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CIWA-Ar for Alcohol Withdrawal

Calculators  Multiple body systems
The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scale has ten items, each evaluated independently then aggregated to yield a score correlating with severity of alcohol withdrawal.
Nausea/vomiting
Ask 'Have you vomited? Do you feel sick to your stomach?'
No nausea and no vomiting 0
Mild nausea and no vomiting 1
(More severe symptoms) 2
(More severe symptoms) 3
Intermittent nausea with dry heaves 4
(More severe symptoms) 5
(More severe symptoms) 6
Constant nausea, common dry heaves, and vomiting 7
Tremor
Arms extended and fingers spread apart
No tremor 0
Not visible, but can be felt fingertip to fingertip 1
(More severe symptoms) 2
(More severe symptoms) 3
Medium, with patient's arms extended 4
(More severe symptoms) 5
(More severe symptoms) 6
Severe, even with arms not extended 7
Paroxysmal sweats
No sweat visible 0
Barely perceptible sweating, palms moist 1
(More severe symptoms) 2
(More severe symptoms) 3
Beads of sweat obvious on forehead 4
(More severe symptoms) 5
(More severe symptoms) 6
Drenching sweats 7
Anxiety
Ask, 'Do you feel nervous?'
No anxiety, at ease 0
Mildly anxious 1
(More severe symptoms) 2
(More severe symptoms) 3
Moderately anxious, or guarded, so anxiety is inferred 4
(More severe symptoms) 5
(More severe symptoms) 6
Parallel to acute panic states as seen in severe delirium or acute schizophrenic reactions 7
Agitation
Normal activity 0
Somewhat more activity than normal activty 1
(More severe symptoms) 2
(More severe symptoms) 3
Comparatively fidgety and restless 4
(More severe symptoms) 5
(More severe symptoms) 6
Paces back and forth during most of the interview, or constantly thrashes about 7
Tactile disturbances
Ask, 'Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?'
None 0
Very mild itching, pin and needles, burning, or numbness 1
Mild itching, pin and needles, burning, or numbness 2
Medium itching, pin and needles, burning, or numbness 3
Fairly severe hallucinations 4
Severe hallucinations 5
Very severe hallucinations 6
Continuous hallucinations 7
Auditory disturbances
Ask, 'Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?'
Not present 0
Very mild harshness or ability or frighten 1
Mild harshness or ability or frighten 2
Common harshness or ability or frighten 3
Relatively severe hallucinations 4
Severe hallucinations 5
Very severe hallucinations 6
Continuous hallucinations 7
Visual disturbances
Ask 'Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?'
Not present 0
Very mild sensitivity 1
Mild sensitivity 2
Medium reactivity 3
Relatively severe hallucinations 4
Severe hallucinations 5
Extremely severe hallucinations 6
Continuous hallucinations 7
Headache/fullness in head
Ask 'Does your head feel different? Does it feel like there is a band around your head?' Do not rate for dizziness or lightheadedness. Otherwise, rate 'severity.'
Not Present 0
Very gentle 1
Mild 2
Medium 3
Quite severe 4
Severe 5
Very severe 6
Very severe 7
Orientation/clouding of sensorium
Ask 'What day is this? Where are you? Who am I?'
Oriented, can do serial additions 0
Can't do serial additions or is uncertain about date 1
Disoriented for a date by no more than 2 calendar days 2
Disoriented for the date by more than 2 calendar days 3
Disoriented to place or person 4
Result:

Background

Measured Factor
CIWA-Ar score
Measured Factor Disease
  • Alcohol withdrawal
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.
Speciality
Multi-Speciality
Body System
Multiple body systems
Measured Factor High Impact
  • Alcohol withdrawal

Result Interpretation

Ranges Ranges
  • 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
Result High Conditions
  • Alcohol withdrawal
Test Limitations
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.
References: 1

Studies

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.
References: 2
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.
References: 3
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.
References: 4
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.
References: 5
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.
References: 6
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.
References: 7

Authors

Edward M. Sellers
MD, 1972
President, DL Global Partners Inc.
Research Interests: Clinical psychopharmacology and pharmacogenetics for substance abuse
http://www.neuroscience.utoronto.ca/faculty/list/sellers.htm

References

  1. Knight E, Lappalainen L. Clinical Institute Withdrawal Assessment for Alcohol-Revised might be an unreliable tool in the management of alcohol withdrawal. Can Fam Physician. 2017 Sep;63(9):691-695.
  2. Reoux JP, Miller K. Routine hospital alcohol detoxification practice compared to symptom triggered management with an Objective Withdrawal Scale (CIWA-Ar). Am J Addict. 2000 Spring;9(2):135-44.
  3. Sullivan, JSykora, K; Schneiderman, J; Naranjo, CA; Sellers, EM. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). 1989. Br. J of Addict.. 84 (11): 1353–7
  4. Stuppaeck CH, Barnas C, Falk M, Guenther V, Hummer M, Oberbauer H, Pycha R, Whitworth AB, Fleischhacker WW. Assessment of the alcohol withdrawal syndrome--validity and reliability of the translated and modified Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-A. Addiction. 1994 Oct;89(10):1287-92.
  5. Bacon O, Robert S, Vanden Berg A. Evaluating nursing satisfaction and utilization of the Clinical Institute Withdrawal Assessment for Alcohol, revised version (CIWA-Ar). Ment Health Clin. 2016 May 6;6(3):114-119.
  6. Rappaport D, Chuu A, Hullett C, Nematollahi S, Teeple M, Bhuyan N, Honkanen I, Adamas-Rappaport WJ, Sanders A. Assessment of alcohol withdrawal in Native American patients utilizing the Clinical Institute Withdrawal Assessment of Alcohol Revised Scale. J Addict Med. 2013 May-Jun;7(3):196-9.
  7. Nuss MA, Elnicki DM, Dunsworth TS, Makela EH. Utilizing CIWA-Ar to assess use of benzodiazepines in patients vulnerable to alcohol withdrawal syndrome. W V Med J. 2004 Jan-Feb;100(1):21-5.