Incidence and Factors Related to Prolonged Postoperative Cognitive Decline (POCD) in Elderly Patients Following Surgery and Anaesthesia: A Systematic Review

Figures & data

Figure 1 PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guideline showing the allocation of evidence for final review.

Notes: PRISMA figure adapted from Liberati A, Altman D, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Journal of clinical epidemiology. 2009;62(10):e1-34. Creative Commons.¹⁹

Table 1 Incidence of POCD and predicting factors in elderly patients after non-cardiac surgeries (n=16 articles)

Author, country	Study design	Sample size	Data analysis	Type of surgery	Age, years	Overall incidence (%)	Predicting variables
Tang^Citation20 China	RCT	200	One way ANOVA, χ^2, Fisher’s exact test	GI (rectal resection)	60–99	31.5 at week 1	Use of sevoflurane (no statistical significance)
Valentin^Citation21 Brazil	RCT	140	Generalised estimation equation	Non-cardiac and non-neurologic	60–87	26 at week 1	High serum S100β and lack of dexamethasone premedication
Cosmo^Citation22 Italy	RCT	571	Pearson χ^2 test and Spearman rho test	Major abdominal	>60	10.5 at week 1	Not specified
Saleh^Citation23 China	RCT	141	χ^2 test and logistic regression	GI	>60	26 at week 1	Advanced age, longer anaesthesia and surgical duration, and lack of preoperative cognitive training
Silbert^Citation24 Australia	Prospective observational clinical trial	351	t, Mann–Whitney U tests	Non-cardiac	>60	2.6 at 12 months	Presence of preoperative cognitive impairment
Mehanna Gabrielli^Citation25 USA	Prospective cohort	167	Parametric and non-parametric methods	Spine, thoracic, urological, and general	>65	2.2 at 3 months	No predicting variable found
Zhu^Citation26 China	Double-blinded randomised clinical consort	134	χ^2 test, repeated-measure ANOVA	Orthopaedic surgery	>65	9 at 3 months	High serum levels of IL1β, IL6 and TNFα (P<0.05)
Zhu^Citation27 China	RCT	132	One-way ANOVA and χ^2 test	Gastric cancer resection	65–92	15 at week 1	No predictor variable found
Xi^Citation28 China	RCT	68	Fisher’s exact test, χ^2 test	GI tumour resection	>62	31.3 at day 3	—
Wang^Citation23 China	Prospective cohort	126	Multiple logistic regression	Hip-fracture fixation	>65	29 at week 1	High expression of FKBP51 in leucocytes and glucocorticoid resistance
Sun^Citation29 China	RCT	300	Repeated-measure and one way ANOVA	Hip-joint replacement	75–90	9.3 at week 1	No predictor variable found
Fan^Citation30 China	Retrospective analysis	572	Logistic regression	Laparoscopic GI	>60	12 at day 3	History of cerebral infarction, low SpO2, and longer duration of surgery
Quan^Citation31 China	RCT	120	Spearman’s, Mann–Whitney U, and χ^2 tests	Abdominal	>60	12.5 at 3 months	Light anaesthesia
Orhun^Citation32 Turkey	RCT	116	Student’s t and Fisher’s exact tests	General and urological	>60	25 at week 1	No predictor variable found
Zhang^Citation13 China	RCT	392	Logistic regression	Major cancer	65–90	19 at week 1	No predictor variable found
Li^Citation12 China	RCT	164	Unpaired t and Kruskal–Wallis tests	Knee arthroplasty	>65	13 at 12 months	No predictor variable found

Abbreviations: GI, gastro-intestinal; RCT, randomised controlled trial; SpO₂, saturation of peripheral oxygen.

Table 2 Incidence of POCD and predicting factors in elderly patients after cardiac surgery (n=7 articles)

Author, country	Study design	Sample size	Data analysis	Type of surgery	Age, years	Overall incidence (%)	Outcome variables
Sun^Citation33 China	RCT	340	Multivariate logistic regression	Radiofrequency ablation for AF	75–89	11.8 at week 1	Intra-operative haemodynamic instability
Stessel^Citation34 Belgium	Observational prospective cohort	180	Repeated-measure ANOVA	Endo-CABG	>64	12.2 at 3 months	Not specified
Nemeth^Citation35 Hungary	Controlled prospective observational	42	Spearman correlation	Cardiac surgery	>60	35.7 at week 1	No predictor variable found
Wan^Citation36 China	Cross-sectional	362	Logistic regression	CABG	>60	27.1 at week 3	Red cell distribution width of >14.7%
Brown^Citation37 USA	Prospective observational	142	Linear regression	Primary or reoperative aortic bypass/aortic valve surgery	62–78	Not specified	POD predicts POCD at 1 month, not at 1 year
Sauër^Citation2 Netherland	Multicentre follow-up	184	Mann Whitney U, linear regression	Isolated CABG and valve surgery	>65	Not specified	POD predicts POCD at 1-month follow-up
Nomura^Citation38 USA	Observational follow-up	133	Linear regression	CABG and valve surgery	>61	Not specified	Frailty predicts POCD at 1 month, not at 1 year

Abbreviations: RCT, randomised controlled trial; Endo-CABG, endoscopic coronary artery bypass grafting, POD, postoperative delirium, POCD, postoperative cognitive dysfunction.

Figure 2 Incidence of POCD (postoperative cognitive decline) at three time points in the postoperative period in older patients undergone both cardiac and noncardiac surgeries.

Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62(10):e1–e34. doi: 10.1016/j.jclinepi.2009.06.006

 PubMed Web of Science ®Google Scholar

Hong QN, Pluye P, Fàbregues S, et al. Mixed methods appraisal tool (MMAT), version 2018. Registration Copyright. 2018;1148552:10.

 Google Scholar

Caza N, Taha R, Qi Y, Blaise G. The effects of surgery and anesthesia on memory and cognition. Prog Brain Res. 2008;169:409–422.

 PubMed Web of Science ®Google Scholar

Goettel N, Burkhart CS, Rossi A, et al. Associations between impaired cerebral blood flow autoregulation, cerebral oxygenation, and biomarkers of brain injury and postoperative cognitive dysfunction in elderly patients after major noncardiac surgery. Anesth Analg. 2017;124(3):934–942. doi:10.1213/ANE.0000000000001803

 PubMed Web of Science ®Google Scholar

Tarasova IV, Trubnikova OA, Syrova ID, Barbarash OL. Long-Term Neurophysiological Outcomes in Patients Undergoing Coronary Artery Bypass Grafting. Br J Cardiovascular Surgery. 2021;36(5):629–638. doi:10.21470/1678-9741-2020-0390

 PubMed Web of Science ®Google Scholar

Vacas S, Degos V, Feng X, Maze M. The neuroinflammatory response of postoperative cognitive decline. Br Med Bull. 2013;106(1):161–178. doi:10.1093/bmb/ldt006

 PubMed Web of Science ®Google Scholar

Saleh AJ, Tang G-X, Hadi SM, et al. Preoperative cognitive intervention reduces cognitive dysfunction in elderly patients after gastrointestinal surgery: a randomized controlled trial. Med Sci Monitor. 2015;21:798. doi:10.12659/MSM.893359

 PubMed Web of Science ®Google Scholar

Bhushan S, Li Y, Huang X, Cheng H, Gao K, Xiao Z. Progress of research in postoperative cognitive dysfunction in cardiac surgery patients: a review article. Int J Surgery. 2021;95:106163. doi:10.1016/j.ijsu.2021.106163

 PubMed Web of Science ®Google Scholar

Patel N, Minhas JS, Chung EM. Risk factors associated with cognitive decline after cardiac surgery: a systematic review. Cardiovasc Psychiatry Neurol. 2015;2015:1–12. doi:10.1155/2015/370612

 Google Scholar

Kitsis P, Zisimou T, Gkiatas I, et al. Postoperative Delirium and Postoperative Cognitive Dysfunction in Patients with Elective Hip or Knee Arthroplasty: a Narrative Review of the Literature. Life. 2022;12(2):314. doi:10.3390/life12020314

 PubMedGoogle Scholar

Brown IVCH, Probert J, Healy R, et al. Cognitive decline after delirium in patients undergoing cardiac surgery. Anesthesiology. 2018;129(3):406–416. doi:10.1097/ALN.0000000000002253

 PubMed Web of Science ®Google Scholar

Nomura Y, Nakano M, Bush B, et al. Observational study examining the association of baseline frailty and postcardiac surgery delirium and cognitive change. Anesth Analg. 2019;129(2):507. doi:10.1213/ANE.0000000000003967

 PubMed Web of Science ®Google Scholar

Silbert B, Evered L, Scott DA, et al. Preexisting cognitive impairment is associated with postoperative cognitive dysfunction after Hip joint replacement surgery. Anesthesiology. 2015;122(6):1224–1234. doi:10.1097/ALN.0000000000000671

 PubMed Web of Science ®Google Scholar

Gong S, Qian D, Riazi S, et al. Association Between the FRAIL Scale and Postoperative Complications in Older Surgical Patients: a Systematic Review and Meta-Analysis. Anesth Analg. 2015

 Google Scholar

Zhang Y, Shan G-J, Zhang Y-X, et al. Propofol compared with sevoflurane general anaesthesia is associated with decreased delayed neurocognitive recovery in older adults. Br J Anaesth. 2018;121(3):595–604. doi:10.1016/j.bja.2018.05.059

 PubMed Web of Science ®Google Scholar

Li W-X, Luo R-Y, Chen C, et al. Effects of propofol, dexmedetomidine, and midazolam on postoperative cognitive dysfunction in elderly patients: a randomized controlled preliminary trial. Chin Med J. 2019;132(4):437–445. doi:10.1097/CM9.0000000000000098

 PubMed Web of Science ®Google Scholar

Wan J, Luo P, Du X, Yan H. Preoperative red cell distribution width predicts postoperative cognitive dysfunction after coronary artery bypass grafting. Biosci Rep. 2020;40(4):4. doi:10.1042/BSR20194448

 Google Scholar

Tang N, Ou C, Liu Y, Zuo Y, Bai Y. Effect of inhalational anaesthetic on postoperative cognitive dysfunction following radical rectal resection in elderly patients with mild cognitive impairment. J Int Med Reserch. 2014;42(6):1252–1261. doi:10.1177/0300060514549781

 PubMed Web of Science ®Google Scholar

Valentin LSS, Pereira VFA, Pietrobon RS, et al. Effects of single low dose of dexamethasone before noncardiac and nonneurologic surgery and general anesthesia on postoperative cognitive dysfunction—a Phase III double blind, randomized clinical trial. PLoS One. 2016;11(5):e0152308. doi:10.1371/journal.pone.0152308

 PubMed Web of Science ®Google Scholar

Zhu Y-Z, Yao R, Zhang Z, Xu H, Wang L-W. Parecoxib prevents early postoperative cognitive dysfunction in elderly patients undergoing total knee arthroplasty: a double-blind, randomized clinical consort study. Medicine. 2016;95:28.

 Web of Science ®Google Scholar

Fan Y, Liu X, Wu S, Liu Y. The risk factors for cognitive dysfunction in elderly patients after laparoscopic surgery: a retrospective analysis. Medicine. 2021;100(2):2. doi:10.1097/MD.0000000000023977

 Web of Science ®Google Scholar

Sauër AC, Veldhuijzen DS, Ottens TH, Slooter AJC, Kalkman CJ, van Dijk D. Association between delirium and cognitive change after cardiac surgery. BJA. 2017;119(2):308–315. doi:10.1093/bja/aex053

 Google Scholar

Wang L-W, Zhu M-J, Li Y, et al. FKBP51 is associated with early postoperative cognitive dysfunction in elderly patients undergoing Hip fracture surgery. Medicine. 2019;98:5.

 Web of Science ®Google Scholar