Preoperative butyrylcholinesterase activity and risk of postoperative delirium: A meta-analysis

doi:10.5498/wjp.v16.i1.112450

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World Journal of Psychiatry

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Meta-Analysis

World J Psychiatry. Jan 19, 2026; 16(1): 112450
Published online Jan 19, 2026. doi: 10.5498/wjp.v16.i1.112450

Preoperative butyrylcholinesterase activity and risk of postoperative delirium: A meta-analysis

Yuan-Li Qiu, Cheng Song, Cui-Wan Huang, Wei-Gang Shen

Yuan-Li Qiu, Cheng Song, Cui-Wan Huang, Wei-Gang Shen, Department of Anesthesiology, Affiliated Hospital of Shaoxing University, Shaoxing 312000, Zhejiang Province, China

Author contributions: Qiu YL, Song C, and Huang CW wrote the initial draft; Qiu YL and Song C performed database search, data collection, and study quality evaluation; Qiu YL and Shen WG conceived and designed the study; all authors performed statistical analysis and interpreted the results, revised the manuscript, and read and approved the final version of the manuscript.

Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.

PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.

Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

Corresponding author: Wei-Gang Shen, Director, Department of Anesthesiology, Affiliated Hospital of Shaoxing University, No. 999, Zhongxing South Road, Chengnan Sub-district, Yuecheng District, Shaoxing 312000, Zhejiang Province, China. 313693178@qq.com

Received: July 28, 2025
Revised: September 12, 2025
Accepted: October 22, 2025
Published online: January 19, 2026
Processing time: 156 Days and 11 Hours

Abstract

BACKGROUND

Postoperative delirium (POD) is a common and serious complication in surgical patients, particularly older adults. Alterations in cholinergic function have been implicated in its pathophysiology.

AIM

To evaluate the association between preoperative serum cholinesterase (ChE) activity—specifically butyrylcholinesterase (BuChE) and acetylcholinesterase (AChE)—and the risk of POD in adult surgical patients in a meta-analysis.

METHODS

A systematic search was conducted in PubMed, EMBASE, and Web of Science up to March 28, 2025 for studies reporting preoperative serum BuChE or AChE activity in relation to subsequent POD incidence. Standardized mean differences (SMDs) and odds ratios (ORs) with 95% confidence intervals (CIs) were pooled using random-effects models. Subgroup and sensitivity analyses were performed based on follow-up duration and analytic models.

RESULTS

Thirteen studies (n = 2730 patients) were included. Patients who developed POD had significantly lower preoperative BuChE activity than those who did not (SMD = -0.28; 95%CI: -0.39 to -0.16; I² = 18%). Higher BuChE activity was associated with a reduced risk of POD (OR per 100 unit increment = 0.97; 95%CI: 0.95-0.99; I² = 0%). In contrast, pooled AChE activity did not differ significantly between POD and non-POD groups (SMD = -0.25; 95%CI: -0.53 to 0.03; P = 0.08; I² = 80%), and the ORs per 1 unit increment in AChE activity were not statistically significant (OR = 0.98; 95%CI: 0.95-1.01).

CONCLUSION

Lower preoperative serum BuChE activity is associated with an increased risk of POD in adults undergoing surgery. BuChE activity may serve as a potential preoperative biomarker for POD risk stratification.

Keywords: Acetylcholinesterase; Butyrylcholinesterase; Activity; Postoperative delirium; Meta-analysis

Core Tip: This meta-analysis synthesizes evidence from 13 studies involving 2730 surgical patients to assess the association between preoperative cholinesterase activity and postoperative delirium (POD). We found that lower preoperative butyrylcholinesterase (BuChE) activity was significantly associated with increased POD risk, whereas acetylcholinesterase activity showed no consistent association. These findings suggest that serum BuChE may serve as a simple, accessible biomarker for POD risk stratification. Our study provides the most comprehensive evidence to date linking peripheral cholinergic dysfunction to POD and highlights BuChE as a potential target for early identification and intervention.