For very frail older adults, choosing nonoperative treatment for a hip fracture shifts the goal from repair to comfort and symptom control. Care usually focuses on regular acetaminophen, short, closely supervised opioid courses for breakthrough pain, and comfort measures such as nerve blocks, ice and thoughtful positioning. Activity is progressed slowly with safe transfers and appropriate mobility aids. Early involvement of physiotherapy and palliative or geriatric teams is encouraged. Monitoring emphasizes delirium prevention, skin care, hydration and clear family communication. Because overall prognosis is often guarded, care is guided by individualized goals and realistic expectations.
Key Takeaways
Nonoperative management (NOM) is mainly considered for very frail older adults after shared decision‑making and advance care planning.
NOM prioritizes comfort: scheduled acetaminophen, short opioid bursts for breakthrough pain, and adjuncts such as nerve blocks and ice.
Mobility plans are tailored—limited weight‑bearing when needed, appropriate mobility aids, and early gentle physiotherapy focused on safe transfers.
A multidisciplinary approach reduces complications: delirium protocols, hydration checks, skin monitoring, thrombosis screening, nutrition support and caregiver education.
Prognosis after NOM is generally poorer than after surgery, so decisions need individualized risk assessment and alignment with palliative goals.
When nonoperative care is considered for elderly hip fractures
When is nonoperative management chosen for an older person with a hip fracture? NOM is usually reserved for a small subgroup of frail patients when surgery is declined or deemed too high‑risk. These choices come from shared decision‑making and advance care planning and reflect patient or family preferences, medical contraindications, or both. Patients managed nonoperatively are often older, have worse pre‑fracture mobility and higher rates of dementia, which complicates direct outcome comparisons. One study reported NOM in about 7.1% of orthogeriatric admissions and 2.6% of all hip fracture cases. Reported mortality in NOM groups varies widely and can be substantially higher than with surgery, with some case series showing very high 30‑day and 1‑year mortality in the frailest groups.
Pain control and medication strategies
After choosing NOM, the priority is comfort while limiting medication harms. Baseline analgesia typically uses scheduled acetaminophen; NSAIDs are reserved for short periods when benefits clearly outweigh risks. Short courses of stronger opioids are used for breakthrough pain with close clinical review. Analgesic plans are individualised, reviewed frequently, and tied to advance care goals. Monitoring focuses on sedation, kidney function and gastrointestinal risk. Nonpharmacologic supports—positioning, ice and nerve blocks when appropriate—can reduce opioid needs and improve comfort.
Strategy | Rationale |
Scheduled acetaminophen | Provides steady baseline pain relief with a favourable safety profile |
Limited NSAIDs | Short‑term use only when clear benefit outweighs risks |
Short opioid course | For breakthrough pain under careful supervision |
Adjunct measures | Ice, positioning and nerve blocks to improve comfort and reduce opioid needs |
Review plan | Regular reassessment to keep treatment aligned with goals and limit side effects |
Mobility, rehabilitation, and fall prevention
How should mobility be managed for a very frail older adult treated nonoperatively? Activity is advanced slowly and personalised, balancing frailty, pain and safety. Nonoperative management usually begins with initial rest and limited weight‑bearing, moving to use of appropriate mobility aids (walker, cane or wheelchair) as pain and tolerance allow. Early physical therapy focuses on gentle range‑of‑motion, safe bed‑to‑chair transfers and strengthening to prevent stiffness and deconditioning. Rehabilitation sets realistic goals that reflect prognosis and the patient’s wishes. Fall prevention is essential: home hazard assessment, suitable footwear, assistive devices and caregiver training help reduce recurrence. Good nutrition and coordination with palliative or support services support function. Clear, ongoing communication about likely outcomes helps the care team and family adjust the plan.
Monitoring, complication prevention, and supportive care
Monitoring and complication prevention support comfort and mobility goals. Care follows palliative principles with structured analgesia, sensible mobility limits and delirium prevention measures such as sleep routines, orientation aids and medication review. Multidisciplinary co‑management brings together nursing, geriatrics, physiotherapy, nutrition and social support. Regular checks of vital signs, skin and wounds, hydration status and thrombosis risk, plus early range‑of‑motion for unaffected joints, help reduce decline. Advance care planning and transparent family communication guide any escalation. Resource planning should consider home or nursing home needs and bone‑health strategies, balancing comfort and safety while deferring interventions better discussed later.
Monitoring | Intervention |
Vitals & hydration | Correct fluids and monitor clinical status |
Pain & analgesia | Opioid‑sparing strategies with frequent review |
Delirium risk | Orientation aids, sleep routines and medication review |
Skin & mobility | Pressure relief, regular repositioning and mobility support |
Nutrition & support | Dietitian referral and meal planning |
Expected outcomes, prognosis, and decision making
What outcomes are reasonable to expect when nonoperative management (NOM) is chosen for very frail older adults with hip fracture? When NOM is chosen through shared decision‑making, comfort and symptom control are the primary aims, but prognosis is often poor. Reported short‑ and long‑term mortality is higher than after surgery (example cohort: 30‑day ~87%, 1‑year ~99% versus 7% and 28% with operation), although baseline frailty, advanced age, limited pre‑fracture mobility and dementia bias these figures. The literature shows wide 1‑year mortality ranges (5–65%) after NOM, highlighting that NOM commonly reflects very high perioperative risk or a care plan focused on comfort. Decisions should use individual risk assessment, advance care planning and multidisciplinary input so treatment matches the patient’s values and realistic expectations.
Frequently Asked Questions
How long does it take for an elderly person to recover from a hip fracture?
Recovery often takes months. Bone healing may need 6–12 weeks, but regaining strength, balance and independence usually takes several months and can be longer in frail older adults. Pre‑fracture mobility, cognition, other health conditions, nutrition and the chosen treatment all influence recovery time.
Can a broken hip heal without surgery in the elderly?
Yes. Some older patients with stable, non‑displaced fractures can heal without surgery with good pain control, protected weight‑bearing and rehabilitation. Healing is typically slower and functional outcomes may be worse than after surgery, so careful selection and follow‑up are important.
What is the surgery for a broken hip in the elderly?
Surgical options commonly include internal fixation (screws or plates) or hip arthroplasty (hemi‑ or total replacement) to restore alignment, stability and mobility — comparable to fixing a worn hinge so the joint moves smoothly again.
How do you rehab a hip fracture?
Rehabilitation focuses on early pain control, protected weight‑bearing, progressive mobility and targeted physiotherapy for hip, leg and core strength, range‑of‑motion and gait training with aids. It also includes thrombosis prevention, nutrition support and ongoing multidisciplinary follow‑up.
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Sources
Kim, S., Park, H., & Lee, D. (2020). Outcome of nonoperative treatment for hip fractures in elderly patients: a systematic review of recent literature. Journal of Orthopaedic Surgery, 28(2). https://journals.sagepub.com/doi/10.1177/2309499020936848
Lim, W. and Kwek, E. (2018). Outcomes of an accelerated nonsurgical management protocol for hip fractures in the elderly. Journal of Orthopaedic Surgery, 26(3). https://journals.sagepub.com/doi/10.1177/2309499018803408
Givens, J., Sanft, T., & Marcantonio, E. (2008). Functional recovery after hip fracture: the combined effects of depressive symptoms, cognitive impairment, and delirium. Journal of the American Geriatrics Society, 56(6), 1075-1079.https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2008.01711.xNon‑surgical hip fracture care for older adults
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