Purpose <p>This systematic review seeks to investigate whether tranexamic acid (TXA) should be administered to patients over 65 years of age undergoing hip fracture surgery. This select patient population is at increased risk of requiring red blood cell transfusions, why there might be a case for TXA intervention.</p> Methods <p>Following PRISMA guidelines, a systematic search was conducted on EMBASE and PubMed databases on the 27th of November 2023. Only randomized controlled trials (RCT) with a mean age of above 65 years where eligible for inclusion. Only studies with intravenous intervention and control with saline were included. A Cochrane Risk of Bias tool was used to investigate potential biases. The certainty of each outcome was interpreted using the GRADE approach. The primary outcome was red blood cell transfusion rate and the secondary outcome was thromboembolic event rate.</p> Results <p>This review comprised of 12 RCTs with a combined 1397 patients, of whom 699 received TXA and 698 received saline. Pooled results show a significant reduction in blood transfusion rate for patients who received TXA (RR 0.612, 95%CI 0.480–0.779, p-value &lt; 0.001). Thromboembolic event rate was reported in 9 studies, tallying 1147 patients. Results showed no significant change in thromboembolic event rate for patients receiving TXA intervention (RR 0.922, 95%CI 0.603–1.411, p-value = 0.710).</p> Conclusion <p>Tranexamic acid significantly reduced the need for blood transfusion in patients undergoing hip fracture surgery. Furthermore, no significant change in thromboembolic events is present, but due to low thromboembolic event rate in the patient population, no definite conclusion can be made regarding the safety of tranexamic acid. Furthermore, a higher grade of homogeneity between studies with regards to TXA intervention timing and dose would be helpful. In conclusion, intervention with TXA appears promising with regards to transfusion requirement in the targeted population.</p>