Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly
Clinical Institute Withdrawal Assessment
Scale for Alcohol, Revised
Purpose : Assessment of alcohol withdrawal symptoms
Admin time : 5 min
User Friendly : High
Administered by : GP or nurse
Content : 10-item questionnaire that measures the current degree of severity of an individual’s alcohol withdrawal symptoms.
Items 1-9 are scored on a scale from 0 to 7, 0 being no symptoms and 7 being severe symptoms.
Item 10 is scored on a scale from 0 to 4:
0 = oriented and can do serial additions
1 = cannot do serial additions or is uncertain about date
2 = disoriented for date by no more than 2 calendar days
3 = disoriented for date by more than 2 calendar days
4 = disoriented for place/or person
Author : Sullivan JT, 1989 access
Copyright : Free to use.
The CIWA-Ar scale is intended only for patients who have been drinking recently.
It relies on patients’ ability to respond to questions about their symptoms.
Patients must be able to communicate and have a clear enough sensorium to reply logically, because many of the items require coherent answers.
The CIWA-Ar scale has not been validated in complex medical patients, postsurgical patients, and critically ill patients. Therefore, the CIWA-Ar may not be applicable or reliable in critically ill patients, particularly in mechanically ventilated patients, as it relies on patient communication for information regarding nausea, vomiting, anxiety, tactile and auditory disturbances, and headache.
This Tool is used in the assessment of Alcohol Problems
Back To : Alcohol Problems
Back To : Thorny Issues
This is one of several topics presented in the Thorny Issues sector of this toolkit