Appendix 1 - Screening and Diagnostic Instruments

This section contains a range of clinical assessment tools for screening and diagnosis for problems related to alcohol consumption. While most assessment can be used for any patient, such as the AUDIT for screening for unhealthy alcohol use, other assessments pertain to specific populations, such as women who are pregnant, or specific assessments for a patient, such as for cognitive impairment for withdrawal severity.


Alcohol Use Disorders Identification Test (AUDIT)

The AUDIT is a simple and effective method of screening for unhealthy alcohol use, defined as risky or hazardous consumption or any alcohol use disorder. The AUDIT-C is a shortened derivative that focuses on the first three questions, which pertain to consumption of alcohol.

View in Guidelines

TWEAK

The TWEAK test is a screening tool for identifying women who are risk drinkers. Screening for risk drinking has the potential to improve pregnancy outcomes among women who are risk drinkers by targeting them for intervention to cease or reduce their alcohol intake.

View in Guidelines

T-ACE

The T-ACE is a 4-item screening tool to assist health professionals with identifying women who are using alcohol during pregnancy. The screening tool asks patients about four domains titled tolerance, annoyance, cutting down and eye-opener.

External Link

CAGE

The CAGE is a 4-item screening instrument designed to identify and assess potential dependence. An affirmative answer to two or more questions indicates that further assessment of potential alcohol dependence is required.

View in Guidelines

Michigan Alcohol Screening Test (MAST)

The MAST is a self-report 25-item questionnaire designed to provide reliable screening to identify individuals with an alcohol-related problem, scoring to one of three levels: no apparent problem, early or middle problem drinker, and problem drinker.

View in Guidelines

Severity of Alcohol Dependence Questionnaire Form-C (SADQ-C)

SADQ-C is a short, self-administered, 20-item questionnaire designed to measure severity of dependence on alcohol. The SADQ-C emphasises tolerance and withdrawal symptoms, and physical dependence.

View in Guidelines

Short Alcohol Dependence Data (SADD) Questionnaire

The SADD is a 15-item questionnaire that measures the physiological and behavioural features of dependence, such as the salience of the drink-seeking behaviour, with the sum of scores indicating low, moderate or high dependence.

View in Guidelines

Leeds Dependence Questionnaire (LDQ)

The LDQ questionnaire is similar in format to the SADD and SADQ-C and measures dependence. The authors of the SADD have also developed the LDQ. This questionnaire asks questions about the importance of alcohol and/or other drugs in the patient’s life.

View in Guidelines

Readiness to Change Questionnaire (RTCQ)

The RTCQ is a 12-item form to measure 'stage of change' regarding alcohol consumption for a patient. Completing the scale allocates a patient into one of three stages of readiness: pre-contemplation, contemplation, and action.

View in Guidelines

Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES)

SOCRATES is a 19-item clinical assessment tool that aims to assess readiness for change in a patient. This clinical tool yields three factorially-derived scale scores for the following domains: recognition, ambivalence, and taking steps.

View in Guidelines

Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)

The ASSIST is a screening tool developed for the World Health Organization (WHO) to detect and manage substance use and related problems, mainly in primary and general medical care settings. The assist is available 8 different languages.

External Link

Mini-Mental State Examination

The Mini-Mental State Examination is a 30-item questionnaire that is used in clinical and research settings to measure cognitive impairment in patients. The Mini-Mental State assesses various domains including orientation, attention, memory, language and visual-spatial skills.

External Link

Indigenous Risk Impact Screen (IRIS)

The IRIS is a clinical assessment screening tool that is culturally validated and recommended for working with Aboriginal and Torres Strait Islander peoples to assist with the early identification of alcohol and other drug problems, and mental health risks.

View in Guidelines

Alcohol Problems Questionnaire (APQ) / Common (APQ-C)

The APQ is a 44-item scale assessing alcohol use and problems for the individual, and (if applicable) their spouse, their children, and work-related domains. The APQ-C, comprising questions 1-23 of the APQ, is often used as a brief version or where the other domains are not considered relevant.

View in Guidelines

University of Rhode Island Change Assessment (URICA) Scale

The URICA scale is a 32-item self-report questionnaire, assessing for states of change in a patient across four sub-scales (pre contemplation, contemplation, action, and maintenance).

View in Guidelines

Clock Drawing Test

The clock drawing test is used to asses for cognitive impairment by asking the patient to draw a clock face, with numbers included. You then ask the patient to draw a specific time; 10 minutes past 11 is often used. Once completed, points are allocated for drawing the various features of the clock correctly.

View in Guidelines

NIAAA-Recommended Screener

The National Institute on Alcohol Abuse and Alcoholism (NIAAA), part of the U.S. National Institutes of Health, recommends the following question to be asked to screen for unhealthy alcohol use: How many times in the past year have you had 5 or more (for men)/4 or more (for women) drinks in a day? A response of 1 or more is considered positive.

View in Guidelines

Montreal Cognitive Assessment (MoCA)

The MoCA is a cognitive screening test designed to assist Health Professionals in the detection of mild cognitive impairment. The test assesses across a range of cognitive domains including short-term memory, executable performance, attention, focus, abstract reasoning, among others.

External Link

Addenbrooke's Cognitive Examination-III (ACE-III)

The ACE-III is a neuropsychological test used to identify cognitive impairment and diagnose frontotemporal dementia, with a range of versions available including for hearing impaired individuals and translated into 30 different languages.

External Link

Repeatable Battery for the Assessment of Neuropsychological Status (R-BANS)

The R-BANS is a 30-minute individually administered battery to measure cognitive decline or improvement across five domains: Immediate Memory, visuospacial or constructional, language, attention, and delayed memory.

External Link

Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)

The CIWA-Ar is a 10-item assessment tool to help determine and manage the severity of alcohol withdrawal that a patient is currently experiencing, allocation a score of mild, moderate or severe withdrawal.

View in Guidelines

Alcohol Withdrawal Scale (AWS)

The AWS is a 7-item assessment tool to help health professionals determine and manage the severity of alcohol withdrawal in a patient. Like the CIWA-Ar, the scale scores the patient for mild, moderate or severe withdrawal severity.

View in Guidelines

Short Alcohol Withdrawal Scale (SAWS)

The SAWS is another withdrawal assessment tool comprising 10-items. This scale is completed by the patient, whereas CIWA-Ar and AWS are administered to the patient by a health professional.

View in Guidelines