Household Firearm Ownership and Storage, Suicide Risk Factors, and Memory Loss Among Older Adults: Results From a Statewide Survey

Suicide-related behavior and firearm access among perpetrators of domestic violence subject to domestic violence protection orders

Perpetrators of domestic violence (DV) may be a population at elevated risk of suicide. Domestic violence protection orders (DVPOs) can include the removal of firearms from the individual subjected to the order (i.e., the respondent) to protect the victim-survivor. While removal of firearms in a DVPO is designed to protect the victim-survivor; it may also prevent suicide of the respondent by reducing access to lethal means. Therefore, we examined the association of respondent suicide-related behaviors with firearm possession and weapon use in DV among a sample of granted DVPO petitions in King County, Washington (WA), United States from 2014 to 2020 (n = 2,537). We compared prevalence ratios (PR) of respondent firearm possession and use of firearms or weapons to threaten or harm by suicide-related behavior. Overall, respondent suicide-related behavior was commonly reported by petitioners (46 %). Approximately 30 % of respondents possessed firearms. This was similar between respondents with and without a history of suicide-related behavior (PR: 1.03; 95 % CI: 0.91-1.17). Respondents with a history of suicide-related behavior were 1.33 times more likely to have used firearms or weapons to threaten/harm in DV compared to those without a history of suicide-related behavior (44.1 % vs. 33.8 %; 95 % CI: 1.20-1.47). In conclusion, both firearm possession and suicide-related behaviors were common among DVPO respondents. History of suicide-related behavior may be a marker for firearm-related harm to the victim-survivor. Evaluations of DVPO firearm dispossession should consider both firearm-related injury of the victim-survivor and suicide of the respondent.

Older Adults' Preferences Regarding Firearm Locking Device Use: Results of a National Survey

OBJECTIVES

Use of firearm locking devices may reduce the risk of suicide and injury among older adults. This study describes older adults' preferences when choosing a firearm locking device.

METHODS

We conducted a secondary analysis of a nationally representative survey of US adult firearm owners (N = 2,152). We compared older adults (≥65y) with relatively younger adults (<65y), stratified by self-reported gender.

RESULTS

The top three factors cited as impacting firearm locking device selection included speed (53.6%) and ease of firearm access from device (52.4%), and cost of the device (28.7%). These top factors were comparable for all adults across genders. A larger proportion of older vs younger males reported that a primary preference was whether the device allows the firearm to remain loaded with ammunition; smaller proportions of older vs younger males reported strength of device (device durability) and costs.

CONCLUSIONS

Preference among older adults, particularly older males, for locking devices that maintain the firearms easy to access - especially, loaded with ammunition - might impact firearm injury prevention efforts for this high-risk group.

CLINICAL IMPLICATIONS

For harm reduction, use of any firearm locking device may reduce the risk of firearm injury or death. Clinicians are encouraged to explore reasons for locking device selection within motivational interviewing frameworks.

Fatal and non-fatal firearm-related injuries in Canada, 2016-2020: a population-based study using three administrative databases

BACKGROUND

Firearms are a substantial cause of injury-related morbidity and mortality in Canada and globally, though evidence from contexts other than the USA is relatively limited. We examined deaths, hospitalizations and emergency department (ED) visits due to firearm-related injuries in Canada to identify population groups at increased risk of fatal and non-fatal outcomes.

METHODS

We conducted a population-based study using three national administrative databases on deaths, hospitalizations, and ED visits. ICD-10 codes were used to identify firearm-related injuries from January 1, 2016, through December 31, 2020. Fatal and non-fatal firearm injuries were classified as suicide/self-harm, homicide/assault, unintentional, undetermined or legal intervention injuries. We analyzed the data with counts, rates and proportions, stratified by sex, age group, province/territory, and year.

RESULTS

Over the 5-year period, we identified 4005 deaths, 3169 hospitalizations, and 2847 ED visits related to firearm injuries in various jurisdictions in Canada. Males comprised the majority of fatal and non-fatal injury cases. The highest rates of fatal and non-fatal firearm injuries were among 20- to 34-year-olds. The leading cause of fatal firearm injuries was self-harm (72.3%). For non-fatal firearm hospitalizations and ED visits, assault (48.8%) and unintentional injuries (62.8%) were the leading causes of injury. Rates varied by province and territory.

CONCLUSIONS

Our results showed that males comprised the majority of fatal and non-fatal firearm injuries in Canada. The rates of both fatal and non-fatal firearm injuries were highest among the 20- to 34-year-old age group. This comprehensive overview of the epidemiology of firearm injuries in Canada provides baseline data for ongoing surveillance and policy evaluation related to public health interventions.

Firearm ownership, attitudes, and safe storage practices among a nationally representative sample of older U.S. adults age 50 to 80

Firearms are a leading cause of injury mortality across the lifespan, with elevated risks for older adult populations. To inform prevention efforts, we conducted a probability-based web survey (12/1/2019-12/23/2019) of 2048 older adults (age 50-80) to characterize national estimates of firearm ownership, safety practices, and attitudes about health screening, counseling, and policy initiatives. Among older U.S. adults, 26.7% [95%CI = 24.8%-28.8%] report owning one or more firearms. The primary motivation for ownership was protection (69.5%), with 90.4% highlighting a fear of criminal assault. 39.4% of firearm owners reported regularly storing firearm(s) unloaded and locked, with 24.2% regularly storing at least one loaded and unlocked. While most firearm owners found healthcare screening (69.2% [95%CI: 64.9-73.1]) and safety counseling (63.2% [95%CI = 58.8-67.3]) acceptable, only 3.7% of older adults reported being asked about firearm safety by a healthcare provider in the past year. Among firearm owners, there was support for state-level policy interventions, including allowing family/police to petition courts to restrict access when someone is a danger to self/others (78.9% [95%CI = 75.1-82.3]), comprehensive background checks (85.0% [95%CI = 81.5-87.9]), restricting access/ownership under domestic violence restraining orders (88.1%; 95%CI = 84.9-90.7], and removing firearms from older adults with dementia/confusion (80.6%; 95%CI = 76.8-84.0]. Healthcare and policy-level interventions maintained higher support among non-owners than owners (p's < 0.001). Overall, data highlights opportunities exist for more robust firearm safety prevention efforts among older adults, particularly healthcare-based counseling and state/federal policies that focus on addressing lethal means access among at-risk individuals.

Suicide risk in first year after dementia diagnosis in older adults

INTRODUCTION

Receiving a diagnosis of Alzheimer's disease or related dementias (ADRD) can be a pivotal and stressful period. We examined the risk of suicide in the first year after ADRD diagnosis relative to the general geriatric population.

METHODS

We identified a national cohort of Medicare fee-for-service beneficiaries aged ≥ 65 years with newly diagnosed ADRD (n = 2,667,987) linked to the National Death Index.

RESULTS

The suicide rate for the ADRD cohort was 26.42 per 100,000 person-years. The overall standardized mortality ratio (SMR) for suicide was 1.53 (95% confidence interval [CI] = 1.42, 1.65) with the highest risk among adults aged 65 to 74 years (SMR = 3.40, 95% CI = 2.94, 3.86) and the first 90 days after ADRD diagnosis. Rural residence and recent mental health, substance use, or chronic pain conditions were associated with increased suicide risk.

DISCUSSION

Results highlight the importance of suicide risk screening and support at the time of newly diagnosed dementia, particularly for patients aged < 75 years.

Self-reported Access to Firearms Among Patients Receiving Care for Mental Health and Substance Use

Question

Did patients respond to a standard question about firearm access on a mental health questionnaire, and, if so, how did they respond?

Findings

In this cross-sectional study of 128 802 patients receiving care for mental health and substance use, 83% of primary care patients answered a standard question about firearm access and 21% reported access. In mental health clinics, 92% of patients answered the question and 15% reported access.

Meaning

In this study, most patients reported firearm access on standard questionnaires; this screening practice may improve efforts to identify and engage patients at risk of suicide in discussions about securing firearms.

Importance

Firearms are the most common method of suicide, one of the “diseases of despair” driving increased mortality in the US over the past decade. However, routine standardized questions about firearm access are uncommon, particularly among adult populations, who are more often asked at the discretion of health care clinicians. Because standard questions are rare, patterns of patient-reported access are unknown.

Objective

To evaluate whether and how patients self-report firearm access information on a routine mental health monitoring questionnaire and additionally to examine sociodemographic and clinical associations of reported access.

Design, Setting, and Participants

Cross-sectional study of patients receiving care for mental health and/or substance use in primary care or outpatient mental health specialty clinics of Kaiser Permanente Washington, an integrated health insurance provider and care delivery system.

Main Outcomes and Measures

Electronic health records were used to identify patients who completed a standardized self-reported mental health monitoring questionnaire after a single question about firearm access was added from January 1, 2016, through December 31, 2019. Primary analyses evaluated response (answered vs not answered) and reported access (yes vs no) among those who answered, separately for patients seen in primary care and mental health. These analyses also evaluated associations between patient characteristics and reported firearm access. Data analysis took place from February 2020 through May 2021.

Results

Among patients (n = 128 802) who completed a mental health monitoring questionnaire during the study period, 74.4% (n = 95 875) saw a primary care clinician and 39.3% (n = 50 631) saw a mental health specialty clinician. The primary care and mental health samples were predominantly female (63.1% and 64.9%, respectively) and White (75.7% and 77.0%), with a mean age of 42.8 and 51.1 years. In primary care, 83.4% of patients answered the question about firearm access, and 20.9% of patients who responded to the firearm question reported having access. In mental health, 91.8% of patients answered the question, and 15.3% reported having access.

Conclusions and Relevance

In this cross-sectional study of adult patients receiving care for mental health and substance use, most patients answered a question about firearm access on a standardized mental health questionnaire. These findings provide a critical foundation to help advance understanding of the utility of standardized firearm access assessment and to inform development of practice guidelines and recommendations. Responses to standard firearm access questions used in combination with dialogue and decision-making resources about firearm access and storage may improve suicide prevention practices and outcomes.

Unintentional firearm mortality in African-American youths, 2010-2019

BACKGROUND/ PURPOSE

There is a dearth of studies that have examined unintentional firearm-related mortality in African-American (AA) youths. The purpose of this article is to assess the epidemiology of unintentional firearm mortality in AA youth, examine the risk factors associated with unintentional AA youth firearm mortality, and explore the evidence for preventing unintentional firearm-mortality in AA youths.

METHODS

In this cross-sectional study, the Web-Based Injury Statistics Query and Reporting System (WISQARS) data from the Centers for Disease Control and Prevention (CDC) was used. Data were analyzed from the years 2010-2019 using descriptive statistics.

RESULTS

Between the years 2010 and 2019, the AA youth unintentional firearm mortality rate increased by 48% while the rate for White youths declined by 29%. The decade from 2010 to 2019 saw almost 400 AA youths lose their lives to unintentional firearm trauma. AA male children averaged 87% of all AA unintentional firearm deaths during this time. The years of potential life lost due to unintentional firearm mortality ranged between 21,200 and 24,300 years. The risk factors for unintentional firearm mortality in AA youths include living in states with high rates of firearm ownership, living in a home with firearms, being an older adolescent, and being of lower socioeconomic status. Of all the strategies to prevent unintentional firearm mortality in youths, the most effective include strong (felony penalty) Child Access Prevention laws, the absence of Stand-Your-Ground laws, and physicians engaging in anticipatory guidance with patients regarding safe storage of firearms.

CONCLUSIONS

Despite the limited scale of unintentional firearm mortality in AA youths, primary prevention dictates that public health professionals intervene to keep this public health problem from becoming an epidemic and a larger contributor to health disparities.

Views on Firearm Safety Among Caregivers of People With Alzheimer Disease and Related Dementias

IMPORTANCE

The population of adults with Alzheimer disease and related dementias (ADRD) is increasing, and many people with ADRD have access to firearms. Little is known, however, about how caregivers of people with ADRD think about or address firearm safety.

OBJECTIVE

To assess views on firearm safety risks among caregivers of persons with ADRD, experiences of caregivers with health care professional-delivered counseling, and their preferred sources of information about firearm safety.

DESIGN, SETTING, AND PARTICIPANTS

This survey study used a probability-based online survey (National Firearms Survey, July 30 to August 11, 2019) with weights used to generate nationally representative estimates of adults living in households with firearms to assess firearm safety views of English-speaking adults 35 years or older. Respondents for the National Firearm Survery were drawn from I KnowledgePanel, a frame with approximately 55 000 US adults selected on an ongoing basis using address-based sampling methods.

MAIN OUTCOMES AND MEASURES

Caregivers were asked whether the person with ADRD owned or had access to firearms. Additional ADRD-related measures assessed perceptions about the likelihood of types of firearm injuries involving people with ADRD, support for firearm safety counseling by health care professionals with regard to dementia, and history of ever having received such counseling.

RESULTS

Of 6712 invited panel members, 4030 completed the survey (completion rate, 65%). For this analysis, we excluded the youngest participants (aged 18-34 years; n = 498); among the remaining 3532 participants, 124 reported being caregivers for persons with ADRD. Of the 124 caregivers, 51% were female and the mean (SD) age was 60 (12.5) years. Most participants (71%; 95% CI, 69%-72%) thought that a person with ADRD was more likely to hurt someone else unintentionally than intentionally hurt themselves or someone else. Many participants thought health care professionals should always (45%; 95% CI, 43%-47%) or sometimes (34%; 95% CI, 32%-37%) talk about firearm safety with caregivers or patients with dementia, but only 5% of caregivers (95% CI, 2%-12%) reported that a health care professional had ever spoken to them about firearm safety. Among the 41% (95% CI, 31%-51%) of caregivers who lived with a person with dementia, 31% (95% CI, 18%-49%) said the person with dementia could access firearms in the home.

CONCLUSIONS AND RELEVANCE

In this study, few caregivers of adults with ADRD reported having received health care professional counseling about firearm safety, although most thought health care professionals should provide such counseling. These findings raise concerns about home firearm access among adults with ADRD and indicate potential opportunities for enhanced education by health care professionals and community organizations.

The impact of gun violence restraining order laws in the U.S. and firearm suicide among older adults: a longitudinal state-level analysis, 2012-2016

BACKGROUND

Older adults complete suicide at a disproportionately higher rate compared to the general population, with firearms the most common means of suicide. State gun laws may be a policy remedy. Less is known about Gun Violence Restricting Order (GVRO) laws, which allow for removal of firearms from people deemed to be a danger to themselves or others, and their effects on suicide rates among older adults. The purpose of this study was to examine the association of state firearm laws with the incidence of firearm, non-firearm-related, and total suicide among older adults, with a focus on GVRO laws.

METHODS

This is a longitudinal study of US states using data from 2012 to 2016. The outcome variables were firearm, non-firearm and total suicide rates among older adults. Predictor variables were [1] total number of gun laws to assess for impact of overall firearm legislation at the state level, and [2] GVRO laws.

RESULTS

The total number of firearm laws, as well as GVRO laws, were negatively associated with firearm-related suicide rate among older adults ages 55-64 and > 65 years-old (p < 0.001). There was a small but significant positive association of total number of firearm laws to non-firearm-related suicide rates and a negative association with total suicide rate. GVRO laws were not significantly associated with non-firearm-related suicide and were negatively associated with total suicide rate.

CONCLUSION

Stricter firearm legislation, as well as GVRO laws, are protective against firearm-relate suicides among older adults.

Suicide in Older Adults With and Without Known Mental Illness: Results From the National Violent Death Reporting System, 2003-2016

INTRODUCTION

Suicide risk increases with age, and evidence exists for the underdiagnosis and undertreatment of suicide risk in older adults. Recent data suggest that many U.S. adults who die from suicide do not have a known mental health condition. This study compares the characteristics and precipitating circumstances of geriatric suicide decedents with and without known mental illnesses.

METHODS

This study was a retrospective analysis of suicide deaths for adults aged ≥65 years from the National Violent Death Reporting System, 2003-2016 (n=26,884). ORs compared sociodemographic and clinical characteristics, cause of death, and precipitating circumstances based on coroner/medical examiner and law enforcement reports. Data were collected and analyzed in 2019.

RESULTS

Most older male (69.1%) and female (50.2%) suicide decedents did not have a known mental illness. A physical health problem was the most prevalent precipitating circumstance but was more common among older adults without known mental illness. Past suicide attempt, disclosure of suicidal intent, depressed mood, and substance use were more common among those with a known mental illness. More than three fourths of suicide decedents did not disclose their suicidal intent. Most suicide deaths involved firearms, which were disproportionately used by decedents without known mental illness (81.6% of male and 44.6% of female decedents) compared with those with known mental illness (70.5% of male and 30.0% of female decedents).

CONCLUSIONS

Most older adults who die from suicide do not have a known mental health condition. The rapidly growing U.S. geriatric population calls for more effective methods to identify and treat at-risk older adults, particularly those who are male.