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.

In this first of a two-part series, Eric Gordon, PA-C, and Dr. Steve Arze break down practical, evidence-based strategies for managing Behavioral and Psychological Symptoms of Dementia (BPSD) without reaching for the prescription pad. They clarify the key differences between BPSD and delirium, introduce the “Five P’s” framework for uncovering unmet needs, and explore real-world tools like redirection, music and reminiscence therapy, validation techniques, and dementia mapping. Through clinical examples and practical tips, this episode equips clinicians and caregivers to interpret behavior as communication and address the root causes. Be prepared to improve care while minimizing risks associated with medications.

In this milestone tenth episode of Key Perspectives, Eric Gordon, PA-C, and Dr. Arze explore the art of “narrating your care”, a simple but powerful way clinicians can bridge the gap between clinical excellence and patients’ perception of excellence.

Too often, patients leave an encounter uncertain about what was done, why it was done, or when to expect results. Eric and Dr. Arze unpack why vague phrases like “we’ll get some labs” or “we’ll follow up soon” can unintentionally create confusion or dissatisfaction, even when the right care was delivered. Instead, they share practical strategies for bringing patients into your decision-making process, explaining broad categories of what you’re checking, setting clear timelines, and even inviting patients’ perspectives on their own conditions.

The discussion covers:

• Why perception of care is as critical as the care itself.

• Common communication pitfalls that frustrate patients.

• Practical ways to narrate your thought process in real time.

• Using “wish” language to soften necessary limitations.

• How involving patients in the dialogue can reveal key insights.

Narrating your care isn’t about over-explaining; it’s about giving patients a window into your clinical reasoning so they feel heard, validated, and informed.

In this episode, we wrap up our heart failure series with a practical, case-based discussion. Building on the foundation of diagnostics, fluid management, and guideline-directed medical therapy covered in earlier episodes, we bring it all together by working through real-world patient scenarios.

We explore:

• Case 1: A new diagnosis of HFrEF in a patient with multiple comorbidities.

• Case 2: Medication optimization in a patient with chronic HFrEF and CKD.

• Case 3: Managing HFpEF with suboptimal volume status.

• Case 4: An acute decompensated heart failure exacerbation with critical management decisions.

This case-focused discussion highlights the stepwise approach to diagnosis, optimization of GDMT, and the importance of tailoring treatment to each patient’s comorbidities, lifestyle, and access to care.

Whether you’re managing heart failure in the hospital, clinic, or home setting, this episode brings the series full circle with practical insights you can apply directly to patient care.

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In this episode of Key Perspectives, we continue our heart failure series with Part 6: a deep dive into SGLT2 inhibitors. Originally developed for diabetes, these medications have become essential tools in managing both HFrEF and HFpEF, regardless of whether a patient has diabetes.

We’ll explore how SGLT2 inhibitors work, their surprising benefits in heart failure and chronic kidney disease, and the mechanisms that make them effective beyond glycemic control. We also discuss key topics such as:

• How SGLT2 inhibitors reduce preload and afterload

• Their metabolic benefits in the failing heart

• Contraindications and when to hold therapy

• Dosing strategies and how they interact with diuretics

• How to recognize and manage euglycemic DKA

• Cautions related to renal function, infection risk, and more

Whether you're managing patients in a SNF, clinic, or home setting, this episode offers practical insights for safely incorporating SGLT2 inhibitors into your treatment approach.

In this fifth installment of our Heart Failure series, we dive deep into one of the core pillars of guideline-directed medical therapy (GDMT) for patients with HFrEF: Beta Blockers.

You’ll learn:

• How beta-1, beta-2, and beta-3 adrenergic receptors work

• Why slowing the heart rate helps in HFrEF

• The evidence-based beta blockers for HFrEF (and their dosing)

• Common pitfalls in prescribing, like confusing metoprolol tartrate vs. succinate

• When to avoid beta blockers—and how to safely use them in patients with COPD or asthma

This episode is packed with pearls for clinicians working in geriatrics, primary care, and cardiology. Whether you're managing patients in the SNF, in the home, or via telemedicine, this practical review will help you optimize outcomes for patients with heart failure.