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Background and Aims Background: Perioperative administration of benzodiazepines is considered a risk factor for early postoperative cognitive decline; however, the association between Remimazolam, a newly developed ultrashort-acting benzodiazepine for anesthetic purpose and postoperative cognitive decline is under research. Aims: The primary aim of this prospective randomized study was to evaluate whether Remimazolam administration during elective surgery under spinal anesthesia influences the incidence of early cognitive decline in patients with no prior cognitive disorders. Secondary outcomes included the evaluation of mean arterial pressure and heart rate.

Methods 80 patients (age>65 years) scheduled for short surgical procedures under spinal anesthesia were randomized 1:1 to receive Propofol (PRO group) or Remimazolam (RMZ group) aiming a Modified Observer’s Assessment of Alertness/Sedation score of 3 or 4. Both groups were assessed through the Mini-Cog test at three time points: preoperative, first 24 hours and 48 hours postoperative.

Results Both groups were similar in terms of age, gender, BMI, ASA score and comorbidities. Preoperative Mini-Cog score were similar across both groups. Patients receiving Remimazolam demonstrated a better Mini-Cog score at both 24 and 48 hours compared to those receiving Propofol (4,41 vs. 4,0, diff means=-0,41± 0,18, 95%CI 0,79-0,04, p=0,02; 4,3 vs. 3,9, diff means=-0,41± 0,19, 95% CI 0,813-0,0160, p=0,04). Patients in RMZ group had a lower incidence of hypotension and bradycardia during procedural sedation.

Conclusions Remimazolam usage for procedural sedation is safe and does not worsen early cognitive outcome in older patients undergoing short elective surgical procedures. Furthermore, it offers a better hemodynamic profile which can improve patients outcome.