The Elderly Offender Graeme A. Yorston

OFFENCE TYPES

Despite an ageing population, statistical data from the UK and US show the number of convictions of people over the age of 60 has been remarkably stable over the past 12 years^1,2. Broadly speaking, the elderly account for around 1% of recorded crime, though this figure varies considerably for the type of crime.

Sexual Offences

Sexually inappropriate behaviour in dementia is a familiar problem to all old age psychiatrists. Most of this behaviour is mild in severity and does not reach the attention of the police or criminal justice system. Older adults can and do commit more serious sex crimes, however, and account for approximately 1% of convictions for these offences in the UK, with broadly comparable figures from other countries.

The proportion of older adults is rather higher for those convicted of sexual offences against children, and a number of possible explanations for this have been proposed, including the greater ease by which children may be dominated by someone of declining physical strength, the degree of trust afforded grandparental figures, ready access to grandchildren, and regression to childhood fantasy objects. The proportion of older sex offenders with suspected or proven organic psychiatric diagnoses varies in published case series from 0% to 60%^3–5. Other diagnoses reported in the literature include antisocial personality disorder, alcoholism, learning disability, depression and schizophrenia. Though research has consistently shown that older adults are capable of committing the most serious violent penetrative offences, there has been a tendency to minimize the seriousness of offending by this group in the past⁶. Several studies have shown lower rates of recidivism for older offenders^7–9, but some of these failed to account for the reduced time at risk of re-offending of elderly men, and the fact that, as a group, older sex offenders tend to commit less serious offences which have lower recidivism rates. It should also be borne in mind that the lower recidivism rate is of little help in assessing risk in individual cases, which should be approached in a structured manner. The potential for serious harm should never be underestimated on the basis of age alone.

Homicide

There have been few psychiatric studies of elderly homicide offenders, though the individual case study literature is much richer. Rollin¹⁰ described a typical case of a 71-year-old man with a history of depressive illness who battered his wife to death after becoming convinced that she was beginning to fail in health and was too proud to allow herself to be looked after by anyone else should anything happen to him. Large homicide case series often include a small number of elderly cases: in Gillies’ classic series of 400 homicides in Scotland¹¹, there were only three men over the age of 65 and the oldest woman was 54. Unlike the majority of people accused of homicide, who were considered mentally normal (82%), all three of the over-65s were psychotic at the time of the offence.

In a comparison of older and younger homicide and attempted homicide suspects in Canada¹², much lower rates of previous convictions and past hospitalization for mental illness were found in the elderly group. Half of the elderly group had psychotic diagnoses, with none found in those under the age of 30; 19% of the elderly group had an organic mental disorder, with none in the younger group; 50% had alcohol problems (31% in the younger group); and only 13% had antisocial personality disorder (compared to 68% of the younger group). Surprisingly, though, fewer of the elderly group were found not guilty by reason of insanity (19% compared to 30%). This finding contrasts with sentencing data from Scotland in the 1990s, which showed that elderly homicides were more likely to be given hospital disposals than younger offenders and far less likely to be given life sentences (F. Thorne, personal communication).

Forensic pathologist Bernard Knight¹³ coined the term Darby and Joan syndrome for elderly couple homicides which occurred in apparently close, loving relationships, in contrast to younger partner homicides which typically occurred against a background of infidelity, jealousy and money disputes, fuelled by alcohol or drugs. He cited the case of a woman in her seventies who killed her husband with repeated brutal blows to the back of his head with a heavy metal object while he was sitting watching television. No rational explanation for the act could be obtained. Knight commented on the extreme brutality used in elderly couple homicides and cited two cases of octogenarian men who killed their elderly wives with hammers – one of whom rained down 37 blows on his wife’s head, resulting in multiple compound fractures of her skull. He also commented on the presence of bizarre postmortem bondage in many of the cases he was involved with, describing how a man trussed his wife up in a chair with twine and cord after killing her and then bound her face with towels and cloths secured by more twine.

Though the psychiatric literature emphasizes the differences between elderly homicide offenders and younger homicides, criminological data from US studies show that though elderly homicide rates vary between different US states, they are correlated with the non-elderly rates, which are themselves strongly correlated with urbanization and poverty, suggesting that the same societal pressures influence young and old alike¹⁴. Other US studies have shown that the elderly are more likely to kill family members, to use firearms and to carry out the offence in the home^15,16. The majority of elderly homicides are committed by men, but in a study of coroner’s office and county prosecutor files of 179 homicides by the over-60s in Cincinnati and Detroit¹⁷ it was found that women accounted for 18% of cases. There have been no systematic studies of elderly women homicides, however, though there are a number of brief case descriptions^18,19.

Homicide–Suicide

A number of studies have demonstrated that homicide followed by suicide is commoner in older adults²⁰. It usually occurs in a spousal relationship, and depression and alcohol problems are common. One study showed a mean age difference of 18 years between perpetrators and victims along with prominent histories of discord, violence and separation. There are published case studies of homicide–suicides that have no history of conflict, however: for example, an 82-year-old man who shot his frail 84-year-old wife and then himself after becoming unable to provide care for her after he suffered a myocardial infarction²¹. In such cases it can be difficult to distinguish between homicide–suicide cases and suicide pacts.

Non-Fatal Violence

Minor aggression in elderly dementia sufferers is common, with up to 90% displaying some sort of aggression during the course of the illness²². Most is not serious and relatively easily managed, in contrast to the type of behaviour described in an Australian case series of fourteen older adults accused of attempted homicide^23,24. The only one who succeeded in killing his victim in this series was a 68-year-old man who shot his neighbour with a shotgun.

Arson

There is no published literature on arson by the elderly. Clinical experience suggests that pyromaniacs, fascinated by fire and fire services, do not typically present in old age, but such individuals, many of whom have spent years in secure hospital or prison, may live on to old age and develop a neurodegenerative disorder. Such cases present extraordinary difficulties for psychiatric and social services, and the criminal justice system, which often struggle to balance the risk to others and individual vulnerability issues. It is not clear how risk to others from arson, or indeed sexual or violent offending, changes with the progression of a dementing illness, and so care generally has to be provided in an environment where risks can be managed through relational and procedural security measures. What appears to be more common in old age is the emergence of a pattern of setting small fires, often within residential homes. Though many of these fires cause little actual damage, because of the potentially devastating consequences, all fires in elderly care settings have to be taken seriously. As few old age psychiatrists have much experience of assessing fire setters, referral for a forensic psychiatric assessment is recommended. Arson in the elderly has been linked with personality disorder, psychosis, dementia and previously unrecognized learning disability.

Acquisitive Offending

Shoplifting is the commonest offence of late life, but most cases of acquisitive offending never come to the attention of old age psychiatrists. Anecdotally there is said to be an association with depressive illness, but there have been few studies on this topic. The shame of being arrested for shoplifting can have disastrous consequences for individuals with no previous criminal history, and the case of Lady Isobel Barnett, a British television personality who committed suicide four days after being convicted of stealing a can of tuna and carton of cream in 1980, is well known²⁵.

Drug- and Alcohol-Related Crime

For people born in the 1940s or before, drug use was uncommon when they were going through their period of highest risk; however, this is not the case for those born in the following decade, and old age psychiatry services are now beginning to see people with active drug problems, something that was almost unheard of previously. At present drugs do not present major problems in UK older adult secure hospital services, unlike services for younger patients, but this is likely to change over the coming years. Alcohol is being increasingly recognized as a problem in older adults²⁶ and alcohol problems are common among older men in prison in the US²⁷. When this is linked to offending behaviour it has serious implications for risk management. The assessment of older offenders with a history of alcohol abuse is further complicated by the possibility of alcohol-related cognitive impairment.

DIAGNOSTIC CONSIDERATIONS

All of the mental disorders that occur in late life can lead to criminal behaviour; for the overwhelming majority of individuals, changes in

behaviour as a result of mental disorder are recognized as such and dealt with by medical services. Sometimes, however, the behaviour can be so sudden and so severe that health services are not involved until after an offence has been committed. In these circumstances it is important that the individual receives an assessment by a clinician familiar with the psychiatry of old age.

Delirium

Metabolic and other causes of delirium, superimposed on the early stages of dementia or a pre-existing depressive illness, can lead to fatal aggression. Some of the bizarre, apparently motiveless homicides described above and many from my own experience have been the result of delirium, often occurring as a side effect of medication, including steroids, anti-parkinsonian medication and the anticholin-ergic effects of first-generation antidepressants.

Dementia

There are isolated case reports of crime associated with dementia, but given that it is so common, it is surprising that there are not more and that it has not been more systematically studied. Experience suggests that individuals with more than a mild degree of dementia are easily identified as such and not dealt with by the criminal justice system. This is not the case for those with very early dementia, or in cases of frontotemporal dementia with a well-preserved social façade. Dementia can present with a change in behaviour: either the emergence of new behaviours that were not present at all previously, or a change in the type, frequency and character of existing behaviour. Old age psychiatrists are familiar with the evaluation of such issues by taking careful histories from carers and relatives, but forensic psychiatrists are generally more used to assessing individuals through detailed mental state examinations, which may reveal little in early dementia. In a study of referrals to a regional medium secure unit in England, it was found that forensic psychiatrists did not routinely use standardized rating scales for the assessment of cognitive functioning²⁸

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