While it’s important throughout life to maintain good dental

health, it isn’t uncommon for senior citizens to unintentional-

ly let their oral health habits fall by the wayside. Whether it

be other, seemingly more important, health issues or the

physical inability to practice proper oral care, like arthritis,

disability, and demen-

tia - a staggering num-

ber of elderly citizens

are experiencing a state

of oral decay and along

with that, adverse

health issues.

The decay of the teeth

and gums is preventa-

ble. By practicing good

oral hygiene and keep-

ing scheduled dental

hygiene visits with

your dentist, you’ll

keep and maintain

strong and healthy

teeth and gums. In

turn, you can worry

less about developing uncomforta-

ble gum disease-related illnesses.

An online study published by the Cen-

ter for Disease Control and Preven-

tions (CDC) shows that one in five

senior citizens have untreated tooth

decay and 68% of seniors aged 65 or

older have some form of periodontitis,

commonly referred to as gum disease.

Periodontal disease is an infection of

the muscle and bone surrounding the

tooth. The muscle and bone include the

gums, the cementum that covers the

tooth and its root, the periodontal liga-

ment, and the alveolar bone. In its ear-

liest stages, only the gums are affected and may show signs

of inflammation, including sensitivity, bleeding, or soreness.

As gum disease progresses, all of the supporting tissue and

bones are affected.

The bacteria found in plaque buildup is the primary cause of

periodontitis. How-

ever, other factors

including hormonal

changes, illnesses

such as cancer and

diabetes, medica-

tions, poor oral

hygiene, poor nu-

trition, and a fami-

ly history of dental

disease can con-

tribute to the devel-

opment of perio-

dontitis.

If plaque is not re-

moved through

proper brushing

and flossing, it

hardens and turns

into tartar. Tartar is

calcified plaque

that sits on the enamel below the gum line and is difficult to

remove. Without proper care and routine dental visits, plaque

and tartar will continue to spread. The spread of plaque and

tartar under the gum line increases the risk of inflammation

and increases the likelihood that you’ll experience new

health problems as the bacteria enters the bloodstream.

Untreated periodontitis can lead to cavities, root decay, and

darkened teeth. Symptoms include persistent bad breath, red

or swollen gums, bleeding gums, pain when eating, loose

teeth, receding gums, and increased sensitivity – all of which

can be especially uncomfortable for a senior citizen.

If allowed to spread without treatment, it can lead to a num-

ber of additional, and potentially dangerous, health condi-

tions including heart disease, respiratory infections, kidney

The Benefits & Importance of Oral Health

A Publication of Neil Medical Group, The Leading Pharmacy Provider in the Southeast

May/June 2019

PHARM NOTES

Volume 22, Issue 3

Continued on page 4

Inside this issue:

The Benefits &

Importance of

Oral Health

1

Kratom: A New

Opiod?

2-3

Conclusion: The

Benefits of Oral

Health

4

Consequences of

Long Term Laxa-

tive & Probiotic

Use

5

F-757: Unneces-

sary Medication

Tag

6-7

Neil Medical

Group Contact

Information

8

Kratom: A New Opiod?

Page 2

PHARM NOTES

Have you ever heard of the plant known as Kratom? Some

people think that it is the world’s next miracle drug, while oth-

ers say it is dangerous and should be illegal to use. With our

nation experiencing an opioid epidemic, the increased availa-

bility of kratom in the United States has led to the concern

about where the natural opioid should fit into medical prac-

tice.

Kratom, also known as Mitragyna speciosa, is a tree that is

found in parts of Africa and Southeast Asia, specifically in

Thailand, Malaysia, Indonesia and Papua New Guinea. The

tree has large dark green leaves that are broad, glossy and oval

shaped. The leaves and small stems of the tree are what is pri-

marily used for consumption. Kratom can be extracted from

leaves being dried and brewed as a tea, chewed, smoked, or

crushed into a powder to be packaged into capsules. The

leaves contain approximately 0.8% in weight of mitragynine

but this can vary based on the season and geographic location

of the tree. Mitragynine is the most prevalent of the kratom

alkaloids (60% of the total alkaloid content)

and exhibits its psychoactive effects by acti-

vating the µ- (mu) opioid receptor, similar to

morphine. Other prevalent alkaloids include

isopaynantheine, mitraciliatine, paynanthe-

ine, speciociliatine, speciogynine, and 7-

hydroxymitragynine which aid in activation

of δ-(delta) and κ-(kappa) opioid receptors.

At low doses, consumption of kratom pro-

duces stimulant effects and at high doses it

produces sedative effects. Noticeable effects

are often observed within 10-20 minutes of

consumption, full effects are seen after 30-60

minutes and can last for 5-7 hours after in-

gestion. Activation of these opioid receptors

leads to the analgesic properties which is

why kratom is most often used to treat

chronic pain and opioid withdrawal. Other

uses include: anxiety, cough, depression,

diabetes, diarrhea, hypertension, sexual per-

formance, mood improvement, and to enhance physical endur-

ance. Due to the similarity with opioids, kratom has many

similar side effects, which can be found in Table 1.

Notable drug interactions include the

use of kratom along with other CNS

depressants, which further increases

the risk of respiratory depression by

activation of the µ-receptor. It is also

recommended to be cautious with the

use of kratom when used together

with medications that are CYP 450

1A2, 2C19, 2D6 and 3A4 substrates.

In vitro studies suggest that kratom is

an inhibitor of these enzymes, which

results in an increase in the blood

concentrations of drugs that are me-

tabolized by these pathways. Specific

examples of medications often used

in Long Term Care facilities that af-

fected by CYP 450 pathways can be

found in Table 2. In patients with

psychiatric disorders, evidence has

shown patients that consume kratom

Table 1. Common Side Effects With The Use of Kratom

Hallucinations Aggression

Nausea Hypothyroidism

Vomiting Intrahepatic cholestasis (impaired re-lease of bile from liver cells caus-ing impaired liver function).

Constipation

Delusions

Serious Side Effects

Respiratory depression Seizures

Severe withdrawal upon cessation of habitual use

Signs of Withdrawal

Decreased appetite Anxiety

Diarrhea Insomnia

Muscle pain, spasms, tremors Nervousness

Hot flashes Negative mood changes

Page 3

Volume 22, Issue 3

have an increased risk of suicide com-

pared to people who do not have a psy-

chiatric disorder. Also, with side effects

of hallucinations and delusions, existing

psychiatric disorders may be exacerbat-

ed. Kratom has been illegal in Thailand

since 1946, under the Kratom Act, and in

Australia since 2005. It is currently legal

to possess and consume kratom within

the United States, however Alabama,

Arkansas, Indiana, Tennessee and Wis-

consin have banned the use of kratom

and several other states are in the process

of banning kratom through legislation. In

November 2017, the Food and Drug Ad-

ministration (FDA) released a public

health advisory about deadly risks asso-

ciated with kratom. The FDA stated that

kratom is being used to treat serious

health conditions such as opioid use disorder, pain, anxiety

and depression, which should be treated

under the oversight of a licensed medical

provider. There has been a 10-fold increase

in calls to poison control centers regarding

kratom use from 2010-2015; and, a reported

36 deaths associated with kratom-

containing products. The FDA has not eval-

uated any products containing kratom to

assess its safety and effectiveness, and has

exercised jurisdiction over the unapproved

drug by conducting seizures and detaining

shipments of kratom products from entering

the United States. The Drug Enforcement

Administration (DEA) currently has kratom listed

as a Drug and Chemical of Concern. Due to the

opioid crisis, the FDA states action must be taken

against new products that have the potential to

cause addiction and that scientific evidence should

be utilized to determine the appropriate medicinal

use of kratom based on its risks and benefits.

Based on pharmacologic properties, kratom has

the potential to benefit those who are experiencing

pain and opioid withdrawal. However, kratom has

not been studied appropriately to determine its true

effectiveness, along with its risks. Using kratom to

treat pain and opioid withdrawal may pose serious

risks, which is why these conditions should be

managed under the supervision of a licensed

healthcare provider.

Article by Kayla Barker, PharmD Candidate

Wingate University School of Pharmacy

Table 2. Drug-Drug Interactions With the Use of Kratom

CYP 450 1A2 Clozapine Olanzapine

Haloperidol Cyclobenzaprine

CYP 450 2C19

Amitriptyline Citalopram

Diazepam Phenytoin

Warfarin Proton Pump Inhibitors

CYP 450 2D6

Metoprolol Fentanyl

Paroxetine Risperidone

Tramadol Trazodone

CYP 450 3A4 Alprazolam Budesonide

Simvastatin Carbamazepine

Page 4

The Benefits & Importance of Oral Health………………….continued from page 1

PHARM NOTES

disease, diabetes, rheumatoid arthritis, and risk of cancer.

You can prevent the build-up of plaque and bacteria by taking

care to brush your teeth twice a day, flossing daily, and using

an antiseptic mouthwash that contains fluoride. Brushing re-

moves the transparent layer of plaque from the surface of the

tooth and loosens food particles between the teeth and gums.

Brushing also stimulates blood flow in the gums which keeps

them healthy and helps to prevent periodontitis. It is recom-

mended that you brush your teeth twice a day for two minutes.

Flossing works to dislodge food particles and bacteria. If done

regularly, flossing can create and maintain a healthy gum

structure for your teeth. If you have inflammation or bleeding

of the gums, you can continue to floss your teeth. It’s even

likely that you’ll see a decrease in these symptoms. If your

gums continue to bleed or if you continue to experience pain-

ful inflammation after flossing, you should consult a dentist.

Take care to rinse with an antiseptic fluoride mouthwash.

You’ll kill remaining bacteria in your mouth while the fluoride

provides extra protection against cavities and works to prevent

tooth decay and strengthen weak spots and exposed roots.

Cavity prevention is an important aspect of proper oral and

dental hygiene. It is recommended that you rinse with mouth-

wash each time you brush.

Proper oral and dental hygiene keeps your mouth healthy and

in turn, decreases the risk of developing additional health

problems. For senior citizens, it is especially important to

practice proper oral care. Our immune system weakens as we

age, and we are no longer able to fight off infections or disease

as quickly and effectively as we once were. That’s why it’s

important to practice good oral hygiene to rid ourselves of the

bacteria before it can cause other health issues.

There are many benefits of practicing proper oral hygiene and

your smile is just one of many. From keeping a bright smile to

preventing dementia, you’re taking care of your body in a way

that has a profound effect on your overall health and wellness.

Benefits of good oral hygiene:

Removes surface stains. Removing surface stains helps

achieve a whiter and brighter smile. It also prevents per-

manent discoloration of the teeth and gums.

Freshens breath. Proper oral care helps to remove and

keep bacteria away from your mouth. If bacteria is left in

place, it will continue to spread and cause a foul odor.

Taking care to brush, floss, and rinse daily prevents bad

breath from occurring.

Saves money. An ounce of prevention is worth a pound

of cure. Taking care of your teeth now will help prevent

future tooth and gum related health problems, saving you

money on future dental bills.

Prevents gum disease. We’ve discussed how lack of

good oral care can lead to gum disease and other serious

health issues. Practicing proper oral hygiene helps prevent

gum disease and its associated symptoms and reduces the

risk of developing related diseases.

Reduces your chances of a heart attack or stroke. Good

oral care means preventing the bacteria and plaque build-

up from entering your bloodstream, effectively reducing

your chances of a heart attack or stroke.

Prevents or minimize diabetes. Gum disease makes it

harder to control your glucose and has the potential to af-

fect blood glucose levels. The inability to control your

blood glucose can contribute to the onset and progression

of diabetes.

Prevents dementia and Alzheimer’s disease. Research

shows that poor oral health increases your risk of develop-

ing dementia and Alzheimer’s disease. Studies have found

that when bacteria that enters the bloodstream reaches the

brain, brain cells are killed, leading to confusion and

memory loss.

Promotes wellness. When your teeth are proper ly

cared for, you feel a sense of wellness. This sense of well-

ness helps improve confidence and overall self-esteem. A

healthy mouth is a healthy body and mindset.

The best way to prevent future health problems related to gum

disease and create a healthy mouth is to practice good oral

care. Your routine should consist of brushing, flossing, and

rinsing using fluoridated products. This routine should be

completed twice a day, every day.

Maintaining your healthy smile shouldn’t be considered a

chore. Consider your routine to be a crucial part of your day. If

necessary, set aside ten minutes twice a day to brush, floss,

and rinse. With time, your routine will become a habit. Don’t

forget, good oral care requires routine check-ups with a den-

tist.

You should see a dentist twice a year to be sure your teeth and

gums are in good health. By practicing good oral health habits

and keeping your dentist appointments, you’ll learn to care for

your teeth to create a healthier mouth and a healthier you.

Article by Jennifer Brougher, PharmD, BCGP

Consultant Pharmacist, Neil Medical Group

Page 5

Volume 22, Issue 3

Consequences of Long Term Laxative & Probiotic Use in the Elderly

Constipation is one of the most frequently diagnosed gastroin-

testinal disorders with prevalence rising with age due to natu-

ral physiological changes often paired with increased use of

medications. The increased prevalence of constipation in elder-

ly patients not only leads to diminished quality of life, but also

a high economic burden related to complications. Complica-

tions from constipation such as fecal impaction and stercoral

ulcers can result in hospital visits for correction. Because of

the serious side effects associated with chronic constipation,

many patients are prescribed long-term daily laxative and/or

probiotic treatment. Approximately 50% to 74% of long-term

care (LTC) residents use laxatives and probiotics on a regular

basis for relief and prevention of constipation. Since many of

these laxative and probiotic medications are sold over-the-

counter at local drug stores, their use is widely accepted as

safe. However, research shows that prolonged use of laxative

agents and/or probiotics may not be as safe as commonly

thought. Below is an overview of the most commonly used

laxative agents and concerns related to each class with pro-

longed use.

Stimulant laxatives:

Stimulant laxatives work by directly stimulating the muscles

that line the gut and colon leading to increased intestinal motil-

ity and fluid secretion into the bowel. Medications commonly

used in this category are: Senna, aloe and Bisacodyl. There is

limited evidence to support the routine use of these agents due

to the side-effects associated with them. Although they typical-

ly result in relief of constipation, they can lead to dependence

if used long-term and are associated with side effects such as

abdominal cramping and discomfort, electrolyte abnormalities

and melanosis coli (a histologic finding of brown pigmentation

in the colonic mucosa). There are also concerns that long-term

use of Senna can lead to malabsorption and cathartic colon.

Cathartic colon results in loss of bowel function due to neuro-

muscular damage which may be irreversible and can be fatal

for older adults.

Osmotic laxatives:

Osmotic laxatives such as Miralax (polyethylene glycol), lac-

tulose, milk of magnesia and magnesium citrate work by creat-

ing an osmotic gradient in the intestines resulting in increased

water content in the stool making it easier to flow through the

colon. Prolonged use of these agents may lead to abdominal

cramping, bloating, flatulence and electrolyte imbalances.

More concerning is that prolonged use can lead to dehydration

resulting in central nervous system changes. Moreover, there is

a growing concern that polyethylene glycol-containing laxa-

tives may cause worsening neuropsychiatric events such as

dementia, depression, Alzheimer’s and Parkinson’s diseases

due to toxic byproducts that form when ethylene glycol is bro-

ken down in the body. This is concerning as many LTC resi-

dents already suffer from these diseases. Also, since these lax-

atives block the absorption of nutrients in the small intestine,

there is growing alarm for malnutrition specifically in older

adults.

Enemas and suppositories:

Enemas and suppositories are useful in patients that cannot

tolerate oral laxatives or are suffering from stool impaction.

Enemas should not be used long-term due to the risk of elec-

trolyte disturbances. Specifically, phosphate enemas should be

avoided in older adults due to the high risk of electrolyte ab-

normalities which has been reported fatal in some instances.

Mineral oil enemas are a safer alternative with only local ad-

verse effects reported of perianal irritation or soreness. Like-

wise, glycerin suppositories are safe alternatives to enemas and

have been shown effective in relieving constipation.

Chloride-channel activators:

The chloride-channel activator laxative Amitiza (lubiprostone)

is a prescription only medication that activates chloride chan-

nels to secrete chloride into the intestines increasing stool wa-

ter content without directly affecting the smooth muscle of the

colon. Electrolyte changes have not been significantly reported

with this agent, but prolonged use has been associated with

nausea, extreme diarrhea and headache. This agent is typically

reserved for constipation that does not respond to less expen-

sive treatment options and its long-term side effects are widely

unknown.

Probiotics:

Probiotics are commonly recommended for prevention and

treatment of constipation, but surprisingly, the strongest evi-

dence for the use of probiotics is in the management of diar-

rheal diseases such as diarrhea associated with antibiotic use

and infectious diseases. Probiotics work by aiding in the re-

plenishment of intestinal microbiota. Although probiotics are

widely accepted as being safe agents, they are not regulated by

the Food and Drug Administration (FDA), but instead are reg-

ulated as dietary supplements. This means there are often no

requirements for safety, purity, or potency before marketing

probiotics. Besides the obvious concerns of lack of control by

the FDA, another safety concern is the increased risk of infec-

tion posed by the long-term use of probiotics. Many strains of

probiotics have been chosen for use due to their ability to ad-

here to the intestinal mucosa which may also increase bacterial

translocation. Microbes can attach to the probiotics that adhere

to the intestines leading to infection. Studies have shown that

the increased risk of infection associated with prolonged probi-

otic use is low in healthy patients, but increases in those with

chronic diseases and those who are immune compromised or

debilitated which often describes residents of LTC facilities.

Long-term laxative and/or probiotic use in elderly patients

may not be as safe as once thought. It is vital that the risks as-

sociated with these seemingly harmless medications are con-

sidered before used long-term LTC residents.

Article by Anna Bruckelmeyer, PharmD Candidate

F-757: Unnecessary Medication Tag

Page 6

PHARM NOTES

How often have you heard, “Every drug must have an indica-

tion”? Nurses are being expected on a daily basis to deter-

mine why a medication is being used.

Unnecessary Medications

CMS regulation F-757 Unnecessary Medications requires an

indication for every medication ordered—chronic and short

term.

F-757 Unnecessary Medications is a broad classification: Per

CMS guidance, an unnecessary medication is any medication

that is:

In excessive dose (including duplicate therapy); or

For excessive duration; or

Without adequate monitoring; or

Without adequate indication for its use; or

In the presence of adverse consequences which indicate

the dose should be reduced or discontinued; or

Any combination of the reasons above.

Unnecessary medication is a frequent citation on state sur-

veys. According to CASPER, 21.6% of facilities were cited

for a F-329 (now F-757) deficiency based on a March 1, 2016,

report of data on the last standard health survey of active

SNF/NF. That is the sixth highest in the number of citations

for that reporting period.

What’s the Basis for the CMS Regulation?

Indication encompasses both a diagnosis such as seizure dis-

order, or short term symptom such as nausea, or wellness such

as influenza prevention. Technically, indication and diagnosis

are not identical, however, often these terms are used inter-

changeably.

Diagnosis is the traditional basis for decision-making in clini-

cal practice, providing a structure for organizing and interpret-

ing signs, symptoms and laboratory tests. An accurate diagno-

sis impacts positive outcomes as clinical decisions will be

made with a correct understanding.

It provides the foundation for a large part of what goes on

with the patient, determining prognosis, nursing care plan and

various therapies such as physical therapy and medication

regimens.

The diagnosis can affect whether a medication or durable

medical equipment is reimbursed, a prior authorization is ap-

proved or how clinical practice guidelines are implemented.

MDS data is dependent on diagnoses, too.

“Oh, Just Write Anything Down. What Difference

Does it Make?”

Sometimes the nurse thinks drug X is given for Diagnosis A

because that’s what the medication is usually used for. The

focus should be patient centered and the real question is not

what the drug can be used for, but what the drug is being used

for in this particular resident.

Deprescribing

Polypharmacy is a common occurrence in the elderly. As pa-

tients progress though life and acquire new diagnoses, medi-

cations are added. More medications can lead to adverse con-

sequences of their own as well as drug interactions and in-

creasing costs. Periodically, a patient’s medication regimen

should be reviewed to determine if any drugs could be re-

duced or stopped. Deprescribing is the planned and supervised

process of dose reduction or stopping of medications that

might be causing harm, or may no longer be of benefit ac-

cording to Deprescribing.org. The diagnosis being treated is

the first step in the process of evaluation for discontinuation.

Good resources can be found at the website:

https://deprescribing.org/ as well as https://medstopper.com

Sometimes a resident has a diagnosis but the medication is no

longer beneficial. Cholelithiasis can cause nausea and vomit-

ing. An antiemetic and Proton Pump Inhibitor may be added.

However, after the cholecystectomy recovery period, most

likely neither medication will still be needed.

Medications that are initially prescribed for cognitive impair-

ment should be re-evaluated over time. These medications do

not reverse dementia, rather they may slow the loss of certain

cognitive functions on a modest basis. As cognitive decline

continues, at some point there is little to no benefit. Money

that the family is using to purchase these medications could

be transferred to providing other needed services for their

family member.

When a patient elects to enter hospice care, most of their di-

Page 7

Volume 22, Issue 3

agnoses do not disappear, however, the need to treat con-

cerns such as hyperlipidemia need to be re-evaluated and

most medications like statins can be stopped.

As there is a concerted effort to reduce opioid use, there are

opportunities for reduction. Changing the dressing of a new

wound may be very painful at first, and a narcotic before the

change may provide comfort for the resident. As the wound

heals, the pain may diminish and the opioid can be stopped.

The opioid order will need to specify what type of pain it is

being used for so that the opportunity to stop it can be cor-

rectly assessed.

Two Wrongs Don’t Make it Right

Diagnostic errors are a common occurence. Adding wrong

indications to a patient’s medical record can also lead to

wrong information that moves through the medical record and

treatment plan into perpetuity. For example, if the nursing

home medication order states the PPI is for GERD and sends

the resident to the hospital, then the hospital picks up that di-

agnosis, continues the PPI and includes that diagnosis as well.

When the resident is readmitted back to the nursing home, the

PPI and the diagnosis of GERD get carried forward. This

toolkit is a great resource https://www.slideshare.net/

EngagingPatients/diagnostic-error-toolkit

Need to Know NOW!!!

In the era of paper charting, when a resident was admitted and

the nurse had trouble determining why a medication was giv-

en, the prescriber could be asked to clarify during a daily

“batch call”. The diagnosis could then be added to the direc-

tions, permanent problem list and care plan usually within the

first 24 hours. A common admission scenario now with EHR

is that the indication is a required data field for order entry of a

medication. Thus without an indication right now, the medica-

tion cannot be entered into the computer. And if the medica-

tion is not entered at that moment, the entire process is held

up. Thus, the nurse tries to find a feasible diagnosis, enters it

and moves on. By trying to improve the process of “every

drug must have an indication”, in some circumstances, a cas-

cade of events is set off with possibly an incorrect indication.

Searching High and Low

The best solution is for the prescriber to include the indication

in the directions. Additionally, when the provider verbally

gives an order, the nurse should ask for the indication or if the

nurse calls the prescriber for a problem and an order is given

the nurse should add that problem to the directions (for exam-

ple, “for nausea”, “ for diarrhea”)

Where to look:

EHR diagnosis list

Hospital or other facility H&P

Hospital or other facility Discharge Summary

PCP notes

ED reports

SLP reports

Consults—cardiology, eye care, psychiatry, wound

And one day you just might even ask Alexa!

Remember that the drug may be used for two diagnoses at the

same time, such as Metoprolol for HTN and Afib. Include

both in the indication. And finally, when a prescriber gives the

diagnosis for the medication, double check to make sure it’s

placed on the permanent problem list and on the nursing care

plan if it impacts that.

Pharmacists can be your best asset in dealing with this prob-

lem. Pharmacists, too on a daily basis, review the resident’s

medications and clinical information pouring over the above

listed areas to determine the indication for use and request an

indication from the prescriber if unable to find one.

.

Article by Wendy Nash, PharmD, BCGP, BCPS

PHARM NOTES

Kinston Pharmacy

2545 Jetport Road

Kinston, NC 28504

Phone 800 735-9111

Louisville Pharmacy

13040 East Gate Parkway

Suite 105

Louisville, KY 40223

Phone 866-601-2982

Mooresville Pharmacy

947 N. Main Street

Mooresville, NC 28115

Phone 800 578-6506

To all the Pharm Notes Family,

With all the negativity in the news…..I thought I would end the newsletter this month on a light-

hearted note. So, I will leave you with……

Things to Ponder

1. If the No. 2 pencil is the most popular, why is it sill No. 2?

2. Why do we press harder on the remote control when we know the batteries are getting weak?

3. Why are you “in” a movie, but “on” TV?

4. What was the best thing BEFORE sliced bread?

5. Why do we drive on parkways & park on driveways?

6. Why do “fat chance” and “slim chance” mean the same thing but “wise man” and “wise guy”

are opposites?

7. Why do feet smell and noses run?

8. Why is QUITE A FEW the same as QUITE A LOT?

9. When does it stop being partly cloudy & start being partly sunny?

10. When French people swear, do they say “Pardon my English?”

11. Why do people say “heads up” when you should duck?

12. How does a building BURN UP as it BURNS DOWN?

13. Why is it called a HAMburger when its made of beef?

14. Why do psychics have to ask you for your name?

15. Why doesn't glue stick to the inside of the bottle?

Till next time……

Cathy Fuquay

Pharm Notes Editor

Pharm Notes is a bimonthly publication by Neil

Medical Group Pharmacy Services Division.

Articles from all health care disciplines pertinent

to long-term care are welcome. References for

articles in Pharm Notes are available upon request.

Your comments and suggestions are appreciated.

Contact: Cathy Fuquay (cathyf@neilmedical.com)

1-800-735-9111 Ext 23489

...a note from the Editor

Thank you for allowing Neil Medical Group to partner with

you in the care of your residents!