The role of the GP in the care of people with neurological problems
As a GP, your role is to:
- recognise that neurological conditions are common causes of serious disability and have a major impact on health and social services
- adopt approaches to assess and manage common neurological conditions, including but non-specific presentations such as headache, which can present diagnostic challenges and may have serious consequences if misdiagnosed
- take a holistic approach to supporting patients with chronic neurological conditions and help to coordinate care in the community, with access to specialist clinical networks
- diagnose and appropriately manage acute neurological emergencies.
Knowledge and skills guide
For each problem or disease, consider the following areas within the general context of primary care
- the natural history of the condition, including whether acute or chronic
- the incidence and prevalence, including in different demographic groups
- typical and atypical presentations
- recognition of normal variations throughout life
- risk factors, including lifestyle, socio-economic and genetic factors
- diagnostic features and differential diagnosis
- recognition of ‘alarm’ or ‘red flag’ features
- appropriate and relevant investigations
- interpretation of test results
- management, including initial and continuing care, chronic disease monitoring and emergency care
- patient and carer information and education, including self-care
- prognosis.
Symptoms and signs
- Cognitive impairment, such as memory loss, delirium and dementia
- Collapse
- Disturbance of smell and taste
- Dizziness
- Features differentiating between upper and lower motor neurone function
- Memory problems
- Movement disturbances, such as athetosis, chorea and tremor
- Neuralgic and neuropathic pain
- Nystagmus and symptoms or signs of cerebellar and vestibular dysfunction
- Seizures and convulsions
- Sensory and motor symptoms: weakness (such as foot drop), spasticity, paraesthesia
- Signs of raised intracranial pressure
- Speech and language deficits
- Visual problems, such as diplopia, ptosis, pupillary abnormalities and visual field defects.
Investigations
- Blood tests (eg vitamin B12, confusion screen)
- CT/ MRI scans
Examinations and procedures
- Assessment of capacity
- Counselling and investigating people with a family history of genetic neurological disease
- Fundoscopy
- Targeted central and peripheral nervous system examination, including testing of peripheral nerve and root symptoms and signs (for example, dermatomes, reflexes, sensory and motor testing) and tests of cranial nerve function
- Tests of cognition and interpretation in relation to memory loss, dementia, delirium and associated diseases
- Visual assessment (such as visual fields)
Common and important conditions
- Acute confusional states or coma, with underlying causes such as metabolic, infective or drug-induced
- Autonomic neuropathies (diabetic, drug-induced, metabolic, Covid-related dysautonomia, multiple system atrophy)
- Causes of and risk factors for recurrent falls
- Cerebellar disorders, including tumours
- Demyelination such as MS
- Complex regional pain syndrome
- Cranial nerve disease, for example, Bell’s palsy, trigeminal neuralgia, bulbar palsy
- Dementia, for example, Alzheimer’s disease, vascular dementia, Lewy body dementia, frontotemporal dementia, normal pressure hydrocephalus, other causes of memory loss and confusion
- Epilepsy, including generalised and focal seizures, febrile convulsions and other causes of seizures (such as hypoglycaemia, alcohol and drugs) especially in the presence of learning disability
- Falls, their causes and risk factors
- Head injuries with or without loss of consciousness, concussion and more serious cranial or intracranial injuries, and relevant long-term care with brain injuries, including secondary epilepsy and behavioural problems
- Headaches, including tension, migraine, cluster and raised intracranial pressure, including idiopathic intracranial hypertension
- Infections such as meningitis, encephalitis and arachnoiditis
- Intracranial haemorrhage, including subarachnoid, subdural and extradural, and thrombosis such as sinus thromboses and congenital aneurysms
- Motor neurone disease (MND), including progressive bulbar palsy and muscular atrophy
- Movement disorders, including restless legs syndrome, tremor and gait problems including athetosis, chorea, tardive dyskinesia, dystonia, tics; underlying causes such as Sydenham’s chorea, Huntington’s disease, drug-induced, parkinsonism
- Multiple sclerosis and other demyelinating disorders such as transverse myelitis
- Muscle disorders such as muscular dystrophy, myasthenia gravis and associated syndromes
- Parkinson’s disease and parkinsonism secondary to other causes such as drugs
- Sensory and/or motor disturbances (peripheral nerve problems) including mononeuropathies and polyneuropathies such as nerve compression and palsies, Guillain-Barré syndrome, loss of smell in Covid
- Speech disorders, including stroke, cerebellar disease, cerebral palsy, MND
- Spinal cord disorders such as root and cord compression, cauda equina syndrome, spinalstenosis, syringomyelia; metastatic cord compression in at-risk patients
- Spinal injuries causing paralysis and relevant care of tetraplegic and paraplegic patients, including bowel and bladder care, potential complications such as pressure sores, autonomic dysfunction, aids to daily living and mobility
- Stroke, including transient ischaemic attacks, with underlying causes such as cardiac arrhythmias, arterial disease, thrombophilia
- Tumours of the brain and peripheral nervous system such as meningiomas, glioblastomas, astrocytomas, neurofibromatosis and secondary metastases
Service delivery
- Timely review and ongoing support of patients discharged from secondary care services
- Structured and personalised care planning
- Access to and quality of neurorehabilitation and reablement, including return to work, supporting people to manage their neurological condition to avoid crisis and coordinated pain management services
- Sources of help and support in the local community for people with neurological disabilities through strategic partnerships with local authorities, third-sector providers and charitable organisations
Additional important content
- Appropriate advice regarding epilepsy medication, including drug interactions, side effects, and contraceptive and pregnancy advice
- Understanding standards on fitness to drive
Case discussion
Trevor Scott, a 62-year-old manager in a haulage company, presents with a history of increasing difficulty walking, loss of energy and a noticeable tremor at rest. His speech has become less distinct, and he sleeps poorly.
Clinically, you strongly suspect he has Parkinson’s disease. He has no other relevant medical history other than antihypertensive treatment and well-controlled blood pressure. He is married with a grown-up family who now live away.
Questions
These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | How confident do I feel in my ability to take responsibility for a diagnosis that will have significant long-term implications for this patient? What are my initial priorities for Trevor’s immediate safety and wellbeing, and that of the public? |
An ethical approach This is about practising ethically with integrity and a respect for equality and diversity. | What will I tell Trevor about my suspicions when I have not yet established a diagnosis? How do I balance honesty and transparency with provoking uncertainty and distress for the patient? How do I advise him about his work? What if he is resistant to my advice about informing the Driver and Vehicle Licensing Agency (DVLA)? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in-person and remote methods. | What explanation of the problem will I give Trevor? What are the possible reactions I could anticipate to sensitive issues I need to discuss? How will I handle this consultation? What possible communication difficulties might I encounter? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | What are the essential details in history and examination that will clarify the diagnosis? What could be the differential diagnosis? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | What clinical signs would I expect to find and how do I assess their impact or significance? What mental state examination would be relevant? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | How do I assess the degree of urgency for intervention or referral? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | How will I manage this problem in general practice? Should all patients be referred for a neurological opinion? What is the role of and evidence base for medication in this age group? |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | What are the wider implications of having Parkinson’s disease for this patient? What potential drug interactions might I expect if Trevor is started on medication? What can I do for him in the interim if there is a substantial wait for an opinion by a neurologist? |
Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | What is the role of the Clinical Nurse Specialist (CNS) in providing support? What is the role of the specialist versus the generalist in managing Parkinson’s disease? What can I do to coordinate a multiprofessional approach to care? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | If I feel uncertain about managing this patient, how can I address this? What resources would I use? What issues might be addressed by a quality improvement process in my practice? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | Should there be a call and review system for patients with Parkinson’s disease? What purpose would it serve? How might I disseminate my learning experience among the wider practice team? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | What precautions should I suggest in Trevor’s everyday life? Who can help me to assure that I have provided a truly holistic assessment of his needs? What social and financial support is available to patients with long-term conditions such as Parkinson’s disease? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | What is the role of charitable sector organisations in contributing to healthcare? How can primary care provide an alternative to scarce secondary care resources in a locality? How well is disability access supported in the community? What could be done to improve access? |
How to learn this area of practice
Work-based learning
In general practice, patients present with various neurological problems at varying stages of the natural history. As a GP registrar, critical professional discourse with your trainer will aid you in developing ‘heuristics’, that is, strategies for problem-solving in the cases you see. Supervised practice will also give you greater confidence.
Following up cases during your training period allows you to observe for yourself the natural history of neurological diseases and how they develop. Such clinical experience during training will be supported by your GP trainer and experienced members of the primary healthcare team.
Many patients with chronic neurological conditions are resident in accommodation provided by voluntary organisations within the community. They usually have an appointed GP, and it is important that you gain experience for caring for patients in this environment. This might require working with another practice if your training practice does not look after such a ‘home’.
Most specialist care is provided in outpatient settings. These are ideal places for you to see concentrated groups of patients with neurological problems. They provide opportunities to observe many of the common conditions, as well as treatments for conditions such as migraine, epilepsy, stroke and Parkinson’s disease. You should consider attending specialist neurology clinics during your general practice-based placements.
Self-directed learning
You can find an eLearning module(s) relevant to this topic guide at elearning for healthcare.
Learning with other healthcare professionals
Neurological problems are often exemplars of teamwork and the multidisciplinary approach, so take the opportunity to understand the different roles with the many professional and non-professional groups who work as a team within both primary and secondary care. Physiotherapists, occupational therapists, specialist nurses and district nurses, in particular, have important expertise in the management of neurological disease and rehabilitation. You will also find that specific case conferences are often held to organise and focus efforts on the provision of care.
Examples of how this area of practice may be tested in the MRCGP
Applied Knowledge Test (AKT)
- Red flag neurological symptoms
- Interpretation of neurological symptoms and signs
- Long-term condition management, such as Parkinson’s disease, epilepsy
Simulated Consultation Assessment (SCA)
- A patient brings a letter from a hospital accident and emergency (A&E) department documenting a witnessed epileptic fit while he was on holiday
- A man has recurrent headaches that are now daily and not responding to simple analgesia
- A woman developed a weak and clumsy hand last night, dropping her book, but has no symptoms this morning
Workplace-based Assessment (WPBA)
- Case-based Discussion (CbD) on organising a social care package for an older woman with rapidly deteriorating mobility and frequent falls
- Clinical examination and procedural skills (CEPS) on a focused neurological examination for a man who is concerned that he has a brain tumour, although the symptoms are more likely to be migrainous
- Log entry about a man who is diagnosed with MND after presenting with dysphagia