M.J. Needham, C.E. Webb, D.C. Bryden British Journal of Anaesthesia

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Postoperative cognitive dysfunction and dementia: what we need to know and do M.J. Needham, C.E. Webb, D.C. Bryden British Journal of Anaesthesia Volume 119, Pages i115-i125 (December 2017) DOI: 10.1093/bja/aex354 Copyright © 2017 The Author(s) Terms and Conditions

Fig 1 Preoperative and postoperative cognitive trajectories. This illustrates possible preoperative and postoperative cognitive trajectories for a single patient. Curve (A) illustrates a patient experiencing cognitive decline before surgery whilst in contrast curve (B) represents a patient with relatively stable cognitive function. A number of postoperative trajectory curves (a-e are possible). In patient (A), curve (b) represents a continuation of the preoperative trend. Curve (a) would be an acceleration of cognitive decline and curve (c) would be a reduction in cognitive decline, or even cognitive improvement. Without knowing Patient A's cognitive trajectory in the pre-op period, curves (a–c) could all be interpreted as POCD. For patient (B), curve (c) shows POCD, curve (d) is no change from the preoperative course, and curve (e) represents a cognitive improvement. Of note curve c can be interpreted as relative cognitive improvement for patient (A) and relative cognitive decline for patient (B), hence the importance of knowing the preoperative cognitive trajectory for an individual. Reproduced with permission from.12 British Journal of Anaesthesia 2017 119, i115-i125DOI: (10.1093/bja/aex354) Copyright © 2017 The Author(s) Terms and Conditions

Fig 2 Cognitive trajectories of patients with no existing cognitive impairment (blue) and existing cognitive impairment (orange) who underwent surgery (solid lines) or no surgery (dashed lines). Over 10 yr the cognitive decline of people with existing cognitive impairment was seemingly accelerated by surgery. A cut off of 79 in the CAMCOG is traditionally used to diagnose dementia. Reproduced with permission from.55 British Journal of Anaesthesia 2017 119, i115-i125DOI: (10.1093/bja/aex354) Copyright © 2017 The Author(s) Terms and Conditions

Fig 3 Suggested flow diagram for the perioperative process of patients at high risk of POCD. Developed by C. Webb, M. Needham, D. Bryden. British Journal of Anaesthesia 2017 119, i115-i125DOI: (10.1093/bja/aex354) Copyright © 2017 The Author(s) Terms and Conditions