Preventing Gun Violence in Patients With Dementia

Ways to reduce the risk of violence from firearms by people with dementia were described during a webinar hosted earlier this week by the BulletPoints Project, an initiative that was authorized and funded by California’s state legislature in collaboration with the University of California.

Five million Americans, or 1.6% of the population, have Alzheimer’s dementia or related dementias. This number is projected to double by 2060, according to BulletPoints.

About one in three adults over age 65 own a gun, while another 12% live with a gun owner, said gun safety advocate Emmy Betz, MD, MPH, an emergency physician at the University of Colorado Hospital in Aurora, during the webinar.

The precise number of people with dementia who have access to guns is unclear. One survey from a dementia clinic found that 60% of families reported having a gun in the home, but Betz suggested that is “probably on the high end.”

While the numbers may be fuzzy, what is clear is that changes in personality, behavior, and cognition — all symptoms of dementia — can increase the risk of firearm injury, said Betz, who is also director of the Firearm Injury Prevention Initiative at the Injury & Violence Prevention Center at the University of Colorado.

“We want to support independent healthy aging and rights of older adults for as long as possible, but recogniz[e] that … in the progression of dementia, there comes a point when someone probably is no longer safe to have access” to firearms, she added.

When to Intervene

In offering her advice on preventing gun violence among people with dementia, Betz noted that there is no “gold standard set of rules.”

Dementia presents across a certain trajectory, Betz said. A person can have mild objective deficits, identified primarily through testing, but continue to be able to engage in the typical aspects of daily living, such as driving and grocery shopping. As the disease progresses, people with dementia may begin to show memory loss that can impede at least one of these aspects, she noted.

Later, as more “profound impairment” sets in, they may start to show behavioral symptoms, including hostility or aggression and lose the ability to recognize friends and family.

But during these earlier stages of mild cognitive impairment is when clinicians and others should “ideally” engage the older adult directly and empower them to begin making decisions and planning for future changes. This can include discussing access to firearms, the kitchen, and driving.

Asked whether there are observable behaviors that would indicate that it’s time to intervene, Betz said the focus should be on the person’s memory and their ability to recognize others.

“So, if somebody is really not recognizing trusted … family members, for example, that to me is a big red flag, because it could … pose a risk in the middle of the night, say, to the family members, or could pose a risk to somebody else coming over to the house,” she added.

Betz recalled a 2015 incident, where a woman named Dee Hill, 75, of The Dalles, Oregon, was shot in the stomach by her husband, Darrell Hill, a former local police chief, who had dementia, as reported by PBS in 2018.

Her husband was used to seeing his guns daily, Betz explained, and had persuaded her to let him at least look at one of them. “She thought it was empty,” she added. Hill survived the shooting, but it took 30 pints of blood and a 7-week hospital stay, according to PBS.

Betz also warned caregivers to look for “significant behavior changes,” including agitation, aggression, paranoia, and “new symptoms that were not part of the way they used to be.”

While a person with dementia may have the strength and the ability to use a firearm, the question to ask is whether they can do so responsibly.

“Can they think through their actions and the ramifications of potentially shooting someone?” Betz posed. If not, she urged friends, family, and caregivers to “trust your gut … imagine if something happened to them or to someone else in the household.”

Betz also stressed that the primary concern around firearms and dementia isn’t homicide, but suicide.

The use of a firearm is the most common means of suicide among people with dementia; 73% of suicide deaths in those with dementia were due to a firearm in comparison with 50% of suicide deaths in people of all ages.

Ways to Intervene

As for potential policy levers that might address these issues, Betz pointed out that only two states have legislation related to brain illness and firearms.

Hawaii prohibits possession of a firearm if a person has an “organic brain syndrome,” but there isn’t any clear distinction around the severity of the disease and it’s unclear how effectively the law has been applied.

In Texas, a person with dementia is prohibited from carrying a handgun, but that individual may still purchase a handgun or possess one, noted Betz.

In addition, federal background checks for firearms include “antiquated language” around a person being “a mental defective,” and while theoretically that could prevent a sale if the condition was logged, Betz said it’s unlikely that someone with dementia would be flagged and blocked from buying a gun.

Some states also have Extreme Risk Protection Orders or “Red Flag” laws, which are another potential tool that caregivers can consider if the person with dementia is the gun owner, Betz noted. These are essentially “gun violence restraining orders,” she said, and they are issued when a court deems an individual a risk to self or others.

However, to be clear, government measures may not be the complete answer. Betz drew a distinction between the legal right to a firearm and actual reduced access. As with driving, “you could lose your license and still get behind the wheel, if you have access to the keys,” she noted.

To that end, Betz and colleagues developed “firearm advanced directives,” which can help begin conversations around firearm access by asking a person with dementia to consider “who would you trust to tell you when it’s time” to give up access to a gun, and “what would you want to happen.”

Betz and team also recently developed the Safety in Dementia website and just received funding to test the tool and see if it helps caregivers in making decisions around firearm access.

She also cited a survey that asked caregivers where they might look for information about gun safety. Some responded that they would ask family and friends, others said healthcare providers and dementia groups, and a small number said firearm organizations.

“This is going to take all of us … I think we really need resources and tools across a broad spectrum of options for people,” Betz said.