Older Patients’ Postoperative Neurocognitive Recovery: A Narrative Review

Background

Life expectancy is increasing worldwide, and the number of older adults (≥65 years) is growing rapidly, particularly those aged 85 and older.¹ Advancing age is associated with a higher prevalence of mild cognitive impairment and dementia.² Concurrently, a growing proportion of older adults are undergoing surgery, largely due to medical advances that make complex procedures feasible and safe in this age group. This increase is particularly common for procedures such as knee and hip replacements, cardiac surgeries, bladder surgeries, and prosthetic lens implantation. On average, surgical patients are 14.5 years older than the general population, reflecting the increasing representation of older adults among surgical cohorts.³ Despite the growing number of older adults undergoing surgery, post-surgical hospital stays remain relatively short, with an average duration of five days.³ This leaves a substantial portion of postoperative recovery to take place at home.⁴

During this recovery phase, patients often have to manage co-occurring symptoms and illnesses on their own, and if possible, with support from their next of kin.^4,5 Postoperative complications in older patients are more likely to be medical than surgical, with perioperative neurocognitive disorders being a common issue.⁶ Furthermore, over 50% of the older population experiences multimorbidity, further complicating recovery and hindering their ability to resume daily activities.⁷ It has been suggested that early recognition of postoperative neurocognitive decline, along with the provision of comprehensive care for older patients, may improve outcomes.⁸ This narrative review, therefore, aims to explore recent advances in perioperative neurocognitive recovery, focusing on symptomatology, patient and next of kin experiences, assessments, care interventions and ethical aspects.

Perioperative Neurocognitive Disorder

Neurocognitive decline is the most common complication following otherwise uneventful surgery.⁹ It is characterized by a reversible decline in cognitive performance compared to baseline levels prior to surgery. The factors contributing to the onset of neurocognitive decline are numerous and complex. Among the various theories presented, the neuroinflammation hypothesis stands out as the most significant. This theory posits that surgery initiates a systemic inflammatory response that compromises the blood-brain barrier, results in neuronal harm, and subsequently causes postoperative neurocognitive decline.^10–12 Additionally, the combination of chronic low-oxygen conditions associated with aging and sudden hypoxic events, along with the stress of surgery, can contribute to these issues. Surgery can exacerbate hypoxia due to factors such as reduced blood circulation, inadequate ventilation, fluid accumulation in the lungs, and blood loss.¹³ Other proposed mechanisms for postoperative cognitive decline include cerebral hypoperfusion, the presence of cerebral microemboli, and hemodynamic changes, particularly following cardiac surgery.¹⁴

The risk of postoperative neurocognitive decline is especially pronounced in patients over the age of 65 who have pre-existing cognitive disorders, depression, poor functional status, frailty, and those undergoing a longer duration of surgery.^15–19 Previous literature shows that background health conditions or injuries that lead to surgery may impact cognitive performance.²⁰ The prevalence of MCI prior to surgery in older patients is estimated to be between 7%-25%,²¹ and many older patients are unaware of their cognitive impairment before surgery. Studies show a high prevalence of unrecognized cognitive impairment: 37% in elective non-cardiac surgeries and 50% in emergency surgeries²² and preoperative cognitive impairment is associated with a higher risk of postoperative neurocognitive decline and medical complications for both cardiac²³ and non-cardiac surgeries.^16,24

Various cognitive domains can be affected, including memory, attention, information processing, and executive functions.²⁵ Following the nomenclature of if present within seven days after surgery, it is defined as postoperative delirium (POD). The incidence of POD after major surgery is between 10% and 60%^26–28 and typically develops within a few hours to days and is often reversible. Three subtypes can be distinguished: hyperactive (eg, hypervigilance, agitation, aggression); hypoactive (eg, lethargy, decreased psychomotor performance); and mixed, with symptoms common to both of the above.^26,29 The hypoactive and mixed subtypes are the most common but can often remain undiagnosed without use of screening tests.^28,30 It is essential to recognize that these conditions should not be viewed as dichotomous. Rather, they exist on an ordinal spectrum of severity, similar to pain, which can be measured using a scale (NRS: 0–10).³¹ Additionally, symptoms of POD that do not fully meet the diagnostic criteria for delirium are often referred to as subsyndromal delirium, representing a less pronounced or more subtle manifestation compared to full delirium.³² Emergence delirium (ED) is a state of cognitive decline that should be viewed independently from postoperative delirium (POD). ED generally occurs right as a patient starts to regain consciousness from general anesthesia and typically lasts between 5 to 15 minutes.³³ Pre-existing undetected cognitive issues prior to the surgery can elevate the risk of ED in older patients, especially those with hearing impairments.³⁴ The occurrence of ED serves as a significant indicator of POD.^33,35 If cognitive decline occurs within 30 days after surgery, it is referred to as delayed neurocognitive recovery (dNCR). If it persists up to one year after surgery, it is classified as postoperative neurocognitive disorder (p-NCD).^31,36–38 The cognitive changes associated with dNCR/p-NCD can vary from mild to severe, impacting one or more cognitive functions. These changes are often reversible but can last from a few weeks to several years.³⁹ The incidence of dNCR/p-NCD is between 10 and 25%,²⁶ Figure 1.

Figure 1 Timeline of postoperative neurocognitive disorders.

Both POD and dNCR/p-NCD negatively impact the quality of life and are linked to a higher risk of morbidity and mortality.^8,31 Several studies have investigated the relationship between POD and dNCR/p-NCD, but the results remain conflicting. It is still unclear whether POD constitutes an independent risk factor for delayed or persistent neurocognitive dysfunction dNCR/p-NCD, which would suggest that patients who develop POD in the postoperative phase³¹ are at increased risk of subsequent cognitive decline. According to Brown et al,⁴⁰ these patients may exhibit a more pronounced reduction in processing speed one year after surgery, indicating a potential link between acute and long-term neurocognitive outcomes. However, further longitudinal studies are needed to clarify causal relationships and underlying mechanisms.

Patient Experiences and Cognitive Symptoms

Patients who experience POD, describe that the symptoms often fluctuate, and that it can be challenging to stay oriented to the environment and time of day. Being in a delirious state can feel like a strange world of dreams with hallucinations and delusions. These hallucinations can be connected to earlier experiences in life or nightmares, such as being chased and threatened with one’s life, trapped in a cage, trying to cry for help but not being heard or seen, watching a blood pressure cuff turn into a bomb, or seeing the next of kin hurt. Conversely, hallucinations can also be pleasant and amusing. Moreover, the delirious state feels like a parallel world, a crossroad between reality and a surreal state and one can experience feeling completely clear and lucid, despite being in a surreal state.^41–44

POD changes the patient’s sense of their surroundings and ability to perform tasks as usual, patients may feel detached and disconnected, which can be distressing⁴⁴ and worry about the negative impact on their next of kin and healthcare professionals (HCP). Further, patients may feel ashamed and apologize for their behavior.⁴⁵ Therefore, past delirium becomes a painful memory that could bother patients for a long time^42,45 and essential to acknowledge that the patients’ experiences are hallucinations. POD can also have long-term cognitive impacts on the individual, including difficulties with orientation, forgetfulness, reduction in energy, misplacing items, reading challenges, slowed cognitive processing and feelings of sadness.^42,44 This makes it challenging to distinguish between cognitive complications caused by POD, symptoms from dNCR /p-NCD, and those related to cognitive ageing or dementia.

Patients with dNCR/p-NCD frequently experience a range of cognitive symptoms, such as problems with intellectual functioning, concentration issues, subjective concerns about cognitive abilities, and memory deficits.³¹ These issues can significantly affect their recovery and daily lives. Additionally, cognitive difficulties may also be present in patients who have not been diagnosed with dNCR/p-NCD.^46,47 Cognitive difficulties are symptoms, signs, and problems that patients experience in the postoperative period, including memory loss, difficulties executing daily tasks, engaging in social activities or housework, decreased focus, and fatigue.^5,47 Patients can express this state as “not being the same since the surgery”^48,49 and often attributing it to medications. Further, emotional reactions including anger outbursts, sadness and anxiety are related to cognitive difficulties.^5,47,49 Earlier research^49–51 indicate POD and dNCR/p-NCD are strongly associated with a decrease in independence due to impaired daily activities, and depression, which subsequently reduces autonomy and self-capacity.⁵¹

Next of Kin Experiences of Their Family Members’ Cognitive Symptoms

Next of kin experience significant distress when witnessing POD in a family member. This distress is often heightened by observing personality changes in their state, deterioration in medical conditions, and behaviors such as anger outbursts, paranoia and irrationality.^52,53 Unexpected emotional and behavioral changes due to POD can lead to increased anxiety and fear among next of kin. They often experience intense, alternating feelings of distress, especially when they have difficulties recognizing their family member, who has become unfamiliar as a result of these changes.⁵⁴ Next of kin struggle with the uncertainty about whether the delirium could become permanent.^53,55 A lack of information about POD in general, and their family members’ specific needs in particular, can lead to individuals creating their own explanations for their family members’ symptoms. Such explanations include blaming sleep deprivation⁵⁶ or medications, resulting in a feeling of loss of control.⁵⁴ However, providing accurate information, before the surgery and during an episode, can alleviate some of their distress and help them better manage the situation.⁵⁶ Guiding next of kin on how to best support the patient is crucial in easing their emotional burden.⁵⁷ Furthermore, as next of kin plays a key role in assisting HCPs by helping tailor care and identifying new symptoms they need to be kept well-informed.⁵⁵

Next of kin expect professional support in the discharge process as patients at times are sent home with POD symptoms.⁵⁶ After discharge, changes in neurocognitive function can affect family dynamics, often leading to grief and frustration for the next of kin.⁵⁸ But also increased anxiety about the long-term effects and the recurring risk of POD, especially since some patients had already experienced memory deterioration.⁵⁴ This is particularly challenging for older couples dealing with multimorbidity, which can limit their ability to care for each other.⁵⁸ However, next of kin experience of their family members’ cognitive symptoms are rarely studied, in particular regarding dNCR/p-NCD.

Assessment of Neurocognitive Function

Understanding the difference between “neuropsychological assessment” and “cognitive screening” is imperative. Although often used interchangeably, these terms refer to two distinct evaluations. Neuropsychological assessments are comprehensive, standardized evaluations conducted by clinicians with training in neuropsychology, considering clinical, demographic, and medical factors. In contrast, cognitive screening tests focus on selected neurocognitive domains and use pre-specified cut-off scores. While these tests do not replace neuropsychological assessments, they are valuable in busy clinical settings for identifying at-risk patients.^59,60

Preoperative Assessment and Screening of Neurocognitive Function

An ideal preoperative cognitive screening tool should take ≤5 min to conduct, have high sensitivity and specificity, and be validated in the preoperative geriatric population. Examples of such screening tools are Rapid Cognitive Screening (RCS), Six-Item Screener (SIS) and Mini-Cog⁶¹ (Table 1). Traditionally, the Mini-Mental State Examination (MMSE)⁶² has been used as the standard screening tool for dementia. However, it cannot fully capture cognitive deficits observed in MCI for all populations and is limited by a ceiling effect.^62–66 A more sensitive test for detecting cognitive impairment is the Montreal Cognitive Assessment (MoCA)^67,68 (Table 1). However, the level of education can affect the results from both MMSE and MoCA as well as age, emotional status, and gender.⁶⁹

Table 1 Example of Cognitive Screening Tools and and Their Characteristics for Assessing Cognitive Decline Before and After Surgery

The best time to perform a baseline assessment is 1–2 weeks before surgery, at the preoperative visit.^20,70 However, it is important to know that cut-off scores used in cognitive screening can limit outcome analyses as cut-off scores do not inherently consider the patient’s cognitive strengths and weaknesses. Therefore, it is encouraged to integrate screening tools with interdisciplinary team engagement and consultation.⁵⁹

Postoperative Assessment of POD

Delirium diagnosis according to the DSM requires a comprehensive assessment of several complex and, at times, subjective criteria (eg, consciousness, attention, cognition, and temporal course). Many POD assessment tools—such as the Confusion Assessment Method (CAM), the 4AT, or the Nursing Delirium screening scale (Nu-DESC)—are designed to rapidly screen for or identify delirium, rather than to replace a full diagnostic evaluation based on DSM criteria. Yet, early detection is crucial to treating it effectively. Routine screening is recommended by several guidelines for clinical practice and is emphasized to be more important than the actual diagnosis for POD care.^{2,17,31,60,71} Nurses play a pivotal role in the early detection of postoperative delirium due to their continuous, round-the-clock monitoring and clinical assessment of patients throughout the perioperative period. Therefore, it has been emphasised that nurses should have access to a user-friendly screening tool for assessing delirium.^42,72–74

The Confusion Assessment Method (CAM) is a commonly used tool for identifying delirium.⁷⁵ However, routine screenings may not be practical because the use of CAM takes a relatively long time and requires professional training to make an accurate assessment.^72,76,77 An easy-to-use clinical tool that requires no specific training for detecting delirium is the 4 “A”s Test (4AT) consisting of four items^73,78 (Table 1). Moreover, the Nursing Delirium Screening Scale (Nu-DESC) is an observational tool to detect and monitor delirium⁷⁹ (Table 1). As with many other delirium screening instruments, Nu-DESC does not require any patient performance, which might be a disadvantage. But due to its short duration of approximately one minute, it can be more readily adaptable in clinical practice.^72,73 The Nu-DESC consists of five domains⁷⁹ in which the fifth domain, “psychomotor retardation,” can be helpful in detecting hypoactive delirium.⁷³ This is a more subtle form of delirium that is easily overlooked.^42,73 However, it has been reported that nurses have had difficulty interpreting hypoactive delirium using Nu-DESC, leading to underdiagnosis.⁴¹ Additionally, Confusion Assessment Method-Intensive Care Unit (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC) are the most common delirium assessment tools for critically ill intensive care patients in clinical practice.⁸⁰ Such tools enable the early detection of POD in patients who undergo prolonged mechanical ventilation after surgery.

Postoperative Assessment of dNCR/p-NCD

Neurocognitive tests are required to detect impairment in neurocognitive function. The timing of postoperative assessments is a crucial factor that influences the incidence rates of neurocognitive decline. Research follow-up periods have ranged from one day to five years after surgery.²⁰ In a Statement of Consensus (CS) from 1995, Murkin et al recommend that studies on dNCR /p-NCD have at least one cognitive follow-up assessment postoperatively.⁸¹ It is advisable to delay testing for patients experiencing postoperative complications that could lead to fatigue or decreased motivation. However, not having a standardized time-point for measuring postoperative neurocognitive function after surgery can lead to a significant methodological issue. This is because dNCR /p-NCD may be more prevalent in patients who are unable or unwilling to undergo testing at the usual time of discharge.⁷⁰ The CS recommends using a specific set of tests called the “core battery” to assess cognitive abilities, which include verbal memory, attention, and psychomotor ability.⁸¹ However, there has been heterogeneity in the methodology used to study dNCR /p-NCD and a large variety of diagnostic rules since the publication of the 1995 Consensus Statement.⁸² When conducting neurocognitive assessments, balancing the desire to evaluate multiple domains with practical considerations is important. For instance, if a patient is about to undergo surgery or has physical limitations, the tests should not be too demanding or lengthy. This is because lengthy assessments can lead to poor performance due to pain or fatigue, or the patient may lose interest. Many commonly used assessment batteries may not be suitable for routine clinical practice due to their resource-intensive and burdensome nature.²⁰

A well-established test in research for the assessment of postoperative neurocognitive function in patients is the neuropsychological test battery developed by the International Study Group of Postoperative Cognitive Dysfunction (ISPOCD).^70,82,83 Montreal Cognitive Assessment (MoCA) has also been used in research to assess postoperative cognitive function. ISPOCD and MoCA evaluate different cognitive abilities, such as memory, executive functions, and visuospatial skills^70,83,84 (Table 1).

Digital cognitive assessments offer numerous benefits in both remote and healthcare settings. They reduce the workload of healthcare practitioners, simplify repeat testing, and improve cost and time efficiency. Older adults are increasingly using both smartphones and tablets. Adopting this technology for cognitive screening in various settings is feasible, even for older adults with no prior experience with touchscreen technology.^85,86 Additionally, they can provide screening to underserved and under-resourced populations since their adaptability to multiple languages helps address healthcare disparities.^86,87 Examples of digital self-administered tests comparable to analogue tests such as ISPOCD and MoCA are Mindmore,⁸⁵ XpressO,⁸⁸ and Geras Solutions cognitive tests.⁸⁷ However, according to the Diagnostic and Statistical Manual for Mental Disorders, fifth edition, DSM-5,²⁹ diagnosing dNCR/p-NCD requires subjective cognitive complaints from the patient, informant, or clinician, objective evidence from neurocognitive tests, and changes or decline in instrumental activities of daily living (IADL).^36,89

Next of Kin Assessment of dNCR/p-NCD

Assessment of dNCR/p-NCD by a next of kin is considered a more reliable measure than patients’ self-assessment.⁹⁰ The Cognitive Failures Questionnaire-for-Others (f-CFQ) is an eight-item questionnaire designed for next of kin to assess the frequency of failures in daily living related to memory, attention, action, and perception.⁹¹ However, the assessment of next of kin regarding their family members’ cognitive symptoms, particularly in relation to dNCR/p-NCD, is rarely studied, and no research has been found concerning POD.

Care Interventions for POD

Recommended care interventions for POD include preoperative screening and identification of risk factors.^2,92 Patients and their next of kin should receive information about the signs, symptoms, risk factors, and outcomes of POD. They should also be guided on how to identify and manage delirium early. A “Getting to know you” form can help collect personal information about the patient, such as the names of their next of kin, assistive devices, profession, hobbies, and preferred terms for activities. This information can assist frontline professionals in assessing and understanding cognitive functions during the postoperative recovery period.^2,93 Understanding the causes and treatments of POD and communicating with others can help individuals cope with their experience.⁴²

Postoperative care is crucial for reducing the risk of POD. Strategies to prevent POD include orienting the patient to time and place, maintaining regular communication with them, allowing time for understanding and responses, keeping explanations simple, rephrasing if necessary⁹⁴ and asking straight and concrete questions.⁵⁷ However, if the patient experiences POD, it can be challenging for them to articulate their thoughts clearly, leading HCPs to view them as suspicious and paranoid toward the staff. As a result, patients may appear to endure their struggles silently, coming across as introverted and difficult to engage with.⁵⁷ In such cases, family members can act as mediators to facilitate communication between the nurse and the patient.⁵⁴ Therefore, allowing a next of kin or caregiver to accompany the patient into the post-anesthesia care unit is beneficial.^95,96 Encouraging early mobilization is also advantageous^67,74,96,97 however, physical signs that may be perceived as symptoms of hypoactive delirium can include patients appearing extremely fatigued and being difficult to motivate for mobilization.⁵⁷

Additionally, creating a supportive environment – such as allowing the patient to sit upright, minimizing unnecessary noise, and providing access to glasses and hearing aids – is essential.⁹⁵ Identifying and treating hypoxia, hypotension, pain, hypothermia, infection, urinary retention, and inability to void are critical as well.^2,74,95–97 Having an empathic approach and providing emotional support can also be effective in caring for a patient suffering from POD.⁹² A critical task is to maintain the patient’s circadian rhythm. To reduce disturbances during sleep, it is important to minimize nighttime inspections and limit noise from the corridor and medical equipment. To help prevent patients from feeling isolated at night, doors can be left open, and delirious patients can be placed in rooms closer to the nursing desk. Furthermore, engaging in daytime activities, such as physiotherapy, has been found to improve sleep quality at night.⁵⁷

Care Interventions for dNCR/p-NCD

Current evidence does not sufficiently determine whether preoperative cognitive training has a positive impact on dNCR/p-NCD and POD.^98–100 Cognitive function training includes programs with structured exercises aimed at improving specific cognitive tasks. These exercises focus on enhancing performance across various cognitive areas, such as memory, attention, and executive function.¹⁰¹ Cognitive training can encompasses a wide range of approaches, including traditional paper-and-pen exercises that promote cognitive engagement, as well as modern digital programs that use interactive platforms to facilitate learning and memory enhancement. Among these, complex cognitive tasks challenge individuals through puzzles and problem-solving activities, while sensorimotor integrative training combines physical movements with cognitive tasks to enhance both mental and motor function. Additionally, advancements in technology have led to the use of virtual reality applications, which create immersive environments for cognitive training, and psychotherapeutic techniques that integrate biosensor feedback to help monitor and improve cognitive performance in real-time. Presently, computer-based cognitive training stands out as the most widely used method.^99,100 However, cognitive training can lead to feelings of being overwhelmed, technical difficulties, and constraints related to preoperative timelines, which may increase anxiety and apprehension, especially among older patients.¹⁰²

Treatment and support should extend beyond the hospital setting and continue after discharge. Patients and their next of kin should not be left to navigate the burdens of perioperative neurocognitive disorders without assistance. Caring for these patients requires a multidisciplinary approach where HCPs collaborate with the patients and their next of kin to develop tailored interventions. Perioperative neurocognitive disorders can significantly impact a patient´s quality of life, affecting their activity of daily living, engaging in social activities, or maintaining independence.⁴⁴ Therefore, appropriate follow-up care and support for both patients and next of kin are essential.

Ethical Challenges

Providing care for patients with impaired cognitive functions presents several ethical challenges. One major issue is that perioperative neurocognitive disorders can compromise a patient’s ability to make informed healthcare decisions, if the patient suffers from communication and behavioral problems⁹² particularly if cognitive difficulties are prolonged. The fluctuating nature of POD complicates the assessment of a patient’s decision-making capacity.¹⁰³ In cases of hyperactive and mixed subtypes of delirium, patients may exhibit disturbing behaviors such as aggression or and violence,¹⁰³ which can endanger both themselves and the HCPs.⁹² Additionally, delirious patients may resist treatment, leading HCP to consider using physical or chemical restraints.¹⁰⁴ The use of restraints raises ethical dilemmas due to violations of personal integrity and autonomy, as well as potential adverse effects on the patient.^105,106

If a patient temporarily or permanently loses their decision-making capacity and refuses treatment, legal grounds for restraint exist only if justified by a severe psychiatric condition. This situation poses challenges for patients with long-term cognitive impairment who do not meet these criteria, increasing the risk of inadequate healthcare under current regulations. Consequently, there is a significant risk that patients with impaired decision-making capacity who refuse treatment will not receive the necessary healthcare.¹⁰⁷ Another ethical issue involves resource allocation and prioritization of patients with POD compared to other patients needing care. If POD leads to prolonged hospital stays or increased healthcare needs post-surgery, it can strain healthcare resources.¹⁰⁸ Therefore, timely interventions and treatment strategies for this patient group are crucial.

Ethical considerations also arise regarding the balance between the potential benefits of surgery and the risk of cognitive decline, especially in older patients or those with pre-existing cognitive impairment. Additionally, the right to know is a fundamental human right.¹⁰⁹ Patients at risk should be thoroughly informed about the risk of postoperative neurocognitive decline before surgery. They should receive individually tailored information that is easy to understand and meaningful.¹⁰⁹ Accurately predicting individual risk is challenging, and if patients are not fully informed about the likelihood of cognitive difficulties after surgery, it may lead to inadequate informed consent. Another ethical concern is how to manage the results of screening for POD and dNCR/p-NCD. Simply identifying patients having POD or dNCR/p-NCD without a treatment or support plan is ethically unjustifiable.

Future Perspectives

Perioperative neurocognitive disorders are a significant health issue for older patients, particularly those undergoing major surgery. Delirium is increasingly recognized as a multifactorial and multidisciplinary clinical challenge, particularly in the context of perioperative care and geriatric medicine.¹¹⁰ The effective use of screening instruments to identify neurocognitive complications requires adequate knowledge and, consequently, that HCP receive appropriate training and education. Conducting screening alone is insufficient; results must be accurately interpreted, systematically followed up, and integrated into routine clinical practice. For screening to be meaningful, a structured protocol is essential, whereby results are actively sought, thoroughly documented, and utilized as a basis for ongoing clinical decision-making.^41,77,110

While reliable and sensitive instruments are available for preoperative screening and postoperative detection of these complications, clinical routines for assessing neurocognitive function remain inadequate. Barriers to screening-tool implementation are related to HCPs’ limited knowledge of cognitive complication, their competency in using the tools and management of cognitive complications. There are also team collaboration related and organizational barriers to consider. A perioperative neurocognitive recovery is a multifaceted issue, it require an interprofessional team approach to education, identification, and management.¹¹¹ We recommend that future research focus on strategies to enhance the implementation of evidence-based interventions for detecting neurocognitive complications and supporting patients with cognitive difficulties after surgery. This requires applying theoretical approaches from implementation science to understand the barriers and facilitators to changing practices in the perioperative setting.¹¹²

Although guidelines exist for preventing and managing POD, knowledge about the effectiveness and timing of care interventions for dNCR/p-NCD is limited. Unlike POD, which occurs soon after surgery, dNCR/p-NCD often manifests when patients are at home, managing neurocognitive symptoms independently, or with support from their next of kin.¹¹² Given the short duration of inpatient care, patients must oversee their recovery, relying on their self-care capacity to navigate daily life. Effective self-care involves knowledge of symptom management, monitoring, and coping strategies.¹¹³ By assessing and discussing these strategies, HCPs can increase patients’ self-efficacy in coping with their conditions.¹¹⁴

To enhance surgical follow-up, we propose a “brain and function check in”. This would involve clinicians gathering information and asking specific questions about cognitive function, and any psychological symptoms that have emerged or changed during the postoperative period. It should also assess the implications of these changes on a functional level, from both patient’s and next of kin’s perspective. If needed, a multidisciplinary team could then provide support, including neurocognitive training, education, home assistance or cognitive behavioral therapy.

Conclusions

The global population is aging, and older adults undergoing surgery are at risk of various postoperative complications. Among these, POD and dNCR/p-NCD are particularly concerning, as they can have severe and potentially life-threatening effects. HCP must provide optimal care by preventing and minimizing perioperative neurocognitive disorders through evidence-based practices and careful monitoring. However, there is a knowledge gap regarding functional status, symptom experiences, and the use of restraints related to postoperative neurocognitive decline. Additionally, we need to better understand the experiences of patients’ next of kin and how to effectively support patients dealing with these disorders.

Addressing ethical challenges requires a multidisciplinary approach that includes HCP, policymakers, patients, and their families. We must collaborate to develop strategies and clinical practices that promote the well-being and rights of older patients experiencing postoperative neurocognitive decline, while considering their individual needs, capacities, and vulnerabilities.