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DEMENTIA: FIREARM ACCESS

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Title: DEMENTIA: FIREARM ACCESS


1
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

2
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.

3
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

4
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

5
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

6
Cognitive functional changes
  • Loss of recent memory
  • Impaired
  • Attention concentration
  • Orientation
  • Processing
  • Insight and judgment
  • Sequencing
  • Visual comprehension

7
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)

8
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)


9
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
10
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
11
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.
12
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.
13
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

14
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

15
Good Practice Ideas
  • Multi-disciplinary approach
  • Demonstration/Practice
  • Written recommendations and instructions
  • Use of photographs
  • Outreach with follow-up telephone contacts with
    veteran/caregiver

16
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

17
Firearms and Dementia Questionnaire


18
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

19
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

20
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
21
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
22
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
23
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
24
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
25
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
26
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
27
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

28
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

29
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
30
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 (734) 222-4328.
  • 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.
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