The ageing prison population
The worldwide population is ageing dramatically.Footnote 1 This phenomenon is also reflected in correctional populations throughout the world. For example, in the United Kingdom the overall prison population grew by 51% between 2000 and 2009, while the population over the age of 60 grew by 216%.Footnote 2 In Japan, the number of prisoners over the age of 60 increased by 160% between 2000 and 2006.Footnote 3 Such a rapid rise in the number of older prisoners has been described as a correctional “ageing crisis” which poses an urgent challenge for correctional health-care systems – especially those poorly equipped to meet the complex needs of older adults.Footnote 4
While these ageing trends are seen in many criminal justice systems throughout the world, they are most profound in the United States. From 1990 to 2009, the total US prison population doubled while the number of incarcerated individuals aged 55 or older increased by 300%,Footnote 5 and the median age of state prisoners increased from 30 to 36 years.Footnote 6 This demographic shift has continued in the United States even as the growth of the general prison population has decreased; between 2009 and 2013, the population of US federal prisoners aged 49 or younger decreased by 1%, whereas the number of prisoners aged 50 or older increased by 25%.Footnote 7 Older prisoners now represent approximately 10% of the US state prison population.Footnote 8
This article describes some of the challenges facing correctional systems tasked with providing health care to older adults, highlights some innovative approaches being taken to optimize the care of incarcerated older adults, and draws attention to some areas in need of reform. Drawing on evidence developed primarily in the United States and to a lesser extent Europe, it draws conclusions and makes observations that are widely applicable to correctional facilities worldwide.
Geriatric health-care in the correctional setting
While health-care professionals outside of the criminal justice system typically use the age of 65 to define which individuals are “older adults” or “geriatric”, the demarcation between “young” and “old” in correctional settings is less well defined. This is because many criminal justice-involved individuals experience multiple chronic physical and/or mental health conditions and physical disabilities at relatively young ages.Footnote 9 They are also more likely to have experienced profound stress and/or trauma over their lifetime, to have a history of substance use disorder and/or homelessness, and to have had limited access to quality health-care and education.Footnote 10 The high degree of early-onset medical and social complexity found in this population is often referred to as “accelerated ageing”.Footnote 11 To account for accelerated ageing, many jurisdictions consider individuals in their 50s to be “older prisoners”.Footnote 12
Most correctional facilities were designed to restrict the liberty of young people, not to provide optimal care for the aged. As a result, correctional facilities are often ill-equipped to meet the needs of older adults with complex medical conditions and physical disabilities. These facilities often require residents to contend with challenging environmental features such as poor lighting, steep staircases, dimly lit walkways, high bunk beds and low toilets. The rise in the number of incarcerated older adults has led some correctional facilities to introduce environmental modifications for residents with physical disabilities and system-wide enhancements to manage their complex health needs. Together these factors likely contribute to high correctional costs.Footnote 13
Yet a precise accounting of the health-care costs generated by incarcerated older adults is frequently hampered by a lack of data transparency on the part of correctional systems, and by differences in how systems that do share their cost data define and report on expenses.Footnote 14 , Footnote 15 Best-guess estimates suggest that the average incarceration-related costs for older adults in the United States are up to nine times higher than for younger adults.Footnote 16 In 2013, the US Office of the Inspector General found that the Federal Bureau of Prisons spent $881 million to incarcerate individuals aged 50 or older.Footnote 17 Furthermore, state prisons that house the highest proportion of older adults generate medication costs that are fourteen times higher than the prisons with the lowest proportion of adults aged 50 and older.Footnote 18
Incarcerated older adults also experience unique criminal justice outcomes. Compared to their younger counterparts, older adults tend to incur fewer disciplinary actions while incarcerated and have lower recidivism rates once released. For example, in the US Federal Bureau of Prisons statistics, individuals aged 50 or older account for 19% of the population but generate only 10% of misconduct incidents.Footnote 19 Over the same period, the three-year recidivism rate for all individuals leaving US federal prisons was 41%, while it was 15% for persons aged 50 or older.Footnote 20
In many nations, incarcerated individuals are entitled by law to an equivalent standard of health care that is received by free individuals in their community. For example, the International Covenant on Economic, Social and Cultural Rights affirms “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”.Footnote 21 The United Nations Basic Principles for the Treatment of Prisoners establishes that “[p]risoners shall have access to the health services available in the country without discrimination on the grounds of their legal situation”. The European Court of Human Rights has affirmed the right to standard of care for prisoners through case law.Footnote 22 This is also the case in the United States, where in 1976, the Supreme Court guaranteed prisoners’ rights to “community-standard” health care.Footnote 23 This concept, commonly referred to in European nations as “equivalence of care”, is often used to define the minimal health-care standards required of correctional facilities.
While ethicists suggest that equivalence of care is difficult (and sometimes impossible) to achieve in a setting where patients have compromised autonomy, competing priorities (for example, legal concerns or safety issues) and considerable social and health-care needs that strain the resources available to treat them,Footnote 24 it is a useful concept for developing a basic expected standard of care. When the equivalence of care test is applied to the care of older adults in the correctional setting, it is important to use the field of geriatrics as the community benchmark for care. Geriatrics is the field of medicine that aims to optimize the health, function, independence and quality of life of older patients through the lens of bio-psycho-social assessment and treatment.Footnote 25 The field of geriatrics takes a patient-centred approach to prioritizing and assessing the risks and benefits of different (and at times competing) interventions offered to patients with multiple medical conditions and disability through a comprehensive assessment of their personal goals of care. To incorporate a geriatric health-care model in correctional settings requires an understanding of the clinical conditions prioritized in geriatric care.
Medical conditions prioritized in geriatric care
Functional ability
In geriatrics, “functional ability” refers to an individual's capacity to attend to their own “activities of daily living” (ADLs), such as dressing, toileting and feeding oneself, and to common daily tasks called “instrumental activities of daily living” (IADLs), such as shopping and managing one's finances and medications.Footnote 26 A person's functional ability is a result of the interaction between their cognitive and physical abilities and the environment in which they live.
Assessing and optimizing functional ability in older adults is critical to maximizing their health, safety and well-being. In the community, research has consistently shown that a decline in an older adult's ability to independently perform their ADLs and IADLs is a harbinger of worsening health, rising health-care costs and mortality.Footnote 27 As a result, physicians and other health-care professionals who practice geriatric medicine focus primarily on assessing their patients’ capacity to perform these tasks, an assessment which often results in recommendations for how to modify the living environment in order to maximize their independence. As an example, simple tools such as specialized button hooks and Velcro shoes can be used to overcome the difficulty experienced with severe arthritis.Footnote 28
Assessing functional ability in the correctional setting can be complicated. In the United States, for example, most – if not all – incarcerated individuals do not manage their own grocery shopping, cooking or finances. This makes it difficult to assess a patient's capacity to perform these daily activities. In contrast, other tasks may commonly be required of incarcerated individuals, such as standing for a long time for head count or climbing onto an assigned top bunk.Footnote 29 Unique daily activities such as these vary between facilities and even between housing units in the same facility. For this reason it is important to identify the physical tasks required to maintain independence (“activities of daily living for prison”) in each housing unit and assign individuals according to their ability to perform these required tasks.Footnote 30
Multimorbidity and medical complexity
Incarcerated older adults shoulder a disproportionate burden of chronic medical conditions.Footnote 31 One study that assessed the health of men aged 60 or older in prisons in England and Wales found that 85% reported at least one major chronic illness, a rate higher than that reported by their age-matched community counterparts and far higher than reported in younger prisoners.Footnote 32 In Switzerland, incarcerated older adults have been found to seek medical attention more frequently – and for more complicated chronic conditions (such as diabetes and heart failure) – than younger prisoners.Footnote 33 In addition, common chronic illnesses, such as diabetes, advanced liver disease and coronary artery disease, can make the management of co-occurring conditions such as paraplegia more difficult.Footnote 34
Incarcerated older adults are also particularly vulnerable to infectious disease. One study in Texas found that rates of tuberculosis, hepatitis B and C, resistant staphylococcal infections (such as methicillin-resistant Staphylococcus aureus, or MRSA), syphilis and pneumonia were disproportionately high in incarcerated older populations compared to younger prisoners and to community-dwelling older adults.Footnote 35
Geriatric Syndromes in the Correctional Setting
In addition to chronic medical conditions, older adults frequently experience other “geriatric syndromes” that can have a negative impact on their physical function and quality of life. Examples include frequent falls, cognitive impairment and dementia, incontinence, sensory impairment and polypharmacy.Footnote 36 The presence of geriatric syndromes such as these contributes to an older adult's overall frailty and poor health outcomes.Footnote 37 Older adults warrant a full geriatric evaluation upon intake at correctional facilities to identify whether any geriatric syndromes are present and, if so, to make recommendations for how to address these conditions. Persons ageing in prisons should receive periodic reassessment (i.e., annually) to identify and address new geriatric syndromes as they arise.
Falls
Falls are a leading cause of serious injury and death among older adults.Footnote 38 Loss of muscle mass, pain due to arthritis, impaired balance due to loss of nerve sensation, and hearing or visual impairment are examples of the many drivers of high fall risk among older adults.Footnote 39 In the correctional setting, many factors can heighten the risk of falls, such as dimly lit or crowded walkways. Furthermore, institutionalized older adults who spend the majority of their time indoors are at heightened risk for vitamin D deficiency due to insufficient sun exposure.Footnote 40 Vitamin D is critical for both muscle and bone health, and vitamin D deficiency puts older people at risk of falls.Footnote 41 Any additional obstacles to normal ambulation – such as being required to walk with ankle or wrist restraints – are also likely to enhance the risk of falling. Moreover, those who have few opportunities to exercise may experience physical deconditioning, a strong risk factor for serious fall-related injury.Footnote 42
Cognitive Impairment
Normal age-related cognitive changes can include slower reaction times and slower performance on timed tasks.Footnote 43 In contrast, the diagnosis of abnormal cognitive changes (dementia) requires both memory impairment and impairment in at least one additional cognitive domain, such as judgement or executive function, plus some degree of new functional impairment (newly impaired ability to perform ADLs or IADLs).Footnote 44
The World Health Organization (WHO) estimates that there are 47.5 million people worldwide living with dementia, and that this number will increase to 75.6 million by the year 2030.Footnote 45 The incidence of dementia increases with advancing age; while the prevalence of dementia amongst people aged 70–79 is 5%, this number jumps to 37% for people over 90.Footnote 46 Many of the risk factors for dementia – such as poor educational attainment – are common in correctional populations.Footnote 47 Although there exists little research in this area,Footnote 48 it has been estimated that the prevalence of cognitive impairment in incarcerated older adults is high, reaching as high as 19% to 30% among incarcerated adults aged 55 or older.Footnote 49 One study found that dementia was listed as a diagnosis in 40% of older adults in one state prison system in the United States.Footnote 50
While the regimented daily schedule in correctional facilities may make it difficult to detect signs of cognitive impairment and dementia (such as getting lost, misplacing belongings and mismanaging money), early diagnosis is of critical importance in the correctional setting. Cognitive changes, personality changes that often accompany dementia, and “dementia-related behaviours” (such as wandering, fighting and poor impulse control) may put individuals at heightened risk for unwarranted disciplinary action, victimization or failure to comply with parole instructions following release. One important resource for detecting cognitive impairment in its early stages is to educate those who spend the most amount of time with individuals in prison – such as correctional officers – to recognize early warning signs. One study found that correctional officers with no special training suspected the presence of cognitive impairment in five times as many individuals as clinical staff.Footnote 51
Urinary incontinence
Although urinary incontinence is common among older adults, it is not a normal part of ageing and it always warrants a thorough medical evaluation.Footnote 52 In the community, incontinence is often underreported and underdiagnosed.Footnote 53 Studies show that patients rarely bring it up to their health-care providers without prompting.Footnote 54 Indeed, in one survey of correctional health-care directors, respondents reported that they were 30% more likely to ask their patients about asthma than incontinence during a physical exam.Footnote 55 In the correctional setting, malodorous clothing due to incontinence could put older adults at heightened risk of victimization or intimidation. It is therefore critical for correctional health-care providers to ask all older adults about incontinence, and for prisons to stock appropriate incontinence hygiene supplies and allow older adults with incontinence to change clothes as often as needed.Footnote 56
Sensory impairment
At least one third of individuals aged 60 or older and more than 80% of individuals above age 85 have some degree of hearing impairment, while approximately one in three individuals over age 80 are visually impaired.Footnote 57 Hearing and vision impairment may present unique challenges for incarcerated individuals, such as interfering with the ability to respond to correctional officers’ orders or to fully participate in a court hearing.Footnote 58 Sensory impairments also heighten the risk of injurious falls and can lead to distressing social isolation.Footnote 59 Incarcerated older adults should receive screening for hearing loss, as hearing aids can improve social and emotional well-being.Footnote 60 Older adults should also receive annual vision testing and should be considered for hearing and vision testing after a fall, or if they become more withdrawn over time.Footnote 61
Polypharmacy
“Polypharmacy” describes the simultaneous prescription of multiple medications, the use of any medication known to cause adverse events in older adults, and/or the use of a medication to treat the adverse effects of another medication.Footnote 62 Older adults are particularly vulnerable to medication interactions and adverse medication side effects, both common in polypharmacy, due to age-related changes in drug metabolism that affect both the delivery and clearance of medications from the body.Footnote 63 Polypharmacy also can exacerbate the adverse effects of other geriatric syndromes (such as falls, incontinence or cognitive impairment) and is frequently an overlooked contributor to older patients’ physical complaintsFootnote 64 . For these reasons, geriatrics experts pay special attention to polypharmacy and frequently engage in “deprescribing” – reviewing and reconciling medication lists at every clinical visit to eliminate unnecessary and low-yield medications or those with a poor side-effect profile for older adults.Footnote 65 Polypharmacy is also common in the correctional setting – in a study focused on one state prison system, patients over 65 years of age were taking an average of nine different types of medication.Footnote 66 These patients were more likely to receive medications deemed inappropriate for older patients than those in comparable studies of community-dwelling elders.Footnote 67
Mental health disorders and isolation
Many incarcerated older adults face psychosocial challenges that can exacerbate physical disability. For example, approximately half of US prisoners have at least one mental health condition.Footnote 68 Estimates of the prevalence of serious mental illness in incarcerated older adults in the United States range from 10% to 40%.Footnote 69 Post-traumatic stress disorder is present in up to a third of incarcerated older individuals.Footnote 70 Older adults may also experience heightened anxiety related to their impending release to the community.Footnote 71 Others may feel distress at the prospect of dying while incarcerated.Footnote 72 For some, limitations in the ability to perform prison activities of daily living are associated with higher rates of depression and suicidal ideation.Footnote 73
Mental health can be further affected by feelings of isolation in the correctional setting. Compared to incarcerated younger adults, older adults generally have fewer regular visitors and fewer connections within the prison to social networks and self-help groups.Footnote 74 This relative social isolation can lead to diminished functional capacity or may be exacerbated by it, putting older adults at a heightened risk for subsequent worsening loneliness and physical disability.Footnote 75
The health of older women prisoners
Between 1980 and 2014, the number of incarcerated women in the United States increased by more than 700%.Footnote 76 In 2015, 7% of women prisoners in the state and federal prison systems were aged 55 or older.Footnote 77 In England and Wales, a growth in the population of women in correctional facilities is also outpacing the population of men: while the number of incarcerated men in these countries has been reduced by approximately 50% since 2004, the number of incarcerated women has doubled.Footnote 78 The number of incarcerated women is also growing at a faster rate than that of incarcerated men in Australia and New Zealand, and in many Latin American and European nations.Footnote 79 Yet the needs of older women risk being overlooked in many correctional systems that were originally designed to care for young, healthy men.
Few studies have considered the health-care needs of older women in correctional facilities. Much of what is known about women's health in correctional settings has been focused on the reproductive health of younger women.
Some inferences can be made about the health-related needs of incarcerated older women based on the few studies focused on this population, studies about incarcerated younger women, and what is known about the health-care needs of community-dwelling older women. For example, incarcerated women are more likely to have HIV/AIDS and other sexually transmitted diseases (STDs) than incarcerated men.Footnote 80 Studies from Texas have demonstrated that the prevalence of hepatitis B and C, HIV/AIDS, MRSA and syphilis are higher in incarcerated older women than in incarcerated older men.Footnote 81 The high prevalence of sexually transmitted diseases is perhaps not surprising given the large number of incarcerated women who have experienced a history of physical or sexual abuse (57% in one study)Footnote 82 or victimization (between 77% and 90%),Footnote 83 or who have engaged in commercial sex work. For example, 6.5% of women admitted to the New York City jail system in 2009 were sex workers, and these women were found to have a higher prevalence of STDs than non-sex workers.Footnote 84
Incarcerated women are also more likely to report drug or alcohol addiction and to be incarcerated for a drug-related crime compared to men (e.g., 59% of incarcerated women in the federal prison system in the United States compared to 40% of incarcerated men in the same corrections system in 2015).Footnote 85 The interconnected challenges of mental health and substance use disorders, histories of trauma, and sexually transmitted disease warrant special interventions in this population. As a result, many have advocated for the training of correctional clinicians to provide “trauma-informed care” to women in correctional settings.Footnote 86
In the community, geriatric syndromes including cognitive impairment and dementia, incontinence, falls and functional impairment are more common in women than in men.Footnote 87 Osteoporosis, which increases the chance that a fall will lead to a fracture and to temporary or permanent disability, is four times as common in women over age 50 than men.Footnote 88 In a study of incarcerated women aged 55 or older in California, 16% reported needing help with at least one ADL and 55% reported a fall in the past year.Footnote 89 The disproportionate burden of medical illness and disability reported by incarcerated women may explain their high health-care utilization ratesFootnote 90 and could suggest that incarcerated older women are significant contributors to increasing correctional health-care costs. In addition, the worse health profile of incarcerated women in the United States has resulted in a relative risk of mortality in the first two years following release from prison being 5.5 times greater than the community norm, while the relative risk for men is 3.3 times greater than the community norm.Footnote 91
Conditions of Confinement
Environmental and systemic challenges for the geriatric prisoner population
Conditions of confinement in most correctional facilities present challenges to many older adults who are unable to adapt to the environment's unique physical demands. Sometimes the correctional facility's physical layout presents dangers to older adults.Footnote 92 For example, uneven flooring, poor lighting and excess crowding can contribute to a risk of falls.Footnote 93 Correctional facilities that significantly restrict freedom of movement for much of the day may run the risk of contributing to physical deconditioning in older adults, an additional risk factor for falls, morbidity and mortality. Older individuals who require additional time to get places may require assistance with ambulation and travel to safely move between settings or to get places on time, such as for meals.Footnote 94 Additionally, older adults can experience impaired thirst and temperature regulationFootnote 95 which can pose a significant danger for those incarcerated in facilities with inadequate heating or cooling systems.Footnote 96 Moreover, some US correctional facilities have been found to fall short on universal accessibility requirements due to budgetary constraints.Footnote 97
A physical impairment need not lead to disability if the environment can be modified to meet the individual's needs; installation of grab bars and seats in the shower and the placement of special doorknobs to accommodate poor dexterity due to arthritis are examples of environmental modifications that can improve independent living.Footnote 98 A comprehensive inventory of the tasks required of an incarcerated individual to function in his or her housing unit and a systematic assessment of his or her capacity to meet those expectations are necessary to identify the environment most conducive to maintaining his or her independence. This is important because this so-called “environmental/functional mismatch” is often underappreciated, placing older adults at avoidable risk of injury or loss of independence.Footnote 99
Some environmental/functional mismatch may also be overcome with additional staffing to assist older adults with self-care. According to the US Bureau of Labor Statistics, nearly a million Americans are employed in the community as home health aides or personal care workers, an industry that is expected to grow significantly over the coming years.Footnote 100 Personal care workers are trained to assist with ADLs such as transferring, dressing and feeding for those patients in need. While most prisons do not allow personal care workers to provide physical assistance that could compromise the safety or dignity of patients (such as with toileting or bathing), personal care volunteers in correctional settings are sometimes used to provide companionship or to accompany older adults around the facility, such as to the dining hall for meals.
Sometimes, older adults face challenges accessing correctional health-care services and programming. For example, some correctional facilities require payment for health-care visits, written requests for medical appointments or standing in waiting areas for an appointment,Footnote 101 all of which may pose barriers to care for some older adults. Additionally, individuals who experience prolonged incarcerations rely on institutional programming for stimulation, socialization and opportunities for personal development. But prison programming is rarely designed to meet the physical, developmental and social needs of older adults, who, for example, may already have a high-school degree and therefore not benefit from high-school education programming, may not be able to participate in employment training that is reliant upon physical labour, and may feel out of place when spending their days in the company of much younger adults.Footnote 102
Some facilities have developed age-segregated housing to overcome the common mismatch between correctional housing units and the needs of older adults. Such units can be constructed and staffed to mitigate environmental hazards and facilitate access to clinical health-care staff, and can sometimes minimize fear of elder abuse.Footnote 103 Yet many consider older adults to be a stabilizing force in prisons and to serve as a source of wisdom and support for younger adults.Footnote 104 In addition, many incarcerated older adults have developed rich relationships with incarcerated younger adults, some of whom act as informal caregivers.Footnote 105 Age-segregated units can fracture these relationships and lead to enhanced social isolation for older adults.Footnote 106
Sending older adults to specially constructed geriatric facilities may also result in moving them further away from their families and home communities, which can decrease their access to outside visitors.Footnote 107 Additionally, constructing and running special facilities that appropriately accommodate the highest level of need for older adults is expensive. At a New York State nursing home-style unit designed to house incarcerated older adults with dementia, an average individual's care costs more than twice what it would cost to live in a nursing home outside of the correctional setting.Footnote 108 Further research is needed to understand the impact of segregated housing units as a solution for some of the problems posed to incarcerated older adults.Footnote 109
The risk of administrative segregation for older adults
Administrative segregation – also called solitary confinement, special housing units, special needs units or supermax – is defined in the Mandela Rules as confinement for twenty-two hours or more per day without meaningful human contact.Footnote 110 In the United States, solitary confinement often refers to the even more punitive correctional practice of housing prisoners in a small cell (roughly six by eight feet) for approximately twenty-three hours a day, with little to no human interaction and only three to seven hours of exercise per week.Footnote 111 The use of solitary confinement is common in the United States with estimates that nearly one fifth of the country's incarcerated population – approximately 400,000 individuals – spend time in solitary confinement over the course of a year.Footnote 112 While in solitary confinement, prisoners often lack regular access to exercise and exposure to sunlight. These conditions pose a challenge for providing adequate health care and managing ageing-related health conditions.
Geriatric conditions like dementia, arthritis and osteoporosis can be exacerbated by the conditions found in solitary confinement such as profound lack of exercise, decreased exposure to sunlight leading to lower vitamin D levels, and minimal social interaction.Footnote 113 Studies among community-dwelling older adults have found that spending too much time alone poses a risk for developing increased blood pressure, physical deconditioning and depression.Footnote 114 Social isolation and loneliness alone have been associated with increased mortality.Footnote 115 Based on what is known about the risk of worsening health in older adults, the health-related impact of isolation on incarcerated older adults is likely profound.
Serious, life-limiting illness, dying in prison and compassionate release
As the correctional population ages, an increasing number of incarcerated individuals are at risk of developing serious, life-limiting illnesses and dying while incarcerated. Serious, life-limiting illnesses are often debilitating for a long period of time before death and require enhanced medical attention, which can create challenges for correctional staff and strain health system resources. Clinicians with advanced training in the management of symptomatic distress in advanced illness are needed so that incarcerated patients do not experience severe pain or distressing symptoms that unnecessarily cause a loss of their functional capacity. Older adults in correctional settings have reported a particularly high symptom burden compared to their younger counterparts.Footnote 116
Moreover, a rising death rate in US correctional facilities has created an urgent need for correctional staff training in the management of the seriously ill, and a need for improved housing options for those with serious illness or who are dying.Footnote 117 As a result, many correctional facilities are exploring options for improving the care of dying patients while simultaneously considering the expansion of opportunities for early medical release for the seriously ill.Footnote 118
Palliative care and hospice care in correctional facilities
One out of every eleven US prisoners is serving a life sentence; of these, a third have no possibility of obtaining parole.Footnote 119 In 2013 there were over 3,800 deaths in US prisons. Over 80% of individuals who died in state prisons were over 45 years old, and 85% of those deaths were attributed to chronic illness.Footnote 120
Correctional facilities may face challenges when providing care to terminally ill and actively dying patients. The community standard of care for persons with a life-limiting or serious illness is palliative care.Footnote 121 Palliative care is specialized medical care for people with serious illness; its goal is to improve quality of life for the patient and their loved ones.Footnote 122 Palliative care-trained clinicians have advanced training in symptom management and in the science of prognosis.Footnote 123 Without training in prognosis, correctional clinicians may fail to identify potential candidates for early medical release programmes before it is too late for them to live through a prolonged assessment process.Footnote 124
Correctional settings present unique ethical and policy challenges in the provision of community-standard palliative care. For instance, there exists a great potential for patient–clinician mistrust due to the power imbalance inherent in the correctional setting.Footnote 125 The clinician–patient relationship may be strained further when patients fear that their treatment wishes will not be kept confidential or that their wishes for care at the very end of their life could affect their immediate needs for medical treatment.Footnote 126 An essential component of high-quality palliative care is patient-centred “advance care planning”, a process by which a patient appoints a health-care proxy and documents his or her goals and wishes for treatment at the end of life. Research in US correctional facilities has suggested that several barriers exist to conducting effective advance care planning for incarcerated patients, including lack of staff support for the practice, patient–provider mistrust, and difficulty transferring and communicating advance care plans between correctional and non-correctional settings.Footnote 127 More research is needed to understand how to improve and optimize the delivery of advance care planning in correctional facilities.
In contrast to palliative care, which is appropriate at any time throughout the course of serious illness, hospice care is focused on providing pain and symptom management – including managing existential and psychological distress – to patients in their last months of life. Quality hospice care provides comprehensive support that is focused on comfort and ensuring dignity in the dying process.Footnote 128
Many correctional facilities have developed hospice programmes or dedicated hospice facilities for dying patients.Footnote 129 Yet hospice eligibility restrictions in correctional facilities sometimes pose a challenge for optimal care of patients with serious illnesses. Most prison hospice units require that a patient has a prognosis of less than six months and has agreed to a “do not resuscitate” (DNR) order.Footnote 130 This second criteria, a DNR order, is not usually shared by community hospice organizations and can introduce an obstacle for individuals who do not wish to acquiesce to the order. It is important for correctional hospice programmes to follow national guidelines for best practices so that the level of care and services provided does not vary significantly by institution.Footnote 131
Successful prison hospices are often staffed in part by prisoner-volunteers. These volunteers may derive great benefit themselves from the experience of caring for a dying patient.Footnote 132 They often receive extensive training and mentored experience in hospice practices.Footnote 133 However, volunteers require support from health-care staff, since it is common to feel overburdened when taking on critical caretaking roles, especially in the absence of adequate training.Footnote 134 As is standard of care in the community, an experienced and trained interdisciplinary care team that includes social workers, volunteers and chaplains should staff prison hospices.Footnote 135 Correctional facilities that fail to meet this interdisciplinary approach fall well below community care standards. Finally, symptom management for both seriously ill and dying patients is sometimes compromised by institutional limits on the use of evidence-based opioid analgesics, or other controlled substances, for seriously ill patients.Footnote 136 This presents obvious challenges for achieving adequate symptom control in patients who are in pain or who have other distressing symptoms that can best be treated with opioids, such as shortness of breath.
Early medical release
Early medical release (also called compassionate release or medical parole) is a policy that allows incarcerated patients with serious illness to die outside of a correctional setting before sentence completion.Footnote 137 These policies are grounded in the theory that a change in health status may affect the four principles justifying incarceration: retribution, rehabilitation, deterrence and incapacitation.Footnote 138 Early medical release policies generally consist of two components: (1) medical eligibility, based on physical health evidence; and (2) administrative approval (outside of the health-care system) for release based on legal and correctional evidence. Initiatives to expand early release policies in the United States in recent years have been prompted by the increasing number of incarcerated older adults and their high associated costs.Footnote 139 It is imperative that correctional health-care professionals understand the eligibility requirements for early release so that they know when it is appropriate to proceed with a petition.
For seriously ill patients who are difficult to care for in the correctional environment, early release policies should be pursued when a safe release plan has been identified. Unfortunately, the early release process in many US jurisdictions is rife with obstacles that prevent potentially eligible candidates from even being evaluated for their medical eligibility and, once approved, from being released in a timely fashion. Between August 2013 and September 2014, only 320 federal prisoners in the United States submitted requests for compassionate release, and only 111 were released.Footnote 140 This is surprising given that the system has over 4,000 prisoners over the age of 65, and many have serious or debilitating illnesses.Footnote 141
One important barrier to accessing early release is that applications are often submitted too late in a person's disease trajectory, when they are likely to die or become incapacitated prior to having their request approved.Footnote 142 Furthermore, it is common for physicians to be required to attest that the applicant has a fixed, short-term prognosis.Footnote 143 This can put excessive burden on the clinician since many common terminal illnesses, such as Alzheimer's disease, end-stage liver disease and congestive heart failure, have an unpredictable trajectory but are profoundly incapacitating for many years prior to death.
To increase their effectiveness, early medical release policies should reflect the different ways in which people experience serious illness. Patients should be able to apply for release at a stage in their illness when they are profoundly functionally or cognitively impaired, even when they have several months or years to live, so they can benefit from release.Footnote 144 In the United States, the Federal Bureau of Prisons and several states have expanded their early medical release programmes. Some have introduced a mechanism for early release for older adults based on age alone, after a specified portion of their sentence has been completed.Footnote 145
Returning to the community: Addressing the needs of older adults released from prison
The period following release from prison is a challenging and often dangerous time for many individuals, and older people are especially vulnerable to adverse outcomes. One study identified a dramatic increase in mortality compared to age-matched controls for people recently released from prison.Footnote 146 Some of this excess mortality risk was due to chronic disease (coronary artery disease, cancer), suggesting that the cause is sometimes attributable to interruptions in care, resources and/or social support.Footnote 147
Moreover, without skilled support, older adults may have particular difficulty navigating the processes required to obtain social benefits, finding employment and suitable housing, and getting connected to health care following release.Footnote 148 As a result, they may risk running out of medication, requiring visits to the emergency department and/or hospitalization for decompensation of chronic medical conditions that could have been managed in an outpatient clinic.Footnote 149
To help individuals who are transitioning back to the community achieve success, the same geriatric transitional care models that are effective for hospital discharge should be adapted for older prisoners.Footnote 150 Such models include assigning case managers prior to discharge who assess needs and anticipate issues that might arise, and who follow their client post-discharge to help troubleshoot concerns.Footnote 151 Exemplary models of transitional care that incorporate elements of hospital discharge programmes have been designed to meet the needs of individuals re-entering the community after a period of incarceration. One such programme, Project START, provides sequential risk assessment and personalized counselling sessions to young men with HIV and hepatitis C both before and after they are released from prison.Footnote 152 Similarly, the Transitions Clinic programme in San Francisco pairs recently released individuals with community health workers who have a personal history of incarceration, and has been shown to decrease emergency room visits in the period following release from prison.Footnote 153 Similar strategies should be adapted to the specific needs of geriatric patients with complex medical needs who are returning to the community.
Discharges of older adults can be particularly difficult to plan when the individual requires a nursing-home level of care.Footnote 154 In the United States, it can be difficult to find nursing homes willing to accept individuals being released from prison, especially those with a history of sex offences or violence. In response to this challenge, the state of Connecticut now manages its own community-based skilled nursing facility where older adults in need of skilled care can be released on parole.Footnote 155
Where do we go from here?
The challenge of providing community-standard health-care to an ageing prison population has been the subject of multiple recent convenings to establish a research and policy agenda and to share best practices.Footnote 156 Improving care for this population depends on interprofessional partnerships including correctional leadership and front-line staff, public health researchers, community agencies, neighbourhood associations, formerly incarcerated individuals and their families, law enforcement, and community and correctional clinicians. In addition, research money must be allocated by national grant-making agencies to build the evidence base needed for effective models of care for this population.Footnote 157
As health-care providers, researchers and corrections officials continue to build a fund of knowledge about the impact of incarceration on older adults and the impact of an ageing prisoner population on correctional facilities, leaders in the field of corrections should simultaneously adapt effective community-based geriatric care programmes to the correctional setting. One place to start would be to better align the approach to geriatric health in correctional settings with the standard of care that older adults are offered in the community. This would require training clinical staff to recognize and manage geriatric conditions, along with evidence-based prognostication and symptom management. Models exist for training of community clinicians in the practice of palliative care and geriatrics by primary care doctors who have not undergone speciality training in these areas.Footnote 158 These models have been adapted successfully for use in some correctional systems to train both clinicians and corrections staff,Footnote 159 and should be expanded and made part of universal training protocols in all correctional settings.
Furthermore, hospitals and community clinics have increasingly recognized the need to “geriatricize” their clinical spaces and to provide dedicated programming for geriatric patients, a practice which should be adopted for correctional facilities as well.Footnote 160 Some correctional medical units have begun this process. For example, HPM Whatton, a correctional facility in England with a large number of older patients, offers elderly inmates the opportunity to live in cohorted spaces that are accessible to individuals with mobility issues.Footnote 161 This prison trains staff in geriatric care, provides targeted activities for older adults and has developed a paid peer support programme.Footnote 162
To meet the community standard of care, all prisoners of advanced age, or who are seriously ill, should have access to palliative care and hospice services. Concurrent expansion of compassionate release policies would also limit the need for these resources and decrease the burden on prisons to accommodate the elderly or seriously ill who may be better served in the community. For this reason, compassionate release policies should be designed to incentivize saying “yes” to an applicant's release rather than “no” and should be designed with input from medical specialists in prognostication, geriatrics and end-of-life care.
Another important avenue of inquiry is in the evaluation and optimization of effective alternatives to incarceration for older adults, especially those with cognitive impairment or dementia. Such alternatives might include house arrest, the use of electronic tracking devices, or diversion to nursing homes or hospices rather than prisons.Footnote 163 To avoid incarcerating those in the early stages of dementia, all older arrestees should be screened for cognitive impairment and assessed for their appropriateness for living in a correctional facility.
Finally, as we consider the impact that incarcerating older adults has on the individual, we cannot lose sight of the profound adverse impact that incarcerating older citizens can have on our communities. The psychologist Erik Erickson famously described the life stages of middle and old age as opportunities for “generativity”, or caring for the next generation and offering guidance, and “ego integration”, a chance to reflect and take stock.Footnote 164 When older adults do not have the chance to interact meaningfully with younger generations and offer their reflections and advice, they are deprived of an important social role and their family and community fails to gain their accumulated experience, perspective and wisdom.
Overall, at a most basic level, providing appropriate care for older or seriously ill prisoners is complex and, oftentimes, daunting. This complexity, in combination with the exorbitant costs generated by older prisoners, provokes important social questions that we will have to answer as our world population continues to grow older. Are there some people for whom incarceration is not appropriate? How do we determine when that moment has arisen? And what alternative mechanisms exist to restrict a person's liberty? It is time to start asking these questions now.
