While gun violence data is scarce, a Kaiser Health News investigationÌýwith PBS NewsHour published in June uncovered over 100 cases across the U.S. since 2012Ìý in which people with dementia used guns to kill themselves or others.Ìý The shooters often acted during bouts of confusion, paranoia, delusion or aggression — common symptoms of dementia.Ìý 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 “blind spot” in her clinical practice. After reading it, she looked up the American Academy of Neurology’s advice on treating dementia patients. Its suggest doctors consider asking about “access to firearms or other weapons” during a safety screen — but they don’t 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’s progression a person becomes unfit to handle a gun.

Most doctors don’t ask about firearms, research has found. In a , 58 percent of internists surveyed reported never asking whether patients have guns at home.

“One of the biggest mistakes that doctors make is not thinking about gun access,” 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 “I find the conversation goes quite smoothly.”

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.ÌýDr. Arthur Przebinda, director of , framed Wintemute’s 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 “to propagandize Americans against their constitutionally protected rights to gun ownership and privacy.”

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’t doctors do it?

The top three reasons are lack of time, being unsure what to tell patients and believing patients won’t heed their advice about gun ownership or gun safety, of family physicians found.

“There’s no medical or health professional school in the country that does an adequate job at training about firearms,” 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’t believe they should ask. Przebinda argues that doctors should almost never ask their patients about guns, except in “very rare, very exceptional circumstances” — for example, if a patient is despondent or homicidal. He said placing patients’ 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 “investigating or establishing the suspected diagnosis of dementia.” The Alzheimer’s Association also , “Are firearms present in the home?” 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 “counsel 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.”

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, “serious, poorly controlled mental illness” or being part of “a demographic group at increased risk of firearm injury.”

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’s Association that locking up guns may not be enough, because people with dementia may “misperceive danger” 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’t: 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 “red flag” 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, “Do you have firearms in the home?”

“I get so much pushback,” she said. About 60 percent of her patients refuse to answer, she said.

Patients tell her, “It’s none of your business,” “I have the freedom to not answer that question” or “It’s my Second Amendment right,” she said. “They make it sound like I’m judging, and I’m really not.”

Dr. John Morris, director of the Knight Alzheimer’s 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.

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

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

“It’s very difficult to tell your father he can no longer have his firearms,” Morris said. The father responded: “I have never misused my firearms. … It’s not going to be a problem,” Morris recalled. “But, he’s remembering his past history — he can’t predict the future.”

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. “They’re forced to make decisions, often against the persons’ will,” he said, “but they have to do it for the person’s safety and well-being.”

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“My husband accidentally shot me,” Hill, 75, of The Dalles, Ore., groaned on the May 16, 2015, call. “In the stomach, and he can’t talk, please …”

Less than four feet away, Hill’s husband, Darrell Hill, a former local police chief and two-term county sheriff, sat in his wheelchair with a discharged Glock handgun on the table in front of him, unaware that he’d nearly killed his wife of almost 57 years.

The 76-year-old lawman had been diagnosed two years earlier with a form of rapidly progressive dementia, a disease that quickly stripped him of reasoning and memory.

“He didn’t understand,” said Dee, who needed 30 pints of blood, three surgeries and seven weeks in the hospital to survive her injuries.

As America copes with an epidemic of gun violence , there has been vigorous debate about how to prevent people with mental illness from acquiring weapons. But a little-known problem is what to do about the vast cache of firearms in the homes of aging Americans with impaired or declining mental faculties.

Darrell Hill, who died in 2016, was among the estimated , a group of terminal diseases marked by mental decline and personality changes. Many, like the Hills, are gun owners and supporters of Second Amendment rights. Forty-five percent of people 65 and older have guns in their household, .

But no one tracks the potentially deadly intersection of those groups.

A four-month Kaiser Health News investigation has uncovered over 100 cases across the U.S. in which people with dementia used guns to kill or injure themselves or others.ÌýAlong with our partner , we shed new light on an aspect of guns and public health that is rarely discussed.

From news reports, court records, hospital data and public death records, KHN found 15 homicides and more than 95 suicides since 2012, although there are likely many more. The shooters often acted during bouts of confusion, paranoia, delusion or aggression — common symptoms of dementia. They killed people closest to them — their caretaker, wife, son or daughter. They shot at people they happened to encounter — a , a police officer, . At least four men with dementia who brandished guns were fatally shot by police. In cases where charges were brought, many assailants were deemed incompetent to stand trial.

Many killed themselves. Among men in the U.S., the suicide rate is highest among those 65 and older; firearms are the most common method,

These statistics do not begin to tally incidents in which a person with dementia waves a gun at an unsuspecting neighbor or a terrified home health aide.

Volunteers with Alzheimer’s San Diego, a nonprofit group, became alarmed when they visited people with dementia to give caregivers a break — and found 25 to 30 percent of those homes had guns, said Jessica Empeño, the group’s vice president.

“We made a decision as an organization not to send volunteers into the homes with weapons,” she said.

At the same time, an analysis of government survey data in Washington state found that about 5 percent of respondents 65 and older reported both some cognitive decline and having firearms in their home. The assessment, , suggests that about 54,000 of the state’s more than 1 million residents 65 and older say they have worsening memory and confusion — and access to weapons.

About 1.4 percent of those respondents 65 and older — representing about 15,000 people — reported both cognitive decline and that they stored their guns unlocked and loaded, according to data from the state’s 2016 Behavioral Risk Factor Surveillance System survey. Washington is the only state to track those dual trends, according to the CDC.

In a politically polarized nation, where gun control is a divisive topic, even raising concerns about the safety of cognitively impaired gun owners and their families is controversial. Relatives can take away car keys far easier than removing a firearm, the latter protected by the Second Amendment. Only five states have laws allowing families to petition a court to temporarily seize weapons from people who exhibit dangerous behavior.

But in a country where the potential for harm is growing, said Dr. Emmy Betz, associate research director at the University of Colorado School of Medicine, a leading researcher on gun access and violence. Even as rates of dementia fall, , and the number of dementia cases is expected to soar as well.

By 2050, the number of people with dementia who live in U.S. homes with guns could reach between roughly 8 million and 12 million, according to a by Betz and her colleagues.

“You can’t just pretend it’s not going to come up,” Betz said. “It’s going to be an issue.”

Polling conducted by the Kaiser Family Foundation for this storyÌý about the potential dangers of elders and firearms. Nearly half of people queried in a nationally representative poll in June said they had relatives over 65 who have guns. Of those, more than 80 percent said they were “not at all worried” about a gun-related accident. (Kaiser Health News is an editorially independent program of the foundation.)

Dee Hill had ignored her husband’s demands and sold Darrell’s car when it became too dangerous for him to drive. But guns were another matter.

“He was just almost obsessive about seeing his guns,” Dee said. He worried that the weapons were dirty, that they weren’t being maintained. Though she’d locked them in a vault in the carport, she relented after Darrell had asked, repeatedly, to check on the guns he’d carried every day of his nearly 50-year law enforcement career.

She intended to briefly show him two of his six firearms, the Glock handgun and a Smith & Wesson .357 Magnum revolver. But after he saw the weapons, Darrell accidentally knocked the empty pouch that had held the revolver to the floor. When Dee bent to pick it up, he somehow grabbed the Glock and fired.

“My concern [had been] that someone was going to get hurt,” she said. “I didn’t in my wildest dreams think it was going to be me.”

as an assault and referred it to Wasco County District Attorney Eric Nisley, who concluded it was “a conscious act” to pick up the gun, but that Darrell didn’t intend to harm his wife.

“I evaluated it as if a 5- or 6-year-old would pick up the gun and shoot someone,” Nisley said.

Dee was outraged at the suggestion she consider pressing charges.

“I didn’t want anyone to think it was intentional. Nobody would have believed it anyway,” she said.

Proponents of gun ownership say guns are not to blame.

The National Rifle Association declined to comment for this story.

Dr. Arthur Przebinda, who represents the group Doctors for Responsible Gun Ownership, said researchers raising the issue want to curtail gun rights guaranteed by the U.S. Constitution, and are “seeking ways to disarm as many people as possible.”

Focusing on the potential of people with dementia shooting others is a “bloody shirt-waving tactic that’s used to stir emotions to advance support for a particular policy endpoint,” he said.

“I’m not disputing the case that it happens. I know it can happen,” Przebinda said. “My question is how prevalent it is, because the data is what should be driving our policy discussion, not fear or fear-mongering. It’s bad science.”

Two decades of NRA-backed political pressure that quashed public health research into the effects of gun violence partly explain the lack of data, experts said. But that doesn’t mean there’s no problem, said Dr. Garen Wintemute, director of the Violence Prevention Research Program at the University of California-Davis.

“[Critics] are arguing as if what we have is evidence of absence,” he said. “We have something quite different, which is absence of evidence.”

Even some families grappling with the problem are wary about calls to limit gun access.

“I hope your intent is not to ‘bash’ us for our beliefs and actions with guns,” said Vergie “Verg” Scroughams, 63, of Rexburg, Idaho, who showed KHN reporters how she hid a loaded gun from her husband, who developed dementia after a stroke in 2009.

Verg became worried after Delmar Scroughams, 83, grew angry and erratic earlier this year, waking up in the night and threatening to hit her. It was out of character for the former contractor who previously built million-dollar Idaho vacation homes for families of politicians and celebrities.

“In 45 years of marriage, we’ve never had a big fight,” she said. “We respect each other and we don’t argue. That’s not my Delmar.”

Six months ago, Verg took the loaded .38-caliber Ruger from a drawer near Delmar’s living room recliner, removed the bullets, and tucked it under socks in a box on a high shelf in her closet. “He’ll never look there,” she said.

She doesn’t want Delmar to have access to that gun ― or to his collection of six shotguns locked in the bedroom cabinet. But Verg, a real estate agent who shows homes in remote locations, doesn’t want to give up the weapons she counts on for comfort and protection. She carries her own handgun in the console of her car.

“We live in Idaho. Guns have been a big part of our lives,” said Verg, who got her first rifle at age 12 and recalls hunting trips with her two sons among her fondest memories. “I can’t imagine living without guns.”

Guns Under The Pillows

Federal law prohibits people who are not mentally competent to make their own decisions, including those with advanced dementia, from buying or owning firearms. But a mere diagnosis of dementia does not disqualify someone from owning a gun, said Lindsay Nichols, federal policy director at the Giffords Law Center to Prevent Gun Violence. If a gun owner were reluctant to give up his arsenal, his family would typically have to take him to court to evaluate competency.

Since the school shooting in Parkland, Fla., in February, more states are taking action to make it easier for families ― including those with a loved one with dementia ― to remove guns from the home.

Eleven states have passed “red flag” gun laws that allow law enforcement or other state officials, and sometimes family members, to seek a court order to temporarily seize guns from people who pose a threat to themselves or others. Red flag bills have proliferated across the country since the Parkland shooting; six were passed this year and six more are pending.

In Connecticut, which in 1999 enacted the nation’s first red flag law, police used the measure to seize guns from five people reported to have dementia in 2017, according to a KHN records review.

Last summer, an 84-year-old man with dementia alarmed his neighbors at a senior living community in Simsbury, Conn., by announcing that he had a gun and planned to shoot a bear. The man later reported that his .38-caliber Colt revolver was missing; police found it, loaded, in the console of his car. Police got a court order to seize that gun and a rifle he had in his closet.

In December, police seized 26 guns from the Manchester, Conn., home of a 77-year-old man with dementia who was threatening to kill his wife. She told police that he was a danger to himself, and that his threats were “normal baseline behavior.”

In 2008, police in Manchester also seized nine firearms from a 70-year-old man with dementia who had pointed a gun at his daughter when she went to check on him because he didn’t recognize her at first. The man had been sleeping with loaded guns under his pillows and hiding guns in drawers, and his daughter was worried for the safety of his home health aides.

In Ohio, at one memory care clinic, 17 percent of patients diagnosed with dementia reported having a firearm in their homes, according to .

But many families are reluctant to take away the sense of safety, independence and identity that their loved one, often the family patriarch, derives from guns.

‘A Guilt I’ll Never Ever Get Away From’

In the Appalachian mountains of West Virginia, Malissa Helmandollar, a 46-year-old assistant in an optometrist’s office, regrets not taking her father’s guns away.

Her dad, Larry Dillon, loved to hunt. Even after a coal-mining accident left him paralyzed from the waist down at age 21, Dillon would shoot turkey, squirrel and deer from the seat of his four-wheeler. For as long as she could remember, her father kept a gun under the cushion of his wheelchair.

“He felt he couldn’t take care of us, or himself, without it,” she said.

In June 2017, when her father was 65, she began to notice strange behavior.

“He would see people crawling out of the washing machine,” she said. He forgot how to tell time. Sometimes he would just stare at his dinner plate “like he didn’t know what to do.”

Every night for weeks, Dillon grew scared that people were trying to break in and burn his house down, Helmandollar said. Dillon slept with a 9 mm semiautomatic Glock pistol at his nightstand in the double-wide trailer he shared with his wife, Sandy, in Princeton, W.Va.

Helmandollar made him an appointment with a neurologist, but he never made it to the doctor.

Five days before his appointment, on July 6, 2017, Helmandollar’s 9-year-old daughter was sleeping over at her Mamaw and Papaw’s house, as she loved to do. That evening, Helmandollar got a frantic call from her daughter.

Helmandollar sped to the house with her son. She found her stepmother, Sandy, dead in an armchair with several bullet wounds. Helmandollar heard her father tell police that he saw intruders breaking in to the house, so he grabbed his Glock and where his wife and granddaughter were watching TV.

But there had been no intruders that night. Dillon, who was deemed incompetent to stand trial for murder, was diagnosed with Lewy body dementia, a disease whose early symptoms can include vivid visual hallucinations.

Helmandollar said her father never understood what he had done. Before he died in April, he kept asking Helmandollar why his wife never visited him. She could never bring herself to tell him.

Meanwhile, Helmandollar’s daughter and 18-year-old son are in counseling for the trauma they experienced.

“It crossed my mind that maybe I should’ve taken the guns, and I didn’t,” Helmandollar said. “It’ll be a guilt that I’ll never ever get away from.”

Belated diagnoses of dementia are too common, according to Dr. Melissa Henston, a geriatric psychologist in Denver who administers cognitive exams that can confirm impairment. She said many of the patients she sees have moderate or even severe dementia before being diagnosed.

“There’s denial and a false belief that a lot of cognitive problems are just normal for age,” she said. “These conversations that need to take place never take place until it’s too late.”

For Alzheimer’s disease and other dementias, there are limited treatments and no cure. About one-third of people with the disease become combative during the course of their illness, according to the Alzheimer’s Association. And more than 20 percent who develop dementia become violent toward their caretakers, .

Advocates have long warned patients and families about the potential risk of guns, said Beth Kallmyer, the Alzheimer’s Association vice president of care and support.

“The reality is, there’s no way to know who’s at risk for becoming agitated or even violent,” she said.

‘We Need To Pay More Attention’

In Minnesota, Sharon Van Leer, the 70-year-old director of diversity and inclusion at Mitchell Hamline School of Law, said she never would have predicted the phone call she got from police nearly three years ago.

Her father, Kenneth Bowser, a 90-year-old Army veteran and retired postal worker, had been living for many years with his oldest son, Larry, 65, in the St. Paul suburb of Maplewood.

At 5:30 p.m. on Sept. 12, 2015, Kenneth Bowser dialed 911.

“Who is bothering you?” the dispatcher asked him, according to a transcript of the call.

“My oldest son, oldest son and I shot him, I shot him,” Bowser replied. “He’s laying there dead, dead.”

“Where is the gun?” the dispatcher asked.

“The gun is in my hand,” Bowser said.

Van Leer said she believes her father never intended to be violent: “Daddy was never like that.”

In the 911 call, Bowser appears confused. “I’m 70 — uh, 100 — 91 years old,” he said. “I’m paralyzed on one side.”

Bowser, who had not been diagnosed with dementia before the shooting, was confirmed to have Alzheimer’s and deemed not competent to stand trial.

Now Van Leer drives 90 minutes most Sundays to visit her 93-year-old father in a locked, state-run nursing home where he’s set to spend the rest of his life. Staff wheel him out to a windowless visitation room, where Van Leer and her sister spoon-feed him nutrition shakes and give him back rubs.

Van Leer said she had noticed some signs of decline before the shooting — he would leave bacon on the stove and burn it, or forget where he put his cigars. But because she did not live with him, she said, she didn’t realize how far his dementia had progressed.

“We need to pay more attention, as our parents get older, to the changes,” Van Leer said. “They can disguise it really well.”

Removing guns from the home is the best way to prevent violence, and other experts advise. But Dr. Diana Kerwin, director of the Texas Alzheimer’s and Memory Disorders program at Texas Health Dallas, said that’s not the answer for all families.

“I don’t do a blanket ‘guns are bad, you can’t have guns in the home,’” she said.

Instead, she advocates storing guns safely — locked up, unloaded, with the ammunition kept separate from the guns. Firearms can also be disabled or, in some cases, replaced with a decoy, although that raises the risk of them being mistaken for a real weapon in an emergency.

“We had one patient with a gun with rubber bands that he would shoot and he was fine with that,” Kerwin said. “He was used to shooting varmints. You try to help them maintain the lifestyle they always had.”

Hair-Trigger Tempers

Families walk a fine line, balancing independence with safety.

Christal Collins, a 50-year-old massage therapist in South Carolina, never got along with her dad. He beat her and her mother before the couple divorced, she said. But when he nearly died from spinal meningitis in 2013, Christal agreed to take him in — along with his small arsenal.

Bill Collins, a retired heavy-equipment operator and Army veteran, was so attached to his guns that he kept a .22-caliber pistol in his pocket day and night, even while he slept. On Saturdays, he’d load it with rat shot and fire the tiny pellets at snakes as he mowed the lawn. On Sunday mornings, as he watched Shepherd’s Chapel sermons on TV, he’d clean the gun and reload it with Magnum bullets.

Bill also kept a cabinet stocked with three handguns, three sawed-off rifles, three hunting rifles and a thousand rounds of ammo. While he had stopped hunting, he told his family he didn’t want to be caught without a gun when the “race war” broke out.

As he grew older and sicker, Bill shuffled around the house in slippers and didn’t seem as physically threatening, Christal said. But his bouts of aggression and paranoia grew worse, and in November 2014, after Bill had gotten lost for two hours at a local convenience store, his doctor said he was showing signs of dementia.

Christal considered sending her father to an assisted living complex, but when he found out he couldn’t bring his guns or knives, he refused to go. And she swore she would never put her parents through the neglect she saw when she worked at a nursing home. So she stayed in the house with him, in a rural, swampy stretch of Conway, S.C., not far from Myrtle Beach.

Christal tried to limit her father’s access to guns. One day, she slipped the key to his gun cabinet off his keychain — a difficult feat, since he slept with the keychain hooked to his belt. It was “war” in the house for three days, she said, as he hounded her and accused her of stealing the key. He then busted the original lock with a hammer and screwdriver and installed three new padlocks.

Bill also slept with a loaded .357 Magnum under his pillow.

“There was no gun safety,” Christal said. “Every time I tried to talk about it, it would be a fight or an argument or a problem.”

On June 14, 2015, a Sunday, her father started “cussing and ranting and raving,” accusing someone of stealing things from his room, she said. Bill, who was 75, raised his hand to hit Christal — something he hadn’t done in his old age — and her fiancé, Allen Holtzman, stepped in to intervene.

In a flash, Bill pulled the .22 pistol out of his pocket and fired at Holtzman’s chest, knocking him down to the couch.

“Dad, you shot him!” Christal yelled in disbelief. Then she saw him put the gun at the base of Holtzman’s skull. She knocked it away just as he fired.

“Wrong damn shells!” Bill declared in disappointment, discovering he had fired rat shot.

Bill aimed the gun at Holtzman’s 20-year-old daughter, and then at Christal. He had a look in his eyes “like the lights were on but nobody was home,” Christal recalled. She dragged Holtzman, who was bleeding from over 200 rat pellets, toward safety in their bedroom, as more pellets flew behind them.

As Christal talked to a 911 dispatcher on the phone, she heard two bangs. The first was her father slamming the door to his room. The second was her father taking the gun and, after replacing the cartridges, shooting himself in the head.

Some argue that people should have the right to end their lives on their own terms instead of suffer through the debilitating decline of dementia. But Christal said she hates that her father harmed others along the way. And the aftermath of a suicide can be horrific, she said.

“When you clean your dad’s brain matter off the wall, the pillow, the carpet …” she said, trailing off in tears, the trauma still raw nearly three years later, as she sat with her fiancé in their double-wide trailer home.

Holtzman, a 42-year-old construction worker, shrugged off his own injuries, saying the pellets just burned. But Christal said they were lucky her father forgot to change the ammo.

“Allen, you would’ve been dead,” Christal said.

Christal said if she had to do it again, she would have removed the guns from the home.

Though, she reflected, “I honestly don’t know if we could have taken them away.”

Giving Up The Guns

For families grappling with such decisions, one option is to establish a “gun trust” that outlines how the weapons will pass to family members once a person becomes incapacitated or dies. These trusts may make it easier for people who must give up firearms in order to move into a nursing home, for instance, said David Goldman, an estate-planning lawyer in Jacksonville, Fla., who said he has drawn up over 20,000 gun trusts. But the process works best when the gun owner complies.

“They rarely want to give up their guns,” Goldman said. Another obstacle is that gun trusts must be drawn up before dementia becomes too advanced.

Ideally, families should discuss firearm access soon after a diagnosis of dementia and consider setting a “firearm retirement date,” akin to an advance directive for guns, Betz and colleagues advise. It’s similar to discussions about taking away the car keys when driving becomes dangerous, she said.

“One of the tricky things is, for driving, there are some assessments you can do,” Betz said. “They’re not perfect, but they’re helpful. There isn’t anything for firearms.”

Doctors who routinely ask dementia patients about driving should also ask about guns, Wintemute said. Too often, though, they don’t.

“Docs say: ‘I don’t know enough about the risks and benefits, I don’t have the time,’” Wintemute said. “Only about one-third do it with any frequency.”

Critics of gun restrictions like Przebinda argue that the essential difference between driving and guns is that one is a privilege and the other is a protected constitutional right.

“The two are not the same,” he said. “You do not have a right to conveyance. You have a right to self-defense, you have a right to protecting your home and your family that’s intrinsic to you as a human being.”

He balks at any formal assessment of firearm use among people with dementia, saying it could lead to “a totalitarian system that decides when you can have rights and when you cannot.”

Instead, the decision should be left to families, Przebinda said. “People who own guns know what measures are available to them.”

Even that knowledge, however, may not be enough. Dee Hill of Oregon said it was “strictly an accident” that her husband, the retired sheriff, shot and critically wounded her. To this day, she doesn’t regret showing him the guns.

“That sounds stupid, but, no, I don’t,” she said. “He spent darn near 40, almost 50 years in law enforcement and a gun was always with him, and so to deprive him of not even seeing them, in my heart of hearts, I couldn’t deny him.”

For Verg and Delmar Scroughams of Idaho, the dilemma of keeping guns in the house remains. In a lucid moment in May, Delmar acknowledged that the weapons he’s had all his life could be dangerous.

“I got a disease I don’t know the name of and, eventually, anything could happen,” he said.

Such moments of awareness are becoming rare, Verg admitted. Soon, Delmar may no longer recognize her. As his condition worsens, she said, it’s up to her to make sure no one is harmed.

“I would feel extremely responsible,” she said. “It would be my fault.”

This story is part of a partnership between Kaiser Health News and

Â鶹ŮÓÅ Health News' coverage of these topics is supported by , and

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Ìý

What can families do ahead of time?

Talk to your loved one about how to safely transfer ownership of their guns if they should become incapacitated. Consider writing a “gun trust,” a legal document outlining that process.

Doctors are legally allowed to inquire about access to firearms when a person is diagnosed with dementia. But, experts say, they often don’t. If the health provider doesn’t bring it up, families should ask about gun safety along with other concerns, such as driving and use of kitchen appliances and power tools.

What if a person with dementia wants to transfer their guns?

Most states allow the temporary transfer of firearms to a family member without a background check, according to Jon Vernick, co-director of the Johns Hopkins Center for Gun Policy and Research. But seven states don’t: 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

What if family members don’t want to accept guns?

Some law enforcement agencies will temporarily store guns if there’s a potential threat. In some cases, distressed families have dropped off firearms at gun shops or shooting ranges for safekeeping, though that is not ideal, noted Jacquelyn Clark, owner of in Lakewood, Colo. Dealers may be able to buy or consign the guns.

What if the gun owner doesn’t want to give them up?

By federal law, a person loses the right to buy or own a gun if a judge deems them mentally incompetent to make decisions. Family members usually have to go to probate court for this kind of ruling, where they can be appointed as a guardian and take control of the guns.

What about veterans?

Veterans who have been deemed mentally incompetent to manage their finances also lose their right, under federal law, to buy or own guns. As of March, nearly 109,000 veterans were barred from gun ownership because of their enrollment in the Veterans Affairs fiduciary program.

What if they’re making threats?

In any state, police can take guns away from someone who threatens a specific crime. In the 11 states with “red flag” gun laws, law enforcement can seek a court order to temporarily seize guns from a person who exhibits dangerous behavior. In five of those states — California, Washington, Oregon, Maryland and New Jersey — family or household members can also initiate these gun-seizure requests.

What if families want to keep the guns at home?

Store the guns 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.

Sources: Giffords Law Center to Prevent Gun Violence; state legislatures; Texas Alzheimer’s and Memory Disorders program at Texas Health; Bristlecone Shooting, Training and Retail Center

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“Mi esposo me disparó por accidente”, gimió Hill, de 75 años, de The Dalles, Oregon, en la llamada del 16 de mayo de 2015. “En el estómago, y él no puede hablar, por favor…”

A poco más de un metro, Darrell Hill, un ex jefe de policía local y dos veces sheriff del condado, estaba sentado en su silla de ruedas con una pistola Glock descargada sobre la mesa, sin saber que casi había matado a la que ha sido su esposa por casi 57 años.

El ex oficial de 76 años había sido diagnosticado dos años antes con una forma de demencia que avanza rápidamente, una enfermedad que le quitó la razón y la memoria en un abrir y cerrar de ojos.

“No entendió lo que hizo”, dijo Dee, que necesitó 30 unidades de sangre, tres cirugías y siete semanas en el hospital para sobrevivir a esa herida.

Mientras Estados Unidos enfrenta una epidemia de violencia con armas de fuego que , se ha encendido un debate enérgico sobre cómo evitar que personas con enfermedades mentales adquieran armas. Pero un problema poco conocido es qué hacer con el vasto arsenal de armas de fuego en los hogares de estadounidenses que envejecen con facultades mentales deterioradas o en debacle.

Darrell Hill, quien falleció en 2016, se encontraba entre el mayores de 65 años diagnosticados con demencia, un grupo de enfermedades terminales marcadas por el deterioro mental y los cambios de personalidad. Muchos, como los Hills, son propietarios de armas y partidarios de los derechos de la Segunda Enmienda. El 45% de las personas de 65 años y más tienen pistolas en su hogar, según una encuesta del .

Pero nadie monitorea la intersección potencialmente mortal de esos dos grupos.

Una investigación de cuatro meses de Kaiser Health News (KHN) ha descubierto decenas de casos en el país, de personas con demencia que usaron armas de fuego para matar o lesionar a otras personas.

Desde informes de noticias, registros judiciales, datos de hospitales y certificados de defunción, KHN encontró 15 homicidios y más de 60 suicidios desde 2012, aunque es probable que haya muchos más.

Los que dispararon el gatillo a menudo lo hicieron durante episodios de confusión, paranoia, alucinaciones o agresión, todos síntomas de la demencia. Mataron a las personas más cercanas a ellos: su cuidador, esposa, hijo o hija. Dispararon a los que se topaban con ellos: , un oficial de policía, . Al menos cuatro hombres con demencia que portaban armas fueron abatidos por la policía. En los casos en que se presentaron cargos, a muchos agresores se los consideró incompetentes para ser juzgados.

Muchos se suicidaron. Entre los hombres, la tasa de suicidios es más alta entre los mayores de 65 años; y las armas de fuego son el método más común, según el .

Estas estadísticas no cuentan los incidentes en los que una persona con demencia agita un arma contra un vecino desprevenido o un cuidador en el hogar.

Voluntarios de Alzheimer’s San Diego, un grupo sin fines de lucro, se alarmaron cuando visitaron a personas con demencia para darles un respiro a sus cuidadores, y descubrieron que del 25% al 30% de esos hogares tenían armas, dijo Jessica Empeño, vicepresidenta del grupo.

“Tomamos la decisión, como organización, de no enviar voluntarios a las casas con armas”, dijo.

Al mismo tiempo, un análisis de los datos de las encuestas gubernamentales en el estado de Washington encontró que alrededor del 5% de los encuestados de 65 años o más reportaron las dos cosas: tener deterioro cognitivo y un arma en el hogar. La sugiere que alrededor de 54,000 de los más de un millón de residentes del estado de 65 años o más dicen que han empeorado la memoria y la confusión, y el acceso a las armas.

Alrededor del 1,4% de los encuestados mayores de 65 años, alrededor de 15,000 personas, informaron deterioro cognitivo, y tener sus armas sin seguro y cargadas, según datos de la encuesta del Sistema de Vigilancia del Factor de Riesgo Conductual del estado de 2016. Washington es el único estado que rastrea esas tendencias duales, según los Centros para el Control y Prevención de Enfermedades (CDC).

En una nación políticamente polarizada, donde el control de armas es un tema que divide aguas, incluso plantear preocupaciones sobre la seguridad de los propietarios de armas con deterioro cognitivo y sus familias es controversial. Los familiares pueden quitarle las llaves del auto mucho más fácil que un arma de fuego, esta última protegida por la Segunda Enmienda. Solo cinco estados tienen leyes que permiten a las familias solicitar a un tribunal el decomiso temporal de armas de personas con conductas peligrosas.

Pero en un país donde , el potencial de daño está creciendo, dijo la doctora Emmy Betz, directora asociada de investigación de la Escuela de Medicina de la Universidad de Colorado e investigadora sobre acceso a armas y violencia. Incluso a medida que las tasas de demencia bajan, , y se espera que el número de casos de demencia aumente también.

Para 2050, la cantidad de personas con demencia en el país, que viven en hogares con armas de fuego, podría alcanzar entre aproximadamente 8 millones y 12 millones, según por Betz y sus colegas.

“No se puede pretender que no va a aparecer”, dijo Betz. “Va a ser un problema”.

Las encuestas realizadas por Kaiser Family Foundation para esta historia sugieren que por los peligros potenciales de los adultos mayores y las armas de fuego. Casi la mitad de las personas consultadas en una encuesta representativa a nivel nacional en junio dijeron que tenían parientes mayores de 65 años con armas de fuego. De ellos, más del 80% dijo que “no estaban en absoluto preocupados” por un accidente relacionado con armas de fuego. (Kaiser Health News es un programa editorialmente independiente de la fundación).

Dee Hill ignoró las demandas de su marido y vendió el auto de Darrell cuando se volvió demasiado peligroso para él conducir. Pero las armas eran otro asunto.

“Estaba casi obsesionado con ver sus armas”, dijo Dee. Le preocupaba que estuvieran sucias, que no se las cuidara. A pesar que las había guardado en una bóveda en el garaje, ella cedió después que Darrell le había pedido, repetidas veces, que revisara las armas que había llevado todos los días de su carrera de casi cincuenta años en el cumplimiento de la ley.

Una clasificó el incidente como un asalto y lo remitió al fiscal de distrito del condado de Wasco, Eric Nisley, quien concluyó que era un “acto consciente” recoger el arma, pero que Darrell no tenía la intención de dañar a su esposa.

“Lo evalué como si un niño de 5 o 6 años recogiera el arma y disparara a alguien”, dijo Nisley.

Dee se indignó ante la sugerencia de que considerar presentar cargos.

“No quería que nadie pensara que fue intencional. Nadie lo hubiera creído de todos modos “, dijo.

Los defensores de la posesión de armas dicen que las armas no tienen la culpa.

La Asociación Nacional del Rifle (NRA) declinó hacer comentarios sobre esta historia.

El doctor Arthur Przebinda, quien representa al grupo de Doctors for Responsible Gun Ownership, dijo que los investigadores que plantean el tema quieren reducir los derechos de armas garantizados por la Constitución. Y están “buscando formas de desarmar al mayor número posible de personas”.

Centrarse en el potencial de las personas con demencia para disparar a los demás es una “táctica sangrienta agitadora, y que se usa para estimular las emociones y ayudar a avanzar una agenda política”, dijo.

“No discuto el caso de que suceda. Sé que puede suceder “, dijo Przebinda. “Mi pregunta es cuán frecuente es, porque los datos son lo que debería impulsar nuestra discusión de políticas, no el miedo. Eso es mala ciencia”.

Dos décadas de presión política respaldada por la NRA que anuló la investigación de salud pública sobre los efectos de la violencia armada explican en parte la falta de datos, dijeron expertos. Pero eso no significa que no haya ningún problema, dijo el doctor Garen Wintemute, director del Programa de Investigación sobre Prevención de la Violencia en la Universidad de California-Davis.

“[Los críticos] están discutiendo como si lo que tenemos fuera evidencia de ausencia”, dijo. “Tenemos algo bastante diferente, que es la ausencia de evidencia”.

Incluso algunas familias que lidian con el problema desconfían de las llamadas para limitar el acceso a las armas de fuego.

“Espero que su intención no sea ‘criticarnos’ por nuestras creencias y acciones con armas”, dijo Vergie “Verg” Scroughams, de 63 años, de Rexburg, Idaho, quien le mostró a los periodistas de KHN cómo ocultó un arma cargada a su marido, quien desarrolló demencia después de un accidente cerebrovascular en 2009.

Verg comenzó a preocuparse después que Delmar Scroughams, de 83 años, se mostrara enojado y errático a principios de este año, despertando en la noche y amenazando con golpearla. Algo fuera de lo normal para el ex contratista que construyó casas de vacaciones de millones de dólares en Idaho para familias de políticos y celebridades.

“En 45 años de matrimonio, nunca hemos tenido una gran pelea”, dijo. “Nos respetamos y no discutimos. Ese no es mi Delmar “.

Seis meses atrás, Verg tomó la Ruger calibre .38 cargada de un cajón cerca del sillón reclinable de la sala de Delmar, quitó las balas y la metió debajo de los calcetines en una caja en un estante alto de su armario. “Él nunca mirará allí”, dijo.

Ella no quiere que Delmar tenga acceso a esa arma, ni a su colección de seis escopetas encerradas en el armario del dormitorio. Pero Verg, un agente de bienes raíces que muestra casas en lugares remotos, no quiere renunciar a las armas que tiene para su comodidad y protección. Ella tiene su propia pistola en la consola de su auto.

“Vivimos en Idaho. Las armas han sido una gran parte de nuestras vidas”, dijo Verg, quien tuvo su primer rifle a los 12 años y recuerda los viajes de cacería con sus dos hijos entre sus mejores recuerdos. “No me puedo imaginar viviendo sin armas”.

Pistolas bajo las almohadas

La ley federal prohíbe que las personas que no son mentalmente competentes tomen sus propias decisiones, incluidas las que tienen demencia avanzada, compren o posean armas de fuego. Pero un simple diagnóstico de demencia no descalifica a alguien como dueño de un arma, dijo Lindsay Nichols, directora de política federal del Centro Legal de Giffords para Prevenir la Violencia con Armas. Si el dueño de un arma fuera reacio a renunciar a su arsenal, su familia normalmente tendría que llevarlo a la corte para evaluar su competencia.

Desde el tiroteo en la escuela en Parkland, Florida, en febrero, más estados están tomando medidas para facilitar que las familias, incluidas las personas con un ser querido con demencia, retiren las armas del hogar.

Once estados han aprobado leyes “bandera roja” para armas, que permiten que las fuerzas del orden u otros funcionarios estatales, y en ocasiones familiares, soliciten una orden judicial para confiscar temporalmente armas de personas que representan una amenaza para ellos mismos o para otros. Los proyectos de ley de bandera roja han proliferado en todo el país desde el tiroteo en Parkland; seis se aprobaron este año y seis más están pendientes.

En Connecticut, que en 1999 promulgó la primera ley de bandera roja de la nación, la policía utilizó la medida para confiscar armas de cinco personas que, según los informes, tenían demencia en 2017, según una revisión de registros de KHN.

El verano pasado, un hombre de 84 años con demencia alarmó a sus vecinos en una comunidad de adultos mayores en Simsbury, Connecticut, al decir que tenía un arma y planeaba dispararle a un oso. El hombre más tarde informó que su revólver Colt calibre .38 había desaparecido. La policía lo encontró, cargado, en la consola de su auto. La policía recibió una orden judicial para incautar esa arma y un rifle que tenía en su armario.

En diciembre, la policía confiscó 26 armas de fuego de la casa de Manchester, Connecticut, en donde vivía un hombre de 77 años con demencia que amenazaba con matar a su esposa. Ella le dijo a la policía que él era un peligro para él mismo, y que sus amenazas eran “un comportamiento de base normal”.

En 2008, la policía de Manchester también confiscó nueve armas de fuego a un hombre de 70 años con demencia que apuntó con un arma a su hija cuando fue a ver cómo estaba porque no la reconoció. El hombre había estado durmiendo con pistolas cargadas debajo de las almohadas y escondiendo pistolas en los cajones, y su hija estaba preocupada por la seguridad de los cuidadores.

En Ohio, en una clínica de atención de la memoria, el 17% de los pacientes diagnosticados con demencia informaron tener un arma de fuego en sus hogares, según .

Pero muchas familias son reacias a perder el sentido de seguridad, independencia e identidad que su ser querido, a menudo el patriarca familiar, coloca en las armas de fuego.

Los diagnósticos tardíos de demencia son demasiado comunes, según la doctora Melissa Henston, psicóloga geriátrica de Denver que realiza exámenes cognitivos que pueden confirmar el deterioro. Agregó que muchos de los pacientes que ve tienen demencia moderada o incluso grave antes de ser diagnosticados.

“Hay una negación y una falsa creencia que muchos problemas cognitivos son normales para la edad”, dijo. “Estas conversaciones que deben tener lugar nunca se llevan a cabo hasta que es demasiado tarde”.

Para la enfermedad de Alzheimer y otras demencias, hay tratamientos limitados y ninguna cura. Alrededor de un tercio de las personas que las padecen se vuelven combativos durante el curso de su enfermedad, según la Asociación de Alzheimer. Y más del 20% de los que desarrollan demencia se vuelven violentos con sus cuidadores, mostró un estudio de 2014.

Defensores han advertido durante mucho tiempo a los pacientes y sus familias sobre el riesgo potencial de las armas de fuego, dijo Beth Kallmyer, vicepresidenta de atención y apoyo de la Asociación de Alzheimer.

“La realidad es que no hay manera de saber quién está en riesgo de agitarse o incluso de ser violento”, dijo.

La eliminación de armas de fuego del hogar es la mejor manera de prevenir la violencia, aconsejan la y otros expertos. Pero la doctora Diana Kerwin, directora del programa Texas Alzheimer’s and Memory Disorders en Texas Health, dijo que esa no es la respuesta para todas las familias.

“No digo las pistolas son malas, no puedes tener pistolas en casa”, dijo.

En cambio, Kerwin aboga por el almacenamiento de armas de forma segura, con cerrojo, descargadas, con la munición separada de las armas. Las armas de fuego también se pueden desactivar o, en algunos casos, reemplazar con un señuelo, aunque eso aumenta el riesgo de que se las confunda con un arma real en caso de emergencia.

Las familias caminan a través de una línea delgada, equilibrando la independencia con la seguridad.

Renunciar a las armas

Idealmente, las familias deberían analizar el acceso a las armas de fuego poco después de un diagnóstico de demencia y considerar establecer una “fecha de retiro de armas”, similar a una directiva anticipada para armas de fuego, aconsejan Betz y sus colegas. Es parecido a las discusiones sobre quitar las llaves del auto cuando conducir es peligroso, dijo.

“Una de las cosas complicadas es que, para conducir, hay algunas evaluaciones que puedes hacer”, dijo Betz. “No son perfectas, pero son útiles. No hay nada para armas de fuego”.

Los médicos que por rutina preguntan a pacientes con demencia sobre el manejo también deberían preguntar por las armas, dijo Wintemute. “Solo alrededor de un tercio lo hace con cualquier frecuencia”.

Los críticos de las restricciones de armas como Przebinda argumentan que la diferencia esencial entre conducir y disparar es que uno es un privilegio y el otro es un derecho constitucional protegido.

“No son lo mismo”, dijo. “No tienes derecho a transporte. Tienes derecho a la autodefensa, a proteger tu hogar y a tu familia que es algo intrínseco del ser humano”.

En cambio, la decisión debería dejarse en manos de las familias, dijo Przebinda. “Las personas que poseen armas saben qué medidas están disponibles”.

Pero incluso eso puede no ser suficiente. Dee Hill, de Oregon, dijo que fue “claramente un accidente” que su esposo, el alguacil retirado, le disparara y la hiriera de gravedad. Al día de hoy, ella no se arrepiente de mostrarle sus armas.

Para Verg y Delmar Scroughams, de Idaho, el dilema de mantener armas en la casa continúa. En un momento de lucidez, en mayo, Delmar reconoció que las armas que ha tenido toda su vida podrían ser peligrosas.

“Tengo una enfermedad de la que no sé el nombre y, eventualmente, podría pasar cualquier cosa”, dijo.

Esos momentos de conciencia se están volviendo raros, admitió Verg. Pronto, Delmar ya no podrá reconocerla. A medida que su condición empeora, dijo, depende de ella asegurar que nadie sufra daños.

“Me sentiría extremadamente responsable”, dijo. “Sería mi culpa”.

Esta historia es parte de una alianza entre Kaiser Health News y .

La cobertura de KHN de estos temas está respaldada por , y .

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).