What is a Clinical Institute Withdrawal Assessment (CIWA) score and how is it calculated?

CIWA Score: Assessment Tool for Alcohol Withdrawal Syndrome

The CIWA (Clinical Institute Withdrawal Assessment) score is a standardized assessment tool used to measure the severity of alcohol withdrawal syndrome, with scores ranging from mild (5-12), moderate (13-24), moderately severe (25-36), to severe (>36). 1

What is the CIWA Score?

The CIWA score is a validated clinical instrument designed to objectively quantify the severity of alcohol withdrawal symptoms. It helps clinicians:

• Assess the need for pharmacological intervention
• Monitor response to treatment
• Guide medication dosing in a symptom-triggered approach
• Predict risk of withdrawal complications (seizures, delirium tremens)

Components of the CIWA Score

The CIWA assessment includes evaluation of the following symptoms:

1. Vital Signs

   • Resting pulse rate (measured after patient sits/lies for 1 minute)
     • 0 = pulse rate ≤80/min
     • 1 = pulse rate 81-100/min
     • 2 = pulse rate 101-120/min
     • 4 = pulse rate >120/min

2. Gastrointestinal Symptoms (over last 30 minutes)

   • 0 = no GI symptoms
   • 1 = stomach cramps
   • 2 = nausea or loose stool
   • 3 = vomiting or diarrhea
   • 5 = multiple episodes of diarrhea or vomiting

3. Sweating (over past hour, not due to room temperature/activity)

   • 0 = no report of chills or flushing
   • 1 = subjective report of chills or flushing
   • 2 = flushed or observable moistness on face
   • 3 = beads of sweat on brow or face
   • 4 = sweat streaming off face

4. Tremor (observation of outstretched hands)

   • 0 = no tremor
   • 1 = tremor can be felt but not observed
   • 2 = slight tremor observable
   • 4 = gross tremor or muscle twitching

5. Restlessness (observation during assessment)

   • 0 = able to sit still
   • 1 = reports difficulty sitting still, but is able to do so
   • 3 = frequent shifting or extraneous movements of legs/arms
   • 5 = unable to sit still for more than a few seconds

6. Yawning (observation during assessment)

   • 0 = no yawning
   • 1 = yawning once or twice during assessment
   • 2 = yawning three or more times during assessment
   • 4 = yawning several times/minute

7. Pupil Size

   • 0 = pupils pinned or normal size for room light
   • 1 = pupils possibly larger than normal for room light
   • 2 = pupils moderately dilated
   • 5 = pupils so dilated that only the rim of the iris is visible

8. Anxiety

   • 0 = none
   • 1 = patient reports increasing irritability or anxiousness
   • 2 = patient obviously irritable or anxious
   • 4 = patient so irritable or anxious that participation in assessment is difficult

9. Bone or Joint Aches (only additional component attributed to withdrawal)

   • 0 = not present
   • 1 = mild diffuse discomfort
   • 2 = patient reports severe diffuse aching of joints/muscles
   • 4 = patient is rubbing joints or muscles and unable to sit still due to discomfort

10. Runny Nose or Tearing (not due to cold symptoms or allergies)

    • 0 = not present
    • 1 = nasal stuffiness or unusually moist eyes
    • 2 = nose running or tearing
    • 3 = nose constantly running or tears streaming down cheeks

Calculating and Interpreting the CIWA Score

The total CIWA score is calculated by adding the points from all ten items, with a maximum possible score of 67. The score is interpreted as follows:

• 5-12 points: Mild withdrawal
• 13-24 points: Moderate withdrawal
• 25-36 points: Moderately severe withdrawal
• >36 points: Severe withdrawal 1

Clinical Significance and Application

Research has shown that patients who develop seizures or confusion tend to score higher on the CIWA scale (21.7 ± 1.2) compared to those who remain uncomplicated (15.6 ± 0.55), even before these complications develop 2. Patients scoring greater than 15 are at significantly increased risk of severe alcohol withdrawal if left untreated (RR 3.72; 95% CI 2.85-4.85) 2.

The CIWA score is typically used to:

1. Guide treatment decisions: Scores ≥8-10 often indicate the need for pharmacological intervention, typically with benzodiazepines 3

2. Monitor withdrawal progression: Regular assessments (typically every 4-8 hours) help track the patient's clinical course 1

3. Determine medication dosing: In symptom-triggered protocols, medication doses are based on CIWA scores 3

4. Predict complications: Higher scores correlate with increased risk of withdrawal seizures and delirium tremens 2

Practical Considerations

• Assessment should be performed by trained healthcare providers
• The frequency of assessment varies based on clinical status, typically every 4-8 hours or more frequently if symptoms are severe 1
• The CIWA score should be documented along with vital signs
• Withdrawal symptoms typically peak 48-72 hours after the last drink and resolve within 7-14 days 1

Limitations

• Some patients with low CIWA scores may still develop complicated withdrawal 2
• The scale requires patient cooperation and accurate self-reporting
• The assessment may be difficult in patients with communication barriers or altered mental status
• Symptoms may overlap with other conditions (pain, anxiety, infections)

The CIWA score remains one of the most widely used and validated tools for assessing alcohol withdrawal syndrome, providing an objective measure to guide clinical decision-making and treatment.