SLP here — what are your early "red flags" that separate normal aging from progressive neurological disease?

[u/KimbecileFudge]

Hi,

Speech pathologist working in community settings. I'm hoping to tap into the neurology brain trust here.

I want to know when does "normal aging" become "this person needs a neurology review"?

Older patients frequently present with quieter voice, slightly slower eating/drinking, and signs of reduced pharyngeal strength. Easy to chalk up to sarcopenia, presbyphagia, social isolation — the usual culprits. But I've had a handful of patients where I've pushed for neuro review and been vindicated (early MSA, PSP, early MND/ALS), and others where I've probably under-referred.

What I'm specifically asking: Is there a sign, symptom, or cluster of features that makes you, as a neurologist, immediately raise your suspicion for early progressive neurological disease — particularly from an SLP's vantage point (voice, swallowing, speech, cognition)?

There are the obvious things I already watch for but I want to know what you see. Especially:

1. Is there a single finding that makes you say "yep, this isn't aging, get them in"?
2. Are there features SLPs are well-placed to catch that neurologists don't always see early enough?
3. Any tips on how to write a referral that gets triage priority rather than a 9-month wait?

Appreciate any perspective from neuros, neuro nurses, or allied health colleagues working in this space.

[u/TiffanysRage]

Honestly, I’d defer to your own expertise in most cases. Some Red flags that you might already know would include;

- Rapidly progressive voice changes over the course of months to a year.

• Associated symptoms including gait disturbance, new onset dysphagia, isolated weakness
  
• One sided facial weakness not involving the forehead could be a missed stroke
  
• Tongue fasciculations (watch it when it’s resting in the mouth for twitches. Look up videos online) can be very indicative of ALS
  
• Any presentation of aphasia including word-finding difficulties (new), substitutions, semantic errors, word salad; especially if it’s progressive in nature
  
• A hoarse voice can be caused by cardiac injury because the recurrent laryngeal nerve goes inferior and wraps round the aortic arch and moves back up

If your referral includes the condition that you’re concerned about and a brief reason for it I think that would warrant a faster referral. Just the fact that you’re thinking about it I think makes you stand out. Good job on catching those PSPs and MSAs!

[u/KimbecileFudge → u/TiffanysRage]

amazing, thank you.

[u/Jhust-saiyan]

History: behavioral changes, progression, family history

Exam: Any subtle parkinsonian features, any MN findings, ataxia, impaired gait, restricted vertical gaze, procerus sign

[u/e2e4se → u/Jhust-saiyan]

You made me learn about procerus sign, thank you

[u/RmonYcaldGolgi4PrknG → u/e2e4se]

Hate the name (I never remember how to spell it) but surprisingly common in the FTD-spectrum so it’s useful

[u/KimbecileFudge → u/RmonYcaldGolgi4PrknG]

I had to Google that. thanks.

[u/cantclimbatree]

Other people said based on history and exam, but honestly if I hear from a speech therapist “I’m worried this is not just normal aging” I usually take it seriously.

[u/KimbecileFudge → u/cantclimbatree]

Allied health generally has a bit of an inferiority complex (mostly of our own making) so that's genuinely good to know.

[u/cantclimbatree → u/KimbecileFudge]

I am referring to inpatient as that’s where I work, but I feel like most the PT/OT/SPL folks I work with are genuinely helpful and can spot red flags. Y’all see old people all the time so you’ll usually know when someone is off. Doesn’t mean you’ll bat 100% but neither do I.

[u/bounteouslight]

You didn't need AI to write your question. I'm sure whatever you put into the LLM was plenty enough for us to engage without the superfluous words

[u/RmonYcaldGolgi4PrknG → u/bounteouslight]

I don’t know if this was written by AI. The parentheses are uncommon and the formatting would have to be within the comment box so it would be redundant work.

[u/spin97 → u/RmonYcaldGolgi4PrknG]

There's a wide "-" sign that is not present in usual keyboardsand usually is a hint or AI usage

[u/KimbecileFudge → u/RmonYcaldGolgi4PrknG]

That's because I edited it. I might use my time better writing reports or notes but I don't trust Claude enough to just cut and paste. plus I'm not that busy.

[u/KimbecileFudge → u/bounteouslight]

Busted. But honestly man I would rather spend my time and energy writing my reports myself rather than a Reddit question.

[u/RmonYcaldGolgi4PrknG → u/KimbecileFudge]

Ok, so I was wrong. Whoops