Preoperative Anxiety and Postoperative Delirium: A Mini Review of the Association, Mechanisms, and Preventive Strategies

Abstract

Preoperative anxiety, a common perioperative psychological state characterized by restlessness and somatic symptoms, has been reported to affect a broad range of adult surgical patients, with prevalence estimates ranging from approximately 11% to 80% across observational studies, and affects a similar proportion of pediatric patients, with one cross‑sectional study reporting an incidence of around 67.6% in Chinese children undergoing elective surgery. Mounting evidence suggests that preoperative anxiety may be a potential contributing factor to postoperative delirium (POD), an acute cognitive disturbance associated with poor prognosis, increased mortality, and elevated healthcare costs. This mini-review synthesizes the role of preoperative anxiety in predicting POD, highlighting its significance in identifying high-risk populations. This mini-review aims to synthesize current evidence on the impact of preoperative anxiety on POD, clarify underlying pathophysiological mechanisms, and summarize recent pharmacological and non-pharmacological preventive strategies. Mechanistically, preoperative anxiety contributes to POD via systemic and neuroinflammatory responses, blood-brain barrier disruption, postoperative pain amplification, and oxidative stress. Pharmacological interventions (eg, dexmedetomidine, ketamine in pediatric patients) and non-pharmacological strategies (eg, music therapy, virtual reality-based cognitive-behavioral interventions) effectively alleviate preoperative anxiety and reduce POD incidence. Despite progress, the mechanisms linking preoperative anxiety to POD remain incompletely understood, particularly the roles of neuroinflammatory pathways, blood–brain barrier disruption, and the comparative effectiveness of pharmacological versus non-pharmacological interventions. Targeted research in these areas is needed to optimize preventive strategies and improve surgical outcomes.