Certain conditions, prevalent among older adults, including early cognitive changes associated with Alzheimer’s Disease and Alzheimer’s Disease-Related Dementias (AD/ADRD), place them at high-risk for firearm suicide. The increased rate of firearm ownership among these patients is typically not addressed in clinical practice despite recommendations to do so f from relevant medical societies. How to store firearms and when to relinquish them is a decision that is best made in primary care prior to advanced impairment, when patients are able to participate in decision- making, state preferences, and comprehend alternatives. Older adults often want to be primarily involved in decision-making about their own treatment and care and a person-centered approach would require it. Shared Decision Making (SDM) integrates the patient’s informed preferences into the decision-making process with the leading clinician. SDM is especially appropriate for firearm decisions due to the enmeshment of firearm and identity, and firearm as means for safety and sign of independence among older adult firearm owners. Estimates suggest that between 40-60% of older adults, including those with memory problems, either own a firearm or live with one in the home. Over half of all suicides involve the use of a firearm, a highly lethal method, with up to 90% mortality. There are currently no decision aids targeted to the person with early AD/ADRD and/or depression to assist in shared decision making in a primary care context with the leading provider, to encourage safer firearm storage. In this phased innovation proposal, we will partner with the Washington, Wyoming, Alaska, Montana, and Idaho [WWAMI] Practice and Research Network (WPRN) to refine and test an SDM video decision aid. Guided by the Ottawa Decision Support Framework and Fuzzy Trace Theory, in Aim 1 we will conduct key informant interviews of patients and leading clinical providers to refine and finalize an ODSF-based video decision aid using peer narratives to help older adults make decisions on safer firearm storage. In Aim 2 we will evaluate the feasibility, acceptability, and generate an effect size estimate for use of the video decision aid among persons with early AD/ADRD and/or depression in three WPRN primary care clinics. Provided we successfully achieve our transition milestones, we will test the intervention in a two-arm full-scale randomized controlled trial to test the impact of a video decision aid on safer firearm storage in Aim 3 (R33 phase). We hypothesize that this tool will improve firearm safe storage among persons with early AD/ADRD and/or depression. Engaging an interdisciplinary team of experts, our Aims follow Stage 1 (R21) and Stage 2 (R33) of the NIH stages of Behavioral Changes Intervention Development.

PROJECT NARRATIVE Persons with Mild Cognitive Impairment/ early dementia and/or depression are at an increased risk for firearm injury – particularly suicide. We propose, in two phases, to refine and evaluate an innovative decision aid to promote safer firearm storage for older adults with MCI/early dementia and/or depression.