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• History should be taken to understand how tremor impacts daily living and
function, to determine if treatment is indicated.
• Activities to ask about include eating, drinking, writing, hygiene, dressing,
work, and hobbies.
• The social disability/stigma and embarrassment with ET can be significant,
so this should be discussed.
• There are a number of scales that can be used to quantify the impact of
tremor on the patient's function. This includes: Bain and Findley Tremor
ADL scale, TETRAS ADL scale and QUEST Essential Tremor Rating Scale.
Some treatments may require these scales be performed to document
medical necessity of the treatment.
• Neuroimaging to measure dopamine uptake (DaTscan) can be done if there
is suspicion of underlying PD.
• Synuclein assays of tissue and fluids are now available, and emerging as a
way to confirm underlying PD pathology.
• Examination of the patient includes assessment of the various parts of the
body that can be affected.
Assessment/Screening
Parkinson's Disease
• There are many red flags that suggest the patient may be developing PD,
which is the diagnosis most often confused with ET.
▶ Aspects of the tremor that suggest PD include unilateral tremor onset and notable
rest tremor.
▶ Rest tremor often appears when the hand is down at the side, so walking should be
part of a tremor evaluation.
▶ Rest tremor may also re-emerge after holding a posture for several seconds.
▶ Additionally, PD patients should demonstrate bradykinesia, and often rigidity of
the limbs.
▶ Bradykinesia can be assessed by watching the patient do rapid repetitive
movements such as finger tapping, hand opening/closing, and foot tapping.
▶ Patients with PD may have prodromal non-motor symptoms such as hyposmia
and REM sleep behavior disorder, so these should be elicited.
Differential Diagnosis
