Gun ownership is highest among the elderly. When dementia strikes, few laws can step in to keep these patients and their caregivers safe.

Lawmakers have been shy to enact legislation that keeps dementia patients separate from their firearms. But convincing Virginia Templeton only took one phone call. Templeton is a doctor and the executive director of MemoryCare, an organization in Asheville, N.C., that treats patients with Alzheimer’s and other cognitive disorders. She had arranged a driving evaluation for one patient, and his state of mental confusion resulted in his license being taken away. A few days later, his wife called to say that the patient had left the house with his gun and three bullets: one for his primary care doctor, one for the DMV evaluator and one for Templeton.

No one was hurt, but the episode points to a curiously American blind spot. While common sense would argue for preventing someone who is cognitively impaired from possessing a deadly weapon, legislation to that effect is almost nonexistent, especially when the population in question suffers from dementia. And while President Obama tried in January to make it more difficult for some dementia patients to buy guns, even this small step faces steep political challenges, and largely leaves the problem of regulating these weapons where it currently stands—with physicians, families and caregivers.

People 65 and older have the highest rates of gun ownership in the United States. One 2007 study found that 40% of VA patients with dementia had a gun in the home. An earlier, smaller study found guns in the home of 60% of dementia patients. Firm numbers on how that translates to violence are difficult to come by—in their early stages of dementia, those who shoot people often haven’t been diagnosed yet—but stories of tragedies and near misses are not hard to find.

A Minnesota man suffering from dementia shot his son during an argument about television. One Texas patient’s daughter found a loaded gun under his pillow—in the bedroom where her small children were playing. A dementia patient in Georgia shot and killed the home health care worker who was tending the patient—an example of the elevated risks increasingly faced by health care workers, according to Ellen Pinholt, the former chief of geriatrics at Walter Reed Hospital in Maryland. Some health care companies now stipulate that their workers won’t enter homes with unsecured guns, which empowers employees to leave if they see an unsecured firearm in the home of a patient with cognitive problems.

A few laws do exist that might keep guns out of the hands of people with dementia, but they are tough to enforce. The federal Gun Control Act of 1968 bars gun sales to anyone who has been deemed a “mental defective.” But that designation usually requires that a court find the person to be a danger to themselves or others, or unable to manage their own affairs. In early dementia, a time when problem-solving skills start to fade, patients may not qualify as mentally defective but they are still impaired, particularly in the areas that affect firearm use or misuse. “Reasoning, decision-making—these are early victims of the disease, as much as memory,” says Templeton.

In some states, those who apply for a gun permit must provide the name of a doctor to testify to that person’s fitness to handle a weapon. Those laws, in Templeton’s estimation, are also tricky to enforce. “Even when it’s absolutely obvious in so many objective ways that it’s unsafe for the person to have access to a weapon, I’ve never succeeded in having a concealed-carry license revoked,” says Templeton. “And I have tried.”

The Veterans Administration has been exploring other avenues to mitigate the risks. The names of veterans with dementia who have a fiduciary—indicating that they are no longer mentally fit enough to manage their own finances—are now placed in the National Instant Criminal Background Check System (NICS) database. That can help prevent them from purchasing guns, and while it technically bars them from possessing guns, there is no clearly established mechanism in place to take away guns already owned. The number of people this affects is minuscule, says Mark Kunik, the director of the VA’s South Central Mental Illness Research Education and Clinical Center, based in Houston. “It’s just not that common that veterans have payees,” he says.

Because President Obama’s executive order was modeled on the VA program, it has the same effect: keeping those who are mentally unfit to process their own Social Security checks from purchasing guns. But even if the measure overcomes political challenges, it doesn't establish procedures to deal with guns those patients already have. And the population it targets—people with dementia so far advanced that they can no longer handle their own affairs—may not be at the highest risk.

New legislation in California may offer a way forward. The Gun Violence Restraining Order (GVRO), which took effect in January, allows concerned family members to petition a court to temporarily take away someone’s guns if that person presents a danger to themselves or others. The GVRO was created in response to the May 2014 shootings in Isla Vista, Calif., in which a young man with mental health issues amassed a stockpile of guns despite his parents' appeal to authorities to intervene. The man later shot 10 people. And while this measure wasn’t designed specifically for dementia patients, Shannon Frattaroli, associate professor at the Johns Hopkins Center for Gun Policy and Research, believes that such rules, if more widely adopted, could also be used to help patients with dementia.

Those passionately in favor of the right to bear arms make more far-reaching laws unlikely, however. Robert Young, a clinical associate professor of psychiatry at the University of Rochester Medical Center and member of Doctors for Responsible Gun Ownership, worries that a blanket policy regarding dementia and gun ownership could deny due process. “Just because there is a gun in the household doesn’t mean it’s a risk to someone,” says Young.

Young and other advocates for gun rights object to policies targeting dementia in general, and instead favor a tougher process, one that parallels how a patient gets committed to psychiatric care. Physicians would need to testify to the diagnosis of dementia, there would need to be evidence of danger, and the patient would have the right to representation and appeal. “The conditions are inconvenient and frustrating for doctors like me. But they’re very strong in terms of protecting civil liberties,” he says.

Not all doctors agree with such a high bar. But whatever the solutions the U.S. political process makes possible, they can’t come a minute too soon. According to the Alzheimer’s Association, 5.3 million Americans are currently living with Alzheimer’s disease, and 16 million might have the disease by 2050, a number that doesn’t account for other forms of dementia. But if the threat of gun violence in this population is growing, at least awareness is growing too. Recently, at the national meeting of the American Geriatrics Society, Pinholt presented an educational poster about guns in the homes of dementia patients. “It was the home physical therapists, home occupational therapists, the home workers who came up to me,” she says. “They said, ‘Oh, finally someone’s talking about this. Because we don’t know what to do.’”