The population of the United States is growing older and people are living longer than ever before. With these increases in life expectancy, health concerns such as Alzheimer disease and related dementias (ADRD) are becoming more prevalent. The existent literature suggests that persons with dementia (PWD) may be at high risk for self-harm or aggressive behavior toward others1,2; however, less is known about how these behaviors may further increase the risk of self or inter-personal harm when juxtaposed with firearm access among older adults.3
In their article published this week in JAMA Network Open, Betz and colleagues4 highlight PWD and their caregivers as an important, but understudied, group of individuals who own or have access to firearms and are potentially at high risk for injury incidents. Caregivers for PWD were surveyed only if they resided in a firearm-owning household. Authors delve into practical and timely questions, such as the frequency by which providers are discussing firearm safety with caregivers and the knowledge among caregivers for PWD about risk for firearm injury.4 The authors have done a commendable job in beginning to estimate the proportion of residents of firearm-owning households who are providing care to PWD—some of whom also have access to household firearms. They found that among caregivers who cohabitate with PWD in firearm-owning homes, 31% of caregivers reported that the PWD could access a gun. Over 80% of caregivers agreed that there are times when it is appropriate for health care professionals to discuss firearms with patients in the context of ADRD, and nearly 65% of caregivers reported that they had looked or would look to health care professionals for information about firearm safety; nonetheless, very few caregivers reported a health care practitioner ever broaching the subject.4 The lack of dialogue between patients, caregivers, and clinicians may at least partially explain why of the 11% of caregivers who expressed concerns about PWD having firearm access, only 53% reported that they or family and friends acted on that concern.4
Estimates of gun ownership and access among PWD vary widely reflecting some of the foundational challenges facing researchers and clinicians for prevention. As clinicians and families continue to care for an aging population, there is a need to quantify how many PWD have access to firearms and this study has begun to do just that within the subset of PWD cared for or living with someone who lives in a gun-owning home. Future qualitative work can shed light on how both intentional and unintentional injuries involving firearms and PWD unfold; the majority of respondents who lived in firearm-owning homes and cared for PWD listed “accidental” injury as their top concern.4 Determining the true frequency of these incidents and the manner in which they play out will help both clinicians and caregivers find potential points of effective intervention.
Some guidelines addressing firearm safety and conversations in clinical settings have been published for PWD and health care professionals.5 These guidelines are primarily written with clinicians in mind and frame the issue of firearm safety the same way that experts frame other concerns for injury among older adults and PWD. The clinical considerations also suggest that it is better to have these crucial conversations as early as possible, which may help reduce the amount of time that a PWD has access to a firearm and thereby remains at risk for injury. This would also grant agency to individuals just beginning to exhibit symptoms of cognitive decline in the decision-making process and allows them to determine what solutions best meet their needs. Unfortunately, most caregivers in this survey reported that they have not had these conversations.4 This is an opportunity to reflect on this shortcoming and plan to improve moving forward.
The responsibility of leading discussions around firearm safety with older patients and those at early stages of cognitive decline should not fall solely to clinicians. Friends, family, and caregivers for PWD all have an obligation to keep their loved ones safe. People value the input of their friends and family when making decisions around firearm ownership and storage.4,6 Many understand the necessity of eventually letting go of the car keys, and conversations around firearm safety can be similar. When these conversations begin in earlier stages of dementia, family and friends can reassure loved ones that they are cared for and are keeping their best interests in mind when making these recommendations and initiating pertinent discussions. These conversations are likely to become more difficult as cognition declines. In the study by Betz et al, caregivers reported that they would also seek advice from Alzheimer groups at the national and local levels.4 Collaborations between researchers in firearm injury and those in the field of aging will be essential in providing accessible messaging to PWD and their caregivers.
There is little research on which firearm injury prevention strategies can be most effective for older adults and how they can be tailored to meet the needs of PWD. One-on-one conversations are not the only tool in preventing firearm injuries among PWD. Policy is another mechanism to mitigate potential risk. Laws governing purchasing prohibition and dispossession differ across the country; 2 states—Texas and Hawaii—have explicitly included dementia as a prohibiting factor in attempts to reduce risk for firearm injury.7 States across the country continue to introduce extreme risk protection order policies—so called “red flag laws”—which allow for the removal of a firearm from those who may be at high risk of harming themselves or others. These policies are not designed to be punitive in nature but rather to reduce injury risk when concerns are recognized, and grant the respondent due process and the opportunity to maintain or restore their possession rights when the immediate risk has subsided. Betz et al found that among the 17% of respondents caring for firearm-owning PWD, only 20% reported that there was a written plan in place for securing, removing, or transferring guns if it became unsafe for the PWD to handle them.4 In the absence of these written agreements, extreme risk protection orders and similar policies may be of special importance for PWD.
As the burden of ADRD continues to grow, the injury prevention community must dedicate efforts toward mitigating the potential harms of firearm access among PWD. Betz et al found that only 5% of caregivers had ever discussed firearm safety with a clinician and that caregivers residing in a firearm-owning household reported the common misconception that an unintentional injury is the most likely potential cause of firearm injury.4 This suggests opportunities to improve the safety of PWD in our communities led by clinicians, public health experts, and policy makers. These opportunities may include, but are not limited to collecting additional data on firearm ownership, acquisition, and use among PWD and their households; providing training for clinicians and families on firearm safety for PWD, including written plans of action for safe storage and removal if or when symptoms of ADRD worsen; communicating to families that extreme risk protection orders are available should ADRD symptoms warrant the removal of a firearm; and improving messaging about firearm safety among older adults to the community. Only through such concerted efforts can we meaningfully reduce the burden of firearm injury and death in this vulnerable population.
Published: July 15, 2020. doi:10.1001/jamanetworkopen.2020.11182
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Morgan ER et al. JAMA Network Open.
Corresponding Author: Erin R. Morgan, MS, Department of Epidemiology, School of Public Health, University of Washington, 1959 NE Pacific St, Health Sciences Bldg, F-262, Box 357236, Seattle, WA 98195 (email@example.com).
Conflict of Interest Disclosures: None reported.
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Morgan ER, Rowhani-Rahbar A. Firearm Safety in an Aging United States. JAMA Netw Open. 2020;3(7):e2011182. doi:10.1001/jamanetworkopen.2020.11182
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