Perioperative Neurocognitive Disorders: A Narrative Review of Pathophysiology, Prevention, and Management Strategies

Background/Objectives: Perioperative neurocognitive disorders (PNDs), including delirium and postoperative cognitive dysfunction, affect 10–50% of elderly surgical patients and are associated with increased morbidity and mortality, as well as substantial healthcare costs. Despite their clinical significance, the underlying mechanisms remain incompletely understood and effective interventions are limited. This narrative review synthesizes current evidence on the pathophysiology, risk factors, and management strategies for PNDs. Methods: We conducted a comprehensive literature review of peer-reviewed publications addressing PND epidemiology, mechanisms, assessment, and interventions. Key databases were searched for studies published through 2025, with emphasis on systematic reviews, meta-analyses, and landmark clinical trials. Results: PND represents a spectrum of cognitive impairments with multifactorial etiology involving neuroinflammation, neurotransmitter imbalances, and blood–brain barrier dysfunction. Advanced age, pre-existing cognitive impairment, and surgical factors constitute major risk domains. Validated assessment tools including the Confusion Assessment Method (CAM) and 4AT enable systematic detection. Multicomponent non-pharmacological interventions demonstrate 30–40% delirium reduction, while pharmacological prevention shows limited efficacy. Emerging evidence links perioperative delirium to accelerated long-term cognitive decline and increased dementia risk. Conclusions: PND represents a significant public health challenge requiring systematic attention in aging surgical populations. Evidence-based multicomponent interventions should be integrated into routine perioperative care pathways. Future research must elucidate mechanistic pathways linking acute delirium to chronic cognitive impairment and develop targeted therapies to preserve cognitive health in surgical populations.