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Some patients refuse to answer. Many doctors do not ask. As the number of Americans with dementia increases, health professionals are wondering when and how to ask the question: "Do you have guns at home?"
While data on gun violence is scarce, a Kaiser Health News survey of "PBS NewsHour" published in June revealed more than 100 cases in the United States since 2012 in which people with dementia used guns to kill themselves or others. Shooters have often acted in cases of confusion, paranoia, delirium or aggression – common symptoms of dementia. Tragically, they shot dead spouses, children and caregivers.
Yet, across the country, health care providers say they have not received enough guidance to know if, when, and how to advise families on gun safety.
Dr. Altaf Saadi, a neurologist at UCLA and practicing medicine for five years, said the KHN article revealed a "blind spot" in his clinical practice. After reading her, she consulted the American Academy of Neurology's advice regarding the treatment of patients with dementia. His guidelines suggest that physicians consider asking questions about "access to firearms or other weapons" during a security check – but they do not say what to do if a patient is armed.
In the absence of national data on gun safety, there is no scientific standard on the cases in which a health care provider should discuss the access of people with cognitive impairment to a firearm or the time when the progression of dementia becomes unsuitable for the handling of a firearm.
Most doctors do not ask about firearms, according to research. In a 2014 study, 58% of internists surveyed said they had never asked if patients had guns at home.
"One of the biggest mistakes doctors make is not to think about access to firearms," said Dr. Colleen Christmas, geriatric primary care physician at Johns School of Medicine. Hopkins and a member of the American Neurological Association. Firearms are the most common method of suicide among seniors, she noted. Christmas said that she was asking every incoming patient about access to firearms, with the same neutral tone that she asked about seat belts, and "I find that the conversation goes smoothly.
Recently, health professionals have become increasingly important in the prevention of gun violence. In the aftermath of the Las Vegas shootout that claimed the lives of 58 spectators last October, more than 1,300 health care providers publicly pledged to question patients about firearms ownership and the availability of firearms. firearm safety in the presence of risk factors.
The promises were made in response to an article by Dr. Garen Wintemute, director of the Violence Prevention Research Program at the University of California at Davis. In response to the comments in this article, her center has developed a toolkit called What You Can Do, providing health professionals with advice on how to reduce the risk of gun violence.
In a deeply divided nation on gun ownership issues, in which many ardently defend the right to bear arms under the Second Amendment, these efforts have given rise to oppositions. Dr. Arthur Przebinda, Director of Physicians for the Responsible Use of Firearms, described Wintemute's efforts as part of a larger bias on the part of institutional medicine. Przebinda said that asking doctors to sign such a pledge encourages them to "spread the Americans' constitutionally protected rights to the possession and confidentiality of firearms."
Przebinda said he was receiving several requests a day from patients looking for gun-friendly doctors. Some, he said, are tired of having their doctors send them anti-gun videos and other media on YouTube. Its more than 1,400-member group has set up a referral service linking patients to firearms-friendly physicians.
For doctors and other health professionals, it can be difficult to solve this politically complex problem. Here are the main problems:
Q: Is it legal to talk to patients about firearms?
A: Yes No federal or state law prohibits health professionals from raising the problem.
Q: Why do not doctors do it?
A: The top three reasons are lack of time, not knowing what to say to patients, and believing that patients will not consider their advice on gun ownership or gun safety. fire, revealed a survey of family physicians.
"There is no medical school or health professional in the country that can train in firearms," said Wintemute. He indicated that he was currently working with the American Medical Association to design a continuing medical education course on the subject.
Other doctors do not believe they should ask. Przebinda says doctors should almost never ask their patients questions about firearms except in "very rare and very exceptional circumstances" – for example, if a patient is discouraged or deadly. He added that placing information about the ownership of patients' firearms in an electronic medical record puts their privacy at risk.
Q: When should they approach the subject?
A: The Veterans Health Administration recommends asking questions about firearms as part of a security check when "investigating or making an alleged diagnosis of dementia". The Alzheimer's Association also recommends asking "Are firearms present at home?" As part of a security check. This screening is part of a care planning session that Medicare covers after the initial diagnosis of dementia and each year as the disease progresses.
The American College of Physicians recommends that physicians "advise patients about the risk of owning a firearm at home, especially in children, adolescents, people with dementia, people with mental illness , people with disorders related to the use of substances or other people who present an increased risk of harming themselves or others are present. "
Wintemute stated that he was not suggesting to all doctors to systematically ask each patient about firearms. His group recommends doing so when risk factors are present, such as a risk of violence to oneself or others, a history of violent behavior or substance abuse, a "serious and poorly controlled mental illness", or Belonging to a "demographic group with an increased risk of firearm injuries". "
Q: What should health care providers recommend to patients with their firearms?
A: The National Rifle Association and What You Can Do offer tips on how to store guns safely, including using trigger locks and safes.
The Alzheimer's Association recommends locking down firearms may not be enough, because people with dementia can "misperceive the danger" and break into a gun cabinet to protect themselves. To fully protect a family, the organization recommends removing the firearms from the home.
But health professionals may be reluctant to recommend this because of legal issues, said Jon Vernick, co-director of the Johns Hopkins Center for Gun Policy and Research. Most states allow the temporary transfer of firearms to a family member without background checks. But seven states do not: Connecticut, Hawaii (for handguns), Massachusetts, Michigan, New Jersey, North Carolina and Rhode Island, according to Vernick. He recommends that health professionals consult their national firearms laws at sites such as the NRA Legislative Initiative Institute or the Giffords Law Center for the Prevention of Armed Violence.
In addition, 13 states have passed laws allowing law enforcement, and sometimes family members, to ask a judge to temporarily seize firearms from an owner of weapons fire which presents a dangerous behavior.
Q: What happens when clinicians ask questions about firearms?
A: Natasha Bahr, a teacher and social worker who works with geriatric patients at a clinic specializing in memory disorders at the Health Science Center of the University of North Texas, said in connection with a standard evaluation at home? "
"I'm so repelled," she said. About 60% of her patients refuse to answer, she said.
Patients say, "It's none of your business," "I'm free not to answer that question," or "This is my second amendment," she said. "They give the impression that I judge, and I really am not."
Dr. John Morris, director of the Knight Alzheimer's Disease Research Center at Washington University in St. Louis, said he was interviewing his patients about firearms in the context of other safety concerns. When safety is at stake, he usually advises families to lock guns and store ammunition separately.
"People with dementia usually lack understanding of their problems. So they will protest, "he said. Dementia is characterized by "the gradual deterioration not only of memory but also of judgment, problem solving and good decision-making," noted Morris.
In one case, Morris said, he had to persuade the daughter of a patient with dementia to get his father's shotguns. Uncomfortable with the reversal of roles, she was reluctant to do so.
"It's very difficult to tell your father that he can no longer get his guns," Morris said. The father replied, "I have never used my firearms badly. … it will not be a problem, "said Morris. "But, he remembers his past – he can not predict the future."
Finally, the girl decided to remove the guns from the house. After a few weeks, his father has forgotten everything, Morris said.
Morris said that the story highlights how difficult it is for families to care for people with dementia. "They are forced to make decisions, often against their will," he said, "but they must do so for the safety and well-being of the person."
(Kaiser Health News (KHN) is a national health policy information service, an independent editorial program of the Henry J. Kaiser Family Foundation. .)
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© 2018 Kaiser Health News
Visit Kaiser Health News at www.khn.org
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