Mohammed T. Abou-Saleh

628 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYby suicide. Knight described several cases, noting that there isgenerally no history of previous violence or discord 16 .The disinhibition and irritability of mania may also lead toaggressive behaviour, although serious violence is uncommon.Both types of mood disorder may be associated with shoplifting,on account of poor concentration, diminished concern aboutsocial rules or associated dynamic factors. In relation to shoplifting,an emotional disturbance following a life crisis but fallingshort of depressive illness may form the background to theoffence. It should also be borne in mind that the trauma of arrestitself in an elderly person with no previous symptoms may lead topsychiatric sequelae, including suicidal ideation.Case History 1: Depressive HomicideA 68-year-old man with previous episodes of depressive illnessdeveloped depressed mood and agitation over several weeks.There was no history of violence and he was known as a quietkindly man. He became preoccupied with two themes, first thatthe water supply in his house was infected and had caused hiswife’s psoriasis, and second with guilt regarding a minor sexualmisdemeanour that had occurred during his teens. His wife askedhim to just try and do the shopping, something he foundparticularly difficult when depressed. He experienced the suddenthought that if he killed her, the action would have the dualbenefit of releasing his wife from her misery and ensuring that hereceived a life sentence, a fitting punishment for the sexualmisdemeanour. He strangled her and rang the police. He wasbailed to hospital and later placed on probation, with a conditionof psychiatric treatment.Case History 2: Shoplifting and DepressionA 75-year-old retired plasterer with no previous convictionsreceived the news that his son-in-law was having an affair. Hehimself had endured a stressful marriage for a lifetime. He becamedepressed in mood and overwhelmed by intrusive, angry thoughtstowards his son-in-law. His sleep became disturbed and hispowers of concentration diminished. While shopping he wasobserved to pick up a paint brush and slip it into his jacket. Hethen clambered over a barrier to leave the store. The shop refusedto stop proceedings, but the Court dismissed the charge onhearing psychiatric evidence. The emotional crisis subsided withtime and a period of supportive counselling.SchizophreniaThe most common offence associated with schizophrenia in thosethat are homeless is shoplifting. However, both violent offencesand arson may occur, on account of paranoid ideation.Case History 3: Violence Associated with Paranoid DelusionsA 75-year-old man was arrested following his approaching agroup in his local pub, grabbing one person by the neck andcutting his lower throat with a carving knife. The publicanreported that the elderly man was a moderate drinker and that hehad been expressing abnormal ideas over the previous year. Hehad had a partial pneumonectomy for lung cancer 3 years prior tothe offence. At interview he said that neighbours watched him allthe time, made derogatory remarks about him and had a lasermachine which they used on his body. On the day of the offence,he said he had heard one of the group of men say ‘‘He stinks’’, andconcluded that they were associated with those acting against him.He returned home for a knife and said later he only wished tofrighten the victim. No evidence of recurrence of his lung cancerwas found at that stage. Following treatment with antipsychoticmedication, he no longer complained of abnormal experiences,although he retained some delusional ideas. He became relaxedand content in contrast to his agitated state prior to treatment andsaid that he had no desire to revenge himself on the peopleinvolved in the paranoid ideation. He pleaded guilty to woundingwith intent and was placed on a hospital order under Section 37 ofthe Mental Health Act (1983), with restrictions on dischargeunder Section 41. There were no management problems, althoughhe remained in hospital until his death with metastases 18 monthslater.DementiaAssaultative behaviour in dementia is not uncommon, althoughwithin a family or institutional setting the behaviour is unlikely toform the basis of a formal charge. Disinhibition, misinterpretationand the pressures of close living with others may be contributoryfactors. Petrie et al. 17 studied a series of 222 consecutiveadmissions to a psychogeriatric unit in the USA and noted that139 had shown verbal aggression or violence, 18 incidentsinvolving the use of knives or guns; 39 of these patients weresuffering from senile dementia and the remainder from functionalpsychoses. Disinhibited sexual behaviour or fire-setting may alsoreflect the loss of cortical inhibiting factors in dementia.Persistent theft from shops may be linked with absent-mindednessin the early stages of illness or with a more generaldeterioration in social behaviour at a later stage. Mendez describeda case of persistent stealing in a 71-year-old man with dementiawho constantly picked up small items with no explanation for hisactions 18 .AlcoholismIn addition to alcohol-related offences, such as driving whileintoxicated, problem drinking may be associated with theft,criminal damage, violent or sex offences. Many cases involve avariety of factors, e.g. about one-third of elderly homicideoffenders in a series studying coroners’ files had been drinkingat the time of the killing 6 .ASSESSMENT OF THE ELDERLY OFFENDERA careful assessment of mental and physical health and of theperson’s social circumstances and the quality of relationshipswithin this is necessary. Particular note should be taken of the useof alcohol and of prescribed or proprietary medication. Where thecharge is more serious, full details of the allegation should beobtained from witness statements and informants.In assessing a defendant’s fitness to plead, consideration isparticularly given to the defendant’s ability to understand thenature of the charge and the significance of his plea and to followthe process of the trial. In some cases, discontinuation ofproceedings may be more appropriate.THE ELDERLY WITHIN THE CRIMINALJUSTICE SYSTEMAppropriate assessment that would identify those offendersrequiring social and psychiatric intervention is often lacking,