What Is Recovery Like After a Hip Fracture in an Older Adult?

Recovery after a hip fracture in an older adult usually starts with surgery, followed by getting out of bed with a physical therapist and a stay in the hospital, a rehabilitation facility or at home with support. Healing and regaining walking often take months, and outcomes vary from person to person. Some problems, such as sudden shortness of breath or stroke signs, need 911. This article covers the stages of recovery, pain medicines, complications, bone health and how families can help.

Recovery after a hip fracture in an older adult: the big picture

A hip fracture is a break in the upper part of the thigh bone, close to the hip joint. In older adults it often happens after a fall from standing height, and it is often linked to thinning bone. Research on a sideways fall onto the hip, such as the modeling study QCT/FEA models of proximal femur stiffness and fracture load during a sideways fall on the hip, helps explain why a fall that seems minor can still break a weakened bone.

Recovery is rarely a straight line. Most people need surgery, a period of intensive rehabilitation, and then weeks to months of rebuilding strength and confidence. Several factors shape the outcome, including walking ability before the fall, other medical conditions, memory and thinking, nutrition, and how much help is available at home.

The hospital stage: surgery and the first days

Surgeons commonly recommend repairing a hip fracture, because prolonged bed rest carries its own risks, such as blood clots, pneumonia, pressure sores and loss of muscle. The surgical team weighs the timing of surgery against the person's medical stability, other health conditions and any blood thinners already in use, and also decides how long clot prevention continues. The choice of operation depends on where the break is, how the bones line up, and the person's overall health and prior activity. Your surgeon will explain which option fits.

• Internal fixation: screws, a plate or a rod hold the bone together while it heals. This is often used when the bone pieces are in good position.
• Partial hip replacement (hemiarthroplasty): the broken top of the thigh bone is replaced with a metal implant.
• Total hip replacement: both the ball and the socket are replaced. It may be considered for some people who were active and walking well before the fracture.

Many hospitals now use shared care between the surgical team and a doctor who specializes in older adults. A report in the NIH's PubMed Central, Effects of Protocol-driven Care by Internists on Adherence to Clinical Practice Guidelines for Hip Fracture Surgery Patients, examined how structured, protocol-driven care by internal medicine doctors relates to following clinical practice guidelines in hip fracture surgery patients. Before leaving the hospital, it is reasonable to ask the team which activities are allowed on the operated leg and whether any movements should be avoided, since instructions differ by surgery type.

Confusion after surgery

Delirium is a sudden change in attention and thinking that can follow surgery, infection, strong pain medicine or an unfamiliar setting. A person may seem sleepy, restless, suspicious or unable to follow a conversation. It is common in older adults after a hip fracture and is often temporary, but it needs medical attention because it can signal infection, medication effects or other problems.

Rehabilitation: getting moving again

Physical therapists often help people stand and walk with support soon after surgery, as the surgical team allows. Early movement is generally encouraged because it can lower the risk of complications that come from lying still. At first this may be only a few steps with a walker and a helper. It can feel frightening and painful, which is normal.

After the hospital, people go to different places depending on their needs and coverage:

• An inpatient rehabilitation unit or skilled nursing facility, for those who need daily therapy and nursing care.
• Home with visiting therapists or outpatient therapy, for those who are stable and have help available.

Therapy usually focuses on transfers (bed to chair, chair to toilet), standing balance, walking with a walker or cane, stairs, and strengthening the hip and leg muscles. Occupational therapists work on dressing and bathing, and may recommend equipment such as a raised toilet seat or a shower chair. General strength loss during a hospital stay is covered in a related article on why older adults lose strength after a hospital stay.

What progress may look like

Many people regain much of their earlier walking ability, but some need a cane or walker permanently, and some do not return to the level of independence they had before. A realistic conversation with the care team early can help families plan without giving up on rehabilitation.

Pain and medicines: questions for the prescriber

Pain after hip surgery is expected, and good pain control makes it easier to take part in therapy. Clinicians often combine approaches, such as scheduled acetaminophen (Tylenol), ice, positioning, and in some cases stronger prescription medicine for a short time.

• Opioid pain medicines can cause drowsiness, constipation, confusion and unsteadiness, which matter a great deal in an older adult at risk of another fall. Their labels carry boxed warnings about serious, life-threatening breathing problems, addiction and misuse, and about the danger of combining them with sedating medicines such as benzodiazepines. Slow or shallow breathing, or being unable to stay awake after a dose, is an emergency: call 911. Ask the prescriber or pharmacist how to use them safely, whether naloxone should be kept at home, and how the dose will be lowered or stopped. Do not stop opioids suddenly after regular use without the prescriber's guidance. Do not drink alcohol while taking them.
• Acetaminophen (Tylenol) is part of many pain plans, but it is also an ingredient in many combination prescription and over-the-counter products, so doses can add up without the person noticing. Check labels, stay within the daily maximum the prescriber or pharmacist gives you, and ask them before using more than one product that contains it.
• Anti-inflammatory pain relievers such as ibuprofen or naproxen can affect the stomach, kidneys and blood pressure and may raise bleeding risk, especially alongside a blood thinner or with kidney disease. Ask the surgeon or pharmacist whether they are appropriate before taking them.
• Blood thinners (for example aspirin, enoxaparin, apixaban, rivaroxaban or warfarin) are often prescribed for a period after surgery to lower the risk of clots. They can raise the risk of bleeding, so tell the team about any unusual bruising, black stools or bleeding that is hard to stop. Enoxaparin, apixaban and rivaroxaban carry boxed warnings about spinal or epidural bleeding (hematoma) after spinal or epidural anesthesia, which can lead to paralysis. Ask the prescriber which warnings apply to your medicine. New severe back pain, new numbness or leg weakness, or loss of bladder or bowel control after spinal or epidural anesthesia needs emergency care: call 911 or go to the nearest emergency department. Do not stop or skip a prescribed blood thinner without talking to the surgeon or prescriber, because stopping may raise the risk of a clot. Follow the prescriber's plan and keep any recommended monitoring.

Bring a complete list of prescription medicines, over-the-counter products and supplements to every transition of care, and check with a pharmacist before adding anything new.

Complications that can slow recovery

Most people do not experience every complication, but knowing the warning signs helps families act early. Several factors, including immobility, surgery and other illnesses, can contribute.

• Blood clots in the leg (deep vein thrombosis): a swollen, warm, tender or painful calf or thigh. A clot can travel to the lungs, which causes sudden shortness of breath or chest pain and needs emergency care.
• Pneumonia and other lung problems: cough, fever, fast breathing or new weakness. Deep breathing and sitting up regularly can help, as your team directs.
• Wound infection: increasing redness, warmth, swelling, drainage or a bad smell at the incision, or a fever.
• Pressure sores: red or broken skin over the tailbone, heels or hips from staying in one position. Changing position and checking the skin helps.
• Urinary problems: burning, new confusion or a change in urination, which may point to a urinary tract infection.
• Constipation: common with reduced activity and some pain medicines. Tell the care team if it persists.
• Problems with the repair itself: new or gradually worsening hip pain without a fall, or trouble putting weight on the leg, may suggest a problem with the hardware, implant or healing bone and needs same-day medical evaluation. If a fall may have happened, including one nobody saw, treat it as a fall: with severe hip pain, a leg that looks shorter, deformed or turned outward, or inability to move the leg or bear weight, call 911, because a dislocation or a break around the implant can be present.
• Another fall: a person who falls again needs medical evaluation. A hit to the head, especially while taking a blood thinner, or a fall with a suspected hip or leg injury needs emergency care.

Nutrition, mood and sleep

Healing takes protein, calories, calcium and vitamin D. Appetite is often poor after surgery, and weight loss can slow recovery. Ask the clinician before starting calcium or vitamin D supplements, since the right amounts depend on diet, kidney health and other medicines.

Low mood, anxiety and fear of falling are common after a hip fracture, and some people limit their activity out of fear, which can lead to further weakness. Tell the clinician if sadness, hopelessness or withdrawal lasts, because depression can be treated. If anyone is thinking about harming themselves, call or text the 988 Suicide and Crisis Lifeline, or call 911 if there is immediate danger.

A hip fracture is also a message about bone health

A hip fracture after a low-impact fall is often called a fragility fracture, and it is commonly associated with osteoporosis. The NIH-hosted review Fragility Fracture: 10 Commandments discusses how care after such a fracture includes looking at the underlying bone disease and the risk of the next break, not only fixing the first one. Tools such as FRAX estimate fracture risk, and a review of how treatment thresholds based on FRAX are set is available in A systematic review of intervention thresholds based on FRAX. Research on bone structure, such as DXA-derived hip shape is associated with hip fracture, shows that risk depends on more than bone density alone.

Practically, tell the clinician you would like to discuss osteoporosis treatment as well as bone density testing, so they can decide what is appropriate. The related articles on bone density testing and on osteoporosis drugs such as alendronate cover those topics, including drug risks. Any osteoporosis medicine should be started, timed and adjusted only by the prescriber.

Preventing the next fall

Because a previous fall raises the chance of another, prevention is part of recovery. The care team may review vision, footwear, blood pressure when standing, medicines that cause dizziness, and strength and balance exercises. A home safety evaluation by an occupational therapist can identify loose rugs, poor lighting, missing grab bars and stair hazards.

How family and caregivers can help

• Attend discharge teaching and write down the surgeon's movement and weight-bearing instructions.
• Keep a single updated medicine list and bring it to every appointment.
• Watch for changes in thinking, breathing, skin, appetite and mood, and report them early.
• Look after yourself too. Caregiver exhaustion is common, and social workers at the hospital or rehabilitation facility can point you toward respite and home-care resources.

The longer road: what recovery may look like over months

Recovery is usually measured in months, and many people keep improving for a year or more; the surgeon and therapist can give a more personal estimate. Pain generally eases, walking improves and many people return to more of their routine, but fatigue, stiffness and a limp can linger. With surgery, rehabilitation, bone health treatment and fall prevention, many older adults regain meaningful independence.

When to Seek Medical Care