CIWA scale: how the 10 items are scored and what each score range means for the nurse

The 10 CIWA-Ar items and what the nurse is rating

The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised) was built for research and later adopted at the bedside. ASAM calls it the most well-known and widely adopted withdrawal scale and notes it has shown validity and interrater reliability. The descriptions below are summaries, not the instrument's wording.

Notice how many items depend on the client answering questions honestly and clearly. That design is the root of most of the scale's blind spots, which are covered in the last section of this page.

CIWA score ranges and the nursing action at each band

Add the 10 item scores for a total out of 67. The bands below follow the examples used in the 2020 ASAM guideline. ASAM points out that the scale itself defines no severity ranges, so published cutoffs differ.

Other sources draw the lines elsewhere. AAFP lists 8 or less as absent or very mild, 9 to 14 mild, 15 to 20 moderate and over 20 severe, while the scale's developers suggested different actions under 10, at 10 to 20 and above 20. On an exam, follow the cutoff the question gives you; in practice, follow your facility's protocol.

Worked example: scoring a hypothetical client

Practice case, not a real order set: a client admitted for a hip fracture last drank about 30 hours ago. MSD Manuals places withdrawal seizures in the 6 to 48 hour window, so the timing alone raises the stakes.

The weaker response is to rescore at the next routine vital signs four hours later. A moderate score this deep into the seizure window calls for medication per protocol and reassessment inside the 1 to 4 hour window ASAM gives, or sooner if the protocol says, with seizure precautions in place.

How often the CIWA is reassessed

ASAM recommends reassessing every 1 to 4 hours for 24 hours when withdrawal is moderate or severe or the client needs medication. Once the score has stayed under 10 for 24 hours, monitoring can stretch to every 4 to 8 hours for the next 24 hours.

A client with mild withdrawal and low risk of complications may be observed for up to 36 hours, after which ASAM says more severe withdrawal is unlikely. That does not cover delirium tremens timing in every case: MSD Manuals describes onset 48 to 72 hours after the last drink, so a low early score is not a reason to stop watching.

Where the CIWA score misleads

Scores can run falsely high. ASAM lists fever from infection and withdrawal from another substance as examples, and MDCalc warns that infection, trauma and metabolic problems can mimic or coexist with withdrawal. In a medical or surgical client, ASAM advises trusting a low score more readily than a high one.

Scores can also run falsely low. Beta blockers and other sympatholytic drugs blunt tremor, sweating and tachycardia. Because several items need self-report, the CIWA-Ar is a poor fit for a client who is delirious, critically ill, intubated or unable to communicate; ASAM recommends a scale based on objective signs for those clients. A sedated client scoring 3 is not the same as a calm client scoring 3.

Sources and further reading

ASAM Clinical Practice Guideline on Alcohol Withdrawal Management (2020). Severity examples under 10, 10 to 18 and 19 or more; scale defines no ranges; reassessment every 1 to 4 then 4 to 8 hours; 36-hour observation; false highs and lows, beta blockers, communication limits.

AAFP: Management of Alcohol Withdrawal Syndrome (2013). Alternative bands (8 or less, 9 to 14, 15 to 20, over 20) and clients under 10 usually needing no medication.

MSD Manual Professional Version: Alcohol Toxicity and Withdrawal. Withdrawal timeline: symptoms from about 6 hours, seizures 6 to 48 hours, delirium tremens 48 to 72 hours.

MDCalc: CIWA-Ar for Alcohol Withdrawal. The 10 items, 0 to 7 and 0 to 4 ranges, maximum of 67, and conditions that mimic withdrawal.