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Elderly inmates are considered the fastest-growing segment of the incarcerated population. In turn, they pose unique challenges for corrections management, particularly as it relates to their health. This review includes a description of the historic growth of an older prison population, the current health-care demands being placed upon prison services and budgets, and the attendant controversies about how to best address these demands. This research paper concludes with the open questions that must necessarily be answered in moving forward with the effective care and management of an ever-growing group of older, and often infirm, inmates.
There is unprecedented growth in the incarcerated elderly population. These prisoners are now the fastest-growing group of inmates, increasing at a rate three times that of the general prison population. Thousands of inmates are baby boomers, and as they age, prisons find themselves having to plan to care for an aging population (Gater 2010). Among reasons for this growth are changes in sentencing and parole practices, recidivism rates, and increasing incarceration rates in several major offense categories (Reimer 2008). For example, in the past decade, the war on drugs and tough mandatory sentencing laws have doubled the number of incarcerated persons. Inmates sentenced to life, or practical life, represents the future of the already growing population of older inmates. This population has an increased potential for medical problems and emergencies, and these circumstances often develop sooner in prison populations.
Understanding and addressing prisoner health care is a relatively recent phenomenon, primarily in the past 30 years. Prior to the 1970s, little was known about how inmates were cared for in prison. What really put the health-care issue on the forefront for change were lawsuits filed by inmates against prisons. As a result, the US Supreme Court became more interested in changing healthcare practices. Professional standards of care were implemented, beginning with the American Public Health Association and followed by the American Medical Association, American Correctional Association, and the National Commission on Correctional Health Care.
Older Prison Inmates Today
Defining The Elder Inmate
It is difficult to determine how states classify their elderly inmates and what differences exist among prisons. In a statement made in a report written about California, regarding the differing ages, “it is virtually impossible to determine how many elderly are incarcerated nationwide because scholars and correction officials differ as to what age is an appropriate cut off to label someone as elderly” (Gubler and Petersilia 2006, p. 10). Using the National Institute of Corrections as the benchmark, the elderly incarcerated are defined as any inmates above the age of 50 years, because, morphologically, the average prisoner has a reduced health status approximating the health condition of a non-incarcerated person who is 10–15 years older. In turn, research indicates that since 1995, the total population of older prisoners has grown by about 10,000 per year (Aday 2003). Prison administrators have found that the “graying” of America is evident in the prison population as well.
Due to high-risk lifestyles and the lack of regular health care before their incarceration, many inmates age faster than their contemporaries on the outside. So, for example, a 50-year-old inmate may be considered a “senior citizen” and would need to take advantage of services and facilities for the aging (Gater 2010). The inherent stress of prison life, along with the declining health of many inmates, also contributes to them being elderly before their time. As a result, they have become the major consumers of corrections services (Aday 2003). Collectively, Beckett et al. (2003) found that incarceration results in aging in place, challenges to self-care abilities, and greater likelihood of parolees that leave prison with serious health problems.
Reasons For Their Imprisonment
Tougher sentencing accounts for much of the increase in the proportion of correctional populations who are considered old. In the 1980s, many states abolished parole and passed “three strikes and you’re out” laws. The intention of three strikes laws has been to ensure longer prison sentences and greater punishment for those who commit a felony and have been previously convicted of serious and/or violent felony offenses (California Penal Code, Section 667.5). Though the average age of persons nationally who fall under three strikes legislation is 31 (Reimer 2008), individuals convicted of second or third strikes may not be granted probation and must serve their sentences in state prisons. Unintended consequences of this legislation include an overcrowding crisis and an aging prison population.
Using California as a major example, at the end of 2004, there were almost 43,000 inmates serving time in prison under the three strikes law, making up about 26 % of the total prison population. Of the striker population, more than 35,000 were second strikers, and about 7,500 were third strikers. The most common offenses for which strikers were currently serving time in prison were robbery, burglary, assault, and possession of drugs (California Legislative Analyst’s Office 2005, pp. 15–16). But critics of these laws seriously question their cost-effectiveness. For example, Greenwood (1994) and colleagues constructed a mathematical model that predicted the benefits and costs of the three strikes law in California and found a possible increase to the costs of that state’s criminal justice system of an average of $5.5 billion annually.
At the federal level, Congress imposed mandatory sentencing guidelines, such as determinate terms, requiring the application of maximum sentences for crimes of violence and the doubling of maximum penalties for all felony classes (Reimer 2008). Truth-in-sentencing laws (requiring the convicted criminal to serve 85 % of the time imposed before qualifying for release) will push these numbers even higher. More inmates will remain in prison for longer periods of time. And more inmates will grow old in prison.
Recidivism is another factor accounting for an ever-older inmate population nationally. Reimer (2008) defines recidivism as a new criminal activity or technical violation of parole, probation, or nondepartmental community placement within 3 years of release. Colorado is used as an example to show the high frequency of recidivism. The average recidivism for males is 53.15 % and for females is 51.1 % (Bureau of Justice Statistics 2006). This amounts to one person for every two that are released from prison returning to prison within 36 months (Reimer 2008).
Factors Negatively Impacting Elder Inmates And Their Health
The increasing numbers of older offenders behind bars have resulted in greater numbers of persons needing specialized medical treatment, meaning they will consume a disproportionately large share of health-care resources. This reality of a larger portion of health care being consumed by a smaller subgroup of prisoners parallels the phenomenon in the general US population: approximately one-fifth of all persons consume about 80 % of all medical resources. Offenders are more likely to require hospitalization than younger offenders and account for a large proportion of hospital and specialty services costs to prisons. Much like the free world populations, the aging offender population has a high incidence of hypertension, diabetes, atherosclerotic heart disease, and other medical conditions that require long-term and oftentimes expensive treatment. Issues concerning diet also arise, especially if inmates require liquid diets or restricted diets due to an illness or other condition (Caverley 2006).
Stress is yet another factor contributing to the acceleration of the aging process in prison. For example, there is an increasing concern about the growing number of older prisoners and their safety (Aday 2003), including a fear of victimization by younger, stronger inmates.
Similar to older males, older female inmates housed in the general prison population often express a need for greater privacy, and studies report that many older inmates prefer to live with people of their own age (Walsh 1992). Research indicates that these older females are much more likely to see other inmates as aggressive and violent than do older male inmates (Krabill and Aday 2005). In one study, a significant number (30 %) of the older female inmates stated that they were either occasionally, frequently, or always afraid (Kratcoski and Babb 1990). Additionally, older women are significantly less likely to be involved in various forms of sporting and recreational activities (Krabill and Aday 2005), thereby contributing to the possibility of victimization due to their relatively poorer health.
Along with an increase in medical issues that may typically accompany the aging process is the effect that poor health-care services and prison conditions may have on inmates’ health. It is believed that the reality of being imprisoned as well as the conditions therein may adversely impact older inmate’s health (Aday 2003; Haugebrook et al. 2010). Other issues exist as well, such as confrontations among older and younger inmates. Assaults are common among prisoners, especially among those inmates other prisoners view as weak. This may further contribute to the weakened state of elderly inmates and therefore increase their need for medical attention (Oklahoma Department of Corrections 2008). Many older inmates have to address the fact that they may die while incarcerated, and the social support to deal with such issues is lessened for them while in prison (Haugebrook et al. 2010).
Prisoners’ Rights To Health Care
Although prisoners have diminished rights compared to those in the free world, health care is one right to which they are entitled. They are given a basic right to health care, because they are unable to care for themselves and once they are imprisoned, they are the responsibility of the state. The landmark case that addressed prisoners’ right to health care was Estelle v. Gamble, in which the US Supreme Court ruled that deliberate indifference to a prisoner’s medical needs is considered cruel and unusual punishment under the Eighth Amendment (Estelle v. Gamble, 429 U.S. 97 1976). This established the minimum standards for prisoner health care, which instructed prison officials that a basic level of health care was required for prisoners and intentionally overlooking their needs would be unacceptable. Although the case did not create specific guidelines for prison officials to follow when implementing health-care policies, it still indicated that prison officials can be held accountable for the mistreatment of their prisoners’ medical needs and rights. Estelle, however, was not the only case to address prisoner health care.
West v. Atkins declared that the state has an obligation under the Eighth Amendment to provide proper medical care to an incarcerated inmate (West v. Atkins, 487 U.S. 42 1988). This case was significant because it stated that even state prisons that contracted physicians to care for inmates could still be held accountable for the care provided to its inmates. Therefore, the physician has a duty to provide the necessary medical procedures to ensure the well-being of the inmate. Under the decision of Fernandez v. United States in Florida, it was decided that prisons must provide “services at a level reasonably commensurate with modern medical science and of a quality acceptable within prudent professional standards” (Fernandez v. United States and 500 U.S. 948, at 10 1991, p. 10). Finally, Tillery v. Owens stated that all prisoners are to receive a “level of health services reasonably designed to meet routine and emergency medical, dental and psychological or psychiatric care” (Tillery v. Owens, 907 F23d 418 1989, p. 1301). This decision was decided in Pennsylvania and upheld by the State Supreme Court as well, making it a requirement for all prisons in the state. Combining the declarations of the landmark cases on the issue, all inmates have three basic rights to health care. They are the right of access to care, the right to the care that is ordered by officials, and the right to a medical judgment by a professional in the field (Oklahoma Department of Corrections 2008). Prisoners are the only persons in the USA who have a constitutionally protected right to health care, and the courts show no sign of extinguishing that right.
Considering that elderly prisoners may face more serious illnesses, and more frequent illnesses, what level of care is considered appropriate and satisfactory? Things to consider for elderly prisoners include kidney dialysis, routine exams such as colonoscopies, glasses, canes, walkers, and other tools to help them function, as well as cancer treatment.
It has long been believed that aged inmates should receive special attention reflecting the physiological, psychological, and sociological effects of aging. Yet in a prison system assessment conducted by the Criminal Justice Institute (2001), only 15 of the 49 state prison systems had housing areas designated for elderly inmates. Of these 15, seven were only available for elderly inmates who may have had special medical needs or were eligible for hospice care. Thus, an overarching theme to the current challenges of providing for health-care and related needs of older prisoners is that current services and programs are inadequate. For example, elderly inmates need additional preventive care, orderly conditions, safety, and emotional support. Geriatricians also recommend the immediate step of increasing preventive care and educating older prisoners in strategies for maintaining and monitoring their own health (Aday 2003).
The mental health needs of inmates, including dementia among older persons, currently represent another major challenge to correctional programs. Sufficient community-based treatment resources are presently inadequate to support and stabilize mentally ill persons in their communities, with the result that prisons and jails have become the principal institutions for housing mentally ill persons. Also, according to Reimer (2008), conditions of poverty, isolation, and abandonment may contribute to anger and depression in the aging incarcerated population. Those who are depressed and suicidal must be taught what symptoms may be part of a condition that is treatable (Goldney et al. 2002). Even though older prisoners still encompass a relatively small percentage of the inmate population, they represent significant managerial challenges in relation to adapting prison programs to meet their developmentally specific needs for counseling, health care, education, recreation, and vocational training (Aday 2003).
Typically, recruiting prison physicians trained in specialties has been difficult. A common solution is to hire specialists on a consulting basis to conduct periodic “clinics” at the prisons. Some prisons, however, have determined that it is cost-effective to buy equipment and to build suites for certain frequently used technologies, such as x-rays. Further, some prisons have implemented medical copayments as well as educational programs as means of controlling the use of medical services and their attendant costs.
Another barrier in responding fully to the special needs of the aging inmate is a deficit of the necessary staff aptitudes or essential skills to manage elderly people. This lack of gerontological training for correctional officers suggests that they may fail to properly supervise and safeguard an aging prison population (Aday 2003). Experts believe that corrections staff who work with the elderly should receive specialized training to effectively provide care for the physical and mental health of these inmates (Reimer 2008). In addition, there is much debate about inmates receiving advanced medical care that is not equally available to poorer, uninsured people in the free world.
Prison- and Community-Based Options
In 1992, Flynn recommended that corrections officials pursue a number of strategies to address the health care of elderly inmates, including modify existing work and education programs to include health-care education, preventive medicine, and counseling of the elderly. Staff should also be encouraged to seek inmates who have no close ties to the free world and encourage them to become involved in organized educational, recreational, and vocational activities (Krabill et al. 2005). Corrections professionals must find a way to balance public safety concerns and public demands for a government that operates with economy and efficiency, while responding appropriately to legitimate correctional interests.
Health Care and Other Costs of Older Inmates
Increasing costs are arguably the major issue associated with this rapid increase in older inmates. Studies indicate that inmates 55 and older suffer from an average of three chronic illnesses at a time, and they may experience these illnesses at earlier ages than the general population due to conditions of imprisonment and difficult lives prior to incarceration (Aday 2003). Part of the recent increased cost of elderly inmates includes the mental health services they require, as elderly inmates are more likely to suffer from mental illnesses than other inmates (Caverley 2006). As a result, it is estimated that average annual costs nationally for inmates over age 50 is $70,000, three times the cost of younger inmates (Davidson 2009; Rikard 2007). It is expected that these costs will continue to increase rapidly, especially if the cost of health care in the free world increases.
Current Examples Of Meeting The Challenges
A recent edition of the Correctional Health Care Report (National Institute of Corrections 2004) highlights some examples of how the program, housing, and treatment considerations of elder inmates are being accommodated. For example, in Fishkill, New York, there is a 30-bed center for inmates who are cognitively impaired. This facility provides for the treatment of inmates with dementia-related conditions, which is something that typically worsens with age. Within the unit, the staff is specially trained to handle inmates with dementia and other related conditions. Although the inmates may commit acts while imprisoned that would typically result in punishment, they often times may not understand the implications of their actions because they lack the cognitive ability (New York Department of Corrections 2008).
Some other examples of special facilities prisons have implemented include Texas, which has a Type I Geriatric Facility that is specifically designed for geriatric offenders and eight Type II Geriatric Facilities to house portions of geriatric offenders. In Michigan, there is a men’s geriatric unit and a long-term care unit, while Rhode Island has special housing for wheelchair-bound male inmates. Nevada has one geriatric prison in the entire state, while Alabama also has one facility for elderly and medically disabled inmates. In Florida, there are two facilities for elderly inmates and dorms at two other facilities for elderly inmates within those facilities (Price
The State of Washington (2010) has an extensive health-care plan that is listed on their Department of Corrections website. Inmates are eligible for infirmary and hospital care, medical and surgical services, maternity services, chemical dependency treatment, mental health services, dental care, emergency care, skilled nursing care and hospice, preventive care, access to pharmacies, durable medical equipment, optical care, and hearing care. While this represents the treatments and options available for all prisoners, there are certainly many treatments that are applicable to elderly inmates, such as hearing, optical, nursing care, and hospice. Although all of the treatments are restricted by necessity, approval, and other means of regulation, the State of Washington clearly has an expansive array of services that it provides to its inmates.
Oklahoma also has health assessments for all prisoners. According to the state’s procedure on assessments, “periodic health assessments are to be done every 3 years for offender’s age 18–39; every 1–3 years for offenders age 40–64; and annually for offenders 65 and older” (Oklahoma Department of Corrections, p. 7). The increased frequency for elderly prisoners over the age of 65 indicates the importance of monitoring inmates more frequently as they age in order to better assess their needs and conditions as time progresses.
North Carolina conducted an extensive survey of elderly inmates and their health conditions while in prison. The state experienced a 61 % increase in its elderly inmates in a 5-year span, while the overall inmate population only increased by 16 % (Price 2006). Concerning the health status of elderly inmates, 20 % of the surveyed inmates were on a special diet due to various health issues. Furthermore, 28 % of those surveyed required some type of walking assistance, whether it was a cane, brace, or wheelchair. Finally, the cost of housing inmates 50 and older was almost four times the cost of housing younger inmates (Price 2006). Taking all of the costs into consideration, it is understandable why officials are concerned with the growth in the elderly prison population.
As indicated by the above examples, some state prisons provide thorough care of elderly inmates. This increased concern and care, however, is not without its problems. Victims and their families are upset over the care given to the offenders who have negatively impacted their lives so significantly. For example, a proposal in Illinois which would have provided for a path to parole for inmates over 50 years of age who had served more than 25 years in prison has been voted down three times (Davidson 2009). Families of victims advocated against the bill because they believed the prisoners should serve their full sentences.
A major concern when discussing the early release of older prisoners is research indicates that many elderly inmates are in prison due to violent or sexual offenses (Abner 2006). The facility in New York that was described above, however, took the risk offenders may present into consideration when designing the facility. As a result, the facility is analogous to a maximum security prison and has the ability to house all levels of offenders. Facilities with this security level may be more satisfactory to those concerned with the risk presented by violent offenders, regardless of their age.
The cost of treating sick, elderly inmates as compared to early release is another issue that brings about several concerns among policy makers and the general population alike. A specific issue that has been considered for elderly prisoners is compassionate release and whether it should be an option for some low-status offenders. Compassionate release programs are those which “call for the early release of prisoners with terminal illnesses that are expected to die within 6 months and whose release poses no risk to society” (del Carmen et al. 2008, p. 15). However, this too continues to be a controversial means of addressing the ever-growing proportion of elder inmates.
Budgetary concerns will continue to increase as the population increases, thus perpetuating the argument for alternative options. Related to early release for low-status elderly prisoners is the idea of transferring some low-risk inmates to nursing homes. However, there are still several issues that exist with this alternative, including the fact that the burden of paying for their care shifts from prisons to other government agencies. Furthermore, statutes that require nursing homes to make public the criminal records of their residents may cause serious public backlash. Although the inmates who were transferred may be too unhealthy or physically unable to present any harm to the other residents, the public may still resent the idea of having convicted offenders residing with other elderly people who have no criminal record.
Yet another unprecedented challenge for corrections management of older prisoners is the provision of end-of-life services. Action needs to be taken to ensure that elderly inmates are adequately provided for while incarcerated, including those inmates who will pass away during the span of their sentence. Presently, the California Department of Corrections and Rehabilitation (CDCR) operates a licensed hospice for terminally ill inmates. In New York, terminally ill inmates are not dealt with according to age per se, but rather their ability to take care of themselves. Some 70-year-old inmates are in very good shape while some in their 50s are not (Gater 2010). In Virginia, end-of-life or palliative care approaches are provided in-house, and inmates are directly involved in delivery of hospice services to fellow inmates in Angola, Louisiana. Family involvement, including liberal visitation, is also a vital feature to this process. The balance is between addressing public safety concerns while providing for the unique end-of-life care requirements of the elderly (Gater 2010).
Elderly prisoners will continue to serve prison sentences within facilities, whether it is offenders who age while incarcerated or those who are imprisoned at an older age. As a result, it will be interesting to see if, or when, the Supreme Court rules on a case dealing with the compassionate release of an elderly, low-status offender who is in fragile health. This is something to consider for the future, knowing that the elderly prison population continues to increase. Related to this is the question of what is considered deliberate indifference, and if these standards will also evolve over time or if detaining inmates with chronic illnesses who are almost to the point of death will ever be viewed as cruel and unusual punishment. The important question to ask concerning all of these possibilities is if the country will ever be at a place to allow such a release. As it stands now, the general population may view compassionate release as a policy that is too lenient for prisoners, regardless of the crime they committed and their current age and health condition.
Conclusions And Future Research
States are struggling with the best models of both facilities and programs to deal with an aging inmate population (Aday 2003). Also, the diversity of the growing number of older offenders should be recognized and incorporated into rehabilitative programs. In some cases, instead of preparing the inmate for reentry as a productive member of society, wellness programs which aim to keep the individual alert and active are needed. It is also the case that, in order to transfer elderly offenders back to the community, housing and financial assistance must usually be secured for inmates who have been imprisoned for long terms and who have lost all contacts in the community.
There are several ways this current research could be expanded upon in order to increase our understanding of the health care of elderly inmates. One interesting approach would be to study the different needs that exist among male and female elderly inmates, since men and women suffer from different illnesses and chronic diseases throughout the life course. Furthermore, some states have specialized facilities for male elderly inmates, but few have such facilities for female elderly inmates.
Another area for more in-depth research will be to further investigate different chronic illnesses and ailments from which elderly inmates suffer. Instead of looking at the health care of elderly inmates in general, focusing on specific diseases such as cancer and examining how prisons respond to these inmates would be beneficial. Related to this, some research indicates that those inmates who have aged in prison may be healthier than individuals who were older at the time of their incarceration (Caverley 2006). Among other things, this may give us a better assessment of the health services provided in prison.
At this practical level, Aday (2003) points out that corrections administrators and policy makers still want empirical answers to some fundamental questions. These include what may be categorized as the relative costs (savings) to relative benefits of long-term incarceration versus early parole or extended medical furlough for infirm prisoners. Administrators and policy makers also need more information on aging lifers without parole and the effects of long-term institutionalization, as well as the impact of sentencing law changes on the size of the long-term inmate populations. At both programmatic and policy levels, there remain many open questions and much work to be done as it relates to the graying of the US prison population.
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