Barbara Herrington, a geriatric care manager in Polk County, Fla., was calling on a 72-year-old woman with dementia and a long history of alcoholism.
Ms. Herrington knew her client would be angry that morning. Her daughter had taken the car away the day before because her mother was ignoring a neurologist’s instructions to stop driving and was heading out at night to buy liquor.
The door to the woman’s small home stood open — she often left it unlocked for her caregivers — so Ms. Herrington knocked, then leaned in and called her client’s name.
“She came out of the bedroom holding a pistol with both hands,” Ms. Herrington recalled. The woman took aim at her visitor, announcing that she wanted her car back.
“Her hands were shaking, shaking, shaking,” Ms. Herrington said. “I didn’t know if it was loaded or not, and I didn’t care.” She backed away and called the daughter and the police, who later that day removed two Berettas and a pellet gun from the house.
The attachment to guns often dies hard for older people. Even after dementia develops, relinquishing them can feel “almost like an amputation,” said Dr. Michael Victoroff, a family medicine specialist at the University of Colorado School of Medicine (and a certified firearms instructor).
One of his patients, a retired police officer, had long slept with his .38 service revolver by his bed. But as he neared age 80 and his dementia deepened, “he would wake up at night and not recognize his wife, see her as a stranger in his house,” Dr. Victoroff said.
Once Dr. Victoroff learned that the man had pointed the loaded .38 at his wife, the situation grew urgent. They turned to the man’s former partner on the police force, someone he trusted, to persuade him to give up his weapon.
Frightening stories like these — and of older adults, particularly white men, committing suicide with guns — may become more common in coming years. About a third of Americans over age 65 own a gun, and 12 percent of all Americans live with someone who does, the Pew Research Center reported last year.
Though the dementia rate has declined in the United States, the growing number of older Americans means more people will develop it. At the same time, gun sales have risen dramatically.
Perhaps not coincidentally, suicide rates have also climbed, up 28 percent from 1999 to 2016. More than 8,200 older adults committed suicide in 2016, according to the Centers for Disease Control and Prevention. Among men, those over age 65 are the likeliest to take their lives, and three-quarters of them use a gun.
“Suicide risk is elevated in people with dementia, but it’s more of a factor early in the illness,” said Dr. Yeates Conwell, a psychiatrist and director of the Office for Aging at the University of Rochester School of Medicine.
Later on, “people are less able to organize a suicide attempt and more apt to be under supervision.”
While older adults make many fewer suicide attempts than younger cohorts, they die more often, in part because they use such lethal methods. Yet health care providers who ask older patients about driving and wandering may not ask about guns.
“Safety planning for adults with dementia is something every clinician thinks about, but I don’t think firearms are often on the radar,” said Dr. Donovan Maust, a psychiatrist at the University of Michigan Medical School and co-author of a recent article on guns and dementia in the Annals of Internal Medicine.
They should be. At various stages of dementia, people may grow unable to distinguish loved ones from intruders. Their decision-making ability deteriorates. They can become paranoid, depressed, impulsive, agitated or aggressive.
Just when they need help, home care agencies and other services may refuse to send staffers to clients with unsecured weapons.
The question, as Dr. Victoroff put it: “What practical strategies can you use to pry a gun out of the hands of someone who’s not safe with it anymore?”
At a minimum, owners should use locks and safes to secure firearms. Those insistent on keeping loaded weapons handy could use an inexpensive rapid access safe with a keypad. “You can get in in two to three seconds, but your grandchild can’t,” Dr. Victoroff said.
But that won’t solve the problem of impaired judgment. (Nor does removing a firing pin or hiding ammunition, since others — including police — won’t know a gun is inoperable.)
So Dr. Marian Betz, lead author of the Annals article and an emergency physician at the University of Colorado School of Medicine, has proposed a family firearm agreement, a sort of advance directive for guns.
The article contains a simple, four-paragraph template, in which the signer concedes that while he wants to control his firearms as long as possible, “the time may come when I can no longer make the best decisions for the safety of myself and others.”
The document names an individual to tell him when that time arrives.
“It’s not legally binding,” Dr. Betz acknowledged. Moreover, friends and family members may struggle to determine when a person with dementia — which can worsen subtly and vary by day or within days — reaches the point at which he should surrender his guns.
Still, Dr. Betz sees the document as a way to begin a tough conversation, “ideally, early enough to involve the older adult himself in the decision.”
Alternatively, gun owners can establish a firearms trust, which is legally binding. A trustee can use a gun until disability, including dementia, or death triggers a provision transferring possession to the other trustees.
In some states, families can also turn to involuntary measures like extreme risk protection orders and so-called “red flag laws.” They allow family members or law enforcement officials to seek a court-ordered surrender of guns from people who’ve been determined to be dangerous.
The majority of Americans who don’t own or live with guns might find these dilemmas puzzling. Relinquishing guns at older ages often gets compared to giving up car keys, but that analogy has limitations.
In many rural and suburban communities with inadequate public transit, older people who can’t drive may face genuinely constricted lives. Guns, on the other hand, don’t seem essential to quality of life. Given that dreadful accidents do happen, and that thousands of older people kill themselves with guns annually, why all the conflict over giving them up?
Many gun enthusiasts argue that while driving is a privilege, the Constitution protects keeping and bearing arms. And they find firearms a crucial part of their identities and sense of security.
Overriding those instincts when necessary requires planning and tact.
Ms. Herrington and a colleague found themselves outside a client’s home one morning this month, waiting with his daughter, a locksmith and the county sheriffs while the man, 79, drove off for breakfast. His dementia had intensified and he’d made alarming financial decisions; a court had given his daughter temporary guardianship.
In his absence, the team removed the loaded pistol under his pillow and about 20 other guns. When the man returned, they explained what they’d done and why.
“He stated he would feel naked without his gun,” Ms. Herrington said in email. “The police officer assured him he could call 911 anytime and they would be there immediately.”
The reassurances continued for hours. Now, Ms. Herrington said, they will see how things go.