Durable, functionally impactful, and subjectively evident cognitive decline is a feared outcome of anesthesia and surgery, particularly for older adults (Br J Anaesth 2017;118:486-8). We need to look no further than Dr. Daniel Cole, a coauthor of this article and the editor for this column, to find someone impacted by permanent cognitive decline after major surgery. He has written here, and in a Washington Post article, about his father's experience after coronary artery bypass grafting (CABG). Better handling of the discussion of outcomes like his father's – unanticipated permanent cognitive decline that produces adverse functional impacts perceived by the patient and/or their loved ones – is, and must be, a focus of our care.

Three main streams of evidence inform our approach (Figure 1) to long-term postoperative neurocognitive disorder (PND), formerly termed postoperative cognitive dysfunction/decline (POCD).

Most anesthesiologists are familiar with primary cohort studies of older...

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