Brain-Protective Perioperative Care for Reducing Postoperative Cognitive Impairment in Older Adults: A Scoping Review

Postoperative cognitive impairment (POCI) occurs in 10-50% of older adults after surgery and is associated with increased morbidity and accelerated cognitive decline. The focus of perioperative prevention has expanded from opioid-sparing analgesia to broader brain-protective perioperative care; however, evidence for individual strategies remains variable, and cognitive outcome assessment is heterogeneous. This scoping review aimed to map perioperative interventions used to prevent POCI in older surgical patients and characterize how cognitive outcomes are defined, assessed, and prioritized. The review followed Joanna Briggs Institute methodology and PRISMA-ScR reporting guidance. Seven electronic databases were searched without a date restriction. Eligible studies included adults aged 60 years or older undergoing surgery and evaluated at least one perioperative strategy with a delirium or cognitive outcome. Twenty-three studies were identified across five strategy categories: opioid-sparing and multimodal analgesia; anesthetic agents and techniques; intraoperative neuromonitoring; physiological optimization; and multicomponent non-pharmacological care and pharmacological prophylaxis. Multicomponent non-pharmacological interventions showed the most consistent signal for reducing postoperative delirium, whereas findings for individual pharmacological and technical strategies were inconsistent. Long-term cognitive outcomes were infrequently evaluated. The evidence supports a whole-pathway approach to brain-protective perioperative care while highlighting important gaps in long-term outcome assessment, standardization of cognitive testing, and direct evaluation of cognitive outcomes associated with opioid-sparing strategies.