Perioperative approaches to prevent delayed neurocognitive recovery and postoperative neurocognitive disorder in older surgical patients: A systematic review and meta-analysis of randomized controlled trials.

Abstract

Background and aims: Delayed neurocognitive recovery (DNR) and postoperative neurocognitive disorder (P-NCD) are common postoperative complications affecting older patients. This review evaluates perioperative approaches for preventing DNR and P-NCD in older noncardiac surgical patients.

Material and methods: We searched databases for relevant articles from inception through June 2022 and updated in May 2023 (PROSPERO ID CRD42022359289). Randomized controlled trials (RCTs) utilizing intervention for DNR and/or P-NCD were included.

Results: We included 39 RCTs involving anesthetic (25 RCTs, 7422 patients) and other pharmacological and nonpharmacological approaches (14 RCTs, 2210 patients). Seventeen trials investigating four interventions were included in the meta-analysis for DNR. Perioperative dexmedetomidine (relative risk [RR]: 0.59, 95% confidence interval [CI]: 0.35-0.97; P = 0.04) and propofol-based total intravenous anesthesia (TIVA) (RR: 0.81, 95% CI: 0.66-0.98; P = 0.03) significantly decreased the risk of DNR versus control. There was no significant decrease in the risk of DNR with regional anesthesia (RA) versus general anesthesia (GA) (RR: 0.89, 95% CI: 0.63-1.26) or bispectral index (BIS) monitoring (RR: 0.79, 95% CI: 0.60-1.04) versus the control groups. Evidence regarding the effects of interventions on P-NCD is limited. Although all included trials were at low risk of bias, the quality of meta-analysis pooled estimates was low.

Conclusions: Our meta-analysis of RCTs showed that dexmedetomidine and TIVA decrease the risk of DNR in older patients undergoing noncardiac surgery by 41% and 20%, respectively, versus control. Further RCTs of adequate power and methodology on the effects of interventions on DNR and P-NCD are warranted.