Postoperative Cognitive Dysfunction: An Integrated Surgical and Psychiatric Perspective on a Complex Neurocognitive Syndrome

Abstract

Postoperative cognitive dysfunction (POCD) and postoperative delirium (POD) represent major neurocognitive complications affecting surgical patients across all ages, with particular prevalence in older populations. This comprehensive review examines POCD from an integrated surgical-psychiatric perspective, addressing the complex pathophysiological mechanisms, diagnostic considerations, risk stratification, and clinical outcomes. Current evidence demonstrates that POCD affects 17–43% of surgical patients postoperatively, with incidence decreasing over time. POCD occurring within 30 days of surgery is associated with increased mortality (relative risk 2.04 for cardiac surgery, 1.84 for noncardiac surgery), prolonged hospitalization, and enhanced dementia risk. The pathophysiology involves multiple interconnected mechanisms including neuroinflammation, blood-brain barrier dysfunction, anesthetic-related effects, and neuroimmune signaling. Key psychiatric comorbidities including preoperative depression, anxiety, and cognitive impairment significantly augment POCD risk. Early identification using validated risk prediction tools such as the PIPRA algorithm, combined with appropriate preoperative psychiatric assessment and perioperative optimization, may improve outcomes. This review synthesizes recent evidence to provide clinicians with a framework for understanding POCD as a complex neurocognitive syndrome requiring integrated surgical-psychiatric management.