Efficacy of Repetitive Transcranial Magnetic Stimulation on Postoperative Delirium in Elderly Patients Undergoing Non-Cardiac Major Surgery: A Randomized Controlled Trial

Abstract

Background: Postoperative delirium (POD) is a frequent complication among elderly surgical patients and is associated with adverse outcomes and increased mortality. Current preventive and therapeutic strategies remain limited. Repetitive transcranial magnetic stimulation (rTMS) has recently shown promise in enhancing cognitive function across various neurological and psychiatric conditions. Objective: This trial aimed to investigate the efficacy of preoperative rTMS on POD in elderly patients undergoing elective non-cardiac surgery. Methods: This double-blind, randomized controlled trial included 254 patients aged 60 years or older undergoing elective non-cardiac surgery, randomly assigned to either active rTMS group or sham rTMS group. Patients received two sessions of 10 Hz rTMS over the left DLPFC, at 110% RMT, totaling 1080 pulses before surgery. The primary outcome was the incidence of POD within 7 days after surgery. Results: In the intention-to-treat analysis of 249 patients (median age 69 years [IQR 63 to 73] years; 46.2% women), the incidence of POD was significantly lower in the active rTMS group (10 of 124 [8.1%]) compared with the sham rTMS group (36 of 125 [28.8%]) (relative risk, 0.22; 95% CI 0.10 to 0.46; p < 0.001). Compared with the sham rTMS group, patients in the active rTMS group had significantly lower pain intensity and sleep quality on postoperative days 1 and 3 (p < 0.001 for each), lower anxiety and depression scores on postoperative days 3 and 7 (p < 0.001 for each), and lower frailty scores on postoperative days 1 and 7 (p < 0.001 for each), while there was no significant differences in PONV scores at any time pointy (p > 0.05 for each). Conclusions: Preoperative high-frequency rTMS targeting left DLPFC was associated with a reduced incidence of POD in elderly patients undergoing elective non-cardiac surgery.