MAGENT

CIWA-Ar score: how the alcohol withdrawal scale is added up

The CIWA-Ar score adds ten items from the revised Clinical Institute Withdrawal Assessment for Alcohol scale published by Sullivan and colleagues in 1989. Nine items are scored 0 to 7 and orientation is scored 0 to 4, so the total runs from 0 to 67. Magent's calculator adds the item scores a clinician has assigned.

Not a medical device. Not a diagnosis or dosing recommendation.

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What is the CIWA-Ar?

The CIWA-Ar is a structured way of recording signs and symptoms of alcohol withdrawal. A clinician asks about or observes ten things, such as nausea, tremor, sweating and anxiety, and gives each a whole-number score using the scale's descriptions. The scores are added for a total.

The "Ar" stands for "alcohol, revised". Sullivan and colleagues described the revised, shorter scale in the British Journal of Addiction in 1989.

Magent's calculator doesn't assess anyone. It takes the ten item scores, checks each is in range and returns the total with the maximum of 67.

This page explains the arithmetic. It doesn't say what a score means for a particular person.

The CIWA-Ar formula

item                                   points
nausea and vomiting                    0 to 7
tremor                                 0 to 7
paroxysmal sweats                      0 to 7
anxiety                                0 to 7
agitation                              0 to 7
tactile disturbances                   0 to 7
auditory disturbances                  0 to 7
visual disturbances                    0 to 7
headache, fullness in head             0 to 7
orientation and clouding of sensorium  0 to 4

CIWA-Ar total = sum of the ten items        (0 to 67)

Exact expression the calculator uses:

CIWA-Ar = nausea_vomiting + tremor + paroxysmal_sweats + anxiety + agitation + tactile + auditory + visual + headache + orientation; nine items 0-7, orientation 0-4; max 67

Inputs

InputItemValues accepted
nausea_vomitingNausea and vomiting0 to 7
tremorTremor0 to 7
paroxysmal_sweatsParoxysmal sweats0 to 7
anxietyAnxiety0 to 7
agitationAgitation0 to 7
tactileTactile disturbances0 to 7
auditoryAuditory disturbances0 to 7
visualVisual disturbances0 to 7
headacheHeadache, fullness in head0 to 7
orientationOrientation and clouding of sensorium0 to 4

All ten are required whole numbers. An out-of-range item returns invalid_ciwa_item, and an out-of-range orientation returns invalid_ciwa_orientation.

How the calculation works

  1. Score each item using the scale's descriptions. Nine items run 0 to 7. Orientation runs 0 to 4.
  2. Check the ranges. Orientation can't go above 4.
  3. Add the ten scores. The total is the CIWA-Ar score, from 0 to 67.

Nine items at 7 plus orientation at 4 gives the maximum of 67.

Units

Each item and the total are points with no units. Items are whole numbers. The calculator doesn't accept fractions of a point.

Worked examples

These use Magent's own expected values for the calculator.

Example 1: every item 0

  1. All ten items scored 0.
  2. CIWA-Ar 0.

Example 2: orientation at its top value

  1. Orientation scored 4. The other nine items scored 0.
  2. CIWA-Ar 4.

Example 3: nausea and vomiting at 7, the rest 0

  1. Nausea and vomiting scored 7. The other nine items scored 0.
  2. CIWA-Ar 7.

Example 4: every item at its top value except tremor

  1. Tremor scored 0. The other eight 0-to-7 items scored 7, and orientation scored 4.
  2. CIWA-Ar 60.

Example 5: every item at its top value

  1. Nine items scored 7 and orientation scored 4.
  2. CIWA-Ar 67, the maximum of 67.

History of the CIWA-Ar

The calculator cites Sullivan and colleagues, British Journal of Addiction, 1989, titled "Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar)". The paper published the ten items and their ranges. The calculator returns the total and doesn't add any score bands.

When it's used

The CIWA-Ar is used to record alcohol withdrawal signs and symptoms in a consistent way, so that scores can be compared over time.

Where it's used

It is completed at the bedside, most often in hospital wards, emergency departments and units that look after people stopping alcohol.

Who uses it

A clinician scores each item after asking and observing. The calculator checks the ranges and adds the scores.

Limits of the calculation

  • The calculator doesn't observe the patient or score the items. The scores come from the person entering them.
  • It returns the total and the maximum. It has no severity bands and applies no protocol cut-offs.
  • It doesn't order or adjust any medicine, and this page doesn't say what to do with a score.
  • The total describes symptoms at the time of scoring. It doesn't confirm that symptoms are caused by alcohol withdrawal.

Clinical decisions belong to a qualified clinician who knows the patient.

  • CAGE questionnaire asks four yes/no questions about drinking. The CIWA-Ar scores current withdrawal symptoms.
  • AUDIT-C adds three answers about drinking habits. The CIWA-Ar doesn't ask about drinking habits.

Glossary

  • Withdrawal: symptoms that appear when a person who drinks heavily stops or cuts down.
  • Paroxysmal sweats: bouts of sweating that come and go.
  • Tactile, auditory and visual disturbances: unusual sensations of touch, sound and sight.
  • Clouding of sensorium: reduced clarity of awareness.

Common mistakes

  • Scoring orientation out of 7. Orientation runs 0 to 4.
  • Treating all ten items as 0 to 7. With orientation capped at 4, the maximum is 67.
  • Reading a band into the total. The calculator returns the total and the maximum, with no bands.
  • Leaving an item out. All ten items are required.

Source

Sullivan JT, et al. 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. PMID: 2597811

Frequently asked questions

How many items are in the CIWA-Ar?

Ten. Nine are scored 0 to 7 and orientation is scored 0 to 4.

What is the maximum CIWA-Ar score?

67.

Why is orientation scored 0 to 4?

That is the range Sullivan 1989 gives for orientation and clouding of sensorium. The other nine items run 0 to 7.

Does the calculator say what a score means?

No. It returns the total and the maximum, with no bands or cut-offs.

Does the calculator score the items for me?

No. A clinician scores each item and the calculator adds them.