DEMENTIA: FIREARM ACCESS

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DEMENTIAFIREARM ACCESS
Dementia and Firearm Access Audio Conference VHA
Dementia Safety Review Workgroup
August 27, 2009 300 420 PM ET

• Karen Elechko, MSN, RN
• VAMC Coatesville
• Dave Oslin, MD
• VAMC Philadelphia
• Kerry Knox, MS, PhD
• VAMC Canadaigua

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Objectives

• Describe cognitive and functional changes
  associated with dementia, and how these impact
  firearm safety and use.
• Describe at least one VISN good practice idea on
  dementia and firearm access.
• Cite recommended features of a clinical reminder
  on dementia and firearm access.
• Discuss strategies to counsel Veterans and
  caregivers about limiting access to firearms and
  removing firearms from the home of a cognitively
  impaired individual.

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Background

• OMI Report Firearm Access and Automobile Driving
  Among Veterans with Dementia, June 18, 2004
• http//vaww.va.gov/geriatricsshg/docs/finalrpt.pdf
  
• Initial incident
• 44 of dementia patients surveyed drove
• 40 of dementia patients surveyed had firearm in
  home
• Firearms and driving questionnaire and pamphlets
  developed
• DUSHOM compiled roll up document summarizing
  common VISN responses (e.g. staff education,
  review of state and local laws, clinical
  reminders)

DVA OMI GEC Strategic Healthcare Group (2004)
http//vaww.va.gov/geriatricsshg/docs/finalrpt.pdf

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BackGround

• Dementia Safety Review Workgroup, November 10,
  2008
• http//vaww1.va.gov/geriatricsshg/docs/VISNDementi
  aSafetyReviewWorkgroupFinalReport2008.doc
• Multidisciplinary workgroup assembled to review
  VISN responses to recommendations 4 and 7 of OMI
  Report Firearm Access and Automobile Driving
  Among Veterans with Dementia, June 18, 2004

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background

• Recommendation 4
• VA Medical Centers should ascertain the rules
  with respect to dementia, driving and firearm
  ownership in the States where they are located
  and provide guidance on these topics to their
  practitioners.
• Recommendation 7
• As part of good clinical practice, VHA should
  strongly encourage the assessment and appropriate
  counseling regarding driving practices and
  availability of firearms in the
  assessment/management of patients with dementia.
  The assessment of these issues can be conducted
  via an interview or with a formal questionnaire.

DVA OMI GEC Strategic Healthcare Group (2004)
http//vaww.va.gov/geriatricsshg/docs/finalrpt.pdf

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Cognitive functional changes

• Loss of recent memory
• Impaired
• Attention concentration
• Orientation
• Processing
• Insight and judgment
• Sequencing
• Visual comprehension

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Cognitive functional changes
Diagnostic Criteria (DSM-IV-TR)

• Significant impairment in MEMORY functioning
• With one or more of the following
• Problems with language (interpreting voices
  and/or sounds in the home as a possible intruder)
• Impaired ability to carry out motor tasks
  (confusing barrel and trigger of the firearm)
• Failure to recognize or identify objects (newer
  family members and friends and/or changes in
  furniture arrangement in the home)
• Inability to organize and execute complex and/or
  multi-part behavioral sequences (failure to carry
  and/or store a firearm and ammunition properly)

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Cognitive functional changes

• Incorrect loading/unloading/storage of a firearm
  as well as ammunition storage
• Thoughts of infidelity of significant other
• Belief of a perceived threat with difficult
  redirection
• Misinterpretation of the environment
• Home situational changes adult children and/or
  grandchildren move in
• Home vs. combat
• Potential near misses marksman hunter with
  dementia hits something other than the targeted
  item (i.e. other object, self, friend)

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Clinical Reminders

• Veteran with an established diagnosis of dementia
• Option to turn off reminder permanently if
  patient does not have dementia
• No age criterion
• Due every year
• No specific set of questions (can use questions
  from OMI Questionnaire)
• Use of the OMI Pamphlet

VHA DVA (2008) http//vaww1.va.gov/geriatricsshg/d
ocs/VISNDementiaSafetyReviewWorkgroupFinalReport20
08.doc
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Clinical Reminders (cont.)

• Provide practitioners additional guidance on
  veteran/family education
• Visible to some or all providers, in some or all
  settings - according to options of the Clinical
  Application Coordinator
• VISN or local policy decides responsibility for
  completing the reminder
• Example VISNs 4, 6, 11, 19
• Pilot-test prior to full implementation

VHA DVA (2008) http//vaww1.va.gov/geriatricsshg/d
ocs/VISNDementiaSafetyReviewWorkgroupFinalReport20
08.doc
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Dementia Firearm Access Research

• Sample of 106 patients and family members in New
  Hampshire and South Carolina
• 60 of households had a firearm
• 44 of owners kept the firearm loaded

Spangenberg, et al. (1999) Journal of the
American Geriatrics Society 47 1183-6.
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Dementia Firearm Access Research (cont.)

• In another study sample of older primary care
  patients (1023)
• 27.9 of older persons have access to firearm
• Of that, 19.7 have access to a handgun
• Patients with symptoms of suicidal ideation,
  cognitive impairment, and high levels of
  depression are likely to have a firearm.
• Conclusion Providers need to inquire about
  firearm availability provide education on
  firearm safety as routine clinical practice for
  older adults with behavioral problems

Oslin, D. et al., (2004). Managing suicide risk
in late life Access to firearms as a public
health risk. American Journal of Geriatric
Psychiatry, 12(1), 30-36.
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Good Practice Dementia and
Firearm Access

• Collaboration with the Alzheimers Association,
  VA Police, County Sheriffs Office, NRA Firearm
  Safety Instructor, and State Police
• Firearm Access Safety Training
• Provider, Caregiver, Senior Centers
• Patient Health Education Pamphlet developed for
  available free gunlock within the community of
  VISN 4
• Free gun locks offered with education on
  application by VA Police departments and Golden
  Memory Clinic in VISN 4
• Clinical Reminder

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I Want to Protect My Home Family.

• Understanding the personal and cultural context
  of the home setting
• Must have a trusting relationship with
  Interdisciplinary Team
• Partnership with caregivers who provide care in
  the home of the Veteran with dementia

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Good Practice Ideas

• Multi-disciplinary approach
• Demonstration/Practice
• Written recommendations and instructions
• Use of photographs
• Outreach with follow-up telephone contacts with
  veteran/caregiver

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Counseling

• May consider initiating the discussion by using
• OMI Firearms and Driving Questionnaire
  www.va.gov/vhapublications/ViewPublication.asp?pub
  _ID1351
• OMI Firearms and Dementia Pamphlet
• http//www1.va.gov/VHAPUBLICATIONS/ViewPublicatio
  n.asp?pub_ID1186

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Firearms and Dementia Questionnaire


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Veteran EducationLimiting Firearm Access

• Presence of firearms in a household has been
  linked to risk of injury or death for everyone in
  or around the home
• This danger is increased when one of the persons
  in the household has dementia
• The best way to reduce gun risk is to remove the
  gun from your home

DVA OMI GEC Strategic Healthcare Group (2004)
http//vaww.va.gov/geriatricsshg/docs/finalrpt.pdf

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Caregiver EducationLimiting Firearm Access

• Keep guns in a sturdy locked cabinet that does
  not have glass
• Always store guns unloaded
• Install trigger guards/locks on all guns to
  prevent them from being used
• Keep all ammunition in a locked fireproof safe in
  a separate place from guns
• Keep keys for trigger guards/locks, gun cabinet,
  and ammunition hidden from children and persons
  with dementia

DVA OMI GEC Strategic Healthcare Group (2004)
http//vaww.va.gov/geriatricsshg/docs/finalrpt.pdf

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Legal Ethical Considerations

• Frequently Asked Questions (FAQ)
• Driving Access to Firearms
• Laws or regulations
• Access and availability
• Surrendering a firearm to a police agency
• Surrendering a firearm at a VAMC
• Storage
• Firearm safety community education

http//vaww1.va.gov/geriatricsshg/docs/VISNDementi
aSafetyReviewWorkgroupFinalReport2008.doc
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Legal Ethical Considerations

• Frequently Asked Questions (FAQ)
• Driving Access to Firearms
• 1. Are there any laws or regulations that
  require individuals with dementia to be assessed
  for safety with firearms?
• No

http//vaww1.va.gov/geriatricsshg/docs/VISNDementi
aSafetyReviewWorkgroupFinalReport2008.doc
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Legal Ethical Considerations

• Frequently Asked Questions (FAQ)
• Driving Access to Firearms
• 2. Do people with dementia have firearms in
  their home?
• Yes

http//vaww1.va.gov/geriatricsshg/docs/VISNDementi
aSafetyReviewWorkgroupFinalReport2008.doc
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Legal Ethical Considerations

• Frequently Asked Questions (FAQ)
• Driving Access to Firearms
• 3. Can firearms be surrendered to police
  agencies?
• Perhaps

http//vaww1.va.gov/geriatricsshg/docs/VISNDementi
aSafetyReviewWorkgroupFinalReport2008.doc
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Legal Ethical Considerations

• Frequently Asked Questions (FAQ)
• Driving Access to Firearms
• 4. Can anyone surrender a firearm at any
  Veterans Affairs Medical Center?
• No

http//vaww1.va.gov/geriatricsshg/docs/VISNDementi
aSafetyReviewWorkgroupFinalReport2008.doc
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Legal Ethical Considerations

• Frequently Asked Questions (FAQ)
• Driving Access to Firearms
• 5. How should firearms be stored?
• Locked sturdy cabinet without glass
• Unloaded
• Trigger guards
• Ammunition in locked fireproof safe-separate from
  the firearms
• Keep keys hidden from children persons with
  dementia
• The best way to reduce gun risk is to remove the
  gun from the home.

http//vaww1.va.gov/geriatricsshg/docs/VISNDementi
aSafetyReviewWorkgroupFinalReport2008.doc
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Legal Ethical Considerations

• Frequently Asked Questions (FAQ)
• Driving Access to Firearms
• 6. Can a patient, family member, or NOK in
  need of firearm guidance receive firearm safety
  assistance from any State or local police agency?
• Perhaps

http//vaww1.va.gov/geriatricsshg/docs/VISNDementi
aSafetyReviewWorkgroupFinalReport2008.doc
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2008 blue Ribbon Panel

• Purpose evaluate the DVA current state of
  suicide prevention activities and develop
  recommendations to reduce the rate of suicide
  among Veterans.
• Recommendations include
• Develop educational materials about suicide
  prevention for families community groups
• Development of gun-safety measures for Veterans
  with children in the home as both a child-safety
  measure as well as a suicide prevention effort

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VHAs office of mental health

• Purchase of 1.5 million gun safety locks
• 3 year distribution (2009-2011)
• Distributed to Veterans their families
• Staggered distribution due to suppliers need for
  production delivery
• Each VHA facility will receive 1 shipment of
  locks per year
• The Center of Excellence at Canandaigua will
  evaluate the impact of this program

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Questions Answers
Karen Elechko, MSN, RN Golden Memory Clinic
Coordinator VAMC Coatesville, VISN 4 Dave Oslin,
MD VA Associate Chief of Staff for Behavioral
Health Director, VISN 4 MIRECC VAMC Philadelphia
Kerry Knox, MS, PhD. Director, Center of
Excellence for Suicide Prevention VISN 2 VAMC
Canadaigua
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Contact Information

• For information about this specific presentation,
  please contact Karen Elechko at
  karen.elechko_at_va.gov Dave Oslin at
  dave.oslin_at_va.gov or oslin_at_mail.med.upenn.edu or
  Kerry Knox at kerry.knox_at_va.gov.
• For any questions about the monthly GRECC Audio
  Conference Series, please contact Tim Foley at
  tim.foley_at_va.gov or call [phone].
• To evaluate this conference for CE credit, please
  obtain a Satellite Registration form and a
  Faculty Evaluation form from the Satellite
  Coordinator at your facility. The forms must be
  mailed to EES within 2 weeks of the broadcast.