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PSYCHIATRISTS have thrown a spotlight on the increased risk of firearm-related harms among people with dementia, calling on doctors to routinely check if patients have access to guns and the capacity to safely use them.
In an Ethics and law article published online by the MJA, the authors warned that dementia posed “theoretical risks in relation to firearm violence” due to behavioural changes, cognitive decline and symptoms such as psychosis, depression and aggression. They specifically raised concern about the risk of suicide. (1)
Under current state and territory laws, doctors are obliged to report patients to the police if they believe the patients are “at risk” of harm to themselves or others through possessing a firearm.
However, the authors wrote that doctors should also proactively screen patients with cognitive decline or dementia for firearm possession and use a “combined capacity and risk assessment approach to evaluating fitness for firearm licences”.
They suggested doctors assess whether patients understood the responsibilities and safety regulations of owning a firearm, whether they had insight into their diagnosis and the risks it posed to firearm safety, and whether they had taken steps to mitigate those risks.
“Overall, the emphasis should be on comprehensively assessing capacity to possess and use a firearm, and managing identified risks, rather than simply focusing on physical or mental health diagnoses.”.
Some patients with dementia would lose the capacity to use a firearm early in their disease while others “may have preserved crystallised intelligence … enabling them to retain the required information and skills to safely possess and use a firearm for longer”, the authors wrote.
There is no formal mechanism currently under state and territory legislation for subsequent monitoring or practical assessment of the ability to use a firearm for licence holders whose capacity is later questioned.
The authors put forward a model for assessing capacity and risk, which they said could be conducted in 40‒60 minutes, with regular reassessment.
However, they cautioned that “patients may be reticent to disclose mental illness and homicidal or suicidal thoughts knowing it may affect their chances of obtaining or keeping a firearm”.
Associate Professor Russell Roberts, national chair of the Alliance for Rural and Remote Mental Health, told MJA InSight the risks associated with firearm ownership should be carefully assessed and managed by rural GPs, adding “many already do this”.
“It is standard practice for psychiatrists and mental health clinicians, who usually work with the at-risk patients’ relatives to restrict access to firearms and other means of self-harm”, he said.
Professor Roberts said it made sense to incorporate assessment of capacity to own and safely use a firearm when older patients were routinely applying to renew their drivers licence.
However, he stressed that the major risk among older gun owners was suicide, usually associated with depression, not homicide.
“Gunshot wounds inflicted on others by older people with deteriorating physical and cognitive capacity are virtually non-existent, so we need to recognise and respond to the real risk; and this is suicide”, he said.
Dr Anne Wand, lead author of the MJA article, told MJA InSight available evidence from both Australia and overseas suggested doctors did not routinely assess their patients for firearm access or capacity to use them safely.
Dr Wand, a psychiatrist and senior lecturer in the School of Psychiatry at the University of NSW, cited a survey of GPs and psychiatrists from Queensland which found only 85% of psychiatrists and 50% of GPs reported “sometimes” asking patients about firearms access. (2)
Figures from the Australian Bureau of Statistics from 1980 to 1995 also showed that among people aged over 65 years the types of deaths as a proportion of firearm deaths were suicides 92.5%, homicides 4.9% and accidents 1.9%. (3)
1. MJA 2014; Online 1 December
2. MJA 1998; 168: 143-144
3. ABS: Firearms Deaths, Australia, 1980 to 1995
(Photo: Lokibaho / iStock)
I coordinated and helped create SA’s compusory firearms safety program (for licencing) and have, with the former coroner’s OK, studied almost all firearm deaths in SA since about 1985. I agree with the sentiment of the article, although there are going to be difficulties because potential victims won’t self-report and possilbly because many GPs don’t understand firearms well enough. Enough older people self harm wth guns for this to be taken very seriously. Gun security is paramount & regular police audits are crucial. If guns & ammo are properly secured impulsive self harm is less likely.
Well said Dr Wade. BTW: I am a licensed gun owner.
We are doctors and we are trained how to read, understand and evaluate scientific publications.
I am a GP in a rural community and I have first hand experience of both suicide by firearm and homicide by an elderly farmer. The exception I take to the post by “anonymous” is that apart for being anonymous the anecdotal comment of ” I know some excellent shooters well into their 80’s” is a meaningless statement on many levels.
Firstly, the point of the article is that some cognitively impaired shooters retained the ability to use the forearm effectively, but did not posses the cognitive function to use it safely. This makes them MORE dangerous, not less.They are more likely to actually inflict damage with the higher skill level on an unwitting person
Secondly, the fact that the poster “knows” an excellent shooter (or 2 or 3) is irrelevant to the facts. Surely we have moved past applying what we “know” and should be applying what IS known.
Thirdly, it is not a nanny state directive to apply the same regulation to a firearms licence as is applied to a driving licence. In fact I often use this analogy when speaking to a patient about the importance of ensuring that they are medically fit to hold a driver’s licence. I say ” a driver’s licence allows you to drive a car, which is a potentially lethal weapon, just like a gun” I fully support the need for all holders of firearm’s licences to be declared medically (and psychiatrically) fit.
It has the potential to save the lives of the gun owner and their victim.
In 2008, Constitution Arms, a New Jersey gun maker, announced it would produce the 9.65mm calibre Palm Pistol, which has a single-chamber firing mechanism that can be fired via a squeeze ball instead of the standard trigger. It was designed for people who had limited manual dexterity and was stated to be ideal for seniors. The manufacturer then registered the pistol as a medical device, which would make it reimbursable under US Medicare and other US health care plans.
The US Food and Drug Administration initially accepted the application, then revoked the registration a few days later. Apparently preproduction reservations are currently being accepted and the device is expected to soon be on the market. The Palm Pistol is cited as an indicator that the firearm industry is interested in the elderly as potential consumers. It is estimated that in the US some 17 million people aged 65 and over own a gun.
See: Current Considerations About the Elderly and Firearms. Am J Public Health. 2012 March; 102(3): 396–400. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3487668/
These days most doctors have very little knowledge about firearms and even less have experience n their use.
To suggest the there be some screening at the time of driving license applications is really taking the nanny state too far. I know some excellent shooters well into their 80’s.
The continued flow of illegal guns should be of more concern to the authors if they are really concerned about firearm safety.
I wonder if any of the proponents have any experience in the use of firearms.