Analysis of risk factors for postoperative cognitive dysfunction in older patients undergoing surgery for oral malignancies

doi:10.21203/rs.3.rs-1621663/v1

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Analysis of risk factors for postoperative cognitive dysfunction in older patients undergoing surgery for oral malignancies

https://doi.org/10.21203/rs.3.rs-1621663/v1

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Background: This study aimed to analyse the incidence and risk factors associated with postoperative cognitive dysfunction (POCD) after malignant tumour resection and cervical lymphatic dissection in older adults undergoing oral and maxillofacial surgery.

Methods: A total of 112 older patients (aged≥ 55 years) were selected for extended resection of descending oral malignancies at the Affiliated Stomatological Hospital of Chongqing Medical University from December 2020 to December 2021. Participants were cognitively evaluated using the neuropsychological test scale one day preceding and seven days after the surgery to determine whether they had developed POCD. Based on whether POCD occurred after seven days,patients were divided into the POCD and non-POCD groups. Logistic regression was applied to perioperative factors to analyse the risk factors for POCD onset.

Results: Seven days following surgery for oral malignancy, there were 37 (33.1%) POCD morbidities. Multiple factor logistic regression analysis revealed that age (OR=1.269, 95%CI 1.056-1.525, P<0.05), low education levels (OR=0.792, 95%CI 0.644-0.974, P<0.05), hypertension (OR=4.153, 95%CI1.335-12.732, P<0.05), dyssomnia (OR=1.272, 95%CI 1.001-1.617, P<0.05), prolonged anaesthesia (OR=1.009, 95%CI 1.001-1.018, P<0.05), and intraoperative hypotension (OR=5.512, 95%CI 1.240-24.506, P<0.05) increased the risk of POCD in older patients who underwent surgery for oral malignancies.

Conclusion: Venerable age, low knowledge reserve, hypertension, dyssomnia, prolonged anaesthesia, and intraoperative hypotension are independent risk factors for POCD in older patients with oral malignancies.

Postoperative cognitive dysfunction

Oral and maxillofacial malignancies

Risk factors

Anaesthesia

Older patients

Postoperative cognitive dysfunction (POCD) is a postoperative central nervous system complication that often occurs hours to days after surgery. Occasionally, onset can be months or even years after surgery, causing disorders in consciousness, cognition, orientation, thinking, memory, and sleep [1], In the short term, POCD can aggravate other postoperative complications, extend the duration of hospitalisation, increase hospitalisation costs,and in the long term can negatively impact recovery of body function, reduce the quality of life, and even increase the postoperative mortality rate [2].The global population is rapidly aging, and the number of older individuals undergoing surgery is increasing. Several clinical studies suggest a higher incidence of POCD in older patients at approximately 3–61% [3,4]. Most POCD cases are reversible, but some patients are chronically affected. Some studies report that POCD still exists at three months after surgery, and can progress from chronic disease to long-term cognitive impairment [5].At the same time, POCD has the same pathological manifestations as dementia (Alzheimer Dementia, AD). POCD can therefore be considered as the critical stage between normal aging and dementia, and the annual transition rate from POCD to AD is estimated at 10–15% [5]. At present, perioperative brain health has garnered considerable attention, and effectively preventing the occurrence of POCD is of utmost priority. Therefore, screening for perioperative risk factors in older patients to facilitate timely intervention can be an effective method to prevent and treat POCD.

Over the past 30 years, the incidence and mortality of oral malignancies has increased annually [6]. According to a global survey,there are over 60,0000 new cases of oral malignant tumours, accounting for approximately 10% of all cancers, making it one of the most common clinical malignant tumours [7,8]. It affects the head, neck, and jaw, particularly the tongue, cheek, gums, jaw, salivary glands, and other important anatomical components, and can cause serious harm to human health [9]. The main pathogenic factors associated with oral and maxillofacial malignancies include alcohol consumption, smoking, betel nut chewing, long-term physicochemical factor stimulation, and human papilloma virus (HPV) infection [10,11]. Depending on the clinical stage of the patient, different treatment options can be selected, such as surgical resection, radiotherapy, chemotherapy, and comprehensive sequence treatment. For surgical resection, cervical lymphatic dissection and flap transplantation with a vascular pedicle may be performed based on the location and size of the primary focus, and the patient's physical condition. Because this operation involves important vascular and nerve tissues in the head and neck, large trauma requires long anaesthesia and surgery time, postoperative ICU stay, and long hospitalisation time; therefore, it is more likely to cause POCD in older patients. This study explored and analysed the incidence of POCD and its associated risk factors in older patients after expanded primary focal resection of oral tumours and cervical lymphatic dissection.

Case selection and Grouping

We selected 164 patients who underwent descending oral malignant tumour resection and cervical lymphatic dissection surgery under general anaesthesia between December 2020 and December 2021. Inclusion criteria: ASA(American Society of Anesthesiologists) I to III, age ≥ 55 years, education level to complete the cognitive function measurement, and willingness to cooperate. Exclusion criteria: age < 55 years, a mini-mental state examination (MMSE)score ≤ 23 points; central nervous system disease or cerebrovascular disease with sequelae; sedative and anti-depressants, severe alcoholism, or drug dependence; auditory or visual disorders; psychiatric disorders, posttraumatic stress disorder, developmental or mental intellectual disability and cognitive impairment; a history of previous seizures; history of cardiac surgery and neurosurgery; and previous neuropsychological tests.

During the course of the experiment, some patients abandoned surgery for various reasons, changed the operation mode, had an intraoperative tracheotomy, failed to complete the postoperative evaluation, or became unwilling to cooperate with the test postoperatively. Finally, 112 subjects were divided into the POCD and non-POCD groups according to whether POCD occurred within seven days after surgery. The study was performed with the approval of the Ethics Committee of the Stomatological Hospital affiliated to Chongqing Medical University.

Anesthesia Method

Several studies have reported a correlation between depth of anaesthesia and anaesthetic drugs in POCD [12–14]. Therefore, a unified anaesthesia protocol was used in this study.

The patient inhaled oxygen and the heart rate (HR), blood pressure (BP), SpO₂ were monitored, and open peripheral veins. All patients underwent static aspiration compound general anaesthesia, induced with midazolam injection (0.04 mg / kg), rocuronium (0.6 mg / kg), remifentanil hydrochloride injection (2ug / kg), and 1% propofol (1.5−2 mg/kg IV).After nasal tracheal cannulation, the anaesthesia machine was connected and the parameters were set using capacity control mode as follows: tidal volume (VT) 6–8 mL/kg, breath ratio 1:2.0, breathing rate 10–12 times/minute to maintain SpO₂ above 98% and end expiratory carbon dioxide (ETCO₂) of 35–45 mmHg. After induction of anaesthesia, the internal jugular vein and dorsal foot artery were catheterized to continuously monitor the invasive artery pressure (ABP) and central venous pressure (CVP), maintain circulation stability, and place the temperature catheter to monitor internal body temperature. Anaesthesia was maintained by an intravenous pump continuously pumping propofol for sedation [(3–5 mg/(kg·h)], remifentanil hydrochloride analgesia [0.05–0.15 g / (kg · min)], and sevoflurane with a compound inhalation concentration of 1.5-2%. The patient was administered rocuronium to maintain muscle relaxation during the appropriate time period, petCO₂ and inhaled anaesthetic concentration were continuously monitored, and the BIS value of anaesthesia was between 50–60. The patient was connected to the analgesic pump and returned to the ICU. PCIA(Patient Controlled Intravenous Analgesia) configuration: sufentanyl 1 ug / kg + dezocine 0.15 mg / kg + dexmetomidine hydrochloride 1ug / kg + 0.9% normal saline to 100 mL, load of 2 mL, continuous infusion of 2 mL / h, amount of automatic analgesia (PCA) of 1 mL, and locking time of 15 min.

Recorded Indicators

Possible related risk factors for the onset of POCD were recorded, including preoperative general conditions: sex, age, body quality index (BMI), education level, ASA grade, smoking and alcohol consumption history, preoperative serum potassium concentration, history of surgery under general anaesthesia, preoperative combined disease, dyssomnia and preoperative cognitive function. Operation-related conditions included anaesthesia time, intraoperative bleeding volume, intraoperative hypotension. Postoperative related conditions, duration of ICU stay,postoperative infection, the second operation was performed within seven days thereafter and postoperative cognitive function.

Test Tools

As accurate language testing cannot be performed in patients undergoing surgery for oral malignancy within 7 days after surgery,Therefore, the cognitive function at 1 day and 3 days after surgery could not be evaluated.

All patient tests were performed by dedicated experimenters between 2–5 pm. Sleep disorders were assessed using the PSQI(Pittsburgh Sleep Quality Index) scale, which had a total score of 21 points with seven components: subjective sleep quality, sleep incubation time, sleep time, sleep efficiency, night-time sleep disorder, sleeping medication use, and daytime dysfunction, with a maximum of 3 points per component, with higher scores indicating greater sleep disturbances [15].

Cognitive function assessment at one day and seven days postoperatively using multiple neuropsychological test scales to evaluate patient cognitive function changes, including: ① (MMSE), MMSE with a highest score of 30 points, is the most widely used cognitive function assessment scale, which includes 19 items, such as time and location orientation, language immediate memory, attention and computing, reading understanding, drawing, and long-term memory. It has a low sensitivity to mild cognitive impairment ( MCI) [16].In recent years, applications have been limited owing to copyright issues and poor sensitivity [17].②Addenbrooke’s Cognitive Examination (ACE-Ⅲ), ACE-Ⅲ with a maximum score of 100, takes 15–20 min, includes the assessment of five cognitive domains: attention and orientation, memory, verbal fluency, and verbal and visual spatial ability, and a total of 21 cognitive tests. Hsieh et al. [18] found that subtests of attention, memory, language, and optic spatial ability in ACE-Ⅲ were consistent with standard neuropsychological tests; studies have shown that when the cut-off value is 85 points, the sensitivity of the Chinese version of ACE-III diagnosis is 97.3%, and the specificity is 90.7% [19].③Memory and execution screening (MES) is a test mainly used for screening for MCI, without subject writing, little education impact, and high sensitivity and specificity [20].The highest score is 100 points; it takes 5–10 min, and includes tests for immediate memory, fluency, finger, short delay memory, executive ability, and long delay memory, which allows a comprehensive assessment of cognitive and executive functions. Guo et al. [20] found that the MES total score area under the curve (AUC) (95% CI,0.85–0.92) was 0.89, with a sensitivity of 79.5%, and a specificity of 82.8%. When the cut-off value was set to less than 75, there was a correct classification rate of 81%; the MES total score AUC (95%CI, 0.93–0.97) was 0.95, the sensitivity was 87%, the specificity was 91%, and when the cut-off value was set to 72, the correct classification rate was 90% .

For the patients who were unwilling to undergo surgery, 15 patients were selected as controls to undergo cognitive function the diagnosis of POCD was made using the "Z score" comprehensive score method recommended by ISPOCD [21]. POCD was diagnosed if two or more scale tests of Z value ≥ 2 or a total Z value of ≥ 2 existed in the same patient, eliminating the effect of the learning effect in the experimental group; this and is a more reasonable method for the diagnosis of POCD [22].

Statistical analysis

Statistical analysis was performed using SPSS 26.0 software package, data prior normality test, and homogeneity of variance test; normal distribution measures are presented as x ± s, with two independent sample t-tests or non-parametric anecdotal sum tests (Wilcoxon tests) between groups, and skewed distribution measurements were represented as median (M) and interquartile range (IQR), Mann–Whitney U test for group comparisons, and within-group differences were determined by one-way analysis of variance (ANOVA).Count data were statistically analysed using a chi-square test or Fisher exact probability method, and multivariate analysis was performed using logistic regression analysis (P < 0.05).

General condition of the patient

A total of 164 patients were included in the trial, and eventually 112 patients completed the study. Figure 1 illustrates the study flow. There were 72 men (64.3%), 40 women (35.7%), and the average age was (63.83 ± 3.43) years. Judging by the "Z score" comprehensive scoring method, the postoperative incidence of 7-d POCD was 33.1%, including 37 patients in the POCD group and 75 patients in the non-POCD group.

The results of the cognitive function tests in both groups are shown in Table 1; the Day 7 postoperative test results in the POCD group were worse than those of the non-POCD group, and MMSE, ACE-Ⅲ, and MES scores were significantly different compared to the non-POCD group (P < 0.05). The ACE-III, and MES scores were significantly different in the POCD group as compared to the preoperative scores on postoperative Day 7 (P < 0.05).

Table 1

Neuropsychological test results of the POCD and non-POCD groups (x ± s)
	POCD(n = 37)	Non-POCD(n = 75)
	1 d before surgery 7 d after surgery	1 d before surgery	7 d after surgery
MMSE	25.86 ± 1.53 23.05 ± 1.68*	25.55 ± 1.38	25.56 ± 1.46
ACE-Ⅲ	73.73 ± 8.17 65.89 ± 7.71^#*	72.85 ± 6.09	72.69 ± 6.17
MES	72.24 ± 9.60 62.38 ± 9.17^#*	70.09 ± 5.59	69.8 ± 5.28

Comparison of general physical signs and preoperative indicators

A comparison of the general preoperative characteristics and perioperative indicators of group 2 patients is shown in Table 2. Univariate analysis revealed that age, education, preoperative history (including diabetes, hypertension, coronary heart disease, and cerebral infarction), reduced serum potassium concentration, and dyssomnia can increase the risk of 7-d POCD after surgery. The POCD group was older, had a higher incidence of diabetes, hypertension, coronary heart disease, cerebral infarction, low potassium levels, and sleep disturbance. Meanwhile, there were no significant differences between the POCD and non-POCD groups regarding sex, BMI, ASA status, living habits, and respiratory history (P > 0.05).

Table 2

Demographics and clinical data associated with POCD in older patients
	POCD(n = 37)		Non-POCD (n = 75)		P price
Age (year)	65.03 ± 3.69		63.24 ± 3.16		0.023
Sex (n,%)	0.742
Women	14	37.80%	26	34.70%
Men	23	62.20%	49	65.30%
BMI(kg.m^− 2)	24.58 ± 1.60		24.36 ± 1.12		0.456
ASA grade (n,%)	0.383
Ⅰ	15(40.50%)		36(48%)
Ⅱ	18(48.60%)		34(45.30%)
Ⅲ	4(10.80%)		5(6.70%)
Education level (years)	4.97 ± 2.65		6.31 ± 2.61		0.017
Living habits (n,%)
History of smoking	14(37.80%)		33(44.00%)		0.534
History of drinking	15(40.50%)		31(41.30%)		0.936
Medical history (n,%)
History of general anaesthesia surgery	12(32.40%)		23(30.70%)		0.850
Diabetes mellitus	9(24.30%)		6(8.00%)		0.035
Hypertension	16(43.20%)		14(18.70%)		0.006
Coronary disease	8(21.60%)		5(6.70%)		0.029
Disease of respiratory system	3(8.10%)		3(4.00%)		0.364
History of cerebral infarction	7(18.90%)		4(5.30%)		0.039
Sleep disorders (points)	5.51 ± 2.70		4.03 ± 1.99		0.010
Low potassium	9(24.30%)		7(9.30%)		0.033

Comparison of perioperative characteristics

The univariate analysis of the main perioperative characteristics is shown in Table 3. There were no significant differences between the two groups regarding intraoperative bleeding, time in ICU, secondary surgery within 7 days, and postoperative infection (P > 0.05). However, long anaesthesia time and intraoperative hypotension can increase the incidence of POCD 7 days after surgery (P < 0.05).

Table 3

Main perioperative factors associated with POCD in older patients
	POCD(n = 37)	Non-POCD (n = 75)	P price
Time of anaesthesia (min)	514.05 ± 66.35	483.27 ± 61.77	0.013
Intraoperative hypotension (n,%)	9(24.30%)	6(8.00%)	0.035
Intraoperative bleeding (mL)	532.43 ± 127.59	566.67 ± 144.34	0.223
Length of ICU stay (days)	3(2 ~ 4)	2(2 ~ 3)	0.114
Secondary operation within 7 days (n,%)	5(13.50%)	7(9.30%)	0.527
Postoperative infection (n,%)	4(10.80%)	7(9.30%)	0.523
Analysis of the high-risk factors for POCD

Several associated risk factors with significant differences in the univariate analysis were subjected to binary logistic regression analysis. The results are presented in Table 4. Venerable age (OR = 1.269, 95% CI 1.056–1.525, P < 0.05), low education levels(OR = 0.792,95%CI 0.644–0.974,P < 0.05),hypertension(OR = 4.153,

95%CI1.335-12.732,P < 0.05),sleep disorder (OR = 172, 95%CI 1.001-117,P < 0.05),time of anaesthesia extended(OR = 1.009,95%CI1.001-1.018, P < 0.05),and intraoperative hypotension(OR = 5.512,95%CI1.240-24.506,P < 0.05)were independent risk factors for POCD in older patients with oral tumours.

Table 4

Multivariate logistic regression analysis of risk factors for POCD
	OR	The 95% confidence interval was used		P price
		lower limit	superior limit
Age	1.269	1.056	1.525	0.011
Education level	0.792	0.644	0.974	0.027
Diabetes mellitus	2.924	0.653	13.093	0.161
Hypertension	4.153	1.355	12.732	0.013
Coronary disease	2.321	0.417	12.925	0.336
A history of cerebral infarction	3.543	0.639	19.649	0.148
Dyssomnia	1.272	1.001	1.617	0.049
Low potassium	1.206	0.240	6.066	0.820
Anaesthesia time	1.009	1.001	1.018	0.035
Intraoperative hypotension	5.512	1.24	24.506	0.025

The incidence of POCD is widely reported, with studies showing an incidence of 18–32% within one week after undergoing general anaesthesia and non-cardiac surgery in older patients [21,23–26]. Comparing the incidence of patients with POCD one week following several common major surgeries and the duration of surgical anaesthesia with the results of this study (Fig. 2), It was found that the incidence of POCD at one week in older patients with oral malignancies was 33.1%, which is higher than the rates observed in other types of non-cardiac surgery; the duration of surgical anaesthesia was nearly twice that of other procedures. This was a higher incidence than that reported above, possibly because surgery for oral malignancy requires repair to the tissue structure of the defect after tumour resection, surgical trauma is extensive, and excessive stretching and rotation in cervical lymphatic surgery can cause intimal injury to the arterial lining of the head and neck, thereby promoting the formation of micro-emboli, creating carotid artery stenosis, cerebral tissue hypoperfusion, and other risks causing cerebral ischemia [27–29]. These factors often lead to brain damage in patients, causing a decline in cognitive function.

Note: Data were obtained from references 23–26

Advanced age is currently a more explicit risk factor for POCD, and similar results were obtained in the present study. Several studies suggest that the pathogenesis of POCD is neuroinflammation and age are related [30]. The mechanism may be that brain volume and brain white matter integrity decrease with age. Moreover, blood flow to the brain decreases with age, resulting in reduced oxygen delivery, slow metabolism, and age-induced central nervous system apoptosis, which affects neurons, synapses, and neurotransmitters, leading to an increased incidence of POCD in older patients. At the same time, older patients often exhibit a variety of comorbid conditions, and the ability of the body to cope with the injuries caused by surgery and anaesthesia is consequently reduced. Therefore, the risk of perioperative complications and POCD also increases accordingly [31,32]. In conclusion, older patients are more likely to develop POCD after surgery.

The level of education is closely related to the occurrence of POCD [33]. Feinkoh et al. [34] found that in middle-aged and older patients undergoing surgery, years of education are inversely proportional to the incidence of cognitive impairment, and patients with high cognitive reserve display more active brain activity and can better adjust or activate synaptic connections between neurones using neuronal reserve, bypassing damaged areas, and increasing synaptic efficacy to deal with injury. In addition, with low education, there may be exposure to more harmful factors in the living environment, and an unhealthier lifestyle. As such, there may be more serious pathological manifestations in the brain than that of their peers, such as Aβ deposition, which are exacerbated by anaesthesia and progress to cognitive deficiency [35].

In recent years, more researchers have focused on the association between dyssomnia and POCD. The results obtained in this study showed that sleep disturbance is an independent risk factor for POCD. Sleep accounts for about 1/3 of an individual’s life-span and is closely related to human health. Various aspects of sleep are affected to varying degrees in most older adults [36]. Dyssomnia is not conducive to protein synthesis and the establishment of new synaptic connections in the brain, affecting the change in cerebral cortical cognitive potential, leading to neuroendocrine disorders, decreased immune function, deterioration of behaviour, anxiety, depression, irritability, and other complications, thereby inducing or aggravating postoperative cognitive dysfunction [37]. A meta-analysis revealed that various types of sleep disorders, such as difficulty remaining asleep, reduced sleep duration, reduced sleep efficiency, and daytime dysfunction can significantly increase the risk of cognitive impairment [38]. Studies have demonstrated that the intraoperative use of dexmedetomidine can significantly stabilise patient haemodynamics, reduce the occurrence of inflammatory reactions, inhibit free radical generation, reduce sleep disorders caused by the use of other anaesthetic drugs, and exert a certain protective effect on the sleep of patients under general anaesthesia [39].

Hypertension is a common cardiovascular complication in older patients, and studies suggest that hypertension is often accompanied by cerebrovascular and carotid atherosclerotic plaque, which leads to cerebrovascular autoregulation function. Under the stimulation of various related factors during the perioperative period, there can be local or whole cerebral blood flow, cerebral oxygen content further declines, central nervous system transmitter release is reduced, particularly the cholinergic nervous system function is declined, leading to impaired brain function, making hypertensive patients more prone to postoperative cognitive function damage [40]. Spence et al.[41] demonstrated that for every 10 mmHg increase in systolic blood pressure, the risk of cognitive dysfunction increased by 7% compared with that of the control group, and the systolic blood pressure was > 160 mmHg, and cognitive decline was significantly increased .

The duration of anaesthesia was also an independent risk factor for the onset of POCD in this group, and the mean anaesthesia time of patients in the POCD group was higher than that in the non-POCD group, and perhaps the more complex surgical steps during this period led to the occurrence of POCD.More complex surgical steps imply an increase in surgical anaesthesia duration,one study revealed a significant increase in POCD in patients who underwent surgery exceeding 450 min, and prolonged surgical time is a further important predictor of POCD [42]. A systematic review by Freddi Segal-Gidan et al. [43] concluded that shorter anaesthesia time was associated with less risk of POCD. Animal studies confirmed that anaesthesia exposure can change amyloid and tau in mice, which leads to cognitive dysfunction [43].

Currently, the relationship between intraoperative blood pressure and postoperative cognitive function is controversial. Intraoperative hypotension in this study was an independent risk factor for POCD. Operative hypotension leads to a low perfusion state of the brain blood supply and induces free radical damage and other pathological changes. In addition, oxidative stress response can also cause a range of changes in neuronal degeneration and protein apoptotic genes, reducing the molecular expression that create and maintain synaptic connections, thereby impacting memory and cognitive function. A prospective clinical study demonstrated that a single longest cerebrovascular modulation of BP change over 5.03 min was associated with decreased postoperative cognitive function [44]. Therefore, sustained hypotension during general anaesthesia may cause damage to the nervous system of patients with chronic insufficient cerebral perfusion (such as older patients), and preventing intraoperative hypotension helps to prevent POCD [45].

Due to the peculiarity of oral tumour surgery, patients were unable to test for language after surgery, and to mitigate the impact on neuropsychological testing, patients failed to study their altered cognitive function within 7 d after surgery, and in the multivariate analysis, some insensitive indicators were not analysed. In this study, diabetes mellitus, coronary heart disease, history of cerebral infarction, and hypokalaemia were associated with the onset of POCD, but were not independent risk factors for the onset of POCD.A small number of studies have found that risk factors affecting postoperative cognitive impairment may also include intraoperative bleeding, prolonged ICU stay, secondary surgery, and postoperative infection. These two conditions may be related to the present study, this study as a single-centre experiment with a small sample size, so the results no statistically significant differences. Consequently, multicentre observational studies involving large cohorts are required to determine whether current risk factors are of high predictive value.

In 2016, ASA proposed the "Perioperative Brain Health Initiative", which aims to focus on anesthesia-related brain health of elderly patients, explore effective perioperative brain protection measures through multidisciplinary collaboration, and reduce the incidence of CNS complications such as postoperative cognitive dysfunction in elderly patients. The occurrence of POCD is directly related to postoperative recovery and even affects postoperative survival. The aim of this study was to draw high clinical attention to POCD, early detection, early intervention, and to prolong postoperative survival in older patients with oral malignancies.

In this study, the incidence of POCD at 1 week after oral tumour surgery of the older patients was higher than in other non-cardiac surgeries. Advanced age, low education level, hypertension, sleep disturbance, long duration of anaesthesia, and intraoperative hypotension were independent risk factors for POCD in older patients with oral malignancy. Therefore, the active prevention of POCD in older patients with oral malignancies is a problem that clinicians should be paid significant attention and must address. The prevention and treatment of POCD mainly adopts various measures to reduce perioperative brain function injury, including preoperative high-risk screening and postoperative cognitive recovery, reduce adverse stimulation of sleep disorders, cycle stability was maintained, optimize anaesthesia surgery, shorten surgery and anaesthesia time, and avoid the use of drugs with impact on cognitive function. Clinical medical workers are key members of the multidisciplinary perioperative team, and should understand the solutions to reduce the incidence of POCD, identify and manage the perioperative risk factors early, and provide effective preventive intervention treatment for high-risk groups.

Ethics approval and consent to participate

We ensure all methods are implemented in accordance with the relevant guidelines and regulations.

All experimental protocols have been approved by the Ethics Committee of Chongqing Medical University,and participants were explained the ethical aspect of the study.

This work has been carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans, and informed consent was obtained from all subjects.

This study was approved by the Ethics Committee of the Stomatology Hospital affiliated Chongqing Medical University (registration no.CQHS-NT10-2020-121)

Consent for publication

Not applicable.

Availability of data and materials

All data generated or analyzed during this study are not publicly available due to privacy, but are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This study was supported by the Joint project of Chongqing Health Commission and Science and Technology Bureau (Grant No: 2020MSXM098）

Authors' contributions

Dr.Wu prepared all figures and illustration,wrote the main manuscript text.

According to the design of experiment, Dr. Gao regularly followed-up postoperative cognitive function in patients with screening scales, collected and sorted the experiments data.

Dr.Yu was responsible for the experiment of overall planning, designed experiment method path and did the feasibility analysis.

All authors reviewed the manuscript.

Acknowledgements

The authors thank the oral and maxillofacial surgeons of Stomatology Hospital of Chongqing Medical University for their generous and unselfish assistance.

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Analysis of risk factors for postoperative cognitive dysfunction in older patients undergoing surgery for oral malignancies

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Method

Case selection and Grouping

Anesthesia Method

Recorded Indicators

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Statistical analysis

Results

General condition of the patient

Comparison of general physical signs and preoperative indicators

Comparison of perioperative characteristics

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