CAGE Questionnaire Criteria
The CAGE questionnaire consists of four yes/no questions, with a score of 2 or more positive responses indicating clinically significant alcohol-related problems. 1
The Four CAGE Questions
The acronym CAGE represents the key elements of each question 1, 2:
- C (Cut down): "Have you ever felt you should cut down on your drinking?" 1
- A (Annoyed): "Have people annoyed you by criticizing your drinking?" 1
- G (Guilty): "Have you ever felt bad or guilty about your drinking?" 1
- E (Eye-opener): "Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?" 1
Scoring and Interpretation
- Each "yes" response scores 1 point, each "no" response scores 0 points 1, 2
- A total score of ≥2 is considered clinically significant and indicates an alcohol use disorder 1, 2
- The questionnaire demonstrates pooled sensitivity of 71% and specificity of 90% when using the ≥2 cutoff 1
Performance Characteristics by Score
Higher CAGE scores correlate with increased probability of alcohol abuse or dependence 3:
- Score 0: 7% probability of alcohol disorder 3
- Score 1: 46% probability 3
- Score 2: 72% probability 3
- Score 3: 88% probability 3
- Score 4: 98% probability 3
Clinical Utility and Limitations
Strengths
- Simple and brief: Only four questions with yes/no answers, easily incorporated into clinical history or self-administered 1
- High specificity: 89-94% specificity across multiple validation studies 1, 4, 5
- Well-validated: Extensively tested across diverse populations over decades 1
Important Limitations
- Focuses on consequences rather than quantity: Does not assess actual amount of alcohol consumed 1
- Lifetime pattern assessment: Refers to lifetime behaviors rather than recent or short-term changes 1
- Poor sensitivity for risky drinking: Particularly insensitive for detecting hazardous drinking in older adults (14-39% sensitivity) and pregnant women (38-49% sensitivity) 6
- Better for dependence than abuse: Sensitivity is 84% for alcohol dependence but only 61% for alcohol abuse 4
- The "E" (eye-opener) question: Differentiates sharply between abuse (18% sensitivity) and dependence (46% sensitivity), making it less useful for milder forms of alcohol misuse 4
Clinical Application Caveat
While CAGE remains widely used and familiar to physicians, the U.S. Preventive Services Task Force and other guidelines now prefer AUDIT, AUDIT-C, or single-question screening for detecting the full spectrum of alcohol misuse 6, as these tools better identify risky or hazardous drinking patterns before progression to dependence. CAGE performs best as a screening tool for more severe alcohol use disorders, particularly alcohol dependence, rather than early-stage problematic drinking 1, 6, 4.