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Extreme Risk Protection Order Cases in Older Adults with Cognitive Impairment

A new study led by CU Firearm Injury Prevention Initiative researchers evaluates ERPO cases and risks in a historically understudied population.

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Written by Colleen Miracle on September 20, 2023

Emmy Betz, MD, MPH, director of the University of Colorado Firearm Injury Prevention Initiative and professor of emergency medicine in the CU School of Medicine, led a study that examined Extreme Risk Protection Orders (ERPOs) cases for older adults in six states. The study was funded by the National Collaborative on Gun Violence Research and published earlier this month in the journal Clinical Gerontologist.

Extreme Risk Protection Orders (ERPOs) allow a court to restrict firearm access for individuals at imminent risk of harm to themselves or others. While there are multiple studies analyzing cases state-by-state, little is known about the use of ERPOs for older adults, a population with higher rates of suicide and dementia. 

“This study is significant because it’s one of the first of its kind to evaluate ERPO cases of older adults with cognitive impairment,” says Betz. “There’s been public discussion on how ERPOs could be used for cognitive impairment, but now we have data and analysis of how they are actually being used in this population.”

Collaboration, analysis, and results

The funding from the National Collaborative on Gun Violence Research brought together researchers across the country to look at how ERPOs are being used across multiple states, Betz says. In addition to researchers from the CU Firearm Injury Prevention Initiative, the research team includes other leading ERPO experts who had existing knowledge of how to obtain ERPO documents and data from their states. 

The lead investigators on the larger, multi-state study of ERPO use were April Zeoli PhD, MPH, associate professor of health management and policy at the University of Michigan, and Shannon Fratteroli, PhD professor of health policy and management at Johns Hopkins University.

The research team abstracted all ERPO cases from California, Colorado, Connecticut, Florida, Maryland, and Washington through June 30, 2020. States began implementing ERPOs at different times throughout the past decade, so some states had six months worth of data and some had years.

The researchers restricted their analysis to ERPO petitions for respondents equal to or greater than 65 years of age, stratified by documented cognitive impairment. Among 6,699 ERPO petitions across the six states, 672 (10%) were for older adults and 14% of these noted cognitive impairment. 75% identified as white and 90% identified as male.

Cognitively impaired respondents were, on average, six years older than non-cognitively impaired respondents and were more likely to have documented irrational or erratic behavior. Cognitively impaired respondents were less likely to have documented suicidality (34%) than non-cognitively impaired respondents (55%).

At the time of the petition, 56% of older adult respondents had documented firearm access.

Implications for states, individuals, and clinicians

Betz explains that examining ERPO use among adults with cognitive impairment is useful not only for understanding how the laws are being used, it also is a reminder for action on an individual level.

“We, as physicians and researchers, always encourage older adults who own firearms to think ahead about what they would want to happen to their guns, should they develop cognitive impairment or other conditions that impair their safe firearm handling,” she says. “The Firearm Life Plan is an anonymous planning tool that is free for use by the public.”

Betz and researchers from CU Anschutz and the Eastern Colorado Veterans Affairs Geriatric Research Education and Clinical Center (GRECC) created the Firearm Life Plan, one of many resources the Firearm Injury Prevention Initiative highlights to help prevent injury or death while recognizing individuals’ independence and preferences.

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Emmy Betz, MD, MPH