Elderly individuals in forensic MH servicesAn increasing trend

Mathieu Dufour, MDHelen Ward, MD

HSJCC, 25 November 2013

Outline

• Demographic change: Aging population

• Elderly in corrections

• Elderly in forensic

– At the Royal

– In other centers

• Solutions

• Plenary discussion

More elderly in jail?

Elderly in corrections

• Increased numbers

– Aging population

– 50% have mental disorder (Fazel et al., 2001) (Barak et al., 1995)

• Depression is the most common diagnosis

• Increased proportion

– Tougher and mandatory sentencing

– Reduced option for early prison release

Elderly offenders in federal corrections

Sexual offences

11%

Violence/Assaults/Robberi

es52%B & E

7%

Use of prohibited weapons

12%

Other18%

Sexual offences

78%

Violence/Assaults/Robberie

s17%

Use of prohibited weapons

2%

Other3%

30 yo and younger 65 yo and older

OCI Annual report 2010-11

• Special focus on elderly offenders

– Growing number

– Increased of 50% in last decade

– Issues

• Mobility

• Treatment of chronic diseases

• Palliative care

• Victimization

• Vocational programming

More elderly in forensic?

Royal Ottawa Health Care Group

• Royal Ottawa Mental Health Centre

– 284 beds

• Brockville Mental Health Centre

– 183 beds

• University of Ottawa Institute of Mental Health Research

• Royal Ottawa Foundation for Mental Health

Offences

Diversion

Hospital (section 17)

Community programs

Charged

Fitness?

Unfit

ORB

Fit

Criminally responsible?

NCR

ORB

No NCR

Regular trial

Mental Health issues for

sentencing?

% of Assessments for elderly individuals

Inpatient

Outpatient0

1

2

3

4

5

6

20092010

20112012

2013

Inpatient

Outpatient

Increasing Trend

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

0 1 2 3 4 5 6

Axi

s Ti

tle

Axis Title

Series1

Linear (Series1)

Types of Assessments

Fitness42%

Criminal responsibility

15%

Section 21 (Sexual)

25%

Section 2115%

DO3%

Charges

Sexual57%

Assault17%

Threats-harassment

6%

Robbery6%

Homicide3%

Arson3%

Minor (resisting, breaches, mischief)

8%

Elderly offenders in federal corrections

Sexual offences

11%

Violence/Assaults/Robberi

es52%B & E

7%

Use of prohibited weapons

12%

Other18%

Sexual offences

78%

Violence/Assaults/Robberie

s17%

Use of prohibited weapons

2%

Other3%

30 yo and younger 65 yo and older

Offences

Diversion

Hospital (section 17)

Community programs

Charged

Fitness?

Unfit

ORB

Fit

Criminally responsible?

NCR

ORB

No NCR

Regular trial

Mental Health issues for

sentencing?

Elderly under ORB

Elderly7%

Non-elderly93%

Ottawa

Elderly6%

Non-elderly94%

Brockville

Diagnosis

Schizophrenia spectrum

55%

Dementia36%

Bipolar9%

Dementia

Alzheimer

Steady decline

Vascular

Step-wise decline

Fronto-temporal

Lewy BodyTraumatic

brain injury

Dementia severity

• Mild

–Difficulties with instrumental ADLs

• Moderate

–Difficulties with ADLs

• Severe

– Fully dependent

Diagnosis

Schizophrenia spectrum

55%

Dementia36%

Bipolar9%

“Classic” NCR

Schizophrenia spectrum

Get older

New NCR

Dementia

Minor charges

(Low risk)

Lives in community

Serious charges

(High risk)

Placement issues

“Classic” NCR

Schizophrenia Spectrum

Acute psychosis

Paranoid delusions

Pre-emptive strike

Command auditory

hallucinations

Violence

Elderly NCR

Vascular dementia

Disinhibition

ViolenceInappropriate

sexual behaviors

Fazel (2002) International Journal of Geriatric Psychiatry

• Sweden, n=210

• 4-weeks inpatient NCR assessment

• Elderly more likely

– Dementia or Affective psychosis

– Be NCR

– Charged with sexual offence or homicide

• Elderly less likely

– Personality disorder or Schizophrenia

Fazel (2002) International Journal of Geriatric Psychiatry

Psychotic illness39%

Personality disorder

24%

Substance18%

Depressive-Anxiety disorder

10%

Dementia9%

Lewis (2005) JAAPL

• South Carolina, n=99

• Criminal responsibility/competency-to-stand-trial

Lewis (2005) JAAPL

Substance (Alcohol)

43%

Dementia28%

Antisocial personality

disorder20%

Schizophrenia9%

Sex offenders: Recidivism decreases with age (Hanson,2002) (Barbaree, 2003)

Violent offenders

• Some evidence that recidivism decreases with age

• Risk assessment tools include

– Young age at first offence

– Young age at index offence

• Not as strong as for sex offenders

Violence in nursing homes

Placement issues

• Unfit to stand trial associated with dementia (Freirson, JAAPL, 2002)

– High rates of unfit in elderly offenders: 30% (Lewis, JAAPL, 2006)

– Likely irreversible

• Nursing homes reluctant because history of violence

• Forensic hospital not necessarily geared to needs

Screening for dementia

• Cognitive screening

– MMSE (Folstein)

– MOCA

• At each junction

– Police – Mobile Crisis team

– Mental Health Court

• Lawyers

– Corrections

– Forensic

Corrections

• Intake

– Cognitive screening

– Functional assessment (CSC)

• Geriatric team

– Focus on cognition and mood disorders

• Special units (US)

– “Nursing home prisons”

– Older prisoners have a stabilizing effect

Forensic

• Staff training on unique geriatric issues (Tomar, 2005)

• Similar issues with other patients with cognitive difficulties (? Cognitive pathway)

– Developmental delay

– Traumatic brain injury

– Severe schizophrenia

Forensic

• Forensic Geriatric Psychiatry – Supra-regional services (Yorston, 1999)

– Dedicated secure beds for elderly offenders

– Deliver services to prison and probation services

– Deliver sex offenders treatment

• Collaboration between Forensic and Geriatric Psychiatry

• Training to deal with elderly offenders

Multidisciplinary team• Nurse

– Home visit– Falls risk

• Social Work– Collateral– Family therapy

• Psychiatrist– Diagnosis– Medications– Capacity

• Psychology– Psychological assessment– Neuropsychological

assessment

• OT– Cognitive assessment– Functional assessment

• Community agency– CCAC

• Capacity• Placement

• Other MH professionals– PT (Mobility)– GP-NP: Medical health– Geriatric Psychiatry services

Offences

Diversion

Hospital (section 17)

Community programs

Charged

Fitness?

Unfit

ORB

Fit

Criminally responsible?

NCR

ORB

No NCR

Regular trial

Mental Health issues for

sentencing?

Take-home points

• Small but increasing number

– Assessment

– ORB patients

• Different population than “classic” forensic

• Typical elderly offenders: Dementia + Sexual offences

• Adapt our forensic MH services

• Tip of iceberg

– Diversion

– Prevention

Plenary discussion

• What is your experience with elderly offenders (correctional, forensic, community)?

• What issues did you encounter?

• What could be potential solutions?

Thank you

LHIN Champlain

Number of Assessments for individuals of more than 65 yo

Inpatient

Outpatient0

1

2

3

4

5

6

7

8

9

20092010

20112012

2013

Inpatient

Outpatient

0

1

2

3

4

5

6

2009 2010 2011 2012 2013

1.7

0

2.9

4.5

2.3

3.5

4.3

5.3

3.4

2.3

2.6

2.15

4.13.95

Inpatient Outpatient Inpatient + Outpatient

Federal sentence

General population

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

65 to 69

70 and over

Federal

Elderly and criminality

• Less crime offending

• Less crime victimization

• Research shows that age reduces recidivism

Violent offense among elderly

• Risk factors for arrest

– male gender

– Minority status

– low socioeconomic status

– history of past violent offenses

Age and crime

• Criminal activity peaks in late adolescence-early adulthood and decreases as person ages

• Age decreases recidivism

– “Age out”