What are the components of the Clinical Institute Withdrawal Assessment (CIWA) score?

Components of the Clinical Institute Withdrawal Assessment (CIWA) Score

The Clinical Institute Withdrawal Assessment (CIWA) score consists of 10 components that assess the severity of alcohol withdrawal symptoms: nausea/vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, headache, and orientation/clouding of sensorium.

The 10 Components of CIWA

The CIWA score is a standardized assessment tool used to evaluate alcohol withdrawal syndrome severity. Each component is rated on a specific scale:

1. Nausea and Vomiting (0-7 points)

   • Ranges from no nausea (0) to constant nausea with multiple episodes of vomiting (7)

2. Tremor (0-7 points)

   • Assessed with arms extended and fingers spread apart
   • Ranges from no tremor (0) to severe tremor even with arms not extended (7)

3. Paroxysmal Sweats (0-7 points)

   • Ranges from no sweat visible (0) to drenching sweats (7)

4. Anxiety (0-7 points)

   • Ranges from no anxiety (0) to acute panic states (7)

5. Agitation (0-7 points)

   • Ranges from normal activity (0) to constantly thrashing about (7)

6. Tactile Disturbances (0-7 points)

   • Ranges from none (0) to continuous hallucinations (7)

7. Auditory Disturbances (0-7 points)

   • Ranges from none (0) to continuous hallucinations (7)

8. Visual Disturbances (0-7 points)

   • Ranges from none (0) to continuous hallucinations (7)

9. Headache (0-7 points)

   • Ranges from not present (0) to extremely severe (7)

10. Orientation and Clouding of Sensorium (0-4 points)

    • Assesses orientation to time, place, person
    • Ranges from fully oriented (0) to disoriented (4)

Clinical Application and Interpretation

The total CIWA score ranges from 0-67 points and is interpreted as follows:

• Score < 8: Mild withdrawal
• Score 8-14: Moderate withdrawal
• Score ≥ 15: Severe withdrawal with high risk of complications 1

Important Clinical Considerations

• The CIWA protocol should not be used for diagnosing alcohol withdrawal syndrome, as high scores may also be seen in other conditions such as anxiolytic withdrawal, anxiety disorders, sepsis, hepatic encephalopathy, and severe pain 2.

• While CIWA is widely used, it has limitations including poor internal consistency (Cronbach alpha of 0.46) 3.

• Patients scoring greater than 15 on the CIWA scale are at significantly increased risk of severe alcohol withdrawal if left untreated (RR 3.72; 95% CI 2.85-4.85) 4.

• For patients with severe AWS, psychiatric consultation is recommended for evaluation, treatment planning, and long-term abstinence planning 2.

• Benzodiazepines remain the standard pharmacological treatment for AWS, with treatment decisions guided by CIWA scores 2, 1.

Alternative Assessment Tools

Shorter assessment tools have been developed to address the time-consuming nature of the CIWA:

• The Brief Alcohol Withdrawal Scale (BAWS): A 5-item scale that has shown good sensitivity (85.3%) and specificity (65.8%) compared to CIWA-Ar 5.

• The Anxiety Sweats Tremor (AST) Scale: A simplified 3-item scale with better internal consistency (Cronbach alpha of 0.68) than CIWA-Ar, and good ability to identify significant withdrawal (sensitivity 93%, specificity 63%) 3.

The CIWA score remains a valuable tool for monitoring alcohol withdrawal and guiding treatment decisions, though clinicians should be aware of its limitations and interpret results within the clinical context of each individual patient.