Household Firearm Ownership and Storage, Suicide Risk Factors, and Memory Loss Among Older Adults: Results From a Statewide Survey
Authors: Erin R. Morgan, Anthony Gomez, Frederick P. Rivara, Ali Rowhani-Rahbar
Journal: Annals of Internal Medicine (2019)

Letters6 August 2019Household Firearm Ownership and Storage, Suicide Risk Factors, and Memory Loss Among Older Adults: Results From a Statewide SurveyFREEErin R. Morgan, MS, Anthony Gomez, BS, Frederick P. Rivara, MD, MPH, and Ali Rowhani-Rahbar, MD, PhDErin R. Morgan, MSUniversity of Washington, Seattle, Washington (E.R.M., F.P.R., A.R.), Anthony Gomez, BSPublic Health—Seattle & King County and University of Washington, Seattle, Washington (A.G.), Frederick P. Rivara, MD, MPHUniversity of Washington, Seattle, Washington (E.R.M., F.P.R., A.R.), and Ali Rowhani-Rahbar, MD, PhDUniversity of Washington, Seattle, Washington (E.R.M., F.P.R., A.R.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M18-3698 SectionsSupplemental MaterialAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: Firearm access poses a danger to older persons with cognitive impairment; their families and caregivers; visitors, such as grandchildren; and potentially others. Given that 91% of firearm deaths among older U.S. adults in 2017 resulted from self-inflicted wounds, the well-established relationship between cognitive impairment and depression is particularly concerning in this population (1, 2). Those with dementia may also shoot themselves or others because of confusion or increased agitation and the associated aggression (3). Recent publications have encouraged clinicians to discuss with patients their own or their aging loved ones' access to firearms (4); however, little is known about the prevalence of household firearm ownership and storage practices among older adults.Objective: To characterize adults aged 65 years or older residing in firearm-owning households and their firearm storage practices with regard to self-reported sociodemographic features, suicide risk factors, and confusion or memory loss. Data from the 2016 Washington State Behavioral Risk Factor Surveillance System (BRFSS) were used.Methods and Findings: The BRFSS uses a complex survey design to gather representative estimates of various behaviors (Appendix). We focused on alcohol consumption, mental health, and memory loss in addition to household firearm ownership and storage practices (Supplement). Storage was characterized in 3 mutually exclusive categories: all firearms stored locked and unloaded (the safest option), 1 or more firearms stored either unlocked and unloaded or locked and loaded, and 1 or more firearms stored unlocked and loaded (the least safe option). The analyses were conducted using Stata 15 (StataCorp). The Washington State Department of Health and University of Washington institutional review boards have determined that the BRFSS is exempt from review and approval.A total of 5074 older adults responded. After exclusion of 581 who did not respond to the firearms module and 65 who reported household firearm ownership but did not report on storage, 4428 responses were available for analysis. Overall, 38.6% reported a firearm in the home (an estimated 410 000 statewide). Respondents from firearm-owning households tended to be younger and were more likely to be white, male, and married (Table 1). Among firearm-owning households, 32.5% stored all firearms locked and unloaded, and 23.5% stored at least 1 firearm unlocked and loaded. Those reporting unlocked and loaded storage were more likely to be male, to be a veteran, and to reside in a rural area than those reporting safer storage.Table 1. Demographic Characteristics of Washington Residents Aged 65 Years or Older, by Household Firearm Ownership and Storage Practices*The prevalence of diagnosed depression and frequent mental distress was 17.4% and 6.9%, respectively. Memory loss in the previous year was reported by 12.2% of participants, and 5.6% reported discussing it with a clinician. The prevalence of these conditions did not vary meaningfully by household firearm ownership (Table 2). Among those in firearm-owning households, the prevalence of suicide risk factors or memory loss did not vary meaningfully by storage practice.Table 2. Prevalence of Suicide Risk Factors and Indicators of Memory Loss, by Household Firearm Ownership and Storage Practices*Discussion: In this statewide representative study of older adults in Washington, the prevalence of mental health or memory loss indicators did not vary by household firearm ownership or storage practices. Given the association between firearm ownership and suicide (5), limiting access to lethal weapons for the older adult population represents an important avenue for suicide prevention. This is especially important among aging adults with firearms in the home who are beginning to show symptoms of depression or dementia.The lack of significant differences in suicide risk factors and memory loss among older adults in households with and without firearms is concerning and indicates the need for action on the part of policymakers, physicians, and families to address this issue. In addition to patient–provider communication, risk-based policies on eligibility for firearm ownership reduce access to lethal means. Some states currently restrict access for persons with mental illness, but few mention dementia. As "red flag" laws continue to be adopted throughout the country, the potential risk for firearm injury among older adults with memory loss should be considered an important indication. Recently published guidelines provide recommendations on the timing and content of conversations about firearms and suggest that providers include screening questions when seeing persons with dementia (4). These conversations with older patients could be crucial opportunities to prevent injuries and save lives.Appendix: BRFSS MethodsHealth characteristics estimated from the BRFSS pertain to the U.S. noninstitutionalized population aged 18 years or older. In 2011, a new weighting method called iterative proportional fitting, or "raking," replaced the poststratification method to weight BRFSS data. Raking allows incorporation of cellphone survey data and permits the introduction of such demographic characteristics as education level, marital status, or home renter or owner status in addition to age, race/ethnicity, and gender to improve the degree and extent to which the BRFSS sample reflects the sociodemographic makeup of the individual state. The 2016 BRFSS raking method includes categories of age by gender, detailed racial and ethnic groups, education level, marital status, regions within states, gender by race and ethnicity, telephone source, renter or owner status, and age by race and ethnicity. In 2016, all 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands collected samples of interviews conducted by landline and cellphone. Data from before and after the 2011 change are not directly comparable, and the Centers for Disease Control and Prevention (CDC) advises against using both in the same analysis.Each year, states—represented by their BRFSS coordinators and the CDC—agree on the content of the questionnaire. The questionnaire consists of a core component, optional modules, and state-added questions. Many questions are taken from established national surveys, such as the National Health Interview Survey or NHANES (National Health and Nutrition Examination Survey). This allows the BRFSS to take advantage of questions that have been tested and allows states to compare their data with those from other surveys. Any new questions that states, federal agencies, or other entities propose as additions to the BRFSS must undergo cognitive testing and field testing before being included. In addition, a majority vote of all state representatives is required before questions are adopted. The BRFSS guidelines, which are agreed on by the state representatives and the CDC, stipulate that all states ask the core component questions without modification. They may choose to add any, all, or none of the optional modules and may add questions of their choosing (state-added questions). Questions on alcohol consumption and a limited set of questions on other subjects are part of the core, additional questions on mental health and cognitive decline are optional modules, and Washington has inquired about firearm ownership and storage through state-added questions. The 2016 survey was the only one after the change in methods in which Washington added the cognitive decline modules.Data from the BRFSS are made available by the Washington State Department of Health, Center for Health Statistics, Behavioral Risk Factor Surveillance System and supported in part by the Centers for Disease Control and Prevention (cooperative agreements U58/SO000047-3 [2013], U58/DP006066-01 [2015], and NU58/DP006066-02-02 [2016]). Additional information on the survey can be found on the CDC Web site.References1. Centers for Disease Control and Prevention. Injury Prevention & Control: Data & Statistics (WISQARS). Atlanta: Centers for Disease Control and Prevention; 2019. Accessed at www.cdc.gov/injury/wisqars on 14 January 2019. Google Scholar2. Bennett S, Thomas AJ. Depression and dementia: cause, consequence or coincidence? Maturitas. 2014;79:184-90. [PMID: 24931304] doi:10.1016/j.maturitas.2014.05.009 CrossrefMedlineGoogle Scholar3. 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 Scholar4. Betz ME, McCourt AD, Vernick JS, Ranney ML, Maust DT, Wintemute GJ. Firearms and dementia: clinical considerations. Ann Intern Med. 2018;169:47-9. [PMID: 29801058]. doi:10.7326/M18-0140 LinkGoogle Scholar5. Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide and homicide victimization among household members: a systematic review and meta-analysis. Ann Intern Med. 2014;160:101-10. [PMID: 24592495] LinkGoogle Scholar Comments0 CommentsSign In to Submit A Comment Erin R. Morgan, MS, Anthony Gomez, BS, Frederick P. Rivara, MD, MPH, Ali Rowhani-Rahbar, MD, PhDUniversity of Washington17 September 2019 Authors' Response Dr. Ross has called to attention the assumptions on what constitutes safe storage. While preference for firearm storage techniques varies by owner circumstance, many professional medical and public health organizations have been consistent in messaging locked and unloaded storage as the safest practice.1 These positions are informed by decades of research beginning with the 1992 publication by Kellermann and colleagues which found associations between firearms in the home and suicide risk, which increased in magnitude when firearms were stored either unlocked or loaded.2 More recently, this question was assessed among adults over the age of 50, and storage was again found to be significantly associated with suicide death.3 Given the evidence supporting the association between locked and unloaded storage and reduced risk of suicide at all ages, and that several professional health organizations have published position papers supporting these methods, we believe that it is appropriate to consider firearms kept locked and unloaded as "safe" storage. Additionally, the availability of pushbutton locks on lockboxes can assure access to firearms within seconds, making such storage compatible with protection as the reason for owning a firearm. Dr. Ertle raised the important issue of implications of safe storage specific to an older adult population and means substitution if firearms are not available. Firearm ownership and risk of suicide among those aged 50 and older has been studied and results are similar to those of other age groups.3 Increased risk of suicide in older adults across the world is significant but is not solely explained by the availability of firearms. It is important to note that the case fatality of firearm suicide attempts is far higher than suicide attempts by other means.4 While individuals making serious attempts to die by suicide may use other means, these means are less likely to be fatal. Some other countries with a lower prevalence of firearm ownership may have higher rates of suicide among older adults; however, it is important to consider that the difference in firearm ownership is not the only difference between the United States and Japan or China. Complex cultural differences in healthcare, socializing, views of the older adults, stigma surrounding mental health, and honor—among other differences—may also partially explain higher rates of suicide despite limited access to firearms.5 We recognize that limiting access to firearms alone is not sufficient to prevent all suicide deaths. Nonetheless, this is one potential opportunity for prevention. 1. Butkus R, Doherty R, Bornstein SS. Reducing Firearm Injuries and Deaths in the United States: A Position Paper From the American College of Physicians. Ann Intern Med. 2018;169(10):704. doi:10.7326/M18-1530 2. Kellermann A, Rivara F, Somes G, et al. Suicide in the home in relation to gun ownership. N Engl J Med. 1992;327(7):467-472. 3. Conwell Y, Duberstein P, Connor K, Eberly S, Cox C, Caine ED. Access to Firearms and Risk for Suicide in Middle-Aged and Older Adults. Am J Geriatr Psychiatry. 2002;10(4):407-416. doi:10.1097/00019442-200207000-00007 4. Shenassa ED, Catlin SN, Buka SL. Lethality of firearms relative to other suicide methods: a population based study. J Epidemiol Community Health. 2003;57(2):120-124. http://www.ncbi.nlm.nih.gov/pubmed/12540687. 5. Cheng ATA, Lee C-S. Suicide in Asia and the Far East. In: Hawton K, van Heeringen K, eds. The International Handbook of Suicide and Attempted Suicide. Chichester, UK: John Wiley & Sons, Ltd; 2000. Alan R. ErtleEmeritus Enterprises, LLC7 August 2019 Household Firearm Ownership: Does it Make a Difference in the Elderly Suicide Rate? I read the article by Morgan and colleagues with interest. Approximately 1% of Americans will die by suicide (1). Older men and women show the highest suicide rate in almost all countries, including those with very limited access to firearms such as Japan and China where the rate of suicide in the elderly is nearly three times that found in the United States (2,3). The authors cite the article by Angelmeyer and colleagues that concludes that the access to firearms is associated with risk for completed suicide and being the victim of homicide (4). However, this article was not specific to the elderly and thus makes it quite difficult to extrapolate to that population. The authors conclude, "…limiting access to lethal weapons for the older adult population represents an important avenue for suicide prevention." Based on this study, it is impossible for the authors to conclude this. There is no evidence that limiting access to firearms would change the overall rate of suicide in the elderly in the US. Limited access to firearms might reduce the risk of suicide by firearms, but there is no evidence to support that the overall suicide rate would be reduced. This is supported by the higher rates of suicide in the elderly in countries with exceptionally limited access to firearms. With their logic, one should limit access to acetaminophen, ropes, automobiles, stairs, knives, bathtubs and a whole host of other potential suicide risks. 1. Centers for Disease Control and Prevention. [Accessed May 2014];FASTSTATS: Suicide and self-inflicted injury. Available at http://www.cdc.gov/nchs/fastats/suicide.htm. 2. World Health Organization 2017. [Accessed September 15, 2017]. Available from:http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/ 3. Conwell Y, Thompson C. Suicidal behavior in elders. Psychiatr Clin North Am. 2008;31(2):333–356.[PMC free article] [PubMed] [Google Scholar] 4. Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide and homicide victimization among household members: a systematic review and meta-analysis. Ann Intern Med 2014; 160:101-10. Kerry RossSalem Medical Center19 April 2019 "Safe" firearm storage The authors evidence a bias in their definition of what constitutes "safe" gun storage. If an individual chooses to own a firearm for the reason of protection of themselves/their family and their property then storing a firearm unloaded and locked away renders it useless for that purpose. If someone chooses to own a firearm for that reason - which is perfectly valid and legal - then it is perjorative to them to suggest that they are not storing their firearms in as "safe" a manner as other firearm owners. This is what is explicitly stated in the article and it is inappropriate. The true definition of "safe" is a subjective one that depends on the individual firearm owner's situation and personal beliefs/choices. Author, Article, and Disclosure InformationAffiliations: University of Washington, Seattle, Washington (E.R.M., F.P.R., A.R.)Public Health—Seattle & King County and University of Washington, Seattle, Washington (A.G.)Acknowledgment: The authors thankful personnel at Public Health—Seattle & King County and the Washington State Department of Health for their contributions. They also thank the directors and leadership of the local and state public health departments for their dedicated support and encouragement.Financial Support: State-added questions on firearms were funded by Clark County Public Health, Kitsap Public Health District, Public Health—Seattle & King County, Snohomish Health District, Spokane Regional Health District, Tacoma-Pierce County Health Department, and the Washington State Department of Health. This study was funded by Grandmothers Against Gun Violence. Data from the BRFSS are made available by the Washington State Department of Health, Center for Health Statistics, Behavioral Risk Factor Surveillance System and supported in part by the Centers for Disease Control and Prevention (cooperative agreements U58/SO000047-3 [2013], U58/DP006066-01 [2015], and NU58/DP006066-02-02 [2016]).Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-3698.Reproducible Research Statement: Study protocol: Available at www.doh.wa.gov/DataandStatisticalReports/DataSystems/BehavioralRiskFactorSurveillanceSystemBRFSS. Statistical code: Available from Ms. Morgan (e-mail, [email protected]edu). Data set: Available from https://fortress.wa.gov/doh/opinio/s?s=BRFSSDataOrderForm.This article was published at Annals.org on 16 April 2019. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoHousehold Firearm Ownership and Storage, Suicide Risk Factors, and Memory Loss Among Older Adults Erin R. Morgan , Anthony Gomez , Frederick P. Rivara , and Ali Rowhani-Rahbar Household Firearm Ownership and Storage, Suicide Risk Factors, and Memory Loss Among Older Adults Alan R. 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Ertle, MD, MPH, MBA 6 August 2019Volume 171, Issue 3Page: 220-222KeywordsDementiaElderlyFirearm injuriesHealth statisticsHealth surveysMedical risk factorsMemoryPrevention, policy, and public healthRacial and ethnic issuesSuicide ePublished: 16 April 2019 Issue Published: 6 August 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...