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Older adults in Ontario’s forensic psychiatry system often face care decisions shaped more by their past than their present circumstances. Clinicians rely heavily on historical information when assessing risk, such as the original offence that led to psychiatric supervision (known as the index offence) and past psychiatric history. While this information is important, it cannot change nor sufficiently capture current realities. Placing too much weight on the past may overshadow more dynamic, modifiable factors, like treatment adherence, current mental health, and access to community supports.
A new study published in CNS Spectrums by Mark M. Kaggwa, Joan Abaatyo, Arianna Davids, Angela Li, Rebecca Marsh, Precious Agboinghale, John M. W. Bradford, Gary A. Chaimowitz, and Andrew T. Olagunju examined how clinicians assess risk for older adults under forensic supervision in Ontario. Including many members of the Forensic Psychiatry Institute’s team, the authors found that historical factors consistently outweighed dynamic and protective factors.
Dr. Olagunju and his co-authors argue that risk assessments for older adults need to be rebalanced. Effective care planning requires more than documenting past events. It should consider protective elements, such as stable treatment, strong support systems, and the person’s current capacity to manage their health. They recommend age-appropriate, personalized approaches that integrate these factors with clinical needs. By shifting the emphasis toward the present, clinicians can improve rehabilitation outcomes while still maintaining public safety.
These conclusions also highlight the need for policies, resources and innovative practices that ensure risk assessments inform real-world decisions about care and community reintegration.
A Closer Look at Older Adults in Forensic Care in Ontario
The research team examined the Ontario Review Board database for 161 forensic patients aged 55 years and older. Most were men (81%), and nearly two-thirds were diagnosed with schizophrenia. .
Dr. Olagunju and his colleagues tested six groups of factors in sequence to see how each contributed to changes in assessed public safety risk over time. These included:
- Sociodemographic characteristics,
- Circumstances during the index offence,
- Current clinical profile,
- Past psychiatric history and behavioural patterns,
- Criminal history and legal status, and
- Recent violent events.
Historical Factors Still Dominate Risk Assessments
The researchers found that clinicians placed significant weight on historical factors when assessing risk over time. Circumstances during the index offence and the person’s past psychiatric and behavioural history together explained more than half of the differences in how clinicians assessed risk.
Clinical status also played a key role. Clinicians consistently assessed inpatients as being higher risk, suggesting that illness severity and the need for close monitoring shaped these decisions. By contrast, they tended to consider outpatients or people with the capacity to consent to treatment as being lower risk.
Clinicians also considered individuals who were intoxicated during their index offence to be lower risk in later assessments. The authors suggest this may reflect the effectiveness of substance use treatment in forensic settings.
Unemployment initially appeared to be linked to higher assessed risk but became less important when clinical and historical factors were considered.
Resources and Innovation Needed for Better Risk Assessments
The authors call for more resources and policies to support older adults in forensic care, including inpatient services to manage behavioural issues. They also stress the importance of innovative practices that integrate dynamic and protective factors, such as treatment adherence, current health status, and community support. Effective management requires strategies tailored to the specific needs and capabilities of older patients, rather than relying too heavily on historical information.
The authors recommend that future research focus on developing and validating risk prediction and care planning models for older adults. These models should incorporate individual circumstances, dynamic factors, and protective supports. These would improve risk management and guide more effective strategies for rehabilitation and public safety.
Written by Kyle Roerick and approved by Dr. Andrew T. Olagunju.
