A cornerstone of the National Service Framework for Older People is that the same comprehensive range of services should be provided for older adults as for their younger counterparts. Older people with mental illness who commit crime have long been neglected in terms of research and service provision. This is at last beginning to change as inpatient units designed specifically for the assessment and treatment of older offenders develop.

Specialized forensic psychiatric services for adolescents, women, and people with learning disabilities have emerged over the past decade as a result of the recognition that existing services failed to meet their needs. However, older adults with mental health problems who commit offences or who grow old in prison or secure hospital have not received the same attention. This is now beginning to change. Yorston¹ highlighted the need for specialist services for the elderly on the basis that the epidemiology, offence characteristics, mental disorders, and range of appropriate disposals were different for older people compared to younger offenders.

Encouragingly, new services are being established to provide specialist assessment and treatment of these elderly mentally-disordered offenders in secure settings. To date these have been within the independent sector such as St Andrew's Hospital in Northamptonshire and Thornford Park in Berkshire. St Andrew's currently has a 16-bedded unit and there are plans to expand the service to include another 15-bedded ward by April 2002. Referrals come from high secure hospitals, medium secure units, general and old age psychiatry wards, prisons, and courts. Demand is high and it is to be hoped that similar units can be set up within the NHS to reduce the time patients spend in inappropriate facilities which can put their own health, and the health and safety of others, at risk.

The elderly are more commonly the victims of aggression and anti-social behaviour than the perpetrators, but a small minority of elderly people do commit crimes which account for oneper cent of arrests in the UK. Shoplifting is the most common offence making up 80 per cent of cases. But, depending on which data are examined, violence features in up to 10 per cent of elderly offences², which is more frequent than in younger age groups. This possibly reflects the reluctance of police forces to arrest the elderly for anything other than the more serious crimes. Additionally, there are 8-12 homicides committed by older people each year in the UK. It is becoming increasingly recognized that alcohol problems are common in the elderly. It is no surprise to learn, therefore, that alcohol is directly or indirectly involved in a significant number of the offences of elderly age groups; some studies show that the proportion of alcohol-related crime is higher in the elderly than for younger age groups. Schichor³ found that in the US, driving while intoxicated, drunkenness, and liquor law violations accounted for 57 per cent of arrests in those over 55 years of age compared to 28 per cent of those aged under 55 years. Akers and LaGreca (1988) interviewed over 1400 community dwelling elders, also in the US, and found a strong association between problem drinking and self-reports of both commission of crime and contact with the criminal justice system.

The prevalence of mental illness in elderly offenders is high. Needham-Bennett⁵ found that 28per cent of elderly arrestees in Essex suffered from a mental disorder. The prevalence of mental illness within subgroups such as sex offenders and those who commit serious violence and homicide also appears to be higher than in younger age groups. Hucker and Ben-Aron⁶ found that 54 per cent of their sample of 43 elderly sex offenders in Canada had a psychiatric diagnosis and only two per cent had a personality disorder compared with younger patients at the same institute, of whom 80 per cent were diagnosed with an antisocial personality disorder. There are few other satisfactory studies using standardized rating scales and modern diagnostic terminology.

Old age psychiatrists have experience in the assessment of mental illness in the elderly, but they often have little familiarity with the criminal justice and forensic psychiatric systems. Forensic psychiatrists see so few elderly offenders that their assessment skills in this area can become rusty, with the result that older patients may miss out on appropriate care.

With an ageing population and ever dwindling continuing care resources, older people are going to come into conflict with the law more often. For these reasons, development of a specialist old age forensic psychiatric service is warranted. If justice and humanitarian principles are to be upheld, elderly, mentally-disordered offenders must receive the care they need.

Sentencing information suggests the elderly are slightly less likely than younger offenders to have custodial sentences or fines imposed and are more likely to receive probation orders. Despite this apparent leniency, the number of elderly people sentenced to imprisonment is increasing. In 1989, there were 345 prisoners over the age of 60 years; by 1999 this had risen to 1053, of whom 250 prisoners were in their 70s and 21 were over the age of 80 years. Mental illness in these elderly prisoners is common. Taylor and Parrott⁷ found that over half of their sample of men aged over 55 years had active psychiatric disorder and 80 per cent had a history of previous psychiatric treatment. These rates were more than double those seen in younger age groups.

Despite the explosion in numbers and prevalence of serious physical and mental ill-health, there has been little investment in providing suitable accommodation and treatment facilities in the UK.

Elderly offender units are increasingly common in the USA which has five times the number of prisoners per head of population, but there are few in the rest of the world. An exception is the wing for frail and elderly life-sentenced prisoners at HMP Kingston in Portsmouth. The management of prison health care in England and Wales is undergoing significant change, with the NHS taking over responsibility for the first time. It is hoped that improvements will occur bringing standards into line with the rest of the NHS. This will require a substantial investment, however, if the plans are to be converted from civil service spin into reality.

Within the special hospitals there has long been a sizeable minority of elderly patients. Wong et al⁸ found that 8per cent of Broadmoor's current patients were aged over 60 years. Most were admitted in their 20s and 30s and detained into old age because of the seriousness of their offence, but until recently there was no special provision for elderly patients within the hospital.

The moving of elderly forensic psychiatric patients to lower security settings can be difficult. The environment in regional secure units, intensive psychiatric care units, and locked wards is rarely suitable for older patients. Their needs are unmet and so they remain in settings of higher security even when the need for the security has diminished. Independent sector units have been established over the past few years including the semi-secure special needs unit for the elderly at St Andrews Hospital.

The elderly are at very low risk of committing serious violence and this has led to the elderly being largely ignored as a focus for research and service development by forensic psychiatrists. The literature on offending in the elderly is extremely limited; the appropriate age cut-off in research is problematic, often appearing to be determined more by making up numbers than any age-related behavioural changes. Patterns of crime and judicial process vary widely in different countries and cultures, making comparisons difficult so there is an urgent need for more research on elderly offending in the UK. With the current state of knowledge we can only guess at what elderly offenders might be missing in terms of specialist assessment and treatment.

Court diversion programmes for elderly shoplifters, court assessment services for the elderly psychiatrically ill, and elderly prison inmate units in the United States are examples of services being set up for elderly offenders which have few parallels elsewhere. There are, however, encouraging signs from the special hospitals, the prison service, and the independent forensic psychiatric sector in the UK. Perhaps recognition that the elderly form an important minority of mentally-ill offenders with distinct problems and needs is emerging.

Dr Graeme Yorston is Consultant Old Age Psychiatrist, St Andrew's Hospital, Northampton

References

1. Yorston G. Old age forensic psychiatry. Br J Psychiatry 1999; 174: 193-5

2. Barak Y, Perry T, Elizur A (1995) Elderly criminals: a study of the first criminal offence in old age. Int J Geriatric Psychiatry 10: 511-16

3. Shichor D (1984) The extent and nature of lawbreaking by the elderly: a review of arrest statistics. In: Newman ES, Newman DJ, Gewirtz ML, Eds. Elderly Criminals. Oelgeschlager, Cambridge

4. Akers Rl, LaGreca AJ (1988) Alcohol, contact with the legal system and illegal behaviour in the elderly. In: McCarthy B, Langworthy R, eds. Older Offenders ÐÊPerspectives on Criminology and Criminal Justice. Praeger, New York

5. Needham-Bennett H, Parrott J, MacDonald AJ. Psychiatric disorder and policing the elderly offender. Crim Behaviour Mental Health 1996; 6: 24-52

6. Hucker SJ, Ben-Aron MH (1985) Elderly Sex Offenders. In: Langevin R, ed. Erotic Preference, Gender Identity and Aggression in Men: New Research Studies. Lawrence Erlbaum, New Jersey: 211-23

7. Taylor PJ, Parrott JM. Elderly offenders: a study of age-related factors among custodially remanded prisoners. Br J Psychiatry 1988; 152: 340-6

8. Wong MTH, Lumsden J, Fenton GW, Fenwick PBC. Elderly offenders in a maximum security mental hospital. Aggressive Behaviour 1995; 21: 321-4

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