Older forensic mental healthcare patients in England: demographics, physical health, mental wellbeing, cognitive ability and quality of life

Introduction

Providing support, care and treatment for forensic patients that is responsive to their individual needs and strengths is a core tenet of the recovery approach (Simpson & Penney, 2018). Recognising this requires investigating the individual profiles of patients in forensic mental health services and how patients’ backgrounds, characteristics, experiences and perspectives differ. This approach can be seen in recent efforts to develop services and interventions responsive to the lived experiences, strengths and needs of, amongst others, women patients (de Vogel & Nicholls, 2016), culturally and ethnically diverse patients (Hui, 2017), Deaf patients (Wakeland et al., 2019), and older patients (Solares et al., 2020). This latter group was the focus of the ENHANCE study¹, which investigated the demographics, health-related quality of life, recovery rated quality of life, mental wellbeing, cognitive ability, wellbeing and secure hospital restrictiveness rating profiles of forensic mental healthcare patients aged 55 and over.

Forensic mental healthcare patients aged 50 and over constitute about 20% of the UK forensic mental healthcare inpatient population (Di Lorito et al., 2019; Di Lorito et al., 2018b). This proportion is likely to increase as the population ages (World Health Organization, 2017); indeed, the number of forensic inpatients over 65 in Scotland increased by 50% and those aged 56–65 by 27% between 2013 and 2019 (Scottish Government, 2021). The physical and mental healthcare needs of this group are complex as often comorbidities are prevalent (Natarajan & Mulvana, 2017). Many forensic mental healthcare patients have biographies characterised by placements in psychiatric institutions and prisons, and have experiences of substance abuse and long-term serious mental and physical illnesses for which they may have not received appropriate treatment or management (Centre for Mental Health, 2010; Centre for Mental Health, 2013). This constellation of factors means that many forensic patients experience an ‘accelerated aging’, presenting with a level of health need at, for example, 50 years old that would be equivalent to an average member of the general public at 60 years (Merkt et al., 2020).

Compared to younger adult mental healthcare patients, older individuals are more likely to have a higher number of unmet health needs and to experience fewer improvements in their health over time (Das et al., 2011; Das et al., 2012; Girardi et al., 2018). Older patients are more likely to be diagnosed with depression, organic brain syndrome, or delusional disorder (Coid et al., 2002). Disabling health issues are more prevalent in older patients; these include cognitive decline, mobility problems and sensory impairment (Di Lorito et al., 2019). The number of medications given to older patients has been found to double throughout placement in secure hospitals, highlighting a decline in health (Lightbody et al., 2010). Investigating and documenting the disparities between younger and older mental healthcare patients can help shape service provision, develop responsive and appropriate interventions, and address structural disparities in health and wellbeing outcomes (Hui et al., 2021).

Aims and rationale of this study

Despite the growing research and clinical interest in older adult forensic mental health patients there remains a paucity of research data. The aims of this study were to better understand the profiles of this patient group and investigate factors associated with quality of life, recovery, and wellbeing. The current study describes the quality of life, physical health, mental wellbeing, cognitive ability, demographics, and experiences of restrictiveness in secure care of 37 forensic mental healthcare patients, aged 55 and older, from community and low, medium and high security inpatient settings in England.

The research aims were co-authored with the ENHANCE study’s Lived Experience Advisory Panel (LEAP) (a group made up of people with lived experience of mental health issues and forensic mental healthcare service use). These aims were to investigate whether physical health, health-related quality of life, and recovery-related quality of life were correlated with each other in this population, and whether these constructs were associated with: mild cognitive impairment, age, length of stay in secure care, amount of leave (for inpatients), experiences of secure hospital restrictiveness, and treatment setting (i.e. community or low, medium or high security in-patient hospital). The study further investigated to what extent patients’ scores on measures of mild cognitive impairment, recovery-related quality of life, mental wellbeing and experiences of restrictiveness in secure care differed from population norms or samples described in research literature.

Methods

Results

Demographic characteristics and patient outcomes

Age was not significantly linked to any of the outcomes measured. Length of stay in current setting was positively associated with usual activities (ρ= .440) and anxiety and depression (ρ= .384) indicating a greater number of problems in these domains, and negatively associated with EQ-5D-5L index value suggesting poorer health (ρ= -.374). Despite the correlation with the index value, there was no significant relationship with patients' assessments of their health on that specific day.

Mild cognitive impairment scores were negatively correlated with recovery-related quality of life scores (ρ= -.377) and positively with higher restrictiveness ratings (for inpatients, ρ=.474). Premorbid IQ was negatively correlated with the EQ-5D-5L ‘health today’ domain (ρ= -.432). As our sample was too small to conduct analyses of difference between more than two groups (i.e. ANOVA), Figure 1 and Figure 2 demonstrate a tentative finding that were ANOVAs to be conducted, significant differences would be unlikely on measures of recovery-related quality of life, overall wellbeing (EQ-5D-5L index value), mental wellbeing, or experiences of restrictiveness compared across levels of leave or treatment setting.

Figure 1. Mental health and wellbeing across levels of leave.

Figure 2. Mental health and wellbeing across treatment settings.

Discussion

This article describes a sample of 37 forensic mental health patients aged 55 and over in forensic community and inpatient mental healthcare services. It makes a novel contribution to the literature by expanding the relative paucity of published data on this patient group and by investigating their physical health, health-related quality of life, recovery-related quality of life, mental wellbeing, experiences of restrictiveness in secure care,cognitive ability and demographics and comparing several of these outcomes to population norms or published data.

In some respects, our findings align with other cross-sectional studies of this group. Other studies also report: lower proportion of women patients than that reflected in the total forensic population (Coid et al., 2002; women are approximately 18% of the total forensic inpatient population in England and Wales, see Tomlin et al., 2021); a high proportion of serious offences against the person (e.g. murder/manslaughter, assault) (Di Lorito et al., 2018b); multiple chronic physical health needs alongside complex mental health needs (Girardi et al., 2018b), and cognitive impairment and high rates of obesity as classified by BMI (Di Lorito et al., 2019).

On this last point, and considering cardiovascular health more broadly, a recent review of cardiometabolic disease in patients with psychosis of all ages in secure settings reported a weighted pooled prevalence of BMI scores >30 across eight studies of 39.8% (n= 1359); five studies of which reported a weighted pooled prevalence of BMI scores >25 at 72.4% (n= 840) (Ma et al., 2020). Weighted pooled prevalence scores were also reported for metabolic syndrome: 23.5% (k= 5; n= 1,390); diabetes: 11.3% (k= 12; n= 2,561); dyslipidaemia: 29.2% (k= 8; n= 1,135); hypertension: 25% (k=5; n= 857); cardiovascular disease: 15.6% (k=6; n= 1,047). Although direct comparison is not possible given different methods of diagnosis and recording practices, rates of dyslipidaemia were lower in our sample, but diabetes and cardiovascular disease were much higher. Cognisant of methodological caveats, this disparity might reflect a worsening of some forms of cardiometabolic health as patients age and spend more time in care.

The negative relationship between mild cognitive impairment scores and recovery-related quality of life was significant, whilst there was a trend towards significance with mental wellbeing. Cognitive ability scores were commensurate to a representative sample of adults living in Ireland with primary level or no education (Kenny et al., 2013). Using the MoCA threshold of 25/30 or below to indicate possible mild cognitive impairment (Nasreddine, 2017), we found that 22/37 (65%) of our sample could have mild cognitive impairment. Di Lorito & colleagues (2019) found that 21% of their sample had ‘cognitive impairment’ as measured on the CAMCOG. Older forensic patients with poorer cognitive skills will likely need greater support both in hospital and in the community to achieve their recovery goals. A meta-analysis of 49 RCTs comparing interventions to improve global cognition in individuals with mild cognitive impairment found the following intervention types were significantly more effective than control conditions: cognition-based, physical exercise, combined cognition-based and physical exercise, and antioxidants (Xu et al., 2021). Cognitive Stimulation Therapy (CST) has been suggested in the literature as an example of a cognition-based intervention for this population that can be undertaken via computer or tablet and be facilitated with the support of carers and is not resource intensive (Natarajan & Mulvana, 2017).

Recovery-related quality of life scores were associated with more positive perceptions of/satisfaction with ‘usual activities’⁵. This finding underscores the importance of meaningful and accessible activities in the recovery process. Secure inpatient settings have a limited range of activities and community patients can face age-, physical health- or forensic-related barriers to participation (de Smet et al., 2015). Activities that are available to inpatients have been described as childish or boring or repetitive by older patients in our study (Walker et al., 2022b) and elsewhere (Di Lorito et al., 2018a; Visser et al., 2021). Patients in the community also describe a paucity of appropriate and engaging activities (de Smet et al., 2015). Novel, patient-led, and health and age needs-appropriate activities for older patients should be a priority and can be inexpensive to implement compared to complex psychosocial or pharmacological interventions.

Comparing our sample to population norms or published study data, this study found that older forensic patients subjectively rate their mental wellbeing at a level that is not significantly different from the general population (Stewart-Brown et al., 2009), and their recovery-related quality of life as not significantly different from the general population and better than adults receiving general mental healthcare (Keetharuth et al., 2018). Although forensic patients have complex comorbid physical and mental health needs, the level of healthcare assessment, monitoring and support they receive is likely to contribute to explaining the lack of significant differences from the general population on these measures. Qualitative studies of patients’ experiences of care suggest that this group likely has better access to healthcare, professional support, social contact, structured activities, regular food, and exercise equipment than the same age group in the community in the general population (di Lorito et al., 2018a; di Lorito et al., 2017; Visser et al., 2021; Walker et al., 2022b). In line with this, mental wellbeing did not correlate with the ‘mobility’, ‘self-care’, and ‘pain/discomfort’ domains of the EQ-5D-5L.

The link between physical health and mental health was not entirely clear though, as the ‘anxiety and depression’ domain of the EQ-5D-5L did correlate with these three domains, and the ReQoL correlated with the ‘mobility’ EQ-5D-5L domain. This could mean that perceptions of ‘depression and anxiety’ are associated with physical health in a way the broader construct of mental wellbeing is not, or that this reflects a response bias given that these domains were all measured on the same questionnaire (the EQ-5D-5L). Nevertheless, given this and the link between mobility and recovery-related quality of life, the associations between physical health and general mental health should be investigated further and services should ensure barriers to mobility are removed.

Age was unrelated to the outcomes measured in this study. This might be because all our patients were 55 years and older (maximum of 70 years), offering little variance for the statistical analysis. One possible explanation for this null finding is that several qualitative investigations have found age to be a subjective construct for many forensic mental health patients; some reject the ‘older’ label and express feeling young (Visser et al., 2021). As our outcomes were largely subjectively measured it is possible some respondents felt younger or older than others the same age and rated their mental wellbeing, physical health and recovery-related quality of life in line with this. A larger sample with patients aged 18 and older might have led to different findings. Indeed, studies using staff-rated instruments have found that older patients were less likely to have healthcare needs met (Das et al., 2012); and were less likely to improve over the course of treatment on measures of security needs, self-harm, harm to others, mental health disturbance, personal wellbeing, emotional wellbeing, and socio-economic status (Girardi et al., 2018).

In relation to medication, the mean number of psychotropic drugs prescribed (2.1 per patient) does not seem excessive given the range and number of diagnoses. The higher total number of drugs (mean = 7.6 per patient) doubtless reflects the burden of physical morbidity, especially diabetes and cardiovascular conditions, in the sample. Of concern is that the mean anticholinergic effect score was 2.4, which suggest that there is scope for review of these medications as they are known to contribute to the future risk of dementia (Coupland et al., 2019) and are associated with higher risk of mortality and emergency hospitalisation in people with established cognitive impairment (Bishara et al., 2020).

Conclusion

In consultation with a lived experience advisory panel to identify our most important research foci, we investigated correlates of patients’ health-related quality of life, recovery-related quality of life and mental wellbeing. We found that recovery-related quality of life was significantly associated with a measure of mild cognitive impairment and problems engaging in usual activities. Mental wellbeing was trending towards a significant relationship with problems engaging in usual activities (p=0.54). Perceptions of physical health were largely though not entirely uncorrelated to either of these constructs (the exception being recovery-related quality of life and mobility). Age was not correlated with health-related quality of life, recovery-related quality of life or mental wellbeing. There were high levels of possible mild cognitive impairment. Diabetes, vitamin D deficiency, and musculoskeletal and cardiovascular conditions were prevalent. We suggest services co-develop with patients age-appropriate meaningful activities that are mindful of mobility issues and consider implementing cognitive stimulation therapies. This study adds to the growing and much needed literature on older forensic mental health patients and further promotes the importance of studying different marginalised patient groups.

Data availability