REMEDY : BNSSG referral pathways


Checked: 18-08-2018 by vicky.ryan Next Review: not set yet

Who to refer

Refer patients with unexplained recurrent falls (more than one) to the falls clinic for investigation

Refer patients with recurrent falls, or at risk of fall, to the multidisciplinary community falls team for help with falls prevention and rehabilitation after a fall

See also vertigo and dizziness


Identify conditions that might require urgent admission to A&E, secondary care, or other urgent care setting, including:

  • if an older person could walk before a fall and is now unable to walk, they require prompt assessment for injury or acute illness
  • loss of consciousness
  • swellings and tenderness
  • fractures, including hip
  • neurological conditions, eg stroke 
  • cardiovascular conditions:
    • arrhythmia
    • heart attack
    • syncope

Before referral

Physical examination

Any new neurological impairment

Signs of infection

Any cardiac abnormalities

Cognitive impairment

Observe gait

Review Meds

On warfarin / NOAC

Any sedative drug? alcohol, anticholinergics, antipsychotics, tricyclic antidepressants

Consider doing ( if dizziness, syncope, palpitations prior to fall)


Lying and standing BP

Blood tests

FBC, U&E, TSH, B12/folate, LFTs, Calcium.

MSU if urinary symptoms 

Consider multifactorial risk factors for falls

Vision – cataracts, last eye test, visual acuity?

Footwear – appropriate, fit well?

Continence – fluid intake, overactive bladder?

Cognitive function – AMT, confusion screen?

Consider bone health – do FRAX, consider starting calcium and vitamin D

Orthostatic hypotension (OH) is diagnosed when:

  • there are no features suggesting an alternative diagnosis and the history is typical
  • Lying and standing blood pressure changes with repeated measurements while standing for 3 minutes. Classical OH is defined as a decrease in systolic BP ≥20 mmHg and in diastolic BP ≥10 mmHg within 3 mins of standing.

If orthostatic hypotension is confirmed, consider likely causes, including drug therapy (eg: Alpha and Beta blockers, ACE inhibitors, ARBS, Calcium channel blockers, Diuretics, Nitrates, Hydralazine, Diuretics, Antidepressants and alcohol) and manage appropriately. Consider referring on for trial of fludrocortisone.


You can also consult the e-Referral service to consider alternative providers

Multi-factorial falls risk assessment

  • Community Falls Team - Bristol Community Health 
    Falls specialist nurse providing non-urgent comprehensive geriatric assessment for complex patients at risk of recurrent falls, who are registered with a Bristol GP 
  • Community Falls and Balance Service – Sirona, South Gloucestershire 
    Service for adults registered with a GP in the South Gloucestershire area who have been identified as being at an increased risk of falling or who have had unexplained falls or black-outs.
  • Community Falls Team – North Somerset Community Partnership 
    Falls Prevention. Advice and treatment for patients with a history of, or risk of, falling at home.

Secondary Care Assessment – following Multi-factorial risk assessment

  • NBT Falls clinic for older people
    Designed for patients who have fallen due to suspected syncope, patients with unexplained dizziness or who have recurrent falls where a cause has not been found despite performing a multi-factorial falls risk assessment, or patient is falling despite interventions put in place to manage risks
  • UHBT Care of the Elderly Team
    A Falls Service is available at the Day Assessment Unit in South Bristol Community Hospital. This service is provided for patients aged over 60 who have fallen and live within the UH Bristol catchment area
  • UHBT Care of the Elderly Team
    A Syncope clinic is available at the BRI. This service is for patients with unexplained falls, dizziness and blackouts (including younger syncopal patients).
  • Staying steady classes – Bristol & North Somerset
    Staying Steady is a programme of strength and balance classes to help build strength and confidence and lower risk of falling.
    There is a small cost for these classes