Key Perspectives

13 - Pain in Dementia - A Hidden Driver of BPSD

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.

12 - BPSD: Pharmacologic Approach

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.
In this episode, you’ll learn:
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.

11 - BPSD: Non-Pharmacologic Approach

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.

10 - Narrating Your Care

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.

09 - Heart Failure (Part 7): Patient Cases

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.
 
Learn more about Key Medical Care

08 - Heart Failure (Part 6): SGLT2 Inhibitors

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.

07 - Heart Failure (Part 5): Beta Blockers

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.

06 - Demystifying Hospice

In this episode, we take a thoughtful, practical look at a topic that’s often misunderstood: hospice care. Whether you’re a clinician, caregiver, or simply someone trying to navigate the complexities of serious illness, this episode offers clarity on what hospice really is—and isn’t.
 
We cover:
What hospice care truly entails from a clinical and insurance perspective
The full range of support services patients receive under hospice, from 24/7 clinician access to spiritual care and medical equipment at home
How to identify patients who may benefit from hospice earlier in their disease course
How to approach compassionate, honest conversations with patients and families when curative treatment is no longer the goal
 
We also explore tools like the “Surprise Question” and the Serious Illness Conversation Program (SICP) that can help guide clinicians through these critical moments.
 
With nearly 70% of Americans wishing to die at home—but only 30% doing so—we discuss how timely hospice enrollment and skilled communication can help align care with what patients truly value: comfort, dignity, and peace.

05 - Heart Failure (Part 4): RAAS Inhibitors

In this fourth installment of our heart failure series, we dive into another essential pillar of guideline-directed medical therapy (GDMT): the renin-angiotensin system (RAS) inhibitors. This includes ACE inhibitors, ARBs, and ARNIs—cornerstones of treatment for patients with heart failure with reduced ejection fraction (HFrEF).
Join us as we unpack how RAS inhibitors work, when to initiate therapy, and how to navigate clinical decision-making around switching, tolerability, renal function, and blood pressure thresholds. We also discuss practical considerations for initiating or holding therapy during acute kidney injury (AKI) and the evidence-based rationale for continuing these agents even with declining GFR.
Whether you're managing complex patients in the SNF, at home, or via telemedicine, this episode offers clear, clinically grounded insights to optimize care.

04 - Heart Failure (Part 3): GDMT and Spironolactone

In this episode of Key Perspectives, we continue our heart failure series by diving into Part 3: Medication Management, with a focus on spironolactone, a cornerstone of guideline-directed medical therapy (GDMT).
We start by reviewing the distinctions between HFpEF, HFmrEF, and HFrEF, and discuss how treatment strategies differ across these subtypes. The hosts explain what GDMT is, who develops it, and why it's essential in improving outcomes and reducing hospitalizations in heart failure patients.
The spotlight is on spironolactone—its dual role in HFrEF and HFpEF, its mechanism as a mineralocorticoid receptor antagonist, and how it contributes to diuresis, cardiac remodeling prevention, and potassium-sparing benefits. We also cover clinical pearls, including when it can be used alongside loop diuretics like Lasix, and important considerations for avoiding use in patients with hyperkalemia or poor renal function.
Tune in for a concise, clinically relevant discussion that enhances your understanding of heart failure pharmacology and supports your practice in geriatric and complex patient care settings.