CIWA-Ar: Grading Alcohol Withdrawal Severity
The CIWA-Ar grades the severity of alcohol withdrawal across ten signs and symptoms. It is the scale most often used to decide when a patient needs medication.
Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)
The revised Clinical Institute Withdrawal Assessment for Alcohol is a ten item clinician-rated scale for the severity of alcohol withdrawal. It scores nausea, tremor, sweating, anxiety, agitation, tactile, auditory and visual disturbances, headache and orientation, giving a total from 0 to 67. It is repeated at intervals and used to guide symptom-triggered treatment.
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Disease
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What is the CIWA-Ar
Nine items are scored from 0 to 7: nausea and vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, and headache or fullness in the head. The tenth, orientation and clouding of the sensorium, is scored from 0 to 4. Some items are observed, such as tremor and sweating, and others depend on what the patient reports, so the assessment takes a few minutes and requires a patient who can answer.
Sullivan and colleagues published the revised version in 1989, shortening an earlier 15 item scale while keeping its measurement properties. Its main use is symptom-triggered treatment: rather than giving benzodiazepines on a fixed schedule, staff reassess at intervals and medicate when the score passes a threshold. Trials of that approach have found it can reduce the total dose and the length of treatment without increasing complications. The authors state that the scale is not copyrighted and may be reproduced freely.
Item scores are summed for a total from 0 to 67. Totals below 8 to 10 are generally treated as minimal to mild withdrawal, around 8 to 15 as moderate, and above 15 as severe, with rising risk of seizures and delirium tremens. The exact threshold for medication is set by local protocol, most often a score of 8 or 10.
The scale's limits are practical and important. It assumes a patient who can communicate, so it is not valid in someone who is intubated, delirious, severely unwell or unable to speak the language of assessment. Its items overlap with other conditions, including sepsis, hepatic encephalopathy, anxiety disorders and withdrawal from other substances, so a high score is not proof of alcohol withdrawal. And it measures withdrawal that is happening, not the risk of withdrawal to come, which needs a different tool.
Advantages
Develops personalised strategies based on assessment data.
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Minimizes mistakes in clinical data collection.
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Maintains uniform healthcare delivery standards.
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Improves overall healthcare delivery standards.
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Related Instruments
Digital counterpart
Digital biomarkers that measure the same thing with sensors rather than a questionnaire.
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