THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY

https://doi.org/10.1080/14789949.2020.1817525

Service provision for older forensic mental health

patients: a scoping review of the literature
Kate Walkera, Chris Griffithsb, Jen Yatesc and Birgit Völlmd
a
Northampton Healthcare NHS Foundation Trust, Innovation and Research Department,
Berrywood Hospital, Northampton, UK; bNorthampton Healthcare NHS Foundation Trust;
c
School of Medicine Postgraduate Taught Courses, University of Nottingham, UK; dKlinik und
Poliklinik für Forensische Psychiatrie, University Hospital of Rostock

ABSTRACT
Older forensic psychiatric patients (defined as aged 50 or over) have complex
needs and require specialized treatment to enable recovery and reduce risk.
Little is known about what service provision is available for this population, so
a scoping literature review was undertaken to establish the extent of service
provision and if services are specifically modified or designed for this popula­
tion. The literature was searched through academic journal databases and
Google Scholar, and outputs were screened for suitability and assessed for
quality. Eight studies (four qualitative, four quantitative) were included in the
review. Studies were mixed in terms of methodological quality, and with several
limitations. Qualitative data provided perceptions regarding positive (e.g., suffi­
cient types of therapy) and negative (e.g., lack of age-appropriate services)
aspects of interventions. Quantitative data were descriptive, focusing mainly
on identifying provision available (e.g., art therapy, violence reduction) and
where needs were not being met (e.g., physical needs, education). Results
indicate little provision in place adapted specifically for older forensic psychia­
tric patients. Findings highlight the need for further research to understand and
effectively implement interventions and service provision for older forensic
mental health patients to ensure practice is evidence based.

ARTICLE HISTORY Received 24 April 2020; Accepted 25 August 2020

KEYWORDS Forensic mental health; older patients; interventions; service provision

Introduction
The world’s population is aging, and governments need to design innovative
policies and public services specifically targeted to older persons, including
policies addressing healthcare (United Nations, Department of Economic and
Social Affairs, Population Division, 2019). This aging population means a growth
in older people requiring mental health support, including forensic mental health
service provision. In the UK and other Western countries around 20% of secure

CONTACT Kate Walker Kate.Walker@nhft.nhs.uk

© 2020 Informa UK Limited, trading as Taylor & Francis Group
2 K. WALKER ET AL.

patients are over 50 (Di Lorito et al., 2017; Di Lorito et al., 2018; 2017), and this
proportion is likely to grow as people live longer (Coid et al., 2002; Lewis et al.,
2006; Di Lorito, Völlm et al., 2019). Due to common histories that include poor
health management and substance abuse, many people with long-term mental
health disorders also experience the challenges associated with old age earlier
and have significantly reduced life expectancy (15–20 years) (Chesney et al.,
2014). It is necessary that there is adequate and appropriate service provision
for this population.
Over the past 20 years, there has been an increase in demand for forensic
mental health services across many countries, a trend that comes at significant
human resource and economic cost (Jansman-Hart et al., 2011). Forensic men­
tal health patients, defined broadly as those who are ‘both mentally disordered
and whose behavior has led, or could lead to offending’ (Mullen, 2000, p. 307),
sit in a complex intersection of health, social care, and criminal justice systems.
Specific service provisions are required for forensic mental health patients,
including secure hospital units (low, medium and high security) and commu­
nity services. Mental health services need an integrated approach, combining
geriatric old age psychiatry and generic forensic psychiatry services, as older
offenders with mental health difficulties sit within criminal justice, forensic
psychiatry and psychology, and old-age psychiatric services (Curtice et al.,
2003), which as stand-alone services and not integrated ones, struggle to
manage this group of patients (Shah, 2006).
Forensic psychiatric patients present with unique mental, physical and
social care needs, and these are likely to differ from younger patients due
to ageing-related factors (Di Lorito, Völlm et al., 2019). Entrenched mental
illness is a feature for older patients, and they are more likely to be diagnosed
with more serious mental illnesses compared to younger offenders (Fazel &
Grann, 2002). It has been found that psychotic illnesses including schizophre­
nia, schizotypal, delusional disorder and personality disorder are prevalent in
older forensic adults (Yorston & Taylor, 2009), as are dementia and
Alzheimer’s (Paradis et al., 2000). Many older forensic adults experience
comorbid mental health, substance use issues and have histories of trauma
(e.g., childhood neglect and abuse, violence) (Haugebrook et al., 2010; Maschi
et al., 2011). Older forensic psychiatric patients are also more likely to present
with increased rates of co-morbid physical health issues such as sensory
impairment (hearing and eyesight) (Lightbody et al., 2010), cardiac disease,
hypertension and diabetes (Paradis et al., 2000), as well as mobility problems
and issues (Coid et al., 2002). Older patients experience longer, more severe
and/or interrupted episodes of care, all of which impact their presentation,
needs and care requirements. These factors mean that the population of
older forensic patients are likely to require more and different specialist
interventions, activities, treatment and support than those required by
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 3

younger patients; and so it is important to establish how well current evi­

dence indicates their requirements are being met.
The placement of older mentally disordered offenders is particularly diffi­
cult (Coid et al., 2002), as such services tend to be offered sporadically and in
a fragmented fashion, leading to calls for specialist, tailored and age-
appropriate service provision for this population (De Smet et al., 2015;
Natarajan & Mulvana, 2017; A. Shah, 2008; G. A. Yorston & Taylor, 2006). The
rehabilitation of forensic mental health patients should not only focus on
reduction of risk but also targeting how individuals can lead fulfilling lives
within the environments they find themselves in. Theoretically, this is aligned
with the Good Lives Model (GLM: Ward & Brown, 2004; Ward et al., 2012),
which augments the risk, need, and responsivity principles of effective inter­
vention but emphasises the requirement of individuals to develop and imple­
ment meaningful life plans incompatible with future offending.
There is a lack of research informing needs of and services for older adult
forensic patients in the last ten years (Di Lorito, Völlm et al., 2019). Where
there has been research into intervention provision, this is generally within
the jail/prison context and not always specific to mental health. A systematic
review by Canada et al. (2019), examined interventions designed to improve
the health or mental health of older adults living in jail or prison, and the
effects of the interventions on inmates’ physical or mental health. They
identified seven relevant papers, but these only captured five unique inter­
ventions, some of which are potentially relevant for forensic mental health
inpatients based on the target of the interventions and their structure and
design. BE-ACTIV (Behavioural Activities intervention for depression) and TRU-
GRIT (structured living programme) offer positive activities, therapy sessions,
and self-help groups to increase physical, mental and spiritual health in
secure settings. Art Expression and Good Vibe introduce creative therapies,
art, and music to help individuals cope with trauma (Art Expression), manage
emotion and improve communication and social skills (Good Vibe). This is of
potential relevance to the inpatient population and includes activities routi­
nely delivered in secure settings. The fifth, OHSCAP (Older prisoner Health
and Social Care Assessment and Plan), is a health/social care assessment and
care planning process to better identify and manage older prisoners’ needs
(Walsh et al., 2014). As such this would need to be adapted and tested for its
suitability for forensic mental health and in secure hospital setting.
Although these therapies are potentially of relevance to older forensic
inpatients in relation to intervention target, content and structure, a key
challenge found in the review of these interventions in prisons was that,
due to the lack of evidence (e.g., the absence of RCTs), control group com­
parisons, or measures of change overtime it was not possible to assess
intervention efficacy (Canada et al., 2019). The authors also found in their
review that this small pool of studies mainly relied on anecdotes and
4 K. WALKER ET AL.

qualitative methods and the few statistical analyses undertaken could not be
synthesised. This therefore limits the generalizability. They concluded the
knowledge base in this area needs building, perhaps through empirically
adapting interventions that have worked for older adults in the community,
followed by testing in correctional services. The focus of this paper’s review
will establish what is available specifically for older forensic mental health
patients in secure units and the community.
Older forensic patients have been described as ignored, misunderstood, and
poorly served (Yorston, 1999). There is a clear need for forensic mental health
services for older people, as the epidemiology, criminological, and clinical
characteristics of older people are sufficiently different to their younger coun­
terparts (Natarajan & Mulvana, 2017). Research has suggested that for older
adults with serious mental illness, interventions need adapting and developing
to be more individually based to meet specific requirements (Forsman et al.,
2011). However, there is no clear understanding of what provision is currently
provided that is specifically for older forensic mental health patients, what is
missing and if this is appropriate and suitable for this population. This under­
standing is valuable to patients, clinicians, commissioners, The National
Institute for Health and Care Excellence (NICE) and policy makers and ultimately
for being able to establish intervention effectiveness. Therefore, the aim of this
review is to assess what service provision for older forensic mental health
patients is currently offered, specifically addressing the research question:
What interventions and therapies have been designed for older forensic mental
health patients, residing as inpatients in secure hospitals or in the community?

Method
Based on the research question, study inclusion and exclusion criteria were
developed to identify older adults (age ≥ 50 years), forensic mental health
patients (inpatients [low, medium or high security] or in the community), who
had experienced intervention provision. Inclusion criteria comprised: i) the
article described an intervention; (ii) the intervention was for patients in
a secure mental health unit or the community; (iii) the population were forensic
mental health patients; (iv) the population were age ≥ 50 years (male or female);
and v) articles were written in English. Exclusion included: i) articles with no
intervention provision identified; (ii) prison populations, offenders awaiting
sentence, prisoners held in temporary incarceration; (iii) studies on general
mental health populations; iv) the population were age < 50 years and/or all
age ranges were examined as one group; and v) articles not written in English.
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 5

Table 1. Search terms, databases and age filters.

Search Terms1 Databases Age filters
Population PsychINFO [Middle age, Age 40–64, Aged
1. old* 65 years + older]
2 elder* MEDLINE [Middle age, Aged, Age 80 = over]
3. ageing CINAHL [Middle aged, Age 40–64, Age 65
4. aging + years, Aged 80 & over]
5. aged EMBASE [Age 65 + years]
Target AMHED [Age or Aging]
6.‘forensic mental health’ AND Psychology & behavioural N/A
[1–5] sciences collection
7. ‘forensic psychiatr*’ AND [1–5]
8. ‘forensic patient*’ AND [1–5]
9. ‘forensic inpatient*’ AND [1–5]
Intervention
10. intervention* AND [1–5] AND
[6–9]
11. treatment* AND [1–5] AND
[6–9]
12. therap* AND [1–5] AND [6–9]
1
Search terms were combined using Boolean logic (as noted); combined terms are denoted by corre­
sponding numbers.

Search strategy
Initially, a search of academic databases was completed. Table 1, presents the
terms and databases used for this initial search.
Where available a thesaurus search was used for the target and the inter­
vention using the terms psychiatry and psychotherapy. A further search strat­
egy was then implemented, using the search terms [6–8] AND [10–12], but with
age limits applied as a filter to the searches. See Table 1 for the appropriate
filters utilized for each database search.
To extend the reach, Google scholar was searched, using the following terms
(older OR elderly) AND (‘forensic mental health’ OR ‘forensic patient’) AND
(intervention OR treatment OR therapy). This search returned 8900 articles,
and so the first 300 were screened as recommended by Haddaway et al. (2015).
Finally a hand search of the references was also implemented, and poten­
tially relevant articles were identified, located and screened.
Articles were selected following a multi-step process as advocated by
Moher et al. (2009) in their guidelines for conducting and reporting systema­
tic reviews. Figure 1 outlines the process followed.
Initially, manuscripts identified through database searches and Google Scholar
were exported to RefWorks, where duplicates were removed. Titles and abstracts
were reviewed simultaneously. When titles were assessed articles were retained if:
(1) the title implied there was an intervention; (2) the population were forensic
mental health; (3) the population were identified as older/ageing; (4) it was
unclear based solely on the title if the article was relevant or not; and (5) more
information was required from an abstract read to determine if inclusion/exclu­
sion criteria had been met. Following a review of the abstracts, articles were
6 K. WALKER ET AL.

Figure 1. Flow diagram of publication selection process for review.

retained if: (1) the abstract included information that suggested the inclusion
criteria had been met; and (2) it was still unclear if the study was relevant for the
review or not. Finally, full texts were read and reviewed, and relevant articles were
identified and selected.

Analysis
Quality of empirical papers was assessed using the Mixed Methods Appraisal
Tool (MMAT) Version 2018 (Hong et al., 2018). The MMAT is used to provide
a detailed presentation of the ratings of each criterion that it assesses and not
an overall score by each article (Hong et al., 2018). For all the qualitative
articles, the qualitative approach was appropriate to answer the research
questions posed. The methods used across all the studies were adequate in
regard to the method of data collection (e.g., in depth interviews and/or
group interviews, and/or observations) and the form of the data (e.g., tape
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 7

recording, and/or field notes). Three studies were solely reliant on one form,
e.g., interviews (Di Lorito et al., 2018; De Smet et al., 2015) or focus groups (Di
Lorito, Dening et al., 2019), although Visser et al. (2019) utilized observational
field-notes alongside interview data. All of the qualitative articles commented
on the use of multiple coders for the data analysis for accuracy; however, only
one (De Smet et al., 2015) formally assessed and reported inter-rater relia­
bility, finding a Cohen’s kappa score of 0.72 and a degree of agreement of
97.2%, which is considered as substantial. Based on the methodologies used
the findings were adequately derived from the data, although it was unclear
across the studies the epistemological position taken, and some of the
studies (e.g., Di Lorito, Dening et al., 2019) lacked information about the
process of analysis, making it difficult to make a judgement about this
criterion. However, across all studies the participant quotes utilized sup­
ported the themes well.
The quantitative papers were descriptive and relevant analysis not always
the main focus of the research. Of the articles, Di Lorito, Völlm et al.’s (2019)
paper was the strongest of those reviewed in relation to the MMAT criteria. In
the case of the other three, very little information was given about the
methodological approach taken. For all the papers the sampling was ade­
quate (non-probability), although probability sampling would have strength­
ened the research, and there was limited information about sampling
particularly in three of the articles (Das et al., 2011, 2012; Shah, 2006). It is
not apparent across all of the papers if the sample were representative of the
target population, as there is no clear description of the target population or
of the sample, such as respective sizes, inclusion and exclusion criteria and
reasons why certain eligible individuals chose not to participate. The mea­
sures and psychometrics selected were appropriate across the articles,
although there is no reporting of validity or reliability tests, neither those
associated with the measures generally nor those measured specifically for
the samples in the four papers. Information about response bias was sparse
and therefore it was difficult to assess the quality of this within the papers.
Analysis was described in the work by Di Lorito, Völlm et al. (2019), but there
was inadequate detail in the other three papers to make a full assessment
regarding this criterion.

Results
Following review of 176 full text articles, 8 studies were identified as relevant
to include. The articles found and included are described and summarized in
Table 2.
It is apparent there is a dearth of research that has examined service
provision for forensic mental health patients aged 50 and above who are
inpatients or in the community, so the findings offer only a limited insight
 8

Table 2. Summary of articles included in the review.

Authors/
Country Article type and methodology Setting and sample characteristics Intervention assessed/examined
Das et al. Empirical paper Setting: Assessment of placement needs (security level)
(2011) Quantitative analysis Inpatient forensic psychiatric HS and M/LS
U.K. Cross-sectional questionnaire data: Sample:
K. WALKER ET AL.

● Comparison between needs of 30 participants

those in HS versus M/LS1 Age:
All age > 60
Residency:
HS, n = 15 (50%)
L/MS, n = 15 (50%)
Das et al. Empirical paper Setting: Assessment of placement needs (security level)
(2012) Quantitative analysis Inpatient forensic psychiatric HS and M/LS Assessment if needs being met by interventions
U.K. Cross-sectional questionnaire data: Sample: (e.g., substance abuse, sexual expression,
● Comparison made between needs 26 younger patients and 30 older patients (all male) education, physical health)
of older forensic patients and Age:
younger forensic patients Younger group age < 45 years
Older group, age > 60 years
De Smet Empirical paper Setting: Current activities and treatments:
et al. Qualitative analysis Institutional care, penitentiary setting,2 community Day activities, psychiatric follow-up, day care (in
(2015) Sample: psychiatric centre)
Belgium 8 older mentally ill offenders (7 males, 1 female)
Age:
All age > 60 (range 61–72)
Residency:
1 in institutional care,
3 in penitentiary setting
4 in community
(Continued)
Table 2. (Continued).
Authors/
Country Article type and methodology Setting and sample characteristics Intervention assessed/examined
Di Lorito, Empirical paper Setting: Interventions/activities currently provided at
Dening Qualitative analysis Inpatient forensic psychiatric across two sites, to include HS and LS the units
et al. Focus groups Sample:
(2019) ● Inductive thematic analysis 13 members of staff (8 in HS, 5 in LS)
U.K. Professions included: consultant psychiatrist (n = 2); speciality doctor
(n = 2); specialist medical trainer (n = 3); senior mental health nurse
(n = 1); senior practice nurse (n = 1); staff nurse (n = 2);and nursing
assistant (n = 2)
Age:
Participants age not relevant; required experience of secure settings and
to have cared for at least one patient over 50 years
Di Lorito, Empirical paper Setting: Descriptives for:
Völlm Quantitative analysis Inpatient forensic psychiatric across three sites, to include HS, medium Skills development
et al. Clinical records and questionnaire secure (MS) and LS Mental health awareness/psychoeducation
(2019) data: Sample: Art therapy
U.K. ● Descriptives, parametric/non- 94 service users (84 males, 10 females) for total study Healthy lifestyle training
parametric inferential analyses to 41 (44% of total) service users subsample (38 males, 8 females) for Dialectical behaviour therapy
examine: objective 2 which included assessment of type of treatment/ Substance misuse treatment
○ Socio-demographic data intervention received Music/dance therapy
○ Information about residency/ Subsample Violence reduction
admission/offences Ages: Preparation for therapy/motivational work
○ Type of treatment/intervention 50–59 years, n = 32 (48.8%)
received3 60–69 years, n = 8 (19.5%)
○ History of violent incidences 70+ years, n = 1 (2.4%)
○ Risk Ethnicity:
White British, n = 75 (80%)
White (other), n = 5 (5%)
Mixed (any), n = 2 (2%)
THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY

Black/Black British, n = 10 (11%)

Asian/Asian British, n = 2 (2%)
Residency:
9

HS, n = 68 (72%)
MS, n = 15 (16%)
LS, n = 11 (12%)
(Continued)
 10

Table 2. (Continued).
Authors/
Country Article type and methodology Setting and sample characteristics Intervention assessed/examined
Di Lorito Empirical paper Setting: Interventions/activities currently provided at
et al. Qualitative analysis Inpatient forensic psychiatric across three sites, to include HS, MS and LS the units
(2018) Semi structured interviews Sample:
U.K. ● Thematic analysis 15 service users (13 males, 2 females)
Age:
All age ≥ 50 years
K. WALKER ET AL.

Residency:
HS, n = 6 (40%)
MS, n = 7 (46.6%)
LS, n = 2 (13.3%)
Shah (2006) Empirical paper Setting: Descriptives of intervention/management
U.K. Quantitative exploratory audit HS and MS forensic psychiatry unit advice given including:
Prospectively completed case-notes Sample: ● Medical treatment
● Basic descriptive statistics used to 13 referrals, 11 patients, (2 referred twice; 10 males, 1 female) ● Medical tests
describe the data Age: ● Psychological interventions
Median age 66 years (range 58–87 years) ● Speech therapy
Ethnicity: ● Occupational therapy
White British, n = 6 (55%) ● Placement advice
African Caribbean, n = 3 (27%)
Irish, n = 1 (9%)
Hungarian, n = 1 (9%)
Residency:
HS, n = 5 (46%)
Local forensic service, n = 6 (58%)
Visser et al. Empirical paper Setting: Service evaluation including OT intervention,
(2019) Qualitative service evaluation Inpatients at MS and LS units routine activities, one off events
U.K. Semi-structured interviews Sample: Participants asked to pick a specific typical
Accompanying patients to 15 service users (11 males, 4 females) activity for researcher to accompany them to
interventions, observing and Age: Hospital wide activities also attended and
making notes All age > 50 years (range 50 − 71 years) assessed
● Thematic coding using framework
approach
1
HS = high secure, MS = medium secure, LS = low secure.
2
Although penitentiary settings are excluded from the review, this article makes comparisons between settings.
3
This is the only element of relevance for the current review, which comprised descriptives.
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 11

into the phenomenon. The majority of the articles were deemed not relevant
because they either did not focus on older populations or did not include
forensic mental health service users. Findings from a synthesis of the quali­
tative research will be presented first, followed by an examination of quanti­
tative research.

Qualitative Research
Due to the fragmented nature of the research and lack of data, synthesis of
the qualitative research only enabled the identification of two broad themes
to encapsulate the key observations: ‘positive perceptions of service provision’
and ‘negative perceptions of service provision’.

Positive perceptions of service provision

De Smet et al. (2015) undertook a qualitative study, interviewing eight older
(age range 61–72 years) mentally ill offenders (OMIOs) across three different
settings (institutionalize care, community care, penitentiary setting), and this
afforded comparisons between the settings. Part of the analysis included
counts of text fragments, coded as positive or negative. For penitentiary
settings, 35 positive experiences (e.g., opportunity to participate in leisure
and sport activities) were identified; for institutional care this was 6 positive
experiences (e.g., sufficient types of therapy); and for home the count was 24
positive experiences (e.g., good experience with domiciliary follow-up). The
most positive experiences were found in the home; with the authors surmis­
ing this could be because in this environment individuals are able to under­
take valuable activities such as voluntary and paid work, and potentially these
OMIOs have more freedom to make personal choices.
The phenomenological analysis of the interviews with the patients in the
community found service users were positive about the activities offered in
community-based care. They emphasized interventions were sufficient and
useful, specifically voluntary and paid work, sports, cooking activities and
psycho-educational initiatives. As part of this domiciliary psychiatric follow-
up was deemed a very important source of support. A strong preference
emerged from their data for psychosocial intervention encapsulating human
interaction, communication and psychosocial support.
Based on research with 15 service users (in high, medium and low secure
units), examining educational/recreational interventions for older forensic mental
health patients, Di Lorito et al. (2018) found some elements of their narratives
were positive. Feedback suggested interventions prepared them well for return to
the community, activities were relaxing and soothing, they provided a social role
and the activity program was suitable for any age group. The few activities
specifically for the over 50s found in secure units were well received and it was
suggested more should be implemented. Similarly Visser et al. (2019), based on
12 K. WALKER ET AL.

a thematic analysis of interview data and observational notes from service users
(11 males, 4 women) aged 50–71 and over and residing in low and medium
secure units, identified the theme of ‘Participation in activities’, where it was
observed weekly routine activities were important, as was the occupational
therapy program. They found most activities provided in the unit were age
inclusive, although some attracted predominantly younger participants; how­
ever, it was not disclosed why this was the case.
Finally, a factor identified in the review as a positive from the research by
Di Lorito et al. (2018) related to physical health conditions. From service users’
perspectives it was felt these were addressed well (from a medical point of
view), and perhaps better than would be in the community, with access to
consultations widely available. However, this was not mirrored across all
studies as, beyond medical intervention, not all service users felt their physi­
cal needs were addressed or catered for (e.g., Visser et al., 2019).

Negative perceptions of service provision

Analysis undertaken by De Smet et al. (2015) included counts of text fragments,
coded as positive or negative. It was found in penitentiary settings 28 negative
experiences (e.g., poor psychological support) were identified, for institutional
care this was 19 negative experiences (e.g., lack of psychological and psychiatric
support) and for home the count was 8 negative experiences (e.g., too much
spare time). Contrary to authors’ predications, the highest number of negative
experiences was found in intuitional care over that of penitentiary, although it
is not clear why this was the case. It could be postulated this is a sampling bias,
as only a small number of participants were interviewed.
Phenomenological analysis of the narratives by De Smet et al. (2015)
revealed those who experienced institutional care disclosed negative experi­
ences relating to therapeutic and occupational activities; namely: there was
a lack of psychological and psychiatric support available, there were not
enough activities, support was missing in relation to restraining from alcohol
abuse, service users experienced boredom, interventions were not deemed
therapeutic, interventions provided were not useful, some therapies were age
inappropriate, and some interventions were perceived as ‘childish’. Likewise,
participants under community care noted creative therapies and some other
forms of interventions were deemed as too childish, with some participants
reporting boredom with their compulsory psychiatric daycare.
Negative perceptions were also found by Di Lorito et al. (2018) based on
their interviews with 15 service users across three secure settings. Similar to
De Smet et al.’s (2015) findings for some longer-term patients, it was felt
interventions became repetitive; individuals became bored and lacked enthu­
siasm and motivation to engage. Likewise, Visser et al. (2019) reported similar
findings from those over 50 in secure settings: longer-term patients identified
boredom and a lack of motivation to engage with interventions. They also
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 13

noted secure units did not offer age-specific forensic services, a gap in service
provision for this population.
Di Lorito, Dening et al. (2019) examined the views of members of staff who
had worked with older patients in forensic settings with an aim of establish­
ing how well services met the needs of this population. Data were collected
through focus group research with different members of staff, e.g., nurses,
consultant psychiatrists, occupational therapists (across high and low security
units). One of the themes found was ‘Addressing patients’ needs’, which
encapsulated views about barriers to addressing needs and service provision
and improvement. In relation to interventions, a barrier and negative factor
identified was an ability to offer activities suitable for older patients, particu­
larly for longer stay patients who lacked stimulation, a finding mirrored in
service user’s views (e.g., Di Lorito et al., 2018; De Smet et al., 2015; Visser
et al., 2019). In addition, it was suggested a lack of available resource –
financial and staffing – meant specific interventions for older people were
neglected and unlikely to be implemented.
Another negative perception found related to physical health, which
becomes more problematic as people age. Visser et al. (2019) highlighted
that some of the older patients were unable to attend certain interventions
because their physical health prevented them from doing so. The majority of
their participants had extensive physical health issues and staff intervention
in relation to this was generally inadequate (although positive when inter­
vention was with primary care practitioners). Along a similar line, Di Lorito
et al. (2018) found some participants reported issues with inaccessibility for
some interventions due to mobility problems that come with aging and
poorer physical health. Whilst physical activity was seen as positive, it was
noted gym equipment was not always suitable for older patients, i.e., weights
were too heavy.
In summary, patients and staff presented both positive and negative
perceptions about the service provision for older forensic mental health
patients, although some of the findings were contradictory across studies.
Positive narrative related to quality, type and suitability of activities available
in both secure settings and the community, specific provisions for those over
50, psychosocial services, and medical treatment for physical health issues.
However, negative perceptions included narratives about: (i) boredom with
and uselessness of interventions; (ii) inappropriate therapies/lack of age-
appropriate interventions; (iii) poor quality of psychological support; and
(iv) lack of provision for those with poorer physical health.

Quantitative research
Quantitative research was sparse and less comprehensive than the quali­
tative research identified. Only a handful of studies present elements of
14 K. WALKER ET AL.

data regarding this, and generally this was descriptive and not the main
focus of the research. No research has been undertaken specifically collat­
ing an evidence base for service provision and intervention development
or delivery or evaluations of interventions for this age group. Due to the
fragmented nature of the research found, it is not possible to synthesize
findings, so each article and main findings are presented separately.
Di Lorito, Völlm et al. (2019) undertook some quantitative analysis, and
although the main analysis focused on characteristics, a small part examined
the types of interventions older forensic mental health patients receive in
low, medium and high secure settings. The total study sample was 93;
however, the analysis that examined interventions comprised a subsample
of 41 patients (44% of the total population aged ≥ 50 years), of whom only
three were female. The authors reported descriptive data on how many
participants had experienced different types of interventions, finding skills
development, n = 30 (72.2%); mental health awareness/psychoeducation,
n = 12 (29.3%); art therapy, n = 8 (19.5%); healthy lifestyle training, n = 8
(19.5%); dialectical behavior therapy, n = 7 (17.1%); substance misuse treat­
ment, n = 7 (17.1%); music/dance therapy, n = 6 (14.6%); violence reduction
n = 6 (14.6%); and preparation for therapy/motivational work, n = 6 (14.6%).
Results also revealed their needs were met in 12 areas of daily living on
average (SD 3.5), with one of these including ‘treatment’ (n = 30; 74%).
However, 4 areas of needs were unmet, on average (SD 3.0) and one of
these was ‘daytime activities’ (n = 14; 34%). Patients were split into two
subgroups: <55 years old (n = 20) and ≥50 years (n = 21), and it was found
those below 55 years had significantly more unmet needs than those above
although this was not examined by individual categories.
This research offers some descriptives of, and a contextual understanding
into, the types of interventions offered and experienced by those over 50.
Beyond this, the data doesn’t offer any further information on this, such as
how appropriate/suitable interventions were, or about engagement, comple­
tion, or outcomes. However, this was not the main aim focus of this part of the
study. This research allows a basic insight into what is being experienced,
although the data collected doesn’t support generalizability of findings.
Shah (2006) undertook an exploratory audit examining demographic,
clinical features, management advice and appropriateness of referrals to
a consultation-only old-age psychiatry liaison service for inpatients in med­
ium and high secure forensic units. The consultant had one dedicated session
per week for older patients (defined as 60 years and over and younger
patients with dementia). The age range of the participants was 58–87 and
comprised 10 males and 1 female. Basic descriptive data were used, and part
of the audit involved noting the amount and different types of intervention
advice given. The intervention advice included medical (drugs and medica­
tion, scans, x-rays and investigative procedures) but also referral for
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 15

psychological interventions, speech therapy, occupational therapy, and pla­

cement advice. It was found advice was required regarding placements for
patients outside the secure setting, as it was felt these settings were deemed
inappropriate for older patients. It was suggested there is a paucity of facil­
ities that are able and/or willing to accept older forensic mental health
patients. Generally, the reluctance to offer support and accept referral of
these patients was because of their forensic histories. It was proposed that
referring teams were not actually aware of specialist types of facilities avail­
able specifically for older forensic mental health patients and there was
a need to establish a range of facilities that would accept these patients.
Das and colleagues, in two commentaries, compared healthcare and
placement needs of older forensic mental health patients in high security
settings with those in medium/low secure settings (Das et al., 2011), and
healthcare and placement needs of older forensic mental health patients with
a younger forensic psychiatric population (Das et al., 2012). In the first study
(Das et al., 2011), patients over 60 (15 from high security, 15 for medium/low
security) were examined using the Camberwell Assessment of Needs in the
Elderly – Short Version (CANE-S; Orrell & Hancock, 2004), the Camberwell
Assessment of Need – Forensic Short (CANFOR-S; Thomas et al., 2003) and
forensic adaptation of the Nottingham Acute Bed Study questionnaire
(NABUS; Beck et al., 1997). The authors concluded there were significantly
different healthcare and placement needs between those older patients in
high security and those in medium/low. Although the older patients in the
high secure units were relatively younger (61.5 years) than those in the
medium/low (73.4 years) they had more physical health problems that
required treatment. In addition, the high secure patients expressed more
unmet needs in relation to healthcare, psychological distress and basic
education and treatment. Finally, in relation to placement needs half of the
older forensic patients in the high secure setting were deemed as not requir­
ing continued high secure placements, but other placements.
In their second study (Das et al., 2012) 26 younger males (45 years and
below) and 30 older males (60 years and above) were compared. Two ques­
tionnaires (CANFOR-S; Thomas et al., 2003; CANE-S; Orrell & Hancock, 2004)
were used for the older patients, with only the CANFOR-S for the younger
(CANE-S is assessment of needs for elderly hence not suitable for younger
group). In relation to placement issues, it was found there is a lack of low
secure facilities willing to look after the needs of older offenders and manage
the risks. The younger group rated alcohol misuse and drug misuse needs as
met compared to the older group (with met indicating the person has
difficulties in this domain and effective help/intervention is being received).
A third of the older group rated their treatment as an unmet need (with
unmet indicating the person has difficulties in this domain and the patient
either receives no intervention or intervention that does not help). Based on
16 K. WALKER ET AL.

the CANFOR-S more of the younger patients had unmet needs for daytime
activity and education compared to older patients. However, this was as rated
by staff and not patients. Overall, when total needs were compared, signifi­
cantly more younger patients had met needs than the older patients. There
was a significant unmet need for the older patients in relation to their
physical needs, and it was suggested these are complex and may change
over time and so careful consideration about these factors is required when
planning intervention, placement and care.
Overall, the quantitative evidence found is only descriptive data in nature,
from small numbers of participants. The evidence presented is therefore not
strong and robust. As such this provides evidence there are large gaps in the
literature and our knowledge base about service provision for older forensic
mental health patients in secure units and the community.

Limitations
In relation to the qualitative research presented, the data analysis offers the
opportunity to gather rich data and achieve an in-depth insight into
a phenomenon. However, it comes with limitations. De Smet et al. (2015)
acknowledge their findings are drawn from a small sample and so are not
conclusive. In addition to this acknowledgement, the sample was also diluted
further by comparing three different sites and through drop-out and selec­
tion bias. Likewise findings from the other studies need to be viewed as
preliminary and contextualized within limitations including confirmation bias
(Di Lorito, Dening et al., 2019), sampling bias (for example, specifically there
was only 54% participation rate achieved by Visser et al., 2019), and lack of
representation (range of professionals’ views captured, lack of female service
users, different ethnicities and/or range of different units/trusts). It could be
argued those who declined, dropped out or were unable to take part in the
research are perhaps more important to understand. For example, those not
captured by Visser et al. (2019) were identified as more withdrawn from
activities and who spent more time in their room and their narratives about
this would have likely given a very different viewpoint and insight in compar­
ison to those included in the study. This would suggest the scope of this type
of research needs widening, to involve a more diverse sample and examine
the context within which they reside.
As a general observation, no research had explicitly quantitatively examined
interventions for older mental health forensic patients, either in relation to
evaluations, intervention design and development or outcome studies. Of the
studies that examined interventions in some form, the findings were descriptive
rather than detailed statistical analysis of the data. The results expose some of the
different interventions experienced by older forensic mental health patients, with
no research examining the effectiveness or appropriateness of the interventions.
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 17

The studies comprised relatively small samples, i.e. n = 41 (Di Lorito, Völlm et al.,
2019), n = 11 (Shah, 2006), n = 30 (Das et al., 2011, 2012), which limits the
statistical analysis, and does not afford generalizability. Both Shah (2006) and Das
et al. (2011, 2012) were more reliant on information from clinicians and staff
rather than service users. In addition, limited detail is given on the analysis
undertaken and the actual results found, meaning it is not always transparent
as to how they drew their conclusions.

Conclusions and Implications

It is apparent there is a lack of research that has examined interventions for
older forensic mental health patients, in secure units or the community, and
so our understanding of the types and efficacy of interventions for this
population is lacking. Taken together, the studies were heavily reliant on
qualitative methods limiting the scope and generalizability of the findings.
None of the quantitative studies reported any analyses that could be synthe­
sised across studies.
It was found, based on both the qualitative and quantitative research, there
was a wide range of intervention and activities available. However, there was
little detail into the specifics of the interventions, and it would appear that there
are very few interventions specifically designed for older forensic mental health
patients and none that have been evaluated. It is therefore not clear if they are
effective, helpful or suitable for the older patients. From the qualitative
research, a common thread across the articles was both patients and staff felt
some interventions were not age-appropriate, some may be inaccessible
mainly due to physical health of older patients, and for the longer-term
patients, interventions became repetitive and boring and so motivation and
engagement was poor. It was suggested this was the case regardless of place of
residence (De Smet et al., 2015). Of interest, factors such as boredom with and
uselessness of interventions and poor quality of psychological support may also
be common within younger adult forensic population, although to date there is
no qualitative research that has made this comparison.
Another area of consideration in this population is the assessment and
management of risk. Older people in secure settings which they share with
younger adult patients can be vulnerable. Secure forensic inpatient services
could be deemed as unsuitable, and not provide appropriate risk intervention
and assessment for older patients identified as being be frail, vulnerable and
suffering from co-morbid serious physical illness (Coid et al., 2002). It has
been argued that risks of older patients are not always assessed accurately
and are difficult to judge, as assessments used generally rely on younger
adults for standardization, that risk assessments may be biased by societies
views that older people are less dangerous, and risk is complicated by
cognitive impairment, which can cause risk to increase or decrease as the
18 K. WALKER ET AL.

impairment progresses (Natarajan & Mulvana, 2017). Assessment and man­

agement of risk therefore may take longer, be inaccurate or not be possible
due to cognitive decline.
More research is required to understand and identify interventions and
service provision for older forensic mental health patients to ensure practice
is evidence based. This could be achieved through mixed methodological
approaches using qualitative data to generate clearer hypothesis, research
questions, theory and evidence-based interventions and quantitative to ver­
ify, generalize and evaluate. This needs to incorporate a focus on risk factors
as well as resilience and protective factors. In addition, research needs to
compare older adult experiences in different settings, step-down care and in
the community. Longitudinal research would also be beneficial to encapsu­
late changing needs and requirements at different stages of individuals’ lives
as they experience different settings, contexts and interventions.
Mental health services for older people (not specifically forensic) offer
comprehensive, individualized and accessible services, using
a multidisciplinary approach. These mental health-care treatment services
and interventions can be effective for older people (Burns et al., 2001).
However, the use of standardized screening instruments in this environment
needs to be encouraged and developed, but there is a lack of standardized
tools for this population (Natarajan & Mulvana, 2017). Likewise, research
within older prisoner populations, whilst in need of further evaluation for
efficacy, highlights interventions that can be implemented with an older
forensic population, such as art and music therapy, group and individual
counselling, recreational therapy, and intensive assessment (Canada et al.,
2019). Forensic mental health services would benefit from the distribution of
knowledge in relation to interventions and practices that work in other
settings such as prisons and other health-care settings.
The epidemiology, criminology and clinical characteristics of older people
are different from those of younger people (Natarajan & Mulvana, 2017).
Consideration needs to be given to the fact that older forensic mental health
patients are likely to experience comorbid major physical and mental health
issues, substance abuse issues as well as extensive histories of trauma (Maschi
et al., 2012). Older forensic mental health experience longer length of illness,
more severe and/or interrupted episodes of care (Di Lorito et al., 2018), longer
term use of anti-psychotic medication, and older style antipsychotic medica­
tions (which can result in adverse effects on motor skills and cognition)
(Kristian Hill et al., 2010), all of which impact their presentation and on their
needs and care requirements. Therapies that focus on social integration, and
that acknowledge and consider cognitive functioning (e.g., blending cogni­
tive remediation with rehabilitative interventions) are required (Bartels &
Pratt, 2009). For this population, interventions need to integrate health
promotion, healthcare illness management interventions, and use strategies
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 19

to integrate psychosocial rehabilitation, including both mental and physical

health needs thereby addressing the needs and requirements of the ‘whole
person’ (Mueser et al., 2010). In addition, interventions that are not standard
in secure settings, such as cognitive stimulation therapy (CST), life-story and
reminiscence work, and adapted offence-focused work for those with a mild
to moderate dementia, may be appropriate and helpful for older forensic
mental health patients (Natarajan & Mulvana, 2017).
Services need to identify older adults at risk of a decline in independence
and mental wellbeing and provide tailored physical and social activity pro­
grams (NICE, 2016) which address their multiple and complex needs
(Natarajan & Mulvana, 2017). It is important services fit patients’ individual
needs (Anderson, 2011) to enable progression, recovery and better levels of
health, wellbeing and quality of life. An in-depth understanding is required as
to why older patients do not make progress on key outcome measures which
assess a broad range of recovery, clinical, social and risk factors to overcome
barriers to improving health, recovery and wellbeing. Similarly, it is important
to identify and assess unique protective factors for older adults to enable
sustainable improved health, wellbeing and quality of life (De Smet et al.,
2015). This could be developed within a more positive and strengths-based
approach, such as the Good Lives Model, to inform future professional
practice and enhance the experience of care and promote a ‘good’ life for
those older patients both in secure forensic units or in the community.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This paper presents independent research funded by the National Institute for Health
Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant
Reference Number PB-PG-1217-20028). The views expressed are those of the author(s)
and not necessarily those of the NIHR or the Department of Health and Social Care.

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