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AUDIT Questions and Scoring System

• The AUDIT can be administered as a paper-and-pencil test, but the CAGE questionnaire should be administered face to face. The CAGE questionnaire is less reliable when given after asking questions on frequency. If the patient answers questions on the CAGE questionnaire or AUDIT affirmatively, following up with additional questions about circumstances and reasons is important. Additional useful questions are found below (see Additional questions).
• Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria are required to make the diagnosis of alcohol dependence. The diagnosis requires 3 of the 8 criteria in the DSM-IV. The diagnosis of alcohol dependence relies more on the consequences of alcohol use and less on the amount of alcohol consumed. Thus, if one suspects alcohol problems from answers to screening questions, attempt to determine what consequences of alcohol abuse the patient has experienced. The following are diagnostic factors outlined by the DSM-IV:
  • Continued drinking despite physical or psychological consequences caused or exacerbated by alcohol
  • Neglect of other activities
  • Inordinate time spent drinking and recovering
  • Drinking more or over a longer period than intended
  • Inability to control drinking
  • Tolerance (defined as increased amounts needed for effect)
  • Withdrawal symptoms on cessation of alcohol
  • Drinking to relieve or avoid withdrawal symptoms
• The following 5 reasons illustrate the importance of screening for alcohol and drug abuse:
  • Alcoholism is common and serious.
  • Failure to screen leads to misdiagnosis. Approximately 50-90% of alcohol problems are missed in the office.
  • Effective and simple screening tests are available.
  • Effective treatments are available, especially if the diagnosis is made early.
  • Early identification can prevent physical and psychosocial problems.
• Additional questions, as present below, may be helpful when screening for alcoholism:
  • Have you ever had a drinking problem?
  • When was your last drink? (Less than 24 h is a red flag.)
  • Do you use alcohol to relieve pain, anxiety, or insomnia?
  • Have you ever been arrested for drinking, such as driving under the influence?
  • Have you ever lost friends or girlfriends/boyfriends because of your drinking?
  • Have you ever been to an Alcoholics Anonymous (AA) meeting
• The following are additional questions specific to the geriatric population:
  • Did your drinking increase after someone close to you died?
  • Does alcohol make you sleepy so that you often fall asleep in your chair?
• The following are additional questions specific to the adolescent population:
  • Do you drink alone?
  • Do you ever miss school to go drinking or because you have a hangover?

Physical:

• The following are signs and symptoms of alcohol withdrawal:
  • Nausea and vomiting
  • Diaphoresis
  • Agitation and anxiety
  • Headache
  • Tremor
  • Seizures
  • Visual and auditory hallucinations: Many patients who are not disoriented, and who therefore do not have delirium tremens, have hallucinations.
• The following are signs of delirium tremens (ie, alcohol withdrawal delirium):
  • Tachycardia and hypertension
  • Temperature elevation
  • Delirium
• The following are signs of chronic alcoholism:
  • Gynecomastia
  • Spider angiomata
  • Dupuytren contractures (also may be congenital)
  • Testicular atrophy
  • Enlarged or shrunken liver
  • Enlarged spleen
• Ataxia, ophthalmoplegia (usually lateral gaze palsy), and confusion indicate Wernicke encephalopathy.
• Anterograde and retrograde amnesia, often with confabulation and preceded by Wernicke encephalopathy, indicates Korsakoff syndrome.
• Asterixis and confusion suggest hepatic encephalopathy.

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Reviewed: 04/2006