Measured Factor Detail
For calculation of CIWA-Ar score ten items are evaluated on the scale are common symptoms and signs of alcohol withdrawal such as nausea and vomiting, tremor, Paroxysmal sweats, Anxiety, Agitation, Tactile disturbances, Auditory disturbances, Visual disturbances, Headache , Orientation and clouded sensorium. All items are scored from 0–7, with the exception of the orientation category, scored from 0–4. A score of less than or equal to 8 indicates absent or minimal withdrawal, Score of 9-19 indicates mild to moderate withdrawal and score 20 or more shows severe withdrawal.
Multiple body systems
Measured Factor High Impact
- Critical High: 9
- Normal: 0-8
- Normal Adult Male: 0-8
- Normal Adult Female: 0-8
- Normal Geriatric Male: 0-8
- Normal Geriatric Female: 0-8
An important limitation of the CIWA-Ar is its heavily subjective nature. Only 3 of 10 components (tremor, paroxysmal sweats, agitation) can be rated by observation alone. The other 7 components require at least some discussion with the patient. Given that benzodiazepines are provided based on the CIWA-Ar score, there is risk of incorrect dosing when scores are unreliable, which harbours potential for patient harm.
Study Validation 1
In this study, charts of patients hospitalized for uncomplicated alcohol withdrawal were examined and detoxification practices were compared. It was observed that patients detoxified using a Clinical Institute Withdrawal Assessment for Alcohol-revised (CIWA-Ar) based PRN protocol on the addiction unit received significantly fewer chlordiazepoxide milligram equivalents over shorter duration than patients managed by other detoxification methods on other hospital units. Further, significantly fewer patients received benzodiazepines in the CIWA-Ar protocol managed group, but inter-group differences (p < 0.01) remained when only medicated patients were compared.
Study Validation 2
A shortened 10-item scale for clinical quantitation of the severity of the alcohol withdrawal syndrome has been developed. This scale offers an increase in efficiency while at the same time retaining clinical usefulness, validity and reliability. It can be incorporated into the usual clinical care of patients undergoing alcohol withdrawal and into clinical drug trials of alcohol withdrawal.
Study Validation 3
The alcohol withdrawal syndrome is a common phenomenon in psychiatric hospital care. Not only treatment strategies, but also the evaluation of the syndrome, are discussed controversially. The most widely used instrument is the Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) and the succeeding CIWA-Ar. The validity and reliability of the modified and translated scale were analysed by several psychological tests as well as different somatic measures in 31 patients. The German version appears to be a valid and reliable instrument for the assessment of alcohol withdrawal syndrome useful for clinical routine as well as treatment trials.
Study Additional 1
The Clinical Institute Withdrawal Assessment for Alcohol, revised version (CIWA-Ar), developed and validated for research, was used in then in-patient academic medical center. A retrospective chart review included all patients with an order for CIWA-Ar between August 1, 2014, and September 30, 2014. Data collected included demographics, admitting diagnosis, vital signs, admission blood alcohol level, lorazepam total daily dose, and CIWA-Ar scores. Nursing staff was sent an anonymous, 26-question survey in January 2015. The survey collected demographics, training history, and recommendations for modifications to the CIWA-Ar. During the 2-month period, 274 patients had orders for CIWA-Ar, with 113 receiving at least one dose of lorazepam. Lorazepam was not given to 21% of patients when they scored >8 on the CIWA-Ar, whereas 71% of patients received a dose of lorazepam when they had a CIWA score <8. The survey was sent to 2011 clinical nurses, with 284 responses received (14% response rate). Only 36% of responding nurses felt adequately trained to administer the CIWA-Ar. Most nurses preferred on-the-job and online training methods. Results of the present study will be used to improve training for nursing staff regarding scoring of the CIWA-Ar and administering lorazepam to treat alcohol withdrawal syndrome.
Study Additional 2
in this study a case series of all patients seen for alcohol withdrawal at an Acute Drug and Alcohol Detoxification facility was conducted from June 1, 2011, until April 1, 2012. The CIWA-Ar scores were recorded by trained nursing staff on presentation to Triage Department and every 2 hours thereafter. A score of 10 or greater indicated the need for inpatient hospital admission and treatment. Ethnicity was self-reported. Age, sex, blood alcohol concentration, blood pressure, and pulse were recorded on presentation and vital signs repeated every 2 hours. Patients were excluded from the study if other drug use was noted by history or initial urine drug screen. A multivariate logistic regression model was utilized to identify statistically significant variables associated with admission to the inpatient unit and treatment. The relationship of CIWA-Ar scores and ethnicity was compared using analysis of variance. This study suggested that the CIWA-Ar scale may underestimate the severity of alcohol withdrawal syndrome in certain ethnic group such as native americans. Further prospective studies should be undertaken to determine the validity of the CIWA-Ar scale in assessing alcohol withdrawal across different ethnic populations.
Study Additional 3
The aim of this study was to determine whether the use of revised Clinical Institute Withdrawal Assessment (CIWA-Ar) would better guide treatment for the Alcohol Withdrawal Syndrome (AWS). In this study, 16 patients were identified as alcohol dependent or with a positive blood alcohol level on admission. All patients were administered the CIWA-Ar. If it was > or = 10, the patient was randomized to a benzodiazepine. If the CIWA-Ar was < 10, the patient was observed and the CIWA-Ar was administered every eight hours for 48 hours. Seven patients had a score of > or = 10 and entered a benzodiazepine treatment program. The mean CIWA-Ar score was 18 +/- 10. The remaining nine patients had an initial CIWA-Ar < 10, with a mean score of 3.8 +/- 2.4. The results of the study prove that the CIWA-Ar may obviate over-utilization of benzodiazepines in patients with AWS.