Revised Clinical Institute Withdrawal Assessment for alcohol

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Administration

  • Use open-ended questions for each item
  • Assess hourly for the first three hours and also for those who score above 10
    • If a patient scores below 10 for three hours in a row, assessment every four hours thereafter is reasonable
  • Begin treating patients once they score above 10
    • Consider prophylactic treatment regardless of CIWA for patients at high risk for severe withdrawal
  • Reassess an hour after any score above 10 where they were given diazepam

Criteria

Criterion 0 1 2 3 4 5 6 7
Nausea and vomiting
Ask, "Do you feel sick to your stomach? Have you vomited?" Observation
no nausea and no vomiting mild nausea with no vomiting intermittent nausea with dry heaves constant nausea, frequent drug heaves and vomiting
Tremor
Arms extended and fingers apart. Observation.
no tremor not visible, but can be felt fingertip-to-fingertip moderate, with patient's arms extended severe, even with arms not extended
Paroxysmal sweats
Observation
no sweat visible barely perceptible sweating, palms moist beads of sweat obvious on forehead drenching sweats
Anxiety
Ask, "Do you feel nervous?" Observation.
no anxiety, at ease mildly anxious moderately anxious, or guarded, so anxiety is inferred equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions
Agitation
Observation.
normal activity somewhat more than normal activity moderately fidgety and restless paces back and forth during most of the interview, or constantly thrashes about
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?" Observation.
none very mild itching, pins and needles, burning or numbness mild itching, pins and needles, burning or numbness moderate itching, pins and needles, burning or numbness moderately severe hallucinations severe hallucinations extremely severe hallucinations 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?" Observation.
not present very mild harshness or ability to frighten mild harshness or ability to frighten moderate harshness or ability to frighten moderately severe hallucinations severe hallucinations extremely severe hallucinations 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?" Observation.
not present very mild sensitivity mild sensitivity moderate sensitivity moderately severe hallucinations severe hallucinations extremely severe hallucinations continuous hallucinations
Headache, fullness in head
Ask, "Does you 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 very mild mild moderate moderately severe severe very severe extremely severe
Orientation and clouding of sensorium
Ask, "What day is this? Where are you? Who am I?"
oriented and can do serial additions cannot do serial additions or is uncertain about date disoriented for date by no more than 2 calendar days disoriented for date by more than 2 calendar days disoriented for place and/or person
Criterion 0 1 2 3 4 5 6 7

Interpretation

Score Severity
0 to 9 Very mild or absent
10 to 15 Mild
16 to 20 Moderate
21 to 67 Severe

Further Reading

  • Assessment of Alcohol Withdrawal: The Revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar). Br J Addict. 1989;84(11):1353-1357. doi: 10.1111/j.1360-0443.1989.tb00737.x