“Is There a Gun in the Home?” Assessing the Risks of Gun Ownership in Older Adults Ellen M. Pinholt, MD, Joshua D. Mitchell, MD, Jane H. Butler, RN, and Harjinder Kumar, MD
An important ethical and safety concern that geriatricians, primary care providers, and home health professionals need to address is gun ownership by elderly adults. Those aged 65 and older now have the highest rate of gun ownership in America, and they also have a high prevalence of depression and suicide. Dementia can add additional layers of risk. Even older gun owners who are otherwise intellectually intact may benefit from information about gun safety with the increasing numbers of children being cared for by grandparents. Health professionals should ask patients, “Is there a gun in the home?” in the clinic and during home visits. Healthcare professionals must have knowledge and skills to address safe gun ownership in elderly adults. The 5 L’s (Locked, Loaded, Little children, feeling Low, Learned owner) will assist professionals in addressing all aspects of safe ownership. J Am Geriatr Soc 62:1142–1146, 2014.
Key words: gun safety; gun ownership; home safety checklist; workplace safety; competency for home health providers
a gun.2 These older persons also have high rates of suicide.3 The suicide rate for men aged 80 and older from 2005 to 2010 was 41.11 per 100,000 (80% using a firearm), more than double the national average.3 Risks are compounded in individuals with dementia,4 who frequently have access to unlocked firearms and easily accessible ammunition.5,6 Additional concerns revolve around the increasing number of children being cared for by their grandparents.7 Whereas there are well-accepted guidelines for the assessment and counseling of older drivers,8 there is little to help guide clinicians in their discussions with older gun owners. This article addresses legal concerns regarding physician–patient discussions on gun safety, discusses the importance of involvement of primary care physicians (PCPs) and home health providers, and presents the 5 L’s to help with the gun safety assessment of older adults (Locked, Loaded, Little children, feeling Low, Learned owner). Cases from home visits help establish a framework for the discussion.
CASE REPORTS Case 1
G
un safety in the United States is receiving unprecedented attention and is increasingly being framed as a public health concern.1 Considering the aging of the typical gun owner and the potential risks when dementia may be present, geriatric professionals and home health providers have a unique and increasingly important role to play, but there are no national guidelines and a paucity of assessment tools to aid providers in assessing gun safety. The concerns are clear. Reversing long-standing patterns of middle-aged persons as owners, U.S. residents aged 65 and older are now the most likely of all citizens to own
Mrs. B was an 83-year-old married woman living in a row home. She was seen for a posthospital home visit for an episode of atrial fibrillation due to poor adherence to her medications. She and her husband had diagnosed dementia. A nephew and his wife had recently moved into the first floor of the home to be caregivers. While performing a safety check of the upstairs bedroom and bathroom, a loaded shotgun was seen leaning against a wall. Mrs. B’s husband also kept two loaded pistols in their closet, “in case of intruders downstairs.” The adult nephew was informed of the loaded weapons in the home and stated that he would remove them. He did not do so. A few months later, Mr. B threatened him with a gun, and police were called.
Case 2 From the Walter Reed National Military Medical Center, Bethesda, Maryland. Address correspondence to Ellen M. Pinholt, Rapid City Regional Physicians, Rapid City Regional Clinic- Aspen Centre, 640 Flormann Street, Rapid City, SD 57701. E-mail: [email protected] DOI: 10.1111/jgs.12836
JAGS 62:1142–1146, 2014 © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society
Mr. G was an 81-year-old man with dementia and a long history of nightmares and visual hallucinations. His wife and son were present during a posthospital home visit. His wife reported to the team that he had been verbally abusive and, at times, threatened her. Grandchildren
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frequently visited the home. A home safety questionnaire revealed that there were two rifles, both unsecured and one loaded, in his office. The team recommended to the son that the firearms be unloaded and removed from the home immediately because of the combination of dementia-related behaviors and the frequent presence of grandchildren.
ESSENTIALS OF LAWS PERTAINING TO GUN OWNERSHIP With the increasing number of older gun owners and the potential risks involved, it may become routine practice for reasonable physicians to inquire about guns in the homes of their older patients,9 but to frame the discussion appropriately, a physician must first understand the laws pertaining to gun ownership. There is no upper age limit on owning a firearm. Federal law prohibits mentally incompetent persons from possessing a gun, but this applies to a formal finding by a court and not necessarily to a physician’s diagnosis of dementia.10 Laws fail to address the much more likely scenario of diminished capacity in a person who already owns a firearm purchased when he or she younger or more capable. When guardianship is established because of incompetency, laws prohibiting possession of firearms by a “mental defective” presumably apply, but the guardian may not be aware of this fact.10 Providers should be familiar with their state laws, which can be found online.11 Some physicians have questioned whether they are prohibited from asking a patient about firearm ownership after Florida passed HB 155 in June 2011. The bill protected patients from harassment and discrimination regarding ownership of a firearm and protected them from penalties regarding insurance, but it allowed inquiries if relevant to the individual’s medical care or safety of others.9,12 The law has since gone to an appellate court because of concern regarding its infringement on the first amendment right of the physician. It is unlikely that any federal or state law will be ever prevent physicians from asking their patients about gun ownership because of this First Amendment concern.13 “Is there a gun in the home?” is a legal and relevant question during a home visit and pertains to the safety of the patient, family members, and home health workers.
ASK: “IS THERE A FIREARM IN THE HOME?” Geriatricians and PCPs who care for people in the outpatient setting may have this question already formatted in their electronic health record,5 but it is uncertain how often it is actually asked of the patient or caregiver. The presence of a gun in the home becomes even more pertinent during a home healthcare visit. The typical agenda for home visits by professionals includes a home safety check, with the goal of preventing falls or accidents. Personal spaces and problems are addressed during the home visit, and there are contextual reasons to include firearm questions. A well-regarded Reynolds Foundation–sponsored home safety checklist includes two questions. “If you have a firearm in your home, is it stored safely?” and “Do you know how to use
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it?”14 The case reports illustrate the value of following a home safety checklist to avoid the false assumption that an older adult would not own a firearm. The team encountered a 97-year-old woman on one visit who kept a loaded revolver in a small pack on the closet door. She had never been trained in its use but kept it for her protection. The workplace for the home health provider is the client home, which is not a regulated or controlled environment. There are many personal safety risks for home health workers, including firearms.15 One home health agency reported that 30% of their field staff reported being personally exposed to guns.16 The possibility of guns in the workplace is discussed in the guidelines of the National Institute for Occupational Safety and Health (NIOSH) related to preventing workplace hazards for home healthcare workers. The NIOSH recommends that home health agencies establish a no-weapons policy in client homes or, at a minimum, that all weapons be disabled or stored in a secure location.17 Asking about gun ownership in the outpatient setting and certainly during a home visit is a just and defensible concern. It is legal to ask the question in the context of the provider–patient relationship. The possibility of an unsecured weapon is high and can pose a danger to owners, family members, and healthcare workers.
WHEN A FIREARM IS PRESENT Healthcare professionals should respectfully review the possible risks of gun ownership with their patients. Guns are often not secured, grandchildren may have access to the guns, and the prevalence of dementia and depression in older adults increase the risk of accidents and suicide. When the home health checklist or outpatient interview confirms that a firearm is present in the home, the health worker should gather more information using the 5 L’s. The 5 L’s assess the older gun owner by addressing the most important “red flags.”
Is It “LOADED?” Always assume that any gun is loaded. Even in the homes of individuals with dementia, where one could reasonably assume that a weapon would not be loaded, 44.6% of weapons were kept loaded.6 Another 38% of respondents in that study did not know whether the weapon was loaded. Asking whether the weapon is loaded may therefore yield uncertainty. Assume it is loaded. Gun safety training could make the professional in the home more at ease around a weapon.
Is It “LOCKED?” Is the firearm secured in a locked gun safe or is there a trigger lock or cable lock in place (Figures 1 and 2)? If not, would the owner consider any of these safety options? Also ask, “Where is the ammunition stored?” Locking the ammunition separate from the firearm is the recommended safe option. If the firearm is used for sport shooting and hunting, then the client may be persuaded to follow these recommendations, but in rural areas, an empty, locked
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Figure 1. Trigger lock.
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children. These laws, depending on the state, may hold the adult criminally liable for unsafe firearm storage when children are in the environment.20 State laws vary and can be accessed through each state’s Department of Justice website. Despite these laws, more than 40% of homes with children and firearms report the presence of at least one unlocked firearm.21 Some of these households are most certainly grandparent-headed households, and some are homes that grandchildren visit. This is a relevant question and represents an opportunity to educate these grandparents on gun safety. Knowledge of the CAP laws should be a competency for home health providers that will guide counseling on removing or properly storing the weapon and ammunition.
Is the Operator Feeling “LOW?”
Figure 2. Cable locks.
gun may not be considered an option because the purpose may be for home defense or for protection from predator animals. In urban areas, gun owners tend to keep them loaded and unlocked for protection against violent crimes. If the owner presents these rationales, the next three “L’s” assume much greater importance.
As previously stated, elderly adults, especially those aged 80 and older, are at the highest risk of suicide, 80% of which are committed using a firearm.3 The question of a relationship between ready availability of a firearm and risk of suicide in the home was answered in 1992.22 That classic study concluded that readily available guns increased the risk of suicide in the home. The majority of suicides occurred in the home, and a firearm was the means of death most commonly used. As a prevention strategy, the home health provider or PCP should address restricting access to a firearm and ammunition when an older adult is depressed.23 The practices of keeping a gun locked and unloaded and storing ammunition in a separate, locked location is associated with significantly fewer unintentional and self-inflicted firearms injuries and deaths in youth that may be in the home.24
Are LITTLE Children Present? This question’s importance was unfortunately highlighted with the recent death of a 4-year-old boy whose 4-year-old cousin shot him after they found a loaded shotgun under their grandfather’s bed.18 Nearly 6 million children, approximately one in 12, are living in households headed by grandparents.7 This large number includes children who also have their parents present in the home, but some of these grandparents have assumed responsibility for these children without the parent of the child being in the home. This is a growing trend, with numbers increasing from 2.4 million grandparents in 2000 to 2.8 million in 2010 who are living with and responsible for their grandchildren younger than 18.19 When one considers that the concept of home safety and childproofing has occurred after the children of today’s grandparents left home, it is likely that most grandparents will benefit from familiarization with childproofing and home safety concepts, especially as they apply to firearm safety. The culture of childproofing and home safety for children is new. National efforts to prevent childhood unintentional injuries did not begin until 1986 and became a robust coalition called Safe Kids USA in 1995. Laws regarding firearms and child protection have been enacted over time but are still not enacted in all states. The Child Access Prevention (CAP) laws or “safe storage” laws were passed between 1989 and 2000. CAP laws were passed in an attempt to reduce gun-related accidents and suicides in
Is the Operator “LEARNED?” This question should prompt the PCP or home health professional to ask whether this owner knows how to use the weapon. Approximately one-fifth of guns in the home are given or inherited and not intentionally purchased.24 The majority of gun owners, 56% in one survey of 800 gun owners, have received firearm training, but 21% of those owners stored their guns improperly.25 The 97-year-old that the home healthcare team encountered relinquished the gun when it was pointed out that she neither knew how to use it nor how to store it properly. The weapon may have also been used against her.2 “LEARNED” also refers to the possibility of dementia in the client. The Aging, Demographics, and Memory Study in 2007 reported prevalence rates according to age group for dementia.26 The rates increased with age, with 24% of individuals aged 80 to 89 and 37% of those aged 90 and older having dementia. In addition, cognitive impairment often goes unrecognized unless older clients are specifically screened.27 If the owner has dementia, he or she would generally not be considered safe to operate a gun. The great majority of individuals with Alzheimer’s disease are cared for in the home, not in institutions. Guns are not typically removed from these homes. There is a high prevalence of firearms in the homes of individuals with dementia, and they are often kept loaded.6 Case 1 nearly had a disastrous
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outcome when the nephew did not follow through on removing the loaded guns. The PCP or the home health professional should recommend that a family member remove the firearm from the home. If the family is uncooperative, the local Adult Protective Services agency should be notified for investigation.9 When no family member is present, the police should be notified of the concern.
GUN SAFETY FOR HOME HEALTH PROVIDERS Because they are at particular risk, home health providers should learn basic gun safety. Local resources may include the Game, Fish and Parks Department, a private gun shop, and the Izaac Walton League of America (IWLA). Many IWLA chapters feature basic National Rifle Association (NRA) courses taught by NRA instructors. The NRA website also lists courses available. Individuals states will also list courses, and several states have online courses. The worker should not withhold or confiscate a firearm and certainly cannot transport the weapon out of the home. There are strict laws regarding these actions. As in the cases described above, family members may be elicited to handle and remove the weapon. Providers can also call the police to report their assessment of the situation and ask for assistance. A home health provider should also report to their agency when there is a threatening situation in the home.
CONCLUSION Gun ownership is a topic of public debate in the United States. Geriatricians, PCPs, and home health providers are caring for an ever-increasing population of aging gun owners. Older adults owning firearms are a public health concern. There are no easy answers, but there are “red flags” that move senior gun ownership out of the abstract and into daily practice in the clinic and certainly home health. The “red flags” are the areas highlighted in the 5 L’s checklist. It may not be complete, and any additions are welcome. First, ask the question, “Is there a firearm in the home?” It is legal and ethical to ask this question. Make the inquiry as automatic as asking about driving when interviewing individuals with dementia or their families. Ask during the interview of an older person with depression given the high rate of completed suicides by firearms. Ask when there are grandchildren in the home. Second, know your state’s laws to educate the family and bolster your position when it is appropriate to have firearms removed from the home. This would mainly apply to the few individuals who a court has found to be “mentally defective,” but it may also apply if a guardianship or durable power of attorney is in place.10 The CAP laws, which vary according to state, should be reviewed. The penalties imposed may help convince grandparents to secure weapons and ammunition when children live in or visit the home. Background knowledge of the law and explaining the risks uncovered by the 5L’s helped complete the intervention of securing a weapon. Third, know whom to ask for help when intervention is needed. Assistance to secure or remove firearms may
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involve family members, the police, or Adult Protective Services. Fourth, acquire skills and knowledge from a gun safety course. Learn what a trigger lock or cable lock involves (Figures 1 and 2). Learn the difference between a gun cabinet and a gun safe so that you can make recommendations. A gun safety course may eliminate apprehension in providers and instill confidence when interventions are needed. Future topics related to safe gun ownership in older persons could include how to document the discussion in the medical record, more-specific strategies and counseling tips when the weapon needs to be removed from the home, and what alternatives the owner can employ for protection in the home.
ACKNOWLEDGMENTS We would like to thank Mr. Charles Watkins, for technical advice regarding firearms. Presented at the national American Geriatrics Society meeting, Presidential Poster session, May 2010, Orlando, Florida. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Pinholt E. M.: concept, drafting, final submission. Mitchell J. D.: case report, drafting, final approval of manuscript. Butler J. H.: case report, drafting. Kumar H.: case report, drafting. Sponsor’s Role: None. The opinions expressed are those of the authors’ and do not reflect the views of the Department of Defense.
REFERENCES 1. Frattaroli S, Webster DW, Wintemute GJ. Implementing a public health approach to gun violence prevention: The importance of physician engagement. Ann Intern Med 2013;158:697–698. 2. Vanderpool T. Why more senior citizens are carrying guns. Christian Science Monitor, January 6, 2004 [on-line]. Available at http://www.csmonitor.com/2004/01006/p02s01-ussc.html Accessed September 2, 2013. 3. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [on-line]. Available at http://www.cdc.gov/ncipc/wisqars Accessed January 20, 2014. 4. Lynch CA, Moran M, Lawlor BA. Firearms and dementia: A smoking gun? Int J Geriatr Psychiatry 2008;23:1–6. 5. LoConte NK, Gleason CE, Gunter-Hunt G et al. Standardized note template improves screening of firearm access and driving among veterans with dementia. Am J Alzheimers Dis Other Demen 2008;23:313–318. 6. Spangenberg KB, Wagner MT, Hendrix S et al. Firearm presence in households of patients with Alzheimer’s disease and related dementias. J Am Geriatr Soc 1999;47:1183–1186. 7. GrandFacts state fact sheets for grandparents and other relatives raising children [on-line]. Available at http://www.aarp.org/relationships/ friends-family/grandfacts-sheets/ Accessed August 20, 2013. 8. Carr D, Schwartberg J, Manning L et al. Physician’s Guide to Assessing and Counseling Older Drivers, 2nd Ed. Washington, DC: National Highway Traffic Safety Administration, 2010. 9. Kapp MB. Geriatric patients, firearms, and physicians. Ann Intern Med 2013;159:421–422. 10. Greene E, Bornstein BH, Dietrich H. Granny, (don’t) get your gun: Competency issues in gun ownership by older adults. Behav Sci Law 2007;25:405–423. 11. State Laws [on-line]. Available at http://www.nraila.org/gun-laws/statelaws.aspx Accessed March 21, 2014.
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12. Medical Privacy Concerning Firearms, Final Bill Analysis CS/CS/HB 155. Available at http://www.myfloridahouse.gov/Sections/Documents/loaddoc. aspx?FileName=h0155z.JDC.DOCX&DocumentType=Analysis&BillNum ber=0155&Session=2011 Accessed April 9, 2014. 13. Hethcoat GO II. In the crosshairs: Legislative restrictions on patient-physician speech about firearms. DePaul J Health Care Law 2011;14:1–34. 14. vanZuilen MH, Rodriguez O, Mintzer M. Eliminate hazards in your home: A safety checklist with recommendations. POGOe—portal of geriatrics online education, 2010 [on-line]. Available at http://www.pogoe.org/productid/20764 Accessed September 2, 2013. 15. Fazzone PA, Barloobn LF, McConnell SJ et al. Personal safety, violence and home health. Public Health Nurs 2000;17:43–52. 16. Sylvester BJ, Reisener L. Scared to go to work: A home care performance improvement initiative. J Nurs Care Qual 2002;17:71–82. 17. Occupational Hazards in Home Healthcare. NIOSH Hazard Review [online]. Available at http://www.cdc.gov/niosh/docs/2010-125/pdfs/2010–125. pdf Accessed September 2, 2013. 18. Four-year-old girl accidentally shoots dead toddler cousin with rifle she found under her grandfather’s bed [on-line]. Available at http://www.dailymail.co.uk /news/article-2541346/Four-year-old-girl-accidentally-kills-toddler-cousin-rifle -grandfathers-bed.html Accessed January 20, 2014. 19. American Fact Finder. US Census Bureau [on-line]. Available at http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS _11_3YR_B10002&prodType=table Accessed August 20, 2013.
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20. Regulating Guns in America. An evaluation and comparative analysis of federal, state, and selected local gun laws 2008 edition [on-line]. Available at http://www.smartgunlaws.org/wp-content/uploads/2008/01/RegGuns.entire. report.pdf Accessed October 29, 2013. 21. DuRant RH, Barkin S, Craig JA et al. Firearm ownership and storage patterns among families with children who receive well child care. Pediatrics 2007;119:1271–1279. 22. Kellermann AL, Rivara FP, Somes G et al. Suicides in the home in relation to gun ownership. N Engl J Med 1992;327:467–472. 23. Oslin DW, Zubritsky C, Brown G et al. Managing suicide risk in late life: Access to firearms as a public health risk. Am J Geriatr Psychiatry 2004;12:30–36. 24. Grossman DC, Mueller BA, Riedy C et al. Gun storage practices and risk of youth suicide and unintentional firearm injuries. JAMA 2005;293:707– 714. 25. Hemenway D, Solnick SJ, Azrael DR. Firearm training and storage. JAMA 1995;273:46–50. 26. Plassman BL, Langa KM, Fisher GG et al. Prevalence of dementia in the US: The Aging, Demographics, and Memory Study. Neuroepidemiology 2007;29 l:125–132. 27. McCarten JR, Anderson P, Kuskowski MA. Finding dementia in primary care: The results of a clinical demonstration project. J Am Geriatr Soc 2012;60:210–217.
An important ethical and safety concern that geriatricians, primary care providers, and home health professionals need to address is gun ownership by elderly adults. Those aged 65 and older now have the highest rate of gun ownership in America, and they also have a high prevalence of depression and suicide. Dementia can add additional layers of risk. Even older gun owners who are otherwise intellectually intact may benefit from information about gun safety with the increasing numbers of children being cared for by grandparents. Health professionals should ask patients, “Is there a gun in the home?” in the clinic and during home visits. Healthcare professionals must have knowledge and skills to address safe gun ownership in elderly adults. The 5 L’s (Locked, Loaded, Little children, feeling Low, Learned owner) will assist professionals in addressing all aspects of safe ownership. J Am Geriatr Soc 62:1142–1146, 2014.
Key words: gun safety; gun ownership; home safety checklist; workplace safety; competency for home health providers
a gun.2 These older persons also have high rates of suicide.3 The suicide rate for men aged 80 and older from 2005 to 2010 was 41.11 per 100,000 (80% using a firearm), more than double the national average.3 Risks are compounded in individuals with dementia,4 who frequently have access to unlocked firearms and easily accessible ammunition.5,6 Additional concerns revolve around the increasing number of children being cared for by their grandparents.7 Whereas there are well-accepted guidelines for the assessment and counseling of older drivers,8 there is little to help guide clinicians in their discussions with older gun owners. This article addresses legal concerns regarding physician–patient discussions on gun safety, discusses the importance of involvement of primary care physicians (PCPs) and home health providers, and presents the 5 L’s to help with the gun safety assessment of older adults (Locked, Loaded, Little children, feeling Low, Learned owner). Cases from home visits help establish a framework for the discussion.
CASE REPORTS Case 1
G
un safety in the United States is receiving unprecedented attention and is increasingly being framed as a public health concern.1 Considering the aging of the typical gun owner and the potential risks when dementia may be present, geriatric professionals and home health providers have a unique and increasingly important role to play, but there are no national guidelines and a paucity of assessment tools to aid providers in assessing gun safety. The concerns are clear. Reversing long-standing patterns of middle-aged persons as owners, U.S. residents aged 65 and older are now the most likely of all citizens to own
Mrs. B was an 83-year-old married woman living in a row home. She was seen for a posthospital home visit for an episode of atrial fibrillation due to poor adherence to her medications. She and her husband had diagnosed dementia. A nephew and his wife had recently moved into the first floor of the home to be caregivers. While performing a safety check of the upstairs bedroom and bathroom, a loaded shotgun was seen leaning against a wall. Mrs. B’s husband also kept two loaded pistols in their closet, “in case of intruders downstairs.” The adult nephew was informed of the loaded weapons in the home and stated that he would remove them. He did not do so. A few months later, Mr. B threatened him with a gun, and police were called.
Case 2 From the Walter Reed National Military Medical Center, Bethesda, Maryland. Address correspondence to Ellen M. Pinholt, Rapid City Regional Physicians, Rapid City Regional Clinic- Aspen Centre, 640 Flormann Street, Rapid City, SD 57701. E-mail: [email protected] DOI: 10.1111/jgs.12836
JAGS 62:1142–1146, 2014 © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society
Mr. G was an 81-year-old man with dementia and a long history of nightmares and visual hallucinations. His wife and son were present during a posthospital home visit. His wife reported to the team that he had been verbally abusive and, at times, threatened her. Grandchildren
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frequently visited the home. A home safety questionnaire revealed that there were two rifles, both unsecured and one loaded, in his office. The team recommended to the son that the firearms be unloaded and removed from the home immediately because of the combination of dementia-related behaviors and the frequent presence of grandchildren.
ESSENTIALS OF LAWS PERTAINING TO GUN OWNERSHIP With the increasing number of older gun owners and the potential risks involved, it may become routine practice for reasonable physicians to inquire about guns in the homes of their older patients,9 but to frame the discussion appropriately, a physician must first understand the laws pertaining to gun ownership. There is no upper age limit on owning a firearm. Federal law prohibits mentally incompetent persons from possessing a gun, but this applies to a formal finding by a court and not necessarily to a physician’s diagnosis of dementia.10 Laws fail to address the much more likely scenario of diminished capacity in a person who already owns a firearm purchased when he or she younger or more capable. When guardianship is established because of incompetency, laws prohibiting possession of firearms by a “mental defective” presumably apply, but the guardian may not be aware of this fact.10 Providers should be familiar with their state laws, which can be found online.11 Some physicians have questioned whether they are prohibited from asking a patient about firearm ownership after Florida passed HB 155 in June 2011. The bill protected patients from harassment and discrimination regarding ownership of a firearm and protected them from penalties regarding insurance, but it allowed inquiries if relevant to the individual’s medical care or safety of others.9,12 The law has since gone to an appellate court because of concern regarding its infringement on the first amendment right of the physician. It is unlikely that any federal or state law will be ever prevent physicians from asking their patients about gun ownership because of this First Amendment concern.13 “Is there a gun in the home?” is a legal and relevant question during a home visit and pertains to the safety of the patient, family members, and home health workers.
ASK: “IS THERE A FIREARM IN THE HOME?” Geriatricians and PCPs who care for people in the outpatient setting may have this question already formatted in their electronic health record,5 but it is uncertain how often it is actually asked of the patient or caregiver. The presence of a gun in the home becomes even more pertinent during a home healthcare visit. The typical agenda for home visits by professionals includes a home safety check, with the goal of preventing falls or accidents. Personal spaces and problems are addressed during the home visit, and there are contextual reasons to include firearm questions. A well-regarded Reynolds Foundation–sponsored home safety checklist includes two questions. “If you have a firearm in your home, is it stored safely?” and “Do you know how to use
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it?”14 The case reports illustrate the value of following a home safety checklist to avoid the false assumption that an older adult would not own a firearm. The team encountered a 97-year-old woman on one visit who kept a loaded revolver in a small pack on the closet door. She had never been trained in its use but kept it for her protection. The workplace for the home health provider is the client home, which is not a regulated or controlled environment. There are many personal safety risks for home health workers, including firearms.15 One home health agency reported that 30% of their field staff reported being personally exposed to guns.16 The possibility of guns in the workplace is discussed in the guidelines of the National Institute for Occupational Safety and Health (NIOSH) related to preventing workplace hazards for home healthcare workers. The NIOSH recommends that home health agencies establish a no-weapons policy in client homes or, at a minimum, that all weapons be disabled or stored in a secure location.17 Asking about gun ownership in the outpatient setting and certainly during a home visit is a just and defensible concern. It is legal to ask the question in the context of the provider–patient relationship. The possibility of an unsecured weapon is high and can pose a danger to owners, family members, and healthcare workers.
WHEN A FIREARM IS PRESENT Healthcare professionals should respectfully review the possible risks of gun ownership with their patients. Guns are often not secured, grandchildren may have access to the guns, and the prevalence of dementia and depression in older adults increase the risk of accidents and suicide. When the home health checklist or outpatient interview confirms that a firearm is present in the home, the health worker should gather more information using the 5 L’s. The 5 L’s assess the older gun owner by addressing the most important “red flags.”
Is It “LOADED?” Always assume that any gun is loaded. Even in the homes of individuals with dementia, where one could reasonably assume that a weapon would not be loaded, 44.6% of weapons were kept loaded.6 Another 38% of respondents in that study did not know whether the weapon was loaded. Asking whether the weapon is loaded may therefore yield uncertainty. Assume it is loaded. Gun safety training could make the professional in the home more at ease around a weapon.
Is It “LOCKED?” Is the firearm secured in a locked gun safe or is there a trigger lock or cable lock in place (Figures 1 and 2)? If not, would the owner consider any of these safety options? Also ask, “Where is the ammunition stored?” Locking the ammunition separate from the firearm is the recommended safe option. If the firearm is used for sport shooting and hunting, then the client may be persuaded to follow these recommendations, but in rural areas, an empty, locked
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Figure 1. Trigger lock.
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children. These laws, depending on the state, may hold the adult criminally liable for unsafe firearm storage when children are in the environment.20 State laws vary and can be accessed through each state’s Department of Justice website. Despite these laws, more than 40% of homes with children and firearms report the presence of at least one unlocked firearm.21 Some of these households are most certainly grandparent-headed households, and some are homes that grandchildren visit. This is a relevant question and represents an opportunity to educate these grandparents on gun safety. Knowledge of the CAP laws should be a competency for home health providers that will guide counseling on removing or properly storing the weapon and ammunition.
Is the Operator Feeling “LOW?”
Figure 2. Cable locks.
gun may not be considered an option because the purpose may be for home defense or for protection from predator animals. In urban areas, gun owners tend to keep them loaded and unlocked for protection against violent crimes. If the owner presents these rationales, the next three “L’s” assume much greater importance.
As previously stated, elderly adults, especially those aged 80 and older, are at the highest risk of suicide, 80% of which are committed using a firearm.3 The question of a relationship between ready availability of a firearm and risk of suicide in the home was answered in 1992.22 That classic study concluded that readily available guns increased the risk of suicide in the home. The majority of suicides occurred in the home, and a firearm was the means of death most commonly used. As a prevention strategy, the home health provider or PCP should address restricting access to a firearm and ammunition when an older adult is depressed.23 The practices of keeping a gun locked and unloaded and storing ammunition in a separate, locked location is associated with significantly fewer unintentional and self-inflicted firearms injuries and deaths in youth that may be in the home.24
Are LITTLE Children Present? This question’s importance was unfortunately highlighted with the recent death of a 4-year-old boy whose 4-year-old cousin shot him after they found a loaded shotgun under their grandfather’s bed.18 Nearly 6 million children, approximately one in 12, are living in households headed by grandparents.7 This large number includes children who also have their parents present in the home, but some of these grandparents have assumed responsibility for these children without the parent of the child being in the home. This is a growing trend, with numbers increasing from 2.4 million grandparents in 2000 to 2.8 million in 2010 who are living with and responsible for their grandchildren younger than 18.19 When one considers that the concept of home safety and childproofing has occurred after the children of today’s grandparents left home, it is likely that most grandparents will benefit from familiarization with childproofing and home safety concepts, especially as they apply to firearm safety. The culture of childproofing and home safety for children is new. National efforts to prevent childhood unintentional injuries did not begin until 1986 and became a robust coalition called Safe Kids USA in 1995. Laws regarding firearms and child protection have been enacted over time but are still not enacted in all states. The Child Access Prevention (CAP) laws or “safe storage” laws were passed between 1989 and 2000. CAP laws were passed in an attempt to reduce gun-related accidents and suicides in
Is the Operator “LEARNED?” This question should prompt the PCP or home health professional to ask whether this owner knows how to use the weapon. Approximately one-fifth of guns in the home are given or inherited and not intentionally purchased.24 The majority of gun owners, 56% in one survey of 800 gun owners, have received firearm training, but 21% of those owners stored their guns improperly.25 The 97-year-old that the home healthcare team encountered relinquished the gun when it was pointed out that she neither knew how to use it nor how to store it properly. The weapon may have also been used against her.2 “LEARNED” also refers to the possibility of dementia in the client. The Aging, Demographics, and Memory Study in 2007 reported prevalence rates according to age group for dementia.26 The rates increased with age, with 24% of individuals aged 80 to 89 and 37% of those aged 90 and older having dementia. In addition, cognitive impairment often goes unrecognized unless older clients are specifically screened.27 If the owner has dementia, he or she would generally not be considered safe to operate a gun. The great majority of individuals with Alzheimer’s disease are cared for in the home, not in institutions. Guns are not typically removed from these homes. There is a high prevalence of firearms in the homes of individuals with dementia, and they are often kept loaded.6 Case 1 nearly had a disastrous
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outcome when the nephew did not follow through on removing the loaded guns. The PCP or the home health professional should recommend that a family member remove the firearm from the home. If the family is uncooperative, the local Adult Protective Services agency should be notified for investigation.9 When no family member is present, the police should be notified of the concern.
GUN SAFETY FOR HOME HEALTH PROVIDERS Because they are at particular risk, home health providers should learn basic gun safety. Local resources may include the Game, Fish and Parks Department, a private gun shop, and the Izaac Walton League of America (IWLA). Many IWLA chapters feature basic National Rifle Association (NRA) courses taught by NRA instructors. The NRA website also lists courses available. Individuals states will also list courses, and several states have online courses. The worker should not withhold or confiscate a firearm and certainly cannot transport the weapon out of the home. There are strict laws regarding these actions. As in the cases described above, family members may be elicited to handle and remove the weapon. Providers can also call the police to report their assessment of the situation and ask for assistance. A home health provider should also report to their agency when there is a threatening situation in the home.
CONCLUSION Gun ownership is a topic of public debate in the United States. Geriatricians, PCPs, and home health providers are caring for an ever-increasing population of aging gun owners. Older adults owning firearms are a public health concern. There are no easy answers, but there are “red flags” that move senior gun ownership out of the abstract and into daily practice in the clinic and certainly home health. The “red flags” are the areas highlighted in the 5 L’s checklist. It may not be complete, and any additions are welcome. First, ask the question, “Is there a firearm in the home?” It is legal and ethical to ask this question. Make the inquiry as automatic as asking about driving when interviewing individuals with dementia or their families. Ask during the interview of an older person with depression given the high rate of completed suicides by firearms. Ask when there are grandchildren in the home. Second, know your state’s laws to educate the family and bolster your position when it is appropriate to have firearms removed from the home. This would mainly apply to the few individuals who a court has found to be “mentally defective,” but it may also apply if a guardianship or durable power of attorney is in place.10 The CAP laws, which vary according to state, should be reviewed. The penalties imposed may help convince grandparents to secure weapons and ammunition when children live in or visit the home. Background knowledge of the law and explaining the risks uncovered by the 5L’s helped complete the intervention of securing a weapon. Third, know whom to ask for help when intervention is needed. Assistance to secure or remove firearms may
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involve family members, the police, or Adult Protective Services. Fourth, acquire skills and knowledge from a gun safety course. Learn what a trigger lock or cable lock involves (Figures 1 and 2). Learn the difference between a gun cabinet and a gun safe so that you can make recommendations. A gun safety course may eliminate apprehension in providers and instill confidence when interventions are needed. Future topics related to safe gun ownership in older persons could include how to document the discussion in the medical record, more-specific strategies and counseling tips when the weapon needs to be removed from the home, and what alternatives the owner can employ for protection in the home.
ACKNOWLEDGMENTS We would like to thank Mr. Charles Watkins, for technical advice regarding firearms. Presented at the national American Geriatrics Society meeting, Presidential Poster session, May 2010, Orlando, Florida. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Pinholt E. M.: concept, drafting, final submission. Mitchell J. D.: case report, drafting, final approval of manuscript. Butler J. H.: case report, drafting. Kumar H.: case report, drafting. Sponsor’s Role: None. The opinions expressed are those of the authors’ and do not reflect the views of the Department of Defense.
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