Jason K. Hsieh, BS; Jalayne J. Arias, JD, MA; Nehaw Sarmey, BS; Jonathan A. Rose, MS; Babak Tousi, MD
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=L15-0299.
Hsieh J., Arias J., Sarmey N., Rose J., Tousi B.; Firearms Among Cognitively Impaired Persons: A Cross-sectional Study. Ann Intern Med. 2015;163:485-487. doi: 10.7326/L15-5138
Download citation file:
Published: Ann Intern Med. 2015;163(6):485-487.
Background: Firearms in the homes of persons with dementia may pose a risk for serious harm to themselves or others. Prior research suggests that patients with dementia and their caregivers infrequently remove firearms from the home (1). How often firearms remain in the homes of these patients—and whether they have additional symptoms that may increase their risk for harm—is not well-known.
Objective: To determine the frequency of firearms present in the homes of patients evaluated for dementia and the frequency of delusions, hallucinations, and aggressive behavior among this population.
Methods and Findings: In this institutional review board–approved retrospective study, we reviewed the records of all consecutive patients presenting to a single outpatient memory clinic at a tertiary academic center for the initial evaluation of cognitive impairment between October 2011 and October 2013. All patients were evaluated clinically and by standardized measures (such as the Montréal Cognitive Assessment, Patient Health Questionnaire-9 depression scale, and verbal fluency). We recorded whether patients had any documented "behavioral symptoms" defined as physical or verbal aggression toward themselves or others. Firearm presence in the home was uniformly assessed as part of a safety questionnaire administered according to the standard of care. All patients (and caregivers, when available) were interviewed by a nurse and social worker in addition to the treating physician.
Our search identified 506 patients. After exclusion of patients without documentation of a firearm in the home, 495 remained and were included in this study. The average age was 79.9 years; 63% were female. The mean Montréal Cognitive Assessment score was 16.1. Seventy-seven percent of patients were diagnosed with dementia, most commonly suspected to be due to Alzheimer disease (46%) or vascular pathology (21%). Three hundred sixteen patients (64%) had a history of depression or were diagnosed with depression at the index visit.
Eight-nine patients (18%) reported having a firearm in their place of residence. Among these, 63 (71%) were diagnosed with dementia; 33 (37%) had delusions, and 15 (17%) reported having hallucinations (Table)
Among 380 patients with dementia, 63 (17%) reported having a firearm in their residence. A total of 172 of the patients with dementia was confirmed to be living in their own home (as opposed to a supervised setting), and 39 (23%) reported having a firearm. Of the patients with dementia who had a firearm in the home, 31 (49%) had delusions, 14 (22%) endorsed hallucinations, and 27 (44%) had a history of behavioral symptoms. Most delusions (85%) and more than one half of hallucinations (54%) were of paranoid or hostile quality.
Discussion: A considerable proportion of patients diagnosed with dementia reported having a firearm in their home; furthermore, many persons with firearms also had delusions, hallucinations, and behavioral manifestations of their disease. Of note, the frequency of firearms in the home in our study was 18%—lower than the overall rate of firearm ownership in the United States. Whether this difference reflects the specific geographic and social sampling in this single-center trial is not known, and whether the presence of firearms was underreported by those with dementia deserves further study.
Our questionnaire did not assess whether firearms were kept locked or loaded, and whether these patients were able to access or use their firearms is also unknown. Furthermore, firearm use is a complex task that may challenge patients in later stages of dementia. However, in addition to the assumed risk of firearm access among patients with severe disease, high-functioning patients early in the course of dementia have been reported to commit suicide and homicide, presumably in part because of their diagnoses (2, 3).
Our study is limited by its retrospective nature and inability to assess variables absent from the medical record. Nonetheless, research related to outcomes of firearm injury lacks large, high-quality studies, partly because of legislative and funding barriers (4). Several entities, including 8 major health professional organizations together with the American Bar Association, have called for action—including research—to reduce the burden of firearm-related injury in the United States (5).
Our findings highlight the importance of asking specifically about firearms during the evaluation of dementia. In our study, this task was accomplished using a standardized questionnaire. Whether patients with dementia who have a firearm in the home are able to access and use their firearm and whether they or their caregivers are at increased risk for harm is unknown and warrants investigation.
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
Results provided by:
Copyright © 2016 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use
This PDF is available to Subscribers Only