Rethinking perioperative neurocognitive risk reduction in older surgical patients: mobility-preserving analgesia, early mobilization, and multidisciplinary care

Perioperative neurocognitive risk in older surgical patients may be influenced not only by intraoperative anesthetic management, but also by postoperative factors that are modifiable, including pain, opioid exposure, immobility, and delayed rehabilitation. Large randomized trials that compared general anesthesia with neuraxial anesthesia in older patients undergoing hip fracture surgery found no significant differences in the incidence of postoperative delirium (POD) or functional outcomes. These findings have been widely interpreted as evidence that the anesthetic modality used has little impact on perioperative neurocognitive disorders (PND); however, neuraxial techniques and peripheral nerve blocks (PNBs) were not evaluated separately and postoperative analgesic strategies and early mobilization were not standardized in these studies. In this narrative review, we re-examine the current evidence and propose a shift in emphasis from the traditional dichotomy of "general versus regional anesthesia" toward postoperative analgesia, opioid minimization, and early mobilization. We found that, although neuroinflammation is relevant to the biological context of postoperative cognitive decline, direct evidence indicating that PNBs attenuate systemic inflammatory responses or improve neurocognitive outcomes via this mechanism in humans remains limited. Motor-sparing PNBs may be considered potential enablers of effective analgesia, reduced opioid exposure, and early mobilization within a multidisciplinary perioperative pathway, rather than as interventions with an established direct anti-inflammatory or neuroprotective effect. We review procedure-specific recommendations from the PROSPECT guidelines, discuss the role of PNBs within a Brain-Enhanced Recovery After Surgery (Brain-ERAS) framework, and identify priorities for the prospective evaluation of neurocognitive outcomes in older surgical patients.