Substance Abuse Among Older Adults
Treatment Improvement Protocol (TIP) Series 26

How To Use AUDIT

Screening with AUDIT can be conducted in a variety of primary care settings by persons who have different kinds of training and professional backgrounds. The core AUDIT is designed to be used as a brief structured interview or self-report survey that can easily be incorporated into a general health interview, lifestyle questionnaire, or medical history. When presented in this context by a concerned and interested interviewer, few patients will be offended by the questions. The experience of the WHO collaborating investigators (Saunders and Aasland, 1987) indicated that AUDIT questions were answered accurately regardless of cultural background, age, or gender. In fact, many patients who drank heavily were pleased to find that a health worker was interested in their use of alcohol and the problems associated with it.

In some patients, the AUDIT questions may not be answered accurately because they refer specifically to alcohol use and problems. Some patients may be reluctant to confront their alcohol use or to admit that it is causing them harm. Individuals who feel threatened by revealing this information to a health worker, who are intoxicated at the time of the interview, or who have certain kinds of mental impairment may give inaccurate responses. Patients tend to answer most accurately when

• The interviewer is friendly and nonthreatening
• The purpose of the questions is clearly related to a diagnosis of their health status
• The patient is alcohol- and drug-free at the time of the screening
• The information is considered confidential
• The questions are easy to understand.

Health workers should try to establish these conditions before AUDIT is given. When these conditions are not present, the Clinical Screening Instrument following the AUDIT questionnaire may be more useful. Alternatively, health workers may also use AUDIT to guide an interview with a concerned friend, spouse, or family member. In some settings (such as waiting rooms), AUDIT may be administered as a self-report questionnaire, with instructions for the patient to discuss the meaning of the results with the primary care worker. In addition to these general considerations, the following interviewing techniques should be used:

• Try to interview patients under the best possible circumstances. For patients requiring emergency treatment or who are severely impaired, it is best to wait until their condition has stabilized and they have become accustomed to the health setting where the interview is to take place.
• Look for signs of alcohol or drug intoxication. Patients who have alcohol on their breath or who appear intoxicated may be unreliable respondents. Consider conducting the interview at a later time. If this is not possible, make note of these findings on the patient's record.
• If AUDIT is embedded, as recommended, in a longer health interview, then a transitional statement will be needed when the AUDIT questions are asked. The best way to introduce the AUDIT questions is to give the patient a general idea of the content of the questions, the purpose for asking them, and the need for accurate answers. The following is an illustrative introduction: "Now I am going to ask you some questions about your use of alcoholic beverages during the past year. Because alcohol use can affect many areas of health (and may interfere with certain medications), it is important for us to know how much you usually drink and whether you have experienced any problems with your drinking. Please try to be as honest and as accurate as you can be." This statement should be followed by a description of the types of alcoholic beverages typically consumed in the population to which the patient belongs (e.g., "By alcoholic beverages we mean your use of wine, beer, vodka, sherry, and so on."). If necessary, include a description of beverages that may not be considered alcoholic (e.g., cider, low alcohol beer).
• It is important to read the questions as written and in the order indicated. By following the exact wording, better comparability will be obtained between your results and those obtained by other interviewers.
• Most of the questions in AUDIT are phrased in terms of "how often" symptoms occur. It is useful to offer the patient several examples of the response categories (for example, "Never," "Several times a month," "Daily") to suggest how he might answer. When he has responded, it is useful to probe during the initial questions to be sure that the patient has selected the most accurate response (for example, "You say you drink several times a week. Is this just on weekends or do you drink more or less every day?"). If responses are ambiguous or evasive, continue asking for clarification by repeating the question and the response options, asking the patient to choose the best one. At times, answers are difficult to record because the patient may not drink on a regular basis. For example, if the patient was drinking intensively for the month prior to an accident, but not before or since, then it will be difficult to characterize the "typical" drinking sought by the question. In these cases it is best to record the amount of drinking and related symptoms for the heaviest drinking period of the past year, making note of the fact that this may be atypical or transitory for that individual.

Record answers carefully, using the comments section of the interview brochure to explain any special circumstances, additional information, or clinical inferences. Often patients will provide the interviewer with useful comments about their drinking that can be valuable in the interpretation of the total AUDIT score.

The AUDIT Questionnaire

Procedure for scoring AUDIT

AUDIT "Clinical" Questions and Procedure

Scoring and Interpretation of AUDIT

As indicated by the AUDIT questions, each item is scored by checking the response category that comes closest to the patient's answer.

On the basis of evidence from the validation study (Saunders et al., in press), two cutoff points are suggested, depending on the purpose of the screening program or the nature of the research project. A score of 8 or more produces the highest sensitivity, while a score of 10 or more results in higher specificity. In general, high scores on the first three items in the absence of elevated scores on the remaining items suggest hazardous alcohol use. Elevated scores on items 4 through 6 imply the presence or emergence of alcohol dependence. High scores on the remaining items suggest harmful alcohol use. As discussed in the following section on diagnosis, each of these areas of alcohol-related problems implies different types of management.

The Clinical Screening Instrument is considered to be elevated when the total score is 5 or greater. Here, too, the examiner should give careful consideration to the different meanings attributed to alcohol-related trauma, physical signs, and the elevated liver enzyme. It should be noted that false positives can occur when the individual is accident prone, uses drugs (such as barbiturates) that induce GGT, or has hand tremor because of nervousness, neurological disorder, or nicotine dependence.

References

Index of Independence in Activities of Daily Living

The Index of Independence in Activities of Daily Living is based on an evaluation of the functional independence or dependence of patients in bathing, dressing, going to the toilet, transferring, continence, and feeding. Specific definitions of functional independence and dependence appear below the index. (These definitions can be used to convert the data recorded in the evaluation form in the next section into an Index of ADL grade.)

A--Independent in feeding, continence, transferring, going to the toilet, dressing, and bathing.

B--Independent in all but one of these functions.

C--Independent in all but bathing and one additional function.

D--Independent in all but bathing, dressing, and one additional function.

E--Independent in all but bathing, dressing, going to the toilet, and one additional function.

F--Independent in all but bathing, dressing, going to toilet, transferring, and one additional function.

G--Dependent in all six functions.

Other--Dependent in at least two functions, but not classifiable as C, D, E, or F.

Independence means without supervision, direction, or active personal assistance, except as specifically noted below. This is based on actual status and not on ability. A patient who refuses to perform a function is considered as not performing the function, even though he is deemed able.

Bathing (Sponge, Shower, or Tub)

Independent: assistance only in bathing a single part (as back or disabled extremity) or bathes self completely

Dependent: assistance in bathing more than one part of body; assistance in getting in or out of tub or does not bathe self

Dressing

Independent: gets clothes from closets and drawers; puts on clothes, outer garments, braces; manages fasteners; act of tying shoes is excluded

Dependent: does not dress self or remains partly undressed

Going to Toilet

Independent: gets to toilet; gets on and off toilet; arranges clothes; cleans organs of excretion; (may manage own bedpan used at night only and may or may not be using mechanical supports)

Dependent: uses bedpan or commode or receives assistance in getting to and using toilet

Transfer

Independent: moves in and out of bed independently and moves in and out of chair independently (may or may not be using mechanical supports)

Dependent: assistance in moving in or out of bed and/or chair; does not perform one or more transfers

Continence

Independent: urination and defecation entirely self-controlled

Dependent: partial or total incontinence in urination or defecation, partial or total control by enemas, catheters, or regulated use of urinals and/or bedpans

Feeding

Independent: gets food from plate or its equivalent into mouth; (precutting of meat and preparation of food, as buttering bread, are excluded from evaluation)

Dependent: assistance in act of feeding (see above); does not eat at all or parental feeding

Evaluation Form

Name_________________________ Day of Evaluation________________________

For each area of functioning listed below, check description that applies. (The word "assistance" means supervision, direction, or personal assistance.)

Bathing--either sponge bath, tub bath, or shower.

• Receives no assistance (gets in and out of tub by self if tub is usual means of bathing)
• Receives assistance in bathing only one part of the body (such as back or a leg)
• Receives assistance in bathing more than one part of the body (or not bathed)

Dressing--gets clothes from closets and drawers--including underclothes, outer garments, and using fasteners (including braces if worn)

• Gets clothes and gets completely dressed without assistance
• Gets clothes and gets dressed without assistance except for assistance in tying shoes
• Receives assistance in getting clothes or in getting dressed, or stays partially or completely undressed

Toileting--going to the "toilet room" for bowel and urine elimination, cleaning self after elimination, and arranging clothes

• Goes to "toilet room," cleans self, and arranges clothes without assistance (may use object for support such as cane, walker, or wheelchair and may manage night bedpan or commode emptying same in morning)
• Receives assistance in going to "toilet room" or in cleansing self or in arranging clothes after elimination or in use of night bedpan or commode
• Doesn't go to room termed "toilet" for the elimination process

Transfer--

• Moves in and out of bed as well as in and out of chair without assistance (may be using object for support such as cane or walker)
• Moves in and out of bed or chair with assistance
• Doesn't get out of bed

Continence--

• Controls urination and bowel movement completely by self
• Has occasional "accidents"
• Supervision helps keep urine or bowel control; catheter is used, or is incontinent

Feeding--

• Feeds self without assistance
• Feeds self except for getting assistance in cutting meat or buttering bread
• Receives assistance in feeding or is fed partly or completely by using tubes or intravenous fluids

After filling out the form, convert the data collected into an ADL grade by using the definitions provided in the introductory section.

Source: Katz, S.; Ford, A.B.; Moskowitz, R.W.; Jackson, B.A.; and Jaffe, M.W. Studies of Illness in the Aged. The Index of ADL: A standardized measure of biological and psychosocial function. Journal of the American Medical Association 185:914-919, 1963.

References

Katz, S.; Downs, T.D.; Cash, H.R.; and Grotz, R.C.
Progress in development of the Index of ADL. Gerontologist 10(1):20-30, 1970.

Katz, S., and Akpom, C.A.
Index of ADL. Medical Care 14(suppl. 5):116-118. 1976.

Instrumental Activities of Daily Living (IADL) Scale

References

Lawton, M.P.
Scales to measure competence in everyday activities. Psychopharmacology Bulletin 24(4):609-614, 1988.

Lawton, M.P., and Brody, E.M.
Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist 9:179-186, 1969.

Reproduced with permission from M. Powell Lawton, Ph.D.

Geriatric Depression Scale (GDS) Short Form

Choose the best answer for how you have felt over the past week:

1. Are you basically satisfied with your life? YES/NO
2. Have you dropped many of your activities and interests? YES/NO
3. Do you feel that your life is empty? YES/NO
4. Do you often get bored? YES/NO
5. Are you in good spirits most of the time? YES/NO
6. Are you afraid that something bad is going to happen to you? YES/NO
7. Do you feel happy most of the time? YES/NO
8. Do you often feel helpless? YES/NO
9. Do you prefer to stay at home, rather than going out and doing new things? YES/NO
10. Do you feel you have more problems with memory than most? YES/NO
11. Do you think it is wonderful to be alive now? YES/NO
12. Do you feel pretty worthless the way you are now? YES/NO
13. Do you feel full of energy? YES/NO
14. Do you feel that your situation is hopeless? YES/NO
15. Do you think that most people are better off than you are? YES/NO

Answers in bold indicate depression, and each answer counts as one point. For clinical purposes, a score greater than 5 suggests depression and warrants a followup interview. Scores greater than 10 are almost always depression.

Source: Sheikh, J.I., and Yesavage, J.A. Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version. Clinical Gerontologist 5(1&2):165-173, 1986.