The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A) or CIWA-Ar (revised version) is a 10-item scale that is used for the assessment of the symptoms of alcohol withdrawal. This WellnessKeen write-up provides information on the basics of the CIWA scale for alcohol withdrawal.
A serious complication or symptom associated with alcohol withdrawal, delirium tremens (DT) occurs in about 5% of patients. The onset of DT is between 2 to 5 days after discontinuation of alcohol. It must be noted that DT can turn life-threatening in the absence of prompt treatment. However, the mortality rate gets reduced to 1% if medical assistance is sought on time.
The term ‘alcohol withdrawal’ refers to a group of symptoms that occur due to the sudden discontinuation of alcohol consumption in individuals who have been drinking large amounts of alcohol daily. Roughly 2 out of every five drinkers are likely to develop an acute withdrawal syndrome (AWS) on discontinuing alcohol or cutting down their alcohol intake significantly. Though the symptoms can vary in intensity, these often worsen rapidly. Therefore, it is essential to seek medical assistance, even if the symptoms seem to be mild.
Prompt treatment can lower the risk of complications associated with withdrawal, which include seizures and delirium tremens. Besides analyzing the patient’s current medical condition and medical history, healthcare professionals follow certain protocols and use certain tools to monitor and assess the intensity of symptoms so that they can devise a suitable treatment plan that will ensure speedy recovery. The Clinical Institute Withdrawal Assessment – Alcohol, revised (CIWA-Ar) scale is one such standardized tool.
CIWA Scale for Alcohol Withdrawal
The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale is a 10-item assessment tool that is used for measuring the severity of symptoms of alcohol withdrawal. However, the CIWA scale score alone is not considered while deciding the treatment. The patient’s clinical condition, as well as the vital signs must also be taken into consideration. Certain psychiatric and medical conditions can cause symptoms that are similar to those of alcohol withdrawal, and even certain drugs can affect the symptoms. Tests must be conducted to confirm or rule out the medical conditions that commonly affect indigenous heavy drinkers. Thus, proper assessment is required to chalk out the treatment plan. Nursing alcohol withdrawal observation record and CIWA scale must be used at regular intervals to monitor the patient’s condition. In case of the CIWA-Ar scale, the healthcare professionals check for the presence and severity of the following 10 symptoms:
~ Nausea and vomiting (0-7)
~ Tremor (0-7)
~ Paroxysmal sweats (0-7)
~ Anxiety (0-7)
~ Agitation (0-7)
~ Tactile disturbances (0-7)
~ Auditory disturbances (0-7)
~ Visual disturbances (0-7)
~ Headaches, fullness in head (0-7)
~ Orientation and clouding of sensorium (0-4)
CIWA-Ar Score
| Nausea and Vomiting |
|
◉ No nausea and no vomiting: 0
◉ Mild nausea and no vomiting: 1
◉ More severe symptoms: 2 or 3
◉ Intermittent nausea with dry heaves: 4
◉ More severe symptoms: 5 or 6
◉ Constant nausea, frequent dry heaves and vomiting: 7
|
| Tremor |
|
◉ No tremor: 0
◉ Not visible but can be felt at fingertips: 1
◉ More severe symptoms: 2 or 3
◉ Moderate with patient’s arms extended: 4
◉ More severe symptoms: 5 or 6
◉ Severe, even with the patient’s arms not extended: 7
|
| Paroxysmal sweats |
|
◉ No sweat visible: 0
◉ Barely perceptible sweating, with moist palms: 1
◉ More severe symptoms: 2 or 3
◉ Beads of sweat visible on forehead: 4
◉ More severe symptoms: 5 or 6
◉ Drenching sweats: 7
|
| Anxiety |
|
◉ No anxiety: 0
◉ Mildly anxious: 1
◉ More severe symptoms: 2 or 3
◉ Moderately anxious, guarded: 4
◉ More severe symptoms: 5 or 6
◉ Similar to acute panic state observed in conditions such as severe delirium or acute schizophrenic reactions: 7
|
|
Agitation
|
|
◉ Normal activity: 0
◉ Slightly more than normal activity: 1
◉ More severe symptoms: 2 or 3
◉ Restless and moderately fidgety: 4
◉ More severe symptoms: 5 or 6
◉ Paces back and forth during the assessment: 7
|
| Tactile Disturbances |
|
◉ None: 0
◉ Pins and needles/burning/numbness/very mild itching: 1
◉ Mild itching, pins and needles, burning, numbness: 2
◉ Moderate itching, pins and needles, burning, or numbness: 3
◉ Moderately severe hallucinations: 4
◉ Severe hallucinations: 5
◉ Extremely severe hallucinations: 6
◉ Continuous hallucinations: 7
|
| Auditory Disturbances |
|
◉ Not present: 0
◉ Very mild harshness or ability to frighten: 1
◉ Mild harshness or ability to frighten: 2
◉ Moderate harshness or ability to frighten: 3
◉ Moderately severe hallucinations: 4
◉ Severe hallucinations: 5
◉ Extremely severe hallucinations: 6
◉ Continuous hallucinations: 7
|
| Visual Disturbances |
|
◉ Not present: 0
◉ Very mild sensitivity: 1
◉ Mild sensitivity: 2
◉ Moderate sensitivity: 3
◉ Moderately severe hallucinations: 4
◉ Severe hallucinations: 5
◉ Extremely severe hallucinations: 6
◉ Continuous hallucinations: 7
|
| Headaches |
|
◉ Not present: 0
◉ Very mild: 1
◉ Mild: 2
◉ Moderate: 3
◉ Moderately severe: 4
◉ Severe: 5
◉ Very severe: 6
◉ Extremely severe: 7
|
| Orientation and Clouding of Sensorium |
|
◉ Oriented and can do serial additions: 0
◉ Cannot do serial additions or is uncertain about date: 1
◉ Disoriented for date by no more than 2 calendar days: 2
◉ Disoriented for date by more than 2 calendar days: 3
◉ Disoriented for place and/or persons: 4
|
The score is determined by adding the score given to each symptom, depending on the severity of the symptom. With the exception of the tenth symptom (Clouding of the sensorium) which is given a score from 0-4, the rest of the symptoms are scored from 0-7. Thus, the maximum possible score is 67.
According to the revised version of the CIWA scale, 8 points or fewer correspond to mild withdrawal, whereas scores of 8 to 15 correspond to moderate withdrawal. When the score is 15 or above, it indicates severe withdrawal. Prompt medical assistance is vital in case of severe withdrawal to lower the risk of delirium tremens and seizures.
Alcohol Withdrawal Syndrome (AWS)
The symptoms of alcohol withdrawal often appear within 6-24 hours after the last drink. Usually, the symptoms resolve within 2-5 days. However, the condition might sometimes worsen in the absence of treatment, and withdrawal could progress to the second stage. The onset of the second stage is 48 hours after the last drink. The characteristic symptom is hallucinations. The third stage is more severe, and the onset is around 72 hours after the last drink. It is most likely to be observed in those affected by severe alcohol abuse with certain co-existing medical conditions. Since the use of drugs such as benzodiazepines/sedatives could delay the onset, it is essential that the healthcare professionals are informed about the drugs that the patient is taking currently.
Healthcare professionals often evaluate the patient’s medical history and drinking history. At times, carbohydrate-deficient transferrin and/or gamma-glutamyl transferase tests might be conducted to diagnose alcohol overuse and dependence. The severity of the symptoms can depend on the duration for which one has been using alcohol, extent of alcohol intake, as well as prior history of alcohol withdrawal. Care needs to be taken in case of patients with a history of complications related to withdrawal. The characteristic symptoms of alcohol withdrawal include:
~ Anxiety
~ Agitation
~ Hand tremors
~ Insomnia
~ Convulsions
~ Nausea
~ Vomiting
~ Sweating/Flushing
~ Diarrhea
~ Confusion/Disorientation
~ Transient hallucinations (visual, tactile, auditory)
~ Autonomic instability
~ Rapid heartbeat
~ Headaches
~ Chills
Delirium tremens, which is a major complication of alcohol withdrawal, is characterized by the following symptoms:
~ Severe tremors
~ Confusion and disorientation
~ Agitation
~ Violent behavior
~ Fever with/without infection
~ Delusions
~ Severe hallucinations
~ Abnormally rapid heartbeat
~ Delirium
Treatment
While CIWA-AR can help in judging the severity of the symptoms of alcohol withdrawal, doctors don’t solely rely on it. It is extremely essential to monitor and record the vital signs at regular intervals. The heart rate and blood pressure must be checked, so as to rule out autonomic instability. If the CIWA score is less than 8 and the vital signs are normal, drug therapy is usually not required. However, in case the patient’s history is indicative of alcohol withdrawal risk, treatment can be initiated, even if the CIWA score is less than 8.
The pharmacological treatment involves the use of benzodiazepines (oral chlordiazepoxide or oral, sublingual, intramuscular, or intravenous lorazepam). The doses are decided according to the assessed risk. The degree of sedation has to be assessed fifteen minutes after the first parenteral dose. As per the protocol, nursing assessment of the degree of sedation and withdrawal symptoms (CIWA-Ar) is required every six hours.
~ The patient has to be adequately hydrated, and the electrolyte balance has be restored.
~ Multivitamins, folate, and thiamine supplements are administered to prevent nutritional deficiencies.
~ In case of patients with a history of seizures, routine nursing seizure precautions have to be followed.
Individuals who are experiencing mild withdrawal symptoms can be given oral chlordiazepoxide or oral, sublingual, or intravenous diazepam/lorazepam. Oral diazepam 5-10 mg can be given every 6-8 hours for first 48 hours, or lorazepam (Ativan) 2 mg can be given every hour. The vital signs must be checked every 2 hours, and CIWA should be administered every 4 hours. The dose can be increased, according to the severity of the symptoms.
In case of moderate withdrawal, lorazepam 3 or 4 mg can be given initially, followed by repeated doses, or chlordiazepoxide 100 mg or 20 mg chlordiazepoxide can be given four times daily, till the symptoms resolve. In case of severe symptoms, intravenous administration of lorazepam is given in boluses of 2 to 4 mg every 15 to 30 minutes for the first six hours, till the patient is maintained at a sedation level of three. The degree of sedation, CIWA, and vital signs need to be monitored every two hours. Respiratory and oxygen saturation monitoring is required.
During the detoxification process, the healthcare professionals need to closely check for excessive sedation, and hold doses till sedation clears. In case of severe agitation, hallucinations or delusions, other drugs might be prescribed. Once the patient has stabilized for 24 hours, the doses are tapered off. If lorazepam has been used for more than 3 days, the dose of the drug should be tapered over a period of 3 days, reducing the dose by 50% every day for 3 days. The total 24-hour dose should also be reduced by 25% daily over the next 2-3 days. If IM or IV lorazepam was administered for stabilizing the patient, it is advisable to switch to oral chlordiazepoxide at the earliest. Since benozodiazepines are contraindicated in certain cases, drugs must be recommended after a thorough analysis of the patient’s medical history.
On a concluding note, CIWA-A scale is a useful tool in assessing the severity of the symptoms of alcohol withdrawal. Assessing the symptoms with this scale at regular intervals can help the doctors devise a suitable plan, and modify it as per the patient’s condition. However, it should not be solely relied upon. It is essential to check the patient’s vital signs and analyze his/her condition, keeping any existing medical condition in mind.
Disclaimer: The information provided in this article is solely for educating the reader. It is not intended to be a substitute for the advice of a medical expert.
