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Background Temporary, voluntary storage of firearms away from the home is a recommended option for individuals with risk of suicide, but it may also be used in other situations (e.g., long trips). Prior work has explored the availability of storage options and the views of storage locations. Little is known about out-of-home storage practices among those who live in homes with firearms (including owners). Methods We surveyed English-speaking adults (18 or older) in two states (Colorado and Washington) living in a home with a firearm (June–July 2021). Results Among the final sample of 1029, most respondents were white (88.1%) and non-Hispanic (85.0%); half were female (50.8%), and the most common age group was ages 35–44 (25.5%). Just over one quarter (27.3%) of respondents indicated they had stored a firearm away from their home/car/garage in the last 5 years. The place most respondents said they were somewhat or very likely to consider was at a family members home (62.7%) or at a self-storage facility (52.5%). Conclusion Out-of-home firearm storage is a relatively common practice and endorsed by many gun-owners, suggesting out-of-home storage is feasible for firearm owners as an approach to suicide prevention.

ObjectiveFew patients with suicide risk are counseled on lethal means safety by health providers. This study tested the feasibility of different delivery methods for Lock to Live (L2L), a web-based decision aid of safe storage options for firearms and medications.MethodsPatients reporting suicide ideation on the PHQ9 depression screener during outpatient health visits were included. Invitation messages to visit L2L were sent via combinations of email, text, Electronic Health Record (EHR) message, mailed letter, or provider referral, followed by a survey about storage behavior and acceptability. Provider interviews evaluated logistical considerations and acceptability.ResultsThe population-based method reached 2,729 patients and the best method (EHR message plus 2 email reminders) had 11% uptake (L2L visitation rate). Provider referral had small reach (14 patients) and 100% uptake (all visited). Provider interviews identified several strategies to promote uptake including: EHR reminders, provider training, quality metrics with accountability, a clearly communicated lethal means screening/counseling policy, and strong organizational leadership support.ConclusionDespite the low uptake for population-based (11%), far more patients with suicide risk were engaged in the L2L tool through population-based outreach than provider-referral over the same time frame.

The U.S. DoD has identified firearm suicide prevention as a key operational priority. One vital approach to addressing firearm suicides is through promoting lethal means safety, which involves the voluntary use of secure storage for personally owned firearms and/or temporarily moving firearms out of the home during risk periods. Despite promising approaches to lethal means safety, critical gaps remain in research, programming, and communication among and across scientists, DoD programmatic leaders, front-line commanders, and service members. To address these gaps, the first-ever national “Firearm Suicide Prevention in the Military: Messaging and Interventions Summit” was convened in June 2022, bringing together DoD personnel and researchers with expertise in firearm suicide prevention and lethal means safety. The Summit identified 10 recommendations to enhance firearm suicide prevention messaging and interventions in the U.S. military, including (1) repeal or amend prohibitions on questioning service members about personal firearms; (2) develop, examine, and use common language for firearm injury prevention; (3) implement a universal approach to training on comprehensive firearm injury prevention; (4) encourage leadership across disciplines and levels; (5) aim for broad culture change; (6) support innovative research; (7) consider various outcome measures; (8) promote “cultural competence” for better communication; (9) reduce territorialism; and (10) develop creative partnerships. Ultimately, these recommendations can facilitate productive partnerships with a shared goal: to develop, test, and implement strategies that standardize lethal means safety and reduce firearm suicides and other firearm injuries or harm among service members.

Background Temporary, voluntary storage of firearms away from the home during times of risk is a recommended strategy for suicide prevention. Law enforcement agencies (LEAs) are often suggested as storage sites, and online maps in Colorado and Washington display LEAs willing to consider storage. Questions remain about the experiences and views of LEAs, including barriers to providing storage. Methods LEAs in Colorado and Washington were invited to complete a survey via mail or online from June to July 2021; invitations were sent by email and mail, with telephone calls to non-responders. Survey data were analyzed using descriptive statistics, with testing between states and other subgroups using Fisher’s exact tests. Results Overall, 168 LEAs in Colorado (n = 91) or Washington (n = 77) participated (40% participation rate). Of those, 53% provided temporary, voluntary storage upon request by community members at the time of the survey. More LEAs said they had ever provided storage when the requester was under a court order (74% overall). Over half (60%) of responding LEAs had received at least one storage request in the prior 12 months. Many (41%) said they had declined to return a firearm after temporary storage due to safety concerns. Most LEAs supported engagement in suicide prevention (89%) and provision of community services (77%), but they simultaneously preferred being a storage option of last resort (73%). Factors negatively influencing storage provision included liability and funding concerns. Conclusions In Colorado and Washington, half of LEAs currently offer temporary, voluntary firearm storage upon request. While LEAs support suicide prevention and community engagement, broader provision of storage and participation in online maps may be limited by logistic, liability, and financial concerns. Addressing these barriers may facilitate broader suicide prevention efforts.

Introduction Caring for suicidal patients can be challenging, especially in emergency departments without easy access to mental health specialists. The American College of Emergency Physicians and the American Foundation for Suicide Prevention appointed a working group to create an easy-to-use suicide prevention tool for ED providers. Methods The writing group created an easy-to-use mnemonic for the care of adult patients as a way of organizing sequential steps, accompanied by a systematic review of available ED-based suicide prevention literature. The systematic review was performed both to ensure that all relevant evidence was taken into account as well as to evaluate the strength of evidence for each recommendation. Levels of evidence were assigned utilizing the ACEP level of evidence classification. Results The writing group created the mnemonic ICAR2E, which stands for I dentify suicide risk; C ommunicate; A ssess for life threats and ensure safety; R isk assessment (of suicide); R educe the risk (of suicide); and E xtend care beyond the ED. 31 articles were identified in the search, and were included in the systematic review. Conclusions The ICAR2E mnemonic may be a feasible way for practicing ED clinicians to provide evidence-based care to suicidal patients. However, further research is needed.

ImportanceSecure firearm storage may help reduce firearm injury and death. Broad implementation requires more granular assessments of firearm storage practices and greater clarity on circumstances that may prevent or promote the use of locking devices.ObjectiveTo develop a more thorough understanding of firearm storage practices, obstacles to using locking devices, and circumstances in which firearm owners would consider locking unsecured firearms.Design, Setting, and ParticipantsA cross-sectional, nationally representative survey of adults residing in 5 US states who owned firearms was administered online between July 28 and August 8, 2022. Participants were recruited via probability-based sampling.Main Outcomes and MeasuresFirearm storage practices were assessed via a matrix provided to participants in which firearm-locking devices were described both via text and images. Locking mechanisms (key/personal identification number [PIN]/dial vs biometric) were specified for each type of device. Obstacles to the use of locking devices and circumstances in which firearm owners would consider locking unsecured firearms were assessed via self-report items developed by the study team.ResultsThe final weighted sample included 2152 adult (aged ≥18 years), English-speaking firearm owners residing in the US; the sample was predominantly male (66.7%). Among the 2152 firearm owners, 58.3% (95% CI, 55.9%-60.6%) reported storing at least 1 firearm unlocked and hidden, with 17.9% (95% CI, 16.2%-19.8%) reporting storing at least 1 firearm unlocked and unhidden. Gun safes were the most frequently used device both among participants who use keyed/PIN/dial locking mechanisms (32.4%; 95% CI, 30.2%-34.7%) and those who use biometric locking mechanisms (15.6%; 95% CI, 13.9%-17.5%). Those who do not store firearms locked most frequently noted a belief that locks are unnecessary (49.3%; 95% CI, 45.5%-53.1%) and a fear that locks would prevent quick access in an emergency (44.8%; 95% CI, 41.1%-48.7%) as obstacles to lock usage. Preventing access by children was the most often reported circumstance in which firearm owners would consider locking unsecured firearms (48.5%; 95% CI, 45.6%-51.4%).Conclusions and RelevanceIn this survey study of 2152 firearm owners, consistent with prior research, unsecure firearm storage was common. Firearm owners appeared to prefer gun safes relative to cable locks and trigger locks, indicating that locking device distribution programs may not match firearm owners’ preferences. Broad implementation of secure firearm storage may require addressing disproportionate fears of home intruders and increasing awareness of the risks associated with household firearm access. Furthermore, implementation efforts may hinge on broader awareness of the risks of ready firearm access beyond unauthorized access by children.

This case series examines how individuals who died by suicide responded to a survey question regarding access to firearms before death.

Background Firearm safety among individuals with Alzheimer disease and related dementias (ADRD) is an underdiscussed and underresearched concern in the United States, especially given the growing population of community-dwelling adults with ADRD. The “Safety in Dementia” (SiD) web-based decision aid was developed to support caregivers in addressing firearm access; the efficacy of SiD is unknown. Objective Through the SiD decision aid, the Safe at Home (S@H) study aims to support caregivers in making decisions about home safety that align with their goals and values, and behaviors regarding firearm access for persons with ADRD and firearm access. Methods The S@H study is a 2-armed randomized controlled trial to test the effect of the SiD decision aid on caregivers of community-dwelling adults with ADRD who have firearm access. S@H aims to recruit 500 ADRD caregivers (age ≥18 years, fluent in English or Spanish, and in the United States) through online or social media advertisements and through relevant organizations. Participants are randomized to view SiD or a control website at their own pace; all participants complete web-based questionnaires at baseline, 2 weeks, 2 months, and 6 months. The primary outcome is immediate preparation for decision-making; secondary outcomes include longitudinal decision outcomes and self-reported modifications to firearm access. The relative reach and effectiveness of each recruitment method (online/social media and through relevant organizations) will be assessed by examining differences in caregiver participation, retention rates, and relative cost. Results The study enrollment began in May 2022. As of December 2022, a total of 117 participants had enrolled. Conclusions The S@H study is the first randomized trial of a firearm safety decision aid for ADRD caregivers. The results from this study will inform how best to support caregivers in decision-making regarding firearm safety. Further, results may guide approaches for recruiting caregivers and for dissemination of resources. Trial Registration ClinicalTrials.gov NCT05173922; https://clinicaltrials.gov/ct2/show/NCT05173922 International Registered Report Identifier (IRRID) DERR1-10.2196/43702

This Viewpoint discusses lethal means safety (LMS), an approach to reducing suicide risk by reducing access to firearms by at-risk individuals; highlights challenges in implementing LMS interventions in clinical settings; and provides examples of programs and resources for preventing firearm suicide at the individual, patient group, and population level.

Purpose Firearm injury is a leading cause of morbidity and mortality in the United States. However, many medical professionals currently receive minimal or no education on firearm injury or its prevention. The authors sought to convene a diverse group of national experts in firearm injury epidemiology, injury prevention, and medical education to develop consensus on priorities to inform the creation of learning objectives and curricula for firearm injury education for medical professionals. Method In 2019, the authors convened an advisory group that was geographically, demographically, and professionally diverse, composed of 33 clinicians, researchers, and educators from across the United States. They used the nominal group technique to achieve consensus on priorities for health professions education on firearm injury. The process involved an initial idea-generating phase, followed by a round-robin sharing of ideas and further idea generation, facilitated discussion and clarification, and the ranking of ideas to generate a prioritized list. Results This report provides the first national consensus guidelines on firearm injury education for medical professionals. These priorities include a set of crosscutting, basic, and advanced learning objectives applicable to all contexts of firearm injury and all medical disciplines, specialties, and levels of training. They focus on 7 contextual categories that had previously been identified in the literature: 1 category of general priorities applicable to all contexts and 6 categories of specific contexts, including intimate partner violence, mass violence, officer-involved shootings, peer (non-partner) violence, suicide, and unintentional injury. Conclusions Robust, data- and consensus-driven priorities for health professions education on firearm injury create a pathway to clinician competence and self-efficacy. With an improved foundation for curriculum development and educational program-building, clinicians will be better informed to engage in a host of firearm injury prevention initiatives both at the bedside and in their communities.

Author(s): Siry, Bonnie J.; Knoepke, Christopher E.; Ernestus, Stephanie M.; Matlock, Daniel D.; Betz, Marian E. | Abstract: Introduction:nLethal means counseling (to reduce access to firearms or other suicide methods) is a recommended critical yet challenging component of care of suicidal patients. Questions remain about communication strategies for those in acute crisis.Method:nThis qualitative study was an analysis of semi-structured interviews with English-speaking, community-dwelling adults with a history of lived-experience of suicidal ideation or attempts in themselves or a family member. We used a mixed inductive and deductive approach to identify descriptive themes related to communication and decision-making.Results:nAmong 27 participants, 14 (52%) had personal and 23 (85%) had family experience with suicide ideation or attempts. Emergent themes fell into two domains: (1) communication in a state of high emotionality; and (2) specific challenges in communication: initiating, maintaining engagement, considering context.Conclusion:nEngaging suicidal individuals in lethal means counseling may be more effective when messaging and approaches consider their emotional state and communication challenges.

Background Extreme Risk Protection Orders (ERPOs) are a relatively new type of law that are being considered or implemented in many states in the United States. Colorado’s law went into effect on January 1, 2020, after significant controversy and concern over potential misuse of the law to confiscate weapons; many (n = 37 of 64) counties declared themselves “2nd Amendment (2A) sanctuaries” and said they would not enforce the law. Here, reviewed the patterns of use of the law during its first year. Methods We obtained all court records for ERPO petitions filed between January 1 and December 31, 2020. Data elements were abstracted by trained staff using a standardized guide. We calculated the proportion of petitions that were approved or denied/dismissed, identified cases of obvious misuse, and examined patterns by 2A county status. Finding and results In 2020, 109 ERPO petitions were filed in Colorado; of these, 61 were granted for a temporary ERPO and 49 for a full (year-long) ERPO. Most petitions filed by law enforcement officers were granted (85%), compared to only 15% of petitions filed by family or household members. Of the 37 2A sanctuary counties, 24% had at least one petition filed, versus 48% of non-2A sanctuary counties. Across the 2A counties, there were 1.52 ERPOs filed per 100,000 population, compared to 2.05 ERPOs filed per 100,000 in non-2A counties. There were 4 cases of obvious law misuse; none of those petitions resulted in an ERPO or firearm confiscation. Conclusion State-level studies suggest ERPOs may prevent firearm injuries. Robust implementation, however, is critical for maximal effect. Understanding ERPO experiences and challenges can inform policy creation and enaction in other states, including identifying how best to address concerns and facilitate evaluation.

Background Decision-making about when to stop driving for older adults involves assessment of driving risk, availability of support or resources, and strong emotions about loss of independence. Although the risk of being involved in a fatal crash increases with age, driving cessation can negatively impact an older adult’s health and well-being. Decision aids can enhance the decision-making process by increasing knowledge of the risks and benefits of driving cessation and improve decision quality. The impact of decision aids regarding driving cessation for older adults is unknown. Methods The Advancing Understanding of Transportation Options (AUTO) study is a multi-site, two-armed randomized controlled trial that will test the impact of a decision aid on older adults’ decisions about changes in driving behaviors and cessation. AUTO will enroll 300 drivers age ≥ 70 years with a study partner (identified by each driver); the dyads will be randomized into two groups (n = 150/group). The decision aid group will view the web-based decision aid created by Healthwise at baseline and the control group will review information about driving that does not include evidence-based elements on risks and benefits and values clarification about driving decisions. The AUTO trial will compare the effect of the decision aid, versus control, on a) immediate decision quality (measured by the Decisional Conflict Scale; primary outcome); b) longitudinal psychosocial outcomes at 12 and 24 months (secondary outcomes); and c) longitudinal driving behaviors (including reduction or cessation) at 12 and 24 months (secondary outcomes). Planned stratified analyses will examine the effects in subgroups defined by cognitive function, decisional capacity, and readiness to stop driving. Discussion The AUTO study is the first large-scale randomized trial of a driving decision aid for older adults. Results from this study will directly inform clinical practice about how best to support older adults in decision-making about driving. Trial registration ClinicalTrials.gov: NCT04141891. Registered on October 28, 2019. Located at https://clinicaltrials.gov/ct2/show/NCT04141891

This survey study of caregivers of people with Alzheimer disease and related dementias assesses caregiver views on firearm safety risks, experiences with health care professional–delivered counseling, and preferred sources of information about firearm safety., Key Points Question What proportion of adults living in homes with firearms are caregivers for people with Alzheimer disease and related dementias, and what are their characteristics, experiences, and preferences related to firearms? Findings In this survey study of US adults (aged ≥35 years) living in homes with firearms, 2.6% reported being caregivers of a person with Alzheimer disease and related dementias, and 41% of these caregivers lived with that person. Although most caregivers were open to health care professional counseling about firearm safety for persons with Alzheimer disease and related dementias, few caregivers had ever received any such counseling. Meaning The findings suggest that many community-dwelling adults with dementia have firearm access and that there may be a need for enhanced education and resources for their caregivers., Importance The population of adults with Alzheimer disease and related dementias (ADRD) is increasing, and many people with ADRD have access to firearms. Little is known, however, about how caregivers of people with ADRD think about or address firearm safety. Objective To assess views on firearm safety risks among caregivers of persons with ADRD, experiences of caregivers with health care professional–delivered counseling, and their preferred sources of information about firearm safety. Design, Setting, and Participants This survey study used a probability-based online survey (National Firearms Survey, July 30 to August 11, 2019) with weights used to generate nationally representative estimates of adults living in households with firearms to assess firearm safety views of English-speaking adults 35 years or older. Respondents for the National Firearm Survery were drawn from I KnowledgePanel, a frame with approximately 55 000 US adults selected on an ongoing basis using address-based sampling methods. Main Outcomes and Measures Caregivers were asked whether the person with ADRD owned or had access to firearms. Additional ADRD-related measures assessed perceptions about the likelihood of types of firearm injuries involving people with ADRD, support for firearm safety counseling by health care professionals with regard to dementia, and history of ever having received such counseling. Results Of 6712 invited panel members, 4030 completed the survey (completion rate, 65%). For this analysis, we excluded the youngest participants (aged 18-34 years; n = 498); among the remaining 3532 participants, 124 reported being caregivers for persons with ADRD. Of the 124 caregivers, 51% were female and the mean (SD) age was 60 (12.5) years. Most participants (71%; 95% CI, 69%-72%) thought that a person with ADRD was more likely to hurt someone else unintentionally than intentionally hurt themselves or someone else. Many participants thought health care professionals should always (45%; 95% CI, 43%-47%) or sometimes (34%; 95% CI, 32%-37%) talk about firearm safety with caregivers or patients with dementia, but only 5% of caregivers (95% CI, 2%-12%) reported that a health care professional had ever spoken to them about firearm safety. Among the 41% (95% CI, 31%-51%) of caregivers who lived with a person with dementia, 31% (95% CI, 18%-49%) said the person with dementia could access firearms in the home. Conclusions and Relevance In this study, few caregivers of adults with ADRD reported having received health care professional counseling about firearm safety, although most thought health care professionals should provide such counseling. These findings raise concerns about home firearm access among adults with ADRD and indicate potential opportunities for enhanced education by health care professionals and community organizations.

We surveyed self-reported lifetime health conditions (using National Health and Aging Trends Study questions) and related driving reduction in a large multi-site older driver cohort (n = 2,990) from the AAA Longitudinal Research on Aging Drivers (LongROAD) Study’s baseline assessment. Those reporting reduced driving (n = 337) largely attributed reduction to musculoskeletal (29%), neurologic (13%), and ophthalmologic (10%) conditions. Women reported health condition-related driving reduction more often than men (14% versus 8%, p

It is estimated that emergency departments (EDs) could prevent 5% of all suicide attempts and 8% of suicide deaths, making EDs a critical setting in which to identify individuals at risk for suicide and to intervene to mitigate the risk. The goal of this review was to detail recent advances in the identification, assessment, and management of suicide risk in emergency medicine and to provide best practice recommendations for these processes. Advances in caring for patients who present to EDs with suicide risk include improved workflows and tools for ED providers to identify, assess, and manage suicide risk, increased patient-centeredness and quality of ED care for patients at risk of suicide, and shifting beliefs of ED providers regarding the feasibility of integrating the assessment and management of suicide risk into emergency care. ED suicide prevention efforts have notably changed in recent years. Strategies for universal screening, secondary screening tools, and evidence-based workflows for the management of suicide risk all show potential for feasibly addressing suicide risk in EDs. Effective implementation of evidence-based practices is necessary as integrating these new practices requires significant change in the clinical practice and culture of many EDs.

Preventing firearm-related injury and death requires pragmatic, community-based solutions. The authors describe their initial experiences developing a statewide map of locations where firearms may ...

Frailty is linked to poor outcomes in older patients. We prospectively compared the utility of the picture-based Clinical Frailty Scale (CFS9), clinical assessments, and ultrasound muscle measurements against the reference FRAIL scale in older adult trauma patients in the emergency department (ED).We recruited a convenience sample of adults 65 yrs. or older with blunt trauma and injury severity scores9. We queried subjects (or surrogates) on the FRAIL scale, and compared this to: physician-based and subject/surrogate-based CFS9; mid-upper arm circumference (MUAC) and grip strength; and ultrasound (US) measures of muscle thickness (limbs and abdominal wall). We derived optimal diagnostic thresholds and calculated performance metrics for each comparison using sensitivity, specificity, predictive values, and area under receiver operating characteristic curves (AUROC).Fifteen of 65 patients were frail by FRAIL scale (23%). CFS9 performed well when assessed by subject/surrogate (AUROC 0.91 [95% CI 0.84-0.98] or physician (AUROC 0.77 [95% CI 0.63-0.91]. Optimal thresholds for both physician and subject/surrogate were CFS9 of 4 or greater. If both physician and subject/surrogate provided scores4, sensitivity and negative predictive value were 90.0% (54.1-99.5%) and 95.0% (73.1-99.7%). Grip strength and MUAC were not predictors. US measures that combined biceps and quadriceps thickness showed an AUROC of 0.75 compared to the reference standard.The ED needs rapid, validated tools to screen for frailty. The CFS9 has excellent negative predictive value in ruling out frailty. Ultrasound of combined biceps and quadriceps has modest concordance as an alternative in trauma patients who cannot provide a history.

Background and Objectives Balancing both driver mobility and safety is important for the well-being of older adults. However, research on the association of physical function with these 2 driving outcomes has yielded inconsistent findings. This study examined whether physical functioning of older drivers, as measured by the Short Physical Performance Battery (SPPB), is associated with either driving space or crash involvement. Methods Using cross-sectional data of active drivers aged 65–79 years from the AAA Longitudinal Research on Aging Drivers (LongROAD) study (n = 2,990), we used multivariate log-binomial and logistic regressions to estimate the associations of the SPPB with either self-reported restricted driving space in the prior 3 months or any crashes in the past year. Interaction with gender was assessed using likelihood ratio tests. Results After adjustment, older drivers with higher SPPB scores (higher physical functioning) had lower prevalence of restricted driving space (8–10 vs. 0–7, prevalence ratio [PR] = 0.88, 95% confidence interval [CI]: 0.78–0.99; 11–12 vs. 0–7, PR = 0.78, 95% CI: 0.61–0.99). Fair (8–10), but not good (11–12), scores were significantly associated with reduced crash involvement (8–10 vs. 0–7, odds ratio [OR] = 0.71, 95% CI: 0.60–0.84). Gender was not a significant effect modifier. Discussion and Implications This study provides evidence that higher physical functioning is associated with better driving mobility and safety and that the SPPB may be useful for identifying at-risk drivers. Further research is needed to understand physical functioning’s longitudinal effects and the SPPB’s role in older driver intervention programs.

Many support limiting firearm access for persons whose mental illness would place them or others at heightened risk, but less attention has been paid to progressive cognitive impairment and firearm...

This study aimed to assess current education and practices of emergency medicine (EM) residents as perceived by EM program directors to determine if there are deficits in resident discharge handoff training. This survey study was guided by the Kern model for medical curriculum development. A six-member Council of EM Residency Directors (CORD) Transitions of Care task force of EM physicians performed these steps and constructed a survey. The survey was distributed to program residency directors via the CORD listserve and/or direct contact. There were 119 responses to the survey, which were collected using an online survey tool. Over 71% of the 167 American College of Graduate Medical Education (ACGME) accredited EM residency programs were represented. Of those responding, 42.9% of programs reported formal training regarding discharges during initial orientation and 5.9% reported structured curriculum outside of orientation. A majority (73.9%) of programs reported that EM residents were not routinely evaluated on their discharge proficiency. Despite the ACGME requirements requiring formal handoff curriculum and evaluation, many programs do not provide formal curriculum on the discharge transition of care or evaluate EM residents on their discharge proficiency.

Author(s): Kandasamy, Deepika; Platts-Mills, Timothy F.; Shah, Manish N.; Van Orden, Kim A.; Betz, Marian E. | Abstract: Introduction: Social disconnection is a public health problem in older adults, as it can lead to decreased quality of life for this population. This study describes the prevalence of social disconnection and patient interest in social resources to address social disconnection among older adults receiving emergency department (ED) care.Methods: We conducted a cross-sectional survey of community-dwelling older adults (≥65 years) receiving care at two U.S. EDs. We described participant characteristics (demographic, social, and health variables), social disconnection prevalence, and desire for social resources using percentages and 95% confidence intervals. Then, we performed Chi Square tests and logistic regression to determine factors associated with positive screens for social disconnection.Results: Of 289 participants, 51% were female and the median age was 72 (interquartile range: 69-78). Most (76%) engaged with the community regularly, and 68% reported driving. Regarding social disconnection, a substantial minority of participants reported feeling as if they were burdensome to others (37%); as if they didn’t belong (27%); or that people would be better off if they were gone (15%); 52% reported at least one of these. In separate regression analyses, the perceptions of being a burden or better off if gone were each significantly associated with needing help with routine tasks (odds ratio [OR] [5.87, 5.90]); perceived burden was associated with hospitalization in theprior month (OR [2.09]); and low belonging was associated with not engaging in the community regularly (OR [2.50]), not seeing family regularly (OR [3.82]), and difficulty affording food (OR [2.50]). Regarding potential ED referrals, most participants were interested in transportation options (68%), food assistance (58%), and mental health resources (55%). Participants experiencing difficulties affording food were interested in food and housing assistance (p=.03; p=.01).Conclusion: Over half of this sample of older ED patients reported feeling socially disconnected. Social and functional health problems are often related and both must be addressed to optimize older ED patient quality of life. Future research should consider the impact of social disconnection on older adults discharged from the ED and work to develop ED services that could refer this population to programs that may decrease social disconnection.

Reno, Elaine, Talia L. Brown, Marian E. Betz, Michael H. Allen, Lilian Hoffecker, Jeremy Reitinger, Robert Roach, and Benjamin Honigman. Suicide and high altitude: an integrative review. High Alt Med Biol 19:99-108, 2018.Suicide rates are greater at high altitudes, and multiple mechanisms have been suggested for this relationship, including hypoxia, differences in population density, characteristics of suicide victims, and firearms ownership and access. To better understand these potential mechanisms, studies evaluating the associations between high altitude and suicide were examined.A literature review of published studies on high altitude and suicide was conducted in Medline, Embase, Web of Science, the Cochrane Database of Systematic Reviews, and the Cochrane CENTRAL database. We extracted and analyzed all studies that met the inclusion criteria, excluding foreign language studies and letters. Most of the measurements and results were synthesized using modified Letts' criteria.Searches using an extensive list of keywords returned 470 articles, but only 6 met the inclusion criteria. The studies' samples ranged in size from 8871 to 596,704, while studies which did not document sample size reported suicide rates. In five of the studies selected, individuals living at high altitudes were at greater risk of suicide. Four studies used aggregated data at a county or state level to analyze variables, such as age, gender, race, socioeconomic factors, and firearms access. All the studies found that high altitude was independently associated with suicide. One study found that many individual characteristics of those who committed suicide were different at high altitudes than low altitude, including a lack of access or barriers to mental healthcare. Depression exacerbated by hypoxia was hypothesized as a possible biologic mechanism in three studies.These research studies published since 2009 support an association between high altitude and suicide rates at the state or county level, but do not provide sufficient data to estimate the effect of high altitude on an individuals' suicide risk. Although the impact of hypoxia on mood and depression has been hypothesized to be a contributing cause, many other individual factors likely play more important roles.

Introduction: Medical and public health societies advocate that healthcare providers (HCPs) counselat-risk patients to reduce firearm injury risk. Anonymous online media comments often contain extremeviewpoints and may therefore help in understanding challenges of firearm safety counseling. To helpinform injury prevention efforts, we sought to examine commenters’ stated opinions regarding firearmsafety counseling HCPs. Methods: Qualitative descriptive analysis of online comments posted following news items (in May-June, 2016) about a peer-reviewed publication addressing when and how HCPs should counsel patientsregarding firearms. Results: Among 871 comments posted by 522 individuals, most (57%) were generally negative towardfirearm discussions, 17% were positive, and 26% were neutral/unclear. Two major categories andmultiple themes emerged. “Areas of agreement” included that discussions may be valuable (1) whenaddressing risk of harm to self or others, (2) in pediatric injury prevention, and (3) as general safetyeducation (without direct questioning), and that (4) HCPs lack gun safety and cultural knowledge. “Areasof tension” included whether (1) firearms are a public health issue, (2) counseling is effective preventionpractice, (3) suicide could/should be prevented, and (4) firearm safety counseling is within HCPs’ purview. Conclusion: Among this set of commenters with likely extreme viewpoints, opinions were generallynegative toward firearm safety conversations, but with some support in specific situations. Providingeducation, counseling, or materials without asking about firearm ownership was encouraged. Engagingfirearm advocates when developing materials may enhance the acceptability of prevention activities.[West J Emerg Med. 2017;18(5)903-912.]

Mental illness is a growing, and largely unaddressed, problem for the population and for emergency department (ED) patients in particular. Extensive literature outlines sex and gender differences in mental illness’ epidemiology and risk and protective factors. Few studies, however, examined sex and gender differences in screening, diagnosis, and management of mental illness in the ED setting. Our consensus group used the nominal group technique to outline major gaps in knowledge and research priorities for these areas, including the influence of violence and other risk factors on the course of mental illness for ED patients. Our consensus group urges the pursuit of this research in general, and conscious use of a gender lens when conducting, analyzing, and authoring future ED-based investigations of mental illness.

The objective of this study was to describe the services, referral and reporting practices, and barriers to utilization of driver rehabilitation programs (DRPs) for older drivers. Identified through two national association databases, 204 driver rehabilitation programs completed an online survey. DRP availability varies, with a median of one program per 64,151 older adults (range: 1,006–676,981). The median cost for a complete evaluation was $400; 36% of DRPs reported no third-party reimbursement. Participants thought barriers to DRP use include cost/reimbursement, lack of program awareness, and issues with evaluator training. Models for insurance reimbursement, and increased awareness of program benefits by healthcare providers and older drivers, are needed.

Deaths and injuries from firearms are significant public health problems, and clinicians are in a unique position to identify risk among their patients and discuss the importance of safe firearm practices. Although clinicians may be ill-prepared to engage in such discussions, an adequate body of evidence is available for support, and patients are generally receptive to this type of discussion with their physician. Here, we provide an overview of existing research and recommended strategies for counseling and intervention to reduce firearm-related death and injury.

December 2015 saw another Congressional budget standoff and threatened government shutdown. This omnibus bill was particularly important for public health, because – for the first time in years – it contained language that would have reversed a 19-year-old prohibition on Centers for Disease Control and Prevention (CDC) funding for research on firearm injury. Unfortunately, 2016’s final Omnibus Appropriations bill did not reverse this prohibition. And so another year begins with the United States – and the world – debating how to solve the problem of firearm violence in this country, without the benefit of objective public health research.

Objectives The objective was to describe self-harm assessment practices in U.S. emergency departments (EDs) and to identify predictors of being assessed. Methods This was a prospective observational cohort study of adults presenting to eight U.S. EDs. A convenience sample of adults presenting to the EDs during covered research shifts was entered into a study log. Self-harm assessment was defined as ED documentation of suicide attempt; suicidal ideation; or nonsuicidal self-injury thoughts, behaviors, or both. Institution characteristics were compared relative to percentage assessed. To identify predictive patient characteristics, multivariable generalized linear models were created controlling for weekend presentation, time of presentation, age, sex, and race and ethnicity. Results Among 94,354 charts, self-harm assessment ranged from 3.5% to 31%, except for one outlying site at 95%. Overall, 26% were assessed (11% excluding the outlying site). Current self-harm was present in 2.7% of charts. Sites with specific self-harm assessment policies had higher assessment rates. In the complete model, adjusted risk ratios (aRR) for assessment included age ≥ 65 years (0.56, 95% confidence interval [CI] = 0.35 to 0.92) and male sex (1.17, 95% CI = 1.10 to 1.26). There was an interaction between these variables in the smaller model (excluding outlying site), with males

Background As an important indicator of mobility, driving confers a host of social and health benefits to older adults. Despite the importance of safe mobility as the population ages, longitudinal data are lacking about the natural history and determinants of driving safety in older adults. Methods The Longitudinal Research on Aging Drivers (LongROAD) project is a multisite prospective cohort study designed to generate empirical data for understanding the role of medical, behavioral, environmental and technological factors in driving safety during the process of aging. Results A total of 2990 active drivers aged 65–79 years at baseline have been recruited through primary care clinics or health care systems in five study sites located in California, Colorado, Maryland, Michigan, and New York. Consented participants were assessed at baseline with standardized research protocols and instruments, including vehicle inspection, functional performance tests, and “brown-bag review” of medications. The primary vehicle of each participant was instrumented with a small data collection device that records detailed driving data whenever the vehicle is operating and detects when a participant is driving. Annual follow-up is being conducted for up to three years with a telephone questionnaire at 12 and 36 months and in-person assessment at 24 months. Medical records are reviewed annually to collect information on clinical diagnoses and healthcare utilization. Driving records, including crashes and violations, are collected annually from state motor vehicle departments. Pilot testing was conducted on 56 volunteers during March–May 2015. Recruitment and enrollment were completed between July 2015 and March 2017. Conclusions Results of the LongROAD project will generate much-needed evidence for formulating public policy and developing intervention programs to maintain safe mobility while ensuring well-being for older adults.

BACKGROUND: Health care providers have been encouraged to discuss firearms with patients; whether patients view these discussions as appropriate is unclear. OBJECTIVE: To estimate, in a national sample, the perceived appropriateness of provider discussions about firearms. DESIGN: Probability-based online survey conducted in April 2015. Analyses used survey weights to generate nationally representative estimates. SETTING: U.S. adults. PARTICIPANTS: 3914 English-speaking adults (55% participation rate). MEASUREMENTS: Participants were asked, MEASUREMENTS: " MEASUREMENTS: In general, would you think it is never, sometimes, usually, or always appropriate for physicians and other health professionals to talk to their patients about firearms? MEASUREMENTS: " RESULTS: A majority (66% [95% CI, 63% to 69%]) of participants said that it is at least sometimes appropriate for providers to talk to patients about firearms. Specifically, 23% (CI, 20% to 25%) said that provider discussions about firearms were always appropriate, 14% (CI, 11% to 16%) said that they were usually appropriate, and 30% (CI, 27% to 33%) thought they were sometimes appropriate; 34% (CI, 31% to 37%) felt that such discussions were never appropriate. Views varied by firearm ownership: 54% (CI, 52% to 57%) of gun owners said that provider discussions are at least sometimes appropriate, compared with 67% (CI, 62% to 71%) of nonowners living with an owner and 70% (CI, 66% to 74%) of nonowners not living with an owner. Firearm owners who were more likely to think that firearm discussions are at least sometimes appropriate included those with children at home (62% [CI, 57% to 67%]), those who thought that having a gun at home increases suicide risk (75% [CI, 67% to 83%), and those who thought that provider discussions of seat belts are at least sometimes appropriate (73% [CI, 70% to 75%]). LIMITATIONS: The provider discussion question did not specify clinical context. CONCLUSION: Two thirds of non-firearm owners and over one half of firearm owners in the United States believe that health care provider discussions about firearms are at least sometimes appropriate. The observed heterogeneity underscores the need to better understand assumptions that may underlie these views, particularly among firearm owners. PRIMARY FUNDING SOURCE: Fund for a Safer Future and Joyce Foundation. Language: en

Models of self-efficacy and self-esteem pathways to depression were examined in 405 college students. Both models showed excellent fit to the data. The more parsimonious model indicated that efficacy and esteem variables were related to depressive symptoms indirectly through their relationships to the intermediate adjustment variables of career indecision and shyness. Career indecision and shyness were, in turn, directly related to depressive symptoms, although these relationships were small. The strongest predictor of depressive symptoms was global self-esteem. For men and women, respectively, the model accounted for 61% and 64% of the variance in shyness, 28% and 37% of the variance in career indecision, and 41% and 48% of the variance in depressive symptoms. The data thus suggest the importance of both cognitive (efficacy) and affective (esteem) aspects of self-appraisal.

This commentary discusses a recently overturned Florida law that sought to limit physicians discussing firearm safety with patients.

Purpose of the Study: Widespread screening of older dri vers, with in-depth evaluation only of those who screen positive (“tiered assessment”), might efficiently balance driver safety and mobility. To inform program development, we sought to examine the perspectives of older drivers and clinicians on the concept of tiered assessment in primary care settings. Design and Methods: Iterati ve focus groups and interviews with 33 community-dwelling current drivers aged ≥65 years and 8 primary care providers. We used inductive and deductive theme analysis to explore driver and clinician perspectives and to identify barriers and facilitators to establishing a tiered older driver assessment program in primary care settings. Results: F our dominant themes emerged. Two themes addressed the overall concept: (a) support for the concept of tiered older driver assessment and (b) concerns about the consequences of older driver assessment and how these could affect program viability. Two themes addressed screening: (c) tension inherent in using a generalized approach to the highly individualized issue of driving and (d) logistical considerations for screening in primary care settings. Implications: Standardiz ed older driver screening and referral might improve clinician– driver communication, but screening should occur in a context that includes personalized mobility counseling.

The studies presented in this article resulted in the findings that gender differences in self-efficacy for the Holland themes are consistent with previous findings regarding gender differences in Holland interest patterns, although the gender differences are less pronounced in employed adults than in college students. Within occupational group, the self-efficacy profiles of women and men were very similar and closely corresponded to the Holland interest code of the occupation. Confidence for and interest in a theme were moderately correlated, and recommendations for the counseling use of joint combinations of interests and self-efficacy are made.

Physicians have unique opportunities to help prevent firearm violence. Concern has developed that federal and state laws or regulations prohibit physicians from asking or counseling patients about firearms and disclosing patient information about firearms to others, even when threats to health and safety may be involved. This is not the case. In this article, the authors explain the statutes in question, emphasizing that physicians may ask about firearms (with rare exceptions), may counsel about firearms as they do about other health matters, and may disclose information to third parties when necessary. The authors then review circumstances under which questions about firearms might be most appropriate if they are not asked routinely. Such circumstances include instances when the patient provides information or exhibits behavior suggesting an acutely increased risk for violence, whether to himself or others, or when the patient possesses other individual-level risk factors for violence, such as alcohol abuse. The article summarizes the literature on current physician practices in asking and counseling about firearms, which are done far less commonly than recommended. Barriers to engaging in those practices, the effectiveness of clinical efforts to prevent firearm-related injuries, and what patients think about such efforts and physicians who engage in them are discussed. Proceeding from the limited available evidence, the authors make specific recommendations on how physicians might counsel their patients to reduce their risk for firearm-related death or serious injury. Finally, the authors review the circumstances under which disclosure of patient information about firearms to third parties is supported by regulations implementing the Health Insurance Portability and Accountability Act.

Introduction: To describe the epidemiology and characteristics of emergency department (ED) visits by older adults for motor vehicle collisions (MVC) in the United States (U.S.).Methods: We analyzed ED visits for MVCs using data from the 2003–2007 National Hospital Ambulatory Medical Care Survey (NHAMCS). Using U.S. Census data, we calculated annual incidence rates of driver or passenger MVC-related ED visits and examined visit characteristics, including triage acuity, tests performed and hospital admission or discharge. We compared older (65+ years) and younger (18-64 years) MVC patients and calculated odds ratios (OR) and 95% confidence intervals (CIs) to measure the strength of associations between age group and various visit characteristics. Multivariable logistic regression was used to identify independent predictors of admissions for MVC-related injuries among older adults.Results: From 2003–2007, there were an average of 237,000 annual ED visits by older adults for MVCs. The annual ED visit rate for MVCs was 6.4 (95% CI 4.6-8.3) visits per 1,000 for older adults and 16.4 (95% CI 14.0-18.8) visits per 1,000 for younger adults. Compared to younger MVC patients, after adjustment for gender, race and ethnicity, older MVC patients were more likely to have at least one imaging study performed (OR 3.69, 95% CI 1.46-9.36). Older MVC patients were not significantly more likely to arrive by ambulance (OR 1.47; 95% CI 0.76–2.86), have a high triage acuity (OR 1.56; 95% CI 0.77-3.14), or to have a diagnosis of a head, spinal cord or torso injury (OR 0.97; 95% CI 0.42-2.23) as compared to younger MVC patients after adjustment for gender, race and ethnicity. Overall, 14.5% (95% CI 9.8-19.2) of older MVC patients and 6.1% (95% CI 4.8-7.5) of younger MVC patients were admitted to the hospital. There was also a non-statistically significant trend toward hospital admission for older versus younger MVC patients (OR 1.78; 95% CI 0.71-4.43), and admission to the ICU if hospitalized (OR 6.9, 95% CI 0.9-51.9), after adjustment for gender, race, ethnicity, and injury acuity. Markers of injury acuity studied included EMS arrival, high triage acuity category, ED imaging, and diagnosis of a head, spinal cord or internal injury.Conclusion: Although ED visits after MVC for older adults are less common per capita, older adults are more commonly admitted to the hospital and ICU. Older MVC victims require significant ED resources in terms of diagnostic imaging as compared to younger MVC patients. As the U.S. population ages, and as older adults continue to drive, emergency departments (EDs) will have to allocate appropriate resources and develop diagnostic and treatment protocols to care for the increased volume of older adult MVC victims. [West J Emerg Med. 2013;14(6):576–581.]

By 2020, there will be more than 40 million older drivers on U.S. roadways.1 Older drivers face elevated risks of injury and death from car crashes and some may pose risks to the surrounding community, as a variety of impairments (cognitive, mental, physical, or sensory) and medications common in older adults can affect driving ability.2 At the same time, premature driving restrictions may negatively impact older adults’ well-being because of the important link between mobility, independence and good health.2 Almost all older adults will someday face the decision about whether to retire from driving,3 which requires a careful analysis of these risks and benefits. And almost always, such decisions are difficult and emotional. Physicians have a unique and critical role in guiding older drivers because they are trusted by patients and their families, are in a position to have access to information about an individual’s physical and cognitive conditions that might affect driving ability, and have ethical and legal obligations related to patient and community safety.2, 4 This information includes disease diagnosis or prescribed medications that may induce sleepiness or impact cognitive processing speed.5, 6 However, physicians are often reluctant to discuss with a patient their medical fitness to drive.2, 7 Physicians have reported that they find it difficult tell a driver it’s time to “hand over the keys” because of limited training or experience with counseling older drivers, inadequate knowledge of relevant state policies, fears of damaging the physician-patient relationship, or concern about the potentially devastating impact of this transition on an older driver’s life.2 Because of these concerns, as well as competing demands during office visits, physicians may wait to bring up driving until a family member reports a concern or there is a crash other “red flag.”4 But consider this: most Americans will outlive their safe driving ability by approximately 7 to 10 years.3 Therefore, “driving retirement” is inevitable for most older adults.8 Older adults may stop or limit their driving for a variety of reasons, such as physical conditions (for example, declining vision), financial concerns (such as the expense of owning a car), or anxieties about driving.9 Whatever the catalyst, driving retirement can be a profound and distressing experience for an older adult. However, advance planning for driving retirement offers the potential to ease an older adult’s transition from driving to other forms of transportation and possibly to strengthen, rather than harm, the physician-patient relationship. Physicians may want to consider using “anticipatory guidance” with their older patients; this practice is used in pediatrics to prepare parents for coming physical and developmental phases10 but might also be useful in geriatrics. For example, advance planning for driving retirement might be incorporated into discussions about issues relevant to older adults, including home safety, financial security, and mobility. Advance planning for driving retirement is a multi-faceted process that should address a variety of issues.8, 11 First, efforts to help older drivers plan to retire from driving should consider their readiness for change and their ability and willingness to find and use alternative sources of transportation. Older drivers (and concerned family members) should anticipate the older adult’s transportation needs, especially the need to travel for work, shopping, participation in community activities, and visits to family and friends. Older adults should also consider transportation options besides driving. These options might include the availability and willingness of family or friends to provide rides (although older adults may be reluctant to become a “burden”). Senior ride services and public transit should also be explored; ideally, local databases would be available to guide discussions. Older drivers should also consider the relative costs of various forms of transportation, including driving, using available simple financial worksheets. Driving retirement discussions should also address the emotional factors associated with driving,8 especially those related to loss of mobility, independence and self-esteem. Thus these conversations should consider an individual’s motivation for driving, emotional stake in driving, social connectedness related to driving, and ability to learn new approaches to transportation.12 Advance planning for driving retirement should also include a discussion of what an older driver would want to do if, in the future, a new or worsening medical condition begins to affect driving safety. While some at-risk older drivers may trust the recommendation of a trusted physician or family member, others may demand a higher “standard of proof” (such as failure to pass a formal on-road driving examination). There are various options for screening and assessment of an older driver’s ability, although there is still debate about which on- or off-road tests work best to measure risk. The ideal screening test—one that is evidence-based, simple, accurate, predictive and easy-to-administer in a busy clinical setting—does not yet exist. Physicians should consider formalizing discussions about driving retirement by using an “Advance Driving Directive” to document a patient’s wishes. These are non-binding worksheets designed to facilitate conversations about future driving-related decisions, including formal testing and driving retirement.4 They encourage the older driver to identify a trusted individual to help inform future decisions about driving, especially in the case that significant cognitive impairments develop. Ideally, planning for driving retirement should be part of a larger, comprehensive process of planning for aging that covers health and health care, social supports, and environmental factors such as housing and community transportation.13 This process must involve older individuals as well as community planners, the business and medical care communities, and local governments, all working together to support the mobility, independence and social well-being of older adults.13 Within the healthcare setting, advance planning for driving retirement may be too long and complicated a process to complete during a single office visit, especially in the face of competing priorities and time demands. A decision aid may help with the process,14 but older adults will need support from multi-disciplinary teams that may involve general and specialist physicians, nurses, case managers, social workers, and physical and occupational therapists. But the need for a systems-based approach should not minimize the important role physicians play in discussing driving issues with patients and in advocating for more institutional and societal support. Driving is a key activity of daily living (ADL); just as physicians routinely consider other ADLs, such as the ability to obtain and prepare food or manage finances, they should help patients assess their driving ability and, when appropriate, facilitate discussions about driving retirement. Advance planning for driving retirement should become routine in our clinical practices—and in our homes—in order to support older adults and promote their health, safety and independence.