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Emergency physician Emmy Betz, MD, MPH, has yet to treat a gunshot wound inflicted at the hand of an elderly adult with dementia. When she had concerns about patients with dementia and their access to firearms, Betz talked with their caregivers about safety measures. “In those cases, thankfully, the weapons were all locked up,” she said. She’d like to keep it that way.
For Betz, an associate professor of emergency medicine at the University of Colorado School of Medicine in Aurora, those conversations come under the rubric of what she calls patient-centered injury prevention: “How do we, as clinicians, connect with patients to help them prevent injuries and live healthy lives?” By applying that concept to her 2 passions—conducting research on firearm suicide and elderly drivers’ safety—Betz turned her attention to firearms and dementia. In fact, she cofounded the Colorado Firearm Safety Coalition.
“It’s been a really fascinating area to work in,” she said. Just as elderly adults and their caregivers may agonize over when to give up the car keys, so too do many wrestle with when to put away their guns. “For folks going through this, it can be a really traumatic decision.”
In an era when 10 000 baby boomers reach age 65 years every day, Betz recently spoke with JAMA about the risks involved when dementia intersects with firearms kept in the home. The following is an edited version of that conversation.
JAMA:Do you think the risks of gun ownership or living in a home with a gun among people with dementia are underrecognized given that mass shootings attract so much attention?
Dr Betz:Yes, absolutely. When we look at the overall epidemiology of firearm deaths, suicides account for the majority of deaths. So mass shootings get a ton of attention, understandably so, but when we think about the risks our patients face, more often, it's risks from within the home. People often ask me whether dementia is really such a big problem. For a segment of the population who has someone with dementia and when there's a firearm in the home, it's a big deal and a tough issue. It doesn't affect the broad population the same way, but I do think it's been really underrepresented for how complex it is in that subset of the population.
JAMA:How common is gun ownership or living in a home with a gun among people with dementia?
Dr Betz:Prior work suggests somewhere between 40% and 60% of households that have someone with dementia also have a firearm.
JAMA:How does that compare with overall gun ownership among the general population?
Dr Betz:It's probably pretty similar. We know that firearm ownership rates are higher among men, especially middle-aged to older white men, but it's hard to know how that translates into populations with dementia. Very often people with more advanced dementia probably don't have firearms anymore. But we might suspect that that older age group with cognitive impairment or early dementia may have higher firearm ownership rates than, say, millennial populations. But we don't have great numbers. We're hoping to have some data later this year or in 2020.
JAMA:How likely is it that someone who's cognitively impaired will actually handle the gun, recall where it's stored, and how it operates?
Dr Betz:That's going to depend on the stage of dementia. You might imagine that in early dementia, when people are still pretty high functioning, that they may handle the firearm, especially a retired police officer or someone who is used to handling their weapon daily. As impairment progresses, it's likely that the frequency of handling might decrease. But we don't really know. Where we're really worried about frequent access is in the earlier to moderate stages of dementia. By the time people have severe impairment, they're probably not accessing weapons or able to go looking for them.
JAMA:Are people with dementia at greater risk of injury or death from a firearm they can easily access than people who don't have cognitive decline?
Dr Betz:Also something that we don't have a great answer for. We know that among all older adults, about 91% of firearm deaths are suicides. Very often, that's because of a firearm they own or one that is otherwise in the home. So when we think about folks with dementia, we do know that especially at the earlier stages, there may be an increased risk of suicide. Having a firearm we know increases that risk even more because of the lethality of that method compared to other methods. But in the context of dementia, we certainly worry about the potential risk to others in the home as well. There have been some horrific anecdotal experiences that caregivers have gone through, including sometimes being shot by loved ones.
JAMA:What is the primary care physician's role in this issue as you see it?
Dr Betz:Primary care physicians who care for older adults with cognitive impairment or early dementia should bring this up in the same way that we bring up things like driving and general home safety. It may not be an issue on the day of diagnosis, but it probably will become one. We know that firearm ownership, like driving and other things that can be closely tied to someone's identity, can be difficult to approach and difficult for individuals and families to deal with. Ideally, people have time to prepare and make decisions. What we really want is for families and the person with dementia to proactively decide where the firearms will be stored so that it doesn't come down to getting police involved or having someone get hurt. For primary care physicians, the first step is having it on the radar and directing people to resources that can help them make decisions.
JAMA:What are some of those resources?
Dr Betz:The Alzheimer's Association has some information about general home safety, including firearm safety. We've developed a web–based decision aid for caregivers of people with dementia to work through issues around firearm storage, transfers to other people, and your in-home and out-of-the-home storage options. It also includes information around driving and home safety. It’s at safetyindementia.com—a free resource we developed with grant support from the National Institute on Aging. We hope it will be useful.
JAMA:Would it be a good idea if caregivers, physicians, and perhaps patients used this resource together?
Dr Betz:Yes and no. I encourage physicians to be involved in these discussions and to plant the seed for these kinds of storage changes. At the same time, I think it's important to recognize that for these decisions, physicians aren't always going to be the most trusted source of information. It really depends on the situation. In some cases, we're seeing more involvement with firearm instructors, firearm retailers, and shooting ranges. Some patients and caregivers may prefer to get input from those kinds of organizations, and that's understandable. For physicians, though, it's great to be aware of these topics, to bring them up, and to know the resources in your community.
JAMA:What kinds of public policies or potential legislation do you think could help people with dementia, their caregivers, and physicians navigate this issue more effectively?
Dr Betz:It could make sense to clarify in state laws whether and how dementia is included in prohibitions. Now, for example, I believe it's only Hawaii and Texas that explicitly mention dementia in their state firearm ownership policies. I think there are some questions around transfers, how those work, and how and when caregivers can step in. Although in this case, a lot of it is more on the education end and encouraging these kinds of conversations, making it easier for family members to find the information they need to make decisions. From another policy standpoint, it will be important to track, moving forward, how extreme risk protection orders are or aren't used in cases of dementia, to understand whether that's something that family members and caregivers need.
JAMA:What other concerns should the health care community have about firearms and dementia?
Dr Betz:Another area is home health care workers. There are no good numbers on how often a home health care worker is potentially at risk, but I’ve heard anecdotes of some going in to work with a patient and there's a loaded handgun on the coffee table. That's an understandable concern for how we approach these issues. I would add that it's been wonderful to see collaborative work between firearm owners, firearm organizations, and suicide prevention groups. I'm similarly excited to see efforts developed between geriatrics and the firearms world about how we can really work with patients and family members to help them be safer.
JAMA:Are there any specific examples of collaboration with geriatric medicine?
Dr Betz:The first example is Alzheimer's San Diego, a local nonprofit organization in the community. It's been partnering with a firearm store to have materials about dementia in the store for customers and to train their employees about firearm safety and firearm handling so that they feel better equipped to work with caregivers and families. With their permission, we're adapting those materials to try to disseminate them through some of the firearm retailers that we work with here in Colorado. I would love to see higher level collaborations on a national scale between geriatrics or the Alzheimer's Association. It's early, but I think it's coming.
Voelker R. Firearms and Dementia: “A Big Deal and a Tough Issue”. JAMA. 2019;322(17):1639–1642. doi:https://doi.org/10.1001/jama.2019.15496
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