The characteristics, needs and individual experience of older forensic psychiatric patients: across-sectional study in three secure units within one regional service

Intro. Secure forensic psychiatric settings in the United Kingdom offer treatment to mentally-disordered offenders or non-offending patients who present a risk to themselves and others, given the severity or nature of their symptoms. In the last decade, several demographic, socio-cultural and legal factors have caused an increase in the prevalence of patients over 50 years, who currently represent around 20% of residents in forensic psychiatric settings in the UK. However, population growth has not been matched by research. With little to no evidence, it is therefore difficult to determine whether secure services are adequately addressing the individual needs of older patients. Aims and objectives. The present study aimed to build evidence around older forensic psychiatric inpatients in three public (i.e. NHS-funded) secure forensic psychiatric services in Nottinghamshire, by answering the following research questions: (i). What are the characteristics of older forensic psychiatric patients? (ii). What are their individual needs in different areas of daily living? (iii). What is their personal experience of ageing whilst in secure care? (iv). Are the current services meeting the unique needs of older patients? (v). What can be done, if anything, to improve the current service provision? Methods. The project comprised several phases. The preliminary groundwork, which informed the study protocol, consisted of systematic reviews around older people in restrictive settings (Chapters 2, 4 and 5) and in an international case-study to investigate alternative service provision (Chapter 6). The empirical phase of the project consisted of: 1. Investigating the sociodemographic data of all older patients living in three public (i.e. NHS-funded) secure units (Rampton Hospital, Arnold Lodge and the Wells Road Centre) within Nottinghamshire Healthcare NHS Foundation Trust (Chapter 7) 2. Investigating data on socio-demographics, residency, admission, offences, mental health, treatment, physical health, risk and incidents of a sub-sample of patients within these units, by looking at their clinical notes (Chapter 7) 3. Assessing their individual needs in different areas of daily living through administration of the CANFOR-S (Thomas et al., 2003) (Chapter 7) 4. Assessing their cognitive abilities through administration of the CAMCOG-R (Roth et al., 1986) (Chapter 7) 5. Collecting enriched narratives on their experience of ageing whilst in secure care through administration of qualitative interviews (Chapter 8) 6. Investigating the views of members of staff around service provision in meeting the needs of older patients through focus groups (Chapter 9) Results. The preliminary groundwork highlighted a lack of updated information around older patients in forensic psychiatric settings, thus indicating a need for research in this area. Of a total of 496 patients in the three services, 94 (18.9%) [95% C. I. (15-22)] were aged 50 or over. Forty-one older patients (a response rate of 44%) [95% C. I. (34-53)] gave consent and were assessed in studies 2, 3 and 4. The participants presented with complex physical and mental health needs. Long-stay was prevalent and significantly associated with older age, showing the patients’ challenges to move along the care pathway. Participants’ needs were mostly met, but negative feedback was gathered around social opportunities. Cognitive impairment affected 25% [95% CI (15-41)] of the sample. Fifteen patients were sub-sampled for study 5. Despite the positive feedback reported around physical health care, education opportunities, staff and support of religious practices, participants experienced barriers to recovery, caused by social isolation/withdrawal and activities/treatment that did not respond to their complex age-related needs, generating poor motivation to engage. For study 6, three focus groups were carried out with 13 members of staff from two of the three research sites. The participants reported unique age-related issues, which may impact on the patients’ opportunities for recovery, including a lack of specialist training for members of staff, prolonged stay in secure care and a limited number of age-relevant activities. Conclusion. The older participants presented with unique characteristics and needs. Currently, a number of factors keep them motivated and engaged in the treatment process, thus favouring recovery. These include adequate provision of physical healthcare, a variety of age-appropriate educational activities and extensive support from members of staff. However, older patients still experience a number of barriers to recovery, including prolonged stay / long-term institutionalisation, release anxiety, few age-relevant occupational and recreational activities / treatment, limited social opportunities and neglect of sexual needs. Despite the high prevalence of cognitive impairment found in the sample, staff did not receive any training / awareness raising in dementia. The examples of good practice in caring for the needs of older patients were sparse and based on the initiatives of individual services, potentially requiring the development of dedicated policy to ensure equal service provision across services. Further research with more representative (i.e. national, in the private sector) samples is needed for accurate service evaluation