A Psychometric Analysis of CIWA-Ar in Acutely Ill and Injured Hospitalized Patients

Abstract

Alcohol withdrawal syndrome (AWS) manifests after alcohol-dependent individuals suddenly cease alcohol consumption. Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar) is a widely used tool to assess and guide treatment of AWS. CIWA-Ar was developed in voluntarily detoxification centers, and the reliability and validity of CIWA-Ar have been minimally evaluated in hospitalized patients. We performed a retrospective chart review of 479 cases of screening and treatment of AWS using CIWA-Ar, of which 118 were admitted to a trauma/orthopedic (T/O) service and 361 to an internal medicine (IM) service. Exploratory factor analyses with varimax rotation were applied for each population, and reliability testing was performed on the determined subscales. Exploratory factor analyses yielded 2 unique structures, each explaining 56% of the variance of CIWA-Ar. The IM group had a 3-factor structure with the Physical Disturbances (23%), Anxiety (19%), and Confusion (14%) subscales. The T/O group had a 2-factor structure with the Neurological Disturbances (36%) and Physical Disturbances (20%) subscales. Overall, Cronbach's alphas were acceptable (0.74 and 0.82 for IM and T/O, respectively); however, Cronbach's alphas for the IM subscales were 0.66 and 0.69 for physical disturbances and anxiety, respectively. Cronbach's alpha for the Confusion subscale was not calculated because only 1 scale item loaded. The subscales of the T/O factor structure yielded Cronbach's alphas of 0.81 for neurological disturbances and 0.62 for physical disturbances. Our analyses did not support the reliability or validity of CIWA-Ar in acutely ill or injured patients, warranting further investigation and tool development for AWS management in the hospital setting.

Can the alcohol withdrawal scale be applied to post‐operative patients?

“…The internal validity of the test has also been called into question in the setting of acute trauma and internal medicine inpatients. 19 This study indicates that a significant number of patients would meet the criteria for diagnosis and treatment of AWS postoperatively due to physiological responses unrelated to alcohol withdrawal. These findings were not limited to patients with sepsis, and occurred after both elective and emergency operations.…”

“…Indeed, it would appear that the greatest potential from harm with the CIWA‐Ar may be the cognitive bias it can create. The internal validity of the test has also been called into question in the setting of acute trauma and internal medicine inpatients 19 …”

Phenobarbital Monotherapy for the Management of Alcohol Withdrawal Syndrome in Surgical-Trauma Patients

“…10,54 This is often seen in critically ill patients with neurological etiology where both CIWA and MINDS scoring scales have not yet been validated, similar to the trauma patients included in this case series. 55 An advantage of using a fixed-dose regimen is the decrease in frequent assessment and nursing burden. Even though the early discontinuation of the phenobarbital maintenance regimen was recommended based on patient clinical response, the median duration of use of the maintenance taper regimen in this case series was around 5 days, suggesting that patients still required phenobarbital to maintain the levels achieved with the LD.…”

A Comparison Study of Impulsiveness, Cognitive Function, and P300 Components Between Gamma-Hydroxybutyrate and Heroin-Addicted Patients: Preliminary Findings

“…Clinicians score each item on a Likert scale, and the maximum score is 67. The higher the score, the more severe the alcohol withdrawal syndrome (Higgins et al, 2019 ). CIWA-Ar scores of 0–8, 9–15, and 16 or more indicate mild, moderate, and severe withdrawal syndromes, respectively (Mayo-Smith, 1997 ).…”