INTRODUCTION

Extreme Risk Protection Order (ERPO) laws allow for restricting firearm access among individuals who are at substantial risk of harming self or others. ERPOs are court orders requested by “Petitioners” to prompt the “Respondent” to surrender firearms and to prohibit purchase of new firearms. Additionally, ERPOs prevent renewals or requests for new concealed carry licenses.1 With appropriate evidence of concerning behavior, family members, household members, or law enforcement officers in Washington may request an ERPO.2

Particularly vulnerable to firearm injury are the millions of persons with dementia (PWD) living in the USA. Between 40 and 60% of this population has a firearm in home.3 PWD may exhibit combative behavior; in addition, depression is among the most common symptoms, putting them at high risk for suicide.3, 4 One retrospective study found that among veterans with dementia, the majority of suicides (73%) involved the use of a firearm.5

There is scant evidence for guidance6 related to firearm safety among PWD. Unfortunately, firearms often remain accessible beyond a point that is safe for the individual, household members, and visitors such as children. In this case, ERPOs may be a useful tool to remove firearms when there is evidence of danger. There have been no studies reported on dementia and ERPOs. We describe a case series of ERPO filings due to dangerous behavior in the context of age-related cognitive decline, dementia, or Alzheimer disease in Washington between December 2016 and May 2019.

METHODS

We identified all ERPO filings and associated county court records in Washington between December 8, 2016, and May 10, 2019.2 We narrowed our sample to include cases with a mention of cognitive decline, dementia, or Alzheimer disease in the narrative of ERPO petitions or associated court documents. We report brief narrative summaries of each of the cases, ascertained through publicly available court data. The study was approved by the University of Washington Institutional Review Board.

RESULTS

During the study period, 237 individuals had an ERPO filed for them as a respondent; of those respondents, 9 (4%) were PWD, all of whom were men. One of the Respondents was Black and eight were White. Two had family members as Petitioners; the rest were law enforcement entities. ERPOs were granted for six, which resulted in the prohibition of firearms for one year. Five respondents had contact with law enforcement and/or adult protective services due to violent or erratic behavior prior to the ERPO petition filing. All but one of the individuals kept a firearm on their person or in an unsecured location; one individual kept firearms in a locked safe. A brief narrative summary of the nine cases is presented in Table 1. Common themes in the nine cases included a pattern of paranoid behavior, delusions/hallucinations, history of domestic violence, alcohol/substance abuse, and suicidal ideation.

Table 1 Summary Detailsa of Dementia-Related ERPO Cases in Washington from December 8, 2016, to May 10, 2019
Full size table

DISCUSSION

This case series of dementia-related ERPOs in Washington suggests a pattern of firearms being unsafely stored and accessible to PWD with advanced disease and/or individuals exhibiting aggressive and paranoid behavior. For patients with mild cognitive impairment or dementia, providers should assess for the presence of firearms and discuss this with patients and their families, as recommended by a number of professional societies. To maintain autonomy, such guideline-based interventions can use shared decision-making to the extent appropriate within the context of disease progression. The timing of such conversations should be considered as early as possible to address the potential for increased suicide risk immediately after diagnosis,5 as well as to protect against further cognitive decline prior to engagement in decision-making. In the absence of such interventions, ERPOs provide a tool for concerned family members and law enforcement to safeguard PWD and the public for a one-year duration with potential to renew annually in Washington state. Our study is limited because it is a narrative review of available documentation, on a small number of cases mentioning dementia or possible dementia in one state, and therefore may not be representative of other cases of ERPOs filed for PWD. In the absence of data on cognitive functioning, these cases may not have been clinical diagnoses, but were based on petitioner report and/or supporting documentation. Additional research on firearm access in this vulnerable population and on the usefulness of ERPO is critically warranted.