Biting the Bullet: Firearm Ownership in Persons with Dementia. A Registry-Based Observational Study

INTRODUCTION

In Sweden, with a population of 10 million people, there are 601,917 persons with valid weapon license (Swedish Police Authority, private communication), 2,296,000 firearms legally owned [1], and up to 150,000 persons living with a dementia diagnosis [2, 3]. The proportion of firearm owners with dementia in Sweden has not been studied earlier. An example from the United States (US) shows that up to 60% of households where a person with dementia reside have legally held firearms [4]. However, not much is known about persons with dementia who own a firearm nor how to assess risks associated with firearm ownership.

Although older persons rarely commit serious cri-mes, aggression is more common among persons with dementia compared to healthy population of the same age [5–7]. Gradual impairment of executive functions [8, 9] and visuospatial processing [10] can lead to improper firearm handling and to unintentional injuries and deaths. A few homicide cases involving persons with dementia have been described, often as a consequence of the persons’ delusional beliefs associated with the victim, e.g., the imposter syndrome [11–15]. Furthermore, persons with dementia may have an increased risk of suicide [16], particularly within the first three months after the dementia diagnosis [17]. Firearm availability increases suicide risk independently of other suicide risk factors [18, 19]; in contrast, a reduced availability of firearms decreases the suicide rate [20]. Consequently, restricting access to firearms for all persons with dementia at the time of diagnosis may appear reasonable. This procedure has been implemented in two states in the US (Texas [21] and Hawaii [22]). Firearm ownership in Sweden is mostly related to hunting which entails significant social and personal meaning [23]. Similar to losing a driving license, rapid decision about removing a firearm may lead to decreased activity and social iso-lation and add to overall stigma associated with dementia diagnosis [24]. Additionally, the fear of having firearm removed could potentially discourage help seeking behavior and delay diagnosis. With these consequences in mind, the decision to remove a firearm must be carefully assessed for each individual person.

In most of the states in the US, there are few restrictions regulating access to firearms [25]. In Sweden, a license is necessary to own a firearm [26]. According to the Swedish law [26, 27], physicians are obliged to report to the police if a person is considered unsuitable to possess a firearm. The authorities then decide if the license to have a firearm should be revoked. However, there is no official guideline on violence risk assessment (VRA) for persons with dementia. Organic brain disease (frontal or temporal lobe dysfunction), substance abuse, physical or psychiatric comorbidity, evidence of conflict or previous aggression, and changes in the environment were described as potential factors associated with increased aggressiveness which might be important in VRA of persons with dementia [15]. However, choosing who should or should not have access to a firearm is not straightforward. In persons with mental illness, physicians’ VRA had low accuracy, particularly for females [28].

MATERIALS AND METHODS

RESULTS

DISCUSSION

In the aging populations, such as in Sweden, with a high prevalence of firearm ownership as well as a high prevalence of dementia [1–3], it is becoming increasingly important to understand who the persons owning a firearm are and how their suitability to own a firearm should be assessed. In this large register-based study in Sweden, 3.4% of persons with dementia owned a firearm, of whom 356 (22.2%) were reported as unsuitable to own it. We found that, when compared to the persons with dementia without firearm, firearm owners in SveDem were predominantly younger, more often male, and living alone without assistance of home care. Furthermore, living arrangement, dementia subtype, diagnosing unit, APD, and hypnotics prescription, MMSE score, and gender were the most relevant determinants of risk of being reported to the police as unsuitable to own a firearm in SveDem.

In a recent interview in the Journal of American Medical Association, emergency physician Emmy Betz highlighted concerns about the potential risks associated with persons with dementia owing fir-earms [41]. However, given the low contribution of elderly into the general crime statistics, the overall gravity of this issue seems to be understated and has not received much attention, particularly among European researchers. Data surrounding persons with dementia in Sweden, who owned a firearm, resembled data from the US [42]. These findings indicate that persons with dementia who own a firearm may be more independent and overall have better health and therefore potentially still able to handle a firearm correctly. However, 23% of these persons had a moderate severe or very severe dementia. Furthermore, even though the overall use of psychiatric medication was slightly lower in this group, 4% of persons with firearm used antipsychotic medication, 10% hypnotics, and 24% antidepressants. Psychotropics are most often prescribed for behavioral and psychological symptoms of dementia (BPSD) [43], which may include depression, anxiety, psychosis, irritability, and aggression [44]. In addition, given the high proportion of persons who lacked information on firearm ownership, it is possible that physicians often do not ask persons about their firearm status. Findings from different countries indicate that this is potentially a common problem. Only 85% of psychiatrists and 50% of general practitioners in Australia reported “sometimes asking persons about firearm access” [45]. In a US study, only 27% of psychiatrist and 58% physicians treating older persons with depression and suicidal ideation had a routine system for identifying persons who owned firearms [46, 47].

To understand what is considered by physicians in Sweden when deciding to report a person as unsu-itable to own a firearm, we used all persons’ characteristics available in SveDem. The most important factors used by clinicians when making their decision identified in our study were: patients’ living arrangements, diagnosis of FTD, use of psychotropic medication (APD and hypnotics), female gender, and severity of dementia.

The use of psychotropic medications and type of dementia may reflect underlying causes of behavioral changes potentially leading to violent behavior of persons with dementia. As previously mentioned, psychiatric medication is mostly used to alleviate behavioral and psychological symptoms of dementia. Violent acts in these persons are rarely instrumental toward goal but rather stem from cognitive dec-line, disinhibition, paranoia, or agitation and are often a reactive consequence of frustration [48, 49]. Sec-ondly, behavioral-variant of FTD (bvFTD) is characterized by behavioral and executive deficits leading to the gradual loss of the ability to inhibit primary impulses [9, 50] potentially leading to impulsive and disinhibited behavior [50]. Most law breaking incidents have been noted in persons with neurodegenerations impairing frontotemporal and fronto-subcortical circuits (bvFTD and semantic variant of primary progressive aphasia (cvPPA) [51], whereas in AD, where hippocampal and posterior parietal-temporal circuits are most affected, criminal behavior is less frequent [51]. We have in a previous report shown that among persons with dementia unsuitable to have a driver’s license and therefore reported to the police the diagnosis of FTD was overrepresented [52]. The role of severity of dementia in VRA seems to be more complex. Severe dementia can limit person’s ability to plan and complete the suicidal act [16, 17], while the risk of suicide is elevated in early stages of dementia [17, 53]. On the other hand, cognitive impairment has been shown to be associated with the increased risk of psychotic symptoms [54] which may lead to increased risk of violent acts and/or potential accidents because of improper firearm handling. Finally, our results indicate that females have a higher risk of being reported to the police as unsuitable to own a firearm. This result contradicts our preconceptions on gender and violent behavior [55]. Although among persons with mental illness, violent behavior was equal between men and women, the risk of violence among females may be underestimated [56]. However, it may also be possible that physicians used other person related information, e.g., BPSD, which is not included in SveDem. Sex differences in the BPSD were reported with men exhibiting more aggressive behavior and women more depressive symptoms [57], both important from the perspective of the access to firearm.

Persons living with another person have a higher risk of being reported. According to case studies, victims of crimes committed by patients with dementia are more likely to be family members or persons living in the same household [58]. Similarly, persons in close proximity to the person with dementia may have higher risk to be victims of the incidents caused by improper handling of firearms. A cohabitant could thus not only report the firearm status, but also, potentially, report a person as violent or unsuitable to possess a firearm. Persons receiving their diagnosis in primary care compared to in a memory clinic had lower risk of being reported to the police authorities as unsuitable to possess a firearm. This difference in approach between primary care and memory clinic requires further investigation.

To the best of our knowledge, this is a first large, registry-based, study exploring the importance a wide range of characteristics of persons with dementia used by physicians when deciding whether or not to report a person as unsuitable to own a firearm. This study has several shortcomings. First, we did not have access to possible criminal records of the persons concerned so we could not confirm if persons who were reported by physicians have also committed a crime. Second, we had had a fraction of missing data. To manage this, we used the multiple imputation method. Methodologists currently regard multiple imputation as a state-of-the-art technique as it improves accuracy and statistical power relative to other missing data techniques [35]. Moreover, the number of persons with firearms can be underestimated. Given the self-reporting nature of the firearm ownership variable, it is possible that some persons chose to hide this information or, due to cognitive decline, were not able to recall it. SveDem has a coverage of 43% and may not be representative of all persons with dementia. Moreover, the majority of firearm owners reside in the north of Sweden, which is underrepresented in SveDem. Furthermore, given the relatively low discrimination of our model (AUC = 0.66) it is possible that additional factors predicting physicians’ decision to report a person to the police authorities as unsuitable to own a firearm were not recorded in SveDem.

Firearm owners with dementia were mostly younger males who were still living more independent lives. Assessment of the ability to handle the firearm in the newly diagnosed persons with dementia is not easy. By biting the bullet, we refer to the need for practitioners to address this, what can be regarded as a difficult topic. Our findings, and that of others, indicate how the question about firearm status is not often asked. This suggests the need for a more efficient system for screening for firearm ownership to be established. Moreover, diagnosis of dementia does not necessary mean that a person is incapable to handle their firearm appropriately. Removing the firearm automatically at the time of dementia diagnosis could potentially increase the social isolation and compromise personhood of the person of dementia. In Sweden, when taking the decision about removing the firearm, combination of factors (type of dementia diagnosis, gender, severity of cognitive impairment, psychiatric medication, living arrangement) are taken into consideration. Following Betz et al. [59], we suggest that the date of firearm retirement should be proactively discussed between persons with dementia, family members, and healthcare providers. In this way, the safety of persons with dementia can be maintained without compromising their right to make their own decisions.

CONCLUSION

Firearm owners with dementia were mostly you-nger males who were still living more independent lives. The decision to remove a weapon was not solely based on a diagnosis of dementia but a combination of factors was considered.