The healthcare provision for the elderly with a history of offending is under-researched and suffers from a lack of adequate services. Although the number of offences committed by older patients is low, research suggests they are more likely to re-offend, and have significant legal and psychiatric histories (Tomar et al., Reference Tomar, Treasden and Shah2005). Older offenders also have complex medical problems such as neurological disease, including dementia, heart disease, stroke, and hypertension (Lewis et al., Reference Lewis, Fields and Rainey2006).
There are two subgroups of older patients with a forensic and psychiatric history: “graduates” who offend when young and over time come into the older adult group, and older subjects who offend after the age of 60 years. Research is sparse in both these groups. In order to develop adequate service provision for the older offenders, it is imperative that there is an enhanced understanding of their needs (Harty et al., Reference Harty, Shaw, Thomas, Dolan, Davis and Thornicroft2004).
The main aims of the study were (1) to examine the healthcare and placement needs of older forensic psychiatric patients and compare this with those of younger forensic psychiatric patients, and (2) to assess whether the healthcare needs and placement options sought, as derived from the study, would assist in planning adequate service provision for such a population.
The sample was drawn from high- and medium/low-secure settings in southern England – a younger group (45 years and below) and an older group (60 years and above). A distinct age gap between the old and young mentally ill patients with a history of offending was kept in order to clearly differentiate biological, social, and psychological issues in relation to age.
Patients who were able to give valid informed consent and had no difficulty in adequately understanding written or verbal information in English were included in the study.
This was a cross-sectional survey in which a representative sample of patients (male patients recruited from secure settings – high and medium/low) was interviewed to gain answers to their healthcare needs. Data were collected at single points but referred retrospectively to healthcare experiences in the past one month.
The older group were interviewed with two measures: (1) Camberwell Assessment of Need – Forensic short version (CANFOR-S) (Thomas et al., Reference Thomas, Harty, Parrott, Mccrone, Slade and Thornicroft2003), which is a semi-structured interview schedule assessing needs in 25 domains of the person's life. It summarizes the need score for each domain, along with whether problems in each domain contributed to the index offence/reason for referral to the service; and (2) Camberwell Assessment of Needs – Elderly short version (CANE-S) (Orrell and Hancock, Reference Orrell and Hancock2004), an instrument that assesses needs in 24 areas, and includes two items that assess the needs of those who care for the older persons. Both instruments can be rated by users, carers, and staff. The younger group was interviewed only on the first measure, i.e. CANFOR-S.
The case notes were reviewed to obtain sociodemographic and clinical data.
In both groups the patient's Responsible Medical Officer (RMO) was consulted to ascertain placement options using the forensic adaptation of the Nottingham Acute Bed Study: Alternative to Acute Psychiatric Care Questionnaire (NABUS) (Beck et al., Reference Beck, Croudace, Singh and Harrison1997). This was used to record current placement needs. Placement options range from secure hospital placements through to supported and independent accommodation in the community.
A total of 26 younger and 30 older patients were recruited from high- and medium/low-secure settings. All patients were males. In relation to the mean age of the index offence, the younger group was 24 years (20–28 years) and the older group was 35 years (24–46 years). This means that the majority of the older patients were “graduates.”
Significantly more patients in the younger group were single whereas the older group was found to consist of widowed/divorced/separated patients. In relation to the admission source, significantly more patients in the younger group were admitted from either prison or medium-secure setting whereas the older group was from the prison and high-secure setting. History of alcohol and drug misuse was significantly higher in the younger group. When psychiatric medications were considered, significantly more patients in the younger group were on antidepressants and mood stabilizers than the older group. When past medical history was considered, significantly more patients in the older group had eyesight, cardiovascular, and endocrine problems.
In relation to the placement issue as identified by NABUS, half of the younger group needed to continue in the high-secure setting in view of ongoing risks, whereas more than half the older forensic patients actually needed the long-term low-secure setting. There appears to be a lack of low-secure facilities willing to look after the nursing needs of older offenders and to manage risks.
In CANFOR-S as rated by the “user,” significantly more patients in the younger group rated “alcohol-misuse,” “drug-misuse,” and “arson” as “met” needs compared to the older group. A “met” need indicates that the person does currently have some difficulties/problems in the domain and that effective help is currently being received. Significantly, more patients in the younger group rated “sexual expression” and “basic education” as “unmet” needs than the older group. An “unmet” need is defined as a difficulty/problem for which the patient either receives no help or help that helps. A third of the older group rated “treatment” as an “unmet” need, i.e. information regarding the medications prescribed to them was not provided or explained.
In relation to CANFOR-S as rated by the “staff,” significantly more patients in the younger group had their “day time activity,” “education,” and “sexual expression” marked as “unmet” needs compared to the older group. Significantly more staff rated “money” as an “unmet” need in the older group compared to the younger group. When total needs were compared between the younger and older groups, significantly more patients in the former group had “met” needs than the latter group. When the total needs in the older groups in high- and medium/low-secure settings were compared, the group in the high-secure setting complained more of “unmet” needs than the group in the medium/low-secure setting (Das et al., Reference Das, Murray, Driscoll and Nimmagadda2011).
When CANE-S was rated in the older group by the users and the staff, more “unmet” needs were recorded in relation to physical health needs, memory, eyes/hearing/communication difficulties, and personal security. When the older groups in the high- and medium/low-secure settings were compared using the CANE-S, the group in the high-secure setting had more “unmet” needs than the group in the medium/low-secure setting (Das et al., Reference Das, Murray, Driscoll and Nimmagadda2011).
Irrespective of the type of secure settings, information on health problems and needs of older forensic offenders are necessary to plan adequate delivery of care in healthcare settings. Placement is usually difficult due to paucity of adequate facilities. In addition, “unmet” healthcare needs can compromise future placements as poor physical health can have an impact on recidivism, risks, and compliance. Staff who look after older forensic patients should be trained on healthcare issues in late life and mental and physical health screening so that adequate care can be planned and provided.
It is important to consider training staff in use of objective measures to monitor needs at regular intervals as older forensic patients have multiple and complex healthcare needs that may change over time.
