Recently our family was reminded that medications do not act the same way on everyone, and a drug appropriate for some may not be appropriate for all.  My elderly mother was experiencing a bout of insomnia.  She requested Benadryl to help her sleep.  The nurse helping care for her checked with the Doctor and relayed his recommendation against it.  Initially we were puzzled by this, knowing Benadryl is available over the counter.  Additionally, because my sister-in-law is a nurse, she knew that the active ingredient in Benadryl, diphenhydramine, is also the sleep-inducing agent in Sominex and other over-the-counter sleeping pills.  We were very curious why the Doctor would recommend against something we presumed was “safe”.

Some internet research lead to us confirm the doctors recommendation helped us learn a little about advances in geriatric medicine.  Specifically, the Beers List, which is not a menu of what’s on tap or something served with a nice Bavarian pretzel, but rather a list of potentially inappropriate and high-risk drugs for older adults.  It was originally created in 1991 by Dr. Mark Beer and colleagues.  The list was updated most recently in 2012 by the American Geriatric Society.  Drugs can land on the list for several reasons.  Some have a strong link to poor patient outcomes, some have limited effectiveness in older patients, some may be associated with serious problems like delirium, gastrointestinal bleeding, falls, and fracture, and some are on the list because a safer non-pharmacological alternative exists.Watch Full Movie Online Streaming Online and Download

Avoiding the use of inappropriate and high-risk drugs is an important, simple, and effective strategy in reducing medication-related problems and adverse drug events in older adults. [1]

So, back to Mom.  Yes, diphenhydramine is on the Beers List, because of the potential side effects and because safer medications are available.  The recommendation is to avoid, except possibly in special situations such as for treating severe allergic reactions. Here’s the relevant excerpt from the list:

Excerpt from Beers Criteria
So, if Benedryl is out, how do you help Mom get to sleep?  Chamomile tea is one idea.  Or some other ideas are here: Assisting Seniors With Insomnia: A Comprehensive Approach 

Until next time,

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Watch Movie Online Logan (2017)


Drug company advertisements often end with the phrase “Ask your Doctor about…” followed by the newest drug being promoted. While surely they mean to ask if the new drug is right for you to start taking, I suggest a different question to ask your Doctor.

“Of all the drugs prescribed for me, which one is most important for me to take correctly?”

If you, or a person you care for, are struggling to manage a complicated drug regime, you may unknowingly be prioritizing a less important drug over one more critical to your overall health. If you are struggling to take all the medications as prescribed, talk to your doctor about breaking the regime into smaller parts and focusing your energy first on the most important drug or drugs. In the big picture of things, your heart medicine may be much more important than the anti-fungal used to combat toe fungus, so you should focus first on taking your heart medication as prescribed.

Do you know your most important condition and which drug(s) you are taking for it? And the next most important condition? And the one after that? Or do you know which medication is the least likely to have a negative impact if not focused on in the near term? If you don’t know the answers to these questions then ask your doctor.

You should have the conversation with a General Practitioner, or someone who looks at your situation as a whole and knows the full extent of your drug regime. It’s a good idea to bring your list of medications with you. If you don’t already have a list, you can use our spreadsheet template.

Your goal is to get a priority order list of medications given current conditions so you can develop good habits around the most important medications first and then build from there. I’ll talk more about habit formation in another post, but as a preview, it’s about building upon success.

Let’s take the case of Adele to illustrate what I’m talking about. She takes 10 medications 4 different times throughout the day. Currently she is having trouble remembering to take her diabetes meds and her daily blood sugar numbers are elevated. Her multivitamin, calcium, and fish oil are not currently as important in the overall picture. So attention and habit formation for Adele should focus on taking her diabetes medication.

Adele always remembers her morning medications, but sometimes misses the evening dose. She should ask her doctor if she can take her most important medication for her diabetes in the morning when it is less likely to be missed.

Breaking your whole medication regime into parts may be a good first step to building a sustained medication-taking habit. Knowing where to start to have the best impact on your health is key. Ask your doctor about how to prioritize your medications on your next visit.

In Health,


NightingaleRx Founder Speaking at IEEE CNSV

by Mary S on September 26, 2013

NightingaleRx is pleased to announce that Mary Sorber, Founder, is speaking at the IEEE-CNSV (Consultant’s Network of Silcon Valley).

Mary will review the scope of the polypharmacy problem with a focus on chronic conditions in the elderly. She will also review six solutions and their impact, differences between clinical and home settings, and user interface implications.

If you’re in the South Bay area on Tue, Oct 1st please drop by and listen.  The event is free and open to the public.   Details.

UPDATE 10/2/13: We had a great turnout and a lively discussion.  Here are slides and audio from the talk:


Habits in Moderation

by Mary S on July 27, 2013

When do habits work against us?  When they substitute for thoughtful action.  In a blog post Identifying medications by storage location is risky Michael Cohen shared how habitual behavior might lead to medication errors.  The story involves a diabetic man who has two different insulin products, both stored in different places in the fridge.  One day when his wife cleaned the fridge, she accidently switched their location.  Unaware of the switch, the man took a dose of the wrong medication!

Relying totally on where a medicine is stored is risky and can lead to an error. Reading the label each and every time, however simple that sounds, is important. Perhaps storing the medicines in containers with ‘long-acting’ and ‘rapid-acting’ stickers could help differentiate the products. However, diabetics who have vision problems may not be able to read labels or stickers well. In these cases, some people have wrapped adhesive tape or rubber bands around the rapid-acting insulin vial so that they can feel the vial and recognize the correct product.

I love the rubber band idea!  Engaging another sense is subtle but helpful.  Placing stickers on medication bottles is another great idea.  You can use stickers to remind of the proper dosage, distinguish His from Hers, or organize colors by time of day.  You can purchase stickers at any office supply store or see a selection of Avery stickers online.

Until Next Time,



HTF Innovation Conference 2013 BannerAs part of watching industry trends, I recently attended the Health Technology Forum Innovation Conference in San Francisco.  Here are a few interesting take-aways from Patient Engagement for Care Improvement session:

  • Patient engagement is the juggernaut for fixing a broken healthcare industry.
  • System change starts with attitudinal change.
  • Social support should be job number one.  In the current delivery model human needs are significantly underappreciated.  “Information therapy” could be part of the prescription.   (Amy Tenderich, Editor-in-Chief,
  • People don’t respond to managing their health, they respond to managing their self-image.  (Kyra Bobinet, MD, MPH, Behavior Design, Stanford University)
  • Panelists Laura Esserman, MD MBA, UCSF School of Medicine and Jan Oldenburg, VP, Aetna discussed care improvement, including the growth of accountable care organizations.

The moderate, Neil Versel, HIT Journalist, Universal Media, has more detailed coverage on the session in his own article.

My overall sense was there are passionate and dedicated folks actively working on change.  Quite wonderful!

Until Next Time,


Disposing of Medications

by Mary S on October 14, 2012

NightingaleRx is proud to lend its support to SMARxT Disposal, a nationwide public awareness campaign to educate people about how to dispose of medicines in a safe and environmentally protective manner.

The key point to know is that it is no longer recommended to flush or pour most expired, unwanted, or unused medications down the drain.  This is a complete reversal of the advice that I, for one, learned growing up.  Flushing was the norm, but it is no longer recommended because of potential harm to wildlife, pets, the water supply, and other people.

For answers to some common questions about the change in advice, visit the SMARxT site here.

So, what should you do if you have old prescriptions to get rid of?  Here are some options:

  • Keep your eye out for periodic drug take back events sponsored by the Drug Enforcement Agency or your local community.  In a recent drug take-back event, the DEA collected 244 tons of prescription medications from the public.  You can Google “drug disposal event” or “prescription take back” with your city name.
  • Many communities have an ongoing household hazardous waste disposal programs.  While I personally haven’t done this for prescriptions, I did get rid of unused paint this way.  After calling for an appointment on a Saturday morning, I drove to the designated drop off spot.  There I was met be people in HazMat suits, which really reinforced for me the toxins we deal with daily.  Google “household hazardous waste” with your city name to locate your own program.
  • Walgreens Safe Drug Disposal Program at Walgreenspharmacy has a Safe Medication Disposal Program.  You can purchase a prepaid envelope called Take Away at pharmacies nationwide.  It was $3.99 at my local Walgreens and I found it hanging in the section with the pill boxes.  You fill the envelope with your unwanted medications, and just drop it in the mail.  They take care of the rest, incinerating the unopened envelopes.  We had a little challenge fitting the stuffed envelope thru a small mail slot, but other than that it was super simple.

We hope you will use one of these newer methods to dispose of expired, unused or unwanted medications.

Until Next Time,


Dr. Demetra Antimisiaris on Medication Management

by Mary S on September 11, 2012

NightingaleRx had the pleasure of talking recently to Demetra E. Antimisiaris, PharmD, of the University of Louisville Geriatrics Polypharmacy Initiative. We’ll be sharing several posts about what we learned from her, starting with a recent interview she did for Kentucky Educational Television on How to Recognize Side Effects of Over Medication. You can watch the video, or read our notes below with tips for patients and caregivers.

* Healthcare system hasn’t set up a mechanism for overall medication management. Medicare doesn’t pay for medication management. It’s not ideal that personal responsibility is required, but until the system changes, individuals need to do their own advocacy. There is a rising awareness that we can’t have good outcomes without a handle of the whole picture of medications.

TIP: Get involved in the medication management process. Get comfortable asking questions of your doctor. A good question to start with is “What side effects should I be watching for?”

* There is no set number of medications that is too many or too few. The key is to recognize side effects of medication. The hallmark of medication related side effects are non-specific complaints. “My head (or my muscles, or my stomach) hurts”

TIP: Talk to your doctor about changes and pain, even if you can’t pinpoint a reason.

* Allergic reactions happen right away. In longer acting drugs, symptoms take a corresponding longer time to appear. Symptoms can appear days to weeks after beginning a medication.

* Signs of medicine-related problems include: agitation, maniac behavior, confusion, loss of appetite, trouble sleeping, and falls.

* Sometimes antibiotics or other short-term drugs have adverse reactions with long-term medications for chronic disease management.

TIP: Keep a log when you begin a new medication or stop an old one. Review the log with your doctor.

TIP: Be alert to changes in your health and note them in your log. Don’t attribute symptoms to “natural aging process” before discussing with your doctor.

* There are more medications today. The Physicians Desk Reference (a book with drug information published by the drug manufacturers) has grown from 1,500 pages in 1969 to 3800 pages today.

TIP: If you’re elderly and having trouble keeping a log or you have vision problems that prevent you from seeing the writing on the labels, seek help. Your family may able to setup medications each week; your doctor can arrange home health care for you.

* Healthcare providers don’t always communicate with each other about you. Your family doctor might not have accurate information on current medications if you’ve been hospitalized recently and they changed up your medications. If the doctor doesn’t know what you’re taking s/he could make decisions with incorrect assumptions.

TIP: Review your current medication list with your doctor on every visit.

TIP: Keep an up-to-date list of meds in your purse or wallet in case of emergency

TIP: At least annually, bring all everything you take in a bag to the doctor. Include prescription medications, supplements, over-the-counter items (including antacids), and vitamins.

We hope you find these helpful.

Until Next Time,


I was back home recently and had the opportunity to review my Mother’s medication routine with her and my brother.  We noticed that Mom was being prescribed Plavix to help prevent clotting, strokes and heart attacks. My brother, reading up on the drug, found that Plavix can be rendered much less effective when taken with Prilosec, a drug to reduce stomach acid.  The FDA warned against taking Plavix and Prilosec in 2009, and again 2010.  We had that in mind as we looked through the rest of Mom’s medications.  She wasn’t taking Prilosec so that didn’t look to be a problem.

Later in the day, I was at the computer updating Mom’s master list of drugs when I saw a recent addition to her drug regime called Omeprazole which was prescribed by one of her other doctors.  When I looked it up online, I found that it was a generic form of Prilosec! A quick round of calls to the doctor’s office to discuss the drugs she was taking led to the doctor taking Mom off Plavix.

This story has a happy and benign ending.  Mom didn’t have any adverse reactions to the drugs. But it could have easily gone another way.  The cause here was two different doctors treating Mom for two different issues and both prescribing drugs which may or may not interact with each other.  The doctors weren’t talking to each other, and the drug regime wasn’t coordinated.  It brings home the importance of having a medical professional review the whole landscape of drugs being taken to ensure that there are no adverse interactions. (I blogged about medication reviews last month.)  In addition, it’s good to keep track of both the generic and brand names of the medications so you recognize what’s relevant to you no matter how they’re mentioned.

Until Next Time,



Ask for a Medication Review

by Mary S on July 24, 2012

I recently learned of a helpful service for available at some pharmacies.  Medication Therapy Management is the formal name, but you can informally ask the pharmacist to review *all* of your loved ones current medications.  I emphasize all because a big part of the benefit is having a trained professional review everything you loved one is taking, even if the meds were prescribed by different doctors, filled at different pharmacies, or include over the counter items or herbal supplements.  With the complete picture, a pharmacist can look for duplications and things that should not be taken together.  They may be able to suggest lower cost generics.  And with some additional information about your age and health conditions, they might spot medications you no longer need.

A medication review will be easier if you bring the pharmacist a simple spreadsheet.  You can use our spreadsheet template or create your own.  Be sure to include:

  • Drug Name
  • When Prescribed
  • Who Prescribed
  • Why Prescribed
  • Dosage and Frequency

You can also bring the bag of pill bottles to double check, but an accurate, consolidated list is easier for the pharmacist to review quickly.  If you take the time to document your loved ones pills beforehand, you’ll get a higher quality analysis and make the most of a short consultation.

So any time your loved one starts a new medication, consider a visit to your local pharmacy for a medication review, and bring along a spreadsheet.

Until Next Time,


Thanks to Michelle Lam, Doctor of Pharmacy, BumpMD and Khoi Lam, Doctor of Pharmacy, WOMP Works for suggesting this post.


In Step 2 you create a chart or checklist of the daily medicine regime.  At NightingaleRx we’re hard at work reviewing tools to automate the process, but until then, you can tape pills to a note card or piece of paper.  A picture will do, if you don’t want to waste the pills.  And here is a sample filling checklist.

A checklist will help tremendously with the weekly process of filling up a pill box.  It’s easy to get distracted in what can be a long process, so a checklist keeps you on track.  If you’re not already using a pill box, I highly recommend it.  In fact, I’ll talk about that in step 3.  At this point the work with your Mom is done for today.  Congratulate yourself on completing a big step.  Put the tea kettle on, and relax.

While the water is brewing, though, be sure the put the meds back where you found them, or where you’ve now agreed they will be.  If any of these meds need refrigeration, make sure they are stored in the refrigerator.  If you have grandkids visiting the house, be sure to keep them away from the easy reach of little hands.  Until you get a new system in place, try not to cause too much disruption in her daily routine.