COPENHAGEN, Denmark — A new report surveying access to guns by patients with dementia finds that among consecutive patients being evaluated for cognitive problems, caregivers and family members did not consistently remove guns from their homes or keep them in a locked state.

The study, a large survey from a single center, underlines the need for physicians to ask caregivers specifically about the presence of guns in the home and advise them on appropriate action to ensure the safety of both patient and caregiver, the researchers say.

"In conclusion, there is in the US and in our population, a significant presence of firearms in the homes of patients with dementia, and many of these patients suffer from delusions and hallucinations, some of which can be paranoid, persecutory or hostile," said Jason Hsieh, BS, a medical student at Cleveland Clinic Lerner School of Medicine, Case Western Reserve University, Cleveland, Ohio.

"This reinforces the importance of assessing for the presence of firearms during the initial visit," he concluded.

The results of the study, carried out at the Cleveland Clinic Lou Ruvo Center for Brain Health, were presented here at the Alzheimer's Association International Conference (AAIC) 2014.

Suicide, Homicide

In the United States, the elderly population has a relatively high rate of gun ownership; 27% of individuals over the age of 65 years own a firearm, Hsieh said. "In general, almost 40% of households in the US (38%) contain a firearm, and surprisingly, in households with a firearm, the average number of firearms is 6.6," he noted.

The elderly have the highest suicide rate of any segment of the population, and firearms are the most common as well as the most fatal method of suicide. Data from the National Trauma Databank in the United States show that as individuals get older, the proportion of gun injuries that are self-inflicted rises, and other data show that as they age, people are less likely to survive a gunshot and less likely to return home after recovery.

"In addition to suicide, elderly individuals can be the victim of homicide, and this often happens from their caregiver," Hsieh said. "Most of these events happen at home, and again, just like suicide, using a firearm is the most common method."

There are few primary data on firearms and elderly patients with dementia, he noted; most of the literature consists of editorials and review articles, or anecdotes and case reports. "One study done in the Veterans Administration confirms that just like in the nondemented population, suicide in veterans with dementia is most commonly carried out using a firearm, he noted.

Another previous study by Spangenberg et al followed 106 patients with dementia and found that 64 of them (60%) had guns in the home, Hsieh said. "Of those, nearly half of the guns were kept in a loaded condition and 38% were kept in an unknown condition," he said. "Now if you just add those up, only 17% of the guns were kept in a confirmed unloaded condition."

This group also found that gun ownership was equally prevalent in patients regardless of how severe their cognitive deficits were. "This makes the point that caregivers, families, and the patients themselves do not remove guns from the home with worsening dementia," he added.

The concern comes from the fact that patients with dementia more frequently display aggressive behavior than patients without dementia, and increasing dementia is associated with increasing agitation and aggression. Delusions, particularly misidentifications of people, are also associated with aggressive behavior in these patients, he added.

In this study, then, the researchers aimed to describe the prevalence of firearm access in patients who presented to their institution for evaluation of cognitive impairment. "Furthermore, we wanted to know how common dementia, psychotic symptoms such as delusions and hallucinations, and behavioral symptoms such as aggression were present in the patients with access to guns," he said.

After institutional review board approval, the researchers reviewed charts over 2 years for all consecutive patients who presented for initial evaluation for cognitive impairment, collecting demographic data, psychiatric measures (such as the presence of delusions and hallucinations), the degree of dementia, and the presence of depression.

They also noted social variables, including whether a firearm was present in the home and whether patients lived in their own home or a supervised setting.

Included in this analysis were 495 patients, with an average age ± standard deviation of almost 80 years (79.8±8.3), most of whom were female (63%).

The average Montreal Cognitive Assessment (MoCA) score was 16.1. On the PHQ-9, a screen for depression, the average score was 5.8.

Of these 495 patients, 378 (77%) qualified for a diagnosis of dementia, and 64% already had a diagnosis of depression or qualified for a new diagnosis of depression, the authors report.

Of those with an established dementia etiology, 46% had presumed Alzheimer's disease, 21% had vascular dementia, and 34% were classified as "other," including multifactorial dementia.

Of the 378 patients with dementia, 178 had delusions. One hundred forty-four were described in the chart, and among these, 114 of the delusions were described as paranoid or persecutory (ie, delusions that someone was stealing from them or other abuses).

Hallucinations were present in 92 of the patients with dementia; of those, 21 were described as hostile, Hsieh said. "In other words, they see someone attacking them, they see an imposter in the room," he noted.

Of the overall group, 89 of the patients had a gun in the home. Of those with a gun in the home, 62 (71%) had dementia; 33 (37%) had delusions, of which the majority (73%) were persecutory or paranoid delusions, and 15 (17%) had hallucinations, roughly half of which (47%) were hostile hallucinations.

The authors then compared the patients with and those without access to guns and found that in general, patients living in homes with guns tended to be younger, to live in their own home rather than a supervised setting, and to be male, although this difference was not statistically significant.

"In terms of MoCA, PHQ-9, the presence of depression, dementia, delusions, or any of the other measures we collected, there was no significant difference between the group with guns and without guns, Hsieh said. "That underscores the fact that the patients, their families, and caregivers do not consistently remove guns from the households of patients with dementia."

He noted that because this is a descriptive, exploratory study, they did not do strict adjustment for multiple hypothesis testing.

Table. Patients Living in Homes With and Without Access to Firearms

Variable Without Firearms With Firearms P Value
MoCA score 16.2 15.7 .49
PHQ-9 score 5.8 5.7 .82
Prevalence of dementia (%) 78.3 70.5 .13
Delusions (%) 35.8 37.1 .81
Hallucinations (%) 19.0 17.1 .76
Depression (%) 63.8 64.0 1.0


Strengths of their study include being the largest assessment to date of the prevalence of firearms in this population, Hsieh noted, and the first to assess the quality of the delusions and hallucinations experienced by these patients. However, because it used data from a single memory clinic, the results lack generalizability. Further, patients are all self-selected, presenting for evaluation for cognitive impairment, and it's possible that gun ownership may be under-reported.

Outcomes are still unknown for this group of patients in terms of what happens to those with and without access to guns, but it is something the researchers may be able to look at going forward, Hsieh told Medscape Medical News.

"Nonetheless, even though there's still a lot to study, this is an important first step towards understanding the public health concerns about this issue," he concluded.

"But I think that it's important for physicians to assess for the presence of firearms and recommend to the family that they take appropriate steps," Hsieh said.

Other studies in the past in the United States have found that as few as 4% and up to 60% of physicians dealing with this population report assessing for firearms at the initial visit, he noted during his presentation.

"I think the most important thing we try to focus on is, first, ask about this," agreed senior author on the paper, Babak Tousi, MD, Lou Ruvo Center for Brain Health. "Doctors need to ask and assess when there's a concern."

A Safety Issue Like Any Other

Asked for comment on this issue, Beth Kallmyer, vice-president, Constituent Services for the Alzheimer's Association in Chicago, Illinois, said her organization works on a daily basis with families about many safety issues.

"With an illness that's progressive and impacts your cognition, there are all kinds of safety issues that actually come up, and the use of gun is a safety issue, not unlike driving, using power tools, and cooking. I think one of the biggest challenges for families is to sort out when that safety becomes a problem that could be dangerous to the person with the disease, whatever the issue is, whether it's driving or guns," Kallmyer told Medscape Medical News.

"So it's important that we educate people around that as the persons' disease progresses, we have to continually reassess safety issues depending on who the person is, and what's going on," she said.

Specifically though, just because a patient may have past experience with guns doesn't predict that they will still be able to handle them safely once they have the disease, and given the progressive course, it's not clear at what point they may become confused, she pointed out. "They might not recognize a family member or a caregiver, they might think they're an intruder, and when guns are present, really bad things can happen."

Sometimes families opt to simply remove the ammunition, Kallmyer added, but patients may still be able to obtain other ammunition. Furthermore, she points out, "If there's a situation where someone has a gun in their hand, and emergency responders come to the house, they're not asking if it's loaded. So if you play it out, there are issues around people who don't have the cognitive ability to understand the situation. Safety with a gun requires cognitive skills, and once you don't have that, it could lead to a dangerous situation.

"So when we talk to families, we recommend that they remove guns and ammunition from the home when somebody has dementia," she said.

The Alzheimer's Association has a toll-free line for families staffed by masters-level counselors and social workers who can help with questions about these kinds of safety issues and help craft solutions that will fit the individual family, free of charge (1-800-272-3900).

Physicians should be asking families about this and other safety issues, she added, and underline for them that as things change with the patient, they should be reassessed regularly.

Mr. Hsieh has disclosed no relevant financial relationships.

Alzheimer's Association International Conference (AAIC) 2014. Abstract O3-09-06. Presented July 15, 2014.


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