Despite our best efforts, clinicians aren’t great at predicting suicide. It remains a rare but devastating event. That said, the risk isn’t distributed evenly. Older men have the highest suicide rates, and they overwhelmingly use firearms. While rates among older women are lower, firearm-related suicides in this group have risen significantly over the past decade. Medical comorbidities, pain, social isolation, bereavement, and cognitive decline all converge in late life. These factors increase suicide risk, and older adults are more likely than younger people to die on the first attempt, especially when a gun is ­involved.

Roughly one-third of older adults own a firearm (Carter PM et al, Prev Med 2022;156:106955). Most have no clear plan in place if suicidal or homicidal thoughts emerge. Add in cognitive impairment or dementia—both associated with increased impulsivity, paranoia, and impaired judgment—and the risk rises further (Rosen T et al, Health Aff (Millwood) 2019;38(10):1630–1637). While depression screening and treatment can reduce risk, they only get us so far. Most older adults who die by suicide never carry a psychiatric diagnosis, and those who use firearms are even less likely to have one (Schmutte TJ and Wilkinson ST, Am J Prev Med 2020;58(4):584–590). 

Clinical red flags

Revisit firearm safety any time there’s a shift in medical, cognitive, or psychosocial status. Raise concern if your patient shows any of the following: 

Cognitive decline or dementia that affects judgment or increases impulsivity

Worsening depression or new-onset mood symptoms, especially hopelessness, agitation, or withdrawal

Physical illness or chronic pain that leads to loss of function or perceived burden

Social disruption (death of a spouse, family conflict, or sudden isolation)

How to talk about gun safety

Bringing up firearms can feel awkward, especially with older adults who may view gun ownership as tied to identity or independence. When mood symptoms are in remission, keep your antenna up for creeping functional decline or growing isolation. Don’t wait for a crisis to address firearm access.

Don’t simply ask, “Do you have guns at home?” Instead, use a structured framework like the “5 Ls” (Pinholt EM et al, J Am Geriatr Soc 2014;62(6):1142–1146):

Is it Loaded?

Is it Locked?

Are Little children present?

Is the operator feeling Low?

Is the operator Learned? (Trained to use it, cognitively intact?)

Based on your patient’s answers, tailor your response. This may mean counseling them on safer storage, like using a gun lock (often more acceptable than a full safe), locking up ammunition separately, or both. For higher-risk cases, consider disabling the weapon (eg, removing the firing pin), temporarily transferring ownership, or fully removing the firearm from the home (Carter PM and Cunningham RM, N Engl J Med 2024;391(10):926–940).

Involve family members and caregivers when appropriate, especially if the patient has impaired judgment or memory. Document the conversation clearly: who was involved, what steps were agreed on (eg, storage changes or transfers), and the plan for follow-up.

Carlat Take

In older adults with cognitive decline, mood disorders, or recent losses, always ask about firearm access. But don’t stop at yes or no—develop a safety plan. Reassess regularly as medical and psychosocial factors shift.