Firearms and Dementia: Clinical Considerations
Authors: Marian E. Betz, Alexander D. McCourt, Jon S. Vernick, Megan L. Ranney, Donovan T. Maust, Garen J. Wintemute
Journal: Annals of Internal Medicine (2018)

Ideas and Opinions3 July 2018Firearms and Dementia: Clinical ConsiderationsFREEMarian E. Betz, MD, MPH, Alexander D. McCourt, JD, MPH, Jon S. Vernick, JD, MPH, Megan L. Ranney, MD, MPH, Donovan T. Maust, MD, MS, and Garen J. Wintemute, MD, MPHMarian E. Betz, MD, MPHUniversity of Colorado School of Medicine, Denver, Colorado (M.E.B.), Alexander D. McCourt, JD, MPHJohns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (A.D.M., J.S.V.), Jon S. Vernick, JD, MPHJohns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (A.D.M., J.S.V.), Megan L. Ranney, MD, MPHRhode Island Hospital/Alpert Medical School and Brown University, Providence, Rhode Island (M.L.R.), Donovan T. Maust, MD, MSVA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.T.M.), and Garen J. Wintemute, MD, MPHUniversity of California, Davis, School of Medicine, Sacramento, California (G.J.W.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M18-0140 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The estimated number of older persons in the United States with Alzheimer disease is projected to increase from 4.7 million in 2010 to 13.8 million by 2050. An estimated 33% of all adults aged 65 years or older own a gun; another 12% live in a household with someone who does (1). A 1999 study estimated that 60% of persons with dementia (PWDs) live in a household with a firearm (2). If approximately 40% to 60% of households with PWDs also have a firearm, 7.8 to 11.8 million PWDs may live in a home with a firearm by 2050.Almost all adults in the United States (89%) support limiting firearm access for those whose mental illness would place them or others at heightened risk (1). Less attention has been paid to progressive cognitive impairment and firearm access. For PWDs—and their family members and health care providers—discussions about firearm access strongly parallel discussions about driving (3). When do PWDs need to "give up the keys"—whether they are to a gun safe or to a car, and how do they do so? Here, we review clinical and other considerations and provide recommendations.Clinical ConsiderationsFor PWDs, the primary risk for firearm injury is suicide (4): 91% of all firearm deaths in older adults are suicides (4), and firearms are the most common method of suicide among PWDs. Dementia itself may be a risk factor for suicide.Persons with dementia who have firearm access may also place families and caregivers at risk (3). Delusions about home intruders or confusion about the identity of persons in their lives may lead PWDs to confront family members, health aides, or other visitors. Access to a firearm may increase the potential for injury or death in such a situation. (Estimates on the frequency of such confrontations with firearms are not available.)Although family members may underestimate the ability of PWDs to access and use firearms stored in the home, no validated screening tool exists to assess firearm access among cognitively impaired persons. As part of a checklist covering other safety topics, the Alzheimer's Association suggests asking, "Do you have firearms in your home?" (5). A follow-up question may be, "Does the patient have access to any of the firearms?"The most appropriate time and location for screening is also not well-established. Within the Veterans Health Administration, firearms are part of the safety assessment recommended when investigating or establishing a dementia diagnosis; other items include driving status, access to power tools, and kitchen safety (6). It recommends that clinicians "counsel the Veteran with dementia and caregiver on firearm safety and encourage restricted access to firearms and ammunition" (6). Advising family members and others not to bring additional firearms into the home of a PWD may be important.A diagnosis of cognitive impairment or dementia does not in itself mean that a person should not have access to firearms—the level of cognitive impairment is probably most important. In a recent review, Patel and colleagues (7) proposed using the clinical dementia rating scale to estimate the stage of dementia and the person's ability to safely complete complex tasks, including firearm handling (Table).Table. Recommendations for Screening and Counseling Based on Dementia Stage*For patients with minimal cognitive impairment, approaches could be similar to those related to driving, including acknowledging the emotions involved and allowing the PWD to maintain agency in the decision for as long as it is safe (8). As with an "advance driving directive" (8), PWDs, their family members, and their health care providers may proactively discuss firearm access and consider setting a "firearm retirement date" (7). This patient-centered approach may allow an older adult to maintain decisional control and identify trusted family members or providers as future surrogate decision makers (Appendix Figure). To our knowledge, no one has tested the acceptability or efficacy of this approach.Appendix Figure. Sample family firearm agreement.Adapted from www.thehartford.com/sites/thehartford/files/at-the-crossroads-2012.pdf. Download figure Download PowerPoint Other patients may be explicitly identified—either by themselves or caregivers—as unsafe around firearms. Caregivers for these PWDs have 3 main options: Ensure that all guns are securely locked so that the PWD does not have unsupervised access, reduce risk by making guns less lethal (for example, storing them unloaded, replacing live ammunition with blanks, and disabling trigger mechanisms), and remove guns from the PWD's home. In some states, family members can temporarily store guns at their own house without the background checks otherwise associated with firearm transfers. Other storage sites might include gun shops or ranges, pawn shops, and law enforcement agencies. Unwanted firearms can be disposed of permanently by selling them or giving them away (in both cases, the recipient must be legally allowed to possess a firearm) or surrendering them to law enforcement. These options vary by location and may require background checks or other paperwork. To our knowledge, data to support firearm training or retraining courses for PWDs (7) are lacking. The Alzheimer's Association provides materials for family members with specific guidance about firearms, including keeping them locked with ammunition locked separately (5).Other ConsiderationsPhysicians have the right and duty to inquire of and counsel their patients about health risks and to act to protect their patients and others when circumstances warrant such action in the physician's professional judgment. As with driving, physicians must balance the welfare and privacy interests of individual patients with the health and safety of patients' families and the public.Federal laws do not explicitly prohibit purchase or possession of firearms by PWDs, and only Hawaii and Texas explicitly mention dementia or similar conditions in their firearm statutes. Hawaii prohibits possession by any person under treatment for "organic brain syndromes" (9), which could include dementia or similar neurodegenerative conditions. In Texas, persons diagnosed with "chronic dementia" are ineligible for a license to carry a handgun in public (10) but may purchase and possess firearms.Many questions on firearm access in dementia remain unanswered, but the need to address the problem is here now. We believe that a concerted, cooperative effort making the best use of the data at hand can help prevent injuries and deaths while protecting the dignity and rights of older adults.References1. Parker K, Horowitz J, Ingielnik R, Oliphant B, Brown A. America's complex relationship with guns. Pew Research Center. 22 June 2017. Accessed at www.pewsocialtrends.org/2017/06/22/americas-complex-relationship-with-guns on 10 October 2017. Google Scholar2. Spangenberg KB, Wagner MT, Hendrix S, Bachman DL. Firearm presence in households of patients with Alzheimer's disease and related dementias. J Am Geriatr Soc. 1999;47:1183-6. [PMID: 10522950] CrossrefMedlineGoogle Scholar3. Greene E, Bornstein BH, Dietrich H. Granny, (don't) get your gun: competency issues in gun ownership by older adults. Behav Sci Law. 2007;25:405-23. [PMID: 17559168] CrossrefMedlineGoogle Scholar4. Centers for Disease Control and Prevention. WISQARS (Web-based Injury Statistics Query and Reporting System). 2017. Accessed at www.cdc.gov/injury/wisqars/index.html on 29 June 2017. Google Scholar5. Alzheimer's Association. Staying safe. 2007. Accessed at www.alz.org/national/documents/brochure_stayingsafe.pdf on 4 April 2018. Google Scholar6. U.S. Department of Veterans Affairs. VHA Dementia Steering Committee recommendations for dementia care in the VHA health care system. 2016. Accessed at www.va.gov/GERIATRICS/docs/VHA_DSC_RECOMMENDATIONS_SEPT_2016_9-12-16.pdf on 10 October 2017. Google Scholar7. Patel D, Syed Q, Messinger-Rapport BJ, Rader E. Firearms in frail hands: an ADL or a public health crisis! Am J Alzheimers Dis Other Demen. 2015;30:337-40. [PMID: 25107933] doi:10.1177/1533317514545867 CrossrefMedlineGoogle Scholar8. Betz ME, Scott K, Jones J, Diguiseppi C. "Are you still driving?" Metasynthesis of patient preferences for communication with health care providers. Traffic Inj Prev. 2016;17:367-73. [PMID: 26507251] doi:10.1080/15389588.2015.1101078 CrossrefMedlineGoogle Scholar9. HAW. REV. STAT. § 134-7(c) (2018). Google Scholar10. TEX. GOV'T. CODE § 411.172(e)(5)(C) (2018). Google Scholar Comments0 CommentsSign In to Submit A Comment Marian E. Betz, MD, MPH; Alexander D. McCourt, JD, MPH; Jon S. Vernick, JD, MPH; Megan L. Ranney, MD, MPH; Donovan T. Maust, MD, MS; Garen J. Wintemute, MD, MPH(multiple)27 July 2018 Authors respond to Dr. Ertle We agree with Dr. Ertle that dementia is not the only condition that elevates suicide risk – indeed, suicide risk relates to a number of static and transient factors including physical and mental health conditions and social stressors. In all of these cases, access to firearms can elevate acute risk of death because of the high lethality of firearms as a method of suicide. In other publications, we, and many other authors, have discussed firearm suicide prevention in other populations. In "Firearms and Dementia: Clinical Considerations" we sought instead to explore the various firearm injury risks that might be associated with dementia. Dr. Ertle is correct that epidemiologic data are lacking, and we strongly support increasing funding for research and injury surveillance system. In the meantime, however, clinicians and families face decisions about firearm access on a daily basis, and they deserve guidance and resources. Alan R. Ertle, MD, MPH, MBAMercy Medical Group, Inc.17 July 2018 Firearm Suicide and Dementia: Only a Small Part of the Problem I read the article by Betz, et. al., with interest. However, I was disappointed to find that the actual size of the problem of suicide by firearms in patients with dementia (PWD) was not clarified. There is only a theoretical context in that there is a growing number of patients with dementia, some of whom will commit suicide by firearm, and lots of households with firearms. In 2011 an article was published by Seyfried, et. al., that described a 2001-2005 retrospective analysis of the Department of Veterans Affairs data of 294,952 patients (97.2% male) who had dementia and they found that there were 241 suicides during that period, 72.6% by firearms.1 This is estimated to be 11.9 suicides by firearm per 100,000 PWDs per year. There were potential predictors identified including male gender, white race, depression, a history of an inpatient psychiatric stay, prescriptions for antidepressants, and prescriptions for antianxiety medications. The authors of this study also indicate that suicide was much more likely early in the diagnosis. While suicide by firearms is not common in PWD, it does occur, and this is likely to be similar to other patients who are told of a terminal diagnosis or other serious illness. While the general recommendations seem sound, the Betz article would have been more useful if the scope were broadened to discuss the issue of suicide by firearms in all patients given a terminal or serious diagnosis. Author, Article, and Disclosure InformationAffiliations: University of Colorado School of Medicine, Denver, Colorado (M.E.B.)Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (A.D.M., J.S.V.)Rhode Island Hospital/Alpert Medical School and Brown University, Providence, Rhode Island (M.L.R.)VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.T.M.)University of California, Davis, School of Medicine, Sacramento, California (G.J.W.)Disclaimer: The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the funding agencies.Financial Support: By the Paul Beeson Career Development Award Program from the National Institute on Aging, American Federation for Aging Research, The John A. Hartford Foundation, and The Atlantic Philanthropies (grants K23AG043123 and K08AG048321); the Heising-Simons Foundation (grant 2016-219); and the National Institute of Mental Health (grant K23 MH095866). No sponsor had any direct involvement in the study design, methods, participant recruitment, data collection, analysis, or manuscript preparation.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-0140.Corresponding Author: Marian E. Betz, MD, MPH, Mail Stop B215, Leprino Building, University of Colorado School of Medicine, 12401 East 17th Avenue, Aurora, CO 80045; e-mail, marian.[email protected]edu.Current Author Addresses: Dr. Betz: Mail Stop B215, Leprino Building, 12401 East 17th Avenue, Aurora, CO 80045.Mr. McCourt: Johns Hopkins Bloomberg School of Public Health, Center for Gun Policy and Research, 624 North Broadway, Baltimore, MD 21205.Mr. Vernick: Johns Hopkins Bloomberg School of Public Health, Center for Gun Policy and Research, 624 North Broadway, Hampton House Room 594, Baltimore, MD 21205.Dr. Ranney: Department of Emergency Medicine, Alpert Medical School, Brown University/Rhode Island Hospital, 593 Eddy Street, Claverick 2, Providence, RI 02903.Dr. Maust: University of Michigan, North Campus Research Complex 016-226w, 2800 Plymouth Road, Ann Arbor, MI 48109.Dr. Wintemute: Violence Prevention Research Program, University of California, Davis, 2315 Stockton Boulevard, Sacramento, CA 95817.Author Contributions: Conception and design: M.E. Betz, J.S. Vernick, M.L. Ranney, G.J. Wintemute.Analysis and interpretation of the data: M.E. Betz, A.D. McCourt, J.S. Vernick, M.L. Ranney.Drafting of the article: M.E. Betz, A.D. McCourt, J.S. Vernick, M.L. Ranney, D.T. Maust, G.J. Wintemute.Critical revision of the article for important intellectual content: M.E. Betz, J.S. Vernick, M.L. Ranney, D.T. Maust, G.J. Wintemute.Final approval of the article: M.E. Betz, A.D. McCourt, J.S. Vernick, M.L. Ranney, D.T. Maust, G.J. Wintemute.Obtaining of funding: G.J. Wintemute.Administrative, technical, or logistic support: M.E. Betz, M.L. Ranney.Collection and assembly of data: M.E. Betz, A.D. McCourt, M.L. Ranney.This article was published at Annals.org on 8 May 2018. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoFirearms and Dementia Marian E. Betz , Alexander D. McCourt , Jon S. Vernick , Megan L. Ranney , and Garen J. Wintemute Firearms and Dementia Alan R. Ertle Metrics Cited bySuicide risk in first year after dementia diagnosis in older adults"Firearm access in dementia: legal and logistic challenges for caregivers"Older Firearm Owners and Advance PlanningFredrick E. Vars, JDBiting the Bullet: Firearm Ownership in Persons with Dementia. A Registry-Based Observational StudySuicide and Lewy body dementia: Report of a Lewy body dementia association working groupOlder Firearm Owners and Advance Planning: Results of a National SurveyMarian E. Betz, MD, MPH, Matthew Miller, MD, ScD, Daniel D. Matlock, MD, MPH, Garen J. Wintemute, MD, MPH, Rachel L. Johnson, MS, Conor Grogan, MD, Hillary D. Lum, MD, PhD, Christopher E. Knoepke, PhD, MSW, Megan L. 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Morgan, MS, Anthony Gomez, BS, Frederick P. Rivara, MD, MPH, and Ali Rowhani-Rahbar, MD, PhDPhysicians Should Play a Role in Ensuring Safe Firearm OwnershipSuicide in Parkinson's diseasePreventing Firearm-Related Death and InjuryRocco Pallin, MPH, Sarabeth A. Spitzer, BA, Megan L. Ranney, MD, MPH, Marian E. Betz, MD, MPH, and Garen J. Wintemute, MD, MPHFirearm Injury Prevention: AFFIRMing That Doctors Are in Our LaneDarren Taichman, MD, PhD, Sue S. Bornstein, MD, and Christine Laine, MD, MPHFirearms and DementiaAlan R. Ertle, MD, MPH, MBA 3 July 2018Volume 169, Issue 1Page: 47-49KeywordsCaregiversCognitive impairmentDementiaElderlyFire safetyFirearm injuriesPatient advocacyPrevention, policy, and public healthPublic policySuicide ePublished: 8 May 2018 Issue Published: 3 July 2018 Copyright & PermissionsCopyright © 2018 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...