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.

Summary

Across 39 RCTs, perioperative dexmedetomidine reduced the risk of delayed neurocognitive recovery by 41% (RR 0.59), and TIVA reduced it by 20% compared with controls. Evidence for P‑NCD prevention remains limited, warranting further adequately powered trials.

Key Findings

• Meta-analysis of RCTs found dexmedetomidine lowered DNR risk by 41% versus control.
• TIVA reduced DNR risk by 20% compared with non-TIVA techniques.
• Evidence for P‑NCD prevention is insufficient; more robust RCTs are needed.

Clinical Implications

Consider dexmedetomidine-based sedation and TIVA (where feasible) to lower DNR risk in older noncardiac surgical patients, with individualized risk–benefit assessment for bradycardia/hypotension.

Limitations

• Heterogeneity in definitions, timing, and assessments of DNR/P‑NCD across trials
• Limited data on long-term P‑NCD and functional outcomes

Future Directions

Conduct adequately powered RCTs harmonizing cognitive outcomes, compare dexmedetomidine dosing strategies, and test multimodal bundles (e.g., depth monitoring + TIVA + sleep optimization).