Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale

 Alcohol Withdrawal Syndrome

 

Alcohol withdrawal refers to symptoms that may occur when a person who has been drinking too much alcohol every day suddenly stops drinking alcohol.

The spectrum of alcohol withdrawal symptoms ranges from such minor symptoms as insomnia and tremulousness to severe complications such as withdrawal seizures and delirium tremens. Although the history and physical examination usually are sufficient to diagnose alcohol withdrawal syndrome, other conditions may present with similar symptoms. Most patients undergoing alcohol withdrawal can be treated safely and effectively as outpatients. Pharmacologic treatment involves the use of medications that are cross-tolerant with alcohol. Benzodiazepines, the agents of choice, may be administered on a fixed or symptom-triggered schedule. Carbamazepine is an appropriate alternative to a benzodiazepine in the outpatient treatment of patients with mild to moderate alcohol withdrawal symptoms. Medications such as haloperidol, beta blockers, clonidine, and phenytoin may be used as adjuncts to a benzodiazepine in the treatment of complications of withdrawal. Treatment of alcohol withdrawal should be followed by treatment for alcohol dependence. 

Scoring

The cumulative score provides the basis for treatment of patients undergoing alcohol withdrawal.

Cumulative Score
0-8	No medication is necessary
9-14	Medication is optional for patients with a score of 8–14
15-20	A score of 15 or over requires treatment with medication
>20	A score of over 20 poses a strong risk of Delirium tremens
67	Maximum possible cumulative score

Assessment Tool

Nausea and Vomiting

Ask: "Do you feel sick to your stomach? Have you vomited?"

Score
0	no nausea and no vomiting
1	mild nausea with no vomiting
2
3
4	intermittent nausea with dry heaves
5
6
7	constant nausea, frequent dry heaves and vomiting

Tremor

Arms extended and fingers spread apart

Score
0	no tremor
1	not visible, but can be felt fingertip to fingertip
2
3
4	moderate, with patient’s arms extended
5
6
7	severe, even with arms not extended

Paroxysmal Sweats

Score
0	no sweat visible
1	barely perceptible sweating, palms moist
2
3
4	beads of sweat obvious on forehead
5
6
7	drenching sweats

Anxiety

Ask: "Do you feel nervous?"

Score
0	no anxiety, at ease
1	mildly anxious
2
3
4	moderately anxious, or guarded, so anxiety is inferred
5
6
7	equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions

Agitation

Score
0	normal activity
1	somewhat more than normal activity
2
3
4	moderately fidgety and restless
5
6
7	paces back and forth during most of the interview, or constantly thrashes about

Tactile Disturbances

Ask: "Have you any itching, pins and needles sensations, burning sensations, numbness or do you feel bugs crawling on or under your skin?"

Score
0	none
1	very mild itching, pins and needles, burning or numbness
2	mild itching, pins and needles, burning or numbness
3	moderate itching, pins and needles, burning or numbness
4	moderately severe hallucinations
5	severe hallucinations
6	extremely severe hallucinations
7	continuous hallucinations

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?"

Score
0	not present
1	very mild harshness or ability to frighten
2	mild harshness or ability to frighten
3	moderate harshness or ability to frighten
4	moderately severe hallucinations
5	severe hallucinations
6	extremely severe hallucinations
7	continuous hallucinations

Visual Disturbances

Ask: "Does the light appear to be too bright? Is its colour different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?"

Score
0	not present
1	very mild sensitivity
2	mild sensitivity
3	moderate sensitivity
4	moderately severe hallucinations
5	severe hallucinations
6	extremely severe hallucinations
7	continuous hallucinations

Headache, Fullness in Head

Ask: "Does your head feel different? Does it feel as if there is a band around your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity.

Score
0	not present
1	very mild
2	mild
3	moderate
4	moderately severe
5	severe
6	very severe
7	extremely severe

Orientation and Clouding of Sensorium

Ask: "What day is this? Where are you? Who am I?"

Score
0	oriented and can do serial additions
1	cannot do serial additions or is uncertain about date
2	disoriented for date by no more than 2 calendar days
3	disoriented for date by more than 2 calendar days
4	disoriented for place and/or person