Abstract: Objective To evaluate the effect of perioperative use of remimazolam and propofol on postoperative delirium in frail elderly patients undergoing surgery for hip fractures. Methods A total of 210 patients, aged ≥60 years, men or women, with a body mass index (BMI) of 18-25 kg/m², and a Simple Frailty Questionnaire score of 3-5 points, who were scheduled for hip fracture surgery under general anesthesia from October 2022 to January 2024 were enrolled. Through an online randomization method, the patients were divided into two groups (n=105): a propofol group and a remimazolam group. Anesthesia induction: the remimazolam group was intravenously injected with remimazolam at 0.15-0.35 mg/kg, while the propofol group was intravenously injected with propofol at 1.0-2.5 mg/kg. Anesthesia maintenance: the remimazolam group was intravenously infused with remimazolam at 0.3-1.0 mg·kg^-1·h^-1, while the propofol group was intravenously infused with propofol at 4-12 mg·kg^-1·h^-1. The induction time to loss of consciousness, occurrence of injection pain, intraoperative hypotension and bradycardia, postoperative respiratory depression, nausea and vomiting, delirium, and extubation time were recorded. The levels of peripheral blood inflammatory cytokines were measured preoperatively, immediately after surgery, and on postoperative day 1. Results Compared with the propofol group, the incidence of postoperative delirium was also reduced on postoperative day 3 (P<0.05). However, no statistical differences were found in the severity of postoperative delirium between the two groups (P>0.05). The remimazolam group showed significant decreases in tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) levels on postoperative day 1, as well as reduced incidences of injection pain during induction, intraoperative hypotension, bradycardia, and postoperative delirium, and extended induction time to loss of consciousness (P<0.05). There were no statistical differences in extubation time, respiratory depression, or the incidence of nausea and vomiting between the groups (P>0.05). Conclusions Compared with propofol, perioperative use of remimazolam can reduce the incidence of postoperative delirium in frail elderly patients undergoing hip fracture surgery.