A meta-analysis of 13 randomized controlled trials with 1581 elderly surgical patients showed that esketamine significantly reduced the incidence of postoperative delirium (RR = 0.58, 95% CI: 0.43–0.79), postoperative nausea and vomiting (RR = 0.57, 95% CI: 0.44–0.74) and perioperative hypotension (RR = 0.47, 95% CI). Esketamine also reduced opioid requirements during induction of anesthesia (SM = -0.43, 95% CI: -0.59 to -0.26). Negative findings were an increased risk of dizziness (RR = 1.29, 95% CI: 1.03–1.62) and perioperative hypertension (RR = 2.40, 95% CI: 1.16–4.97). The study found no significant differences in pain intensity, cognitive function, or psychological events such as hallucinations or nightmares. Considering the increased risk of perioperative hypertension in elderly patients and the significant heterogeneity of results, the authors conclude that current evidence does not yet support the routine clinical application of esketamine in this population.