Firearms in Frail Hands

Abstract

The incidence of neurocognitive disorders, which may impair the ability of older adults to perform activities of daily living (ADLs), rises with age. Depressive symptoms are also common in older adults and may affect ADLs. Safe storage and utilization of firearms are complex ADLs, which require intact judgment, executive function, and visuospatial ability, and may be affected by cognitive impairment. Depression or cognitive impairment may cause paranoia, delusions, disinhibition, apathy, or aggression and thereby limit the ability to safely utilize firearms. These problems may be superimposed upon impaired mobility, arthritis, visual impairment, or poor balance. Inadequate attention to personal protection may also cause hearing impairment and accidents. In this article, we review the data on prevalence of firearms access among older adults; safety concerns due to age-related conditions; barriers to addressing this problem; indications prompting screening for firearms access; and resources available to patients, caregivers, and health care providers.

Case

An 80-year-old male retired accountant was admitted to an inpatient medicine service for the evaluation of altered mental status after shooting at his neighbors in the middle of the night. The patient had a history of hypertension, was noncompliant with medicines, and frequently missed scheduled appointments. The patient believed that his neighbor’s house belonged to him, and that his neighbor was not paying rent, and was stealing his gas. One night, he aimed at the lighted window of his neighbor’s house with his handgun and fired a few shots. The police ascertained that the neighbor’s house did not belong to the patient and requested an Adult Protective Services investigation. A mandatory geriatric assessment resulted. On evaluation, he scored 23 out of 30 on the Mini-Mental State Examination, with errors in recall, calculation, attention, and visuospatial domains.

What Motivates Older Adults to Possess Firearms?

Many older adults with guns are continuing ownership that began decades earlier. They may own firearms for self-defense, hunting, collection, or other purposes. They may consider ownership a right and an indicator of independence, even if they are no longer able to manage the firearms due to frailty. Notably, the firearm industry advertises its products to senior citizens. For example, in the Concealed and Carry Magazine, there is an “Armed Senior Citizen” column that has articles titled “Senior Citizen Defensive Realities,” “Hold on to Your Gun! Weapon Retention Means Survival,” and “Bear Arms in a Wheelchair.” The “Palm Pistol” has a single chamber firing mechanism that can fire by squeezing a ball instead of conventional trigger and is advertised for older adults with arthritic hands. ¹

Screening for Firearms Possession in Individuals With Cognitive Impairment and Depression

There is a paucity of published medical literature on firearms safety in older adults. A recent national firearms survey conducted in 2004 indicates that 27% of those 65 years of age or older own a firearm. ²

The Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) classifies neurocognitive disorders (i.e., cognitive impairment) into mild neurocognitive disorder (i.e., mild cognitive impairment or MCI) and major neurocognitive disorder (i.e., dementia). A mild neurocognitive disorder is a modest cognitive decline in one or more cognitive domains without affecting activities of daily living (ADLs) but often increasing the effort that is required to complete these activities. A major neurocognitive disorder (or dementia) is a decline in cognition that interferes with at least one ADL. Individuals with suspected cognitive impairment routinely undergo assessment for home safety, ability to perform instrumental and basic ADLs, and perhaps driving as a part of their geriatric or neurological care. Unfortunately, screening for firearms safety is not usually performed in clinical practice, since it is not usually considered an “ADL”.

Improper handling of firearms can result in harm to an older adult as well as those around him or her. Additionally, it is often a means to suicide in a person with depression. In the United States, males aged 85 and older have the highest suicide rate of 43.6 per 100 000, followed by the age-group 75 to 84 with the rate of 30.4 per 100 000. ³ Firearms are responsible for more than 50% of these suicides. ³ Data from the United Kingdom find that 44% of perpetrators of homicide aged 65 or older had depression at the time of offense. ⁴ In a review of data on suicide trend among US veterans with diagnosis of dementia, 75% of all suicides occurred within 3 years of the diagnosis of dementia. Depression was also noted in 59% of those who committed suicide, and firearms were used in 72% of these suicides. ⁵ However, health care providers do not routinely screen for access to firearms during evaluation of patients with depression. Veterans Administration (VA) data on primary care encounters of Afghanistan and Iraq war veterans indicate that only 15% of encounters with positive suicidal risk assessment included discussions about firearms access. ⁶

There is a lack of validated tools to screen for firearms possession in older adults with cognitive impairment or depression. The Injury Control and Risk of Injury Survey (ICARIS) is a public survey conducted by the National Center for Injury Prevention and Control to obtain information on adult injuries. It includes questions about access to, storage, and use of firearms in the past year. There are two questions adapted from the ICARIS-2 survey that may be particularly useful to clinical practitioners:

1. Are there any firearms in/around home?

2. Any firearms kept loaded and unlocked in/around home?

These two questions could be combined with a validated depression screening tool (such as Geriatric Depression Scale, Beck Depression Inventory, or Patient Health Questionnaire 2/9). In case of a new diagnosis of dementia or during follow-up of patients with dementia, the clinical dementia rating scale (CDR) ⁸ can be used to stage dementia and assess an individual’s ability to perform complicated tasks, including ability to safely handle firearms (see Table 1).

Table 1.

Recommendations for Firearms Screening Based on Stages of Dementia (Adapted from “Firearms and Dementia: A Smoking Gun?.” ⁹ ).

Stage of Dementia	Presenting Features	Screening	Recommendations
Mild cognitive impairment (CDR = 0.5)	Mild memory loss Objective cognitive deficits with testing Intact ADL, although they may require more effort	Firearms in home? Loaded and unlocked? Judgment, insight, personality changes? Depressive symptoms?	If no evidence of impairment in judgment or insight, and no behavior or depressive symptoms, recommend practical firearms update course Otherwise, consider neuropsychological or psychiatric referral for definition and treatment of condition Interval reassessment of cognition and ability
Mild dementia (CDR = 1)	Moderate memory loss, interfering with at least one ADL Patients are usually aware of some deficits but lack full insight There may be behavioral symptoms such as hostility or delusions	Obtain information from patient and informant (family) regarding: Firearms in home? Loaded and unlocked? Judgment, insight, personality changes? Depressive symptoms?	Educate patient and family about supervised access to home firearms (check ownership law in jurisdiction) Counsel patient/family to restrict access to firearms if appropriate If psychosis or other behavior problems are present, or if patient refuses to allow restrictions in access, inform authorities and at risk individuals If patient has intact judgment and insight, and is willing to be supervised, recommend practical firearms update course and interval reassessment of cognition and ability
Moderate and severe dementia (CDR = 2-3)	Severe memory loss interfering with multiple ADLs and impairments in: Visuospatial and executive function Praxis Usually has personality and behavior changes May not recognize friends, family	Obtain information from patient and informant (family) regarding: Firearms in home? Loaded and unlocked?	Should not have access to any firearm. Consider immediate risk if patient has access and there are behavior, depressive, or personality problems. Consider involving law enforcement. Family/support system should remove firearms and ensure restrictions in force 24 × 7 to prevent patient access If patient does not permit restriction or if there is inadequate family/support system, inform authorities and at risk individuals

Abbreviations: CDR, clinical dementia rating scale ⁸ ; ADLs, activities of daily living.

Just as some patients with MCI may be able to drive safely at the time of assessment, some patients with cognitive impairment who have intact judgment and insight may be able to handle firearms safely. Education of family members regarding the need to monitor patient function and bring changes to the attention of the clinician may be helpful in ascertaining a “firearm retirement date.” If any concerns about firearms safety exist, for example with individuals with behavioral disturbance due to dementia or major depression, health care providers should recommend removal of firearms from the house, typically by selling them to a licensed dealer, in accordance with current firearm laws in their states. Caregivers can also be advised to contact the local law enforcement office to help with safe disposal. If the weapon is not registered, then the family can ask the local law enforcement agency to dispose of it legally, without prejudice, when the owner is cognitively impaired. Individuals with access to care at the VA can be referred to the VA’s firearm safety program, which provides free information and gun locks for safe storage of firearms.

Legal Challenges

The Second Amendment to the US Constitution protects an individual’s rights to own firearms. However, numerous shootings in public places during the past few years have resulted in significant concern about public health implications of existing firearm laws.

Variation in firearm-related laws by state limits the ability of any health care organization to offer general guidelines to health care providers to counsel patients regarding firearm safety. For example, Nebraska and South Carolina require applicants for a gun license to show “proof of vision” such as a valid state driver’s license or a statement from an optician. ^10,11 In Iowa, persons with physical disabilities, including blindness, cannot be denied the ability to purchase a firearm. ¹² Florida’s Privacy of Firearm Owners Act penalizes health care providers with fines and disciplinary action if they document firearm-related information in the patient’s medical records when it is “not relevant to the patient’s medical care or safety, or the safety of others.” ¹³ Some states have laws that prohibit carrying concealed weapons in “weapon-free zones” including hospitals, hospital affiliates, mental health facilities, and nursing homes. Other states permit concealed carry in any facility unless the facility specifically prohibits concealed weapons. The Brady Handgun Violence Prevention Act mandates background checks on purchase of firearms by a federally licensed dealer, manufacturer, or importer but it doesn’t apply to online or gun show sales. Some states require permits for handguns but not long guns. There are no laws mandating the storage of guns. The Firearm Concealed and Carry Act in Illinois requires health care facilities and clinicians to report to the Illinois Firearm Owner Identification Mental Health Reporting System patients who they believe pose a threat to themselves or others. ¹⁴ However, there is a lack of such laws in many other states. Additionally, the Act specifically includes those who are “developmentally disabled/intellectually disabled” but not specifically those who are demented.

In Japan, where there are fewer firearm-related casualties (10 per 100 000 in United States vs 0.06 per 100 000 in Japan ¹⁵ ), an applicant for a firearm license must pass a background check, including a review of criminal and mental health records. Additionally, the gun owner must reapply and requalify for firearm license every 3 years. Civilians in Japan are not allowed to possess hand guns or semi- and fully automatic assault weapons. ^16,17

In Canada, an applicant for a firearm license has to pass a background check, including review of criminal, mental, addiction, and domestic violence records. The background check also involves third-party character references and interviews with applicant’s spouse, partner, or next of kin before a gun license can be issued. The gun owner must reapply and requalify for firearm license every 5 years, and authorities maintain a record of licensed individuals. Private possession of fully automatic weapons is prohibited in Canada. ¹⁸

Recommendations

The case of our 80-year-old patient shooting at his neighbor’s house highlights how possession of a firearm by an individual with cognitive impairment, impaired judgment, and delusional behavior can endanger lives of those around him.

There is a need for validated screening tools for firearms possession in older adults due to age-related conditions. Physicians could counsel elders who are cognitively intact but have vision or mobility impairments to consider a practical firearm training update course to optimize safety. Physicians who are caring for patients who are cognitively impaired should assess the degree of impairment (see Table 1) if there are concerns regarding a patient’s ability to store, load, and use firearms. There is a need for law reform mandating that individuals applying for or renewing a firearm license provide evidence of visual and physical ability to handle the firearm safely and effectively. Families of patients with dementia who find unregistered weapons also need avenues for safe and legal disposal, and clinicians should be able to counsel patients and families as well. Finally, there is a need for state laws to protect health care providers who question patients about ADLs including gun possession so that they can document and report their concerns without threat of penalty or disciplinary action.