With a bullet in her gut, her voice choked with pain, Dee Hill pleaded with the 911 dispatcher for help.
"My husband accidentally shot me," Hill, 75, of The Dalles, Ore., groaned on the May 16, 2015, call. "In the stomach, and he can't talk, please …"
Less than four feet away, Hill's husband, Darrell Hill, a former local police chief and two-term county sheriff, sat in his wheelchair with a discharged Glock handgun on the table in front of him, unaware that he'd nearly killed his wife of almost 57 years.
The 76-year-old lawman had been diagnosed two years earlier with a form of rapidly progressive dementia, a disease that quickly stripped him of reasoning and memory.
"He didn't understand," said Dee, who needed 30 pints of blood, three surgeries and seven weeks in the hospital to survive her injuries.
As America copes with an epidemic of gun violence that kills 96 people each day, there has been vigorous debate about how to prevent people with mental illness from acquiring weapons. But a little-known problem is what to do about the vast cache of firearms in the homes of aging Americans with impaired or declining mental faculties.
Darrell Hill, who died in 2016, was among the estimated 9 percent of Americans 65 and older diagnosed with dementia, a group of terminal diseases marked by mental decline and personality changes. Many, like the Hills, are gun owners and supporters of Second Amendment rights. Forty-five percent of people 65 and older have guns in their household, according to a 2017 Pew Research Center survey.
But no one tracks the potentially deadly intersection of those groups.
A four-month Kaiser Health News investigation has uncovered dozens of cases across the U.S. in which people with dementia used guns to kill or injure themselves or others.
From news reports, court records, hospital data and public death records, KHN found 15 homicides and more than 60 suicides since 2012, although there are likely many more. The shooters often acted during bouts of confusion, paranoia, delusion or aggression — common symptoms of dementia. They killed people closest to them — their caretaker, wife, son or daughter. They shot at people they happened to encounter — a mailman, a police officer, a train conductor. At least four men with dementia who brandished guns were fatally shot by police. In cases where charges were brought, many assailants were deemed incompetent to stand trial.
Many killed themselves. Among men in the U.S., the suicide rate is highest among those 65 and older; firearms are the most common method, according to the Centers for Disease Control and Prevention.
These statistics do not begin to tally incidents in which a person with dementia waves a gun at an unsuspecting neighbor or a terrified home health aide.
Volunteers with Alzheimer's San Diego, a nonprofit group, became alarmed when they visited people with dementia to give caregivers a break — and found 25 to 30 percent of those homes had guns, said Jessica Empeño, the group's vice president.
"We made a decision as an organization not to send volunteers into the homes with weapons," she said.
At the same time, an analysis of government survey data in Washington state found that about 5 percent of respondents 65 and older reported both some cognitive decline and having firearms in their home. The assessment, conducted for KHN by a state epidemiologist, suggests that about 54,000 of the state's more than 1 million residents 65 and older say they have worsening memory and confusion — and access to weapons.
About 1.4 percent of those respondents 65 and older — representing about 15,000 people — reported both cognitive decline and that they stored their guns unlocked and loaded, according to data from the state's 2016 Behavioral Risk Factor Surveillance System survey. Washington is the only state to track those dual trends, according to the CDC.
In a politically polarized nation, where gun control is a divisive topic, even raising concerns about the safety of cognitively impaired gun owners and their families is controversial. Relatives can take away car keys far easier than removing a firearm, the latter protected by the Second Amendment. Only five states have laws allowing families to petition a court to temporarily seize weapons from people who exhibit dangerous behavior.
But in a country where 10,000 people a day turn 65, the potential for harm is growing, said Dr. Emmy Betz, associate research director at the University of Colorado School of Medicine, a leading researcher on gun access and violence. Even as rates of dementia fall, the sheer number of older people is soaring, and the number of dementia cases is expected to soar as well.
By 2050, the number of people with dementia who live in U.S. homes with guns could reach between roughly 8 million and 12 million, according to a May study by Betz and her colleagues.
"You can't just pretend it's not going to come up," Betz said. "It's going to be an issue."
Polling conducted by the Kaiser Family Foundation for this story suggests that few Americans are concerned about the potential dangers of elders and firearms. Nearly half of people queried in a nationally representative poll in June said they had relatives over 65 who have guns. Of those, more than 80 percent said they were "not at all worried" about a gun-related accident. (Kaiser Health News is an editorially independent program of the foundation.)
Dee Hill had ignored her husband's demands and sold Darrell's car when it became too dangerous for him to drive. But guns were another matter.
"He was just almost obsessive about seeing his guns," Dee said. He worried that the weapons were dirty, that they weren't being maintained. Though she'd locked them in a vault in the carport, she relented after Darrell had asked, repeatedly, to check on the guns he'd carried every day of his nearly 50-year law enforcement career.
She intended to briefly show him two of his six firearms, the Glock handgun and a Smith & Wesson .357 Magnum revolver. But after he saw the weapons, Darrell accidentally knocked the empty pouch that had held the revolver to the floor. When Dee bent to pick it up, he somehow grabbed the Glock and fired.
"My concern [had been] that someone was going to get hurt," she said. "I didn't in my wildest dreams think it was going to be me."
An investigation classified the incident as an assault and referred it to Wasco County District Attorney Eric Nisley, who concluded it was "a conscious act" to pick up the gun, but that Darrell didn't intend to harm his wife.
"I evaluated it as if a 5- or 6-year-old would pick up the gun and shoot someone," Nisley said.
Dee was outraged at the suggestion she consider pressing charges.
"I didn't want anyone to think it was intentional. Nobody would have believed it anyway," she said.
Proponents of gun ownership say guns are not to blame.
The National Rifle Association declined to comment for this story.
Dr. Arthur Przebinda, who represents the group Doctors for Responsible Gun Ownership, said researchers raising the issue want to curtail gun rights guaranteed by the U.S. Constitution, and are "seeking ways to disarm as many people as possible."
Focusing on the potential of people with dementia shooting others is a "bloody shirt-waving tactic that's used to stir emotions to advance support for a particular policy endpoint," he said.
"I'm not disputing the case that it happens. I know it can happen," Przebinda said. "My question is how prevalent it is, because the data is what should be driving our policy discussion, not fear or fear-mongering. It's bad science."
Two decades of NRA-backed political pressure that quashed public health research into the effects of gun violence partly explain the lack of data, experts said. But that doesn't mean there's no problem, said Dr. Garen Wintemute, director of the Violence Prevention Research Program at the University of California-Davis.
"[Critics] are arguing as if what we have is evidence of absence," he said. "We have something quite different, which is absence of evidence."
Even some families grappling with the problem are wary about calls to limit gun access.
"I hope your intent is not to 'bash' us for our beliefs and actions with guns," said Vergie "Verg" Scroughams, 63, of Rexburg, Idaho, who showed KHN reporters how she hid a loaded gun from her husband, who developed dementia after a stroke in 2009.
Verg became worried after Delmar Scroughams, 83, grew angry and erratic earlier this year, waking up in the night and threatening to hit her. It was out of character for the former contractor who previously built million-dollar Idaho vacation homes for families of politicians and celebrities.
"In 45 years of marriage, we've never had a big fight," she said. "We respect each other and we don't argue. That's not my Delmar."
Six months ago, Verg took the loaded .38-caliber Ruger from a drawer near Delmar's living room recliner, removed the bullets, and tucked it under socks in a box on a high shelf in her closet. "He'll never look there," she said.
She doesn't want Delmar to have access to that gun - or to his collection of six shotguns locked in the bedroom cabinet. But Verg, a real estate agent who shows homes in remote locations, doesn't want to give up the weapons she counts on for comfort and protection. She carries her own handgun in the console of her car.
"We live in Idaho. Guns have been a big part of our lives," said Verg, who got her first rifle at age 12 and recalls hunting trips with her two sons among her fondest memories. "I can't imagine living without guns."
Guns Under The Pillows
Federal law prohibits people who are not mentally competent to make their own decisions, including those with advanced dementia, from buying or owning firearms. But a mere diagnosis of dementia does not disqualify someone from owning a gun, said Lindsay Nichols, federal policy director at the Giffords Law Center to Prevent Gun Violence. If a gun owner were reluctant to give up his arsenal, his family would typically have to take him to court to evaluate competency.
Since the school shooting in Parkland, Fla., in February, more states are taking action to make it easier for families - including those with a loved one with dementia - to remove guns from the home.
Eleven states have passed “red flag” gun laws that allow law enforcement or other state officials, and sometimes family members, to seek a court order to temporarily seize guns from people who pose a threat to themselves or others. Red flag bills have proliferated across the country since the Parkland shooting; six were passed this year and six more are pending.
In Connecticut, which in 1999 enacted the nation’s first red flag law, police used the measure to seize guns from five people reported to have dementia in 2017, according to a KHN records review.
Last summer, an 84-year-old man with dementia alarmed his neighbors at a senior living community in Simsbury, Conn., by announcing that he had a gun and planned to shoot a bear. The man later reported that his .38-caliber Colt revolver was missing; police found it, loaded, in the console of his car. Police got a court order to seize that gun and a rifle he had in his closet.
In December, police seized 26 guns from the Manchester, Conn., home of a 77-year-old man with dementia who was threatening to kill his wife. She told police that he was a danger to himself, and that his threats were “normal baseline behavior.”
In 2008, police in Manchester also seized nine firearms from a 70-year-old man with dementia who had pointed a gun at his daughter when she went to check on him because he didn't recognize her at first. The man had been sleeping with loaded guns under his pillows and hiding guns in drawers, and his daughter was worried for the safety of his home health aides.
In Ohio, at one memory care clinic, 17 percent of patients diagnosed with dementia reported having a firearm in their homes, according to a 2015 Cleveland Clinic study.
But many families are reluctant to take away the sense of safety, independence and identity that their loved one, often the family patriarch, derives from guns.
'A Guilt I’ll Never Ever Get Away From'
In the Appalachian mountains of West Virginia, Malissa Helmandollar, a 46-year-old assistant in an optometrist’s office, regrets not taking her father's guns away.
Her dad, Larry Dillon, loved to hunt. Even after a coal-mining accident left him paralyzed from the waist down at age 21, Dillon would shoot turkey, squirrel and deer from the seat of his four-wheeler. For as long as she could remember, her father kept a gun under the cushion of his wheelchair.
“He felt he couldn't take care of us, or himself, without it,” she said.
In June 2017, when her father was 65, she began to notice strange behavior.
“He would see people crawling out of the washing machine,” she said. He forgot how to tell time. Sometimes he would just stare at his dinner plate “like he didn't know what to do."
Every night for weeks, Dillon grew scared that people were trying to break in and burn his house down, Helmandollar said. Dillon slept with a 9 mm semiautomatic Glock pistol at his nightstand in the double-wide trailer he shared with his wife, Sandy, in Princeton, W.Va.
Helmandollar made him an appointment with a neurologist, but he never made it to the doctor.
Five days before his appointment, on July 6, 2017, Helmandollar’s 9-year-old daughter was sleeping over at her Mamaw and Papaw's house, as she loved to do. That evening, Helmandollar got a frantic call from her daughter.
Helmandollar sped to the house with her son. She found her stepmother, Sandy, dead in an armchair with several bullet wounds. Helmandollar heard her father tell police that he saw intruders breaking in to the house, so he grabbed his Glock and started shooting in the bedroom where his wife and granddaughter were watching TV.
But there had been no intruders that night. Dillon, who was deemed incompetent to stand trial for murder, was diagnosed with Lewy body dementia, a disease whose early symptoms can include vivid visual hallucinations.
Helmandollar said her father never understood what he had done. Before he died in April, he kept asking Helmandollar why his wife never visited him. She could never bring herself to tell him.
Meanwhile, Helmandollar’s daughter and 18-year-old son are in counseling for the trauma they experienced.
“It crossed my mind that maybe I should've taken the guns, and I didn’t,” Helmandollar said. “It'll be a guilt that I'll never ever get away from.”
Belated diagnoses of dementia are too common, according to Dr. Melissa Henston, a geriatric psychologist in Denver who administers cognitive exams that can confirm impairment. She said many of the patients she sees have moderate or even severe dementia before being diagnosed.
"There's denial and a false belief that a lot of cognitive problems are just normal for age," she said. "These conversations that need to take place never take place until it's too late."
For Alzheimer's disease and other dementias, there are limited treatments and no cure. About one-third of people with the disease become combative during the course of their illness, according to the Alzheimer's Association. And more than 20 percent who develop dementia become violent toward their caretakers, a 2014 study showed.
Advocates have long warned patients and families about the potential risk of guns, said Beth Kallmyer, the Alzheimer's Association vice president of care and support.
"The reality is, there's no way to know who's at risk for becoming agitated or even violent," she said.
'We Need To Pay More Attention'
In Minnesota, Sharon Van Leer, the 70-year-old director of diversity and inclusion at Mitchell Hamline School of Law, said she never would have predicted the phone call she got from police nearly three years ago.
Her father, Kenneth Bowser, a 90-year-old Army veteran and retired postal worker, had been living for many years with his oldest son, Larry, 65, in the St. Paul suburb of Maplewood.
At 5:30 p.m. on Sept. 12, 2015, Kenneth Bowser dialed 911.
“Who is bothering you?” the dispatcher asked him, according to a transcript of the call.
“My oldest son, oldest son and I shot him, I shot him,” Bowser replied. “He’s laying there dead, dead.”
“Where is the gun?” the dispatcher asked.
“The gun is in my hand,” Bowser said.
Van Leer said she believes her father never intended to be violent: “Daddy was never like that.”
In the 911 call, Bowser appears confused. “I’m 70 — uh, 100 — 91 years old,” he said. “I’m paralyzed on one side.”
Bowser, who had not been diagnosed with dementia before the shooting, was confirmed to have Alzheimer’s and deemed not competent to stand trial.
Now Van Leer drives 90 minutes most Sundays to visit her 93-year-old father in a locked, state-run nursing home where he’s set to spend the rest of his life. Staff wheel him out to a windowless visitation room, where Van Leer and her sister spoon-feed him nutrition shakes and give him back rubs.
Van Leer said she had noticed some signs of decline before the shooting — he would leave bacon on the stove and burn it, or forget where he put his cigars. But because she did not live with him, she said, she didn’t realize how far his dementia had progressed.
"We need to pay more attention, as our parents get older, to the changes," Van Leer said. "They can disguise it really well."
Removing guns from the home is the best way to prevent violence, the Alzheimer's Association and other experts advise. But Dr. Diana Kerwin, director of the Texas Alzheimer's and Memory Disorders program at Texas Health, said that's not the answer for all families.
"I don't do a blanket 'guns are bad, you can't have guns in the home,'" she said.
Instead, she advocates storing guns safely — locked up, unloaded, with the ammunition kept separate from the guns. Firearms can also be disabled or, in some cases, replaced with a decoy, although that raises the risk of them being mistaken for a real weapon in an emergency.
"We had one patient with a gun with rubber bands that he would shoot and he was fine with that," Kerwin said. "He was used to shooting varmints. You try to help them maintain the lifestyle they always had."
Families walk a fine line, balancing independence with safety.
Christal Collins, a 50-year-old massage therapist in South Carolina, never got along with her dad. He beat her and her mother before the couple divorced, she said. But when he nearly died from spinal meningitis in 2013, Christal agreed to take him in — along with his small arsenal.
Bill Collins, a retired heavy-equipment operator and Army veteran, was so attached to his guns that he kept a .22-caliber pistol in his pocket day and night, even while he slept. On Saturdays, he’d load it with rat shot and fire the tiny pellets at snakes as he mowed the lawn. On Sunday mornings, as he watched Shepherd's Chapel sermons on TV, he’d clean the gun and reload it with Magnum bullets.
Bill also kept a cabinet stocked with three handguns, three sawed-off rifles, three hunting rifles and a thousand rounds of ammo. While he had stopped hunting, he told his family he didn't want to be caught without a gun when the "race war" broke out.
As he grew older and sicker, Bill shuffled around the house in slippers and didn't seem as physically threatening, Christal said. But his bouts of aggression and paranoia grew worse, and in November 2014, after Bill had gotten lost for two hours at a local convenience store, his doctor said he was showing signs of dementia.
Christal considered sending her father to an assisted living complex, but when he found out he couldn't bring his guns or knives, he refused to go. And she swore she would never put her parents through the neglect she saw when she worked at a nursing home. So she stayed in the house with him, in a rural, swampy stretch of Conway, S.C., not far from Myrtle Beach.
Christal tried to limit her father's access to guns. One day, she slipped the key to his gun cabinet off his keychain — a difficult feat, since he slept with the keychain hooked to his belt. It was "war" in the house for three days, she said, as he hounded her and accused her of stealing the key. He then busted the original lock with a hammer and screwdriver and installed three new padlocks.
Bill also slept with a loaded .357 Magnum under his pillow.
“There was no gun safety,” Christal said. “Every time I tried to talk about it, it would be a fight or an argument or a problem.”
On June 14, 2015, a Sunday, her father started "cussing and ranting and raving," accusing someone of stealing things from his room, she said. Bill, who was 75, raised his hand to hit Christal — something he hadn’t done in his old age — and her fiancé, Allen Holtzman, stepped in to intervene.
In a flash, Bill pulled the .22 pistol out of his pocket and fired at Holtzman's chest, knocking him down to the couch.
“Dad, you shot him!” Christal yelled in disbelief. Then she saw him put the gun at the base of Holtzman's skull. She knocked it away just as he fired.
"Wrong damn shells!" Bill declared in disappointment, discovering he had fired rat shot.
Bill aimed the gun at Holtzman's 20-year-old daughter, and then at Christal. He had a look in his eyes "like the lights were on but nobody was home," Christal recalled. She dragged Holtzman, who was bleeding from over 200 rat pellets, toward safety in their bedroom, as more pellets flew behind them.
As Christal talked to a 911 dispatcher on the phone, she heard two bangs. The first was her father slamming the door to his room. The second was her father taking the gun and, after replacing the cartridges, shooting himself in the head.
Some argue that people should have the right to end their lives on their own terms instead of suffer through the debilitating decline of dementia. But Christal said she hates that her father harmed others along the way. And the aftermath of a suicide can be horrific, she said.
"When you clean your dad's brain matter off the wall, the pillow, the carpet …" she said, trailing off in tears, the trauma still raw nearly three years later, as she sat with her fiancé in their double-wide trailer home.
Holtzman, a 42-year-old construction worker, shrugged off his own injuries, saying the pellets just burned. But Christal said they were lucky her father forgot to change the ammo.
"Allen, you would've been dead," Christal said.
Christal said if she had to do it again, she would have removed the guns from the home.
Though, she reflected, "I honestly don't know if we could have taken them away."
Giving Up The Guns
For families grappling with such decisions, one option is to establish a "gun trust" that outlines how the weapons will pass to family members once a person becomes incapacitated or dies. These trusts may make it easier for people who must give up firearms in order to move into a nursing home, for instance, said David Goldman, an estate-planning lawyer in Jacksonville, Fla., who said he has drawn up over 20,000 gun trusts. But the process works best when the gun owner complies.
"They rarely want to give up their guns," Goldman said. Another obstacle is that gun trusts must be drawn up before dementia becomes too advanced.
Ideally, families should discuss firearm access soon after a diagnosis of dementia and consider setting a "firearm retirement date," akin to an advance directive for guns, Betz and colleagues advise. It's similar to discussions about taking away the car keys when driving becomes dangerous, she said.
"One of the tricky things is, for driving, there are some assessments you can do," Betz said. "They're not perfect, but they're helpful. There isn't anything for firearms."
Doctors who routinely ask dementia patients about driving should also ask about guns, Wintemute said. Too often, though, they don't.
"Docs say: 'I don't know enough about the risks and benefits, I don't have the time,'" Wintemute said. "Only about one-third do it with any frequency."
Critics of gun restrictions like Przebinda argue that the essential difference between driving and guns is that one is a privilege and the other is a protected constitutional right.
"The two are not the same," he said. "You do not have a right to conveyance. You have a right to self-defense, you have a right to protecting your home and your family that's intrinsic to you as a human being."
He balks at any formal assessment of firearm use among people with dementia, saying it could lead to "a totalitarian system that decides when you can have rights and when you cannot."
Instead, the decision should be left to families, Przebinda said. "People who own guns know what measures are available to them."
Even that knowledge, however, may not be enough. Dee Hill of Oregon said it was "strictly an accident" that her husband, the retired sheriff, shot and critically wounded her. To this day, she doesn't regret showing him the guns.
"That sounds stupid, but, no, I don't," she said. "He spent darn near 40, almost 50 years in law enforcement and a gun was always with him, and so to deprive him of not even seeing them, in my heart of hearts, I couldn't deny him."
For Verg and Delmar Scroughams of Idaho, the dilemma of keeping guns in the house remains. In a lucid moment in May, Delmar acknowledged that the weapons he's had all his life could be dangerous.
"I got a disease I don't know the name of and, eventually, anything could happen," he said.
Such moments of awareness are becoming rare, Verg admitted. Soon, Delmar may no longer recognize her. As his condition worsens, she said, it's up to her to make sure no one is harmed.
"I would feel extremely responsible," she said. "It would be my fault."
This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.