UNLABELLED: Continuing antiplatelets during hip fracture surgery may be safe for older adults, while early surgery after discontinuation reduces hospital stay without adverse outcomes. PURPOSE: The safety of continuing antiplatelets or direct oral anticoagulants (DOACs) before surgery in older patients with hip fractures remains uncertain. The feasibility of timely surgery after discontinuation also warrants further investigation. METHODS: We included studies of hip fracture patients aged ≥ 65 years taking antiplatelets or DOACs, comparing continuation versus discontinuation, or early versus delayed surgery. MEDLINE, EMBASE, Cochrane Library, and Web of Science were searched to November 2024. Risk of bias was assessed using the Newcastle-Ottawa Scale. Meta-analyses were conducted using a random-effects model to pool effect estimates. This study was registered with PROSPERO (CRD42022378334). RESULTS: Thirteen observational studies from nine countries involving 885 patients were included. There were no significant differences in transfusion rates in patients who continued the medication (Odds Ratio [OR] = 0.87; 95% Confidence Interval [CI]: 0.37 to 2.03). Surgery within 48 h of antiplatelet discontinuation was associated with shorter hospital stay (mean difference = - 5.71 days; 95% CI: - 8.36 to - 3.06) compared to those with delayed surgery, with no increase in transfusion (OR = 0.75; 95% CI: 0.04 to 13.73) and in-hospital mortality (OR = 0.49; 95% CI: 0.02 to 13.52). For DOAC users, no significant differences were observed in transfusion (OR = 1.09; 95% CI: 0.56 to 2.09) and 30-day mortality (OR = 1.53; 95% CI: 0.45 to 5.19) for early versus delayed surgery. CONCLUSIONS: Surgery without discontinuing antiplatelets may be safe. Early surgery after discontinuing antiplatelets could reduce hospital stays without adverse outcomes. Randomized trials are needed to confirm these findings.