Subjective Cognitive Complaints and Anecdotal Descriptions of Postoperative Cognitive Decline: Missing Pieces of the Postoperative Neurocognitive Disorder Puzzle

Abstract

Postoperative cognitive recovery is deeply important to patients and perioperative clinicians. Despite decades of data on "postoperative cognitive decline" (POCD), a research diagnosis based on objective cognitive test performance, perspectives on subjective cognitive complaints (SCC) after modern surgery/anesthesia have not been systematically collected or studied despite their recent inclusion in the 2018 redefinition of "postoperative neurocognitive disorder." The authors describe the alignment between SCC anecdotes and the research diagnosis of POCD, contextualizing these findings using recent literature within and outside anesthesiology. This article prepares anesthesiologists to discuss what is, and is not, known about subjective cognitive recovery after surgery/anesthesia.

Keywords: Postoperative cognitive dysfunction; Postoperative neurocognitive disorder; Subjective cognitive complaints.

Fig. 1.

Distribution of duration of symptoms, among 19 anecdotes in which a duration was stated or implied. If accompanied by objective neuropsychological deficits, symptoms lasting less than 30 days would be considered delayed neurocognitive recovery (dNCR), while symptoms greater than 30 days would be diagnosed as postoperative neurocognitive disorder (pNCD). pNCD must be diagnosed within the first postoperative year but may last longer than 1 year; the considerable majority of anecdotes were of symptoms of greater than 1 year’s duration.

Fig. 2.

Schematic of a potential strategy for supporting the consideration of SCC after major surgery for older patients. Preoperative individualized discussion of risks, centered on what is most important to and interpretable by older surgical patients, is followed by a brief assessment centered around expected versus experienced symptoms of SCC after an appropriate interval for postoperative healing. For those with SCC, management may include pragmatic or detailed neuropsychological testing and referral for therapeutic strategies depending on the presence of objective cognitive deficits and/or potential new diagnoses of underlying neurocognitive disorders. The conceptual model includes feed-forward of research findings to clinical care, for example, SCC prediction models to individualize risk profile, and feedback of patient experiences and “normal” postoperative cognitive healing to inform preoperative shared decision-making and expectation setting.