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JAMA Forum
February 13, 2020

Challenges of Aging Population Are Intensified in Prison

Author Affiliations
  • 1Partnered Evidence-Based Policy Resource Center, Veterans Health Administration, Boston, Massachusetts
  • 2School of Public Health, Boston University, Boston, Massachusetts
JAMA Health Forum. 2020;1(2):e200170. doi:10.1001/jamahealthforum.2020.0170

Even a brief prison term can turn into a life sentence for an older adult. All prisoners have a right to medical care, but large gaps in illness and symptom management remain.

Older adults comprise more than one-tenth of state and federal prisoners in the United States. Although the term older adults is typically applied to people aged 65 years or older, inmates who experience stress-induced accelerated aging are defined as adults aged 55 years or older, and frequently have chronic or life-limiting illnesses that require intensive management. They are more likely than their community-dwelling counterparts to experience falls, incontinence, difficulty with everyday activities such as bathing or dressing, hearing impairment, and multiple concurrent illnesses.

Many of these older inmates receive inadequate health care and symptom management. Correctional facilities, by definition, are not health care facilities; their institutional focus is security. Limited access to clinicians with geriatric expertise means that diagnoses may be missed. Dental health needs, including the need for dentures, may be overlooked, leading to pain and inadequate nutrition. Institutional menus are counterproductive to the management of diabetes and obesity. Other gaps in care arise from suspicion of prisoners’ motives or attitudes. Pain medication may be restricted due to concerns that pills will be misused. Unusual behavior that occurs with dementia may be misconstrued as deliberate belligerence.

Although the all-cause mortality rate is lower among prisoners than among the general population, the average age of prisoners has increased dramatically since the early 1990s. This has contributed to a near doubling from 2001 to 2015 in the percentage of deaths among state prisoners that occur among those older than 55 years (from 34% of 2869 prisoner deaths to 59% of 3483 prisoner deaths).

Health Needs After Release

In response, the availability of compassionate release and geriatric release (provisions for early release from prison in cases of terminal illness or old age) has increased. Changes to federal compassionate release in 2018 expanded eligibility criteria and provided prisoners the right to appeal denials of early release decisions. Although some version of compassionate release now exists in every state except Iowa, relatively few prisoners benefit from these laws. Access to compassionate and geriatric release is limited due to a lack of knowledge regarding existence of policies or eligibility criteria, insufficient resources to file a petition for early release, and in some cases, the absence of a social or economic support system outside prison.

Even when released from a correctional facility, either through compassionate release or the end of a sentence, older former inmates experience poor outcomes in the community. In 1 study, nearly half of older adults released from jail visited an emergency department at least once within the 6 months following release. Those who have recently left prison have an elevated risk of death following release, relative to older adults residing in the community. Risks of poor outcomes may be heightened from disruptions in insurance coverage and postrelease access to medication.

Barriers to Care in Correctional Facilities

Correctional systems are grappling with the best way to manage illnesses and age-related decline among older prisoners—questions that are challenging enough to address in the community. For instance, a substantial portion of care provided to older adults is often from an unpaid network of family and friends, which is a network that is unavailable to those in prison. Day-to-day symptom management and assistance with activities such as eating and transferring out of a chair is time-consuming. Dedicated assistance with these activities from a paid professional is prohibitively expensive for many outside prison, and is simply not an option within prison. Instead, prisoners have to rely on corrections staff or cellmates for assistance with dressing, bathing, and using the toilet. Routine prison activities (including getting in and out of bunks, walking to the dining hall, and responding to alarms and head count) may become especially difficult for some older prisoners.

For prisoners who are physically frail or whose cognitive function is declining, facilities must decide whether to provide prisoners the option to move to dedicated facilities with nursing care or make accommodations to existing living arrangements. Moving can be problematic because community-based nursing homes are often unwilling to accept prisoners, and few prisons have on-site long-term care facilities. Even when facilities are available, older prisoners who switch facilities lose their social network and are at increased risk of depression.

Relocation may be especially stressful for prisoners with dementia. Moreover, the presence of older prisoners can be a stabilizing social force for fellow inmates; therefore, moving them to a dedicated facility with more nursing care may disrupt an entire cellblock. Retrofitting existing facilities to improve accessibility is possible, but costly. Jails and prisons have narrow doorways and bathroom stalls that do not allow wheelchairs to pass through easily. Bunkbeds need to be replaced with beds at floor level. More feasible accommodations include installation of nonslip flooring and handrails to prevent falls.

Potential Solutions

Some promising programs exist for managing health needs of older inmates, but they are not widely available. Coordination among correctional health systems and primary care clinics is associated with fewer emergency department visits after prison release. A microsimulation study suggests that opt-out screening for hepatitis C infection, which is highly prevalent among incarcerated older adults, could increase early detection and prevent disease-related deaths. For prisoners with life-limiting diseases, select prisons now have hospice and palliative care programs, some staffed with peer volunteers who provide 1-on-1 care for dying inmates.

Withholding health care during imprisonment is considered cruel and unusual punishment under the Eighth Amendment. A prison or jail sentence should entail a loss of freedom but not a loss of health or dignity. Older prisoners (whether newly sentenced at an older age or completing an extended or a life sentence) have myriad health needs that require daily attention.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Corresponding Author: Melissa Garrido, PhD, Partnered Evidenced-Based Policy Resource Center, Veterans Health Administration, 150 S Huntington Ave, Boston, MA 02130 (garrido@bu.edu).

Conflict of Interest Disclosures: None reported.

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