Abstract
Background
The administration of anesthesia during gastrointestinal endoscopy potentially contributes to post-anesthesia cognitive dysfunction (PACD), with detrimental impacts for cognitive function. This study aimed to assess the knowledge, attitudes, and practices (KAP) towards PACD among patients undergoing gastrointestinal endoscopy in Wenzhou region.
Methods
This cross-sectional study was conducted between June and August 2023, and recruited individuals undergoing gastrointestinal endoscopy. Demographic data and KAP scores were collected through questionnaires. Pearson correlation analysis was applied to evaluate correlations between KAP scores, and logistic regression was utilized to identify influential factors.
Results
We collected 405 valid questionnaires, with 54.57% being male and 29.88% aged 31–40 years. Mean KAP scores were 13.99 ± 4.80, 16.19 ± 2.35, and 15.61 ± 2.86, respectively (possible range: 0–16, 0–25, and 0–25). Pearson correlation analysis demonstrated significant positive correlations between knowledge and practice (r = 0.209, P < 0.001), attitude and practice (r = 0.233, P < 0.001), and knowledge and attitude (r = 0.328, P < 0.001). Multivariate logistic regression revealed negative associations of opting for standard gastrointestinal endoscopy (without anesthesia) with knowledge (OR = 0.227, 95%CI: 0.088–0.582, P = 0.002) and practice scores (OR = 0.336, 95%CI: 0.154–0.731, P = 0.006). Additionally, the presence of cognitive-related diseases or symptoms before undergoing gastrointestinal endoscopy was negatively associated with knowledge scores (OR = 0.429, 95%CI: 0.225–0.818, P = 0.010).
Conclusion
Patients undergoing gastrointestinal endoscopy demonstrated good knowledge, neutral attitudes, and moderate practices regarding PACD. Educational interventions and behavior modification are recommended, particularly for individuals with lower monthly income, undergoing standard gastrointestinal endoscopy, or experiencing cognitive-related conditions.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12871-024-02629-z.
Keywords: Knowledge, Attitude, Practice, Gastrointestinal endoscopy, Post-anesthesia cognitive dysfunction
Background
Gastrointestinal endoscopy encompasses the insertion of specialized instruments into the gastrointestinal tract, enabling real-time visualization and inspection of the esophagus, stomach, intestines, and other associated organs [1]. Given its diagnostic precision and therapeutic significance, gastrointestinal endoscopy plays a pivotal role in clinical practice. However, the negative impacts of gastrointestinal endoscopy still exist post-surgically and extend to broader dimensions of patients’ well-being. Patients undergoing gastrointestinal endoscopy often experience significant psychosocial stressors and physical discomfort [2, 3]. Despite the novel sedative drugs to reduce cognitive dysfunction after endoscopic procedures, such as dexmedetomidine [4, 5] and ketamine [6, 7], the post-anesthesia cognitive dysfunction (PACD) can inadvertently emerge, which imposes long-term implications on cognitive function [8, 9].
PACD represents a multifaceted cognitive impairment following exposure to anesthesia and surgical interventions. These deficits can manifest across a spectrum of cognitive domains, including impairment in memory consolidation, attention, and other aspects of cognitive performance [8]. Moreover, PACD can lead to delayed post-operative recovery, prolonged hospital stays, diminished quality of life, and an elevated risk of long-term cognitive decline [10, 11]. Globally, the incidence of PACD varies across different surgical procedures and patient populations, with reported rates ranging from 10 to 18% [12]. In China, under the circumstances of burgeoning aging population and rising demand for surgical procedures, the prevalence of PACD is gaining recognition as a critical concern within the healthcare landscape [13].
Therefore, the practices towards PACD among patients have been emphasized to optimize clinical outcomes, particularly in the context of gastrointestinal endoscopy. Firstly, effective pre-procedural communication and adherence to lifestyle adjustments and medication management, are vital in preventing PACD [14]. Secondly, discussions with healthcare professionals regarding anesthesia options and associated cognitive risks enables early diagnosis and intervention. Thirdly, diligent adherence to cognitive rehabilitation exercises and follow-up appointments facilitates treatment and rehabilitation [15, 16]. Moreover, the sufficient knowledge of PACD can contribute to its early identification and appropriate management. In addition, the positive attitudes can enable the receptivity of PACD diagnosis and compliance to following treatment. The above findings can raise the hypothesis that positive interrelationships of knowledge, attitudes, and practices (KAP) towards PACD may be found. Despite the increasing understanding of PACD as a critical concern in surgical settings, there is a conspicuous gap in the KAP studies of PACD among patients undergoing gastrointestinal endoscopy.
The study was thus aimed to bridge research gaps by elucidating the KAP towards PACD and exploring the influential factors among patients undergoing gastrointestinal endoscopy. The hypotheses were posited that knowledge can contribute to attitude and practice, and attitude can further enhance practice. The findings have implications for effective strategies to ameliorate the PACD symptoms, and improvement of healthcare among patients undergoing gastrointestinal endoscopy.
Methods
Study design and participants
This cross-sectional study was conducted in hospitals within the Wenzhou region of Zhejiang Province, China, from June to August 2023. The study recruited patients undergoing gastrointestinal endoscopy within this geographical area. This study received an ethical exemption from the Ethics Committee of the First Affiliated Hospital of Wenzhou Medical University on April 24, 2023. Despite the exemption, informed consent was obtained from all participants involved in the study.
Inclusion criteria encompassed: (1) Age 18 or above; (2) Undergoing gastrointestinal endoscopy; (3) Capable of independently completing the questionnaire.
Exclusion criteria encompassed: 2) Declining participation or not providing signed informed consent; 2) With questionnaire completion times less than 90 s; 3) With illogical responses or consistently selecting the same item throughout the questionnaire; 4) With abnormal body mass index (BMI) below 10 or above 40, due to its impacts on cognitive decline [17].
Questionnaire design
The questionnaire design was crafted based on relevant academic literature [1, 8, 10, 18–20], and subsequently underwent iterative revisions guided by feedback from three gastroenterology specialists. Following the initial questionnaire draft, a small-scale pilot study involving 50 participants yielded a Cronbach’s α coefficient of 0.703, signifying good internal consistency among the questionnaire items.
The finalized questionnaire was conducted in the Chinese language and was structured into four dimensions. Demographic dimension consisted of 11 items related to demographic details from the participants. The items included age, BMI, gender, marital status, residence, education level, average monthly family income, occupation, reasons for undergoing gastrointestinal endoscopy, type of gastrointestinal endoscopy, history of general anesthesia surgery and cognitive-related diseases or symptoms before undergoing gastrointestinal endoscopy. Knowledge dimension encompassed 8 questions to assess the knowledge of PACD. Correct responses were assigned a score of 2 points, unclear responses were rated a score of 1 point, and incorrect answers received a score of 0 points. The total score of the dimension ranged from 1 to 16 points. Attitude dimension included 5 questions to evaluate the intensity of attitudes towards PACD. All of questions were rated using a five-point Likert scale. The total score of the dimension ranged from 5 to 25 points. Practice dimension comprised 5 questions to gauge the extent of actions related to PACD, and five-point Likert scale was also employed for rating. The total score of the dimension ranged from 5 to 25 points.
To evaluate the levels of KAP, we utilized cutoff values corresponding to 60% and 80% of the total score. Participants were stratified into three categories within each KAP dimension: good knowledge, positive attitude, and proactive practice (80–100%); moderate knowledge, neutral attitude, and moderate practice (60–79%); inadequate knowledge, negative attitude, and inappropriate practice (below 60%) [21].
Sample size calculation
The sample size was calculated using the following formula [22]:
 |
where z = 1.96 at the type I error of 0. 05, and d represents the acceptable margin of error and is set at 0.05. p is assumed to be 0.5 to ensure the maximum sample size. Based on the above, the sample size was calculated as 384.
Questionnaire distribution
An online questionnaire was constructed using the “Wenjuanxing” survey platform integrated with WeChat. A unique QR code was generated for data gathering via WeChat, and participants accessed and completed the questionnaire by scanning the provided QR code. The questionnaires were completed in the preoperative waiting room prior to surgery, ensuring that subsequent anesthesia and surgical procedures do not affect patients’ subjective cognition of PACD. Strict measures were in place to maintain data quality and comprehensiveness. Each IP address was restricted to a single submission, and all questions were obligatory. The research team diligently reviewed questionnaires for completeness, internal consistency, and reasonableness.
Statistical analyses
Descriptive analysis was firstly carried out on demographic data and KAP scores. Continuous data were expressed as mean and standard deviation (SD), while count data were presented as n (%). To assess differences in KAP scores among respondents with varying demographic characteristics, the following approaches were employed. For continuous variables, normality testing was initially conducted, and if data followed normal distribution, Student’s t test was used for comparing two groups; otherwise, the Mann-Whitney test was applied. In cases involving continuous variables with three or more groups, ANOVA was employed for normally distributed data with equal variances, while the Kruskal-Wallis test was used for non-normally distributed data.
Pearson correlation analysis was carried out to explore the interrelationships of KAP scores. Logistic regression analysis was further conducted with KAP scores as dependent variables. The median values of KAP scores in each dimension were utilized as cutoff points for exploring influencing factors. Variables with P values < 0.05 in univariate regression were further included in the multivariate logistic regression analysis. A significance threshold of P < 0.05 was applied for all statistical analyses. Statistical analyses were performed using SPSS 26.0 (IBM Corp., Armonk, N.Y., USA).
Results
Baseline characteristics
A total of 506 questionnaires were initially collected. We excluded questionnaires based on the following criteria: seven were completed in under 100 s, eight lacked informed consent, 16 contained age outliers, and seven respondents were under 18 years old. Additionally, 67 entries were excluded for having abnormal BMI values (BMI < 10 or > 40). Ultimately, 405 questionnaires were considered valid for analysis. The most prevalent age group among participants was 31–40 years (29.88%), and a significant proportion held a bachelor’s degree (26.42%). The majority were male (54.57%), with a BMI ranging from 18.5 to 23.9 kg/m² (56.54%). A considerable number were married (74.57%) and resided in urban areas (53.09%). Regarding the motivation for gastrointestinal endoscopy, 63.95% opted for disease screening (routine check-up), and a substantial 90.86% underwent general anesthesia gastrointestinal endoscopy. Furthermore, 48.64% had a history of general anesthesia surgery, and 15.31% reported cognitive-related diseases or symptoms before undergoing gastrointestinal endoscopy (Table 1).
Table 1.
Baseline characteristics of participants
| N (%) | Knowledge score | Attitude score | Practice score | ||||
|---|---|---|---|---|---|---|---|
| mean ± SD | P | mean ± SD | P | Mean ± SD | P | ||
| Total | 405 | 13.99 ± 4.80 | 16.19 ± 2.35 | 15.61 ± 2.86 | |||
| Age | 0.401 | 0.923 | 0.573 | ||||
| 30 years and below | 106 (26.17) | 13.62 ± 4.85 | 16.24 ± 2.52 | 15.52 ± 3.20 | |||
| 31–40 years | 121 (29.88) | 13.87 ± 4.81 | 16.20 ± 2.31 | 15.48 ± 2.56 | |||
| 41–50 years | 118 (29.14) | 14.61 ± 5.00 | 16.24 ± 2.36 | 15.60 ± 2.79 | |||
| 50 years and above | 60 (14.81) | 13.67 ± 4.25 | 16.00 ± 2.11 | 16.08 ± 2.96 | |||
| BMI | 0.682 | 0.677 | 0.892 | ||||
| < 18.5 | 47 (11.60) | 14.38 ± 5.14 | 15.91 ± 2.48 | 15.47 ± 2.87 | |||
| 18.5–23.9 | 229 (56.54) | 13.82 ± 4.68 | 16.21 ± 2.27 | 15.67 ± 2.99 | |||
| > 24 | 129 (31.85) | 14.16 ± 4.89 | 16.26 ± 2.44 | 15.57 ± 2.62 | |||
| Gender | 0.408 | 0.966 | 0.367 | ||||
| Male | 221 (54.57) | 13.81 ± 4.77 | 16.19 ± 2.33 | 15.50 ± 2.61 | |||
| Female | 184 (45.43) | 14.21 ± 4.84 | 16.20 ± 2.37 | 15.76 ± 3.13 | |||
| Marital Status | 0.883 | 0.644 | 0.057 | ||||
| Unmarried | 89 (21.98) | 14.04 ± 4.95 | 16.28 ± 2.37 | 15.27 ± 3.15 | |||
| Married | 302 (74.57) | 13.94 ± 4.73 | 16.14 ± 2.35 | 15.75 ± 2.79 | |||
| Divorced | 12 (2.96) | 15.00 ± 5.75 | 16.50 ± 2.11 | 14.25 ± 1.14 | |||
| Widowed | 2 (0.49) | 13.00 ± 4.24 | 18.00 ± 0.00 | 19.00 ± 1.41 | |||
| Residence | 0.011 | 0.607 | 0.428 | ||||
| Urban | 215 (53.09) | 14.56 ± 5.10 | 16.25 ± 2.29 | 15.72 ± 2.78 | |||
| Rural | 190 (46.91) | 13.35 ± 4.35 | 16.13 ± 2.41 | 15.49 ± 2.94 | |||
| Education Level | 0.016 | 0.885 | 0.083 | ||||
| Primary school or below | 32 (7.90) | 13.19 ± 4.12 | 15.88 ± 2.01 | 16.16 ± 3.41 | |||
| Junior high school | 87 (21.48) | 12.80 ± 4.16 | 16.24 ± 2.23 | 15.60 ± 2.40 | |||
| High school/Technical school | 74 (18.27) | 13.59 ± 4.49 | 16.03 ± 2.51 | 15.41 ± 2.71 | |||
| College | 94 (23.21) | 14.36 ± 4.89 | 16.34 ± 2.27 | 15.06 ± 2.89 | |||
| Bachelor’s degree | 107 (26.42) | 14.90 ± 5.31 | 16.26 ± 2.52 | 16.17 ± 3.05 | |||
| Master’s degree or above | 11 (2.72) | 16.36 ± 5.28 | 15.82 ± 2.23 | 14.91 ± 2.63 | |||
| Average Monthly Family Income (in RMB) | 0.025 | 0.183 | 0.009 | ||||
| < 5000 | 83 (20.49) | 13.01 ± 4.04 | 15.98 ± 2.09 | 15.71 ± 3.08 | |||
| 5000–10,000 | 153 (37.78) | 13.62 ± 4.67 | 16.03 ± 2.46 | 15.19 ± 2.61 | |||
| 10001–20000 | 98 (24.20) | 14.86 ± 4.93 | 16.24 ± 2.23 | 16.40 ± 2.91 | |||
| > 20,000 | 71 (17.53) | 14.73 ± 5.43 | 16.70 ± 2.50 | 15.34 ± 2.86 | |||
| Occupation | 0.001 | 0.704 | 0.284 | ||||
| Student | 26 (6.42) | 14.31 ± 4.95 | 16.65 ± 2.43 | 15.65 ± 3.38 | |||
| Worker | 30 (7.41) | 11.60 ± 3.04 | 15.60 ± 1.75 | 14.70 ± 2.17 | |||
| Farmer | 25 (6.17) | 14.40 ± 4.40 | 16.64 ± 2.22 | 16.28 ± 3.27 | |||
| Self-employed | 139 (34.32) | 13.51 ± 4.67 | 16.06 ± 2.37 | 15.42 ± 2.80 | |||
| Civil servant or public institution employee | 59 (14.57) | 16.37 ± 5.06 | 16.20 ± 2.68 | 15.90 ± 2.90 | |||
| Company employee | 89 (21.98) | 14.02 ± 5.02 | 16.37 ± 2.31 | 15.93 ± 2.91 | |||
| Retired | 8 (1.98) | 15.00 ± 4.66 | 16.50 ± 1.60 | 16.88 ± 2.30 | |||
| No formal employment | 14 (3.46) | 13.71 ± 4.36 | 16.21 ± 2.83 | 14.86 ± 2.77 | |||
| Other | 15 (3.70) | 12.13 ± 4.10 | 15.73 ± 1.94 | 15.13 ± 2.53 | |||
| Reasons for Undergoing Gastrointestinal Endoscopy | 0.806 | 0.849 | 0.676 | ||||
| Disease screening (routine check-up) | 259 (63.95) | 14.16 ± 4.92 | 16.27 ± 2.35 | 15.73 ± 3.02 | |||
| Disease diagnosis (recommended by a doctor) | 120 (29.63) | 13.68 ± 4.55 | 16.07 ± 2.40 | 15.49 ± 2.65 | |||
| Disease treatment | 16 (3.95) | 13.88 ± 5.14 | 16.06 ± 1.98 | 15.06 ± 2.08 | |||
| Other | 10 (2.47) | 13.40 ± 4.43 | 15.90 ± 2.18 | 15.10 ± 2.13 | |||
| Type of Gastrointestinal Endoscopy | < 0.001 | 0.185 | 0.003 | ||||
| General anesthesia gastrointestinal endoscopy | 368 (90.86) | 14.28 ± 4.86 | 16.24 ± 2.33 | 15.75 ± 2.80 | |||
| Standard gastrointestinal endoscopy (without anesthesia) | 37 (9.14) | 11.14 ± 2.89 | 15.70 ± 2.44 | 14.30 ± 3.12 | |||
| History of General Anesthesia Surgery | 0.837 | 0.884 | 0.213 | ||||
| Yes | 197 (48.64) | 14.04 ± 4.76 | 16.17 ± 2.33 | 15.80 ± 2.96 | |||
| No | 208 (51.36) | 13.94 ± 4.85 | 16.21 ± 2.36 | 15.44 ± 2.76 | |||
| Cognitive-related Diseases or Symptoms Before Undergoing Gastrointestinal Endoscopy | 0.004 | 0.054 | 0.634 | ||||
| Yes | 62 (15.31) | 12.39 ± 4.17 | 15.66 ± 2.34 | 15.77 ± 2.66 | |||
| No | 343 (84.69) | 14.28 ± 4.85 | 16.29 ± 2.34 | 15.59 ± 2.90 | |||
Knowledge
The participants exhibited an average knowledge score of 13.99 ± 4.80. Those residing in urban areas (P = 0.011), holding a master’s degree or higher (P = 0.016), having an average monthly income of 10,001–20,000 RMB (P = 0.025), working as civil servants or in public institutions (P = 0.001), undergoing general anesthesia gastrointestinal endoscopy (P < 0.001), and not reporting cognitive-related diseases or symptoms before the procedure (P = 0.004) achieved significantly higher knowledge scores (Table 1). Correct response rates varied from 20.99 to 64.94% within the Knowledge section. For example, 69.94% were aware that major surgery under anesthesia may result in memory decline, cognitive impairment, decreased reasoning ability, visual and hearing impairments, etc. (K7). Conversely, only 20.99% were familiar with the notion that pain-free gastrointestinal endoscopy may lead to postoperative difficulty in concentration (K1). Furthermore, a mere 24.44% of participants knew that pain-free gastrointestinal endoscopy may lead to memory decline (K3) (Table 2).
Table 2.
Distribution of scores in the knowledge dimension
| Knowledge | Correct N (%) |
|---|---|
| 1. Pain-free gastrointestinal endoscopy may lead to postoperative difficulty in concentration. | 85 (20.99) |
| 2. Pain-free gastrointestinal endoscopy may result in difficulty in language expression. | 128 (31.60) |
| 3. Pain-free gastrointestinal endoscopy may lead to memory decline. | 99 (24.44) |
| 4. Pain-free gastrointestinal endoscopy may cause postoperative cognitive impairment. | 185 (45.68) |
| 5. Pain-free gastrointestinal endoscopy may affect reasoning ability and result in slowed thinking. | 141 (34.81) |
| 6. Pain-free gastrointestinal endoscopy may lead to visual and hearing impairments. | 158 (39.01) |
| 7. Major surgery under anesthesia may result in memory decline, cognitive impairment, decreased reasoning ability, visual and hearing impairments, etc. | 263 (64.94) |
| 8. Pain-free gastrointestinal endoscopy has a short anesthesia duration, and anesthesia drugs are metabolized quickly, usually being excreted from the body within 4–6 h. | 154 (38.02) |
Attitude
The participants exhibited an average attitude score of 16.19 ± 2.35 (Table 1). The positive response rates varied from 17.53 to 59.50%. A majority (59.50%) of participants expressed a positive attitude toward being open to receiving more information from the doctor about the procedure’s complications to better comprehend potential risks related to gastrointestinal endoscopy and to alleviate concerns about cognitive dysfunction (A3). In contrast, only 17.53% of participants agreed with the notion that questions about cognitive function caused anxiety and concern during the anesthesia assessment before gastrointestinal endoscopy (A2). Similarly, a mere 21.73% concurred that their primary reason for choosing standard gastrointestinal endoscopy was its cost-effectiveness rather than concerns about anesthesia-related complications (A5) (Table 3).
Table 3.
Distribution of scores in the attitude dimension
| Attitude | Strongly agree N (%) | Agree N (%) | Neutral N (%) | Disagree N (%) | Strongly disagree N (%) |
|---|---|---|---|---|---|
| 1. Are you concerned about the possibility of experiencing cognitive dysfunction after undergoing general anesthesia surgery? | 23 (5.68) | 105 (25.93) | 100 (24.69) | 113 (27.90) | 64 (15.80) |
| 2. During the anesthesia assessment before gastrointestinal endoscopy, did questions about cognitive function cause you anxiety and concern? | 10 (2.47) | 61 (15.06) | 144 (35.56) | 122 (30.12) | 68 (16.79) |
| 3. Before undergoing gastrointestinal endoscopy, would you be willing for the doctor to provide more information about the complications of the procedure to help you better understand the potential risks associated with gastrointestinal endoscopy and alleviate your concerns about cognitive dysfunction? | 93 (22.96) | 148 (36.54) | 95 (23.46) | 45 (11.11) | 24 (5.93) |
| 4. Do you believe that pain-free gastrointestinal endoscopy is more comfortable than standard gastrointestinal endoscopy, but due to the use of anesthesia agents, it is not as safe as standard gastrointestinal endoscopy? | 30 (7.41) | 73 (18.02) | 184 (45.43) | 105 (25.93) | 13 (3.21) |
| 5. Do you think the primary reason for choosing standard gastrointestinal endoscopy is that it is more cost-effective rather than concerns about the complications of anesthesia? | 25 (6.17) | 63 (15.56) | 203 (50.12) | 91 (22.47) | 23 (5.68) |
Practice
The participants demonstrated an average practice score of 15.61 ± 2.86. Significantly higher practice scores were achieved by participants with an average monthly family income of 10,001–20,000 RMB (P = 0.009) and those who chose general anesthesia for gastrointestinal endoscopy (P = 0.003) (Table 1). Adherence to recommended practices varied among participants, with rates ranging from 5.18 to 26.92%. The highest proportion (26.92%) of participants actively advocated for pain-free gastrointestinal endoscopy among friends and family in their circle (A5). Conversely, the lowest proportion (5.18%) opted for standard gastrointestinal endoscopy due to concerns about cognitive dysfunction (A1). Similarly, 9.88% of participants reduced the frequency of gastrointestinal endoscopy examinations due to concerns about cognitive dysfunction (A2) (Table 4).
Table 4.
Distribution of scores in the practice dimension
| Practice | Always N (%) | Often N (%) | Sometimes N (%) | Occasionally N (%) | Never N (%) |
|---|---|---|---|---|---|
| 1. Would you choose standard gastrointestinal endoscopy due to concerns about cognitive dysfunction? | 16 (3.95) | 5 (1.23) | 82 (20.25) | 92 (22.72) | 210 (51.85) |
| 2. The general recommendation is to undergo a gastrointestinal endoscopy every 2–3 years. Would you reduce the frequency of examinations due to concerns about cognitive dysfunction? | 24 (5.93) | 16 (3.95) | 110 (27.16) | 88 (27.16) | 167 (41.23) |
| 3. Before the examination, do you proactively seek information about pain-free gastrointestinal endoscopy, especially regarding cognitive aspects? | 37 (9.14) | 37 (9.14) | 111 (27.41) | 110 (27.16) | 110 (27.16) |
| 4. Would you voluntarily undergo cognitive function assessment after a pain-free gastrointestinal endoscopy? | 28 (6.91) | 29 (7.16) | 113 (27.90) | 92 (22.72) | 143 (35.31) |
| 5. Do you actively recommend pain-free gastrointestinal endoscopy to friends and family in your circle? | 50 (12.35) | 59 (14.57) | 129 (31.85) | 103 (25.43) | 64 (15.80) |
Correlation analysis and logistic regression analysis of KAP scores
Pearson correlation analysis revealed significantly positive correlations between knowledge and practice (r = 0.209, P < 0.001), attitude and practice (r = 0.233, P < 0.001), and knowledge and attitude (r = 0.328, P < 0.001) (Table S1).
Multivariate logistic regression analysis indicated that compared to individuals with an average monthly family income of less than 5000 RMB, those with 10,001–20,000 RMB (OR = 2.478, 95%CI: 1.191–5.155, P = 0.015) and over 20,000 RMB (OR = 2.671, 95%CI: 1.215–5.874, P = 0.015) had significantly higher knowledge scores. Moreover, in contrast to students, participants in the workforce (OR = 0.265, 95%CI: 0.075–0.938, P = 0.039) and those with other occupational types (OR = 0.150, 95%CI: 0.026–0.848, P = 0.032) exhibited significantly lower knowledge scores. In contrast to participants choosing general anesthesia gastrointestinal endoscopy, those who opted for standard gastrointestinal endoscopy (without anesthesia) exhibited a negative association with knowledge scores (OR = 0.227, 95%CI: 0.088–0.582, P = 0.002). Additionally, the presence of cognitive-related diseases or symptoms before undergoing gastrointestinal endoscopy was negatively associated with knowledge scores (OR = 0.429, 95%CI: 0.225–0.818, P = 0.010) (Table 5).
Table 5.
Univariate and multivariate logistic regression analysis of knowledge dimension
| Univariate analysis | Multivariate analysis | ||||
|---|---|---|---|---|---|
| OR (95%CI) | P | OR (95%CI) | P | ||
| Age | |||||
| 30 years and below | ref | ||||
| 31–40 years | 0.950(0.561 1.610) | 0.850 | |||
| 41–50 years | 1.178(0.695 1.996) | 0.542 | |||
| 50 years and above | 0.997(0.526 1.890) | 0.994 | |||
| BMI | |||||
| < 18.5 | ref | ||||
| 18.5–23.9 | 0.865(0.461 1.624) | 0.653 | |||
| > 24 | 0.928(0.475 1.814) | 0.828 | |||
| Gender | |||||
| Male | ref | ||||
| Female | 1.258(0.848 1.865) | 0.254 | |||
| Marital Status | |||||
| Unmarried | ref | ||||
| Married | 0.846(0.526 1.359) | 0.489 | |||
| Divorced | 1.119(0.335 3.737) | 0.855 | |||
| Widowed | 1.119(0.068 18.455) | 0.937 | |||
| Residence | |||||
| Urban | ref | ||||
| Rural | 0.725(0.488 1.076) | 0.110 | |||
| Education Level | |||||
| Primary school or below | ref | ||||
| Junior high school | 0.859(0.364 2.029) | 0.729 | |||
| High school/Technical school | 1.455(0.614 3.445) | 0.394 | |||
| College | 1.830(0.795 4.213) | 0.156 | |||
| Bachelor’s degree | 2.096(0.921 4.770) | 0.078 | |||
| Master’s degree or above | 3.341(0.801 13.943) | 0.098 | |||
| Average Monthly Family Income (in RMB) | |||||
| < 5000 | ref | ref | |||
| 5000–10,000 | 1.576(0.897 2.772) | 0.114 | 1.585(0.807 3.114) | 0.181 | |
| 10001–20000 | 2.582(1.402 4.756) | 0.002 | 2.478(1.191 5.155) | 0.015 | |
| > 20,000 | 2.255(1.169 4.350) | 0.015 | 2.671(1.215 5.874) | 0.015 | |
| Occupation | |||||
| Student | ref | ref | |||
| Worker | 0.200(0.058 0.684) | 0.010 | 0.265(0.075 0.938) | 0.039 | |
| Farmer | 1.273(0.423 3.831) | 0.668 | 2.723(0.806 9.197) | 0.107 | |
| Self-employed | 0.635(0.274 1.473) | 0.290 | 0.717(0.300 1.712) | 0.454 | |
| Civil servant or public institution employee | 2.105(0.820 5.406) | 0.122 | 2.000(0.756 5.294) | 0.163 | |
| Company employee | 0.854(0.356 2.048) | 0.724 | 0.916(0.371 2.264) | 0.849 | |
| Retired | 1.667(0.328 8.462) | 0.538 | 2.059(0.392 10.827) | 0.394 | |
| No formal employment | 0.556(0.146 2.114) | 0.389 | 1.047(0.252 4.351) | 0.950 | |
| Other | 0.154(0.029 0.822) | 0.029 | 0.150(0.026 0.848) | 0.032 | |
| Reasons for Undergoing Gastrointestinal Endoscopy | |||||
| Disease screening (routine check-up) | ref | ||||
| Disease diagnosis (recommended by a doctor) | 0.943(0.609 1.458) | 0.791 | |||
| Disease treatment | 0.740(0.261 2.095) | 0.570 | |||
| Other | 1.233(0.348 4.361) | 0.745 | |||
| Type of Gastrointestinal Endoscopy | |||||
| General anesthesia gastrointestinal endoscopy | ref | ref | |||
| Standard gastrointestinal endoscopy (without anesthesia) | 0.218(0.089 0.535) | 0.001 | 0.227(0.088 0.582) | 0.002 | |
| History of General Anesthesia Surgery | |||||
| Yes | ref | ||||
| No | 0.963(0.651 1.426) | 0.852 | |||
| Cognitive-Related Diseases or Symptoms Before Undergoing Gastrointestinal Endoscopy | |||||
| Yes | 0.422(0.232 0.767) | 0.005 | 0.429(0.225 0.818) | 0.010 | |
| No | ref | ref | |||
Univariate logistic regression analysis revealed the positive association between knowledge and attitude scores (OR = 1.129, 95%CI: 1.081–1.179, P < 0.001) (Table 6). Furthermore, both knowledge (OR = 1.066, 95%CI: 1.016–1.118, P = 0.009) and attitude scores (OR = 1.108, 95%CI: 1.008–1.219, P = 0.034) were positively associated with practice scores. Compared to participants with primary school education or below, those with college education exhibited a negative association with practice scores (OR = 0.332, 95%CI: 0.136–0.808, P = 0.015). Furthermore, participants who chose standard gastrointestinal endoscopy (without anesthesia) instead of general anesthesia gastrointestinal endoscopy demonstrated a negative association with practice scores (OR = 0.336, 95%CI: 0.154–0.731, P = 0.006) (Table 7).
Table 6.
Univariate and multivariate logistic regression analysis of attitude dimension
| Univariate analysis | Multivariate analysis | |||
|---|---|---|---|---|
| OR (95%CI) | P | OR (95%CI) | P | |
| Knowledge score | 1.129(1.081 1.179) | < 0.001 | ||
| Age | ||||
| 30 years and below | ref | |||
| 31–40 years | 1.236(0.727 2.101) | 0.435 | ||
| 41–50 years | 1.293(0.758 2.203) | 0.345 | ||
| 50 years and above | 1.057(0.553 2.020) | 0.867 | ||
| BMI | ||||
| < 18.5 | ref | |||
| 18.5–23.9 | 1.713(0.880 3.336) | 0.113 | ||
| > 24 | 1.536(0.758 3.112) | 0.233 | ||
| Gender | ||||
| Male | ref | |||
| Female | 1.192(0.802 1.772) | 0.384 | ||
| Marital Status | ||||
| Unmarried | ref | |||
| Married | 1.318(0.810 2.143) | 0.266 | ||
| Divorced | 0.848(0.237 3.036) | 0.801 | ||
| Widowed | - | - | ||
| Residence | ||||
| Urban | ref | |||
| Rural | 0.991(0.668 1.471) | 0.964 | ||
| Education Level | ||||
| Primary school or below | ref | |||
| Junior high school | 1.413(0.60 3.286) | 0.422 | ||
| High school/Technical school | 1.376(0.580 3.263) | 0.468 | ||
| College | 1.610(0.699 3.709) | 0.264 | ||
| Bachelor’s degree | 1.333(0.584 3.042) | 0.494 | ||
| Master’s degree or above | 1.591(0.395 6.407) | 0.514 | ||
| Average Monthly Family Income (in RMB) | ||||
| < 5000 | ref | |||
| 5000–10,000 | 1.005(0.582 1.734) | 0.987 | ||
| 10001–20000 | 1.045(0.576 1.897) | 0.885 | ||
| > 20,000 | 1.649(0.869 3.128) | 0.126 | ||
| Occupation | ||||
| Student | ref | |||
| Worker | 0.415(0.131 1.310) | 0.134 | ||
| Farmer | 1.477(0.486 4.460) | 0.489 | ||
| Self-employed | 0.920(0.394 2.150) | 0.847 | ||
| Civil servant or public institution employee | 1.074(0.423 2.730) | 0.880 | ||
| Company employee | 1.219(0.504 2.945) | 0.661 | ||
| Retired | 0.818(0.160 4.172) | 0.809 | ||
| No formal employment | 1.364(0.370 5.028) | 0.641 | ||
| Other | 0.909(0.249 3.313) | 0.885 | ||
| Reasons for Undergoing Gastrointestinal Endoscopy | ||||
| Disease screening (routine check-up) | ref | |||
| Disease diagnosis (recommended by a doctor) | 0.875(0.563 1.359) | 0.552 | ||
| Disease treatment | 0.788(0.278 2.231) | 0.653 | ||
| Other | 1.312(0.371 4.644) | 0.673 | ||
| Type of Gastrointestinal Endoscopy | ||||
| General anesthesia gastrointestinal endoscopy | ref | |||
| Standard gastrointestinal endoscopy (without anesthesia) | 0.631(0.308 1.294) | 0.209 | ||
| History of General Anesthesia Surgery | ||||
| Yes | ref | |||
| No | 0.790(0.532 1.172) | 0.242 | ||
|
Cognitive-Related Diseases or Symptoms Before Undergoing Gastrointestinal Endoscopy |
||||
| Yes | 0.716(0.408 1.257) | 0.244 | ||
| No | ref | |||
Table 7.
Univariate and multivariate logistic regression analysis of practice dimension
| Univariate analysis | Multivariate analysis | |||
|---|---|---|---|---|
| OR (95%CI) | P | OR (95%CI) | P | |
| Knowledge score | 1.083 (1.039 1.129) | < 0.001 | 1.066 (1.016 1.118) | 0.009 |
| Attitude score | 1.143 (1.048 1.245) | 0.002 | 1.108 (1.008 1.219) | 0.034 |
| Age | 1.010 (0.994 1.026) | 0.233 | ||
| 30 years and below | ref | |||
| 31–40 years | 0.974 (0.577 1.645) | 0.921 | ||
| 41–50 years | 1.091 (0.645 1.847) | 0.745 | ||
| 50 years and above | 1.292 (0.685 2.436) | 0.429 | ||
| BMI | ||||
| < 18.5 | ref | |||
| 18.5–23.9 | 0.853 (0.455 1.599) | 0.620 | ||
| > 24 | 0.996 (0.511 1.943) | 0.991 | ||
| Gender | ||||
| Male | ref | |||
| Female | 0.966 (0.653 1.430) | 0.862 | ||
| Marital Status | ||||
| Unmarried | ref | ref | ||
| Married | 1.743 (1.072 2.832) | 0.025 | 1.671 (0.972 2.876) | 0.064 |
| Divorced | 0.154 (0.019 1.250) | 0.080 | 0.132 (0.016 1.104) | 0.062 |
| Widowed | - | - | - | - |
| Residence | ||||
| Urban | ref | |||
| Rural | 0.830 (0.561 1.228) | 0.352 | ||
| Education Level | ||||
| Primary school or below | ref | ref | ||
| Junior high school | 0.511 (0.223 1.172) | 0.113 | 0.549 (0.230 1.308) | 0.176 |
| High school/Technical school | 0.433 (0.185 1.014) | 0.054 | 0.448 (0.183 1.094) | 0.078 |
| College | 0.325 (0.141 0.746) | 0.008 | 0.332 (0.136 0.808) | 0.015 |
| Bachelor’s degree | 0.738 (0.328 1.659) | 0.462 | 0.786 (0.330 1.875) | 0.588 |
| Master’s degree or above | 0.720 (0.180 2.879) | 0.642 | 0.692 (0.161 2.968) | 0.620 |
| Average Monthly Family Income (in RMB) | ||||
| < 5000 | ref | |||
| 5000–10,000 | 0.847 (0.494 1.453) | 0.547 | ||
| 10001–20000 | 1.728 (0.958 3.119) | 0.069 | ||
| > 20,000 | 1.080 (0.571 2.040) | 0.813 | ||
| Occupation | ||||
| Student | ref | |||
| Worker | 0.500 (0.170 1.473) | 0.209 | ||
| Farmer | 1.500 (0.495 4.550) | 0.474 | ||
| Self-employed | 0.738 (0.319 1.707) | 0.477 | ||
| Civil servant or public institution employee | 1.107 (0.440 2.787) | 0.829 | ||
| Company employee | 0.935 (0.390 2.240) | 0.880 | ||
| Retired | 1.667 (0.328 8.462) | 0.538 | ||
| No formal employment | 0.750 (0.203 2.775) | 0.666 | ||
| Other | 0.875 (0.245 3.124) | 0.837 | ||
| Reasons for Undergoing Gastrointestinal Endoscopy | ||||
| Disease screening (routine check-up) | ref | |||
| Disease diagnosis (recommended by a doctor) | 1.048 (0.679 1.617) | 0.832 | ||
| Disease treatment | 1.158 (0.422 3.180) | 0.775 | ||
| Other | 0.772 (0.213 2.801) | 0.694 | ||
| Type of Gastrointestinal Endoscopy | ||||
| General anesthesia gastrointestinal endoscopy | ref | ref | ||
| Standard gastrointestinal endoscopy (without anesthesia) | 0.336 (0.154 0.731) | 0.006 | 0.478 (0.210 1.086) | 0.078 |
| History of General Anesthesia Surgery | ||||
| Yes | ref | |||
| No | 0.755 (0.510 1.117) | 0.159 | ||
| Cognitive-Related Diseases or Symptoms Before Undergoing Gastrointestinal Endoscopy | ||||
| Yes | 1.719 (0.995 2.973) | 0.052 | ||
| No | ref | |||
Discussion
Patients undergoing gastrointestinal endoscopy exhibited good knowledge, neutral attitudes, and moderate practices towards PACD. Positive associations among KAP scores were identified. Additionally, our study unveiled associations between KAP scores and demographic factors, such as average monthly family income, occupation, educational level, type of gastrointestinal endoscopy, and presence of cognitive-related diseases or symptoms prior to gastrointestinal endoscopy. These insights can inform the healthcare interventions and educational initiatives to improve KAP.
Recent studies have explored the efficacy of novel sedatives like dexmedetomidine and ketamine in reducing PACD. Dexmedetomidine, a highly selective alpha-2 adrenergic receptor agonist, has shown promise due to its sedative and analgesic properties with minimal respiratory depression [4, 5]. Similarly, ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, has been noted for its potential neuroprotective properties [6, 7]. However, PACD continues to emerge as a notable complication, suggestive of its multifactorial nature. In consistency to our results, moderate knowledge and high levels of attitude and practice regarding postoperative delirium were observed among cardiac surgery nurses [23]. Comparatively, neutral attitudes herein could stem from limited exposure about PACD in gastrointestinal endoscopy. Besides, moderate practices underscored the need to enhance education and translate knowledge into practices.
High awareness (69.94%) of the cognitive impacts following major surgery under anesthesia indicated a significant recognition of the potential risks, which is essential for informed decisions about medical procedures [24]. Future studies should aim to elucidate the mechanisms of PACD further, identify high-risk populations, and develop strategies to mitigate these risks. Enhancing preoperative education programs to provide comprehensive information about cognitive risks and management strategies could empower patients for improved postoperative outcomes. Conversely, the low awareness levels concerning the cognitive effects of pain-free gastrointestinal endoscopy, particularly in relation to postoperative difficulty in concentration (20.99%) and memory decline (24.44%), highlighted a crucial knowledge gap. This could be due to a lack of comprehensive information or public education regarding the cognitive implications of anesthesia during gastrointestinal endoscopy, which might be perceived as a less invasive procedure compared to major surgeries [25]. Our findings underlined the need for more effective patient education and communication in the context of gastrointestinal endoscopy.
In the attitude dimension, it was encouraging that the majority (59.50%) of participants expressed a positive attitude toward receiving more information from their healthcare providers about the potential complications of the procedure, especially those related to cognitive dysfunction. Aligned with the principles of patient-centered care, the finding underscored the importance of effective communication between healthcare providers and patients [26]. Given the encouraging attitude towards receiving more information, healthcare providers should prioritize comprehensive preoperative education programs. These programs should include detailed discussions about the risks of cognitive dysfunction, the signs and symptoms of PACD, and strategies for prevention and management. Conversely, only 17.53% agreed that questions about cognitive function during the anesthesia assessment before gastrointestinal endoscopy caused anxiety and concern. This might reflect general trusts in the safety and implications of anesthesia [27]. Furthermore, only 21.73% cited cost-effectiveness as the primary reason for choosing standard gastrointestinal endoscopy over concerns about anesthesia-related complications. Financial considerations might play a minor role in patients’ decision-making processes compared to other factors, such as perceived risks and benefits. Healthcare providers should focus on enhancing patient education about anesthesia-related complications and the overall safety of gastrointestinal endoscopy procedures. This approach can empower patients to make decisions based on a balanced understanding of both medical and financial aspects.
In the practice dimension, 26.92% actively advocated for pain-free gastrointestinal endoscopy among their friends and family. Therefore, it was suggested to acknowledge the influence of patients’ experiences in shaping their recommendations, and advocate for specific healthcare practices based on the interconnectedness of their experiences [28]. On the contrary, only 5.18% opted for standard gastrointestinal endoscopy due to concerns about cognitive dysfunction. Such a low percentage could indicate general trusts in the safety of anesthesia administered during gastrointestinal endoscopy or a lack of awareness regarding the specific risks related to cognitive function [27]. Additionally, 9.88% reduced the frequency of gastrointestinal endoscopy examinations due to concerns about cognitive dysfunction. Despite the limited proportion, the cognitive issues are concerning for patients who require regular gastrointestinal endoscopy for the management of conditions like colorectal cancer, inflammatory bowel disease, or gastrointestinal polyps [29]. Educating patients on the measures taken to minimize these risks, such as using short-acting anesthetics and monitoring cognitive function, can help alleviate fears and encourage adherence to recommended examination schedules.
Positive associations between KAP scores emphasized the necessity of educational interventions to augment knowledge of PACD. According to the theory of planned behavior, attitudes and behaviors are shaped by individuals’ perceptions of the potential outcomes associated with their actions [30]. First, individuals with higher income levels may have greater access to medical information, leading to better understanding of risks in anesthesia in gastrointestinal endoscopy [31]. Second, participants who opted for standard gastrointestinal endoscopy without anesthesia exhibited negative associations with both knowledge and practice scores. This subgroup may have limited interaction with healthcare providers during preoperative counseling sessions, resulting in reduced exposure to information regarding anesthesia-related risks and preventive measures for cognitive dysfunction. Third, cognitive-related diseases prior to undergoing gastrointestinal endoscopy were associated with lower knowledge scores. Conditions like dementia or mild cognitive impairment can impede individuals’ ability to comprehend and retain new information, including details about medical procedures and associated risks [32]. To enhance comprehension and retention of information among patients with cognitive impairments, employing simple language, visual aids, and repetition can be beneficial. Furthermore, involving caregivers or family members in the educational process can offer additional support and reinforce key concepts.
This study had several limitations. Firstly, the cross-sectional design and the limited sample size could hinder the establishment of causal relationships among variables and the generalizability of findings. Secondly, social desirability bias might be induced by self-reported data, potentially leading to score inflation [33]. Thirdly, the single-center design can introduce biases related to demographic, environmental, and procedural factors unique to Wenzhou region. Future research involving multiple centers would help to corroborate these findings and enhance their applicability across different settings.
Conclusions
In summary, individuals undergoing gastrointestinal endoscopy demonstrated good knowledge, neutral attitudes, and moderate practices regarding PACD. Additionally, positive associations were observed among KAP scores. Based on the first investigation into the KAP towards PACD, continued efforts to enhance patient education and research in gastrointestinal endoscopy can contribute to improved patient care and outcomes in the future.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
Not applicable.
Abbreviations
- KAP
Knowledge, attitudes, and practices
- PACD
Post-anesthesia cognitive dysfunction
Author contributions
Xuling Liu and Leilei Wang carried out the studies, participated in collecting data, and drafted the manuscript. Yelong Ren and Wenjun Jin performed the statistical analysis and participated in its design. Peng Li and Xuling Liu participated in acquisition, analysis, or interpretation of data and draft the manuscript. All authors read and approved the final manuscript.
Funding
This study was supported by the Natural Science Foundation of Zhejiang Province [grant number LQ21H090017].
Data availability
All data generated or analysed during this study are included in this published article.
Declarations
Ethics approval and consent to participate
The study was carried out after the protocol was approved by the Ethics Committee of the First Affiliated Hospital of Wenzhou Medical University. I confirm that all methods were performed in accordance with the relevant guidelines. All procedures were performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments, and informed consent was obtained from all participants.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Ponsky JL, Strong AT. A history of flexible gastrointestinal endoscopy. Surg Clin North Am. 2020;100:971–92. 10.1016/j.suc.2020.08.013 [DOI] [PubMed] [Google Scholar]
- 2.Gao N, Chen H, Wang Y, Guo Y, Liu Z, Wang W. Acupuncture to improve patient discomfort during upper gastrointestinal endoscopy: systematic review and meta-analysis. Front Med. 2022;9:865035. 10.3389/fmed.2022.865035 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Utli H, Doğru BV. The Effect of Reiki on anxiety, stress, and comfort levels before gastrointestinal endoscopy: a randomized sham-controlled trial. J PeriAnesthesia Nurs. 2023;38:297–304. 10.1016/j.jopan.2022.08.010 [DOI] [PubMed] [Google Scholar]
- 4.Lu Z, Li W, Chen H, Qian Y. Efficacy of a dexmedetomidine-remifentanil combination compared with a midazolam-remifentanil combination for conscious Sedation during Therapeutic Endoscopic Retrograde Cholangio-Pancreatography: a prospective, randomized, single-blinded preliminary Trial. Dig Dis Sci. 2018;63:1633–40. 10.1007/s10620-018-5034-3 [DOI] [PubMed] [Google Scholar]
- 5.Gao S, Wang T, Cao L, Li L, Yang S. Clinical effects of remimazolam alone or in combination with dexmedetomidine in patients receiving bronchoscopy and influences on postoperative cognitive function: a randomized-controlled trial. Int J Clin Pharm. 2023;45:137–45. 10.1007/s11096-022-01487-4 [DOI] [PubMed] [Google Scholar]
- 6.La Via L, Sanfilippo F, Cuttone G, Dezio V, Falcone M, Brancati S, et al. Use of ketamine in patients with refractory severe asthma exacerbations: systematic review of prospective studies. Eur J Clin Pharmacol. 2022;78:1613–22. 10.1007/s00228-022-03374-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Tuncali B, Pekcan YO, Celebi A, Zeyneloglu P. Addition of low-dose ketamine to midazolam-fentanyl-propofol-based sedation for colonoscopy: a randomized, double-blind, controlled trial. J Clin Anesth. 2015;27:301–6. 10.1016/j.jclinane.2015.03.017 [DOI] [PubMed] [Google Scholar]
- 8.Valentim AM, Gaburro S, Parker MO. Post-anesthesia cognitive dysfunction: how, when and why. Front Behav Neurosci. 2021;15:797483. 10.3389/fnbeh.2021.797483 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Wang Y, Liu X, Li H. [Incidence of the post-operative cognitive dysfunction in elderly patients with general anesthesia combined with epidural anesthesia and patient-controlled epidural analgesia]. Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2016;41:846–51. [DOI] [PubMed] [Google Scholar]
- 10.Ntalouka M, Arnaoutoglou E, Tzimas P. Postoperative cognitive disorders: an update. Hippokratia. 2018;22:147. [PMC free article] [PubMed] [Google Scholar]
- 11.Sandeep C. To compare the effects of sevoflurane under low-flow and medium-flow anaesthesia on cognitive function and recovery in patients undergoing elective laparoscopic cholecystectomy under general anaesthesia. J Cardiovasc Dis Res. 2023;14:2010–7. [Google Scholar]
- 12.Negrini D, Wu A, Oba A, Harnke B, Ciancio N, Krause M, et al. Incidence of postoperative cognitive dysfunction following inhalational vs total Intravenous General Anesthesia: a systematic review and Meta-analysis. Neuropsychiatr Dis Treat. 2022;18:1455–67. 10.2147/NDT.S374416 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Power GM, Sanderson E, Pagoni P, Fraser A, Morris T, Prince C et al. Methodological approaches, challenges, and opportunities in the application of mendelian randomisation to lifecourse epidemiology: a systematic literature review. Eur J Epidemiol. 2023:1–20. [DOI] [PMC free article] [PubMed]
- 14.Rosenberg A, Mangialasche F, Ngandu T, Solomon A, Kivipelto M. Multidomain interventions to prevent cognitive impairment, Alzheimer’s disease, and dementia: from FINGER to world-wide FINGERS. J Prev Alzheimer’s Disease. 2020;7:29–36. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Drew DA, Weiner DE, Sarnak MJ. Cognitive impairment in CKD: pathophysiology, management, and prevention. Am J Kidney Dis. 2019;74:782–90. 10.1053/j.ajkd.2019.05.017 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Irazoki E, Contreras-Somoza LM, Toribio-Guzmán JM, Jenaro-Río C, Van der Roest H, Franco-Martín MA. Technologies for cognitive training and cognitive rehabilitation for people with mild cognitive impairment and dementia. A systematic review. Front Psychol. 2020;11:648. 10.3389/fpsyg.2020.00648 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Burns CI, Boghokian A, Soti V. Obesity and postoperative cognitive dysfunction: a Curious Association. Cureus. 2023;15:e42436. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Skiljic S, Budrovac D, Cicvaric A, Neskovic N, Kvolik S. Advances in Analgosedation and Periprocedural Care for Gastrointestinal Endoscopy. Life. 2023;13:473. 10.3390/life13020473 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Needham MJ, Webb CE, Bryden DC. Postoperative cognitive dysfunction and dementia: what we need to know and do. Br J Anaesth. 2017;119:i115–25. 10.1093/bja/aex354 [DOI] [PubMed] [Google Scholar]
- 20.Kotekar N, Shenkar A, Nagaraj R. Postoperative cognitive dysfunction - current preventive strategies. Clin Interv Aging. 2018;13:2267–73. 10.2147/CIA.S133896 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Bloom BS. Learning for Mastery. Instruction and Curriculum. Regional Education Laboratory for the Carolinas and Virginia, Topical Papers and Reprints, Number 1. Evaluation comment. 1968;1:n2.
- 22.Pourhoseingholi MA, Vahedi M, Rahimzadeh M. Sample size calculation in medical studies. Gastroenterol Hepatol bed Bench. 2013;6:14. [PMC free article] [PubMed] [Google Scholar]
- 23.Zhou C, Qu X, Wang L, Wu Q, Zhou Y. Knowledge, attitude, and practice regarding postoperative delirium among cardiac surgery nurses: a cross-sectional multi‐centre study. J Clin Nurs. 2023. [DOI] [PubMed]
- 24.Belrose JC, Noppens RR. Anesthesiology and cognitive impairment: a narrative review of current clinical literature. BMC Anesthesiol. 2019;19:241. 10.1186/s12871-019-0903-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Yang Y, Ji H, Lu Y, Hong J, Yang G, Kong X et al. Sedative-sparing effect of acupuncture in gastrointestinal endoscopy: systematic review and meta-analysis. Front Med. 2023;10. [DOI] [PMC free article] [PubMed]
- 26.Eklund JH, Holmström IK, Kumlin T, Kaminsky E, Skoglund K, Höglander J, et al. Same same or different? A review of reviews of person-centered and patient-centered care. Patient Educ Couns. 2019;102:3–11. 10.1016/j.pec.2018.08.029 [DOI] [PubMed] [Google Scholar]
- 27.Hoyem RL, Quraishi JA, Jordan L, Wiltse Nicely KL. Advocacy, Research, and Anesthesia Practice models: Key studies of Safety and cost-effectiveness. Policy Polit Nurs Pract. 2019;20:193–204. 10.1177/1527154419874410 [DOI] [PubMed] [Google Scholar]
- 28.Oben P. Understanding the patient experience: a conceptual Framework. J Patient Exp. 2020;7:906–10. 10.1177/2374373520951672 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Wu H, Zhuang Y, Wu W, Huang J, Huang H, Wang L. Post-operative cognitive dysfunction in patients following gastrointestinal endoscopic treatment. Appl Neuropsychology: Adult. 2023:1–6. [DOI] [PubMed]
- 30.Bosnjak M, Ajzen I, Schmidt P. The theory of Planned Behavior: selected recent advances and applications. Eur J Psychol. 2020;16:352–6. 10.5964/ejop.v16i3.3107 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.McMaughan DJ, Oloruntoba O, Smith ML. Socioeconomic Status and Access to Healthcare: interrelated drivers for healthy aging. Front Public Health. 2020;8:231. 10.3389/fpubh.2020.00231 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Blatchford L, Cook J. Patient perspectives about mild cognitive impairment: a systematic review. Clin Gerontologist. 2022;45:441–53. 10.1080/07317115.2020.1805536 [DOI] [PubMed] [Google Scholar]
- 33.Bergen N, Labonté R. Everything is perfect, and we have no problems: detecting and limiting Social Desirability Bias in qualitative research. Qual Health Res. 2020;30:783–92. 10.1177/1049732319889354 [DOI] [PubMed] [Google Scholar]
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Data Availability Statement
All data generated or analysed during this study are included in this published article.