Monday, May 28, 2018
Here's a challenging but potentially important topic for many families on this holiday weekend.
Becky has a post last week about the importance of doctors asking older patients about guns as a safety risk. I've posted in the past, here and here, about related issues, including laws affecting registration of gun ownership when intervivos or testamentary trusts are used as the legal vehicle to pass down weapons to succeeding generations.
The New York Times continues the conversation with In Elderly Hands, Firearms Can Be Even Deadlier. From Paula Span's article:
While older adults make many fewer suicide attempts than younger cohorts, they die more often, in part because they use such lethal methods. Yet health care providers who ask older patients about driving and wandering may not ask about guns.
“Safety planning for adults with dementia is something every clinician thinks about, but I don’t think firearms are often on the radar,” said Dr. Donovan Maust, a psychiatrist at the University of Michigan Medical School and co-author of a recent article on guns and dementia in the Annals of Internal Medicine.
They should be. At various stages of dementia, people may grow unable to distinguish loved ones from intruders. Their decision-making ability deteriorates. They can become paranoid, depressed, impulsive, agitated or aggressive.
Dr. Maust's co-authored commentary, linked above, is worthy of closer reading. Perhaps in an attempt to allay the fears of gun owners that dementia is not an automatic disqualifier for gun ownership, the piece suggests that doctors consider the stage of any neurocognitive impairment as part of a multi-party discussion about access:
A diagnosis of cognitive impairment or dementia does not in itself mean that a person should not have access to firearms—the level of cognitive impairment is probably most important. In a recent review, Patel and colleagues proposed using the clinical dementia rating scale to estimate the stage of dementia and the person's ability to safely complete complex tasks, including firearm handling.
For patients with minimal cognitive impairment, approaches could be similar to those related to driving, including acknowledging the emotions involved and allowing the PWD [person with dementia] to maintain agency in the decision for as long as it is safe. As with an “advance driving directive”, PWDs, their family members, and their health care providers may proactively discuss firearm access and consider setting a “firearm retirement date”. This patient-centered approach may allow an older adult to maintain decisional control and identify trusted family members or providers as future surrogate decision makers. To our knowledge, no one has tested the acceptability or efficacy of this approach.