UK Guidelines Update in Primary Care: Neurological Conditions


  • Clinical Guidance Summaries
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Presented by Doctor Nassif Mansour, a general practitioner in Kingston-upon-Thames with an extended role in neurology and rehabilitation. He was involved as a GP representative in developing the recently- published NICE Guidelines on suspected neurological conditions: recognition and referral.

My name is Nassif Mansour. I am a GP from south west London. I was one of the 2 GP’s who sat and advised NICE in developing the guidelines on suspected Neurological conditions.

1 in 10 people in general practice are coming in with neurological symptoms. So NICE produces 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 GP’s and trainees to be able to use these guidelines practically during the consultation. So the neurological condition assessment in fact 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 is 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.

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. 

So 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 for example patients coming in 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.

30% of referrals to secondary care are for patients with transient loss of consciousness and the vast majority of them have had syncope attack which is a simple fainting attack which is very common in the population but it is filling up neurological clinics up and down the country.

So the guidelines was designed to try and help us identify between the syncopal attacks and the epilepsy or to think about 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.

So I would suggest that if the patient presents with a blackout this is the opening complaint, that’s when I would have the guidelines ready very quickly and opened in order to 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 different sorts of movement disorders, for example shaking of the hands or abnormal ticks or facial movements or rippling of muscles.

And the guidelines helps us to at least remember the important ones. The important ones are the Parkinsons tremors because this helps us reach the diagnosis of Parkinsons disease and as well as the essential tremors because these are the common movement disorders, probably the commonest movement disorders.

So the essential tremors are usually symmetrical. Both hands are effected at the same time. Whilst with parkinsons disease, the vast majority of patients will present with a tremor on just one side before it marches onto the second side of the body.

The essential tremors are tremors in action so if the patients are actually using their hands, picking up a cup of tea for example, it will shake. Unlike the Parkinsons tremor which is usually addressed so when they actually use their hands, the tremor might disappear.

The guidelines from NICE are very clear that if we suspect Parkinsons disease, we need to refer patients on for a conformational diagnosis and treatment. However, for essential tremors, these guidelines help us and protect us and support us as GP’s 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 do not refer the patient. So if I do no refer the patient with classical essential tremors, and later on he developed Parkinsons disease, I have the guidelines to fall back on to support me that I have managed you as the patient according to the guidelines.

Another area that I believe was well-covered in the guidelines is the sleep and sleep disorders. It is a very challenging problem that faces us as Gp’s. Of course 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 jerky 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 from epilepsy.

Other sleep disorders that are commonly and possibly inappropriately referred to a neurological 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 administered locally.

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

I am very excited about these guidelines, not 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 other neurological problems that are challenging, that they 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 feel confident and comfortable managing patients who are presenting with neurological symptoms. Thank you for watching.