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Hip fracture in the older adult: before and after surgery, delirium, positioning and early mobilisation

  • Safe practice

An older adult with a hip fracture needs pain relief, delirium and pressure-injury prevention, surgery without delay and getting out of bed early.

Updated

What it is

A hip fracture in an older adult is a turning point: delirium, pressure injuries, chest and urinary infections, venous thromboembolism and loss of independence are common. Surgery within about 48 hours is linked to lower mortality and fewer pressure sores in observational studies. While the patient waits, pain relief, hydration, nutrition, pressure-area care and delirium prevention continue as active treatment. After surgery, nursing aims to get the patient sitting out, standing and taking assisted steps early, adapted to what the patient can do, and to start fall and bone-health prevention before discharge. Cognitive impairment changes how this care is given, not whether it is given.

What it requires

  • Coordinated care with the orthopaedic and geriatric teams and physiotherapy.
  • Regular pain assessment with a method suited to the patient's cognition.
  • Delirium prevention measures in place from admission.
  • A plan for mobilisation, continence, nutrition and pressure care from the first day.

How it is applied (and why)

  1. Assess pain on arrival and regularly, at rest and on movement, with the same method each time — untreated pain feeds delirium and stops mobilisation.
  2. Screen for delirium and note the patient's usual cognition from the family — a new change is a medical warning sign, not just 'confusion'.
  3. Provide glasses, hearing aids and dentures, orientation, protected sleep, fluids and oxygen as ordered — these non-drug measures reduce delirium.
  4. Relieve pressure on heels and sacrum on a pressure-relieving surface, also while surgery is delayed — immobile older adults get pressure injuries fast.
  5. Position the operated leg as the surgeon orders and use the precautions for the type of surgery — poor positioning can displace the repair.
  6. Help the patient sit out, stand and take assisted steps as soon as allowed, with simple weight-bearing advice — early activity restores independence.
  7. Review urinary catheters and IV lines daily and remove them when no longer needed; watch for retention and constipation — both cause discomfort and delirium.
  8. Record what the patient actually eats, help at mealtimes and check swallowing and teeth — screening helps only if it leads to action.
  9. Give the ordered VTE prevention and teach ankle exercises — immobility after a hip fracture raises the risk of clots.
  10. Plan discharge with the family: transfers, fall risks at home, bone health, delirium warning signs and a contact name — the risk continues after discharge.

In nursing practice

  • Delirium that persists at discharge must be written in the handover so it is not taken for dementia.
  • Calm, simple explanations and a familiar person are the first response to distress; antipsychotic medicines do not treat the causes of delirium.
  • If a mobilisation attempt fails, look for the reason (low blood pressure on standing, pain, a nerve block that has not worn off, severe anaemia) and try again.
  • Demonstration and supervised practice work better than written advice for patients with dementia.
  • Watch for chest and urinary infection, and for calf pain or breathlessness.

Common mistakes

  • Leaving pain relief to 'when needed' in a patient who cannot ask for it.
  • Calling delirium 'normal confusion' and not reporting it.
  • Waiting for surgery without turning the patient or protecting the heels.
  • Keeping a urinary catheter in place out of habit.
  • Discharging without a fall and bone-health plan, or without telling the family who to call.

Test yourself

Think of the answer, then tap the question to see it.

How can pain show in a patient with dementia and a hip fracture?

As grimacing, guarding, crying out, resisting care, withdrawal or reduced movement; assess at rest and on movement.

Which nursing measures help prevent delirium after a hip fracture?

Orientation, glasses and hearing aids, protected sleep, fluids, nutrition, early activity, pain control and treating constipation and retention.

Does early surgery matter after a hip fracture?

Observational studies link surgery within about 48 hours to lower mortality and fewer pressure sores.

What should happen if the first attempt to get the patient up fails?

Find the reason, such as low blood pressure on standing, pain or a nerve block, deal with it and try again in a shorter session.

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Han X, Han W, Yin X, Li M. Multidisciplinary perioperative and post-acute care for older adults with hip fracture and cognitive impairment or dementia: a narrative review. J Multidiscip Healthc 19 (Journal of Multidisciplinary Healthcare (PubMed Central, open access), 2026); Moja L et al. Timing matters in hip fracture surgery: patients operated within 48 hours have better outcomes. PLoS One 7(10):e46175 (PLoS One (PubMed Central, open access), 2012); Hip fracture - discharge, MedlinePlus Medical Encyclopedia (MedlinePlus, US National Library of Medicine, 2026).

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