Theresa Paolo has been around guns most of her life. When she turned 10, her parents gave her a shotgun. Her spouse, Lin, is a retired law enforcement officer who kept a gun on the bedside table even after she was diagnosed with hepatic encephalopathy, a neurologic condition that can result from severe liver disease and can cause confusion and memory loss. In addition, Lin sustained repeated concussions and traumatic brain injuries during her years on the police force and frequently experiences angry outbursts, mood swings, and personality changes.
One night, Lin erupted in anger, spewing vicious verbal attacks. Feeling unsafe, Theresa called 911 and drove to a hotel. When she returned to the house later that night, the police were there and Lin was hiding in the bedroom. Even though Lin's handgun was in the bedroom, she never threatened to use it. “As soon as she heard the officers' voices, she immediately went into ‘cop mode' and calmed down on her own,” says Theresa.
The following day Theresa discreetly took the gun and hid it in the corner of an unlocked bathroom they used as a storage space. She feared that locking the door of the bathroom would draw her spouse's attention and suspicion. Several months later, when Lin asked about the gun, Theresa offered vague answers, and Lin didn't pursue it. More recently, Theresa put a firesafe lockbox in the bathroom-turned-closet and placed the gun inside. “Lin doesn't know where the key is,” she says.
Theresa survived her partner's angry outburst, but others are not so fortunate. A four-month investigation in 2018 by PBS NewsHour and Kaiser Health News discovered more than 100 cases of gun violence by people with dementia. Many were suicides, but in some cases spouses, children, or caregivers were shot. The individuals almost always acted during moments of confusion, paranoia, delusion, or aggression, and most had some condition affecting their cognition and behavior, such as Alzheimer's disease, Parkinson's disease, Lewy body dementia, or frontotemporal dementia.
Talking About Guns
In most cases, having firearms or other weapons in a household creates no problems for responsible gun owners and others in the home. “However, when someone has Alzheimer's disease or another dementia-related disorder, firearms can pose a significant risk to the person living with the disease and their family members,” says attorney Lindsay Nichols, policy director at the Giffords Law Center, a nonprofit organization in San Francisco that advocates for stronger gun laws.
Caregivers often remove knobs from stoves or lock up medicines, and eventually have the difficult conversation about when someone with dementia should stop driving. What's less talked about is what to do about guns in the homes of people living with dementia. That conversation can happen in conjunction with talking about driving, suggests John Morris, MD, FAAN, director of the Charles F. and Joanne Knight Alzheimer Disease Research Center at Washington University in St. Louis. He recommends that firearms be kept locked away and access to the keys be limited to caregivers or family members.
When to remove firearms will vary based on the person's abilities and symptoms and the progression of the disease, experts say. “The goal for caregivers is to balance autonomy and independence with safety,” says Jori Fleisher, MD, MSCE, FAAN, a movement disorders specialist and associate professor of neurological sciences at Rush University in Chicago. “It's not about confiscating guns. It's about having deliberate conversations as a family about what to do before an accident occurs.” Dr. Fleisher, who is a member of the Brain & Life editorial board, likes to use the word “retire” when talking about stopping driving or no longer using guns. “It's gentler than saying: ‘I'm taking everything away, and you can't do this, and you can't do that.'”
Like many caregivers, Theresa struggled to find the right time to talk with her spouse about how to safely store guns in their home. “I was hoping it could be her choice,” she says. “I wanted her to have some dignity as she was slowly losing the ability to make everyday decisions.”
The Alzheimer's Association recommends framing the discussion around safety. For example, caregivers might say, “There may come a time when you can't safely handle a firearm. What should we do with your guns then?”
The key is to involve the person with dementia before symptoms are too severe, says Monica Moreno, senior director of care and support at the Alzheimer's Association in Chicago. “Giving the person a voice can be empowering, and it helps families find an agreed-upon solution should it become necessary to remove guns from the home,” says Moreno.
Those worried about these conversations should consider bringing up the subject during a doctor's appointment. “A few years ago, laws called physical gag rules were enacted, but they've been overturned or watered down. As a result, doctors can discuss firearms with patients,” says Nichols. And it can help when the caregiver has support from someone outside of the immediate family, says Victoria Pelak, MD, FAAN, professor of neurology and ophthalmology at the University of Colorado School of Medicine in Aurora and a member of the editorial board of Brain & Life.
One of Dr. Pelak's patients, Irma Lucas, 64, purchased a gun in 2021—seven years after being diagnosed with posterior cortical atrophy, a rare form of Alzheimer's disease that affects areas of the brain involved in spatial perception and complex visual processing. After the COVID-19 pandemic, the George Floyd murder, and the Black Lives Matter protests, Lucas wanted to protect herself and her husband. “As a Black person living here, I don't feel safe in our society,” says Lucas, who lives in Denver.
A police officer in London for more than a decade during the 1980s, Lucas never carried a firearm. When she bought a gun, she took lessons and regularly went to the shooting range. She also told Dr. Pelak. “Each situation varies based on the person's cognitive impairment,” says Dr. Pelak. “I have talked about this several times with Irma and her husband, and we will continue to address it as things evolve with her health.” Dr. Pelak says she looks for signs of impaired judgment or a lack of insight in her patients. “When they exhibit poor judgment or have no insight about their deficits, I work with them and their families on a plan that removes access to firearms,” she says.
Caregiver Vigilance
Families need to pay attention to the progression of dementia symptoms. “When loved ones don't recognize people who should be familiar to them, that's a sign to keep a close eye on them and consider locking firearms in a secure place,” says Moreno. “The last thing you want is for that person to mistake a family member or a home health aide for an intruder and turn to a gun for protection.”
Theresa Paolo is always tuned in to her spouse's behavior, particularly when her anger starts simmering. To help manage her spouse's emotions, Theresa began fostering cats. “I pop a kitten on her lap, and that will keep her from getting angry.”
Another concern is suicide, says emergency physician Emmy Betz, MD, MPH, who leads the Firearm Injury Prevention Initiative at the University of Colorado School of Medicine. “We know that dementia can increase suicide risk, and access to firearms increases that likelihood,” she says. “Sadly, for people with dementia, firearms are the most common method of suicide.”
Caregivers need to protect themselves as well, especially when loved ones exhibit behavioral problems such as anger, depression, delusion, and hallucinations. “Caregivers don't always consider their own situation, or they haven't thought about what their options might be,” says Dr. Betz, co-founder of the Colorado Firearms Safety Coalition and the Safety in Dementia Project.
A 2020 survey, conducted by Dr. Betz and a research team at the University of Colorado School of Medicine, showed that few dementia caregivers, including spouses, partners, and family members, have received training or professional counseling about how to address gun safety. Of nearly 120 caregivers surveyed nationwide, nearly one-third reported access to firearms in the home, and 71 percent of those expressed concern that their loved one would accidentally harm themselves or someone else.
“Alzheimer's and other kinds of dementia can cause changes in thinking and memory that could make it unsafe to handle a gun—even among those who have a lifetime of experience with firearms,” says Dr. Betz. Loss of memory, judgment, and executive function, and the inability to understand contextual situations, all greatly compromise an individual's ability to use firearms safely.
Laurie Scherrer, who has owned guns for more than 40 years, feels strongly that firearms should not automatically be taken away from people with dementia, especially those who live in rural areas. A resident of rural Alabama, Scherrer, 65, was diagnosed with dementia 10 years ago. She owns several handguns, two semi-automatics, and one .22 caliber rifle that she stores in her bedside table. She's on the board of Dementia Action Alliance, a patient advocacy group for those living with all forms of dementia. She says she feels safer owning guns. She and her husband, Roy, have used them to protect their service dogs from coyotes and rabid animals.
Most of the guns are locked in a safe, and she often forgets the combination. “I don't think there's any reason why guns should be taken from me,” she says. “My husband knows to keep them safe if things get worse with my memory and behavior.”
For families who have guns, experts advise keeping them unloaded in a locked cabinet or safe, with the ammunition stored separately. “You can also disable the guns, replace bullets with blanks, or replace the guns with decoys, but that raises the risk of them being mistaken for a functioning weapon in an emergency,” says Nichols of the Giffords Law Center in San Francisco.
Protective Measures
Another strategy is to temporarily suspend an individual's access to firearms if there are clear signs of a potential threat or violence, including hitting or kicking, destroying property, shouting, or making threats against others or themselves, says Dr. Pelak. Extreme risk protection orders, also known as red flag laws, have been enacted in 21 states and the District of Columbia. They allow families, household members, and law enforcement agencies to petition courts for a civil order to restrict use of firearms.
In cases where gun owners are unwilling to part with their firearms, federal law dictates that they lose the right to buy or own guns if a judge deems them mentally incompetent to manage their own affairs. “This is typically a last resort for most families,” says Nichols. “They usually need to go to probate court and request guardianship to assume control of the guns.”
Dr. Betz and her colleagues developed the Firearm Life Plan, which helps families consider how to pass down firearms just as they would books, coins, chinaware, or other personal items. The site has a downloadable worksheet to help families inventory firearms, pinpoint where they are, and decide who might receive them and when. The plan also includes conversation starters to begin planning how to pass on firearms. A “legacy map” helps gun owners think about the personal importance of their firearms and whether they are used safely.
“There are lots of firearms in this country, and they aren't going anywhere,” Dr. Betz explains. About 33 percent of all adults aged 65 years or older own a gun, and another 12 percent live in a household with someone who does, according to a report in the Annals of Internal Medicine. “Our approach is based on listening to the ideas and experiences of those who own guns, those who don't, and those who have been injured by them. We try to understand all the viewpoints and find common ground.”
Strategies for Gun Safety
For families who own firearms and whose loved ones have dementia or other neurologic disorders that affect cognition, experts offer this advice for avoiding accidents.
Remove ammunition.
Unloaded guns minimize the risk of unintentional discharges, particularly in homes where someone lives with dementia or another neurologic disorder that causes confusion, impaired judgment, or memory loss, says Victoria Pelak, MD, FAAN, professor of neurology and ophthalmology at the University of Colorado School of Medicine in Aurora and a member of the Brain & Life editorial board.
Store safely.
Keep guns unloaded in a locked cabinet or safe with the ammunition stored separately, advises John Morris, MD, FAAN, director of the Charles F. and Joanne Knight Alzheimer Disease Research Center at Washington University in St. Louis. If you don't have a safe storage area, check with local gun stores, shooting ranges, or law enforcement agencies that may temporarily store firearms. Invest in a trigger lock, which blocks the gun's trigger mechanism and can help prevent the unauthorized or accidental use of a firearm.
Transfer ownership.
Set up a gun trust. This legal document specifies the terms under which the firearms are held, used, and transferred from the grantor or owner of the guns to the trustees, usually family members, who are authorized to possess and use the firearms, says Lindsay Nichols, policy director at the Giffords Law Center, a nonprofit organization in San Francisco that advocates for stronger gun laws.
Review gun safety guidance.
For more information about how to handle guns when someone in the family has dementia, check out Dementia and Firearm Safety from HNR Gunworks or the Firearm Life Plan, a tool kit developed in collaboration with the Firearm Injury Prevention Initiative at the University of Colorado Anschutz Medical Campus. “This plan offers guidance to families as they make difficult decisions related to firearm safety,” says Emmy Betz, MD, MPH, who leads the initiative at the University of Colorado School of Medicine.
Take out of the home.
The Alzheimer's Association suggests that some families may consider removing guns from the home altogether to fully protect the family from an accident. “Locking and storing away guns are great first steps, but they do not guarantee that the person will not find the gun or appear to be holding a loaded weapon, potentially prompting reactions from those in proximity,” says Monica Moreno, senior director of care and support at the Alzheimer's Association in Chicago.
Sell. Licensed firearms dealers, gun shows, and online gun marketplaces like GunBroker, Armslist, and Sportsman's Warehouse will purchase guns. Gun buyback programs are available through law enforcement agencies, adds Nichols.
