Ageing in forensic psychiatric secure settings: the voice of older patients

ABSTRACT Older patients account for around 20% of the population in secure forensic psychiatric services in the UK. However, little qualitative research has investigated the experience of ageing in secure settings. This study aimed to gather the individual views of a sample of patients over 50 years old in three services within the region of one NHS Trust in England providing different levels of security: high, medium and low. A total of 15 participants were selected and underwent one-on-one qualitative interviews. The interviews were analysed through thematic analysis, which generated seven themes: Self-agency, activities, social life, practical matters, recovery, physical health and service improvement. Study findings highlighted the complexity of ageing in secure settings. Despite the positive feedback reported in aspects such as physical health care, education opportunities, staff and support of religious practices, participants experienced added 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, thus increasing length of stay in the institution. Our findings call for the development/implementation of programmes tailored to the unique needs of older patients. This process requires an active involvement of the primary stakeholders and further patient-centred research.


Introduction
Secure forensic mental health services in England and Wales offer specialist/ intensive treatment to mentally ill individuals who, given their psychiatric symptoms, may pose a risk of harm to themselves or others.
Demographic trends (e.g. longer life expectancy), more frequent prosecution of historic offences, particularly sexual offences and changes in the legal system (e.g. increased number of lifetime sentences) have caused an accumulation of long-stay and newly admitted older patients in forensic psychiatric care (Frazer, 2003;Moll, 2013; Resettlement and Care for Older ex-Offenders and Prisoners [RECOOP], 2015;Yorston, 2015).
A recent cross-sectional study within one regional service in England found that patients over the age of 50 represented 21% of the total population in high security, 16% in medium security and 15% in low-security settings (Di Lorito, Dening, & Vӧllm, 2018a). Although it is difficult to retrieve further updated statistics in the UK context, prevalence around 20% for patients over 50 years old has also been reported in other European countries, including Italy  and Germany (Di Lorito & Völlm, 2018).
Despite the increasing prevalence, this population has been traditionally neglected in research. The few available studies, however, concurred that older patients have distinct characteristics from younger patients, thus presenting with unique care needs. For example, they are more frequently admitted following non-criminalised behaviour, and have less frequent previous psychiatric admission and prison detention than younger patients (Coid, Fazel, & Kahtan, 2002). Older patients also experience a statistically significant longer stay (Di Lorito et al., 2018a;Vӧllm et al., 2017), which sometimes extends beyond 20 years.
In terms of psychiatric disorder, compared to younger patients, they present with lower prevalence of schizophrenia, antisocial and borderline personality disorder, but with higher prevalence of delusional disorder, schizoid personality disorder, lifetime depression and organic brain syndrome (Coid, Fazel, & Khatan, 2002). Nine out of ten older patients have a documented physical health problem (Di Lorito et al., 2018a). Other than the typical health conditions experienced by patients of all ages, such as obesity and diabetes, they present with age-related problems, including musculoskeletal conditions, sensory impairment, cognitive impairment and dementia (Di Lorito et al., 2018a;Paradis, Broner, Maher, & O'Rourke, 2000;Shah, 2006;Tomar, Treasden, & Shah, 2005).
Although the existing studies have identified some of the unique challenges to recovery that older patients may experience, they have been largely based on clinical data, surveys and reports from staff members, thus neglecting the voices of the patients. In order to gather in-depth data reflecting the individual experience of ageing whilst in secure care, we deemed it timely to undertake qualitative patient-centred research.
We were driven in our inquiry by: (i). The NICE recommendations on mental wellbeing and independence in older people (2015), which advocates the involvement of older people, the 'expert', in research; (ii). The Recovery Model of forensic psychiatric care (Drennan et al., 2014), which places strong emphasis on human agency (Ward, Mann, & Gannon, 2007), thus implying an imperative for patient-based research.
Our study aimed to answer the following questions: (i). What is the experience of older patients in forensic psychiatric services? (ii). Are services meeting their needs? (iii). What can be done to enhance their experience and recovery opportunities?

Methods
This study was part of a larger project on older patients in three forensic psychiatric settings [high (HS), medium (MS) and low secure (LS)], within Nottinghamshire Healthcare NHS Foundation Trust. The project comprised a quantitative element around patients' characteristics and needs (Di Lorito et al., 2018a), and two qualitative studies, one around patients' experience (presented here) and one based on the views of members of staff (Di Lorito, Dening, & Vӧllm, 2018b).

Inclusion criteria
(1) Aged 50 years old or above. The current forensic psychiatric literature has not reached consensus on a definite criterion for 'older age', having adopted cut-offs spanning from 55 (Lightbody, Gow, & Gibb, 2010) to 65 years old (Curtice, Parker, Wismayer, & Tomison, 2003;Tomar et al., 2005). More consistent cut-offs instead, have been used in studies on older prisoners. These have usually applied a cut-off of 50 years old, based on the rationale that, given their history of substance abuse and poor health, older prisoners experience a quicker ageing process of around 10 years compared to community dwellers, for whom a 60-year-old criterion is typically adopted (Baldwin & Leete, 2012;Cooney & Braggins, 2010;Moll, 2013). Because the majority of older patients are admitted into forensic psychiatric services from the prison system (Coid et al., 2002;Curtice et al., 2003;Lightbody et al., 2010) and indeed this was the case in the three services included in our study (Di Lorito et al., 2018a), we deemed 50 years old a sensible inclusion criterion.
(2) Been resident in the service for at least one year, to have experience of secure settings. (3) Able to give full consent, determined by the researcher. (4) No reasons for not participating identified by the clinical team.
Among the 41 study participants from the quantitative study of the project (Di Lorito et al., 2018a), we selected a sub-sample of 16 patients. Selection was carried out through maximum variation purposeful sampling, to ensure that we gained insight into the phenomenon of ageing in secure settings by looking at it from a diverse range of perspectives. We therefore selected a cross-section of the population over 50 in the three recruitment sites, which was as representative as possible in relation to age, gender, ethnicity, length of stay, treatment stage, level of security and psychiatric diagnosis. We also purposefully sampled information-rich cases (i.e. patients who, in light of their good overall level of cognitive functioning, moderate severity of psychiatric symptoms and low risk, were willing/able to provide enriched narratives).
The patients identified as potentially suitable for the qualitative interview were asked to give consent on whether they wished to take part, prior to their involvement. All but one patient consented to take part. We therefore involved 15 patients in the qualitative interviews ( Figure 1).

Data collection
Data collection took place in interview rooms located in the wards in which the participants were accommodated. In two instances, the presence of a member of staff was required, as the patients were in seclusion. All other participants were administered one-on-one interviews by a member of the research team.
Although we used a semi-structured interview schedule (Appendix), new topics that emerged during the session were also explored to ensure that all relevant information were captured. The interview schedule comprised 25 questions including: (i) Likert-type opening prompts to stimulate participants' reflection and administered orally through an easy-read response sheet; (ii) openended questions for further in-depth investigation. It was informed by results from the following pre-study groundwork undertaken by the research team: (i) Systematic reviews and empirical studies around older forensic populations (Di Lorito, , 2018a. Patients consented and involved in the quantitative study of the project (n=41) Patients selected for the qualitative study (n=16) Patients who declined to take part (n=1) Patients involved in the qualitative study (n=15) (ii) Review of the NICE guidelines on mental wellbeing and independence in older people (National Institute for Health and Care Excellence [NICE], 2015). (iii) The primary needs that forensic services should address to promote patients' recovery, as indicated in the Good Lives Model for offender rehabilitation (https://www.goodlivesmodel.com/information). (iv) One Patient and Public Involvement (PPI) exercise carried out with three patients in HS. Through this exercise, we gathered feedback around the interview questions, and edited the schedule to make it more relevant to the patients.
Interviews were audio-recorded and transcribed by the lead researcher. In line with Legard, Keegan, and Ward (2003), we applied data saturation not at the level of the overall dataset, but in relation to the information provided by individual participants. Therefore, interviews with patients continued until a full understanding of the participant's perspective was reached.

Data analysis
The interviews were transcribed, transferred onto NVivo software Version 11 (QSR International Pty Ltd., 2012) and analysed through thematic analysis, a method to report data within themes (Braun & Clarke, 2006). Some of the themes were identified through the preliminary groundwork described in the data collection section above. Their fitness was assessed through initial examination of the interviews' transcripts. In order to prevent selection bias and extract only those quotes that fit into the initial themes, when other relevant information was identified during the examination of the transcripts, we would generate a tentative new theme.
The original and new themes were expanded, restricted, or merged through a back-and-forth process, until a final code book (Table 1) was agreed upon by the whole research team. Relevant data were then extracted and categorised into the final themes. Each member of the research team individually assessed the accuracy of data categorisation into the final themes to prevent single researcher bias.  Health and Social Care, 2005) and the Data Protection Act 1998. To safeguard the patients' anonymity, we did not label any quotation included in this paper (e.g. gender, age of participant). We did, however, provide participants' study numbers and level of security, which allow the reader to contextualise the narratives, while still safeguarding participants' anonymity.

Results
Detailed information about the participants cannot be provided, given the potential risk of re-identification. In brief, we interviewed six patients from a high secure setting, seven from a medium secure setting and two from a low secure setting. Participants were from the male mental health (n = 7), personality disorder (n = 6), and female services (n = 2). Interview administration time averaged 39 min (Range: 18-57 min). The initial list of themes (based on our preliminary groundwork) included: Social life, recovery, self-agency, activities and service improvement. The new themes, which emerged from the participants' interviews were: Practical matters and physical health. We derived seven final themes, each of which included several sub-themes (Table 1). These are discussed below.

Self-agency
The theme of self-agency explored how much in control patients felt in shaping their own present and future. Most patients felt they were in control of some specific practical aspects of daily living: 'I have control on the little things. I bought myself a couple of dresses, and put on some make up, just things to put me up a bit' (P12; MS) Others felt that they had decision-making power to shape their own treatment: 'The OT staff come on the ward and say, 'We would like you to go on this group'. I think about it and make a choice' (P07; MS) Participants also acknowledged that relinquishing a degree of control was to be expected within secure units: 'We have to realise that we are in a secure unit and there are parts of our lives we can't change' (P13; MS) However, several patients, perceived that control was totally in the hands of members of staff: Participants frequently expressed concerns when discussing the future. Some issues related to readjusting to contemporary living: 'Being out will be so strange after so long. The smallest things like crossing the road is going to be a massive step' (P19; HS) Others had concerns around employment: 'I think people wouldn't employ an older person with mental health issues. I can end up relying on benefits, rather than having an active job' (P40; LS) Relapse was also a tangible risk, in the absence of round-the-clock care from the clinical team: 'Because I've done it before, my main concern is: Am I going to fall in the wrong again?' (P11; MS) Given these concerns, several patients exhibited ambivalent feelings about leaving: 'The future scares me a bit. That's why I'm not in a hurry to leave' (P12; MS) These feelings were prominent among those who risked being moved back to prison, by virtue of their section or because they had a life sentence: 'If I do all the work, they put a referral to medium security. But once I've done all the work in an RSU and I am out, they can lock me back in prison' (P19; HS)

Activities
This theme focussed around participants' feedback around educational/ recreational activities and on their suitability for older patients. Participants felt confident that educational activities prepared them to live independently in the community: 'I find IT classes helpful for when I will be outside. It's all done through the internet now' (P40, LS) Patients who regularly attended the local library were also satisfied: 'We got a ward library here, so every Friday we can put our names on the board and go to the library' (P22; HS) When the hospital resources could not fulfil their educational needs, patients had alternative development opportunities: 'I've done distance learning through College on equality and diversity and I'm now nutrition and health' (P12; MS) Leisure activities could also be relaxing and soothing: 'My artwork, it's a chill out for me. It takes me to another place' (P14; MS) Physical activities also provided a social role within the community: 'I got gardening projects starting up. I got plenty to do. I give advice on how to go about in the garden, how to dig holes for plants ' (P18;HS) In addition, such activities promoted outdoor life and contact with nature: 'When I do horticulture, I really feel I'm all one with nature. It is one of the best things I have here' (P19; HS) In relation to the age-friendliness of activities, some patients stated that the activity programme was suitable for any age group: For this reason, the few activities specifically for the over 50s received positive feedback: 'I attend the Sage 1 group once a month. We go to the OT room and we pick an old film to watch. It's so comfortable and relaxing!' (P14; MS) Therefore, most interviewees advocated for a wider implementation of agerelevant initiatives: 'I'd be happier to see more people together in my age group in social functions or in the gym' (P15; MS)

Social life
This theme explored how the participants felt they related with members of staff, peers, and external visitors (e.g. family). Interviewees reported that members of staff exhibited genuine commitment to their emotional wellbeing: 'You always have somebody to talk to. They are very caring.' (P13; HS) They were able to respond to their individual needs: 'Some of the patients haven't got the confidence to ask for support, but they recognise that and they sit down with them' ( The patients recognised that attachment was mutual: 'They have a vested interested to get to know you, cos they also spend most of their life here' (P20; HS) However, some patients felt that the younger members of staff could be insensitive to age-related issues: 'Some of them do not understand that people over 50 might have different problems and treat everybody the same' (P08; MS) Participants felt that mental health problems often got in the way of their relationship with peers: Age difference could also impact on good rapport between patients: 'A lot of the times the younger lads don't want you around. And I struggle to have a conversation with them, because most of their things revolve around computers' (P19; HS) Friendships could end when patients are moved across wards of discharged: 'People from the other ward, I spent time with them every day for three years. They knew when I was sad and I knew when I had to cheer them up. So now I am trying to adjust to new people here' (P18; HS) Some patients, especially those on more settled wards, reported being on good terms with their peers:

Practical matters
Participants were asked to reflect on the practical aspects of their daily routines, which might impact on their experience in secure care. Food reviews were overall positive, but several patients reported unmet agerelated needs: 'I would appreciate some more food that I can chew. An alternative would be good' (P18; HS) These included feeling uncomfortable to dine in boisterous environments: 'I rarely go to the dining room to eat, because of the noise. You get a lot of chairs scraping on the floor, lots of shouting between patients' (P19; HS) Access to the telephone was another area where the older patients reported age-related unmet needs: 'I can't stand for a long time to be able to use the phone. And sometimes, it can get pretty late before I can make a call, so I just miss out' (P14; HS) The hospital shopping arrangements were found to be age-friendly: 'They give me a shopping sheet, I write down what I want and the porter brings it over in boxes' (P20; HS) Concerns were reported around the availability of funds. For this reason, all the participants described saving strategies: 'I try and save each day some pounds in the safe, in the bank and in the room. Today I spent about £5 and managed to save £15 for the next week and that is how I meet my budget' (P07; MS) The interviewees felt that the strict policies around physical contact limited social interaction: 'For me mostly it's just missing on having that interaction with people' (P04; HS) There appeared to be some welcome flexibility within the policy that it is allowed to accommodate the needs of partnered patients: 'I have just got married and when my husband visits me, the staff let us hold hands. I really appreciate it' (Anonymised, given the risk of identification) In relation to sexual expression, the patients generally agreed that intimacy on the ward would be inappropriate and could pose a threat to successful rehabilitation: 'I would view it as inappropriate in a small community, and I think you've got to concentrate on your treatment' (P20; HS)

Others reported no sexual needs:
'I have no worries in that sense. You see, I'm older, so these things don't matter to me' (P05; HS) Autoeroticism, however, was still relevant for some, who complained that regulations had become stricter over time: 'We used to receive magazines back then and they helped a lot. We also had a programme called "Sexcetera" about sexual expression, but they have cancelled it so there's nothing these days' (P05; HS)

Recovery
This theme explores participants' views on recovery and on the different elements that impact on it, including spirituality and treatment. One patient provided an eloquent image of recovery, framed within the metaphor of life as a river: 'Life's like a river. The stream is when you set out for the journey. You are confident, nothing stopping it. Then there's the waterfall. Suddenly, the water has no control of where it's going, just falling. You have the disaster and you can't do a thing about it. The fall ends in the lake, splashing. That's when recovery begins, when you wake to the fact. You reflect on what caused the fall. Each rock represents an issue that caused the fall and as you sort the rocks out, you let go of the pain from them. That's when you've recovered' (P05; HS) Several elements contributed to success in recovery in the view of participants. Personal commitment was key: 'You're not forced to come here. You need to want to come here and you will eventually get better' (P13; MS) Another relevant factor was support from the community: 'We have group meetings here, so I can come here and say what's on my mind and everybody tries to help me to get around that' (P14; MS) Patients believed that recovery was also linked with quality of life. Although most patients spoke well of certain aspects of treatment, such as the staff and activities, they overall did not think of themselves as having great quality of life: Pastoral care was considered akin to talking therapy: 'The chaplain came today. I told him the full story of the psychotic incident and he gave me support' (P05; HS) Given the benefits for the patients, the services were very supportive of any spiritual practice: 'I don't go to church cos it's quite a walk, but I have on ward communion. We also get an Imam, who comes here and a prayer room' (P13; MS) Treatment was another core element of recovery. Very positive feedback was reported around treatment groups: 'We have groups on alcohol, violence, drugs, and relationships. There In a small number of cases, the interviewees stated that there was little emphasis in secure settings to prepare older patients to move along the care pathway:

Physical health
All the participants experienced physical health conditions. They generally held positive views on how their physical health needs were met: 'We've got a good health care system and if the staff notice anything, they immediately get you sorted' (P13; MS) They frequently noted that their health needs were met better than in the community: Information on physical health care was also found to be adequate: 'When I was first diagnosed with diabetes, they immediately gave me information' (P20; HS) Physical activity was a key element to wellbeing, as it boosted selfconfidence, helped promoting a sense of purpose and helped obtain visible physical improvements: 'My kids are saying "Dad, I've never seen you so well". It shows me that I'm achieving something' (P14; MS) Gym sessions were especially popular among the older patients: Small fitness suites were also provided on the wards, an initiative which was very well received: 'We have a private gym here on the ward, so, if you feel edgy, you can just go and relax' (P22; HS) The patients, however, reported that much remained to be improved, to ensure equal opportunities to all patients to get active: The gym equipment was reported to be only suitable for younger patients: 'The weights in the gym are too heavy. The over 50s can't lift 30, 40 or 50 kilos' (P08; MS)

Service improvement
We asked participants to report on any possible improvements in the service to enhance their experience. They reported on dedicated units/wards for ageing patients and understaffing issues. It was felt that dedicated units for the over 50s could be beneficial in some respects. They would reduce social isolation: 'People of the same age stick together and you can be a little cut off if you don't relate with the younger people' (P05; HS) They would solve some irreconcilable intergenerational differences: 'I might want to watch something on TV that a very young person wouldn't want to watch' (P20; HS) They would also reduce the potential risk for bullying/victimisation against the older patients: 'I'd feel a little safer from the young and assaultive guys' (P07; MS) Dedicated wards for the over 50 would be more settled: 'I imagine it'd be a lot quieter. And I can see better conversation, rather than shouting all over the place' (P19; HS) The patients identified barriers to developing these services: 'There's problems with staffing and the prospect of a dedicated ward would be dismissed straightaway' (P19; HS) Other interviewees manifested opposite views toward units for the over 50s: 'I think wards need to be like a community, and in a community, you get people of all ages' (P13; MS) Several interviewees contended mixed environments are more settled: 'When you get younger people coming through, if you have older people around, some of their calm radiates' (P20; HS) They continued that older patients could benefit from mixing with the younger ones: 'The young people can teach us about technology. It's a fast world and you need to be up to date' (P38; LS) Another area in need of improvement was staff-to-patient ratio. Some patients reported that at times wards were run on fewer than three staff. Understaffing could impact on the atmosphere on the ward: 'When the staff do long days, they can get quite edgy, and when you ask for things, they sometimes respond with a nasty follow up' (P08; MS) Another direct consequence was the unequal consideration of patients: 'People who are high dependent and need attention all the time get it. But the guys who are self-dependent tend to be a little bit forgotten' (P20; HS) Given the staff shortages, movement of personnel across units and wards was frequent. This was cause for further disruption of patients' routine: 'Each ward is different, even the small things, like the boxes where they keep the keys. There should be some sort of uniformity, so members of staff would just need to learn the routine of the patients' (P20; HS)

Discussion
This paper presents findings from a qualitative investigation of a sample of older patients living in three secure forensic psychiatric units within the region of one NHS Trust in England, providing novel insight into the experience of ageing in secure care. While we are aware that some of the issues reported in this study are also common among younger forensic psychiatric patients, we feel that the unique challenges of ageing whilst in secure care render the experience of older patients distinctive and worth reporting.
In line with existing literature on old age forensic psychiatry (Yorston & Taylor, 2009), our findings highlighted some good elements of care, such as physical healthcare provision and educational/cultural opportunities. These results are encouraging in light of the vulnerability of older patients to physical health conditions and social exclusion. In addition to the benefits of spirituality documented in the prison literature (Allen et al., 2013;Allen, Phillips, Roff, Cavanaugh, & Day, 2008;Bishop, Randall, & Merten, 2014;Reed, 1980), our participants also provided positive feedback around support for their spiritual needs.
Our results also identified unique challenges to recovery. Despite their availability to provide emotional support to the patients, most members of staff were reported to lack specific training in old-age issues and criticised for adopting a one-size-fits-all approach to dealing with patients' care. Issues like understaffing, work overload and movement of staff across wards further exacerbated a sense of neglect of older patients' needs, especially among those who are more independent and require less monitoring/support. Although 'institutional thoughtlessness' toward age-related issue has been consistently reported in the prison system (Crawley, 2005), it is worrying that it extends to forensic psychiatric settings, whose remit is to provide tailored (e.g. age-sensitive) treatment and care to all patients.
Another major barrier to recovery identified in our study was poor treatment compliance, which resulted from different factors. As reported in the prison literature (Crawley & Sparks, 2006;Loeb, Steffensmeier, & Myco, 2007), the participants expressed concerns around discharge into the community, including readjusting to life in society after long-term institutionalisation, reduced competitiveness in the job market, triple stigma (i.e. against older people, mental health service users and offenders) and a weak support network in the community. This generated older patients' attachment toward forensic units (Yorston & Taylor, 2009), thus affecting their willingness to move along the care pathway.
Poor treatment adherence could also be a tangible risk for the 'prisoner transfers' (i.e. prisoners who, given their psychiatric disorder, were diverted to forensic mental health services). Contrary to other European countries such as Italy , UK legislation does not separate between the penalty and the mental health route, making it possible for a patient to be moved back to prison, once psychiatric symptoms are remitted. This prospect raised concerns among several of the prison transfers in our study, who alluded to a wish to prolong their stay in secure services.
Poor treatment compliance was also reported among the long-stayers, who experienced a lack of enthusiasm to engage in education and activities, which they found repetitive over time. This finding raises important questions around how services are actually meeting the treatment needs of longstay patients to favour their movement along the care pathway. Almost 20 years after the implementation of the accelerated discharge programme, it is evident that many of the older patients have not fully benefitted from the initiative, having remained stuck in the system long-term.
Another barrier to recovery identified in the study was the risk of social exclusion. In line with previous research (Yorston & Taylor, 2009), we found that the participants experienced great difficulties to build good relationships with their own peers. Although poor mental health was recognised as a mediating factor, poor peer relationships were also the result of intergenerational issues, most patients in mixed-age wards being of younger age, and of the frequent transfers of patients across wards/units, which caused severance of existing friendships.
Contrary to previous findings on long-stay patients of all ages  and in line with research in old age forensic psychiatry (Crawley, 2005;Yorston & Taylor, 2009), our participants reported limited contact with their families, a trend which might be related to ageing. Patients' exclusion from the wider community of the hospital was reported by the patients with limited mobility, given the limited accessibility of premises, which have been consistently reported in the previous literature (Yorston & Taylor, 2009) and confirmed by members of staff (Di Lorito et al., 2018b).
Given the added risk of social isolation, participants frequently discussed potential solutions. In contrast with previous evidence (Yorston & Taylor, 2009), when asked to comment on possible units for the over 50s, several patients supported mixed-age wards, contending that the benefits of living in a diverse community outnumbered intergenerational issues. Consensus was instead found on the necessity to develop cross-ward social opportunities for older patients, there being just one initiative for over 50s, in the medium secure setting.
In relation to sexual expression and intimacy, the participants complained about overly stringent policies. This finding reflected a recent comparison study on policies around sexual expression in European countries, which concluded that the UK adopted the most restrictive regulations (Tiwana, McDonald, & Völlm, 2016). Quite interestingly, the older patients were not critical in relation to restrictions around sexual relations, contending that they might interfere with treatment, but rather they lamented the reduced opportunities for human connectedness caused by the stringent regulations around physical contact (e.g. prohibition to hug) and the lack of programmes/support/courses on sexuality and autoeroticism.
These findings challenge the traditional view of older forensic psychiatric patients as asexual (Brown, Reavey, Kanyeredzi, & Batty, 2014;McCann, 2000). In light of evidence suggesting a link between intimacy and mental health recovery (Gilburt, Rose, & Slade, 2008) and in the lack of an a UK national policy around sexual expression, we advocate for the development of tailored care plans looking at individual patients' sexual needs, as required by The Royal College of Psychiatrists (2007).
This study is characterised by some limitations. We are aware that feeling older is a subjective experience and that there are limits in setting an inclusion criterion based on chronological age (i.e. age based on date of birth) rather than biological age (i.e. how old the person feels). However, in the recruitment phase of the study, the potential participants were made aware, through study documents and informal conversations with the researcher, that the study was about 'older' patients. We are confident that, had they not self-identified as being in the older age group, they would have not agreed to be involved in the study.
Sample size and composition might have affected the generalisability of findings. The only two women and one participant of Black ethnicity were from medium security, thus neglecting representation of these populations from other services. In addition, our findings might over represent the views of the more compliant patients, who were more likely to be involved. Also, the views of patients who lacked capacity to consent were not included.
In relation to data collection, our primarily deductive approach may have imposed themes upon the patients. However, being aware of this possibility, we adopted a flexible approach to interviewing, by exploring new issues that emerged during the session, and allowed for new themes to be added in the codebook, if relevant. Regarding data analysis, qualitative means of investigation require a degree of data interpretation, which may alter/filter patients' reports. To mitigate this risk, we kept our text input at a minimum in the results section, to safeguard the integrity of patients' narratives.
In terms of research implications, we were only able to involve three services within a single regional service in our study. Although purposively sampled to reflect the population over 50 in the three services, our participants might not be representative of other populations of ageing patients in secure services. Being aware of the local scope of our study, we advocate for research involving more representative samples to derive more generalisable findings.
Our study has several implications for policy and practice. Forensic psychiatric services face challenges from the increasing numbers of older patients (Di Lorito et al., 2018a), who already experience numerous barriers to recovery, as evidenced in this study. This may challenge the ability of service providers to grant equal opportunities of care to all ageing individuals, including those in forensic settings, as required by the National Institute for Health and Care Excellence (NICE) guidelines on mental wellbeing and independence in ageing people (NICE, 2015) and the Care Act 2015. A timely response is therefore needed.
It remains uncertain whether dedicated units for older patients are practically feasible, financially sustainable and therapeutically effective. However, good practice can be promoted through (further) development of age-sensitive approaches to treatment and care. These may include: (1) Age-inclusive educational, occupational, vocational, recreational and social activities (2) Age-relevant treatment and therapy (e.g. Cognitive Stimulation Therapy, speech and language therapy, arts therapy) (3) Improved accessibility, including modifications to environments (e.g. shower chairs, handrails) and flexible regimes (e.g. dedicated hours for phone calls) (4) Personalised packages (e.g. for discharge, social care, sexual expression) These programmes need to be tailored to older patients' needs, and so optimal allocation of funding and investment of resources is vital. We have shown that older patients do have views about their treatment and needs and, therefore, systems need to be in place to ensure their active input into how services are organised. Because older patients constitute a numerical minority in secure services (Di Lorito, Dening, & Vӧllm, 2018), they are scattered across different wards, and they are typically less assertive to voice their needs (Doron, 2007), they might fail to lobby as effectively as other population groups. Nonetheless, services should actively seek their involvement, so that their distinct service needs can be adequately met. Note 1. The Sage group is a monthly social event in the MS service. It is dedicated to older patients from across all wards, who gather to watch a film. Four of our participants from the MS service attended this group.

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