What's in NICE Guidance on Neurological Conditions for GPs?

Dr Nassif Mansour 

Disclosures

May 18, 2020

GP Dr Nassif Mansour explains why the latest National Institute for Health and Care Excellence (NICE) guidance on neurological conditions is so useful for GPs.

Adapted from Univadis from Medscape.  This transcript has been edited for clarity.

My name is Nassif Mansour. I am a GP from south-west London. I was one of the two GPs who sat and advised NICE in developing the guidelines on suspected Neurological conditions.

One in 10 people who present in general practice are coming in with neurological symptoms.

So NICE produced an overarching set of guidelines that will help us in primary care in order to be able to identify those patients and recognise the conditions that can be managed safely in primary care but also those that need to be referred in a timely fashion to secondary care.

This short film will help us as GPs and trainees to be able to use these guidelines practically during the consultation.

Neurological Condition Assessment

The neurological condition assessment starts from calling the patient from the waiting room. The way they walk in and the way they sit in front of us in general practice.

The best way to start the consultation in my opinion would be to put them at rest and to help them to share the information that they want to share with us.

The important clues are all in the history of any neurological condition. We can then do a brief examination in order to confirm certain aspects from the history.

Red Flags

Also, it is important to identify the red flags. This will determine the urgency of the referrals and the guidelines help us to achieve that.

A couple of examples of red flags would be for example a patient presenting with blackouts. If there are features in the history to suggest that they might have had epilepsy, then this is something we should take note of.

Another example would be patients coming in presenting with poor balance and whilst the patient is sitting there in front of me shows resting tremor on the left or the right side. That to me would indicate Parkinson’s disease.

Thirty percent of referrals to secondary care are for patients with transient loss of consciousness and the vast majority of them have got syncopal attack, which is a simple fainting attack that is very common in the population, but it is filling up the neurology clinics up and down the country. 

So the guideline was designed to try and help us identify between the vasovagal attacks and the epilepsy, or to think of these 2 conditions mainly. And if it is likely to be a syncopal attack then we don’t need to refer unless there are other conditions related to it.

I would suggest that if the patient presents with a blackout and this is the opening complaint, that’s when I would very quickly have the guidelines ready and opened in order to just view the evidence that is there.

Another example, and I believe a useful area covered by the guidelines, are tremors and different movement disorders. So patients will present with all sorts of different movement disorders, for example shaking of the hands, or abnormal tics, or facial movements, or rippling of muscles. 

Movement Disorders

The guidelines help us to at least remember the important ones. The important ones are the Parkinson's tremors because this helps us reach the diagnosis of Parkinson's disease, and as well as the essential tremors because these are probably the most common movement disorder. 

Essential tremors are usually symmetrical. Both hands are affected at the same time, whilst with Parkinson's disease the vast majority of patients will present with a tremor on one side before it marches onto the second side of the body.

The essential tremors are tremors in action, so when the patients are actually using their hands, picking up a cup of tea for example, it will shake. 

Unlike the Parkinson's tremor, which is usually at rest, so when they actually use their hand the tremor might disappear. 

The guidelines from NICE are very clear that if we suspect Parkinson's disease, we need to refer patients on for a confirmation of diagnosis and treatment. 

However, for essential tremors, these guidelines help us and protect us and support us as GPs that we do not need to refer the patients unless they are not responding to the first-line treatment. 

The guidelines protect us if we did not refer the patient. So if I did not refer the patient with classical essential tremors, and later on he developed Parkinson's disease, I have the guidelines to fall back on, to support me, that I have managed you as the patient according to the guidelines. 

Sleep Disorders

Another area that I believe was well covered in the guidelines is sleep and sleep disorders. It is a very challenging problem that faces us as GPs. The commonest one of them would be lack of sleep (insomnia), and the guidelines make it clear that we do not need to refer patients with insomnia.

Also, it encourages us not to refer patients for example when they get, for the first time or repeatedly, jerking movements, for example one of their limbs, a leg or an arm when they go off to sleep. This is a normal physiological phenomenon and it is not epilepsy.

The guidelines make it very clear however that we need to make sure that we are not missing epilepsy and if there is any doubt, the guidelines will easily direct us through the hyperlink to the epilepsy evidence which will help us differentiate between a simple physiological phenomenon and from epilepsy.

Other sleep disorders that are commonly, and possibly inappropriately, referred to the neurology clinic are sleep disorders related to sleep apnoea.

We use the Epworth scale to reach our diagnosis and if it is suspected then we use the sleep apnoea referral pathway that is agreed locally.

Similarly, conditions like narcolepsy and catalepsy, if they are suspected and sleep apnoea is excluded, then they are happy for us to refer, and it encourages us to refer to secondary care.

I am very excited about these guidelines, not just because it covered a very challenging area in general practice, it also gives us the support we need to be able to manage patients safely and effectively. 

These guidelines are very useful as they link to other common neurological problems that are challenging, that need our urgent attention. 

I would encourage you all to use the guidelines, to embrace them, to have them in the background on your desktop, to assist you during the consultation. I promise you it will help you to feel confident and comfortable managing patients who are presenting with neurological symptoms. 

Thank you for watching. 
 

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