In many parts of America, a shotgun is known as a "good door gun," and any suggestion that gun safety falls within the purview of the family doctor is met with opprobrium, if not outright hostility.

Radiating from the heartland, "red" American gun values stretch to the Western bastions of libertarianism, the Southern comfort of conservatism, and the laissez-faire ethos of the rural Northeast, where New Hampshire residents "live free or die" and Vermonters allow anyone and his cousin to carry a concealed firearm, sans permit.

Despite the divisive nature of the great American gun debate, heath experts are advising physicians to broach the subject of gun safety with elderly patients, reminding them that they have the legal right to do so. Although gun safety advocates focus more on households with children, at least some evidence suggests that firearms in the home may pose lethal dangers to the elderly, wrote Marshall B. Kapp, a public health expert, on Monday in Annals of Internal Medicine.

"Even [elderly] individuals with memory impairment often have access to firearms, most of which are unlocked and with readily available ammunition," Kapp wrote. "Geriatric persons are more likely than younger people to suffer self-inflicted — either accidental or intentional — gunshot wounds, especially to the head."

Aside from the risk of accidental discharge inherent with any gun ownership, elderly men and women alike are most likely to commit suicide by using firearms. "To safeguard these persons as well as the rest of the population, a public health approach to preventing gun violence, with physician engagement as a central element, is essential."

In seeking to dispel any perceived "chilling effect" on discussing gun safety with patients, Kapp goes so far as to remind physicians that no federal law proscribes such conversations, including the Patient Protection and Accountability Act of 1996, nor do any state laws seek to restrict a doctor's First Amendment right to broach a subject many consider verboten.

"Some physicians may be deterred by a concern about patient autonomy [but] issues of safety must be balanced against the rights and freedoms of the individual and the possibility of discrimination against older people should be considered, especially when the Second Amendment is involved," Kapp wrote. "However, deferring to a patient's autonomous choices only makes sense when that patient is capable of making decisions, and some geriatric patients with unsecured firearms in the home are not autonomous decision makers."

Conditions that may affect a patient's autonomy with regard to gun safety may include physical and mental decline characterized by dementia, delusions and memory disorders, depression, and problems with vision and hearing. Although gun rights advocates may oppose such inquiries in a clinical setting, Kapp likens the conversation to interventions made routinely with regard to life skills, such as the decision to stop driving or cooking.

In the event that family members refuse to intervene when patients may be endangered, Kapp suggests intervention by the state adult protective services agency. "When the reasonably foreseeable risks are substantial and the family is uncooperative, the danger may be categorized as a form of adult abuse or neglect," he wrote. "In every state, physicians have either a mandatory or permissive responsibility to report suspected danger."

Experts on geriatric psychology say the mere presence of a handgun in the home significantly increases the chances of suicide for men over the age of 50, with elderly white men most at danger of suicide by gun.

Source: Kapp MB. Geriatric Patients, Firearms, And Physicians. Annals Of Internal Medicine. 2013.