The emerging clinical practice of measuring and strengthening brain resilience before, during, and after surgery — and the evidence base that makes it clinically urgent.
In the world of perioperative care, we rarely pause to ask the most basic question about the brain: are we doing enough to protect and strengthen it before surgery?
Most research on post-operative cognitive decline has centered on cognitive assessments — tools like the MoCA or MMSE that capture a snapshot of current function. But they only tell us where a patient stands at a single point in time. They don't show us brain resilience, or what could be changed to help the brain recover from the stress of surgery.
Perioperative brain optimization means taking stock of this landscape — measuring the brain's reserve, its vulnerabilities, and its modifiable factors — and working to shore it up before the stress arrives.
After 16 years and more than 10,000 anesthesia cases, I saw firsthand the missed opportunities to measure and support the brain's ability to recover from surgery. Research shows five main neurologic domains that we can measure and strengthen: cardiometabolic health, medication and pain management, sleep and circadian rhythms, lifestyle choices, and brain and social health. This work led to the creation of the NSRI™.
Surgery is not a niche medical event. It is a universal human experience — and the brain is always in the room.
Standard preoperative protocols focus on cardiac and pulmonary function, medication reconciliation, and surgical risk — while neglecting neurologic resilience assessment entirely.
This is not a minor gap. It is a system-wide blind spot.
The NSRI™ research window (closed March 19, 2026) generated the first large-scale dataset of preoperative neurologic resilience — from a health-literate, self-advocating population.
Perioperative brain optimization is not a hypothesis — it is the clinical convergence of five independently established bodies of literature.
Landmark reports in 2017, 2020, and 2024 showing ~45% of dementia cases are attributable to 14 modifiable risk factors. The perioperative period is when these factors become immediately relevant — a surgery date is the deadline.
The 2018 Nomenclature Consensus established the clinical taxonomy for perioperative neurocognitive disorders. The ASA Brain Health Initiative (2019) and APSF (2024) identified delirium prevention as a patient safety priority. An umbrella review identified 73 independent risk factors for POCD.
Metabolic syndrome raises postoperative delirium risk ~1.85×. Insulin resistance independently predicts POCD (AUC 0.742). Blood pressure, lipid dysregulation, and weight are each independently linked to perioperative cognitive risk.
Anticholinergic burden: OR 1.5–3.0 for cognitive adverse effects. Benzodiazepine use: OR 2.0–4.6 for dementia. Chronic widespread pain: 2.55× increased MCI risk (UK Biobank, n=188,594). Benzodiazepine-induced deficits can persist months to years after discontinuation.
Sleep is the single most impactful modifiable domain in the NSRI™ dataset — strongest domain predictor (r=0.681), highest coefficient of variation (CV=31.6%). Preoperative sleep disturbance: OR 2.8 for POCD. In the research window, 17.8% scored below 10/20 on sleep.
Each domain is independently evidence-based, independently modifiable, and independently measured in the NSRI™.
Cardiovascular and metabolic reserve — blood pressure control, glucose regulation, lipid management, metabolic syndrome, and insulin resistance — all directly shape how the brain handles surgical stress.
Uncontrolled metabolic factors are among the most modifiable brain risks in the preoperative window. They are also where measurable changes can be made fastest.
Pharmacologic load — anticholinergic burden, benzodiazepines, polypharmacy, opioid use, and chronic pain — each independently reduce neurologic reserve. This domain captures the often-invisible cognitive cost of the medications patients carry into the OR.
Sleep is the brain's primary recovery system. Sleep quality, duration, OSA risk, and circadian rhythm integrity determine how much reserve the brain carries into a surgical stress event. It is both the most variable and most impactful modifiable domain in the NSRI™ dataset.
Physical activity, nutritional status, alcohol use, hydration, environmental load, and frailty indicators shape the brain's capacity to handle and recover from neurologic stress. D4 is consistently the lowest-scoring domain across the NSRI™ dataset.
Hearing status (the largest single modifiable population-attributable fraction for dementia), social connection, cognitive engagement, depression burden, and accumulated brain reserve — the measurable factors that determine how much cognitive capital the brain brings to surgery.
Beyond modifiable domain scores, the NSRI™ captures a second distinct construct: historical vulnerability.
The Bottleneck Index™ is a multiplicative modifier derived from 10 history sections covering prior neurologic events, traumatic brain injury, surgical history, cancer treatment, connective tissue and autonomic disorders, hormonal transitions, neuroinflammatory infections, and functional frailty.
In the research window dataset, 96.2% of completers carry at least one Bottleneck factor. The Bottleneck Index correlates with the final score at r=−0.710.
The Neurologic Stress & Recovery Index™, developed by Sandra Bargeron, PA-C, CAA, is the first assessment tool designed to quantify perioperative brain resilience across five modifiable domains plus historical vulnerability factors. Approximately 81% of scored items are modifiable in the preoperative window.
Perioperative brain optimization is not a future discipline. It is a measurable, actionable practice that begins before the next surgical procedure.
127 verified peer-reviewed references. Key studies listed by domain.
