Postoperative delirium is delirium, as the DSM-5 diagnostic manual defines it, that starts after an operation; the 2023 European guideline on postoperative delirium counts it only when a validated screening tool is used at least once a day for at least three days, starting no later than the day after surgery. Postoperative cognitive dysfunction (POCD) is a decline in cognitive function after surgery; the trials pooled in a 2026 review by Wu and colleagues diagnosed it from a change in the Mini-Mental State Examination (MMSE), a short screening test, between before and after the operation, and that review uses perioperative neurocognitive disorder (PND) for both. Cochrane has no review of acupuncture for either. Its 2021 review of non-pharmacological interventions for preventing delirium in hospital included one trial of transcutaneous electrical acupoint stimulation (TEAS) and rated the evidence from it very uncertain. Later reviews, pooling 11 to 29 trials each, report fewer cases of delirium or cognitive dysfunction in older surgical patients given TEAS, electroacupuncture or acupuncture than in those given no stimulation or a sham, mostly over the first week after surgery, and the two 2026 reviews found their trials were all or mostly from China.
What is TEAS?
TEAS passes an electrical current through surface electrodes placed on the skin over acupuncture points, without needles, as the authors of a 2025 trial at Shuguang Hospital in Shanghai describe it. Electroacupuncture passes a current through needles inserted at the points; Electroacupuncture describes the method. In several of the trials below, stimulation starts 30 minutes before anaesthesia, and the sham is the same electrodes with no current.
The 2021 Cochrane review
Burton and colleagues searched to September 2020 and included 22 randomised trials with 5,718 adults in hospital outside intensive care. Against usual care, multicomponent programmes, which combine measures such as reorientation, sleep hygiene and attention to nutrition and hydration, probably reduce the incidence of delirium (risk ratio 0.57, 14 trials, 3,693 people, moderate-certainty evidence).
The one acupoint trial was a 2018 study by Gao and colleagues of 64 older adults with silent lacunar infarcts, small strokes seen on scans without symptoms, who were having spinal surgery. One group had TEAS at LI04 (Hegu) and PC06 (Neiguan) on both sides from 30 minutes before anaesthesia to the end of surgery; the control group had electrodes on the same points with no current. The trial’s authors reported delirium in 6.3% of the TEAS group against 25.0% of the control group in the first three days. Cochrane’s analysis of the same data gave a risk ratio of 0.25 with a 95% confidence interval of 0.06 to 1.09, which includes no effect, and rated the evidence very low in certainty, downgraded for risk of bias, indirectness and imprecision. The review also listed two acupuncture trials as ongoing: a three-arm trial of acupuncture, sham acupuncture and no treatment in 240 people having laparoscopic surgery in Jiaxing (ChiCTR1900027115), and a trial of 135 people having hip replacement (DRKS00013158). A Europe PMC search for either registration number in October 2026 returned only the Cochrane review.
Later systematic reviews
| Review | Method, outcome and comparison | Trials and people | What the authors report |
|---|---|---|---|
| Tang 2021, searched to March 2018 | Acupuncture against no treatment; POCD | 16 trials, 1,241 people | Less POCD on days 1 and 3 (odds ratio 0.32 on day 1), no difference on day 7; most trials at unclear risk of bias |
| Zhang 2021, searched to April 2021 | TEAS against control; POCD | 29 trials, 1,994 people | Less POCD on days 1, 3 and 7 but not day 5; certainty moderate on day 1 (odds ratio 0.33), low thereafter |
| Ou 2021, searched to May 2021 | Electroacupuncture before hip or knee replacement against control; POCD | 11 trials, 949 people | Less POCD at 1, 3 and 7 days and at 3 and 6 months; the authors call for larger, higher-quality trials |
| Huang 2023 | TEAS against no stimulation or sham; delirium | 12 trials, 991 people | Risk ratio 0.40; most trials at high or unclear risk of bias; benefit in orthopaedic and thoracic surgery, not digestive surgery |
| Gan 2025 | TEAS during anaesthesia against control; POCD | 20 trials, 1,549 people | Odds ratio 0.29 in the early postoperative period; the authors say evidence on long-term cognitive dysfunction is still needed |
| Chen 2026, searched to July 2025 | TEAS against sham or no stimulation, over-60s; delirium within 7 days | 20 trials, 2,290 people | Delirium in 5.6% against 17.0% (risk ratio 0.34), moderate-certainty evidence; no serious adverse events reported |
| Wu 2026, searched to March 2025 | Electroacupuncture against sham, standard care or no intervention, over-60s under general anaesthesia; PND | 26 trials, 2,309 people | Risk ratio 0.47, moderate to low certainty; fewer adverse events than control (moderate certainty) |
The reviews overlap in the trials they pool, so their figures are not independent. Wu and colleagues found that all 26 of their trials were run in China and published between 2011 and 2023, and that only five used a sham; they judged the rest at high risk of bias for unblinded participants and staff, and found signs of publication bias in one cognitive score. Chen and colleagues, whose trials were mostly from China, note that the people delivering TEAS could not be blinded and that no trial reported whether the delirium was the hyperactive, hypoactive or mixed kind. Huang and colleagues, Tang and colleagues and Zhang and colleagues each describe the underlying evidence as weak or limited.
Sham-controlled trials
Trials published since the Cochrane search have compared active stimulation with electrodes that pass no current. Sham acupuncture discusses what such controls can and cannot hide from a patient.
- Sun and colleagues randomised 608 people aged 65 or over having orthopaedic surgery to TEAS at Hegu with Neiguan and
ST36(Zusanli) withLV03(Taichong), twice a day for three days before surgery and once more before anaesthesia, or to an identical-looking device that passed no current. Assessors who did not know the groups found delirium in 6.08% of the TEAS group and 17.57% of the sham group over five days. The authors note that the trial ran at one hospital, and that patients in the sham group felt no stimulation, which may have told them their group. - A 2026 three-arm trial by Gao and colleagues randomised 180 people aged 65 or over having laparoscopic gastrointestinal surgery to TEAS at
XH03(Yintang), which the trial labels EX-HN3,HT07(Shenmen), Neiguan and Zusanli before and during surgery and every 8 hours for 72 hours afterwards, to TEAS before and during surgery only, or to sham. Delirium within 72 hours affected 11.9%, 31.0% and 53.6% of the three groups. Skin injury did not differ between them. - A 2026 trial by Liu and colleagues randomised 65 older people having carotid endarterectomy, an operation to clear a narrowed neck artery, to TEAS at
GV20(Baihui),SP06(Sanyinjiao) and Zusanli during surgery or to unpowered electrodes, and reported less delirium, and milder delirium, in the first three days with TEAS.
Trials without a sham
A 2025 trial by Fang and colleagues randomised 120 people aged 65 or over having lower-limb orthopaedic surgery to buccal (cheek) acupuncture during surgery and for two days afterwards, or to none; delirium in the first week affected 7 of 60 with acupuncture and 16 of 60 without (risk ratio 0.44, 95% confidence interval 0.19 to 0.99). A 2025 trial by Long and colleagues randomised 60 people aged 65 or over with hip fractures to electroacupuncture before and after surgery or to what the authors call a non-stimulated control group; of the 53 analysed, PND on the first day after surgery affected 25.0% with electroacupuncture against 56.0% without. Both trials also reported less nausea and vomiting, which Nausea after surgery covers, and lower pain scores, which Postoperative pain covers.
What guidelines say
The European Society of Anaesthesiology and Intensive Care’s guideline, by Aldecoa and colleagues, was published online in August 2023 as an update of its 2017 version and covers literature from April 2015 to February 2022; Europe PMC listed no later update by October 2026. Its working group on non-drug prevention selected 19 randomised trials, 8 of multicomponent and 11 of single interventions, and its summary states that multicomponent preventive measures before, during and after surgery showed potential to reduce the incidence and duration of delirium. Its full text does not mention acupuncture or acupoint stimulation.
The American Geriatrics Society’s abstracted clinical practice guideline for postoperative delirium in older adults, published in January 2015 from its 2014 guideline, makes a strong recommendation, on moderate-quality evidence, that hospitals run multicomponent non-drug programmes delivered by an interdisciplinary team for at-risk older adults having surgery. Europe PMC listed no later AGS guideline on the subject by October 2026, and the text does not mention acupuncture.
NICE’s CG103, Delirium: prevention, diagnosis and management in hospital and long-term care, first published in July 2010 and last updated in January 2023, recommends a tailored multicomponent intervention package delivered by a trained multidisciplinary team. It is not specific to surgery, and its recommendations do not mention acupuncture.
What the reviews could not settle
Most pooled outcomes cover the first week after surgery, and POCD was usually defined by a change in a short screening test; Gan and colleagues and Wu and colleagues each say longer follow-up is needed, and only Ou’s review reports outcomes at three and six months. With most trials from one country, few sham controls, and a sham that passes no current and can be felt to do nothing, the reviews could not say how much of the difference reflects the stimulation itself. None of the three guidelines mentions acupuncture, so none has set out a position on this evidence. Cognitive impairment and dementia reports what the literature says about acupuncture for longer-term cognitive decline.
AcuiQ’s postoperative cognitive dysfunction, postoperative delirium and postoperative attention deficit pages list the protocols individual studies prescribed, each with its citation.