BackgroundPostoperative neurocognitive disorder (PND), including postoperative delirium (POD) and postoperative cognitive dysfunction (POCD), are prevalent and debilitating complications in elderly surgical patients. Remimazolam, a novel ultra-short-acting benzodiazepine with favorable hemodynamic and sedative properties, has not been fully evaluated for its impact on PND.MethodThis systematic review and meta-analysis included studies retrieved from PubMed, Embase, Web of Science, and Cochrane library up to February 2026. Eligible studies compared remimazolam with other sedatives in elderly surgical patients and reported POD or POCD incidence. The primary outcome was the incidence of POD/POCD; secondary outcomes included postoperative MMSE scores, intraoperative opioids consumption, duration of post-anesthesia care unit (PACU) and hospital stay, and perioperative complications.ResultsFifteen randomized controlled trials (RCTs) involving 2,226 patients were analyzed. Remimazolam was not statistically associated with reduction in POD incidence on postoperative days 1 or 3, nor did it affect delirium subtypes or duration. However, remimazolam may be associated with a reduced risk of early POCD on days 1, 3, and 5. Remimazolam reduced intraoperative remifentanil consumption and the incidence of perioperative hemodynamic complications (hypotension and bradycardia). MMSE scores were higher on day 7, and no statistically significant differences were observed in postoperative nausea and vomiting, PACU stay, or hospital stay duration.ConclusionRemimazolam was not associated with a reduction in POD incidence but may offer a protective effect against early POCD in elderly surgical patients. It provides a favorable hemodynamic profile, and its opioid-sparing properties indicate that it may be a viable sedative option in this population, though further well-designed trials are required.Systematic Review Registrationhttps://inplasy.com/inplasy-2026-4-0037/.