients were then divided into a CI group (n=49) and non-cognitive impairment (NCI) group (n=80).

Results

Among the 129 patients, 49 (38.0%) were diagnosed with CI, and 9 (7.0%) had severe CI. The age of the CI group (72.88±6.20 years) was significantly greater than that of the NCI group (69.96±4.53 years). In contrast, the postoperative visual analog scale scores and performance statuses did not differ significantly. However, postoperative delirium was more frequent and the hospital stay length was longer in the CI group compared with the NCI group (p<0.05).

Conclusion

A high prevalence of undiagnosed CI was discovered among elderly patients undergoing spine surgery. The existence of CI was associated with higher rates of postoperative delirium and prolonged hospital stays, which affected clinical outcomes. Thus, CI assessments should be included in preoperative evaluations of elderly patients prior to spine surgery.

Autophagy activation prevents sevoflurane-induced neurotoxicity in H4 human neuroglioma cells

AIM

The inhaled anesthetic sevoflurane may induce cognitive impairment in both animals and humans. Previous study has shown that sevoflurane triggers ER stress and may lead to apoptosis in rat hippocampal neurons. In this study, we examined whether sevoflurane caused autophagy and its contributions to sevoflurane induced neuronal cell injury.

METHODS

H4 human neuroglioma cells were exposed to 4.1% sevoflurane for 6 h. Cell viability and apoptosis ratio were assessed using a CCK8 kit and flow cytometry, respectively. Autophagosomes in the cells were detected using GFP-LC3 plasmid transfection or transmission electronic microscopy. The expression of LC3B, p62/SQSTM, C/EBP homologous protein (CHOP) and glucose-related protein 78 (GRP78) was assessed with Western blotting.

RESULTS

Sevoflurane treatment induced apoptosis and markedly increased the LC3-II level and GFP-LC3 puncta number, decreased p62 expression in H4 cells. Activation of autophagy by rapamycin (1 μmol/L) significantly reduced sevoflurane-induced apoptosis and increased cell viability, whereas inhibition of autophagy with 3-MA (5 mmol/L) caused the opposite effects. Furthermore, sevoflurane treatment markedly increased the expression of CHOP and GRP78, two hallmark proteins of ER stress. Inhibition of ER stress by 4-phenylbutyrate (500 μmol/L) abrogated sevoflurane-induced autophagy and apoptosis, and improved the viability. Moreover, sevoflurane-stimulated expression of CHOP and GRP78 was inhibited by rapamycin, but further enhanced by 3-MA.

CONCLUSION

Sevoflurane treatment induces ER stress and activates autophagy, which antagonizes sevoflurane-induced apoptosis in H4 human neuroglioma cells. The results suggest that autophagy may be a potential therapeutic target in preventing sevoflurane-induced neurotoxicity.

Postoperative Cognitive Dysfunction: Minding the Gaps in Our Knowledge of a Common Postoperative Complication in the Elderly

Postoperative cognitive dysfunction (POCD) is a common complication associated with significant morbidity and mortality in elderly patients. There is much interest in and controversy about POCD, reflected partly in the increasing number of articles published on POCD recently. Recent work suggests surgery may also be associated with cognitive improvement in some patients, termed postoperative cognitive improvement (POCI). As the number of surgeries performed worldwide approaches 250 million per year, optimizing postoperative cognitive function and preventing/treating POCD are major public health issues. In this article, we review the literature on POCD and POCI, and discuss current research challenges in this area.

Neuroprotective effects of intravenous lidocaine on early postoperative cognitive dysfunction in elderly patients following spine surgery

Background

This study aimed to evaluate the effects of lidocaine treatment on cognitive impairment in aged patients undergoing spine surgery and to explore the underlying mechanism.

Material/Methods

Patients were randomly divided into 2 treatment groups: (1) saline (control) and (2) lidocaine. After induction of anesthesia, the lidocaine group received lidocaine as a bolus of 1 mg/kg over 5 minutes, followed by a continuous infusion at 1.5 mg/kg/h until the end of the surgery. We examined the effects of lidocaine treatment on the improvement of cognitive function using the Mini-Mental State Examination (MMSE) at preoperation and 3 days postoperation. Serum samples were collected to assess the levels of IL-6, TNF-α, MDA, S100β, and NSE before inducing anesthesia, at the end of surgery, and 3 days after the end of surgery.

Results

We found that the MMSE scores in the lidocaine group were markedly higher than those in the control group at 3 days after surgery. Moreover, lidocaine treatment markedly suppressed the release of IL-6, S100β, and NSE into the serum at the end of surgery and 3 days after the end of surgery. In the control group, serum MDA levels increased by 3 days after the end of surgery. The lidocaine group had lower serum MDA levels than those in the control group.

Conclusions

Lidocaine may be an effective neuroprotective agent in treating early postoperative cognitive dysfunction in elderly patients undergoing spine surgery.

MicroRNA-572 improves early post-operative cognitive dysfunction by down-regulating neural cell adhesion molecule 1

Post-operative cognitive dysfunction (POCD) is a commonly-seen postoperative complication in elderly patients. However, the underlying mechanisms of POCD remain unclear. miRNAs, which are reported to be involved in the pathogenesis of the nervous system diseases, may also affect POCD. In this study, miRNA microarray technology was used to analyze the circulating miRNA expression profile of POCD patients. Among the altered miRNAs, miR-572 had the greatest decrease, which was also verified in vivo in rat POCD model. Further analysis found that miR-572 could regulate the expression of NCAM1 in the hippocampal neurons and interfering miR-572 expression could facilitate the restoration of cognitive function in vivo. Moreover, clinical correlation analysis found that the miR-572 expression was associated with the incidence of POCD. Collectively, miR-572 is involved in the development and restoration of POCD and it may serve as a biological marker for early diagnosis of POCD.

Recovery of postoperative cognitive function in elderly patients after a long duration of desflurane anesthesia: a pilot study

Postoperative cognitive dysfunction (POCD) increases morbidity and mortality. The mechanisms underlying POCD remain elusive; however, systemic responses induced by anesthesia and surgery might trigger neuroinflammation and POCD. Desflurane is a preferable volatile anesthetic agent for elderly patients because it facilitates shorter recovery from general anesthesia. The aim of this study was to determine whether quality of emergence and cognitive function in elderly patients undergoing a long duration desflurane anesthesia are better than those in the case of sevoflurane anesthesia. Forty-two patients who were older than 65 years of age and scheduled for surgery of more than 4 h in duration were enrolled in this study. Patients were randomly assigned to a desflurane anesthesia group (D group) and sevoflurane anesthesia group (S group). General anesthesia was maintained with 3.5 % desflurane (D group) and 1.0 % sevoflurane (S group). The Mini-Mental State Examination (MMSE) was used for assessing cognitive function 24 h before and after surgery. Postoperative MMSE score in the D group was significantly improved compared to that in the preoperative period. In conclusion, elderly patients undergoing desflurane anesthesia have significantly better quality of emergence and may have better cognitive function than those in elderly patients undergoing sevoflurane anesthesia.

Surgical stress induces brain-derived neurotrophic factor reduction and postoperative cognitive dysfunction via glucocorticoid receptor phosphorylation in aged mice

AIMS

This study explored whether surgical stress-induced glucocorticoid receptor (GR) phosphorylation is related to postoperative cognitive dysfunction (POCD) in aged individuals. Inhibition of GR activation could be an effective treatment for POCD.

METHODS

A laparotomy was given to C57/BL6 mice in POCD group both 20 and 6 months old. Animals in control group were treated in identical manners except for laparotomy. Cognitive function was evaluated by Morris water maze and elevated plus maze. Western blot and Elisa assay were used to detect related molecules. Mifepristone and roscovitine were treated as inhibitions of GR phosphorylation.

RESULTS

The cognitive function was impaired, and brain-derived neurotrophic factor (BDNF) was found reduced in aged POCD group. GR translocation into nucleus and elevated GR phosphorylation were found in prefrontal cortex of aged POCD mice. Cyclin-dependent Kinase 5 (CDK5), kinase for GR phosphorylation also elevated in aged POCD mice. With GR antagonist and CDK5 inhibitor, reduction of BDNF and cognitive dysfunction in aged mice were both rescued.

CONCLUSION

These results presented a mechanism that surgical stress-induced GR phosphorylation contributes to POCD in aged individuals. Inhibition of GR activation and phosphorylation might be a potential treatment target of POCD.

Effect of inhalational anaesthetic on postoperative cognitive dysfunction following radical rectal resection in elderly patients with mild cognitive impairment

Aims

To determine the effect of choice of inhalational anaesthetic (sevoflurane vs propofol) on the incidence and severity of postoperative cognitive dysfunction (POCD) in elderly patients (aged ≥ 60 years) with mild cognitive impairment (MCI).

Methods

Elderly patients with MCI undergoing radical rectal resection were randomly assigned to receive sevoflurane or propofol general anaesthesia. Cognitive function was assessed using neuropsychological testing before and 7 days after surgery. POCD severity was graded as mild, moderate or severe using standard deviation cut-offs.

Results

At 7 days after surgery, the incidence of POCD was 29.7% in the propofol group ( n = 101) and 33.3% in the sevoflurane group ( n = 99). There was a significant between-group difference for POCD severity: sevoflurane anaesthesia had a more severe impact on cognitive function than propofol anaesthesia.

Conclusions

There was no difference in the incidence of POCD at 7 days after radical rectal resection under sevoflurane or propofol-based general anaesthesia. Both propofol and sevoflurane were associated with negative cognitive effects, but sevoflurane had a more severe impact on cognitive function than propofol, in elderly patients with MCI.

Postoperative cognitive dysfunction: current developments in mechanism and prevention

Postoperative cognitive dysfunction (POCD) is a subtle disorder of thought processes, which may influence isolated domains of cognition and has a significant impact on patient health. The reported incidence of POCD varies enormously due to lack of formal criteria for the assessment and diagnosis of POCD. The significant risk factors of developing POCD mainly include larger and more invasive operations, duration of anesthesia, advanced age, history of alcohol abuse, use of anticholinergic medications, and other factors. The release of cytokines due to the systemic stress response caused by anesthesia and surgical procedures might induce the changes of brain function and be involved in the development of postoperative cognitive dysfunction. The strategies for management of POCD should be a multimodal approach involving close cooperation between the anesthesiologist, surgeon, geriatricians, and family members to promote early rehabilitation and avoid loss of independence in these patients.