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

Abstract

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.

Keywords: delirium; neurocognitive disorders; perioperative period; postoperative cognitive complications.

FIGURE 1

Classification of perioperative neurocognitive disorders

FIGURE 2

Suggested algorithm for assessment, prevention, and treatment of delirium

FIGURE 3

Suggested algorithm for assessment, prevention, and treatment of delayed neurocognitive recovery and postoperative neurocognitive disorders