There are 2.2 million people in prisons and jails in the United States, more than any other country in the world. The incarceration rate is 738 prisoners per 100,000 Americans, which is 4% to 7% higher than in other Western countries. Russia has the second highest rate, with 607 per 100,000 (Katel, 2007). The likelihood of a health care encounter with a prisoner who has been released or is still serving time is high, given that an estimated 1 of every 15 individuals will serve time in a prison during his or her lifetime, and more than 5.1 million men and women in the United States are on probation or parole.
Of particular concern is the older prisoner, defined in this article as those older than age 50. It is estimated that by 2030 one third of U.S. prison inmates will be older prisoners (Enders, Paterniti, & Meyers, 2005). Consequently, health care providers need to understand the challenges faced by this vulnerable population, as well as issues related to the graying of American prisoners. The purpose of this article is to examine the implications for those prisoners aging in place and for those prisoners who will transition from custody to community.
Graying of American Prisoners
People are living longer, and this global trend is likely to have a profound impact on the delivery of health care services worldwide. It is estimated that currently there are 605 million people age 60 and older around the world, and this population is projected to increase to more than 2 billion by 2050, exceeding the population of children younger than age 15 (U.S. Administration on Aging, 2003). The group of those age 85 and older accounts for the most rapid growth overall. In the United States, the 80 million Baby Boomers (those born between 1946 and 1964) have already or will become the new senior citizens. It is not surprising then that this aging trend has not bypassed the U.S. prison population.
Rikard and Rosenberg (2007) suggested there has been a “convergence of trends” in the U.S. correctional system. These trends include the historical evolution of America’s criminal justice philosophy from rehabilitation to incapacitation, the resultant explosion of the prison population, and the significant current and future growth of the older prisoner population. The shift away from rehabilitation in the U.S. correctional system began in 1984 with the passage of the federal Sentencing Reform Act, which had mandatory minimum sentencing and specified sentences for certain federal offenses (King & Mauer, 2001). The Violent Crime Control and Law Enforcement Act of 1994 went further and tied money to states that adopted truth-in-sentencing laws, coupled with a caveat that a minimum of 85% of the sentence must be served before the prisoner is eligible for release. This led to decreased judicial discretion to consider other factors in sentencing, such as ill health, age, or risk to the community (Rikard & Rosenberg, 2007).
According to Rikard and Rosenberg (2007), “more sentences, longer sentences, and mandatory sentences coupled with medical advances that keep older prisoners alive longer, have led to the current growth of the older prisoner population” (p. 152). King and Mauer (2001) indicated that the “three strikes” sentencing is contributing to the older prisoner population. In the first 5 years of the three strikes law in California, the proportion of felony admissions older than age 40 increased from 15.3% in 1995 to 23.1% in 1999. The average age of “third strikers” in California is 36.1, and they will serve sentences of 25 years to life (King & Mauer, 2001). It is estimated that it will cost $1.5 million to imprison an older prisoner for the minimum of 25 years due to health care and other needs (Zimbardo, 1994). Mauer (2003) suggested that an increase in crime can explain only 12% of the increase in the prison population, whereas the new sentencing policy accounted for 88% of the increase.
A snapshot of the U.S. correctional system population reveals a disproportionate number of minority prisoners. In 2006, there were 3,042 Black male prisoners per 100,000 Black men in this country. This compares to 1,261 Hispanic male prisoners per 100,000 Hispanic men, and 487 White male prisoners per 100,000 White men. If the current rates of incarceration continue, it is projected that 32% of Black men, 17% of Hispanic men, and 5.9% of White men will serve time in state or federal prisons at some point during their lifetime (Bureau of Justice Statistics, 2007). In addition, men have a higher likelihood of going to prison than women. The percentage of female prisoners increased to 6.6% in 2001, up from 6% in 1995 (Bureau of Justice Statistics, 2007). Similar to the situation with men, more women are incarcerated in the United States than in any other country (Hartney, 2006).
Recidivism rates are difficult to find with a national aggregate; however, of the 272,111 individuals released in 1994 from prisons in 15 states, an estimated 67.5% were rearrested for a felony or serious misdemeanor within 3 years, 46.9% were reconvicted, and 25.4% were resentenced to prison for a new crime (Bureau of Justice Statistics, 2002). In California, 70% of prisoners are reincarcerated within 3 years of release (Katel, 2007). It is known that committing crimes declines with age, regardless of gender, race, country of origin, ethnicity, or offense, and a federal study of state recidivism statistics revealed that older parolees and probationers are less frequently reincarcerated (National Center on Institutions and Alternatives, 1998).
Investment in the prison industry is booming, with buildings, staffing, and prisoner beds taking priority (Clemmitt, 2007). Unfortunately, the economic contribution to health care and rehabilitation efforts is hampered by the need to provide the infrastructure to house and secure prisoners. The economic cost for the nation to house prisoners is projected to reach more than $40 billion by 2011 (Clemmitt, 2007). There is a growing consensus that viable alternative sentencing and programs need to be considered for the nonviolent prisoners, who account for more than 50% of the prison population. Early release programs are too few and are aimed at terminally ill prisoners. Older prisoners have the lowest rates of recidivism, so these programs could be a legitimate alternative. However, 75% of older prisoners committed a violent crime and are serving out their first sentence, so the public response to release or alternative placement may be untenable (Sheppard, 2001).
Health Status of Older Prisoners
Health care is a constitutional right for prisoners that was established in 1976 in the legal case Estelle v. Gamble (Siegel & Senna, 2004). Older prisoners must be provided the same medical care as “free world” citizens, and they require a full range of services to manage their complex health problems and functional limitations. Given this, the cost of caring for an older prisoner may be up to three times the cost of caring for a younger prisoner. This cost is currently estimated to be approximately $70,000 per year and to consume a disproportionately larger share of the health care budget of correctional institutions (Williams et al., 2006). The fiscal impact on the state and federal correctional systems has caused great concern.
While older prisoners are most commonly defined as those age 50 and over, many reporting agencies still use age 55 (Aday, 2003; Loeb & Abudagga, 2006). Long histories of no medical care, alcohol and substance abuse, and poor diet contribute to a 10- to 11.5-year addition to chronological age (Aday, 2003). Health care problems in the general prison population center around communicable diseases (e.g., HIV, sexually transmitted diseases, tuberculosis, hepatitis B and C), chronic diseases (e.g., asthma, diabetes, hypertension), oral health, mental health, and substance abuse (Williams, 2007).
Comorbidities are found in approximately 85% of older prisoners, and most have three or more chronic health conditions (Loeb, Steffensmeier, & Myco 2007). Loeb and Abudagga (2006) completed an integrative review related to older prisoners’ health and found that the most commonly reported conditions in this group were cardiovascular conditions, arthritis and/or back problems, psychiatric conditions, respiratory diseases, endocrine disorders, sensory deficits such as vision and hearing problems, and substance abuse, with alcohol being abused most often.
Variables related to health and the onset of chronic conditions are multifactorial and include lifestyle, environmental and socioeconomic conditions, lack of access to health care, and heredity—all of which contribute to the risk for chronic conditions among prisoners and increase the need for more long-term care services in the future. In addition, Loeb, Steffensmeier, and Lawrence (2008) remarked that health disparities in this population can be “attributed to underlying socioeconomic factors that contribute to unhealthy lifestyles prior to incarceration, unhealthy lifestyles during incarceration and the general harshness of the prison environment” (p. 235).
The disproportionate minority population housed in prisons, particularly Black and Hispanic individuals, reflects the national problem of health disparities. The Centers for Disease Control and Prevention, Office of Minority Health & Health Disparities (2007) stated that “the demographic changes that are anticipated over the next decade magnify the importance of addressing disparities in health status” (p. 1). They also reported that minority groups who are already in poor health will grow as a proportion of the total population. They concluded that “the future health of America as a whole will be influenced substantially by our success in improving the health of these groups” (p. 1). The prison health care system is in an ideal position to begin to address these issues with prisoners through education and early diagnosis and for the older prisoner specifically, interventions for diabetes, cardiovascular disease, obesity, and hypertension.
Chronic illnesses account for the greatest cost burden and disability in the United States and are the leading cause of death in the free world (Centers for Disease Control and Prevention, 2009). Chronic diseases are prevalent among older prisoners as well and often lead to functional impairments that interfere with daily life. Williams et al. (2006) described the functional impairment of female prisoners and how the prison environment aggravated the impairments. Using the usual five activities of daily living (ADLs)—bathing, eating, toileting, dressing, and transferring—another layer of activities was defined for prisoners. Prison ADLs are the five activities most commonly required of older prisoners: dropping to the floor for alarms, standing for head count, getting to the dining hall for meals, hearing orders from staff, and climbing on and off the top bunk. Decrements in these activities can dramatically alter older prisoners’ ability to function in the prison environment. Careful and deliberate management strategies and measures to control and mitigate outcomes are required. Developing and implementing such strategies increases the work of health care providers in the correctional system and requires resources that simply may not be available.
Stein and Alaimo (1998) described a phenomenon known as transin-stitutionalization, which refers to the movement of patients from large psychiatric facilities to nursing homes and correctional institutions, which occurred in the 1970s era of deinstitutionalization of the mentally ill population in the United States. This increased the percentage of prisoners with mental illness (National Institute of Corrections, 2001). Ditton (1999) found signs of mental illness in inmates older than 55 in state (15%) and federal prisons (9%). Mental health issues are a major contributor to the quality of life and physical health of older prisoners. Reporting on morbidity and mortality in people with serious mental illness (SMI), Parks, Svendsen, Singer, and Foti (2006) stated that individuals with SMI are now dying 25 years earlier than the general population. The increased mortality and morbidity of this population from cardiovascular disease, diabetes, respiratory disease, and infectious disease is “several times that of the general population” (p. 5). Parks et al. (2006) also reported that “psychotropic medications may mask symptoms of medical illness and contribute to symptoms of medical illness and cause metabolic syndrome” (p. 6). In addition, second-generation antipsychotic medication is associated with weight gain, diabetes, dyslipidemia, insulin resistance, and metabolic syndrome (Parks et al., 2006). Due to the large number of incarcerated people with SMI, early intervention can begin in the prison setting to address modifiable risk factors affected by psychotropic medications, thus reducing some of this disparity.
Fortunately, the National Commission on Correctional Health Care (NCCHC) (2008) has published Standards for Health Services in Prisons. Specific guidelines have been written for those with chronic illnesses, communicable diseases, physical handicaps, terminal illnesses, mental illnesses, and developmental disabilities, as well as for frail older adults. Health care providers can access guidelines that offer indicators of how to manage prisoners’ health care problems and provide information about barriers to usual treatment due to the correctional facility setting. The NCCHC (n.d.) also provides accreditation of prison health services; more than 500 prisons and jails have been accredited.
Implications for Prisoners Aging in Place
If a prisoner must age in place, the implications for the correctional system and society can be costly. However, improvements can be made in the environment to assist older prisoners. First and foremost is a strong, proactive health promotion program for all prisoners. This will lead to healthier aging with a slowing of the functional and physical decline of this population. In a study by Loeb et al. (2007), prison health programming, recommended by older prisoners, included topics related to healthy aging; diet and exercise; understanding and managing symptoms of diseases such as asthma, diabetes, and HIV; and more frequent screening for prostate cancer.
Williams et al. (2006) reported harmful experiences in prison that could benefit from stress management interventions for older prisoners. The adverse experiences included feeling depressed, feeling unsafe in one’s prison cell, and reporting physical abuse by another prisoner. Educational programs that could identify and strengthen coping behaviors related to these experiences would benefit older prisoners. Because there are very real dangers in the prison setting for vulnerable older prisoners, providing an arena for discussion and solutions that empowers older prisoners is needed to promote safety and “peace of mind.”
Mainstreaming older prisoners into the general population versus segregation in special housing units is an issue that must be addressed, given the particular challenges associated with U.S. correctional system. Aday (2003) suggested that prisons were constructed for younger, noisier, violently active prisoners and that these units do not meet the needs of older prisoners. In addition, the environmental press of prisons, which demands that individuals adapt to the social and physical environment around them, does not bode well for older prisoners (Aday, 2003). For older prisoners who are vulnerable and less able to protect themselves, predatory victimizations can be an issue.
Issues of safety, physical mobility, age-appropriate interventions for physical and cognitive conditions (e.g., diet, 24-hour nursing care, functional assistive devices), and cost containment compete in the quest for a humane environment for older prisoners (Aday, 2003). Of particular concern are vulnerable older prisoners with dementia, who must be segregated from the general population for safety reasons. The correctional system must become proactive in planning care for older prisoners to address safety issues and retrofitting spaces, such as including ramps and handrails, wide doorways, and levers instead of knobs.
Many states now have or are building special care units for older prisoners. These may be secure nursing homes or renovations in older buildings that accommodate wheelchairs and walkers and are geared toward functional limitations of older prisoners (Smyer, Gragert, & Martins, 2006). The National Prison Hospice Association (n.d.) provides comfort-oriented care for dying prisoners.
Implications for the Transition from Custody to Community
Not all older prisoners will die in prison, and it is important that job training and “discharge planning” be instituted early. Often, released offenders lack a basic understanding of how to survive outside prison; they have poor education and literacy skills, often no employment skills, and may have little or no family or social support. It is unclear how they will earn incomes and find food, clothing, and a place to live (Smyer et al., 2006). Those with chronic illness may have no access to medications or health care. Even in the free world, the 50 to 65 age group may fall through gaps in the health care system with no Medicare coverage or access to senior housing; this is true for newly released prisoners as well. In a study by Loeb et al. (2007), the postincarceration fears about health and well-being identified by older male prisoners were paying for health care and/or medications, finding and accessing health programs and providers, managing chronic conditions, avoiding return to substance abuse, and avoiding contracting HIV.
Failure to provide transitional support may affect the community to which prisoners return, as well as the prisoners themselves, because of possible communicable diseases or postrelease crime. Roberts, Kennedy, and Hammett (2004) defined discharge planning within the correctional setting “as the process of helping prisoners prepare to make the transition from prison or jail to society” (p. 336). They described two phases essential for the process: helping prisoners link with medical care, social services, and case management in the community before release; and following up with prisoners to ensure access to services and support to transition into the community after release.
Early release programs are being instituted and considered by various states. The most successful has been the Project for Older Prisoners (POPS), which pairs law students with prisoners to evaluate them for early release and then help the prisoners with reentry into society. Early release may use an electronic home-detention system or be coupled with job training so released prisoners can support themselves. It has been reported that the POPS, with more than 100 older prisoners in the program, is successful with no recidivism since inception (Greco, 2004, Williams et al., 2006).
Compassionate release options exist in 33 states along with the Federal Bureau of Prisons. This is usually for prisoners who are terminally ill and/or medically fragile and no longer pose a threat to society. Two purposes of incarceration are punishment and protection of society, so for those with advanced dementia, continued incarceration does not serve either purpose and is very costly for the prison system. However, the requirements for these release programs are rigorous, and many prisoners die before the review process is complete. The National Center on Institutions and Alternatives (1998) recommended that an appropriate policy might be to provide a structured, supervised release for prisoners who are age 65 and older, have committed a nonviolent offense, have served a substantial part (one third or more) of their sentence, and are deemed not to present a significant risk to the community.
The larger societal implication is related to a serious collaboration between prison systems and the community to which the prisoner returns. Supporting the transition of older released prisoners involves ensuring continuity of care through access and availability to health care, medications, and appropriate living arrangements, as well as jobs. This collaboration can prove less costly in the long term to taxpayers and the correctional system. Costs are currently untenable, with dramatic action required.
As health care providers, nurses can identify and initiate creative and innovative programs that will help this population through awareness of the challenges they face as they reenter the free world. For both prisoners aging in place or transitioning from custody to the community, it is essential to “incorporate a balance between humanitarian efforts, ethical considerations, cost containment, quality health care, positive health outcomes, and social justice” (Smyer et al., 2006, p. 94). As Loeb et al. (2007) stated, the most critical role we can play as health care providers is that of advocate for this vulnerable population.
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