Tuesday, February 26, 2019

Knocking on a Patient’s Front Door at the Intersection of Dementia and Firearm-Safety

As a physician I view the recent public discourse on gun violence and firearm safety as timely and essential.  Apparently I am not alone, as evidenced by the American College of Physicians position paper on firearm injuries released last year, and then by the visceral Twitter hashtag #ThisIsOurLane that went viral after a tweet by the National Rifle Association admonished “self-important anti-gun doctors to stay in their lane.”  It seems that tens of thousands of my valiant colleagues who face the acute- and post-acute effects of gun violence every day were not quite ready to cede their moral and intellectual authority as healers and leaders to the NRA.  Maybe that’s because many of them are military service members or gun owners themselves.

But as a geriatrician, looking upstream into the community - where many of my physician and non-physician colleagues are knocking on the doors of older adults every day to provide medical care, home health, rehabilitation, hospice and other services -  it is the coincident growth of gun ownership and dementia that has me thinking about the safety of our patients, their caregivers and our workforce alike.  

This intersection of dementia and firearms in our communities is truly astounding.  It is estimated that over 50% of persons with dementia now live in a household with a firearm, a concerning statistic given that nearly 20% of persons with dementia will experience violent or aggressive behavior over the course of their disease, and the total number of persons with dementia is expected to rise by over 10 million by 2050.  While there is little data on the estimated number of firearms per patient, 1 in 5 guns in the home have typically been gifted or inherited, making it likely that anecdotal stories of five, ten, even 20 guns per household represent the norm more than the exception for older adults.  As former military service members, law enforcement officers or sportsmen and women, many of our older patients’ interest in, and experience with firearms is lifelong.  Ample time to collect, store, or have been gifted multiple firearms, now possibly in various states of accessibility, readiness or even neglect or disrepair.  

Why does this matter for the small army of home-based healthcare providers that knock on the front doors of older adults with dementia each week?  For the geriatricians, nurses and nurse practitioners, home health and hospice aides, social workers, rehab specialists, case managers, DME delivery drivers, and volunteers from community agencies like Meals on Wheels?  

Unfortunately, stories of caregivers injured or fatally wounded at home by their demented loved ones are no longer rare, and neither are cases of mailmen or neighbors confronted with a pistol-waving older adult on the porch.  Many a home health RN have conducted assessments with a patient’s firearm in plain sight, and they will tell you it can be more or less threatening depending on the patient and the situation.  As for management, agencies are struggling with policies that balance the safety of their workforce with the preferences and freedoms of their patients, which has led in some cases to a reduction of services or an outright refusal to provide care in homes where guns are unsecured.  Though no policy can guarantee safety 100% of the time, home care agencies and home-based practices have a responsibility to align their policies and procedures with the safety of their employees.  Unfortunately access to care may suffer if the perceived threat is too great.  After all, if services can be curtailed due to unsafe hoarding or blatant fire-hazards, then limiting services to homes with unsecured or loaded or brandished firearms is not a stretch.

Like all complex geriatric issues, our approach to the now-intertwined issues of firearm safety and access to home-based care for older adults with dementia will require a multidisciplinary and multifactorial approach.  Many of the better-known strategies are listed below, along with a few ideas that may help as well:
  • Data: Robust data and research has made cars, medications, and tobacco safer - without taking any of those items away from people - and we should allow and support that same level of inquiry for firearms. It is time to let our discussions on firearm safety be guided by high quality data, not by special interest group-think and advocacy alone. 
  • Awareness: Efforts by the Alzheimer’s Association, Dementia Friendly America and others have alerted the public to the high prevalence of older adults with dementia in all aspects of life, in order to raise bystander awareness of this disease.  Similar efforts with the law enforcement community and social service volunteers, highlighting the prevalence of gun ownership and it’s overlap with dementia, will increase their sensitivity to the issue and better prepare them for what they may find when entering the home of someone with dementia, especially if that person is alone.
  • Screening by Physicians: Some physicians are hesitant to inquire about firearms because they are unsure what to do with that information.  I would suggest that physicians put themselves in the shoes of the home-health nurse they may end up sending to that patient’s home.  He or she will ring that patient’s doorbell for the very first time, and knowing what to expect is always better.  While there is no standard evidence-based tool for screening, common sense approaches include:
    • Asking about any guns in the home during a cognitive work up for suspected memory loss
    • Adding guns to the list of common safety concerns - gas stoves, cars, power tools, heavy machinery - when counseling patients with dementia and their families. 
  • Gun ‘contracts’ or ‘trusts’ between patients, their family members and care providers: Adapted from sample agreements about unsafe driving, these allow for the issue to be talked about openly (often the hardest part), recognizes the patient’s desire to continue to use or handle their firearms, honors the patient as the responsible party for both the firearm and for the safety of those around them, lays out specific conditions under which it may be time to put the firearm in the care of a less cognitively impaired person, and occasionally sets a date certain when that will happen.  
  • Red-Flag Laws: Eleven states have already passed or are working on laws that more clearly delineate - for family, for local law-enforcement and for the courts - when and how firearms can or should be urgently removed from the home for reasons of mental defect or alarming behavior.  Ironically the issue is sometimes less about the person with dementia who may be licenced and well versed in firearm safety, and more about the caregiver or family member who accepts the firearm for safe-keeping.  That person may have no license, no training, and little know-how, which can lead to adverse outcomes for them personally, legally and financially.
  • Community partnerships: Gun owners with dementia are unique but they are first-and-foremost members of our communities, our neighbors, our friends. Local community engagement can help: gun shop and firing range owners, local law enforcement, veterans groups, gun clubs and currently enlisted service men and women are all potential allies when it comes to the intersection of firearms and dementia.  They are often strong proponents of the 2nd Amendment, but they also prize safety and security for the elders in their communities and the healthcare workers who transition in and out of those homes every day.  Home visitation by a fellow enthusiast or veteran with unloaded weaponry, trips to the range to handle guns in a safe environment, help from law-enforcement for family members who realize there are far more guns in the home then their loved-one with dementia can maintain, secure or even catalogue.  A variety of opportunities exist to engage with and learn from the experienced gun users in the community; their support should be sought out and welcomed.

Firearm safety is a pressing concern for persons with dementia and the caregivers and healthcare workers who support them at home.  But just as we strive to ensure that an opera lover with dementia is not cut off from the theatre when their memory fails, we must not indiscriminately deny a gun-enthusiast his or her enjoyment as a side-effect of impaired cognition.  Rather we should help families and caregivers talk openly about firearms, let high-quality data guide our policies, engage our community partners for help and expertise, and do our best to ensure that the courageous caregivers and providers who ring doorbells across town each day have confidence that a safe environment awaits as they step acros that next threshold to do some good.

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