The CAGE questionnaire is a brief screening method used in healthcare settings to identify potential issues with alcohol. Developed by Dr. John Ewing, it consists of four questions designed to be easily integrated into a general health history review. Its purpose is to quickly highlight a person’s risk level, signaling whether a more detailed conversation about alcohol consumption is necessary. The tool’s simplicity makes it a common preliminary step for healthcare providers in various clinical environments.
The CAGE Questionnaire and Scoring
The CAGE acronym represents the four questions of the screening tool, each probing a different aspect of a person’s relationship with alcohol. The questions are framed to capture lifetime experience, though a clinician might focus them on a specific timeframe.
- Have you ever felt you should Cut down on your drinking?
- Have people Annoyed you by criticizing your drinking?
- Have you ever felt bad or Guilty about your drinking?
- Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?
Each “yes” answer receives one point and each “no” answer receives zero points. The points are then tallied to produce a final score.
A total score of two or more is considered clinically significant, suggesting that a more thorough evaluation is warranted. While two is the standard threshold, some clinical guidelines suggest that even a single “yes” answer should prompt further inquiry from a healthcare provider.
Clinical Significance of CAGE Data
The questionnaire’s value is measured by its sensitivity and specificity. Sensitivity refers to the tool’s ability to correctly identify individuals who have an alcohol use disorder. Specificity refers to its ability to correctly identify those who do not.
Studies have shown that the CAGE questionnaire has good validity for detecting alcohol abuse and dependence. Across populations such as medical and surgical inpatients, ambulatory patients, and psychiatric inpatients, the tool demonstrates an average sensitivity of 0.71 and an average specificity of 0.90 when using a cutoff score of two or more.
The performance can vary depending on the patient population. For instance, in one meta-analysis, the sensitivity for a cutoff score of two was 87% in hospital inpatients but 71% in primary care patients. Conversely, specificity was higher in primary care settings (91%) compared to hospital inpatient settings (77%). In a study of hospital patients in France, a cutoff score of two yielded a sensitivity of 77% and a specificity of 94% against DSM-IV diagnostic criteria.
Applications in Clinical Practice
Healthcare professionals in settings like primary care offices, emergency departments, and mental health clinics use the CAGE questionnaire. It is often included as part of a standard patient history to screen for alcohol-related problems that might otherwise go unmentioned. The questions are non-confrontational and can be woven into a general conversation about health and lifestyle.
The CAGE questionnaire is a screening instrument, not a diagnostic tool. A positive result, such as a score of two or higher, is not a formal diagnosis of alcoholism. It indicates that a more comprehensive assessment is necessary to determine the nature and severity of the individual’s alcohol use, which may involve more in-depth diagnostic instruments.
Variations and Limitations
To address a wider range of substance use, a modified version of the tool, the CAGE-AID (Adapted to Include Drugs), was developed. It broadens the scope of the original questions by adding “or drug use” to each prompt. This adaptation allows clinicians to use the same framework to screen for issues beyond just alcohol. One evaluation reported that the CAGE-AID has a sensitivity of 0.70 and a specificity of 0.85 for detecting substance misuse.
The original CAGE questionnaire has recognized limitations. Its sensitivity can be lower for detecting less severe forms of problem drinking, such as binge drinking, compared to more established dependence. Studies have also indicated that its performance may be less reliable in certain demographic groups, including women, college students, and prenatal patients. For instance, in one study of college students, the tool’s sensitivity was found to be relatively low.
Because of these limitations, other screening instruments may be chosen in specific contexts. The Alcohol Use Disorders Identification Test (AUDIT), for example, is a 10-question test that is often considered more sensitive for identifying hazardous or harmful drinking patterns that fall short of dependence. The choice of tool often depends on the clinical setting and the specific population being screened.