Clinical Context

In 2013, the American Association for Geriatric Psychiatry (AAGP) and other organizations launched The Coalition on Mental Health and Violence Issues. This coalition mandated the collaboration of mental health programs, federal and local government agencies, and public stakeholders to prevent violence among all age groups.

Despite this effort, clinicians often overlook the risk for violence among the elderly population. The AAGP advocates for safety in general, including that among seniors, and presents this topic at its 2014 Annual Meeting.

Synopsis and Perspective

The risk for violence, including homicide and suicide, in elderly patients with dementia is often overlooked and highlights the need to allow clinicians to ask about gun access and ownership in this population.

Paul Kirwin, MD, immediate past president of the AAGP, told meeting delegates attending the AAGP 2014 Annual Meeting that older white men are 5 times more likely to die by suicide than their younger counterparts and that there have also been serious reports of elder violence toward others.

"Gun-related homicides by the elderly, while rare, are concerning," said Dr. Kirwin.

The Coalition on Mental Health and Violence Issues was first struck in 2013 under the leadership of then-president of the American Psychiatric Association, Dilip Jeste, MD, and involved several organizations, including the AAGP.

It calls for the cooperation of mental health programs, federal and local government agencies, and the public to prevent violence in individuals of all ages.

But Dr. Kirwin, who is also firm director at the Veterans Affairs (VA) Connecticut Healthcare System and an associate professor of psychiatry at Yale University School of Medicine in New Haven, Connecticut, noted that the risk for violence is often overlooked in senior patients.

"In 2004, the VA found that 40% of veterans with mild to moderate dementia had guns in their homes. Deferring to a patient's autonomous choices only makes sense when that patient is capable of making logical decisions," he said.

"Guns, like cars, signify independence and individualism. And the right to own a gun is not in dispute. But one's ability to handle a deadly weapon when physical or mental acuity begins to deteriorate is an issue of public safety."

Elderly Gun Violence Common

Dr. Kirwin noted that Dr. Jeste and Jeremy Lazarus, MD, immediate past president of the American Medical Association, convened the Coalition in Washington, DC, soon after last year's shootings at Sandy Hook Elementary School in Newtown, Connecticut.

"AAGP has no official position on this other than to advocate for safety, including in our elders. And I'm trying to stay politically neutral," said Dr. Kirwin.

"Instead, I want to discuss research done on the topic in our patient population."

He noted that, according to a 2004 national survey, more than 25% of those older than 65 years own guns. Other recent studies have shown that firearms are the most common method used in suicides by both men and women in later life.

"According to the CDC [Centers for Disease Control and Prevention], from 2005 to 2010 firearm injuries accounted for 72% of the suicides among those 65 and older compared with 51% of all suicides," said Dr. Kirwin.

"Elderly men used a gun 79% of the time to end their life. And every day, an estimated 22 veterans kill themselves in the United States, according to the VA."

In an attempt to prevent such events, the VA recently launched a public awareness campaign about gun access and patients with dementia.

Its brochure, which can be downloaded from the the VA Web site, states that if a patient has dementia, a provider should counsel the patient and family to remove any firearms. If that is not possible, the VA recommends several safety tips. It also began distributing free safety locks in 2008, a move Dr. Kirwin suggested clinicians could emulate in their practices.

Locked and Loaded

Dr. Kirwin also noted that a brief report released in 1999 looked at 106 consecutive outpatients referred for dementia workups. It showed that 60% of these households had firearms and 45% of those weapons were loaded.

Another report in 2004 of 1000 outpatients showed that 30% had some type of firearm in their home.

"Inquiries about gun ownership and discussions of gun safety should be a routine part of care. Some geriatric patients with unsecured firearms in their homes are not autonomous decision makers," said Dr. Kirwin.

"Also, confusion, paranoia, and chronic pain can sometimes lead to serious occurrences," he added.

In 2013, Carolyn Block published a study examining homicides among the elderly population in Chicago between 1965 and 2000. It showed that 25% of older women who were killed died at the hands of an intimate partner. A common scenario was a husband killing his wife and then himself.

"The issue is not political, it's about public safety," Dr. Kirwin reiterated after the presentation to Medscape Medical News.

"The point of my talk was to suggest that people with dementia or severe physical degeneration may not be able to safely handle a gun and should be assessed," he said.

Tying Clinicians' Hands

"A lot of people, and even physicians, don't realize that this is a problem in the elderly community," said Dr. Lazarus during the same presentation.

"We aren't talking about taking guns away from competent grandmas and grandpas. Instead, it's important to talk about what we need to do in a reasonable way," he said.

"We believe that physicians should be able to have frank discussions with their patients and their families about firearm safety issues and risks."

However, as reported by Medscape Medical News, the state of Florida has tried to keep clinicians from asking about gun ownership. In addition, 9 other states are considering legislation governing conversations about guns between clinicians and patients.

"This is a pretty dramatic law that we have been fighting against for some time. Studies have shown that asking about gun ownership issues and safe storage options protects people from unfortunate accidents," said Dr. Lazarus.

"I think it was very helpful when we got clarification from the White House that the Affordable Care Act does not prohibit doctors from discussing gun safety. And physicians can report credible threats of violence without fears of penalties from the Health Insurance Portability and Accountability Act [HIPAA] Privacy Rules."

Dr. Jeste noted that many people in the field have a pessimistic view of the future and believe that changes are unlikely, especially because of political infighting, and that there are severe limits to being able to predict individual violence, especially if a patient refuses treatment.

"But there is also an optimistic view based on societal wisdom." He noted that the Mental Health Parity Act is an example of slow but major progress.

"Society has come a long way and we have become more compassionate and collaborative. I truly believe that common sense and reasoning will prevail sooner or later. And I'm hoping that it's sooner rather than later," concluded Dr. Jeste.

The American Association for Geriatric Psychiatry (AAGP) 2014 Annual Meeting. Session 207. Presented March 15, 2014.

Presentation Highlights

• Compared with younger white men, older white men have a fivefold increased risk for completed suicide.
• There have been reports of serious violence by elderly people toward others, including gun-related homicides, which are rare but a reason for serious concern.
• A 2004 report of 1000 outpatients showed that 30% had some type of firearm in their home, and a 2004 national survey showed gun ownership in more than 25% of persons older than 65 years.
• A study of 106 consecutive outpatients referred for dementia evaluation in 1999 showed that 60% resided in homes containing firearms, and that 45% of those firearms were loaded.
• A VA study in 2004 showed that 40% of veterans with mild to moderate dementia kept guns in their homes, raising public safety concerns about the ability of a person with declining physical or mental acuity to responsibly handle a lethal weapon.
• The most common method for suicide in elderly women as well as in elderly men is firearm use, according to recent research, with 79% of elderly men using a gun.
• The Centers for Disease Control and Prevention reported that firearms were implicated in 72% of the suicides occurring from 2005-2010 among persons at least 65 years old vs 51% of all suicides.
• The VA estimates that currently there are approximately 22 suicides every day in the United States.
• A 2013 study of Chicago homicides among elderly people between 1965 and 2000 showed that in one-fourth of murders of older women, the killer was an intimate partner, with frequent scenarios of a husband killing his wife and then himself.
• Clinicians should routinely ask elderly patients and their families about gun ownership and discuss gun safety, as some elderly people living in homes with unsecured firearms are not autonomous decision makers.
• Clinicians should also be aware that confusion, paranoia, and chronic pain may increase the risk for suicide or other violence.
• Elderly people should be evaluated for dementia or severe physical disability that could prevent them from safely handling a gun.
• The VA recently began a public awareness campaign about gun access and patients with dementia in hopes of preventing suicides and other violence.
• A downloadable VA brochure recommends that clinicians counsel patients with dementia and their families to remove any firearms from the home, or to follow various safety tips.
• In 2008, the VA began distributing free safety locks, which providers could also consider for their practices.

Clinical Implications

• The risks for homicide and suicide in elderly patients with dementia are often overlooked but may be significant. Access to firearms is not uncommon in this patient population, according to an AAGP presentation reviewing research in this field.
• Clinicians should be aware of the risk for violence in elderly patients with dementia and evaluate and address such a risk, according to an AAGP presentation reviewing research in this field.

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