Risk factors for postoperative cognitive dysfunction in geriatric trauma: a dual-pathway perspective

Postoperative cognitive dysfunction (POCD) is common in geriatric trauma patients and involves complex underlying mechanisms. Most existing studies have focused on isolated risk factors, with limited attention to how these factors interact. In this perspective article, we propose a dual-pathway theoretical model-central nervous system vulnerability and peripheral stress amplification-to reframe the understanding of POCD pathogenesis. In older adults, POCD rarely stems from a single cause. Instead, it arises from a "second hit" process, in which pre-existing central nervous system vulnerabilities (e.g., neurodegenerative pathology and reduced cognitive reserve) interact with perioperative peripheral stressors (e.g., trauma, surgical stress, and anesthetic exposure) through interfaces such as the blood-brain barrier and neuroimmune circuits. Guided by this dual-pathway framework, future research should move from isolated risk factor screening toward dynamic, multidimensional, and individualized risk stratification, and explore sequential intervention strategies that target both pathways.