History and exam
Key diagnostic factors
common
risk factors
Take a comprehensive history to identify risk factors for alcohol withdrawal, with a specific focus on:
Alcohol-use disorder
Screen the patient for alcohol-use disorder using a formal assessment tool such as AUDIT-C, FAST, PAT, or AUDIT.[2] Decide which to use based on local protocols, the setting of care, and your preference.
AUDIT-C ( Alcohol Use Disorders Identification Test - Consumption Opens in new window)[2]
A total score of ≥5 is a positive screen.
FAST ( Fast Alcohol Screening Test Opens in new window)
Conceived for use in emergency departments but can be used in a wide variety of settings.[3]
PAT ( Paddington Alcohol Test 2011 Opens in new window)
Takes less than a minute to perform and useful in busy clinical settings.[64]
AUDIT ( Alcohol Use Disorders Identification Test Opens in new window)
The full version of AUDIT; takes longer to perform than the other screening tools and therefore may not be suitable in an acute hospital setting.[2]
Practical tip
It is important to calculate units of alcohol formally when using a screening tool as the increasing strength of alcoholic drinks and the larger glass sizes served in bars mean that people often drink more alcohol than they realise.[10]
Calculate units of alcohol as follows:[10]
Number of units of alcohol = % ABV (alcohol by volume) x Volume (Litres)
Online calculators can also be useful. Alcohol Change UK: Unit calculator Opens in new window
The risk of alcohol withdrawal is not directly related to intake. Some people who drink a lot of alcohol do not have withdrawal symptoms if they stop drinking.[60]
Evidence: Validity of formal assessment tools for alcohol-use disorder
Evidence has shown that commonly used formal assessment tools are effective at detecting alcohol-use disorder.
Abbreviated versions of AUDIT, such as AUDIT-C and FAST, were developed for use in acute settings where the full AUDIT would take too long to perform. These compare favourably with the full screening tool.
In a comparison of AUDIT with AUDIT-C and FAST in primary care:[65]
AUDIT-C was more sensitive than AUDIT and therefore a reliable test that could be used in place of the full version
FAST had a lower sensitivity than AUDIT
Therefore, AUDIT-C was recommended over FAST in primary care.
PAT can be administered in about one fifth of the time taken to administer AUDIT and therefore may be useful in busy clinical settings. In a sample of 47 clinicians assessing people presenting to an emergency department in the UK, it took:[64]
20 seconds to complete PAT (SD = 9.53)
1 minute 13 seconds to complete AUDIT (SD = 27.6).
Evidence: Screening for alcohol-use disorder is performed poorly worldwide
Studies in Australia, the UK, the US, and Finland have demonstrated that clinicians infrequently screen for alcohol-use disorder; in at least one third to half of cases where the diagnosis is known, they fail to address the problem.[66][67][68]
Other studies have reported on the quality of history taking in relation to alcohol use and suggested that poor alcohol history taking is prevalent in many clinical settings.[69][70][71] Some data show that no alcohol history of any sort was documented in the medical notes of more than 30% to 40% of acute general medical hospital admissions.[72][73]
It has been shown that screening and brief intervention programmes have beneficial long-term effects in cases of alcohol-use disorder, and hospital-based substance use consultations are reported to improve engagement in alcohol rehabilitation and treatment outcomes.[74][75]
Take a collateral history.
Ask a relative or friend about the patient’s alcohol intake whenever possible as patients may frequently underreport their own consumption.[3]
This may help the patient discuss their alcohol use more openly.
History of alcohol withdrawal
Patients with mild or moderate withdrawal symptoms and a previous history of severe withdrawal, seizures, and/or alcohol withdrawal delirium have a higher risk of developing severe withdrawal.[12]
Poor physical health
Assess for features of chronic or decompensated liver disease due to alcohol-use disorder. Be aware that all these patients need admission.
Features of chronic or decompensated liver disease tend to be late signs of liver disease and therefore may not be present in all patients. These patients should be managed by a specialist. These features include:
Assess for features of poor nutrition. These may include:
Thiamine deficiency
Look for signs of Wernicke’s encephalopathy, including nystagmus, ataxia and confusion.
Vitamin D deficiency. Risk factors include:
Poor dietary intake of vitamin D
Lack of exposure to sunlight
Direct effects of alcohol on vitamin D metabolism
Decreased absorption in patients with alcohol-related steatorrhoea.
Ask about risk factors for hepatitis B, hepatitis C, and HIV infection. These can co-exist with or complicate alcohol withdrawal.
Acute intercurrent illness
Assess for features of acute medical illness. Be aware that all these patients need admission.
Commonly associated acute illnesses include:
Pneumonia
Pancreatitis
Hepatitis
Gastritis.
alcohol dependence
Identify patients who have tested positive for alcohol misuse and are at risk of alcohol withdrawal by assessing their level of alcohol dependence. Decide which screening tool to use based on local protocols and your preference. Use either SAD-Q or the CAGE questionnaire.
SAD-Q ( Severity of Alcohol Dependence Questionnaire Opens in new window)[32]
This can help guide drug doses for treatment as well as identifying those at risk of alcohol withdrawal delirium.
A chlordiazepoxide detoxification regimen is usually indicated for anyone who scores ≥16.
Ask four questions:[42]
C: Have you felt the need to cut down on your drinking?
A: Have you ever felt annoyed by someone criticising your drinking?
G: Have you ever felt bad or guilty about your drinking?
E: Have you ever had an eye-opener - a drink first thing in the morning to steady your nerves?
The test is considered positive if score ≥2.
This is a brief and effective test for lifetime alcohol abuse or dependence. It is commonly used in clinical practice.
However, it fails to detect binge drinking and is less sensitive in screening for mild to moderate alcohol withdrawal than other screening tools. It also does not distinguish between active and past problem drinking.[5][3][76]
Evidence: Use of CAGE
Studies have found that CAGE performs generally well in primary care settings but is less effective in certain populations (e.g., heavy drinkers).
Evidence: Use of SAD-Q
SAD-Q is considered a valid and reliable screening tool that has shown high test-retest reliability.
SAD-Q has showed good test-retest reliability and significant correlations with observer ratings of withdrawal severity and narrowing of the drinking repertoire (e.g., drinking only one brand or type of alcohol rather than a variety of drinks).[82][83]
This has been independently confirmed in a sample of 102 people with alcohol-use disorder.[84]
Take account of the amount of alcohol that the patient reports drinking prior to admission/assessment as well as the result of SAD-Q/CAGE screening.[3]
Ask about changes in drinking patterns, at least during the previous 5 days, as well as the time of the patient’s last drink.[3]
Practical tip
People may present with subtle signs of alcohol dependence:
Frequent falls or other accidents
Smelling of alcohol at inappropriate times (e.g., in the middle of the day).
Take time to ask about their alcohol use. Use a sensitive approach and avoid patronising or judgemental language. Bear in mind that the patient may be defensive about your questioning or fear being labelled as an ‘alcoholic’.
cessation or reduction in alcohol intake
Suspect acute or imminent alcohol withdrawal in any patient who is alcohol-dependent and has stopped or reduced their alcohol intake within hours or days of presentation.[1][2][3][4][5][7]
Ask when the patient’s last alcoholic drink was to determine the timing of onset of their symptoms.
Mild to moderate symptoms tend to start 6 to 12 hours after the patient’s last alcoholic drink and peak between 24 and 36 hours.[2][4][5]
Alcohol withdrawal delirium tends to start 48 to 72 hours after the patient’s last alcoholic drink and peaks at 5 days.[1][2][3][7]
Alcohol withdrawal seizures tend to occur in the first 12 to 24 hours.[10]
Practical tip
Consider other diagnoses if the patient has consumed alcohol in the last 6 hours as alcohol withdrawal is unlikely within this timeframe. However, it is important to remember that patients can experience withdrawal symptoms even if their blood alcohol level has not reached zero.
at least one feature of alcohol withdrawal
Use a validated scoring system, such as CIWA-Ar ( Clinical Institute Withdrawal Assessment of Alcohol, revised Opens in new window) or GMAWS ( Glasgow Modified Alcohol Withdrawal Scale Opens in new window), with your clinical judgement to assess all patients with alcohol withdrawal, to gauge severity and guide management.[1][2][3]
Check local protocols for recommendations on which scale to use and cut-off values for mild, moderate, and severe withdrawal. GMAWS is an alternative to CIWA-Ar for use in an acute hospital setting.[33]
Assign a score to each item, based on your observations and the patient’s answers to structured questioning.
Speak slowly and clearly; reword questions if needed.
Add up the number of points to reach a total.
Use the total CIWA-Ar or GMAWS score to:[2][3]
Determine which patients need drug treatment
In general, patients with a CIWA-Ar score <10 or GMAWS <2 do not require drug treatment. However, they may require a period of monitoring and supportive treatment[3]
Decide whether a patient is suitable for outpatient management
Monitor patients during treatment.
Regardless of severity score, a patient having seizures or alcohol withdrawal delirium during the alcohol withdrawal period indicates severe withdrawal.[46]
Practical tip
Be careful not to underestimate or miscalculate the CIWA-Ar score. The patient may develop worsening withdrawal symptoms if they are not treated according to the severity of their symptoms.
This is a common pitfall when assessing people who are sedated, acutely agitated, or have language barriers. It may be difficult to use CIWA-Ar for these people as it relies on subjective reporting by the patient (e.g., for anxiety, nausea, and headache). Therefore, use your clinical judgement instead of CIWA-Ar score in these patients.
Evidence: Validation of CIWA-Ar
CIWA-Ar has been validated in many clinical settings with some exceptions such as the emergency department.
CIWA-Ar has been shown to be effective for monitoring and determining future treatments. Evidence has shown that using CIWA-Ar to determine dose and frequency of a benzodiazepine reduces the overall amount of benzodiazepine given and the total treatment time.[47][48]
CIWA-Ar has also been validated when translated into other languages such as German.[49]
One study showed that the original CIWA score (an earlier iteration of the CIWA-Ar score with 15 items rather than 10) had good inter-rater validity by comparing scores rated by nurses with a 3-point global rating of severity made by a physician on initial assessment of the patient.[50][51]
However CIWA-Ar has not been validated for use in certain settings such as the emergency department.[51]
Identify patients with features of severe alcohol withdrawal early. Involve senior support and consider referring the patient to critical care. Look for at least one of:[1][2][3][33]
A high or worsening CIWA-Ar ( Clinical Institute Withdrawal Assessment of Alcohol, revised Opens in new window) or GMAWS ( Glasgow Modified Alcohol Withdrawal Scale Opens in new window) score
Failure to improve after two doses of a benzodiazepine
Deranged temperature or deranged blood pressure or deranged blood glucose, alongside any feature or alcohol withdrawal.[45]
Common mild or moderate alcohol withdrawal symptoms include:[1][2][3][7][41]
Anxiety
Nausea and vomiting
Autonomic dysfunction
Tremor
Tachycardia
Sweating
Palpitations
Insomnia.
uncommon
seizures
Seizures are a feature of severe alcohol withdrawal.
Look for generalised tonic-clonic seizures (see our topic Generalised seizures).
These patients require urgent treatment: ensure a patent airway immediately. See the Management Recommendations section for details of other interventions.
Rule out causes other than alcohol withdrawal especially if:[45]
Seizures are focal
There is no definite history of recent abstinence from drinking
Seizures occur more than 48 hours after the patient’s last drink (alcohol withdrawal seizures normally occur in the first 12-24 hours)[10]
The patient has a history of fever or trauma.
Check capillary blood glucose in all patients with seizures.[56]
Practical tip
Seizures may be the first manifestation of alcohol withdrawal in some people.[3]
They develop due to changes in alcohol concentration and therefore may occur before the blood alcohol level has fallen to zero.[6]
Other common causes of seizures include significant head injury and central nervous system infection.[36][57]
Alcohol withdrawal is one of the most common causes of status epilepticus.[3]
Several other legal and illegal pharmacological agents may induce seizures, due to either drug withdrawal (e.g., benzodiazepines) or a direct neurotoxic effect (e.g., antipsychotics, antidepressants, or stimulant drugs). These may complicate the clinical picture and should be considered in the diagnosis of alcohol-related seizures.
Liver dysfunction and hepatic encephalopathy may also present with seizures.
alcohol withdrawal delirium
Involve early senior support and consider referring to critical care if you suspect alcohol withdrawal delirium (also known as delirium tremens).
This is a medical emergency and is present in around 5% of patients with alcohol withdrawal.[9] These patients require urgent treatment (see the Management Recommendations section).
Alcohol withdrawal delirium symptoms are rapid in onset and difficult to control. They tend to appear 48 to 72 hours after the patient’s last alcoholic drink and may include:
Profound confusion/delirium[9][10]
This is fluctuating in nature and the patient may be disorientated to time, person, and place.
There is also clouding of consciousness.
Ask the patient to estimate how long your consultation has lasted.[52] Mild impairment of conscious level can occur in alcohol withdrawal delirium and can cause difficulty in estimating the passage of time.
Always consider Wernicke’s encephalopathy in any confused patient with alcohol dependence. This is a neurological emergency. See our topic Wernicke’s encephalopathy.
Visual, auditory, and tactile hallucinations; characteristically frightening delusions[10]
Coarse tremor[10]
Features of clinical instability, which include tachycardia, fever, ketoacidosis, and circulatory collapse.[10]
Practical tip
Be aware of alcohol-induced psychotic disorder with hallucinations (previously known as alcoholic hallucinosis), a rare condition in chronic heavy drinkers that can be difficult to differentiate from withdrawal-induced psychosis. See the Differentials section for more details.
More info: Alcohol withdrawal delirium
Alcohol withdrawal delirium is fatal in 15% to 20% of patients if untreated.[34][35] Appropriate early management reduces mortality to around 1%.[9] Patients most at risk of death with alcohol withdrawal delirium are those with a high fever (>39.9°C), tachycardia, dehydration and an associated illness (e.g., pneumonia or pancreatitis), or general debility, or where the diagnosis is delayed.[6]
More info: Wernicke’s encephalopathy
Wernicke’s encephalopathy results from thiamine deficiency and has varied neurocognitive manifestations, which typically involve mental status changes and gait and oculomotor dysfunction.[54] It is present in 12.5% of patients with alcohol dependence.[55]
See our topic Wernicke’s encephalopathy.
agitation
May range from restlessness to more severe agitation.[2]
coarse tremor
A coarse tremor may be present in moderate alcohol withdrawal but it is usually a sign of more severe alcohol withdrawal or alcohol withdrawal delirium.[10]
Practical tip
Look for a tremor by asking the patient to extend their arms and spread their fingers apart.[53]
Moderate tremor: can be seen with arms extended.
Severe tremor: can be seen even without arms extended.
hypertension or hypotension
Deranged blood pressure, alongside any feature of alcohol withdrawal, might indicate severe withdrawal.[45]
fever or hypothermia
Deranged temperature, alongside any feature of alcohol withdrawal, might indicate severe withdrawal.[45]
hyperglycaemia or hypoglycaemia
Deranged blood sugar, alongside any feature of alcohol withdrawal, might indicate severe withdrawal.[45]
Other diagnostic factors
common
anxiety
nausea and vomiting
A common presentation.
Consider concurrent acute pancreatitis, a complication of heavy alcohol use, if the patient is nauseous or vomiting.[120] See our topic Acute pancreatitis.
autonomic dysfunction
Signs and symptoms include:
Tremor
Practical tip
Look for a tremor by asking the patient to extend their arms and spread their fingers apart.[53]
Mild tremor: may not be seen; can be felt fingertip to fingertip.
Moderate tremor: can be seen with arms extended.
Severe tremor: can be seen even without arms extended.
Tachycardia
A feature of severe withdrawal and alcohol withdrawal delirium[7]
Sweating
May be seen even in mild withdrawal[59]
Palpitations.[41]
insomnia
A common symptom of mild alcohol withdrawal.[7]
craving for alcohol
Can be present even in those with mild withdrawal.[137]
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