Dementia sufferers facing talks on guns

The man had been a patient for decades, retired from a career in which firearms were a part of the job. He was enjoying his days hunting or at the shooting range with friends.

But episodes of confusion had led to a suspicion of dementia, and the nights were the worst. At sundown, he became disoriented, anxious and a little paranoid, and he had started sleeping with his loaded pistol under the pillow.

One night, he pointed it at his wife as she returned from the bathroom. It wasn’t clear whether he recognized her, but he was certainly confused — and she was terrified.

“I’ve had that patient several times,” said Dr. Michael Victoroff, then a primary care physician in Denver.

What Victoroff knew then is something that has now entered the conversation among primary care physicians across the country: It was time to have “the talk” with his patient about the safety of his guns when dementia had apparently set in.

“He trusts me implicitly,” said Victoroff, who teaches family medicine at the University of Colorado in addition to being a firearms instructor and competitive shooter.

“You’re the doc,” Victoroff would tell himself. “Somebody’s got to do it.”

As a patient’s memory falters and cognitive skills fade, what is to become of the firearms that have long been a source of pride and a mark of responsible adulthood? Should they be locked up? Disabled? Entrusted to someone else?

Those are the questions a group of physicians challenged their colleagues to discuss with their patients, in an essay published last week in the Annals of Internal Medicine.

Pediatricians and emergency room doctors have been debating for years when and how to counsel their patients about gun ownership and safety — and kicked up political controversy in doing so. But with so many gun owners reaching and well into their senior years, the essay writers appear confident that few would question a doctor’s motives in raising the safety of gun ownership when a person’s mental competence has come into question.

“No one would challenge you about discussing driving safety with a patient having memory trouble,” said Dr. Donovan Maust, a University of Michigan psychiatry professor who also practices in the Veterans Affairs Ann Arbor Healthcare System. “I don’t think anyone would question your discussing power tools.

“As a physician, my interest is in the safety of my patient and those around him,” said Maust, one of the essay’s authors. “So this feels like it would be negligent not to discuss this with a patient and his or her family.”

To make it easier, the essay authors offered a chart detailing the stages of dementia and the “clinical considerations” that each stage raises. They also proposed a draft “Agreement with My Family” — an advance directive of sorts for firearms.

And while they have made the case that while restrictions on gun ownership may be a political flashpoint, it is a simple matter of safety in the exam room — and therefore a legitimate topic of discussion.

“As with driving, physicians must balance the welfare and privacy interests of individual patients with the health and safety of patients’ families and the public,” the essay authors wrote.

In households where dementia patients have access to firearms, the doctors raised concerns about suicides, accidental shootings, theft and unauthorized use of guns.

The numbers underlying those concerns are striking.

Roughly 30 percent of adults over 65 in the United States are thought to own guns. Twelve percent more live in households with someone who does.

As seniors turn 70, their odds of developing Alzheimer’s disease in a given year jump from less than 1 percent (among those 65 to 69) to 2.5 percent (among those 70 to 74), and keep rising from there. By 2050, the number of older Americans with Alzheimer’s is expected to reach 13.8 million.

The new effort may build on an earlier program that has united physicians, public health experts and gun owner groups.

Close to two-thirds of the nation’s roughly 34,000 shooting fatalities yearly are suicides. Starting in 2009, the Gun Shop Project brought together these unlikely allies to reduce the number of suicides carried out with guns.

Veterans of the Gun Shop Project see the focus on dementia and guns as a natural next step.

“It wouldn’t be a big leap, and I would think the timing would be relatively similar” to a physician’s focus on a patient’s driving safety, said Jacquelyn Clark, who has owned Bristlecone Shooting, Training & Retail Center on the outskirts of Denver since 2015.

Clark said that while she has seen instances of forgetfulness on the part of longtime customers, it was her gunsmith who first came to her with concerns about dementia and firearms safety. Having watched a family member slide into dementia, he asked himself what he would want done with his guns if he could no longer use them safely.

“There’s really no support system out there that tackles this,” Clark said.