Cage Questionnaire
Alcohol Withdrawal
CAGE Assessment (Alcohol Abuse)
For most people who drink, alcohol is a pleasant addition to eating and to other social activities.
For most adults drinking a moderate amount of alcohol (up to two drinks per day for men, and one drink per day for women and older people) is not harmful. But, many people get into serious trouble because of their drinking.
This short assessment will help you determine if you might have a problem with alcohol. (The name “CAGE” is an acronym formed by taking the first letter of key words from each of the following questions.)
Have you ever felt you should cut down on your drinking? Yes/No
Have people annoyed you by criticizing your drinking? Yes/No
Have you ever felt bad or guilty about your drinking? Yes/No
Have you ever had a drink first thing in the morning (as an “eye opener”) to steady your nerves or getrid of a hangover? Yes/No
Guide to the use of the Alcohol Withdrawal Scale — Revised (AWS)
Item 1: perspiration
0 no sweating
1 palms moist only
2 moist palms and localised beads of sweat, eg on face, chest etc
3 whole body moist from perspiration
4 profuse maximal sweating, clothes, linen, etc are wet.
Item 2: tremor
0 no tremor
1 positional hand tremor only, eg when reaching for something or holding something
2 constant slight tremor of hands
3 constant marked tremor of hands
Item 3: anxiety
0 calm, no anxiety
1 uneasy
2 apprehensive and easily startled
3 anxious and fearful, difficult to calm
4 uncontrollable anxiety including panic attacks.
Item 4: agitation
0 normal activity, no agitation
1 unsettled, fidgety
2 restless, tossing and turning, difficult to maintain bed rest
3 excitable, brisk and frequent movements, purposeless activity; can be persuaded to sit or lie down for brief periods
4 very excitable, unable to settle; constant rapid movements.
Item 5: axilla temperature 0 temperature of 37.0°C or less
1 temperature of 37.1°C to 37.5°C
2 temperature of 37.6°C to 38.0°C
3 temperature of 38.1°C to 38.5°C
4 temperature of above 38.5°C.
Item 6: hallucinations
0 no hallucinations, lucid
1 episodes of distortion of the existing objects in the surroundings; aware that these are not real
2 frank hallucinations occur though they are limited to only some objects or events and of a brief duration; can be easily persuaded that these perceptions are imaginary; retains a reasonable contact with reality
3 limited, frank hallucinations as in the above point, but is resistant to reorientation to reality, difficult to persuade the perceptions are imaginary; distressed by the hallucinations and able to maintain only a tenuous contact with reality
4 hallucinations are generalised; there is no meaningful contact with reality; patient exists in an illusory world.
Item 7: orientation
0 fully orientated
1 orientated in person and place, but has problem with recollecting time
2 orientated in person, patchy orientation in place and time
3 patchy orientation in person, disoriented in place and time disoriented in person, place and time;
4 does not understand where he/she is, who the persons around him/her are and what time it is.
SCORING KEY: AWS TOTAL
1–4 = mild withdrawal 5–9 = moderate withdrawal 10–14 = severe withdrawal 15+ = very severe withdrawal Medical review required if AWS is >10
Often forms have the following added.
BP
Pulse
Temp
Respirations
Conscious Level
1. Alert, obeys, oriented
2. Confused, responds to speech
3. Stuporous, responds to pain
4. Semi-comatose
5. Comatose
Pupils (brisk/sluggish, size) Medication Given
Levels of alcohol consumption associated with withdrawal
Males More than 8 standard drinks (that is 80 g alcohol daily) for 10–20 years, or recent excessive intake of 16 standard drinks (160 g alcohol).
Females More than 6 standard drinks (that is 60 g alcohol daily) for 5–10 years, or recent intake of 12 standard drinks (120 g alcohol).
Adolescents An alcohol withdrawal syndrome is uncommon in this age group, but may occur especially whenthere is concomitant sedative drug use.
Elderly As little as two standard drinks daily. Elderly people have less muscle mass and body water than younger people do. They are also more susceptible to alcohol withdrawal and to confusion and disorientation that may result from withdrawal.