Ever since Bedford’s seminal Lancet case series in 1955, we have known that perioperative care is sometimes followed by significant cognitive dysfunction (1). Although the safety of perioperative care has improved dramatically since 1955, the descriptions of cognitive dysfunction in that case series are eerily similar to the complaints of current patients suffering from post-operative cognitive dysfunction (POCD). POCD remains a common post-operative complication associated with significant morbidity and even mortality, especially among elderly patients. There has been a great deal of interest in and controversy about POCD, from how it is measured, to how long it lasts, to its precise implications for patients. This interest and controversy is reflected partly in the increasing number of papers published on this subject recently (shown in Figure 1). Recent work has also suggested surgery may be associated with cognitive improvement in some patients (2–4), termed Post-Operative Cognitive Improvement (POCI). As the number of surgeries performed worldwide approaches 250 million per year (5) (with an increasing number elderly patients), optimizing postoperative cognitive function and preventing/treating POCD are major public health issues. In this article we review the literature on POCD and POCI, and discuss current research challenges in this area.