Hip Fracture and Anemia in the Elderly: A Systematic Review of Transfusion Strategies and Patient Blood Management

Background: Perioperative anemia is a common and consequential comorbidity in elderly patients with hip fracture, yet the optimal management strategy between transfusion and alternative therapies remains a critical clinical dilemma. Objective: This systematic review synthesizes contemporary evidence (2016-2026) on transfusion thresholds and perioperative anemia management in geriatric hip fracture patients, focusing on clinical outcomes and guideline recommendations. Methods: A systematic literature search was conducted in PubMed, Embase, and the Cochrane Library. Randomized controlled trials, meta-analyses, cohort studies, and clinical guidelines were included. Data were extracted and synthesized narratively. Results: Perioperative anemia affects 40-46% of patients and is an independent predictor of increased mortality, delirium, prolonged hospitalization, and functional decline. High-level evidence supports a restrictive transfusion strategy (hemoglobin threshold <8 g/dL for asymptomatic patients), which reduces transfusion exposure without increasing mortality or impairing recovery compared to liberal strategies. Liberal transfusion is associated with higher risks of infection, acute kidney injury, and cardiovascular events. Adjunctive strategies, particularly intravenous iron and tranexamic acid, significantly reduce transfusion requirements safely. Conclusion: Management should prioritize a restrictive, symptom-guided transfusion policy integrated within a multimodal Patient Blood Management protocol. Preoperative optimization, blood conservation techniques, and targeted pharmacotherapy are essential to improve outcomes and minimize avoidable transfusions in this frail population.