Incidence and Predictors of Postoperative Cognitive Dysfunction among Elderly Elective Surgical Patients at Selected Governmental Hospitals in Southern Ethiopia, 2023 GC: A Multicenter Prospective Single Arm Cohort Study

Incidence and Predictors of Postoperative Cognitive Dysfunction among Elderly Elective Surgical Patients at Selected Governmental Hospitals in Southern Ethiopia, 2023 GC: A Multicenter Prospective Single Arm Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Incidence and Predictors of Postoperative Cognitive Dysfunction among Elderly Elective Surgical Patients at Selected Governmental Hospitals in Southern Ethiopia, 2023 GC: A Multicenter Prospective Single Arm Cohort Study Medhanit Melese, Hailemariam Tesema, Simeneh Molla This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5461944/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Mar, 2026 Read the published version in BMC Geriatrics → Version 1 posted 16 You are reading this latest preprint version Abstract Introduction: Geriatrics population is the fast-growing age group which accounts for one-third of surgical patients. Body of evidence revealed that postoperative cognitive dysfunction is the commonest complication among older surgical patients. However, there is a huge disparity in the incidence, and independent predictors globally. Besides, evidences are lacking in sub-Saharan Africa as well as in Ethiopia. Objective To assess the incidence and predictors of postoperative cognitive dysfunction among geriatric patients undergoing elective surgery in selected southern governmental hospitals, from February 2023 to October 2023 GC. Method A multi-center single arm prospective cohort study conducted in selected governmental hospitals on patients’ age ≥ 60 years old. Binary logistic regression was used to assess the relationship between dependent and independent variables and p value < 0.05 was used to determine the significance and crude and adjusted odds ratio with 95%CI was calculated to determine the strength of association of the variable. The mean difference between preoperative cognitive status postoperative cognitive statuses at each follow up postoperative day analyzed by repeated measure ANOVA. Result The overall incidence of postoperative cognitive dysfunction was 46.5%, and the trend in incidence displayed a gradual decrease in the mean Montreal Cognitive Assessment score from the 3rd postoperative day to the 30th day [0 day (preoperative) 25.94 ± 2.884, 3rd day 24.18 ± 3.9, 7th day 24.84 ± 3.62, and 30th day 25.23 ± 3.561)] P < 0.0001, large effect size (Partial Eta Squared (ηp2) – 0.98). Age, ASA III classification, female gender, major surgeries, frailty, preoperative depression, type of anesthesia, intraoperative hypotension and blood loss, duration of surgery and anesthesia were significantly associated with POCD with p value < 0.05. Conclusion and recommendation: The study found a substantial incidence of postoperative cognitive dysfunction in geriatric patients following elective surgery. The results of this study demonstrate the scope and complexity of POCD as well as the range of important variables that associated with cognitive dysfunction. It's important for healthcare providers to consider cognitive assessments as part of a holistic approach to patient care, especially for those with risk factors for POCD. geriatrics. Montreal cognitive assessment postoperative cognitive dysfunction surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Aging is a universal and progressive physiological process characterized by changes in organ and tissue structure as well as functional status( 1 ). Because of physiologic, pharmacokinetic, and pharmacodynamics changes brought on by aging, patients over 60 are more likely to develop postoperative cognitive dysfunction (POCD) ( 2 ). These adaptations can potentially result in heightened sensitivity and vulnerability to the effects of surgical procedures, anesthetic drugs, and other medications administered before, during, and after surgery, all of which are recognized to have adverse impacts on cognitive function ( 3 ). Postoperative cognitive dysfunction is typically defined as deterioration in cognitive function that occurs in patients following surgery when their postoperative cognitive status is compared to their preoperative cognitive status. It often diagnosed in the first few days to weeks following surgery ( 5 ), However, some studies have examined longer-term cognitive changes that may persist beyond the immediate recovery period( 6 , 7 ). POCD is a common postoperative brain complication in geriatrics population with worldwide incidence range between 10 to 54% in the first several weeks following surgery ( 8 , 10 , 14 ). The exact mechanisms of POCD are not yet completely understood but likely involve a combination of factors, including inflammation, neuroinflammation, oxidative stress, neurotransmitter imbalances, anesthesia-related effects, cerebral hypoperfusion, and individual susceptibility factors ( 9 , 10 ). Currently, researchers believe that POCD results from a complex interaction between the sensitive brains of patients who are at risk and the stress and inflammation brought on by surgery and anesthesia ( 9 , 11 ). POCD exhibit varying degrees of symptoms. While some patients may notice mild variations, others may experience many aspects of the disorder and present in a severe manner, like difficulty recalling and remembering things, incapacity to finish things, inability to keep up with crosswords and reading Combining tasks, multitasking, Decreased psychomotor abilities, difficulties with language comprehension social integration issues( 8 ). Multitudinous risk factors have been associated with the development of POCD. These include advanced age, lesser times of education, preexisting cognitive impairment, the type and duration of surgery, anesthesia types, and comorbidities. Anyone of any age can get POCD, but elders are more likely to experience it ( 5 , 12 , 13 ). The Impact of POCD had been extends beyond immediate cognitive decline, potentially leading to prolonged hospitalization, increased healthcare costs, decreased quality of life, and added stress for patients as well as their families( 21 ). Furthermore Individuals with cognitive impairments frequently experience psychological and social issues such as prejudice, reliance, and stigma. POCD affects not just the patients but also the care givers, families, and the community at large( 22 ) POCD was linked to higher healthcare utilization and deterioration in function following surgery while a patient was in the hospital. When we compared to patients without POCD, those with POCD were more likely to require a longer length of stay (length of stay; 11 days vs. 8 days; P = 0.01) and pay more for their hospital stays (8973.43 USD vs. 5913.62 USD; P 0.001) ( 23 ). Despite extensive research, the precise mechanisms and risk factors underlying POCD are not fully elucidated. This knowledge gap still hinders the development of targeted prevention and intervention strategies ( 26 ). The majority of studies consistently link educational background to POCD, despite the fact that Ethiopia is a country in East Africa with a high rate of illiteracy, poor coverage, and limited access to education( 27 ) It is therefore difficult to infer from the available data due to sociodemographic differences. Furthermore, our search for evidence turned up with no published studies on postoperative cognitive dysfunction in Ethiopia. So the purpose of this study is assessing the incidence and predictors of postoperative dysfunction in geriatric patient who underwent elective surgery. Methods A multi-center single arm cohort study was conducted from June 2023 to august 2022 at Hawassa University Comprehensive Specialized Hospital, Adare General Hospital and Dilla University Teaching Hospital, with one month follow-up duration. Ethical clearance was obtained from the institutional review board Patients aged over 60 years scheduled for elective surgery during study period who have the willingness to participate in this study at selected hospitals in southern Ethiopia were included. Patients undergoes cardiac surgeries , with pre-existing severe cognitive dysfunction, who had a diagnosis or history of psychiatric disorders, severe auditory(Almost complete or total inability to hear any sounds) and visual disability, and patients with prior cardiac surgery within one year, Patient undergoes Neurosurgery were excluded from the study. Sample Size and sampling procedure To determine the sample size, finite population formula by Taro Yamane’s statistical formula was Used (65). By using geriatric surgical patients under the study period of three months in selected study area which is 195 from logbook of three hospitals. Where: n: signifies the sample size, N: signifies the population under study, e: signifies the margin error. n = N/ 1+ N (e)2 N=195 e= 0.05; e2= 0.025 n = 195/1+ 195(0.025)2 n= 131 by adding 10 % contingency the total 144 geriatric surgical patients were included in the study. A situational analysis was done based on the Recorded logbook of geriatric surgery for six months (December 2021 – May 2022) in each hospital. Based on a six-month logbook trend, 100 geriatric patients had surgery at AGH, 90 geriatric patients had surgery at DUGH, and 300 geriatric patients had elective surgeries at HUCSH. The sample size was eventually allocated proportionately to each hospital based on the average three-month case number of each hospital. Data were gathered from the daily operating room schedule lists of the scheduled patients during the study period using a 3/1 ratio to select systematic random sampling. Operational definition Frailty : Frailty is assessed using the Fried criteria, which considers factors like significant weight loss within the past year, feelings of exhaustion, and low levels of physical activity, poor gait speed, and weak grip strength. The presence of three features indicates frailty, one to two features indicate intermediate frailty, and no features suggest non-frailty (61) Montreal Cognitive Assessment Tool (MoCA): The Montreal Cognitive Assessment Tool (MoCA) is a concise, one-page cognitive screening scale consisting of 30 points and typically takes around 10 minutes to administer. A score of 26 is used as a cutoff to distinguish between different preoperative cognitive states: normal cognitive function, mild cognitive dysfunction, and severe cognitive dysfunction. normal (MoCA scores ≥ 26), mild cognitive dysfunction (20 ≤ MoCA scores < 26), and severe cognitive dysfunction (MoCA scores < 20)(27). Postoperative cognitive dysfunction Postoperative cognitive dysfunction refers to a decline in performance on neuropsychiatric tests that becomes noticeable days to weeks after surgery. It is defined as a postoperative reduction in cognitive function of at least 2 standard deviations from the preoperative MoCA score(15) . Geriatric Depression scale : The Geriatric Depression scale is a self-report tool used to assess depression in older adults. Respondents answer 15 questions with "Yes" or "No," and a score greater than 5 indicates the presence of depression when questions are answered negatively(62). Data analysis procedure Once data was collected it was entered with Epi-data version 4.6 then exported and analyzed by IBM SPSS statistical package version 26. The data analysis was carried out using both descriptive and inferential statistics, describing qualitative variables as frequencies and percentages, and quantitative variables as mean and standard deviation (SD). Normality was checked using Kolmogorov–Smirnov test and outliers were checked by both graphical and non-graphical methods. Bivariate analysis was done by binary logistic regression. Both bi-variable and multivariable logistic regression analyses were performed. In the bi-variable logistic regression, variables showing an association with cognitive impairment at a significance level of p-value < 0.25 were considered for inclusion in the multivariable regression model. The results of the multivariable logistic regression model were reported in terms of adjusted odds ratios (OR) and their corresponding 95% confidence intervals (CI). Variables were considered significantly associated with postoperative cognitive dysfunction when p 10 suggesting multi-collinearity). The strength of the association between variables was determined by analyzing both crude and adjusted odds ratios along with their respective 95% confidence intervals. Missing data and loss to follow-up were addressed by complete case analyses by using assumption of missing not at random (MNAR). To examine repeated measurements, repeated measure ANOVA (Analysis of Variance) was used. The model's adequacy was assessed through the Hosmer and Lemeshow goodness-of-fit test (with a p-value > 0.05 indicating a good fit). Ethical consideration : The study obtained a support letter and ethical clearance from the Institutional Research Ethical Review Board (IRB) of Dilla University College of Health Sciences and Medicine. The significance of the research was clearly communicated, and written informed consent sought from each participant by the data collector. To ensure confidentiality, identifying information was omitted, and codes were used to represent the patients. Participation in the study was entirely voluntary, and participants have had the option to withdraw at any time. The study adhered to the principles outlined in the Helsinki Declaration for human research and reported its findings in accordance with the STROBE checklist. Results Sociodemographic characteristics A total of 144 patients were included with a 97.9% response rate. At 30 th day follow up time three patients were dead so the data (30 th postoperative day MoCA score) was addressed as missing value and analyzed by complete case analyses method. Among these elderly patients majority 73.6 % were males. The mean age of the participants were 71.36 (SD = 8.85) years (Table 1). Table 1: Socio-demographic characteristics of study participants at HUCSH, AGH, DUGH October 2023 (N=144) Variables Frequency percentage Sex Male 106 73.6 Female 38 26.4 Age 60 -70 yrs 64 44.4 71-80 yrs 56 38.9 >80 yrs 24 16.7 Smoking history Yes 15 10.4 No 129 89.6 History of alcohol drinking Yes 30 20.8 No 114 79.2 BMI Underweight 12 8.3 Normal 127 88.2 Overweight 5 3.5 Education level Uneducated 65 45.1 Below 6 grade 29 20.1 6 – 12 grade 26 18.1 Above 12 grade 24 16.7 Chronic disease Yes 64 44.4 No 80 55.6 Perioperative Risk Factors As the distributions of preoperative risk factors showed, the majority of patients are ASA II 120 (83.3%), and around 63 (43.8%) of geriatrics in this study are categorized as prefrail (Table 2). Table 2: perioperative variable distribution of study participants at HUCSH, AGH, DUGH October 2023 (N=144) Variables Frequency Percentage ASA STATUS ASA II 120 83.3 ASA III 24 16.7 SHAPE surgery invasiveness Minor 22 15.3 Intermediate 94 65.3 Major 28 19.4 Frailty Nonfrial 48 33.3 Prefrial 63 43.8% Frial 33 22.9% Type of anesthesia GA 47 32.6 RA 96 66.7 Type of surgery General surgery 42 29.2 Urology 64 44.4 Orthopedics 31 21.5 Gynecology 7 4.9 Postoperative pain severity Mild 19 13.2 Moderate 115 79.9 Sever 10 6.9 Incidence of postoperative cognitive dysfunction The cumulative incidence of postoperative cognitive dysfunction found to be 46.5 % within one month period using preoperative MoCA score. The incidence of cognitive dysfunction decreases as the days following the surgery increase evidenced by at 3rd day postoperatively, 67 patients exhibited POCD, at 7 th and 30 th days of postoperative, 41 patients while 23 patients exhibited POCD respectively (Figure 1). A repeated measure one-way ANOVA with a Greenhouse-Geisser correction were used to determine the difference in mean value of MoCA score of cognitive assessments and it shows statistically significant mean difference between preoperative and postoperative scores (3 rd day, 7 th day, and 30 th day) (F (1.544, 432.32) =54.668, P < 0.0001) with large effect size = 0.98. Post hoc test using the Bonferroni correction revealed a slight decrease in the value of MoCA score at all postoperative assessment days compared with preoperative MoCA score but when we compare each postoperative mean MoCA score the trend show an increment from postoperative day 3 to 30. [0 day(preoperative) 25.94± 2.884, 3 rd day 24.18 ± 3.9, 7 th day 24.84 ± 3.62, and 30 th day 25.23 ± 3.561)] P < 0.0001(Figure 2) (Table 3). Factors associated with postoperative cognitive dysfunction Compared with males, female patients have a high risk of developing cognitive dysfunction postoperatively p value = 0.000, AOR - 2.78(4.14-9.49). While uneducated Patients have 3.456 times high risk of developing POCD than that of patient whose grade is above 12 (p value 0.03, 95% CI (1.06-10.4) (Figure 1) (Table 1). ASA III patients are 8 times high likely to develop POCD than ASA II patients with a significance of p value – 0.008, AOR – 8.3(1.74-19.76). Also Age of patient have significant association with POCD, geriatrics with age greater than 80 years have high risk of developing POCD when compared with the age range between 60 to 70.( p value – 0.03, AOR 7.95(1.90-13.24)(Figure 4) (Table 3). Patient with comorbidity have high incidence rate POCD (59.4%) than that of patient who have no any comorbid illness (35.8%) (p value = 0.01, AOR = 3.74(1.36-10.31). frail patient have 5.04(95% CI,1.8-13.4) chance of developing POCD than non-frail patients(p value – 0.02). Surgery duration greater than 2 hour (p value 0.00, AOR – 1.03(1.01 -1.06) are highly associated with POCD. Below on (table 8) shows significant variables analyzed by bivariate as well as multivariate logistic regression. Table 3 Associated factors of postoperative cognitive dysfunction (N = 144) Variable POCD occurred P value COR(95% CI) P value AOR(995%CI) Yes No Age, years 60 -70 12(18.7) 52(81.3) 0.00 1 1 71 – 80 37(66.1) 19(33.9) 8.43 (3.65-19.48) 0.02 8.04(2.87-12.46)* >80 18(75) 6(25) 13 (4.25-39.72) 0.032 7.95(1.90-13.24) * Sex Male 37(34.9) 69(65.1) 0.00 1 0.00 1 Female 30(78.9) 8(22.1) 7.1(2.9-16.8) 2.78(4.14-9.49)** Alcohol history Yes 28(93.3) 2(6.7) 0.00 26.9(6.1-118.9) 0.00 6.31(5.19-13.34)** No 39(34.2) 75(65.8) 1 1 Educational level Uneducated 34(52.3) 31(47.7) 0.001 9.50(2.54-35.51) 0.03 3.456(1.056 – 10.4)* Below 6 grade 19(65.5) 10(34.5) 0.005 5.48(1.69-17.82) 0.70 0.83(0.21-3.23) 6 – 12 grade 10(38.5) 16(61.5) 0.09 3.13(0.82-11.85 0.56 0.20(0.05-0.84) Above 12 grade 4(16.7) 26(83.3) 1 1 Comorbidity Yes 38(59.4) 26(40.6) 0.06 2.57 (1.31-5.05) 0.01 3.74(1.36-10.31)* No 29(36.2) 51(63.8) 1 1 ASA status ASA 2 48(40) 72(60) 0.001 1 0.008 1 ASA 3 19(79.2) 5(20.8) 5.70(1.99-16.30 8.31(1.74 -19.76)** SHAPE surgical complexity Minor 9(40.9) 13(59.1) 1 1 Intermediate 34(36.2) 60(63.8) 0.679 0.82(0.32-2.113) 0.10 0.478(0.13-1.79) Major 24(85.7) 4(14.3) 0.002 8.67(2.23-33.68) 0.01 6.94(2.31– 20.84)* Frailty Nonfrial 7(14.6) 41(85.4) 0.00 1 1 Prefrial 33(52.4) 30(47.6) 6.35(1.99-15.96) 0.07 4.30(1.79-11.08 )* Frial 27(81.8) 6(18.2) 6.44(2.51-16.52) 0.02 5.048(1.8– 13.4)* Preoperative depression Yes 37(60.7) 24(39.3) 0.004 2.72(1.38-5.38) 0.01 3.65(1.37-9.68)* No 30(36.1) 53(63.9) 1 1 Preoperative cognitive statues Normal 27(32.5) 56(67.5) 0.00 1 1 Mild cognitive dysfunction 40(65.6) 21(34.4) 3.95(1.96-7.95) 0.01 4.68(1.56-13.95)* Type of anesthesia GA 34(72.3) 13(27.7) 0.00 4.99(2.32-10.73) 0.001 1.87(1 .01-2.03 )** Regional anesthesia 33(34.4) 63(65.6) 1 1 Blood loss, ml < 500 ml 31(31.0) 69(69.0) 0.00 1 0.007 1 ≥ 500 ml 36(81.8) 8(18.2) 10.01(4.17-24.04) 1.005(1.00 – 1.01)** Intraoperative hypotension Yes 32(71.1) 13(28.9) 0.00 4.50(2.09-9.673) 0.001 1.786(1.47- 3.06)** No 35(35.4) 64(64.4) 1 1 Duration of surgery 2 hour 34(79.1) 9(20.9) 10.39(3.48-30.99) 0.000 1.037(1.01 – 1.06)** Duration of anesthesia 2 hour 47(47.5) 52(52.5) 1.34(1.05-2.13) 0.001 42.4(4.70 – 377)** Data are presented as p value, crude odd ratio as well as adjusted odd ratio with 95% confidence interval POCD, postoperative cognitive dysfunction, * (significant value), ** (very significant value) DISCUSSION In this study, it was found that 46.5% of geriatric patients who underwent non-cardiac surgery experienced post-operative cognitive dysfunction (POCD). This incidence rate falls within the range of global incidence. According to meta-analysis by Insa Feinkohl et al in 2017, the global incidence of POCD in older adults in the initial weeks after surgery ranges from 10–54%( 32 ). The incidence of POCD in our study is four times greater than what has been observed in studies conducted in India. In India, the incidence rates were reported as 12% on day three, 8% on day seven, and 7.5% after 30 days post-surgery. This disparity is might be attributed to a substantial difference in the number of patients (N = 65) with no formal education in our study, in contrast to the Indian research where only 8 patients were found to be illiterate ( 36 ). The incidence of POCD showed a decreasing trend during each of the follow-up visits, implying that the short-term assessment of POCD conducted on postoperative days 3, 7, and 30 also indicated a gradual reduction in the occurrence of POCD. This observation suggests that POCD may exhibit a transient nature in a subset of patients, while in others, it may persist for an extended duration, possibly extending beyond the 30-day period. This gradual decline in POCD over time aligns with the findings of a prospective observational study carried out in India in 2014, involving 200 patients scheduled for elective non-cardiac surgeries( 36 ). The variance in the incidence between our study (46.5%) and the prospective observational studies conducted by Osman et al. (15%) ( 37 ) and Monk et al. (12.7%) ( 35 ) can be attributed to differences in the timing of cognitive assessments. These earlier studies assessed the occurrence of POCD over an extended period, specifically within 3 to 6 months after surgery. In contrast, our study focused on evaluating POCD as early as the third day following surgery. We observed a significant gender-based difference in the occurrence were women are more likely to develop POCD. These findings are in line with a prospective cohort study conducted by Kotekar and colleagues. One potential explanation for this gender difference is the neuroprotective effect of estrogen. Estrogen is believed to play a protective role in preserving cognitive function, and the decrease in sex steroid hormone levels, particularly after menopause, could be a contributing factor to the higher prevalence and increased severity of conditions such as Alzheimer's disease (AD) in women as compared to men ( 66 ). One of the noteworthy factors that emerged as significant in our study is preoperative depression. However, it's important to highlight that a cohort study conducted by Sophia Wang and her team did not observe any correlation between preoperative depression and the occurrence of postoperative cognitive dysfunction (POCD) 3 months after surgery ( 69 ). One potential explanation for this inconsistency could be the difference in the number of depressed patients included in the two studies. In our study, the number of individuals with depression was relatively higher (n = 61 out of 144), whereas in Sophia Wang's study, the number of depressed patients was lower (n = 16 out of 167). This variation in sample size may have influenced the ability to detect link between preoperative depression and POCD in the respective studies. In our study, we found a striking association between history of alcohol consumption and the development of POCD. Specifically, approximately 97.7% of patients with a history of alcohol use experienced POCD, with p-value of 0.00. Furthermore, the adjusted odds ratio (AOR) was 6.31, indicating a substantially increased risk. Our findings align with the results of other research studies. A prospective cohort study by Xiaoyue et al. revealed that alcohol consumption was a significant predictor for developing POCD, with an odds ratio 1.016 and a 95% CI of 1.009 to 1.024 (p < 0.001) ( 67 ). Additionally, Ljiljana G and her team also concluded that alcohol consumption was a substantial risk factor for POCD, with a p-value of 0.001( 68 ). These collective findings highlight the consistent evidence that links alcohol consumption to a heightened risk of developing postoperative cognitive dysfunction. In a prospective observational study conducted in Turkey in 2016, several factors were identified as influencing the occurrence of POCD. These factors comprised older age (P < 0.001), high ASA scores (P = 0.004), the presence of comorbid conditions (P = 0.025), extended surgical durations (P = 0.018), and reduced postoperative hematocrit levels (P = 0.014). ( 38 ). These findings are in line with the results of our own research, except for the observation that postoperative hematocrit levels were not associated with POCD in our analysis. This variation could be attributed to the fact that in our study area postoperative complete blood count (CBC) tests are not routinely performed unless there is a specific clinical indication. In comparison to nonfrail patients, our study found that frail patients faced a more than four-fold heightened risk of experiencing postoperative cognitive dysfunction. This observation is consistent with the findings of Partridge and colleagues, who also identified an independent link between frailty and cognitive dysfunction, with an odds ratio of 12.55 (P < 0.001) ( 70 ). Given that geriatric syndromes such as frailty and cognitive dysfunction often coexist, this strong association is unsurprising, although frailty has not been extensively evaluated in most previous studies. The question of whether the incidence of postoperative cognitive dysfunction differ between regional anesthesia and general anesthesia remains a topic of discussion. In our study, patients who took regional anesthesia had significantly low risk of postoperative cognitive dysfunction (p = 0.006, AOR = 0.185). A randomized trial conducted by Rasmussen et al. also observed a tendency toward improved cognitive outcomes one week following the surgery. Which aligns with our findings. However, the study revealed that there was no established causal relationship between general anesthesia and long-term postoperative cognitive dysfunction ( 50 ). Interestingly, our study did not find a significant difference in the effect of POCD based on the type of induction agent used. In other different RCT study done by Li WX, Luo RY et al (2019) shows that of geriatric patients undergoing hip or knee replacement surgery while under spinal anesthesia found a lower incidence ( 52 ). A prospective cohort study conducted by Zhang Y. et al. presents results that differ from our research findings. They reported no significant differences in operation time, bleeding, or transfusion between the groups with postoperative cognitive dysfunction (POCD) and those without POCD( 72 ). This difference in findings can likely be attributed to the scope and focus of the studies. In our study, we included a diverse range of surgeries with varying levels of bleeding and durations, which can introduce variability in the data. In contrast, Zhang Y. et al.'s study specifically focused on colorectal surgery, which might have different surgical characteristics and risk factors, leading to distinct results. The variation in surgical types and patient populations between the studies underscores the importance of considering the specific context and surgical procedures when assessing the risk factors for POCD. Different types of surgeries may have unique risk profiles and contributing factors. Strength of the study The first strength is that we included elderly surgical patients from a variety of surgical specialties in three different teaching hospitals in southern Ethiopia which increases generalizability. Including a high response rate and the distinction of being the first research in our region to examine postoperative cognitive dysfunction (POCD) while considering a wide range of potential risk factors. Limitation of the study Our study is not without limitations, these are the limitations of this study. Firstly the study relies on self-reported data for behaviors such as smoking and alcohol consumption, which can introduce potential biases. Secondly the short follow-up duration of study, which may not capture the long-term effects of POCD. Furthermore, this study is a single-arm study, which can restrict the ability to make direct comparisons. Conclusion The study found a substantial incidence of POCD, with 46.5% of the geriatric patients experiencing cognitive dysfunction following surgery. This POCD study in the elderly showed a gradual decline incidence of POCD from early postoperative day 3, day 7 to1 month after surgery. Several demographic characteristics were identified as predictors for POCD, which includes advanced Age, female gender and being uneducated. Also Patients with alcohol drinking history, depression, preoperative mild cognitive dysfunction, frailty, ASA III classification and comorbid illness had an increased risk of POCD. Surgical and anesthesia Factors including Major surgeries, longer duration of surgery, and anesthesia, general anesthesia, as well as intraoperative hypotension and blood loss > 500 ml were also found to be significant risk factors for developing postoperative cognitive dysfunction. These findings underscore the significance of socio-demographic factors, patient clinical statues, psychological factors, surgical and anesthesia factor in cognitive outcomes. Recommendation These study findings shows the magnitude and complexity of POCD and the diverse significant predictors that may contributed to its development. Understanding these factors is crucial for identifying at-risk patients and to providing appropriate care. We suggest considering comprehensive preoperative assessments, including cognitive function and psychological well-being, to identify patient at higher risk of developing POCD. Further research on long term and large scale including preventive strategy should be considered. Abbreviations ASA, American Society of Anesthesiologist ; AGH, Adare General Hospital; COD, Crude Odd Ratio; DUGH, Dilla University general Hospital; HUCSH, Hawassa University Comprehensive Specialized Hospital; MoCA , Montreal Cognitive Assessment; OR/AOR , Odd Ratio/Adjusted Odd Ratio; POCD, postoperative cognitive dysfunction. Declarations Human Ethics and Consent to Participate: Ethical approval was made by Dilla University institutional review Board (IRB) and consent to participate was obtained from all the participants. Funding: No funding was received for this work. Competing interests: No conflict of interest to declare. Author contribution: All authors have made substantial contributions to conception, design, analysis, and interpretation of data, and participated in the critical review. They also contributed to conception, design, and acquisition of data, analysis, and interpretation of data as well as on preparing the manuscript to this study. Availability of data and materials: Data and material can be available where appropriate. Acknowledgments: We would like to thank our data collectors, supervisors, and staff anesthetists’ at all study areas for their genuine support and collaboration. Provenance and peer review: Not commissioned, externally peer-reviewed. ‘Clinical trial number: not applicable.’ References Smith-Osborne A. Life span and resiliency theory: A critical review. Advances in social work. 2007;8(1):152-68. Kotekar N, Shenkar A, Hegde AA, editors. Anesthesia Issues in Geriatrics2018. Hofacer RD, Deng M, Ward CG, Joseph B, Hughes EA, Jiang C, et al. Cell age-specific vulnerability of neurons to anesthetic toxicity. Annals of neurology. 2013;73(6):695-704. Vahia VN. Diagnostic and statistical manual of mental disorders 5: A quick glance. Indian journal of psychiatry. 2013;55(3):220-3. Yang X, Huang X, Li M, Jiang Y, Zhang H. Identification of individuals at risk for postoperative cognitive dysfunction (POCD). 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New insights into the pathophysiology of postoperative cognitive dysfunction. Acta anaesthesiologica Scandinavica. 2010;54(8):951-6. Chi Y, Li Z, Lin C, Wang Q, Zhou Y. Evaluation of the postoperative cognitive dysfunction in elderly patients with general anesthesia. Eur Rev Med Pharmacol Sci. 2017;21(6):1346-54. Daiello LA, Racine AM, Yun Gou R, Marcantonio ER, Xie Z, Kunze LJ, et al. Postoperative Delirium and Postoperative Cognitive Dysfunction: Overlap and Divergence. Anesthesiology. 2019;131(3):477-91. Evered LA, Silbert BS. Postoperative Cognitive Dysfunction and Noncardiac Surgery. Anesthesia and analgesia. 2018;127(2):496-505. Tuch G, Soo WK, Luo KY, Frearson K, Oh EL, Phillips JL. Cognitive Assessment Tools Recommended in Geriatric Oncology Guidelines: A Rapid Review. 2021;28(5):3987-4003. van Sinderen K, Schwarte LA. Diagnostic Criteria of Postoperative Cognitive Dysfunction: A Focused Systematic Review. 2020;2020:7384394. 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(2018).6, 4-11 Suraarunsumrit P, Pathonsmith C, Srinonprasert V, Sangarunakul N, Jiraphorncharas C, Siriussawakul A. Postoperative cognitive dysfunction in older surgical patients associated with increased healthcare utilization: a prospective study from an upper-middle-income country. BMC geriatrics. 2022;22(1):213. Boone MD, Sites B, von Recklinghausen FM, Mueller A, Taenzer AH, Shaefi S. Economic Burden of Postoperative Neurocognitive Disorders Among US Medicare Patients. JAMA network open. 2020;3(7):e208931. Steinmetz J, Christensen KB, Lund T, Lohse N, Rasmussen LS. Long-term consequences of postoperative cognitive dysfunction. Anesthesiology. 2009;110(3):548-55. Berger M, Nadler JW, Browndyke J, Terrando N, Ponnusamy V, Cohen HJ, et al. Postoperative Cognitive Dysfunction: Minding the Gaps in Our Knowledge of a Common Postoperative Complication in the Elderly. Anesthesiol Clin. 2015;33(3):517-50. Daniel B, Agenagnew L. 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Incidence and risk factors for postoperative cognitive dysfunction in older adults undergoing major noncardiac surgery: A prospective study. Journal of anaesthesiology, clinical pharmacology. 2015;31(1):30-6. Ozalp Horsanali B, Ozkalkanli MY, Tekgul ZT, Yilmaz F. Effect of preoperative hospitalisation period on postoperative cognitive dysfunction in patients undergoing hip surgery under regional anaesthesia. International journal of clinical practice. 2021;75(5):e14032. Greaves D, Psaltis PJ, Davis DHJ, Ross TJ, Ghezzi ES, Lampit A, et al. Risk Factors for Delirium and Cognitive Decline Following Coronary Artery Bypass Grafting Surgery: A Systematic Review and Meta-Analysis. Journal of the American Heart Association. 2020;9(22):e017275. Brown Ct, Deiner S. Perioperative cognitive protection. British journal of anaesthesia. 2016;117(suppl 3):iii52-iii61. Needham MJ, Webb CE, Bryden DC. Postoperative cognitive dysfunction and dementia: what we need to know and do. British journal of anaesthesia. 2017;119(suppl_1):i115-i25. Bhushan S, Li Y, Huang X, Cheng H, Gao K, Xiao Z. Progress of research in postoperative cognitive dysfunction in cardiac surgery patients: A review article. International journal of surgery (London, England). 2021;95:106163. Feinkohl I, Winterer G, Pischon T. Hypertension and Risk of Post-Operative Cognitive Dysfunction (POCD): A Systematic Review and Meta-Analysis. Clinical practice and epidemiology in mental health : CP & EMH. 2017;13:27-42. Evered LA, Vitug S, Scott DA, Silbert B. Preoperative Frailty Predicts Postoperative Neurocognitive Disorders After Total Hip Joint Replacement Surgery. Anesthesia & Analgesia. 2020;131(5):1582-8. Wang R, Wang G, Liu Y, Zhang M. Preoperative smoking history is associated with decreased risk of early postoperative cognitive dysfunction in patients of advanced age after noncardiac surgery: a prospective observational cohort study. The Journal of international medical research. 2019;47(2):689-701. Gao L, Taha R, Gauvin D, Othmen LB, Wang Y, Blaise G. Postoperative cognitive dysfunction after cardiac surgery. Chest. 2005;128(5):3664-70. Zhu SH, Ji MH, Gao DP, Li WY, Yang JJ. Association between perioperative blood transfusion and early postoperative cognitive dysfunction in aged patients following total hip replacement surgery. Upsala journal of medical sciences. 2014;119(3):262-7. Wang W, Wang Y, Wu H, Lei L, Xu S, Shen X, et al. Postoperative cognitive dysfunction: current developments in mechanism and prevention. Medical science monitor : international medical journal of experimental and clinical research. 2014;20:1908-12. Canet J, Raeder J, Rasmussen L, Enlund M, Kuipers H, Hanning C, et al. Cognitive dysfunction after minor surgery in the elderly. Acta anaesthesiologica Scandinavica. 2003;47(10):1204-10. Rasmussen LS, Johnson T, Kuipers HM, Kristensen D, Siersma VD, Vila P, et al. Does anaesthesia cause postoperative cognitive dysfunction? A randomised study of regional versus general anaesthesia in 438 elderly patients. Acta anaesthesiologica Scandinavica. 2003;47(3):260-6. Chen F, Duan G, Wu Z, Zuo Z, Li H. Comparison of the cerebroprotective effect of inhalation anaesthesia and total intravenous anaesthesia in patients undergoing cardiac surgery with cardiopulmonary bypass: a systematic review and meta-analysis. BMJ open. 2017;7(10):e014629. Li WX, Luo RY, Chen C, Li X, Ao JS, Liu Y, et al. Effects of propofol, dexmedetomidine, and midazolam on postoperative cognitive dysfunction in elderly patients: a randomized controlled preliminary trial. Chinese medical journal. 2019;132(4):437-45. Zhang Y, Shan GJ, Zhang YX, Cao SJ, Zhu SN, Li HJ, et al. Propofol compared with sevoflurane general anaesthesia is associated with decreased delayed neurocognitive recovery in older adults. British journal of anaesthesia. 2018;121(3):595-604. Royse CF, Andrews DT, Newman SN, Stygall J, Williams Z, Pang J, et al. The influence of propofol or desflurane on postoperative cognitive dysfunction in patients undergoing coronary artery bypass surgery. Anaesthesia. 2011;66(6):455-64. Schoen J, Husemann L, Tiemeyer C, Lueloh A, Sedemund-Adib B, Berger KU, et al. Cognitive function after sevoflurane- vs propofol-based anaesthesia for on-pump cardiac surgery: a randomized controlled trial. BJA: British Journal of Anaesthesia. 2011;106(6):840-50. Siepe M, Pfeiffer T, Gieringer A, Zemann S, Benk C, Schlensak C, et al. Increased systemic perfusion pressure during cardiopulmonary bypass is associated with less early postoperative cognitive dysfunction and delirium. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 2011;40(1):200-7. Yocum GT, Gaudet JG, Teverbaugh LA, Quest DO, McCormick PC, Connolly ES, Jr., et al. Neurocognitive performance in hypertensive patients after spine surgery. Anesthesiology. 2009;110(2):254-61. Berger M, Schenning KJ, Brown CHt, Deiner SG, Whittington RA, Eckenhoff RG, et al. Best Practices for Postoperative Brain Health: Recommendations From the Fifth International Perioperative Neurotoxicity Working Group. Anesthesia and analgesia. 2018;127(6):1406-13. Feng X, Hu J, Hua F, Zhang J, Zhang L, Xu G. The correlation of intraoperative hypotension and postoperative cognitive impairment: a meta-analysis of randomized controlled trials. 2020;20(1):193. Langer T, Santini A, Zadek F, Chiodi M, Pugni P, Cordolcini V, et al. Intraoperative hypotension is not associated with postoperative cognitive dysfunction in elderly patients undergoing general anesthesia for surgery: results of a randomized controlled pilot trial. Journal of clinical anesthesia. 2019;52:111-8. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. The journals of gerontology Series A, Biological sciences and medical sciences. 2001;56(3):M146-56. Greenberg SA. How to try this: the geriatric depression scale: short form. AJN The American Journal of Nursing. 2007;107(10):60-9. Wachtendorf LJ, Azimaraghi O, Santer P, Linhardt FC, Blank M, Suleiman A, et al. Association Between Intraoperative Arterial Hypotension and Postoperative Delirium After Noncardiac Surgery: A Retrospective Multicenter Cohort Study. Anesthesia and analgesia. 2022;134(4):822-33. Breivik H, Borchgrevink PC, Allen SM, Rosseland LA, Romundstad L, Breivik Hals EK, et al. Assessment of pain. BJA: British Journal of Anaesthesia. 2008;101(1):17-24. Yamane Y. Mathematical Formulae for Sample Size Determination. Scientific Research; 1967. Zárate S, Stevnsner T, Gredilla R. Role of Estrogen and Other Sex Hormones in Brain Aging. Neuroprotection and DNA Repair. Frontiers in aging neuroscience. 2017;9:430. Wu X, Zhang N, Zhou B, Liu S, Wang F, Wang J, et al. Alcohol consumption may be associated with postoperative delirium in the elderly: the PNDABLE study. BMC anesthesiology. 2023;23(1):222. Gvozdenović L, Antanasković A. History of alcohol abuse after major non-cardiac surgery and postoperative cognitive dysfunction. European Journal of Internal Medicine. 2015;26(9):e51. Wang S, Cardieri B, Mo Lin H, Liu X, Sano M, Deiner SG. Depression and anxiety symptoms are related to pain and frailty but not cognition or delirium in older surgical patients. Brain and behavior. 2021;11(6):e02164. Partridge JS, Dhesi JK, Cross JD, Lo JW, Taylor PR, Bell R, et al. The prevalence and impact of undiagnosed cognitive impairment in older vascular surgical patients. Journal of vascular surgery. 2014;60(4):1002-11.e3. Bekker A, Lee C, de Santi S, Pirraglia E, Zaslavsky A, Farber S, et al. Does mild cognitive impairment increase the risk of developing postoperative cognitive dysfunction? American journal of surgery. 2010;199(6):782-8. Zhang Y, Bao H-G, Lv Y-L, Si Y-N, Han L, Wang H-Y, et al. Risk factors for early postoperative cognitive dysfunction after colorectal surgery. BMC anesthesiology. 2019;19(1):6. Holt NF, Silverman DG. Modeling perioperative risk: can numbers speak louder than words? Anesthesiol Clin. 2006;24(3):427-59 Additional Declarations No competing interests reported. Supplementary Files POCDsupplementaryfiles.docx Cite Share Download PDF Status: Published Journal Publication published 20 Mar, 2026 Read the published version in BMC Geriatrics → Version 1 posted Editorial decision: Revision requested 02 Jun, 2025 Reviews received at journal 15 Feb, 2025 Reviews received at journal 25 Jan, 2025 Reviewers agreed at journal 19 Jan, 2025 Reviews received at journal 19 Jan, 2025 Reviewers agreed at journal 15 Jan, 2025 Reviewers agreed at journal 14 Jan, 2025 Reviews received at journal 31 Dec, 2024 Reviewers agreed at journal 28 Nov, 2024 Reviewers agreed at journal 27 Nov, 2024 Reviewers agreed at journal 26 Nov, 2024 Reviewers invited by journal 25 Nov, 2024 Editor invited by journal 21 Nov, 2024 Editor assigned by journal 21 Nov, 2024 Submission checks completed at journal 21 Nov, 2024 First submitted to journal 15 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5461944","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":383953547,"identity":"be011879-6859-40b9-a3e2-3656b17a5317","order_by":0,"name":"Medhanit Melese","email":"","orcid":"","institution":"Dilla University","correspondingAuthor":false,"prefix":"","firstName":"Medhanit","middleName":"","lastName":"Melese","suffix":""},{"id":383953548,"identity":"f450ca60-cf6e-4483-8d3a-cf0439f87d4e","order_by":1,"name":"Hailemariam Tesema","email":"data:image/png;base64,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","orcid":"","institution":"Dilla University","correspondingAuthor":true,"prefix":"","firstName":"Hailemariam","middleName":"","lastName":"Tesema","suffix":""},{"id":383953549,"identity":"5dc6771a-bcfe-417f-8461-bed572c56073","order_by":2,"name":"Simeneh Molla","email":"","orcid":"","institution":"Dilla University","correspondingAuthor":false,"prefix":"","firstName":"Simeneh","middleName":"","lastName":"Molla","suffix":""}],"badges":[],"createdAt":"2024-11-15 16:38:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5461944/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5461944/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12877-026-07320-1","type":"published","date":"2026-03-20T15:57:40+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":71890306,"identity":"8c873063-981c-4078-a880-393d13acd96a","added_by":"auto","created_at":"2024-12-19 12:56:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":44545,"visible":true,"origin":"","legend":"\u003cp\u003eIncidence of POCD at 3rd, 7th and 30th days postoperatively\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5461944/v1/d4713249155fcb650b41973b.png"},{"id":71889047,"identity":"2fb4504a-9063-4709-9ae5-b5e65f2ecfa3","added_by":"auto","created_at":"2024-12-19 12:48:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":79111,"visible":true,"origin":"","legend":"\u003cp\u003eMean MoCA score of preoperative, 3rd, 7th and 30th postoperative days’ cognitive assessment.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5461944/v1/a01ec343bd83de1aea2b596b.png"},{"id":71889051,"identity":"66dd89d7-762c-473b-9941-1f3e344e3d00","added_by":"auto","created_at":"2024-12-19 12:48:59","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":88671,"visible":true,"origin":"","legend":"\u003cp\u003eEducational statues versus mean MoCA in each follow-up time\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5461944/v1/6be38e86cc93d53d9cfc2067.png"},{"id":71890307,"identity":"f2beb650-9173-4e20-86ec-ad31e964fa99","added_by":"auto","created_at":"2024-12-19 12:56:59","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":57357,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of age in relation to postoperative cognition\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5461944/v1/7fb93a692a8b2a74eb1be108.png"},{"id":105223691,"identity":"20fb4494-79cf-40f3-b03e-738ecfa56288","added_by":"auto","created_at":"2026-03-23 16:09:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1448341,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5461944/v1/8f0163a5-709a-42ce-bd10-b3cca16aa715.pdf"},{"id":71889062,"identity":"e4b5ebfc-f6b6-4ac6-b783-8acaba7bf18c","added_by":"auto","created_at":"2024-12-19 12:48:59","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":178961,"visible":true,"origin":"","legend":"","description":"","filename":"POCDsupplementaryfiles.docx","url":"https://assets-eu.researchsquare.com/files/rs-5461944/v1/b33411808bba1da395e39d75.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Incidence and Predictors of Postoperative Cognitive Dysfunction among Elderly Elective Surgical Patients at Selected Governmental Hospitals in Southern Ethiopia, 2023 GC: A Multicenter Prospective Single Arm Cohort Study","fulltext":[{"header":"Background","content":"\u003cp\u003eAging is a universal and progressive physiological process characterized by changes in organ and tissue structure as well as functional status(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Because of physiologic, pharmacokinetic, and pharmacodynamics changes brought on by aging, patients over 60 are more likely to develop postoperative cognitive dysfunction (POCD) (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). These adaptations can potentially result in heightened sensitivity and vulnerability to the effects of surgical procedures, anesthetic drugs, and other medications administered before, during, and after surgery, all of which are recognized to have adverse impacts on cognitive function (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePostoperative cognitive dysfunction is typically defined as deterioration in cognitive function that occurs in patients following surgery when their postoperative cognitive status is compared to their preoperative cognitive status. It often diagnosed in the first few days to weeks following surgery (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), However, some studies have examined longer-term cognitive changes that may persist beyond the immediate recovery period(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). POCD is a common postoperative brain complication in geriatrics population with worldwide incidence range between 10 to 54% in the first several weeks following surgery (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe exact mechanisms of POCD are not yet completely understood but likely involve a combination of factors, including inflammation, neuroinflammation, oxidative stress, neurotransmitter imbalances, anesthesia-related effects, cerebral hypoperfusion, and individual susceptibility factors (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Currently, researchers believe that POCD results from a complex interaction between the sensitive brains of patients who are at risk and the stress and inflammation brought on by surgery and anesthesia (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePOCD exhibit varying degrees of symptoms. While some patients may notice mild variations, others may experience many aspects of the disorder and present in a severe manner, like difficulty recalling and remembering things, incapacity to finish things, inability to keep up with crosswords and reading Combining tasks, multitasking, Decreased psychomotor abilities, difficulties with language comprehension social integration issues(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMultitudinous risk factors have been associated with the development of POCD. These include advanced age, lesser times of education, preexisting cognitive impairment, the type and duration of surgery, anesthesia types, and comorbidities. Anyone of any age can get POCD, but elders are more likely to experience it (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Impact of POCD had been extends beyond immediate cognitive decline, potentially leading to prolonged hospitalization, increased healthcare costs, decreased quality of life, and added stress for patients as well as their families(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Furthermore Individuals with cognitive impairments frequently experience psychological and social issues such as prejudice, reliance, and stigma. POCD affects not just the patients but also the care givers, families, and the community at large(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003cp\u003ePOCD was linked to higher healthcare utilization and deterioration in function following surgery while a patient was in the hospital. When we compared to patients without POCD, those with POCD were more likely to require a longer length of stay (length of stay; 11 days vs. 8 days; P\u0026thinsp;=\u0026thinsp;0.01) and pay more for their hospital stays (8973.43 USD vs. 5913.62 USD; P 0.001) (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite extensive research, the precise mechanisms and risk factors underlying POCD are not fully elucidated. This knowledge gap still hinders the development of targeted prevention and intervention strategies (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). The majority of studies consistently link educational background to POCD, despite the fact that Ethiopia is a country in East Africa with a high rate of illiteracy, poor coverage, and limited access to education(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIt is therefore difficult to infer from the available data due to sociodemographic differences. Furthermore, our search for evidence turned up with no published studies on postoperative cognitive dysfunction in Ethiopia. So the purpose of this study is assessing the incidence and predictors of postoperative dysfunction in geriatric patient who underwent elective surgery.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u0026nbsp;A multi-center single arm cohort study was conducted from June 2023 to august 2022 at Hawassa University Comprehensive Specialized Hospital, Adare General Hospital and Dilla University Teaching Hospital, with one month follow-up duration. Ethical clearance was obtained from the institutional review board\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatients aged over 60 years scheduled for elective surgery during study period who have the willingness to participate in this study\u0026nbsp;at selected hospitals in southern Ethiopia were included.\u003c/p\u003e\n\u003cp\u003ePatients undergoes cardiac surgeries , with pre-existing severe cognitive dysfunction, who had a diagnosis or history of psychiatric disorders, severe auditory(Almost complete or total inability to hear any sounds) \u0026nbsp; and visual disability, and patients with prior cardiac surgery within one year, Patient undergoes Neurosurgery were excluded from the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample Size and sampling procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo \u0026nbsp;determine the sample size, finite population formula by Taro Yamane\u0026rsquo;s statistical formula was Used (65). By using geriatric surgical patients under the study period of three months in selected study area which is 195 from logbook of three hospitals.\u003c/p\u003e\n\u003cp\u003eWhere: n: signifies the sample size, N: signifies the population under study, e: signifies the margin error. n = N/ 1+ N (e)2\u003c/p\u003e\n\u003cp\u003eN=195 e= 0.05; e2= 0.025 n = 195/1+ 195(0.025)2\u0026nbsp; \u0026nbsp; n= 131 by adding 10 % contingency the total 144 geriatric surgical patients were included in the study.\u003c/p\u003e\n\u003cp\u003eA situational analysis was done based on the Recorded logbook of geriatric surgery for six months (December 2021 \u0026ndash; May 2022) in each hospital.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBased on a six-month logbook trend, 100 geriatric patients had surgery at AGH, 90 geriatric patients had surgery at DUGH, and 300 geriatric patients had elective surgeries at HUCSH. \u0026nbsp;The sample size was eventually allocated proportionately to each hospital based on the average three-month case number of each hospital. Data were gathered from the daily operating room schedule lists of the scheduled patients during the study period using a 3/1 ratio to select systematic random sampling.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperational definition\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFrailty\u003c/strong\u003e: Frailty is assessed using the Fried criteria, which considers factors like significant weight loss within the past year, feelings of exhaustion, and low levels of physical activity, poor gait speed, and weak grip strength. The presence of three features indicates frailty, one to two features indicate intermediate frailty, and no features suggest non-frailty (61)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMontreal Cognitive Assessment Tool (MoCA):\u0026nbsp;\u003c/strong\u003eThe Montreal Cognitive Assessment Tool (MoCA) is a concise, one-page cognitive screening scale consisting of 30 points and typically takes around 10 minutes to administer. A score of 26 is used as a cutoff to distinguish between different preoperative cognitive states: normal cognitive function, mild cognitive dysfunction, and severe cognitive dysfunction. normal (MoCA scores \u0026ge; 26), mild cognitive dysfunction (20 \u0026le; MoCA scores \u0026lt; 26), and severe cognitive dysfunction (MoCA scores \u0026lt; 20)(27).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative cognitive dysfunction\u003c/strong\u003e Postoperative cognitive dysfunction refers to a decline in performance on neuropsychiatric tests that becomes noticeable days to weeks after surgery. It is defined as a postoperative reduction in cognitive function of at least 2 standard deviations from the preoperative MoCA score(15)\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGeriatric Depression scale\u003c/strong\u003e: The Geriatric Depression scale is a self-report tool used to assess depression in older adults. Respondents answer 15 questions with \u0026quot;Yes\u0026quot; or \u0026quot;No,\u0026quot; and a score greater than 5 indicates the presence of depression when questions are answered negatively(62).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis procedure\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOnce data was collected it was entered with Epi-data version 4.6 then exported and analyzed by IBM SPSS statistical package version 26. The data analysis was carried out using both descriptive and inferential statistics, describing qualitative variables as frequencies and percentages, and quantitative variables as mean and standard deviation (SD). Normality was checked using Kolmogorov\u0026ndash;Smirnov test and outliers were checked by both graphical and non-graphical methods. Bivariate analysis was done by binary logistic regression.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBoth bi-variable and multivariable logistic regression analyses were performed. In the bi-variable logistic regression, variables showing an association with cognitive impairment at a significance level of p-value \u0026lt; 0.25 were considered for inclusion in the multivariable regression model.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe results of the multivariable logistic regression model were reported in terms of adjusted odds ratios (OR) and their corresponding 95% confidence intervals (CI). Variables were considered significantly associated with postoperative cognitive dysfunction when p \u0026lt; 0.05 and multi-collinearity was tested using the variance inflation factor (with a VIF \u0026gt; 10 suggesting multi-collinearity). The strength of the association between variables was determined by analyzing both crude and adjusted odds ratios along with their respective 95% confidence intervals.\u003c/p\u003e\n\u003cp\u003eMissing data and loss to follow-up were addressed by complete case analyses by using assumption of missing not at random (MNAR).\u003c/p\u003e\n\u003cp\u003eTo examine repeated measurements, repeated measure ANOVA (Analysis of Variance) was used. The model\u0026apos;s adequacy was assessed through the Hosmer and Lemeshow goodness-of-fit test (with a p-value \u0026gt; 0.05 indicating a good fit).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical consideration\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study obtained a support letter and ethical clearance from the Institutional Research Ethical Review Board (IRB) of Dilla University College of Health Sciences and Medicine. The significance of the research was clearly communicated, and written informed consent sought from each participant by the data collector. To ensure confidentiality, identifying information was omitted, and codes were used to represent the patients. Participation in the study was entirely voluntary, and participants have had the option to withdraw at any time. The study adhered to the principles outlined in the Helsinki Declaration for human research and reported its findings in accordance with the STROBE checklist.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eSociodemographic characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 144 patients were included with a 97.9% response rate. At 30\u003csup\u003eth\u003c/sup\u003e day follow up time three patients were dead so the data (30\u003csup\u003eth\u003c/sup\u003e postoperative day MoCA score) was addressed as missing value and analyzed by complete case analyses method. Among these elderly patients majority 73.6 % were males. The mean age of the participants were 71.36 (SD = 8.85) years (Table 1).\u003c/p\u003e\n\u003cp\u003eTable 1: \u0026nbsp;Socio-demographic characteristics of study participants at HUCSH, AGH, DUGH October 2023 (N=144)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003epercentage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e73.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e26.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e60 -70 yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e44.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e71-80 yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e38.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026gt;80 yrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking history\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e10.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e129\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e89.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of alcohol drinking\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e20.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e114\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e79.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eUnderweight\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eNormal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e127\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e88.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eOverweight\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eUneducated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e45.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eBelow 6 grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e20.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e6 \u0026ndash; 12 grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e18.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eAbove 12 grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChronic disease\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e44.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e55.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003ePerioperative Risk Factors\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs the distributions of preoperative risk factors showed, the majority of patients are ASA II 120 (83.3%), and around 63 (43.8%) of geriatrics in this study are categorized as prefrail (Table 2).\u003c/p\u003e\n\u003cp\u003eTable 2: \u0026nbsp;perioperative variable distribution of study participants at HUCSH, AGH, DUGH October 2023 (N=144)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003eVariables\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003eFrequency\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003ePercentage\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;ASA \u0026nbsp;STATUS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003eASA II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e83.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003eASA III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; SHAPE surgery invasiveness\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003eMinor\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e15.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003eIntermediate\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e65.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003eMajor\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e19.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Frailty\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003eNonfrial\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003ePrefrial\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e43.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003eFrial\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e22.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Type of anesthesia\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003eGA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e32.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003eRA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Type of surgery\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003eGeneral surgery\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e29.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003eUrology\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e44.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003eOrthopedics\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e21.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003eGynecology\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e\u0026nbsp;4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Postoperative pain severity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003eMild\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003eModerate\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e79.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003eSever\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 176px;\"\u003e\n \u003cp\u003e6.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eIncidence of postoperative cognitive dysfunction\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe cumulative incidence of postoperative cognitive dysfunction found to be 46.5 % within one month period using preoperative MoCA score. The incidence of cognitive dysfunction decreases as the days following the surgery increase evidenced by at 3rd day postoperatively, 67 patients exhibited POCD, at 7\u003csup\u003eth\u003c/sup\u003e and 30\u003csup\u003eth\u003c/sup\u003e days of postoperative, 41 patients while 23 patients exhibited POCD respectively (Figure 1).\u003c/p\u003e\n\u003cp\u003eA repeated measure one-way ANOVA with a Greenhouse-Geisser correction were used to determine the difference in mean value of MoCA score of cognitive assessments and it shows statistically significant mean difference between preoperative and postoperative scores (3\u003csup\u003erd\u003c/sup\u003e day, 7\u003csup\u003eth\u003c/sup\u003e day, and 30\u003csup\u003eth\u003c/sup\u003e day) (F (1.544, 432.32) =54.668, P \u0026lt; 0.0001) with large effect size = 0.98. \u0026nbsp;Post hoc test using the Bonferroni correction revealed a slight decrease in the value of MoCA score at all postoperative assessment days compared with preoperative MoCA score but when we compare each postoperative mean MoCA score the trend show an increment from postoperative day 3 to 30. \u0026nbsp; [0 day(preoperative) 25.94\u0026plusmn; 2.884, 3\u003csup\u003erd\u003c/sup\u003e day 24.18 \u0026plusmn; 3.9, 7\u003csup\u003eth\u003c/sup\u003e day 24.84 \u0026plusmn; 3.62, and 30\u003csup\u003eth\u003c/sup\u003e day 25.23 \u0026plusmn; 3.561)] \u0026nbsp;P \u0026lt; 0.0001(Figure 2) (Table 3). \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eFactors associated with postoperative cognitive dysfunction\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eCompared with males, female patients have a high risk of developing cognitive dysfunction postoperatively p value = 0.000, AOR - 2.78(4.14-9.49). While uneducated Patients have 3.456 times high risk of developing POCD than that of patient whose grade is above 12 (p value 0.03, 95% CI (1.06-10.4) (Figure 1) (Table 1).\u003c/p\u003e\n\u003cp\u003eASA III patients are 8 times high likely to develop POCD than ASA II patients with a significance of p value \u0026ndash; 0.008, AOR \u0026ndash; 8.3(1.74-19.76). Also Age of patient have significant association with POCD, geriatrics with age greater than 80 years have high risk of developing POCD when compared with the age range between 60 to 70.( p value \u0026ndash; 0.03, AOR 7.95(1.90-13.24)(Figure 4) (Table 3).\u003c/p\u003e\n\u003cp\u003ePatient with comorbidity have high incidence rate POCD (59.4%) than that of patient who have no any comorbid illness (35.8%) \u0026nbsp;(p value = 0.01, AOR = 3.74(1.36-10.31). frail patient have 5.04(95% CI,1.8-13.4) chance of developing POCD than non-frail patients(p value \u0026ndash; 0.02).\u003c/p\u003e\n\u003cp\u003eSurgery duration greater than 2 hour (p value 0.00, AOR \u0026ndash; 1.03(1.01 -1.06) are highly associated with POCD. Below on (table 8) shows significant variables analyzed by bivariate as well as multivariate logistic regression. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3 Associated factors of postoperative cognitive dysfunction (N = 144)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"652\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePOCD occurred\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOR(95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAOR(995%CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 652px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge, years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e60 -70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e12(18.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e52(81.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.00 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e71 \u0026ndash; 80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e37(66.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e19(33.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e8.43 (3.65-19.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e8.04(2.87-12.46)*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026gt;80\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e18(75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e6(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e13 (4.25-39.72) \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.032\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e7.95(1.90-13.24) \u0026nbsp;*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 652px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e37(34.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e69(65.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.00\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e30(78.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e8(22.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e7.1(2.9-16.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 135px;\"\u003e\n \u003cp\u003e2.78(4.14-9.49)**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 652px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlcohol history\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e28(93.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2(6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e26.9(6.1-118.9) \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.00\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e6.31(5.19-13.34)**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e39(34.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e75(65.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 135px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 652px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003eUneducated\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e34(52.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e31(47.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e9.50(2.54-35.51) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.03\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e3.456(1.056 \u0026ndash; 10.4)*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eBelow 6 grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e19(65.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e10(34.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5.48(1.69-17.82) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 135px;\"\u003e\n \u003cp\u003e0.83(0.21-3.23) \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e6 \u0026ndash; 12 grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e10(38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e16(61.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e3.13(0.82-11.85 \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 135px;\"\u003e\n \u003cp\u003e0.20(0.05-0.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eAbove 12 grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e4(16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e26(83.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 135px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 652px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e38(59.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e26(40.6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e2.57 (1.31-5.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 135px;\"\u003e\n \u003cp\u003e3.74(1.36-10.31)* \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e29(36.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e51(63.8)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 135px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 652px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eASA status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003eASA 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e48(40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e72(60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.008\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eASA 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e19(79.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e5(20.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e5.70(1.99-16.30 \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 135px;\"\u003e\n \u003cp\u003e8.31(1.74 -19.76)**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 652px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSHAPE \u0026nbsp; \u0026nbsp; surgical complexity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003eMinor\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e9(40.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e13(59.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eIntermediate\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e34(36.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e60(63.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.679\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.82(0.32-2.113)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 135px;\"\u003e\n \u003cp\u003e0.478(0.13-1.79) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eMajor\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e24(85.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e4(14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e8.67(2.23-33.68) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 135px;\"\u003e\n \u003cp\u003e6.94(2.31\u0026ndash; 20.84)*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 652px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrailty\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003eNonfrial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e7(14.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e41(85.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003ePrefrial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e33(52.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e30(47.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e6.35(1.99-15.96) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 135px;\"\u003e\n \u003cp\u003e4.30(1.79-11.08 \u0026nbsp; )*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eFrial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e27(81.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e6(18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e6.44(2.51-16.52) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e5.048(1.8\u0026ndash; 13.4)*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 652px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative depression\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e37(60.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e24(39.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.004 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e2.72(1.38-5.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e3.65(1.37-9.68)*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e30(36.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e53(63.9)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 652px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative cognitive statues\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eNormal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e27(32.5) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e56(67.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eMild cognitive dysfunction\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e40(65.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e21(34.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e3.95(1.96-7.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e4.68(1.56-13.95)*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 652px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eType of anesthesia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003eGA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e34(72.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e13(27.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e4.99(2.32-10.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1.87(1 .01-2.03 \u0026nbsp; \u0026nbsp;)**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eRegional anesthesia\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e33(34.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e63(65.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 135px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 652px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlood loss, ml\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026lt; 500 ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e31(31.0) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e69(69.0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.007\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026ge; 500 ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e36(81.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e8(18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e10.01(4.17-24.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1.005(1.00 \u0026ndash; 1.01)**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 652px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntraoperative hypotension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e32(71.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e13(28.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e4.50(2.09-9.673)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1.786(1.47- 3.06)**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e35(35.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e64(64.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 135px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 652px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026lt; 1 hour\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e8(26.7) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e22(73.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e1 \u0026ndash; 2 hour\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e25(35.2) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e46(64.8)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1.49(0.581-3.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e7.69(2.61-22.63) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026gt;2 hour\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e34(79.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e9(20.9) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e10.39(3.48-30.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1.037(1.01 \u0026ndash; 1.06)**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 652px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of anesthesia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026lt; 1 hour\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e4(66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2(33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.25 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e1 \u0026ndash; 2 hour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e23(59.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e16(41.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.45(0.08-2.581)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e0.12(0.01-3.85) \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u0026gt;2 hour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e47(47.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e52(52.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1.34(1.05-2.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e42.4(4.70 \u0026ndash; 377)**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as p value, crude odd ratio as well as adjusted odd ratio with 95% confidence interval POCD, postoperative cognitive dysfunction, * (significant value), ** (very significant value)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this study, it was found that 46.5% of geriatric patients who underwent non-cardiac surgery experienced post-operative cognitive dysfunction (POCD). This incidence rate falls within the range of global incidence. According to meta-analysis by Insa Feinkohl et al in 2017, the global incidence of POCD in older adults in the initial weeks after surgery ranges from 10\u0026ndash;54%(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe incidence of POCD in our study is four times greater than what has been observed in studies conducted in India. In India, the incidence rates were reported as 12% on day three, 8% on day seven, and 7.5% after 30 days post-surgery. This disparity is might be attributed to a substantial difference in the number of patients (N\u0026thinsp;=\u0026thinsp;65) with no formal education in our study, in contrast to the Indian research where only 8 patients were found to be illiterate (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe incidence of POCD showed a decreasing trend during each of the follow-up visits, implying that the short-term assessment of POCD conducted on postoperative days 3, 7, and 30 also indicated a gradual reduction in the occurrence of POCD. This observation suggests that POCD may exhibit a transient nature in a subset of patients, while in others, it may persist for an extended duration, possibly extending beyond the 30-day period. This gradual decline in POCD over time aligns with the findings of a prospective observational study carried out in India in 2014, involving 200 patients scheduled for elective non-cardiac surgeries(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe variance in the incidence between our study (46.5%) and the prospective observational studies conducted by Osman et al. (15%) (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) and Monk et al. (12.7%) (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) can be attributed to differences in the timing of cognitive assessments. These earlier studies assessed the occurrence of POCD over an extended period, specifically within 3 to 6 months after surgery. In contrast, our study focused on evaluating POCD as early as the third day following surgery.\u003c/p\u003e \u003cp\u003eWe observed a significant gender-based difference in the occurrence were women are more likely to develop POCD. These findings are in line with a prospective cohort study conducted by Kotekar and colleagues. One potential explanation for this gender difference is the neuroprotective effect of estrogen. Estrogen is believed to play a protective role in preserving cognitive function, and the decrease in sex steroid hormone levels, particularly after menopause, could be a contributing factor to the higher prevalence and increased severity of conditions such as Alzheimer's disease (AD) in women as compared to men (\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOne of the noteworthy factors that emerged as significant in our study is preoperative depression. However, it's important to highlight that a cohort study conducted by Sophia Wang and her team did not observe any correlation between preoperative depression and the occurrence of postoperative cognitive dysfunction (POCD) 3 months after surgery (\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e). One potential explanation for this inconsistency could be the difference in the number of depressed patients included in the two studies. In our study, the number of individuals with depression was relatively higher (n\u0026thinsp;=\u0026thinsp;61 out of 144), whereas in Sophia Wang's study, the number of depressed patients was lower (n\u0026thinsp;=\u0026thinsp;16 out of 167). This variation in sample size may have influenced the ability to detect link between preoperative depression and POCD in the respective studies.\u003c/p\u003e \u003cp\u003eIn our study, we found a striking association between history of alcohol consumption and the development of POCD. Specifically, approximately 97.7% of patients with a history of alcohol use experienced POCD, with p-value of 0.00. Furthermore, the adjusted odds ratio (AOR) was 6.31, indicating a substantially increased risk. Our findings align with the results of other research studies. A prospective cohort study by Xiaoyue et al. revealed that alcohol consumption was a significant predictor for developing POCD, with an odds ratio 1.016 and a 95% CI of 1.009 to 1.024 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e). Additionally, Ljiljana G and her team also concluded that alcohol consumption was a substantial risk factor for POCD, with a p-value of 0.001(\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e). These collective findings highlight the consistent evidence that links alcohol consumption to a heightened risk of developing postoperative cognitive dysfunction.\u003c/p\u003e \u003cp\u003eIn a prospective observational study conducted in Turkey in 2016, several factors were identified as influencing the occurrence of POCD. These factors comprised older age (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), high ASA scores (P\u0026thinsp;=\u0026thinsp;0.004), the presence of comorbid conditions (P\u0026thinsp;=\u0026thinsp;0.025), extended surgical durations (P\u0026thinsp;=\u0026thinsp;0.018), and reduced postoperative hematocrit levels (P\u0026thinsp;=\u0026thinsp;0.014). (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). These findings are in line with the results of our own research, except for the observation that postoperative hematocrit levels were not associated with POCD in our analysis. This variation could be attributed to the fact that in our study area postoperative complete blood count (CBC) tests are not routinely performed unless there is a specific clinical indication.\u003c/p\u003e \u003cp\u003eIn comparison to nonfrail patients, our study found that frail patients faced a more than four-fold heightened risk of experiencing postoperative cognitive dysfunction. This observation is consistent with the findings of Partridge and colleagues, who also identified an independent link between frailty and cognitive dysfunction, with an odds ratio of 12.55 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e). Given that geriatric syndromes such as frailty and cognitive dysfunction often coexist, this strong association is unsurprising, although frailty has not been extensively evaluated in most previous studies.\u003c/p\u003e \u003cp\u003eThe question of whether the incidence of postoperative cognitive dysfunction differ between regional anesthesia and general anesthesia remains a topic of discussion. In our study, patients who took regional anesthesia had significantly low risk of postoperative cognitive dysfunction (p\u0026thinsp;=\u0026thinsp;0.006, AOR\u0026thinsp;=\u0026thinsp;0.185). A randomized trial conducted by Rasmussen et al. also observed a tendency toward improved cognitive outcomes one week following the surgery. Which aligns with our findings. However, the study revealed that there was no established causal relationship between general anesthesia and long-term postoperative cognitive dysfunction (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). Interestingly, our study did not find a significant difference in the effect of POCD based on the type of induction agent used. In other different RCT study done by Li WX, Luo RY et al (2019) shows that of geriatric patients undergoing hip or knee replacement surgery while under spinal anesthesia found a lower incidence (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA prospective cohort study conducted by Zhang Y. et al. presents results that differ from our research findings. They reported no significant differences in operation time, bleeding, or transfusion between the groups with postoperative cognitive dysfunction (POCD) and those without POCD(\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e). This difference in findings can likely be attributed to the scope and focus of the studies. In our study, we included a diverse range of surgeries with varying levels of bleeding and durations, which can introduce variability in the data. In contrast, Zhang Y. et al.'s study specifically focused on colorectal surgery, which might have different surgical characteristics and risk factors, leading to distinct results.\u003c/p\u003e \u003cp\u003eThe variation in surgical types and patient populations between the studies underscores the importance of considering the specific context and surgical procedures when assessing the risk factors for POCD. Different types of surgeries may have unique risk profiles and contributing factors.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStrength of the study\u003c/h2\u003e \u003cp\u003eThe first strength is that we included elderly surgical patients from a variety of surgical specialties in three different teaching hospitals in southern Ethiopia which increases generalizability. Including a high response rate and the distinction of being the first research in our region to examine postoperative cognitive dysfunction (POCD) while considering a wide range of potential risk factors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitation of the study\u003c/h2\u003e \u003cp\u003eOur study is not without limitations, these are the limitations of this study. Firstly the study relies on self-reported data for behaviors such as smoking and alcohol consumption, which can introduce potential biases. Secondly the short follow-up duration of study, which may not capture the long-term effects of POCD. Furthermore, this study is a single-arm study, which can restrict the ability to make direct comparisons.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study found a substantial incidence of POCD, with 46.5% of the geriatric patients experiencing cognitive dysfunction following surgery. This POCD study in the elderly showed a gradual decline incidence of POCD from early postoperative day 3, day 7 to1 month after surgery. Several demographic characteristics were identified as predictors for POCD, which includes advanced Age, female gender and being uneducated. Also Patients with alcohol drinking history, depression, preoperative mild cognitive dysfunction, frailty, ASA III classification and comorbid illness had an increased risk of POCD.\u003c/p\u003e \u003cp\u003eSurgical and anesthesia Factors including Major surgeries, longer duration of surgery, and anesthesia, general anesthesia, as well as intraoperative hypotension and blood loss\u0026thinsp;\u0026gt;\u0026thinsp;500 ml were also found to be significant risk factors for developing postoperative cognitive dysfunction. These findings underscore the significance of socio-demographic factors, patient clinical statues, psychological factors, surgical and anesthesia factor in cognitive outcomes.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eRecommendation\u003c/h2\u003e \u003cp\u003eThese study findings shows the magnitude and complexity of POCD and the diverse significant predictors that may contributed to its development. Understanding these factors is crucial for identifying at-risk patients and to providing appropriate care.\u003c/p\u003e \u003cp\u003eWe suggest considering comprehensive preoperative assessments, including cognitive function and psychological well-being, to identify patient at higher risk of developing POCD. Further research on long term and large scale including preventive strategy should be considered.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eASA, American Society of Anesthesiologist ; AGH, Adare General Hospital; COD, Crude Odd Ratio; \u0026nbsp;DUGH, Dilla University general Hospital; HUCSH, Hawassa University Comprehensive Specialized Hospital; \u0026nbsp;MoCA , Montreal Cognitive Assessment; \u0026nbsp;OR/AOR \u0026nbsp; \u0026nbsp; \u0026nbsp; , Odd Ratio/Adjusted Odd Ratio; POCD, postoperative cognitive dysfunction.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate:\u0026nbsp;\u003c/strong\u003eEthical approval was made by Dilla University institutional review Board (IRB) and consent to participate was obtained from all the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNo funding was received for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eNo conflict of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution:\u0026nbsp;\u003c/strong\u003eAll authors have made substantial contributions to conception, design, analysis, and interpretation of data, and participated in the critical review. They also contributed to conception, design, and acquisition of data, analysis, and interpretation of data as well as on preparing the manuscript to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eData and material can be available where appropriate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eWe would like to thank our data collectors, supervisors, and staff anesthetists\u0026rsquo; at all study areas for their genuine support and collaboration.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProvenance and peer review:\u0026nbsp;\u003c/strong\u003eNot commissioned, externally peer-reviewed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lsquo;Clinical trial number: not applicable.\u0026rsquo;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSmith-Osborne A. 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Acta anaesthesiologica Scandinavica. 2003;47(10):1204-10.\u003c/li\u003e\n\u003cli\u003eRasmussen LS, Johnson T, Kuipers HM, Kristensen D, Siersma VD, Vila P, et al. Does anaesthesia cause postoperative cognitive dysfunction? A randomised study of regional versus general anaesthesia in 438 elderly patients. Acta anaesthesiologica Scandinavica. 2003;47(3):260-6.\u003c/li\u003e\n\u003cli\u003eChen F, Duan G, Wu Z, Zuo Z, Li H. Comparison of the cerebroprotective effect of inhalation anaesthesia and total intravenous anaesthesia in patients undergoing cardiac surgery with cardiopulmonary bypass: a systematic review and meta-analysis. BMJ open. 2017;7(10):e014629.\u003c/li\u003e\n\u003cli\u003eLi WX, Luo RY, Chen C, Li X, Ao JS, Liu Y, et al. Effects of propofol, dexmedetomidine, and midazolam on postoperative cognitive dysfunction in elderly patients: a randomized controlled preliminary trial. Chinese medical journal. 2019;132(4):437-45.\u003c/li\u003e\n\u003cli\u003eZhang Y, Shan GJ, Zhang YX, Cao SJ, Zhu SN, Li HJ, et al. Propofol compared with sevoflurane general anaesthesia is associated with decreased delayed neurocognitive recovery in older adults. British journal of anaesthesia. 2018;121(3):595-604.\u003c/li\u003e\n\u003cli\u003eRoyse CF, Andrews DT, Newman SN, Stygall J, Williams Z, Pang J, et al. The influence of propofol or desflurane on postoperative cognitive dysfunction in patients undergoing coronary artery bypass surgery. Anaesthesia. 2011;66(6):455-64.\u003c/li\u003e\n\u003cli\u003eSchoen J, Husemann L, Tiemeyer C, Lueloh A, Sedemund-Adib B, Berger KU, et al. Cognitive function after sevoflurane- vs propofol-based anaesthesia for on-pump cardiac surgery: a randomized controlled trial. BJA: British Journal of Anaesthesia. 2011;106(6):840-50.\u003c/li\u003e\n\u003cli\u003eSiepe M, Pfeiffer T, Gieringer A, Zemann S, Benk C, Schlensak C, et al. 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Alcohol consumption may be associated with postoperative delirium in the elderly: the PNDABLE study. BMC anesthesiology. 2023;23(1):222.\u003c/li\u003e\n\u003cli\u003eGvozdenović L, Antanasković A. History of alcohol abuse after major non-cardiac surgery and postoperative cognitive dysfunction. European Journal of Internal Medicine. 2015;26(9):e51.\u003c/li\u003e\n\u003cli\u003eWang S, Cardieri B, Mo Lin H, Liu X, Sano M, Deiner SG. Depression and anxiety symptoms are related to pain and frailty but not cognition or delirium in older surgical patients. Brain and behavior. 2021;11(6):e02164.\u003c/li\u003e\n\u003cli\u003ePartridge JS, Dhesi JK, Cross JD, Lo JW, Taylor PR, Bell R, et al. The prevalence and impact of undiagnosed cognitive impairment in older vascular surgical patients. Journal of vascular surgery. 2014;60(4):1002-11.e3.\u003c/li\u003e\n\u003cli\u003eBekker A, Lee C, de Santi S, Pirraglia E, Zaslavsky A, Farber S, et al. Does mild cognitive impairment increase the risk of developing postoperative cognitive dysfunction? American journal of surgery. 2010;199(6):782-8.\u003c/li\u003e\n\u003cli\u003eZhang Y, Bao H-G, Lv Y-L, Si Y-N, Han L, Wang H-Y, et al. Risk factors for early postoperative cognitive dysfunction after colorectal surgery. BMC anesthesiology. 2019;19(1):6.\u003c/li\u003e\n\u003cli\u003eHolt NF, Silverman DG. Modeling perioperative risk: can numbers speak louder than words? Anesthesiol Clin. 2006;24(3):427-59\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"geriatrics. Montreal cognitive assessment, postoperative cognitive dysfunction, surgery","lastPublishedDoi":"10.21203/rs.3.rs-5461944/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5461944/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eGeriatrics population is the fast-growing age group which accounts for one-third of surgical patients. Body of evidence revealed that postoperative cognitive dysfunction is the commonest complication among older surgical patients. However, there is a huge disparity in the incidence, and independent predictors globally. Besides, evidences are lacking in sub-Saharan Africa as well as in Ethiopia.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo assess the incidence and predictors of postoperative cognitive dysfunction among geriatric patients undergoing elective surgery in selected southern governmental hospitals, from February 2023 to October 2023 GC.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eA multi-center single arm prospective cohort study conducted in selected governmental hospitals on patients\u0026rsquo; age\u0026thinsp;\u0026ge;\u0026thinsp;60 years old. Binary logistic regression was used to assess the relationship between dependent and independent variables and p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was used to determine the significance and crude and adjusted odds ratio with 95%CI was calculated to determine the strength of association of the variable. The mean difference between preoperative cognitive status postoperative cognitive statuses at each follow up postoperative day analyzed by repeated measure ANOVA.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003eThe overall incidence of postoperative cognitive dysfunction was 46.5%, and the trend in incidence displayed a gradual decrease in the mean Montreal Cognitive Assessment score from the 3rd postoperative day to the 30th day [0 day (preoperative) 25.94\u0026thinsp;\u0026plusmn;\u0026thinsp;2.884, 3rd day 24.18\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9, 7th day 24.84\u0026thinsp;\u0026plusmn;\u0026thinsp;3.62, and 30th day 25.23\u0026thinsp;\u0026plusmn;\u0026thinsp;3.561)] P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001, large effect size (Partial Eta Squared (ηp2) \u0026ndash; 0.98). Age, ASA III classification, female gender, major surgeries, frailty, preoperative depression, type of anesthesia, intraoperative hypotension and blood loss, duration of surgery and anesthesia were significantly associated with POCD with p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003ch2\u003eConclusion and recommendation:\u003c/h2\u003e \u003cp\u003eThe study found a substantial incidence of postoperative cognitive dysfunction in geriatric patients following elective surgery. The results of this study demonstrate the scope and complexity of POCD as well as the range of important variables that associated with cognitive dysfunction. It's important for healthcare providers to consider cognitive assessments as part of a holistic approach to patient care, especially for those with risk factors for POCD.\u003c/p\u003e","manuscriptTitle":"Incidence and Predictors of Postoperative Cognitive Dysfunction among Elderly Elective Surgical Patients at Selected Governmental Hospitals in Southern Ethiopia, 2023 GC: A Multicenter Prospective Single Arm Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-19 12:48:54","doi":"10.21203/rs.3.rs-5461944/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-02T15:55:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-15T08:32:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-25T19:57:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"272224996835115536337808550333786767662","date":"2025-01-19T22:00:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-19T13:44:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"337624491271340338578168529343400419827","date":"2025-01-15T18:06:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9385983555103376772664774993438981709","date":"2025-01-15T02:50:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-31T10:07:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"36630848944456441002765251160506265718","date":"2024-11-28T16:16:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"73625327059472441651875770996050075568","date":"2024-11-27T14:40:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"39772331017250796368220306710351845513","date":"2024-11-26T06:39:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-25T14:31:40+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-11-21T12:29:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-21T11:30:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-21T11:28:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2024-11-15T16:28:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a84204d6-35b9-4df4-bb77-b60c580b69a6","owner":[],"postedDate":"December 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T16:06:21+00:00","versionOfRecord":{"articleIdentity":"rs-5461944","link":"https://doi.org/10.1186/s12877-026-07320-1","journal":{"identity":"bmc-geriatrics","isVorOnly":false,"title":"BMC Geriatrics"},"publishedOn":"2026-03-20 15:57:40","publishedOnDateReadable":"March 20th, 2026"},"versionCreatedAt":"2024-12-19 12:48:54","video":"","vorDoi":"10.1186/s12877-026-07320-1","vorDoiUrl":"https://doi.org/10.1186/s12877-026-07320-1","workflowStages":[]},"version":"v1","identity":"rs-5461944","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5461944","identity":"rs-5461944","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}