Suspected Neurological Conditions: Recognition and Referral

National Institute for Health and Care Excellence. (2019).

London (United Kingdom): National Institute for Health and Care Excellence, 1-170.

<div>This guideline provides recommendations for specialist referral of adults and children with suspected neurological conditions. Only recommendations related to speech-language pathology and audiology scope of practice are included in this article summary.&nbsp;</div>

National Guideline Centre (United Kingdom); National Institute for Health and Care Excellence (United Kingdom)

This guideline was reviewed with the following:<ul><li>National Institute for Health and Care Excellence. (2021). Suspected Neurological Conditions: Recognition and Referral (Quality Standard 198). Retrieved from <a href="https://www.nice.org.uk/guidance/qs198">www.nice.org.uk</a></li></ul>

<p class="MsoNormal">Children with neurological conditions such as Duchenne muscular dystrophy, cerebral palsy, other progressive neuromuscular conditions may present with low muscle tone, weakness, feeding, respiratory difficulties, and developmental delays. Children with these symptoms should be referred to neurology for assessment, with the severity and rate of progression of any symptoms determining the urgency of referral. Referral to allied health professionals, including speech-language pathologists, for assessment and treatment should be conducted based on the child&rsquo;s specific developmental needs.</p>

<div>The following recommendations were made regarding speech in children with suspected neurological disorders:</div> <div> <ul> <li>Children with new-onset slurred or disrupted speech, alone or in combination with the loss of other developmental skills, that is not attributable to prescribed medicines, recreational drugs, or alcohol should be urgently referred for neurological assessment.</li> <li>New onset stuttering is likely to be developmental versus neurological in nature. In cases of new onset stuttering with a significant impact on the child&rsquo;s communication, referral should be made to developmental or SLP services.</li> <li>Referral to SLP assessment should be considered in children over the age of two with any form of abnormal speech development. Referral is ideal between the ages of two and three so that treatment can occur prior to school enrollment.</li> <li>Children on the autism spectrum may present with speech or communication delay and regression. However, in children with suspected autism that accompanied loss of other developmental skills, the diagnosis is less likely to be autism, and the child should be urgently referred for neurological assessment.</li> </ul> </div>

<div>The following recommendations were provided regarding children with epilepsy:</div> <div> <ul> <li>Concentration and memory problems are common in children with epilepsy due to the disorder itself and commonly used medications. However, if new memory concerns arise or significant concentration difficulties occur in multiple settings, referral to neurological assessment should be conducted.</li> <li>If there is a significant problem with learning, school progress or behavior, the child should be referred to pediatric neurodevelopmental services, which can then direct the child on the correct pathway.</li> </ul> </div>

<div>The following recommendations were made for adults who have been diagnosed with functional neurological disorder (FND) by a specialist:</div> <div> <ul> <li>Recurrent dizziness might be part of a patient&rsquo;s FND presentation. If recognized, it may be more appropriate to assess and treat the person's FND without referral to neurology services in cases where the patient is not presenting with new neurological signs. These adults should be advised that their dizziness will fluctuate and might increase during times of stress.</li> <li>Memory and concentration difficulties might occur in adults with anxiety disorder or FND. Clinicians should provide education about the common occurrence of these symptoms in the context of FND and/or anxiety. Referral to psychology should be considered, as appropriate. Referral for neurological assessment is not indicated for concentration difficulties alone for cases of FND, myalgic encephalomyelitis/chronic fatigue syndrome, or fibromyalgia. However, neurology referral is appropriate in cases of changes or progressive deterioration in behavior, cognition, language, or physical skills.</li> <li>Word-finding difficulties commonly occur in adults with anxiety disorder or FND. These individuals should be provided with education that their word-finding difficulty may fluctuate, especially in times of stress. Referral to psychological support may be appropriate. However, if word-finding difficulty occurs in the absence of any new neurological signs, referral to neurology might not be needed.</li> </ul> </div>

<div>The following recommendations were made regarding the assessment and referral of adults with dizziness:</div> <div> <ul> <li>For adults with transient rotational vertigo on head movement, the Hallpike maneuver should be used by a trained healthcare provider trained to check for benign paroxysmal positional vertigo (BPPV). If no healthcare professional trained in the Hallpike maneuver is available, refer in accordance with local pathways.</li> <li>BPPV is common after head injury or labyrinthitis. If BPPV is diagnosed, a canalith repositioning maneuver, such as the Epley maneuver, should be offered by a trained healthcare professional if the person does not have unstable cervical spine disease. If there is no healthcare professional trained in a canalith repositioning maneuver, or the person has unstable cervical spine disease, refer in accordance with local pathways. If the symptoms improve immediately, referral to neurology is generally unnecessary. The maneuver can be repeated after a period of time if the symptoms recur or if the patient can be trained how to perform it themselves.&nbsp;</li> <li>A diagnosis of vestibular migraine should be considered by a trained professional in episodes of dizziness that last between 5 minutes and 72 hours in individuals with a history of migraine.</li> <li>For adults with sudden-onset acute vestibular syndrome (e.g., vertigo, nausea), a Head Impulse, Nystagmus, Test of Skew (HINTS) test should be performed by a healthcare professional with training and experience in the use of this test. A negative HINTS test makes the diagnosis of a stroke very unlikely. Patients with any indication of stroke on the HINTS (e.g., normal head impulse test with direction-changing nystagmus or skew deviation) should be immediately referred for neuroimaging. If no clinician with training and experience in the use of the HINTS test is not available, individuals for which BPPV or postural hypotension does not account for their sudden-onset acute vestibular syndrome should be referred in line with local stroke pathways.&nbsp;</li> </ul> </div>

<p class="MsoNormal">Clinicians should advise adults with suspected neurological conditions to:</p> <ul> <li class="MsoNormal">check their local government&rsquo;s information on driving with medical conditions to find out whether they might have a condition that needs to be notified to the appropriate agency (e.g., Department of Driver Services); and</li> <li class="MsoNormal">consider telling their employer, school or college if their symptoms might affect their ability to work or study in order to receive appropriate accommodations.</li> </ul>

<div>When children present with dizziness, clinicians should examine the ears for any signs of infection, inflammation, or eardrum perforation.&nbsp;</div>

<div>The following recommendations were provided regarding speech, language, and voice in individuals with suspected neurological conditions:</div> <div> <ul> <li>Adults with sudden-onset speech or language disturbance should be immediately referred for assessment for a vascular event, in line with local stroke pathways.</li> <li>Adults with progressive slurred or disrupted speech should be referred to neurology for assessment for neuromuscular disorders such as amyotrophic lateral sclerosis or myasthenia gravis, with urgent referral in cases of swallowing impairment or breathlessness at rest or when lying flat. Timely referral enables early access to required therapies and allows individuals to prepare for the rapid progression of the disease through interventions such as communication aids, voice banking, and assessment and management of chewing and swallowing difficulties.</li> <li>Adults over the age of 45 with new, unexplained vocal hoarseness should be urgently referred to otolaryngology for exclusion of malignancy and for assessment for laryngeal dystonia. If accompanied by dysarthria or dysphagia, referral to neurology should be conducted.</li> <li>Persistent dysphonia in adults may represent a neurological disorder such as Parkinson&rsquo;s disease. Especially in the presence of other features of Parkinson&rsquo;s, neurology should be consulted.&nbsp;</li> </ul> </div>