Preoperative geriatric assessment and tailored interventions in frail older patients with colorectal cancer: a randomized controlled trial

AIM

Colorectal cancer (CRC) is prevalent in the older population, and surgery is the mainstay of curative treatment. A preoperative geriatric assessment (GA) can identify frail older patients at risk for developing postoperative complications. In this randomized controlled trial we wanted to investigate whether tailored interventions based on a preoperative GA could reduce the frequency of postoperative complications in frail patients operated on for CRC.

METHOD

Patients > 65 years scheduled for elective CRC surgery and fulfilling predefined criteria for frailty were randomized to either a preoperative GA followed by a tailored intervention or care as usual. The primary end-point was Clavien-Dindo Grade II-V postoperative complications. Secondary end-points included complications of any grade, reoperation, length of stay, readmission and survival.

RESULTS

One hundred and twenty-two patients with a mean age of 78.6 years were randomized. We found no statistically significant differences between the intervention group and the control group for Grade II-V complications (68% vs 75%, P = 0.43), reoperation (19% vs 11%, P = 0.24), length of stay (8 days in both groups), readmission (16% vs 6%, P = 0.12) or 30-day survival (4% vs 5%, P = 0.79). Grade I-V complications occurred in 76% of patients in the intervention group compared with 87% in the control group (P = 0.10). In secondary analyses adjusting for prespecified prognostic factors, there was a statistically significant difference in favour of the intervention for reducing the total number of Grade I-V complications (P = 0.05).

CONCLUSION

A preoperative GA and tailored interventions did not reduce the rate of Grade II-V complications, reoperations, readmission or mortality in frail older patients electively operated on for CRC.

Using the Mini-Mental State Examination to screen for delirium in elderly patients with hip fracture

BACKGROUND

The main aim of this paper was to examine the usefulness of the Mini-Mental State Examination (MMSE) for screening delirium in elderly patients with hip fracture.

METHODS

The sample included 364 elderly patients with hip fracture admitted to two hospitals in Oslo. Delirium was assessed by the Confusion Assessment Method (CAM) as an approximation of the gold standard, DSM-IV. To evaluate the psychometric properties of the MMSE scale, we used the Mokken nonparametric latent trait model for unidimensional scaling.

RESULTS

In total, 76 (21%) patients were diagnosed with delirium based on the CAM, and 141 (43%) had preexisting cognitive impairment. As a screening tool, the recommended MMSE cut-point of 24 showed an acceptable sensitivity of 88% with a specificity of 54%. The prediction of delirium, based on logistic regression on the MMSE total score and on the 5 items selected by the stepwise logistic regression procedure, gave clearly less acceptable results.

CONCLUSIONS

Our study indicates that the MMSE may be useful in screening for delirium, but the high percentage of false positives shows that it does not have diagnostic potential in patients with hip fracture.

"Two per cent isn't a lot, but when it comes to death it seems quite a lot anyway": patients' perception of risk and willingness to accept risks associated with thrombolytic drug treatment for acute stroke

BACKGROUND

Thrombolytic drugs to treat an acute ischaemic stroke reduce the risk of death or major disability. The treatment is, however, also associated with an increased risk of potentially fatal intracranial bleeding. This confronts the patient with the dilemma of whether or not to take a risk of a serious side effect in order to increase the likelihood of a favourable outcome.

OBJECTIVE

To explore acute stroke patients' perception of risk and willingness to accept risks associated with thrombolytic drug treatment.

DESIGN

Eleven patients who had been informed about thrombolytic drug treatment and had been through the process of deciding whether or not to participate in a thrombolytic drug trial went through repeated qualitative, semistructured interviews.

RESULTS

Many patients showed a limited perception of the risks connected with thrombolytic drug treatment. Some perceived the risk as not relevant to them and were reluctant to accept that treatment could cause harm. Others seemed to be aware that treatment would mean exposure to risk. The patients' willingness to take a risk also varied substantially. Several statements revealed ambiguity and confusion about being involved in a decision about treatment. The patients' reasoning about risk was put into the context of their health-related experiences and life histories. Several patients wanted the doctor to be responsible for the decisions.

CONCLUSION

Acute stroke patients' difficulties in perceiving and processing information about risk may reduce their ability to be involved in clinical decisions where risks are involved.

TOAST criteria applied in acute ischemic stroke

BACKGROUND

Etiological subclassification of ischemic stroke has become increasingly important, as new therapeutic agents have been introduced. The aim of this study was to assess the inter-rater reliability of the TOAST classification applied in the acute setting, and further to evaluate the criterion validity of the TOAST classification in discriminating between small vessel disease and other etiologies.

METHODS

From June to December 2001, 38 patients with acute ischemic stroke were included in the present study. All were classified according to the TOAST criteria by two junior registrars shortly after admission. Later, a consensus classification was made based on a comprehensive investigation programme.

RESULTS

The inter-rater reliability between the two junior registrars was very good (kappa 0.88). The overall agreement between initial and consensus classifications was fair (kappa 0.30). The TOAST classification discriminated between small vessel disease and other subgroups in most patients (sensitivity 0.93, specificity 0.83).

CONCLUSION

Etiological subclassification of ischemic stroke requires extensive cerebrovascular investigation. Normally, such resources are not available at admission. Nevertheless, the TOAST classification should be used in this setting to help physicians differentiate between small vessel disease and other etiologies of acute stroke, particularly when therapies with possible harmful side effects are considered an option.

Risk factors for serious fall related injury in elderly women living at home

OBJECTIVES

To study whether balance, function, and other health status indicators can predict serious fall related injury in elderly women living at home.

METHODS

In this prospective study, the authors took a random sample of 307 women aged 75 years and over (mean 80.8 years, response rate 74.5%), living in the community. Serious fall injuries which occurred over a period of during one year were recorded, together with baseline registrations of health, function, and tests of walking and balance.

RESULTS

In all, 155 women (50.5%) fell one or more times. One hundred and fifty six (51%) of the 308 falls resulted in a fall related injury, 74 (24%) in a serious fall related injury, and 40 falls (13%) resulted in fractures. The presence of rheumatic disorders, inability to rise from the floor, arthrosis of the hip, having had more than one fall during the one year follow up period, and an increased tendency to sway in the frontal plane when doing a calculation task were independent and significant predictors for serious fall related injury (fractures included). The independent predictors of fall induced fractures were experiencing more than one fall in the follow up period, cognitive impairment, and receiving care from professional or other.

CONCLUSION

The study suggests that rheumatic disorders and the inability to get up from lying on the floor were the strongest independent risk factors for serious fall related injury. Experiencing more than one fall in the follow up period and cognitive impairment are the strongest independent predictors for fall induced fractures. Age was not a significant predictor of serious fall related injury. Assessment of these markers is feasible in a clinical setting and is a useful way of identifying those who are at risk of serious fall related injuries.

Acute phase predictors of subsequent psychosocial burden in carers of elderly stroke patients

The objective was to describe the psychosocial burden experienced by informal carers of elderly stroke victims, and to identify its predictors among baseline characteristics of the patients. From a prospective study of 171 elderly stroke patients admitted to a geriatric ward for rehabilitation in the acute phase, 68 patients living at home with a primary caregiver were identified 6 months after the stroke. At baseline, all the patients were assessed with respect to motor function, cognitive function, global handicap and activities of daily living, and after 6 months the caregivers were assessed, using the Relatives' Stress Scale. According to this, the most frequent impacts were worries that an accident might befall their relatives, that they had to reorganise their household routines and further, that their social life and ability to take holidays had been reduced. Impaired cognitive function was the only baseline patient characteristic that predicted a subsequent psychosocial burden on the carer. Special attention should be paid to elderly stroke patients initially assessed with impaired cognitive function and their caregivers.

Association between impairments, self-care ability and social activities 1 year after stroke

PURPOSE

To explore how motor and cognitive impairments relate to physical activities of daily living (PADL) and social activities after stroke.

METHOD

The data related to 65 patients (mean age 74.4 years, 43% females), assessed 1 year after stroke by means of the Sødring Motor Evaluation of Stroke patients and the Assessment of Stroke and other Brain damage instruments. The self-care and social activities scales applied were the Barthel ADL Index and the Frenchay Activities Index (FAI). The association between impairment variables on the one hand and PADL and FAI scores on the other was estimated using Kendall rank correlations.

RESULTS

Arm motor function correlated most strongly with the Barthel score (tau = 0.76), and visuospatial function came second (tau = 0.58). Factor analysis of the FAI produced three subscales: a 'domestic' factor most strongly related to arm motor function (tau = 0.49); 'outdoor' related to visuospatial ability (tau = 0.48); and 'hobby' which had no significant correlates.

CONCLUSION

In the chronic phase of stroke, self-care and involvement in social activities relate most strongly to arm motor function and visuospatial ability. Outdoor activities depend mainly on visuospatial function.

Stroke and gender

The literature regarding gender-specific aspects of cerebrovascular diseases is quite sparse. It is well-documented that the incidence of stroke is higher in men than in women in all age classes, and women are, on average, several years older than men when they suffer their first stroke. The prevalence of stroke is higher among men up to the age of approximately 80 years, after which it becomes higher in women. A majority of studies indicate that the case-fatality rate is higher in female than in male stroke patients; there is also some evidence, albeit relatively weak, indicating a better functional outcome in men. Gender differences in risk factor profile and treatment response appear to be weak. The burden of providing informal care to stroke patients seems to constitute a threat to the mental health of the caregivers, who are predominantly women.

How does a cerebral stroke affect quality of life? Towards an adequate theoretical account

PURPOSE

To contribute, through a hypothesis-generating, qualitative study, to a consistent theoretical account of the mechanisms by which strokes affect the quality of lives of patients.

METHOD

A strategic subsample of six persons (65-85 years) was drawn from a larger sample of 60 stroke patients 3 years after stroke. They suffered from some, mostly mild, motor or cognitive impairments, and underwent a semi-structured interview, which was tape-recorded, transcribed and analysed.

RESULTS AND CONCLUSION

Only one of the subjects had any familiarity with the QoL concept. When it was rephrased in familiar terms, all but one stated that their QoL had been reduced after the stroke. All the subjects reported considerable bodily changes. The reduced QoL was not, however interpreted as a direct consequence of these, but as a result of the individual's interpretation and evaluation of the changes. It was essential whether the patient compared the present situation to life prior to the stroke, or to a post-stroke reference point. These personal evaluations interacted with the interpretations of the situation by the patients' significant others.

Validation of the screening instrument for neuropsychological impairment in stroke

BACKGROUND AND PURPOSE

Full neuropsychological assessment is time-consuming and exhausting for the patient in the early phase of stroke. The screening instrument for neuropsychological impairment in stroke (SINS) is a brief, bedside-applicable instrument designed to screen perceptual and cognitive dysfunction related to functional activities in stroke. It has been developed by physiotherapists to be incorporated in the general assessment of the patient. This study evaluates the validity of the method against a more extensive reference method assessing cognitive function.

METHODS AND RESULTS

An unselected group of hospitalized stroke patients (N = 87) was assessed 10 days and 12 months after stroke. Factor analyses (52% explained variance), identified three factors: 'aphasia', 'apraxia' and 'visuocognitive dysfunction'. Receiver operating characteristics (ROC) curves demonstrated that for all factors, high specificity was maintained at the high sensitivity needed for a screening method. Kendall rank correlation coefficients between the scorings on the new instrument and the reference method were high. Effect size analysis showed that the ability of the new instrument to detect change in cognitive functioning during the first year was of the same magnitude as the reference method.

CONCLUSIONS

SINS has a high sensitivity regarding cognitive dysfunction, as diagnosed by the more comprehensive and time-consuming reference method. The instrument would be useful as an initial step in the assessment of neuropsychological impairment in stroke patients.

[Use of antipsychotic drugs in a long-term care institution. Experiences with implementing clinical guidelines]

Anti-psychotic drugs (neuroleptics) are useful for treating psychoses. However, non-psychotic patients, particularly patients with a deviant behaviour pattern, are often also treated with anti-psychotic drugs. The drugs may induce serious side-effects and should only be used on strict indications and at the lowest possible dosage. In a nursing home for deaf people with additional handicaps we introduced clinical guidelines for the use of anti-psychotic drugs and recorded their use during a two-year period. We found there was a reduction in the number of patients taking anti-psychotic drugs (from 32/54 to 26/54, p = 0.03), as well as a decrease in dosage per user (from median 2.4 mg to 1.7 mg equivalents of haloperidol, p = 0.05). Both the number of patients who were given depot injections and the number of different anti-psychotic drugs per patient were reduced. We conclude that it is possible to reduce the use of anti-psychotic drugs in institutions where long-term care is provided for disabled people.

Correlates of subjective well-being in stroke patients

BACKGROUND AND PURPOSE

Data on survival and functioning after stroke needs to be supplemented by measures emphasizing the patients' subjective perception. We studied (1) subjective well-being (SWB) as a latent variable in a common-factor model with four items, (2) the reliability of these four items, and (3) variables related to SWB in stroke patients.

METHODS

Data on all stroke patients (n=1417) and a random subsample of stroke-free individuals of similar age (n=1439) were collected from the Nord-Trøndelag Health Survey, a cross-sectional study of 74977 persons. Based on a two-sample factor analysis model, scores of SWB were calculated, and variables explaining SWB were studied in a regression model.

RESULTS

Four items were a priori believed to measure SWB as a latent variable ("satisfaction," "strength," "calmness," and "cheerfulness"). This was confirmed by factor analysis. The reliability of these items (the proportion of the variance of the items that can be explained by the common factor) was between .42 and .53. Regression analyses showed a significant effect of having had a stroke, gender (lower SWB in men), age (increasing SWB with increasing age), perceived general health, nervousness, loneliness, sleep problems, social support, and use of analgesics. There was no statistical interaction between these variables and having had a stroke.

CONCLUSIONS

Higher SWB after stroke relates to female gender, older age, good general and mental health, and a firm social network.

Disability models in geriatrics: comprehensive rather than competing models should be promoted

The usefulness of different models of disability is discussed. There is no clear-cut demarcation between ability and disability, and a person's functional abilities are highly dependent on societal as well as individual factors. One should not, however, promote models of disability that cover only the social aspects, but rather try to build comprehensive models including medical, psychological and social aspects of disability. The World Health Organization's International Classification of Impairments, Disabilities and Handicaps (ICIDH) provides a useful basis for such model building. The main weakness of the ICIDH is that it fails to take the subjective perceptions of the individual fully into account. Accordingly, it should be supplemented by some model of subjective well-being. Possible relationships between subjective well-being and the ICIDH concepts are discussed.

Are there gender differences in functional outcome after stroke?

PURPOSE

To study gender differences in functional outcome unexpectedly observed in a follow-up study of stroke patients.

DESIGN

Prospective study of hospitalized stroke patients, with evaluations in the subacute phase and after one year.

SETTING

Geriatric and general medical wards, and geriatric outpatient clinic of a university hospital serving as general hospital for a defined population.

SUBJECTS

All stroke patients admitted during a six-month period (n = 165) were considered for inclusion, of whom 87 could be assessed in the subacute phase and 65 after one year.

MAIN OUTCOME MEASURES

Motor function assessed by the Sødring Motor Evaluation of Stroke Patients; cognitive function by the Assessment of Stroke and other Brain Damage; and activities of daily living (ADL) function by the Barthel Index. Nursing-home residency registered after one year.

RESULTS

Men achieved a significantly better score than women on most of the scales used. The age-adjusted odds for a man to have a higher Barthel score than a woman was 3.1 (95% confidence interval (CI) 1.3-7.0) in the subacute phase and 3.3 (95% CI 1.2-9.0) after one year. Differences of the same magnitude were seen on the subscales of the motor and cognitive tests. The same trend was observed on all items of the Barthel Index. The males had a lower likelihood to be permanent nursing-home residents after one year, the age-adjusted odds ratio for nursing-home residency for females versus males being 6.3 (95% CI 1.2-65.3).

CONCLUSION

Women seem to be functionally more impaired by stroke than men.

Subjective well-being one year after stroke

OBJECTIVE

To compare the subjective well-being of stroke patients with that of a reference group, and to study its relationship to patient characteristics.

DESIGN

Cross-sectional study.

SETTING

Interviews performed in the respondents' homes, tests performed at the outpatient clinic.

SUBJECTS

Sixty patients one year after stroke (median age 74 years, interquartile range (IQR) 68-80), and 419 reference individuals (median age 75 years, IQR 71-80).

MEASURES

Subjective well-being assessed with the General Health Questionnaire (GHQ-20). Explanatory variables were demographic and medical characteristics of the individuals and scores on validated tests: Barthel Index, Frenchay Activities Index (FAI), Sødring Motor Evaluation of Stroke Patients, Assessment of Cerebral Stroke and other Brain Damage, and Mini-Mental State Examination (MMSE).

RESULTS

A significantly higher proportion of the stroke patients than of the controls rated their subjective well-being as low, also after adjustment for age and gender (adjusted odds ratio 20.1, 95% confidence interval 9.6-42.0 by logistic regression). In bivariate analyses, leg and arm motor impairment, visuospatial impairment, apraxia, aphasia, low Barthel score, low FAI score, low MMSE score, and institutionalization were highly significant predictors of low subjective well-being (p-values < 0.01). In multiple linear regression, a model with gender (p = 0.3) and upper extremity motor score (p < 0.01) fitted the data well, and explained 48% of the variance in GHQ.

CONCLUSION

Subjective well-being is decreased one year after stroke, and this is mainly attributed to arm motor impairments.

Predictive validity of the Sødring Motor Evaluation of Stroke Patients (SMES)

The Sødring Motor Evaluation of Stroke Patients (SMES) has been developed as an instrument for the evaluation by physiotherapists of motor function and activities in stroke patients. The predictive validity of the instrument was studied in a consecutive sample of 93 acute stroke patients, assessed in the acute phase and after one year. The outcome measures were: survival, residence at home or in institution, the Barthel ADL index (dichotomized at 19/20), and the Frenchay Activities Index (FAI) (dichotomized at 9/10). The SMES, scored in the acute phase, demonstrated a marginally significant predictive power regarding survival, but was a highly significant predictor regarding the other outcomes. The adjusted odds ratio for a good versus a poor outcome for patients in the upper versus the lower tertile of the SMES arm subscore was 5.4 (95% confidence interval 0.9-59) for survival, 11.5 (2.1-88) for living at home, 86.3 (11-infinity) for a high Barthel score, and 31.4 (5.2-288) for a high FAI score. We conclude that SMES has high predictive validity.

The Frenchay Activities Index in stroke patients: agreement between scores by patients and by relatives

The aim of the study was to compare stroke patients' own scorings of the Frenchay Activities Index with scorings based on interviews with their nearest relatives. Fifty-two patients and relatives were interviewed separately 1 year after the stroke. The mean sumscore based upon information from the patients was 29.0, and that based upon the relatives' replies was 27.7 (mean difference 1.4, 95% confidence interval (CI) -0.1 to 2.8). The Kendall tau B correlation between the two sumscores was 0.72 (95% CI 0.63 to 0.81). In half of the patients the two sumscores differed by four points or more, and in every fourth the two sumscores differed by six points or more. The weighted kappa for the single items varied between 0.36 and 0.89. No characteristics of patients or relatives were identified that were related to disagreement between the two scores.

[Treatment of hyperactivity and attention deficit with amphetamine. Experience with five adult prisoners]

Attention deficit hyperactivity disorder (ADHD) is a fairly common syndrome within child psychiatry. Stimulant medication is an important part of the treatment of the disorder. According to the literature, 30-50% of children with ADHD will still suffer from symptoms when they reach adulthood. The syndrome is a risk factor for various psychiatric disorders, drug and alcohol abuse, and criminality. There is some evidence that even adult patients may benefit from stimulant medication. ADHD was diagnosed and stimulant medication was started in five adult men who had been imprisoned for serious crimes of violence. The response to treatment was good in all of them. After 4-6 years two had been successfully rehabilitated.

Description and validation of a test of motor function and activities in stroke patients. The Sødring Motor Evaluation of Stroke Patients

A new method (The Sødring Motor Evaluation of Stroke Patients) has been developed for physiotherapists to evaluate motor function and activities in stroke patients. Its main characteristics are the assessment of motor activity without assisting the patient, and the use of a rating which reflects quantity as well as quality in motor performance. A hospitalised group of stroke patients (n = 93) was assessed three times after the acute event, by means of SMES. The data were analysed regarding construct validity as well as concurrent validity against another assessment method. Factor analyses showed a reasonably stable three-factor pattern ("arm", "gross motor function", and "leg") which explained 84, 89 and 90%, respectively, of the variance at the three study points, with Factor 1 ("arm") as the dominant factor. The ordinality of the rating scale was assessed by means of linear regression analysis and found to be acceptable. The correlation coefficients were high between comparable parts of the new and the reference methods.

The Barthel ADL index: factor structure depends upon the category of patient

The validity and reliability of the Barthel index were studied in 60 geriatric patients, 87 stroke patients, and 102 patients with hip fracture, using a factor analysis methodology which explicitly accounts for the ordinal nature of the scoring on each item. The findings substantiate that the Barthel index is unidimensional among stroke patients, but not among geriatric patients or patients with hip fracture. In the latter two groups, one factor related to mobility, the other to bodily functions. A sum-score to characterize geriatric and hip fracture patients does not take into account the complex structure of the Barthel index.

The Barthel ADL index one year after stroke: comparison between relatives' and occupational therapist's scores

The activities of daily living of 54 patients 1 year after stroke were rated with the Barthel Index by an occupational therapist (OT). A physician independently rated the same patients from interviews with their nearest relative. The mean sum-score obtained by the doctor was 16.7, while the mean sum-score obtained by the OT was 17.1. In more than 80% of the patients, the difference in sum-score was two points or less, which was considered to reflect acceptable agreement. Weighted kappa values of each item varied between 0.42 and 0.92, indicating moderate agreement for the items 'grooming' and 'bladder' and good or very good agreement for the other items. There was a statistically significant bias in the bladder item; the doctor's score being lower than that of the OT. The other items showed no significant bias. The probability of disagreement between the two raters increased with the patient's age; no other factors were found to be related to disagreement.

[Rehabilitation of stroke patients--does it have an effect?]

A search of the literature was carried out in order to identify controlled trials to study the effect of rehabilitation after a stroke. A limited number of studies have been published, and many are of poor quality. Making the organization of rehabilitation more efficient, emphasizing early start of rehabilitation, and close cooperation between the involved health professionals and an improvement of their competence have the best documented effect on mortality and on the percentage of patients who return home. There is also evidence that retraining of motor function and of language skills is effective. Rehabilitation seems to lead to more rapid recovery and a better result overtime. However, the achieved functional level may decline when the rehabilitational efforts are scaled down. The effect of rehabilitation on sensory and cognitive functioning is poorly documented.

Lifestyle factors and risk of cerebral infarction

BACKGROUND AND PURPOSE

We evaluated the impact of lifestyle factors on the risk of ischemic stroke.

METHODS

We used a nested case-control design. The cases comprised 163 persons (median age 69 years) admitted to a stroke unit and diagnosed with acute cerebral infarction. All cases had earlier participated in the North Trøndelag Health Survey. The controls comprised 567 participants from the North Trøndelag Health Survey, matched by sex and year of birth.

RESULTS

Raised systolic (p less than 0.001) and diastolic (p = 0.02) blood pressure, antihypertensive treatment (p less than 0.001), previous myocardial infarction (p less than 0.001), prior stroke (p = 0.002), diabetes (p less than 0.001), and former daily smoking (p = 0.02) were identified as significant risk factors by univariate conditional logistic regression. No difference in risk was detected at different levels of alcohol consumption, salt intake, physical activity, or body mass index. Current smokers had virtually the same risk as nonsmokers. No association was found between stroke and the number of cigarettes smoked per day or the number of years of smoking. Multivariate conditional logistic regression identified diabetes (p = 0.002), raised systolic blood pressure (p less than 0.001), and former daily smoking (p = 0.01) as significant and independent risk factors. Previous myocardial infarction (p = 0.07), previous stroke (p = 0.1), and current daily smoking (p = 0.1) were of marginal significance.

CONCLUSIONS

The established medical risk factors for stroke are confirmed. With the possible exception of smoking, we have not identified any lifestyle factor with a significant impact on the risk of ischemic stroke.

[Dependence on carisoprodol (Somadril)? A prospective withdrawal study among prisoners]

Carisoprodol (Somadril) was gradually withdrawn for a fortnight in nine male prisoners who had been taking daily doses of from 700 to 2,100 mg for at least nine months. The patients were assessed clinically during the withdrawal period, with special attention to the occurrence of abstinence symptoms. Most of the patients reported mental distress, such as anxiety, insomnia and irritability. Cranial and muscular pain and vegetative symptoms were also frequently reported. Most of these symptoms were transient, and no seizures or psychotic reactions occurred. Our information from drug addicts indicates that carisoprodol can be misused as a narcotic. The occurrence of abstinence symptoms during withdrawal supports this supposition. We propose a more gradual reduction of the doses when terminating medication with carisoprodol in general practice.