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This paper elucidates the pathophysiological mechanisms of POCD, including neuroinflammatory cascades, cerebral oxygen metabolism imbalance, blood-brain barrier disruption, and the unique vulnerability of elderly brain tissue. It also analyzes the neuroprotective properties of spontaneous-breathing anesthesia, which optimizes cerebral oxygen supply-demand balance, reduces systemic and central inflammation, and modulates hypothalamic-pituitary-adrenal axis stress responses\u2014demonstrating distinct mechanisms from conventional endotracheal intubation anesthesia. Existing clinical evidence indicates its cognitive protective effects in elderly patients during certain surgeries, though heterogeneity in outcomes across procedure types and methodological limitations in studies persist. Furthermore, this paper outlines key perioperative management points for this anesthetic technique, addresses related controversies, and identifies future research directions such as multimodal monitoring and individualized protocols, providing crucial guidance for perioperative brain health management in elderly patients.<\/jats:p>","DOI":"10.3389\/fsurg.2026.1772706","type":"journal-article","created":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T05:47:35Z","timestamp":1776059255000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Effects of spontaneous breathing anesthesia on postoperative cognitive dysfunction in elderly patients: a narrative review"],"prefix":"10.3389","volume":"13","author":[{"given":"Tongxin","family":"Zheng","sequence":"first","affiliation":[{"name":"Thoracic Surgery Department, School of Clinical Medicine, Hebei University","place":["Baoding, Hebei, 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