How do we determine whether a patient truly has the capacity to make their own medical decisions?

In this episode of Key Perspectives, Eric Gordon, PA-C and Steve Arze, MD dive into one of the most common and ethically complex challenges in geriatrics, palliative care, and acute medicine: assessing medical decision-making capacity.

The discussion focuses on three widely used, evidence-based frameworks and when each is most appropriate:

• Hopkins Competency Assessment Test (HCAT): A more comprehensive, structured evaluation often used for high-stakes, global competency questions such as financial decision-making, guardianship, and activation of durable power of attorney.

• Aid to Capacity Evaluation (ACE): A practical, bedside-ready tool for assessing capacity around a specific medical decision (e.g., surgery, chemotherapy, dialysis, or hospice), organized around key domains such as understanding, appreciation, reasoning, and voluntariness.

• CURVES Mnemonic: A rapid, clinically intuitive framework commonly used in emergency and acute care settings to assess a patient’s ability to choose, understand, reason, and communicate in time-sensitive situations.

Through real-world examples, including refusal of hospitalization, major surgery, and end-of-life decisions, this episode explores how depression, psychosis, and situational distress can influence capacity assessments, and how clinicians can document these evaluations in a defensible, patient-centered way.

Pain is one of the most common and overlooked drivers of behavioral and psychological symptoms of dementia. In this episode of Key Perspectives, we continue our BPSD series as Eric Gordon and Dr. Steve Arze discuss how unrecognized pain often shows up as agitation, vocalization, or resistance to care in patients who cannot reliably communicate their discomfort.

We explore why pain is so frequently undertreated in dementia, how the shift away from opioids has shaped current practice, and why sedation should never be confused with true pain relief. Dr. Arze shares a practical, multimodal approach to pain management that focuses on low-dose, multi-class therapy, scheduled rather than PRN analgesics, and time-limited medication trials to avoid long-term, unnecessary prescribing.

Together, we discuss how to recognize pain as a behavioral trigger, how to use the PAINAD scale to assess response to treatment, and why addressing pain can reduce inappropriate antipsychotic use. We also walk through thoughtful pharmacologic strategies, including acetaminophen, neuropathic agents, muscle relaxants, NSAIDs, opioids, and topical therapies, along with the importance of deprescribing and setting realistic goals with families.

This episode is designed for clinicians caring for patients with dementia in skilled nursing, long-term care, home-based primary care, palliative care, and hospice settings who want to improve quality of life by treating the root cause of behaviors rather than the behaviors themselves.

In Part 2 of our series on Behavioral and Psychological Symptoms of Dementia (BPSD), Eric Gordon, PA-C, and Dr. Steve Arze dive into one of the toughest clinical challenges in geriatrics and post-acute care: when and how to use medications to treat behavioral symptoms in dementia.

Building on last episode’s discussion of non-pharmacologic strategies, this conversation tackles the realities of prescribing in complex older adults, where polypharmacy, overlapping symptom presentations, and regulatory pressures converge.

• Why medications are not first-line treatment and what must be ruled out before reaching for a prescription.

• How serotonin toxicity is often missed, how it mimics BPSD, and why stacking serotonergic agents can fuel agitation, sleep disruptions, tremors, and worsening confusion.

• Which medication classes have evidence and which don’t, including:

  • SSRIs

  • Trazodone

  • Anticonvulsants (valproate, gabapentin)

  • Benzodiazepines

  • Melatonin

  • Cholinesterase inhibitors

• Why valproic acid and gabapentin are widely used but poorly supported for BPSD.

• Why benzodiazepines should generally be short-term “bridge” therapy, not long-term solutions.

• The surprising truth about ABH gel (spoiler: the massage may work better than the medication).

• Key takeaways from Fast Facts #499 from the Palliative Care Network of Wisconsin.

• How cholinesterase inhibitors may still help with behavior even in advanced dementia—and when to consider a trial.

• The importance of continual reassessment to avoid “set it and forget it” prescribing.

This episode is packed with practical pearls for clinicians practicing in SNFs, ALFs, home-based care, hospice, and geriatrics—helping you identify what truly works, avoid common pitfalls, and manage behaviors safely and effectively.