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Some patients refuse to answer. Many doctors don鈥檛 ask. As the number of Americans with dementia rises, health professionals are grappling with when and how to pose the question: 鈥淒o you have guns at home?鈥�

While gun violence data is scarce, a Kaiser Health News investigation聽with PBS NewsHour published in June uncovered over 100 cases across the U.S. since 2012聽 in which people with dementia used guns to kill themselves or others.聽 The shooters often acted during bouts of confusion, paranoia, delusion or aggression 鈥� common symptoms of dementia.聽 Tragically they shot spouses, children and caregivers.

Yet health care providers across the country say they have not received enough guidance on whether, when and how to counsel families on gun safety.

Dr. Altaf Saadi, a neurologist at UCLA who has been practicing medicine for five years, said the KHN article revealed a 鈥渂lind spot鈥� in her clinical practice. After reading it, she looked up the American Academy of Neurology鈥檚 advice on treating dementia patients. Its suggest doctors consider asking about 鈥渁ccess to firearms or other weapons鈥� during a safety screen 鈥� but they don鈥檛 say what to do if a patient does have guns.

Amid a dearth of national gun safety data, there are no scientific standards for when a health care provider should discuss gun access for people with cognitive impairment or at what point in dementia鈥檚 progression a person becomes unfit to handle a gun.

Most doctors don鈥檛 ask about firearms, research has found. In a , 58 percent of internists surveyed reported never asking whether patients have guns at home.

鈥淥ne of the biggest mistakes that doctors make is not thinking about gun access,鈥� said Dr. Colleen Christmas, a geriatric primary care doctor at Johns Hopkins School of Medicine and member of the American Neurological Association. Firearms are the most common method of suicide among seniors, she noted. Christmas said she asks every incoming patient about access to firearms, in the same nonjudgmental tone that she asks about seat belts, and 鈥淚 find the conversation goes quite smoothly.鈥�

Recently, momentum has been building among health professionals to take a greater role in preventing gun violence. In the wake of the Las Vegas shooting that left 58 concertgoers dead last October, over 1,300 health care providers to ask patients about gun ownership and gun safety when risk factors are present.

The pledges came in response to an by Dr. Garen Wintemute, director of the Violence Prevention Research Program at the University of California-Davis. In response to feedback from that article, his center has now developed a toolkit called , offering health professionals guidance on how to reduce the risk of gun violence.

In a nation bitterly divided over gun ownership issues, in which many staunchly defend the right to bear arms under the Second Amendment, these efforts have met dissent.聽Dr. Arthur Przebinda, director of , framed Wintemute鈥檚 efforts as part of a broader anti-gun bias on the part of institutional medicine. Przebinda said asking physicians to sign such a pledge encourages them 鈥渢o propagandize Americans against their constitutionally protected rights to gun ownership and privacy.鈥�

Przebinda said he gets several requests a day from patients looking for gun-friendly physicians. Some, he said, are tired of their doctors sending them anti-gun YouTube videos and other materials. His group, which he said has over 1,400 members, has set up connecting patients to gun-friendly doctors.

For doctors and other health professionals, navigating this politically fraught issue can be difficult. Here are the leading issues:

Is it legal to talk to patients about guns?

Yes. No state or federal law bars health professionals from raising the issue.

Why don鈥檛 doctors do it?

The top three reasons are lack of time, being unsure what to tell patients and believing patients won鈥檛 heed their advice about gun ownership or gun safety, of family physicians found.

鈥淭here鈥檚 no medical or health professional school in the country that does an adequate job at training about firearms,鈥� Wintemute argued. He said he is now working with the American Medical Association to design a continuing medical education course on the topic.

Other doctors don鈥檛 believe they should ask. Przebinda argues that doctors should almost never ask their patients about guns, except in 鈥渧ery rare, very exceptional circumstances鈥� 鈥� for example, if a patient is despondent or homicidal. He said placing patients鈥� gun ownership information into an electronic medical record puts their privacy at risk.

When should they broach the subject?

The Veterans Health Administration about firearms as part of a safety screening when 鈥渋nvestigating or establishing the suspected diagnosis of dementia.鈥� The Alzheimer鈥檚 Association also , 鈥淎re firearms present in the home?鈥� as part of a safety screening. That screening is part of a that Medicare covers after initial dementia diagnosis and annually as the disease progresses.

The American College of Physicians physicians 鈥渃ounsel patients on the risk of having firearms in the home, particularly when children, adolescents, people with dementia, people with mental illnesses, people with substance use disorders, or others who are at increased risk of harming themselves or others are present.鈥�

Wintemute said he does not suggest all doctors routinely ask every patient about firearms. His group doing so when risk factors are present, including risk of violence to self or others, history of violent behavior or substance misuse, 鈥渟erious, poorly controlled mental illness鈥� or being part of 鈥渁 demographic group at increased risk of firearm injury.鈥�

What should health care providers recommend patients do with their guns?

The and both offer tips on how to store guns safely, including using trigger locks and gun safes.

The Alzheimer鈥檚 Association that locking up guns may not be enough, because people with dementia may 鈥渕isperceive danger鈥� and break into a gun cabinet to protect themselves. To fully protect a family, the organization recommends removing the guns from the home.

But health professionals may be reluctant to recommend that due to legal concerns, 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 a background check. But seven states don鈥檛: Connecticut, Hawaii (for handguns), Massachusetts, Michigan, New Jersey, North Carolina and Rhode Island, according to Vernick. He recommends health professionals look up their state gun laws on sites such as the or the .

In addition, have passed 鈥渞ed flag鈥� laws allowing law enforcement, and sometimes family members, to petition a judge to temporarily seize firearms from a gun owner who exhibits dangerous behavior.

What happens when clinicians ask about guns?

Natasha Bahr, an instructor and social worker who works with geriatric patients at a clinic focusing on memory disorders at the University of North Texas Health Science Center, said as part of a standard assessment, she asks every patient, 鈥淒o you have firearms in the home?鈥�

鈥淚 get so much pushback,鈥� she said. About 60 percent of her patients refuse to answer, she said.

Patients tell her, 鈥淚t鈥檚 none of your business,鈥� 鈥淚 have the freedom to not answer that question鈥� or 鈥淚t鈥檚 my Second Amendment right,鈥� she said. 鈥淭hey make it sound like I鈥檓 judging, and I鈥檓 really not.鈥�

Dr. John Morris, director of the Knight Alzheimer鈥檚 Disease Research Center at Washington University in St. Louis, said he asks his patients about firearms in the context of other safety concerns. When safety is at risk, he typically advises families to lock up firearms and store ammunition separately.

鈥淧eople with dementia typically lack insight into their problems. So they will protest,鈥� he said. Dementia is characterized by 鈥渢he gradual deterioration not just of memory but of judgment and problem-solving and good decision-making,鈥� Morris noted.

In one case, Morris said, he had to persuade the daughter of a dementia patient to secure her father鈥檚 hunting rifles. Uncomfortable with the role reversal, she was reluctant to do so.

鈥淚t鈥檚 very difficult to tell your father he can no longer have his firearms,鈥� Morris said. The father responded: 鈥淚 have never misused my firearms. 鈥� It鈥檚 not going to be a problem,鈥� Morris recalled. 鈥淏ut, he鈥檚 remembering his past history 鈥� he can鈥檛 predict the future.鈥�

Eventually, the daughter decided to remove the rifles from the home. After a few weeks, her father forgot all about them, Morris said.

Morris said the story highlights how difficult it is for families to care for people with dementia. 鈥淭hey鈥檙e forced to make decisions, often against the persons鈥� will,鈥� he said, 鈥渂ut they have to do it for the person鈥檚 safety and well-being.鈥�

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