Criteria

Clinical Institute Withdrawal Assessment for Alcohol scale, revised version (CIWA-Ar)[76] CIWA-Ar Opens in new window

The revised scale is a validated tool for monitoring alcohol withdrawal syndrome (AWS) and to assess alcohol withdrawal severity. CIWA-Ar can help guide pharmacologic therapy during the treatment phase.[6] It is used in hospital settings (medical and surgical units) as well as in psychiatric floors.[1][76]

Scores are based on 10 items, with a total point system ranging between 0 and 67.

It is important to note that high scores may be observed in patients with various nonalcohol-related pathologies that produce delirium (such as pneumonia). Although the scale’s reliability and validity have been reported in literature, there are no data concerning specificity. The original study population was without concurrent illness, and, while many patients develop AWS subsequent to voluntary cessation of alcohol intake, others have acute or chronic medical problems that prevent alcohol consumption. Additionally, there may be variations in calculated CIWA-Ar scores due to the number of questions that require a subjective response and/or differences in attitudes and beliefs between ethnic groups and cultures.[77]

Compared with a CIWA-Ar-based protocol using fixed benzodiazepine dosing in critically ill patients, a symptom-triggered benzodiazepine protocol employing the Riker Sedation Agitation Scale (SAS) was associated with a reduction in duration of AWS treatment; length of intensive care and length of hospital stay; need for mechanical ventilation; and benzodiazepine exposure.[78] CIWA-Ar is reliant upon patient cooperation and communication and may, therefore, be difficult to administer in the intensive care unit setting.[78] One systematic review assessed management strategies for alcohol withdrawal and alcohol withdrawal delirium in critically ill patients and found that aggressive, symptom-guided titration of medications is associated with improved treatment outcome, and it proposed use of SAS scoring for symptom severity in situations where CIWA-Ar cannot be accurately performed.[79]

Prediction of Alcohol Withdrawal Severity Scale (PAWSS) PAWSS Opens in new window

This is a risk assessment tool that was developed to identify hospitalized patients who are at risk of developing complicated AWS. The purpose of PAWSS is not to diagnose or determine the severity of the AWS, but to identify at-risk populations who may benefit from prophylactic therapy to prevent the development of severe AWS and its sequelae.[5][49] This scale was developed from data obtained from a systematic review of available literature. 

A small pilot study conducted by the developers of the scale showed that PAWSS had 100% sensitivity, specificity, negative predictive, and positive predictive values.[49] Similar findings were shown in a larger prospective study with sensitivity and specificity of 93.1% and 99.5%, respectively.[80] A recent systematic review evaluating the predictive utility of clinical signs and symptoms of AWS concluded that PAWSS was most useful in identifying high-risk patients.[50]

Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for AWS[73]

A. Cessation of or reduction in alcohol intake, which has previously been prolonged/heavy.

B. Criterion A, plus any 2 of the following symptoms developing within several hours to a few days:

  • Autonomic hyperactivity

  • Worsening tremor

  • Insomnia

  • Vomiting and nausea

  • Hallucinations or illusions, visual, tactile, or auditory

  • Psychomotor agitation

  • Anxiety

  • Generalized tonic-clonic seizures.

C. The above symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The above symptoms are not attributable to other causes; for example, another mental disorder, intoxication, or withdrawal from another substance.

Specify if - with perceptual disturbances - hallucinations (usually visual or tactile) occur with intact reality testing, or if auditory, visual, or tactile illusions occur in the absence of a delirium.

DSM-5 diagnostic criteria for alcohol withdrawal delirium[73]

A. Decreased attention and awareness.

B. Disturbance in attention and awareness developed over a short period of time and represents a change from the normal level, fluctuating in severity during the day.

C. An additional disturbance in memory, orientation, language, visuospatial ability, or perception.

D. No evidence of coma or other evolving neurocognitive disorder that could account for the disturbances described in criteria A and C.

E. History indicates that the disturbance is attributable to alcohol withdrawal.

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