Older Firearm Owners and Advance Planning: Results of a National Survey
Authors: Marian E. Betz, Matthew Miller, Daniel D. Matlock, Garen J. Wintemute, Rachel L. Johnson, Conor Grogan, Hillary D. Lum, Christopher E. Knoepke, Megan L. Ranney, Krithika Suresh, Deborah Azrael
Journal: Annals of Internal Medicine (2020)

LettersFebruary 2021Older Firearm Owners and Advance Planning: Results of a National SurveyFREEMarian 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. Ranney, MD, MPH, Krithika Suresh, PhD, and Deborah Azrael, PhDMarian E. Betz, MD, MPHUniversity of Colorado Anschutz Medical Campus and VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, Colorado (M.E.B.), Matthew Miller, MD, ScDHarvard School of Public Health and Northeastern University, Boston, Massachusetts (M.M.), Daniel D. Matlock, MD, MPHVA Eastern Colorado Geriatric Research Education and Clinical Center, University of Colorado Anschutz Medical Campus, and University of Colorado School of Medicine, Aurora, Colorado (D.D.M.), Garen J. Wintemute, MD, MPHUniversity of California, Davis, Sacramento, California (G.J.W.), Rachel L. Johnson, MSUniversity of Colorado Anschutz Medical Campus, Aurora, Colorado (R.L.J., C.G., C.E.K., K.S.), Conor Grogan, MDUniversity of Colorado Anschutz Medical Campus, Aurora, Colorado (R.L.J., C.G., C.E.K., K.S.), Hillary D. Lum, MD, PhDVA Eastern Colorado Geriatric Research Education and Clinical Center and University of Colorado School of Medicine, Aurora, Colorado (H.D.L.), Christopher E. Knoepke, PhD, MSWUniversity of Colorado Anschutz Medical Campus, Aurora, Colorado (R.L.J., C.G., C.E.K., K.S.), Megan L. Ranney, MD, MPHBrown University, Providence, Rhode Island (M.L.R.), Krithika Suresh, PhDUniversity of Colorado Anschutz Medical Campus, Aurora, Colorado (R.L.J., C.G., C.E.K., K.S.), and Deborah Azrael, PhDHarvard School of Public Health, Boston, Massachusetts (D.A.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-2280 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: Approximately one third of older adults (aged ≥65 years) in the United States own a gun (1); some of them will develop dementia or other impairments that limit their capacity to handle firearms safely (2, 3). Little is known about the extent to which older gun owners have considered future firearm transfers.Objective: To use a nationally representative survey to describe the frequency of advance planning by older gun owners to transfer their firearms to someone else if they can no longer handle them safely or if they die.Methods: Data were obtained from the second National Firearms Survey, conducted online from 30 July to 11 August 2019 by the research firm Ipsos (4). The survey was conducted among a sample of participants in the Ipsos KnowledgePanel, a probability-based web panel of approximately 55 000 noninstitutionalized, English-speaking adults (aged ≥18 years) designed to represent the U.S. population, excluding persons in active military service. The survey sample comprised adults living in a home with firearms, regardless of whether they were gun owners themselves; however, we restricted our analysis to older adults who owned firearms. Participants received points for an Ipsos incentive program, and the Harvard University Institutional Review Board approved the study.Questions assessed whether respondents had a plan for transferring their firearms to someone else in the event of death or their inability to handle guns safely. Participant characteristics included demographics, caregiving for someone with dementia, and firearm-related measures (such as type and number of guns owned, reasons for ownership, training, and frequency of handling). Using the weight variable provided by Ipsos and weighting commands in Stata (version 16.1; StataCorp), we summarized the responses with descriptive statistics. We used study-specific poststratification weights to adjust for nonresponse and under- or overcoverage from the study-specific sample design, demographic distributions (from the U.S. Census Current Population Survey or American Community Survey), and such characteristics as gun ownership (from weighted KnowledgePanel data, for characteristics not available from the national surveys).Findings: The National Firearms Survey included 1001 respondents aged 65 years and older who were living in homes with firearms and were firearm owners themselves (completion rate, 71%; Table 1). These respondents had a median age of 71.0 years and owned a median of 3 firearms. Most were married (74.6%), White (81.4%), and male (73.7%). Although nearly half had handled a firearm once or less in the past year, 18.0% reported carrying a loaded handgun in the past month.Table 1. Demographic and Firearm-Related Characteristics of Firearm Owners Aged 65 Years and OlderAbout one fifth of older firearm owners had a plan for securing, removing, or transferring firearms if they became unable to handle them safely, either written (5.6%) or unwritten (16.1%) (Tables 1 and 2). Nearly half had a plan for transferring firearms to someone upon death, either written (22.5%) or unwritten (25.4%) (Tables 1 and 2). Of participants who had a plan for transfer if they became unable to handle their firearms safely, almost all (87.2%) also had a plan for transfer upon death.Table 2. Demographic and Firearm-Related Characteristics of Firearm Owners Aged 65 Years and Older, by Presence of a Plan (Written or Not) for Securing, Removing, or Transferring Firearms if They Become Unable to Handle Them Safely or for Transferring Firearms to Someone Else Upon DeathDiscussion: In this nationally representative survey, one fifth of older firearm owners had a plan for transferring firearms if they became unable to handle them safely, and half had a plan for transferring them upon death. To our knowledge, this is the first report to address the frequency and mode of contingency plans for firearm transfers due to cognitive or physical decline.Multimodal outreach through various venues might foster more frequent and informed planning about future firearm safety. Some older gun owners may prefer information disseminated through firearm outlets or similar "trusted messengers"; others may prefer education via health care providers (5), aging or dementia organizations, or other community sources. Including firearm-related issues in medical, financial, or legal advance planning also might be useful. Future questions include the utility of an "advance firearm agreement" (2) and the concept of "firearm retirement planning" as part of firearm ownership, as well as how this process parallels discussions about "driving retirement." Recent work suggests that few dementia caregivers have been counseled about firearm safety (4). This, combined with our study findings, highlights opportunities for improved engagement with older adults and dementia caregivers.Our survey included only English-speaking older adults living in homes with guns, so our results may not be generalizable. We did not explore reasons for having (or not having) plans, the sample size limited subgroup analyses, and acceptability bias may have resulted in overreporting of planning.Despite these limitations, this study highlights opportunities for enhanced future planning related to firearms. Informed by this work, trusted messengers—whether from the medical, legal, firearm, or other communities—can help prevent firearm injury by assisting in contingency planning for firearm retirement.References1. Parker K, Horowitz J, Igielnik R, et al. America's Complex Relationship With Guns. Pew Research Center; 2017. Accessed at www.pewsocialtrends.org/2017/06/22/americas-complex-relationship-with-guns on 27 July 2020. Google Scholar2. Betz ME, McCourt AD, Vernick JS; et al. Firearms and dementia: clinical considerations. Ann Intern Med. 2018;169:47-49. doi:10.7326/M18-0140 LinkGoogle Scholar3. Rosen T, Makaroun LK, Conwell Y; et al. Violence in older adults: scope, impact, challenges, and strategies for prevention. Health Aff (Millwood). 2019;38:1630-1637. [PMID: 31589527] doi:10.1377/hlthaff.2019.00577 CrossrefMedlineGoogle Scholar4. Betz ME, Azrael D, Johnson RL; et al. Views on firearm safety among caregivers of people with Alzheimer disease and related dementias. JAMA Netw Open. 2020;3:e207756. [PMID: 32667652] doi:10.1001/jamanetworkopen.2020.7756 CrossrefMedlineGoogle Scholar5. Pallin R, Spitzer SA, Ranney ML; et al. Preventing firearm-related death and injury. Ann Intern Med. 2019;170:ITC81-ITC96. doi:10.7326/AITC201906040 LinkGoogle Scholar Comments0 CommentsSign In to Submit A Comment Alan R. Ertle, MD, MPH, MBAEmeritus Enterprises, LLC6 October 2020 Does the lack of advance firearm planning for older adults matter? I read the article by Betz, et. al. with interest. It seems that this study suggests "solutions" without clearly defining the problem. While only a limited proportion of those surveyed had clear plans for transferring firearms should they become unable to handle them safely, with a greater proportion having plans to transfer them upon their death, there is no provided data that clearly indicates that this lack of planning leads to harm. This study also provides no evidence supporting the notion that additional planning by older adults regarding their firearms would prevent suicides or other firearms-related violence. The authors indicate that approximately one-third of older adults own a firearm, but there has been no significant indication that this, plus the lack of future planning regarding firearms, rises to the level of local, regional, or national concern. So why is it a problem now as it seems it has not been a significant problem in the past, despite older adults owning firearms since pre-revolutionary times? Additionally, where does this fit into the myriad of population health issues for older adults? Medication compliance and affordability, exercise, chronic disease management, fracture prevention, appropriate screening, and even driving automobiles by older adults are far more important and clearly defined issues. Given limited time and resources, should we as spend the time and money to develop an army of "…trusted messengers…" who can help address this "issue" or would our efforts best be spent elsewhere? Marian E. Betz, MD, MPH, Daniel D. Matlock MD, MPH, Garen J. Wintemute, MD, MPH, Deborah Azrael, PhDUniversity of Colorado Anschutz Medical Campus & VA Eastern Colorado Geriatric Research Education and Clinical Center (MB/DM); University of California Davis (GW); Harvard School of Public Health (DA)13 October 2020 Authors' Response We agree with Dr. Ertle that older adults and their family members face myriad health issues. We suggest that information about firearm safety could be easily integrated into other resources or counseling, and our group has developed "Safety in Dementia" (1) to support these considerations. As outlined in prior work, considerations about how and when to reduce firearm access for an older adult are critical in certain contexts – such as worsening dementia or suicide risk (2). Counseling by healthcare providers about these topics, when relevant, is supported by the public (3) and by dementia caregivers (4), although they also identify community organizations as a source for information. Suicide rates rise among older age groups, especially men, with firearms used in a majority of suicide deaths. Particularly in the context of dementia or suicide risk, reduced firearm access could prevent the likelihood of a serious injury or death. But the rationale for engaging older firearm owners in advance planning about firearm access is not solely for prevention of injury – rather, it is to respect autonomy and independence and hopefully minimize the emotional impact for adults and their families of non-voluntary transfers. Dr. Ertle mentions driving among older adults, which we think may be a model for conversations about firearm access. Prior work has shown that older drivers want time to prepare for future changes and want to maintain control of decisions, when they are able (5); facilitating a smoother transition (for example by engaging the "trusted messenger" the older adult has identified) may minimize the negative psychosocial impacts of driving cessation. Similarly, if an older adult already has a plan for when they would transfer firearms or otherwise reduce their access (e.g., development of specific impairments), it may facilitate that family conversation, should the situation arise. Polzer ER et al. "Safety in Dementia": Development of an Online Caregiver Tool for Firearm, Driving, and Home Safety. J Am Geriatr Soc. 2020;Jul 6. Betz ME et al. Firearms and Dementia: Clinical Considerations. Ann Intern Med. 2018;169(1):47-49. Pallin R et al. California Public Opinion on Health Professionals Talking With Patients About Firearms. Health Aff. 2019;38(10):1744-1751. Betz ME et al. Views on Firearm Safety Among Caregivers of People with Alzheimer Disease and Related Dementias. JAMA Netw Open. 2020;3(7):e207756. Betz ME et al. "Are you still driving?" Metasynthesis of Patient Preferences for Communication with Health Care Providers. Traffic Inj Prev. 2016;17(4):367-73. Fredrick VarsUniversity of Alabama School of Law24 October 2020 Better advance firearm planning This letter reports that about one fifth of older firearm owners in a nationally representative survey had a plan for securing or transferring firearms if they became unable to handle them safely (1). Only 5.6% of those plans were written. As the authors correctly observe, the survey "highlights opportunities for enhanced future planning related to firearms." But what form can and should such advance planning take? This comment offers three proposals. The first proposal is more and better use of an existing legal instrument: the gun trust. The survey results suggest untapped demand for this option: 16.1% of respondents had a plan, but not a plan in writing. A gun trust is a commonly used vehicle to control disposition of firearms and, with very minor modification, could turn these unwritten plans into legally binding arrangements (2). Health care providers could suggest this option to patients with early stage dementia, for example. The second proposal requires a legal change: enacting a statute to authorize a streamlined advance directive for firearms (3). This could make the benefits of a gun trust more readily accessible. A section on firearms could even be added to existing advance directive forms. Again, the survey results show the potential of such a change: 64.1% of respondents had written advance directives for health care. The final, and most important, proposal is to use innovative laws in two states to close a major loophole in advance firearm planning. The loophole is that, even if firearms are secured or transferred away from an unsafe owner, very little stops the person from simply buying a new gun (4). In Washington state and in Virginia, however, everyone has the option to add their name to a Voluntary Do-Not-Sell List that would prevent future gun purchases (5). The Voluntary Do-Not-Sell List is an underappreciated form of advance firearm planning, and not just for gun owners. Individuals who have chosen not to own guns---out of fear of suicide, for example---can solidify that choice. References Betz ME, Miller M, Matlock DD, et al. Older Firearm Owners and Advance Planning: Results of a National Survey. Ann Intern Med. 2020. https://doi.org/10.7326/M20-2280. Vars FE, Ayres I. Gun Trust as Private Red Flag Law. Probate & Property 2020;34(4). Ayres I, Vars FE. Weapon of Choice: Fighting Gun Violence While Respecting Gun Rights. Cambridge: Harv Univ Press; 2020. Betz ME, McCourt AD, Vernick JS, et al. Firearms and Dementia: Clinical Considerations. Ann Intern Med. 2018;169(1):47-49. doi:10.7326/M18-0140. Vars FE. Voluntary Do-Not-Sell Lists – An Innovative Approach to Reducing Gun Suicides. N Engl J Med 383;14:1299-1301. doi: 10.1056/NEJMp2011339. Author, Article, and Disclosure InformationAffiliations: University of Colorado Anschutz Medical Campus and VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, Colorado (M.E.B.)Harvard School of Public Health and Northeastern University, Boston, Massachusetts (M.M.)VA Eastern Colorado Geriatric Research Education and Clinical Center, University of Colorado Anschutz Medical Campus, and University of Colorado School of Medicine, Aurora, Colorado (D.D.M.)University of California, Davis, Sacramento, California (G.J.W.)University of Colorado Anschutz Medical Campus, Aurora, Colorado (R.L.J., C.G., C.E.K., K.S.)VA Eastern Colorado Geriatric Research Education and Clinical Center and University of Colorado School of Medicine, Aurora, Colorado (H.D.L.)Brown University, Providence, Rhode Island (M.L.R.)Harvard School of Public Health, Boston, Massachusetts (D.A.)Disclaimer: The contents of this work are the authors' sole responsibility and do not necessarily represent official views of the funders or of the U.S. Department of Veterans Affairs.Financial Support: This project was supported by the National Institutes of Health/National Institute of Mental Health/National Institute on Aging (grant R34MH113539-01) and the New Venture Fund (grant NVF-FFSF-Northeastern University-007811-2018-12-04). Dr. Knoepke was supported by a career development award from the American Heart Association.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-2280.Reproducible Research Statement: Study protocol, statistical code, and data set: Available from Dr. Betz (e-mail, marian.[email protected]edu).Corresponding Author: Marian E. Betz, MD, MPH, Department of Emergency Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, 12401 East 17th Avenue, B-215, Aurora, CO 80045; e-mail, marian.[email protected]edu.This article was published at Annals.org on 6 October 2020. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoOlder Firearm Owners and Advance Planning Fredrick E. Vars Metrics Cited byA Web-Based Decision Aid for Caregivers of Persons With Dementia With Firearm Access (Safe at Home Study): Protocol for a Randomized Controlled TrialCars, Guns, Aging, and "Giving Up the Keys"Firearm ownership, attitudes, and safe storage practices among a nationally representative sample of older U.S. adults age 50 to 80Understanding the circumstances and stakeholder perceptions of gun violence restraining order use in California: A qualitative study"Firearm access in dementia: legal and logistic challenges for caregivers"Firearm Suicides in the Elderly: A Narrative Review and Call for ActionOlder Firearm Owners and Advance PlanningFredrick E. Vars, JD February 2021Volume 174, Issue 2Page: 279-282KeywordsAgingCaregiversDementiaDisclosureElderlyFire safetyFirearm injuriesForecastingMotivationStatistical data ePublished: 6 October 2020 Issue Published: February 2021 Copyright & PermissionsCopyright © 2020 by American College of Physicians. 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