Fear of falling risk after hip surgery in older adults: an updated sex-specific systematic review with GRADE and PAF assessment

Fear of falling (FOF) is a common clinical issue in elderly individuals, especially after hip fractures. Studies show wide variation in FOF prevalence after fractures, with rates ranging from 38 to 72% and notable differences among study groups. Differences in study design and assessment methods make it necessary to conduct a rigorous systematic review. This will consolidate evidence on both epidemiological patterns and modifiable risk factors for FOF. A systematic literature search was conducted across nine electronic databases (PubMed, Web of Science, Cochrane Library, Embase, CINAHL, MEDLINE, PsycINFO, CBM, CNKI, VIP, and Wanfang) from inception through January 1, 2025, to identify observational studies investigating the incidence of FOF and associated risk factors in elderly hip fracture patients. Risk of bias assessment was conducted using the Newcastle–Ottawa Scale. Stata 15.0 software was used for meta-analysis, subgroup analysis, and sensitivity analysis in heterogeneity studies. Publication bias was assessed using funnel plots, Egger tests, and Begg tests. We used the population attributable fraction (PAF) and the grading of recommendations, assessment, development, and evaluation (GRADE) evidence assessment to evaluate the quality of the research results. Nine studies involving 3,088 patients from seven countries were included in the meta-analysis. The results indicated that the incidence of FOF was 66.88% (95%CI 0.64–0.70, P < 0.001) in elderly patients with hip fractures, with a higher incidence observed in developing countries (70.61%) and cases using the simplified International Fall Efficacy Scale (67.00%). The incidence of FOF in female patients (71.95%) was significantly higher than that in male patients (53.97%). Those history of falls (OR = 1.98, 95%CI, 1.50–2.24, P < 0.001), postoperative pain (OR = 1.77, 95%CI, 1.03–3.04, P = 0.04), conjunction with other chronic diseases (OR = 1.25, 95%CI, 1.00–1.55, P = 0.05), poor mobility (OR = 1.62, 95%CI, 1.30–2.02, P = 0.001), and anxiety (OR = 1.13, 95%CI, 1.10–1.15, P < 0.001) were identified as risk factors for fear of falling in elderly patients with hip fractures. The results of the evaluation of evidence showed that the history of falls, pain, and anxiety was of high quality. PAF analysis indicated that postoperative pain for 33.99% (95% CI 4.69–63.97%) and anxiety for 8.00% (95% CI 6.54–9.46%) of FOF. FOF among older adults remains a substantial global health burden, with notable gendered disparities. If postoperative pain was controlled, approximately one in five FOF could be avoided. Future high-quality longitudinal studies are warranted to refine causal pathways and evaluate the effectiveness of targeted interventions in diverse populations. This study was registered in the International Database of Prospectively Registered Systematic Reviews (PROSPERO: CRD42025623930).