Neurological conditions: a symptom-by-symptom guide for nurses
How to care for a patient who has signs and symptoms that may require investigation
- Neurological conditions make up a significant proportion of emergency admissions and GP consultations
- NICE guidance explains the signs and symptoms nurses should look out for in patients
- Read a clinical nurse specialists practical advice
Suspected neurological conditions, excluding stroke, account for about 10% of UK emergency admissions. A similar proportion of GP consultations relate to neurological problems.
people in the UK are affected by a neurological problem
(Source: Brain and Spine Foundation )
Yet diagnosis can be difficult. A survey by the Neurological Alliance found that almost one third of respondents made five or more
...How to care for a patient who has signs and symptoms that may require investigation
- Neurological conditions make up a significant proportion of emergency admissions and GP consultations
- NICE guidance explains the signs and symptoms nurses should look out for in patients
- Read a clinical nurse specialist’s practical advice
Suspected neurological conditions, excluding stroke, account for about 10% of UK emergency admissions. A similar proportion of GP consultations relate to neurological problems.
Yet diagnosis can be difficult. A survey by the Neurological Alliance found that almost one third of respondents made five or more visits to their GP before their neurological condition was diagnosed. About 40% waited more than a year between first noticing symptoms and seeing a specialist.
Last year, the National Institute for Health and Care Excellence (NICE) published guidance designed to help non-specialist healthcare professionals identify patients over 16 who should be referred for specialist assessment and care.
The full guidance, according to symptom, is summarised below, symptom by symptom. It’s worth noting that NICE has also produced separate guidance relating to children under 16.
1. Blackouts
How to help your patient
In new-onset cases where there are features strongly suggestive of epileptic seizures, ask for urgent referral. ‘Urgent’ means the patient should be seen by specialist services within two weeks. Signs of epileptic seizure include a bitten tongue, prolonged limb-jerking and head-turning during the event, and confusion afterwards.
Do not routinely refer if ‘uncomplicated faint’ has occurred. The ‘3 Ps’ indicative of uncomplicated faint are:
- Posture: fainting was preceded by prolonged standing, for example, or where earlier fainting episodes were prevented by lying down
- Provoking factors, such as pain or a medical procedure
- Prodromal symptoms, such as sweating or feeling warm or hot before fainting
If you suspect uncomplicated faint, you should still advise the patient to see their GP, who should arrange an electrocardiogram (ECG) if you have not done so.
2. Dizziness
What to look for
If the person has sudden-onset dizziness and a neurological deficit such as nystagmus, uncontrolled movement of the eyes, or new-onset unsteadiness or deafness, check first for hypoglycaemia if you know the patient has diabetes.
How to help your patient
If the person does not have diabetes, or treating hypoglycaemia does not resolve the symptoms, and if the symptoms are not explained by postural hypotension, seek immediate referral to specialist services to exclude stroke. Immediate referral means within a few hours at least or quicker if necessary.
Dizziness without any other neurological deficit suggests the patient is unlikely to have a serious neurological problem.
3. Atraumatic facial pain
How to help your patient
Patients with facial pain and persistent facial numbness or abnormal neurological signs should be referred urgently for neuroimaging to exclude a lesion.
Those with trigeminal neuralgia, where pain is triggered by touching the affected part of the face, can be managed in primary care but should be referred for specialist neurology review if their condition does not respond to treatment.
Could it be temporal arteritis?
In older people, scalp tenderness and jaw claudication (pain on chewing) may indicate inflammation of the arteries at the side of the head, known as temporal arteritis. This is serious and can lead to permanent neurological damage so must be addressed urgently.
4. Unsteady gait
How to help your patient
Sudden onset of unsteady gait could indicate stroke, and patients require immediate care and treatment, especially if it is an isolated symptom. NICE has a separate guideline on the diagnosis and initial treatment of stroke and transient ischaemic attack (TIA).
In cases of ataxia where unsteady gait is rapidly progressive, patients require urgent neurological assessment. In younger people, multiple sclerosis is the most common cause of rapidly progressive ataxia but brain tumour and some infections are among the differential diagnoses.
Longstanding alcohol use may be suspected if the person’s gait ataxia has progressed more slowly. But the patient should still be referred for assessment by specialists because the ataxia may be unrelated to alcohol.
Older adults with gait apraxia – difficulty initiating and coordinating walking – should be referred to neurology or to a specialist older people’s service. Input from a falls prevention team may also be required.
5. Handwriting difficulties
How to help your patient
Follow local stroke pathways with a patient who has sudden-onset handwriting difficulties with no obvious musculoskeletal cause.
If the handwriting is small and slow, a referral for possible Parkinson’s disease should be considered.
‘As a nurse you should always trust your gut instinct. If you’re looking at somebody and thinking something doesn’t add up, don’t hold fire. Do something about it. Better to be wrong than to have not done anything’
Debbie Quinn, clinical nurse specialist, chair of the RCN neuroscience forum and MS Society specialist adviser
6. Headache in adults
How to help your patient
For more information on when to seek referral for patients with headache, see the NICE guideline on headaches in over-12s.
7. Limb or facial weakness in adults
How to help your patient
Limb weakness with sudden onset may be caused by a stroke or transient ischaemic attack (TIA) and should be assessed in line with the separate NICE guideline mentioned above.
Patients with rapidly progressing symmetrical weakness should be referred immediately for neurological assessment. Cases where there is rapidly progressing single-limb weakness or hemiparesis should be assessed urgently for neurological deficit.
There is no need to routinely refer patients with an uncomplicated episode of Bell’s palsy or with recurrent single-limb weakness who have already been diagnosed with a functional neurological disorder, which means a disorder without an identifiable cause.
Motor neurone disease: the Remember Gary campaign
Healthcare professionals are more likely to meet someone with motor neurone disease (MND) than meet a man called Gary, according to the Motor Neurone Disease Association (MNDA).
The charity is using ‘Gary’ as the face of a campaign aimed at health and social care professionals to remind them that MND is more common than they might think.
Research shows that people often present several times and with various symptoms before being referred to a neurologist and being diagnosed with MND. The MNDA hopes by raising awareness through its Gary campaign, the referral process can be speeded up and people given the right support more quickly.
The charity has produced a ‘red flag’ tool to help health and social care staff determine whether MND is a possible diagnosis for a patient presenting with certain symptoms.
8. Memory failure and cognitive deterioration
Should the patient be referred?
Memory problems and difficulty concentrating can have many causes in adults, including use of recreational and some prescription drugs or alcohol, depression and stress. However, neurodegenerative disorders affecting memory are rare in people aged under 50.
A single episode of dense amnesia (inability to recall the recent past or form new memories) is not a reason for routine referral if:
- It lasts fewer than eight hours.
- There is complete recovery.
- There are no features that suggest an epileptic seizure.
For guidance on referral of adults with progressive memory problems, see the NICE guideline on dementia, particularly the section on initial assessment in non-clinical settings.
9. Posture distortion in adults
How to help your patient
Suspect cervical dystonia, which causes involuntary contraction of the neck muscles, in patients who have persistent abnormalities in their head or neck posture. This symptom often improves if the person touches their chin with their hand. Imaging is unnecessary and can delay treatment.
Dystonia can occur in other parts of the body and can result in a turned-in foot, for example. It can also be triggered by antiemetic and antipsychotic medication.
Patients with suspected dystonia should be referred for assessment and diagnosis.
10. Tingling, numbness
How to help your patient
Patients with sudden-onset one-sided numbness should be assessed in line with the NICE guideline on stroke and transient ischemic attack (TIA).
Patients who have symmetrical numbness with weakness or imbalance, where symptoms have progressed rapidly, should be referred for immediate assessment. Sensory disturbances have many causes, including epilepsy, migraine and peripheral neuropathy. See the full NICE guideline on suspected neurological conditions for recommendations on how to proceed if you have concerns about a patient with such symptoms.
11. Sleep disorder
Is referral necessary?
Isolated brief episodes of sleep paralysis do not routinely require referral, nor do insomnia or jerks on falling asleep. However, any patient who has symptoms suggestive of new-onset epileptic seizures during sleep should be referred urgently for neurological assessment.
Patients with narcolepsy should be seen by neurology specialists too, and a routine assessment may also be required for people with persistent symptoms of sleep behaviour disorders.
Such symptoms include violent or agitated movements that are more complex than a simple jerking motion. In isolated cases, these disorders can endanger life and NICE says non-specialists should exercise clinical judgement in deciding whether to refer.
12. Smell or taste problems
When to refer
Sudden-onset changes in sense of smell or taste are rarely a sign of neurological disorders. However, transient but repetitive hallucinations relating to taste or smell can be caused by temporal lobe epilepsy, so in those cases patients should be referred for assessment.
Loss of sense or smell or taste is a common reason for referral to neurology services but rarely has a neurological cause. An exception is where the symptoms have lasted more than three months and are not related to normal ageing or nose and sinus disease.
13. Speech, swallowing and language problems
How to help your patient
Speech or language disturbance with sudden onset is a reason for urgent referral because it may indicate stroke.
Progressive slurred or disrupted speech may indicate motor neurone disease and should be assessed by specialists. An urgent referral is required if there is evidence of impaired swallowing.
Persistent dysphonia, where the vocal cords are affected by involuntary spasm, making the voice quiet, hoarse or ‘wobbly’, may be symptomatic of Parkinson’s disease. Dysphonia can also be a sign of laryngeal dystonia, which is potentially treatable.
14. Tics and involuntary movements
Can psychological therapy help?
Tics are not usually a reason for seeking a specialist neurologist assessment, unless they are accompanied by other progressive neurological symptoms. Psychological therapy may be appropriate if the tic causes distress to the patient.
Unlike tics, involuntary movements cannot be temporarily supressed by the individual and may benefit from neurological assessment and treatment in a movement disorder clinic, which can help relieve symptoms.
15. Tremor
Ask: could it be Parkinson’s?
A tremor that is mainly unilateral suggests Parkinson’s disease, particularly if the tremor is more prominent when the patient:
- Is at rest.
- Shows slow movement.
- Has balance or gait problems.
28%
of deaths in England associated with neurological conditions in 2012-14 had Parkinson’s disease recorded as the underlying cause of death
(Source: Public Health England)
In such cases the person should be referred for neurological assessment and treatment in line with the NICE guideline on Parkinson’s disease.
If there are no other symptoms of Parkinson’s and the tremor is symmetrical, the patient may have essential tremor, a condition more common in people over 40 that does not affect speed of movement or muscle tone.
Essential tremor is usually managed in primary care, where regular medication and thyroid function will be reviewed and alcohol consumption assessed.
Referral to a movement disorder clinic may help patients with troublesome tremor of the head.
Driving and workplace support
NICE says patients with suspected neurological conditions should be advised to check government information on driving with medical conditions. They may be fined if they fail to disclose a condition that affects their driving.
Patients should also be advised to tell their employer or college if they have neurological symptoms that could affect their ability to work or study.
Expert advice
Debbie Quinn, clinical nurse specialist, chair of the RCN neuroscience forum and specialist adviser to the MS Society says:
‘The difficulty is that people with these sorts of symptoms often don’t even report to their GP because the symptoms come and go.
‘If we’re talking about multiple sclerosis, for example, and you get a bit of neuropathy, you may just think you sat awkwardly. Or you may think you’ve had a cricked neck because it eases in a day or two. A lot of these symptoms start as something quite minor.
Be aware of what might be causing seemingly minor symptoms
‘So if we can make people more aware that there are these other things that might be going on, especially with conditions where early diagnosis can help, it makes a huge difference to future care.
‘But we have to appreciate that neurologists are under a lot of pressure at the moment. A GP or nurse may pick things up early, but there’s still a wait for routine neurology appointments and you may have to wait even longer to see a specialist neurologist.
366,728
deaths in people aged over 20 in England from 2001-14 were associated with neurological conditions
(Source: Public Health England)
Be assertive if you believe a patient needs referral
‘I would say that as a nurse you should always trust your gut instinct. If you’re looking at someone and thinking, “This isn’t quite adding up”, don’t hold fire. Do something about it. Better to be wrong than to have not done anything.
‘And although it’s up to the doctor to do the referral, it’s up to the nurse to make them aware of any concerns. Sometimes it’s about saying, “I really do want this looked into”. It’s about being assertive and forthright, and demonstrating your case.
‘That’s where this guideline is useful. You can say, “I’ve seen this, this and this, which means we should do this”.’
Daniel Allen is a health journalist
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