History and exam
Key diagnostic factors
common
alcohol use
Patients should be screened for alcohol use disorder (AUD) using a formal assessment tool such as AUDIT-C (Alcohol Use Disorders Identification Test - Consumption), CAGE, or FAST (Fast Alcohol Screening Test).[3][5][43] [ Alcohol Consumption Screening AUDIT Questionnaire Opens in new window ] Alcohol use disorders identification test consumption (AUDIT C) Opens in new window CAGE questionnaire Opens in new window Fast Alcohol Screening Test (FAST) Opens in new window
An alternative for situations where there is not time to do a full assessment is an initial one-question screen to identify potential alcohol use disorder, recommended by the US National Institute on Alcohol Abuse and Alcoholism (NIAAA): “How many times in the past year have you had X or more drinks in a day?,” where X is 5 for men and 4 for women.[9][43][44] This test is positive if the patient’s response is >1; a formal assessment tool such as AUDIT should then be used.[9][43][44]
Patients who have tested positive for AUD and are at risk of alcohol withdrawal should have their degree of alcohol dependence assessed using a formal screening tool such as the Severity of Alcohol Dependence Questionnaire (SAD-Q) or the Leeds Dependence Questionnaire.[9][45][46][47][48] AUDIT-C, FAST, CAGE, and AUDIT only identify AUD and do not predict which patients are at risk of alcohol withdrawal.
change in mental status
Such as severe memory disturbances; disorientation to time, place, and person; and waxing and waning levels of consciousness.[56] Profound confusion/delirium is a feature of alcohol withdrawal delirium, a medical emergency that is present in around 5% of patients with alcohol withdrawal syndrome (AWS).[11][12]
hallucinations
Approximately 25% of patients with AWS will experience transient hallucinations (auditory, visual, tactile).[24][60] Hallucinations include insects crawling on the skin or animals circling the bed.[61]
Hallucinations are also associated with alcohol withdrawal delirium, a medical emergency, which occurs in approximately 5% of patients with AWS.[11]
uncommon
seizures
Occur in 10% of patients with AWS and may be the first sign of AWS in some patients.[24][57] Approximately 40% of alcohol withdrawal seizures are isolated seizures; less than 3% of patients develop status epilepticus.[24][58][59] Patients with a history of alcohol withdrawal seizures, or those who experienced a seizure due to acute alcohol withdrawal are at a higher risk of experiencing recurrent seizures.[5] Seizures should only be attributed to alcohol withdrawal if there has been a clear history of a significant reduction in or cessation of alcohol intake in the preceding 24-48 hours and other medical etiologies have been evaluated.[5]
delusions
Associated with alcohol withdrawal delirium, a medical emergency which occurs in about 5% of patients with AWS.[11]
hypertension or hypotension
Features of severe withdrawal. Hypertension is more commonly seen than hypotension.
fever or hypothermia
Features of severe withdrawal. Fever is more commonly seen than hypothermia.
hyperglycemia or hypoglycemia
Features of severe withdrawal.
Other diagnostic factors
common
tremor
nausea and vomiting
Associated with mild withdrawal.[55]
anorexia
A feature of mild withdrawal.[6]
anxiety/restlessness
A feature of mild withdrawal.
emotional lability
A feature of mild withdrawal.
insomnia
A feature of mild withdrawal.[6]
irritability
A feature of mild withdrawal.
diaphoresis
A feature of mild withdrawal.
headache
A feature of mild withdrawal.
fine tremor
A feature of mild withdrawal.
agitation
A feature of mild withdrawal.
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