The need for age-appropriate forensic services

Dr Connolly has rightly pointed out that planning for the development of mental health services requires an understanding of the changing demographics in the country. ¹ We feel every directorate within psychiatry will need to prepare for the demographic transition through thoughtful planning in service development that can provide quality as well as appropriate care to the elderly. Within forensic services, serious thought should be given to development of geriatric forensic service.

Traditionally, it is believed that there is a low crime rate in the elderly. However, studies have shown that there is an increase in criminal behaviour among those 60 or over, ² and the number of people in prison over the age of 60 has grown from 1.3 to 2.4% in England. ³

A study by Needham-Bennett et al concluded that there is a high prevalence (28%) of psychiatric disorders in alleged offenders in the community aged 60 years and over. ⁴ Studies done in the prison populations have shown that the prevalence of psychiatric disorders among remanded male prisoners aged 55 years and over was 50% ⁵ and in sentenced male prisoners 53%. ²

Moreover, up to a half of elderly offenders with psychiatric disorders have a physical illness. In addition, they may have visual impairment, auditory impairment, mobility problems and cognitive impairment. Currently, forensic mental health units with long-term rehabilitation wards provide care for elderly individuals. This longer-term admission is usually due to ongoing risks combined with difficulties in rehabilitating this patient group because of ‘institutionalism’ or ongoing mental health issues. We wondered whether such units were equipped to be able to deliver care for older individuals with increasing physical comorbidities or those who develop certain organic conditions such as dementia. Another issue that needs consideration is the use of risk assessment tools such as Historical Clinical Risk Management 20 (HCR-20) in the older age group in forensic units that are generally used for working-age individuals. It is our view that the current psychological treatment programmes such as the sexual offending treatment programme will need modifications for this client group.

We feel that the complex needs of elderly mentally disordered offenders appear to fall within the domains of geriatric psychiatry services and forensic psychiatry services, but they may not be met by either service alone. Consideration should be given to setting up specialist tertiary forensic geriatric psychiatry. There has been some initiative in the independent sector in this matter.