Lau Ka To, Chiu Lok Ching Sandra, Fong Janet Shuk Yan, Chan Albert Kam Ming, Ho Kwok Ming, Lee Anna
Faculty of Medicine, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, SAR, China.
Department of Anaesthesia and Intensive Care, Faculty of Medicine, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, SAR, China.
Perioper Med (Lond). 2024 Nov 30;13(1):113. doi: 10.1186/s13741-024-00471-y.
Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) are associated with major morbidity and mortality after surgery. This systematic review and meta-analysis determined whether preoperative cognitive training could reduce POD and POCD in patients undergoing elective surgery.
Eligible randomized controlled trials were identified from CENTRAL, MEDLINE, EMBASE, Scopus, Web of Science, and CINAHL databases from inception to April 30, 2024. Two independent reviewers extracted data on trial characteristics and risk of bias for each trial. We rated the quality of reporting of cognitive training interventions using the template for intervention description and replication (TIDieR) and evaluated the overall certainty (quality) of evidence using The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Random-effects models were used to summarize the treatment effect of cognitive training. Post hoc trial sequential analyses (TSA) were performed for POD and POCD to differentiate between "no evidence of effect" and "evidence of no effect."
Seven trials (four high risk and three unclear risk of bias) involving 864 participants (mean or median age between 66 and 73 years old) were considered eligible and subject to meta-analysis. The quality of reporting cognitive training interventions was fair to moderate. Most cognitive prehabilitation programs were home-based, unsupervised, computerized interventions requiring 2.3-10 h over 1-4 weeks before surgery. Cognitive prehabilitation did not reduce POD (risk ratio [RR] 0.82, 95% confidence interval [CI] 0.57-1.18; I = 30%; low certainty of evidence in five trials) or early POCD after surgery (RR 0.93, 95% CI 0.58-1.49; I = 67%; very low certainty of evidence in four trials) compared to usual care. Nonetheless, TSA suggested that the sample sizes were insufficient to exclude the effectiveness of preoperative cognitive training in reducing POD or POCD. The participants' compliance rate was either not reported or mostly below 70%.
Current evidence is insufficient to determine the beneficial effect of preoperative cognitive training on POD or POCD. Given the well-established benefits of long-term cognitive training on cognition in the elderly, the design of future cognitive prehabilitation trials should be adequately powered and incorporated with strategies to improve patient compliance.
术后谵妄（POD）和术后认知功能障碍（POCD）与手术后的主要发病率和死亡率相关。本系统评价和荟萃分析旨在确定术前认知训练是否能降低择期手术患者的POD和POCD。
从CENTRAL、MEDLINE、EMBASE、Scopus、Web of Science和CINAHL数据库中检索自创建至2024年4月30日符合条件的随机对照试验。两名独立的审阅者提取了每项试验的试验特征和偏倚风险数据。我们使用干预描述和复制模板（TIDieR）对认知训练干预措施的报告质量进行评分，并使用推荐分级、评估、制定和评价（GRADE）系统评估证据的总体确定性（质量）。采用随机效应模型汇总认知训练的治疗效果。对POD和POCD进行事后试验序贯分析（TSA），以区分“无效应证据”和“无效应的证据”。
七项试验（四项高风险和三项偏倚风险不明确）涉及864名参与者（平均或中位年龄在66至73岁之间），被认为符合条件并进行荟萃分析。认知训练干预措施的报告质量为中等至良好。大多数认知预康复计划是基于家庭的、无监督的、计算机化的干预措施，在手术前1至4周内需要2.3至10小时。与常规护理相比，认知预康复并不能降低POD（风险比[RR]0.82，95%置信区间[CI]0.57至1.18；I² = 30%；五项试验中证据的确定性较低）或术后早期POCD（RR 0.93，95%CI 0.58至1.49；I² = 67%；四项试验中证据的确定性非常低）。尽管如此，TSA表明样本量不足以排除术前认知训练在降低POD或POCD方面的有效性。参与者的依从率要么未报告，要么大多低于70%。
目前的证据不足以确定术前认知训练对POD或POCD的有益效果。鉴于长期认知训练对老年人认知功能的益处已得到充分证实，未来认知预康复试验的设计应有足够的效力，并纳入提高患者依从性的策略。
