Purpose: Elderly patients undergoing dental extraction are particularly susceptible to delayed cognitive recovery after sedation. This study aimed to compare the effects of remimazolam and midazolam on early postoperative cognitive recovery in elderly patients undergoing dental extraction.

Patients and methods: This was a single-centre randomized controlled study with elderly patients scheduled for receiving dental extraction under sedation of remimazolam (Group R) or midazolam (Group M). The primary outcome was postoperative cognitive recovery, as measured by the Montreal cognitive assessment 5-minute (MoCA 5-minute) 30 min postoperatively (T(30)). Secondary outcomes included MoCA 5-minute score 1 h postoperatively (T(1h)), incidence of post-extraction bleeding, intraoperative adverse events, success rate of sedation, time to discharge, and complications.

Results: 106 patients (53 in each group) were eligible for the study. At T(30), MoCA 5-minute score was 25 (IQR 23.5, 27) in Group R, significantly higher than that of 23 (IQR 21, 25) in Group M (P < 0.001). This difference persisted at T(1h) [27 (IQR 26, 28) vs 26 (IQR 25, 27), P = 0.003]. Group R also exhibited better hemostasis, with a lower post-extraction bleeding rate at T(1) (5.67% vs 33.96%, χ(2) = 13.36, P < 0.001). Group R showed significantly shorter times to peak sedation after the first dose of medication, awake time, and time to discharge compared to Group M (P < 0.001, P < 0.001, P < 0.001).

Conclusion: Remimazolam sedation significantly improves early postoperative cognitive recovery, leading to expedited hemostasis and a shorter discharge time.