History of Incarceration and Its Association With Geriatric and Chronic Health Outcomes in Older Adulthood

This cross-sectional study of data from the Health and Retirement Study examines the association of history of incarceration with risk of chronic health conditions and geriatric syndromes among older community-dwelling US adults.


Introduction
2][3] At the same time, the proportion of incarcerated older adults also rose precipitously. 4 As a result, many community-dwelling older adults have a lifetime history of incarceration since nearly 95% of incarcerated people are eventually released to the community. 5wever, little is known about the health impacts of incarceration in later life or even the precise number of people in the US who have experienced incarceration during their lifetime. 6This is in part due to the fragmentation of data among county, state, and federal correctional institutions and the limited number of national population-based surveys that ask participants about their history of incarceration. 7,8carcerated older adults have higher rates of chronic medical conditions compared with their nonincarcerated peers. 9,10In addition, incarcerated older adults experience higher rates of geriatric syndromes at earlier ages, including urinary incontinence, hearing impairment, and activity of daily living (ADL) impairments (eg, difficulty toileting, bathing, dressing, and feeding oneself). 11This evidence of accelerated aging has led both correctional institutions and researchers to consider incarcerated adults to be older or geriatric at the age of 50 years. 4,12The underlying mechanisms leading to higher rates of disease in this population have been poorly studied; possible etiologies include exposure to acute and chronic stress, variable access to high-quality health care, and incarceration's association with other social determinants of health, including homelessness, unemployment, and food insecurity. 4,11,13,14Although studies 9,11 have examined the associations between incarceration and poor health among older adults who are incarcerated, it is unknown how many community-dwelling older adults have experienced incarceration or whether a history of incarceration confers risk for worse health outcomes in older adults.
Understanding the association between incarceration and health among community-dwelling older adults has important clinical and policy implications.Such knowledge could inform the need for health care professionals to screen patients for a history of incarceration and could support the development of interventions to minimize the long-term effects of incarceration after release.
Additionally, policy makers and public health advocates are increasingly advocating for alternatives to incarceration; establishing data on population incarceration rates and on the longitudinal impacts of incarceration is important for evaluating the impacts of alternatives to incarceration.Therefore, we examined whether a history of incarceration was associated with higher rates of chronic diseases and geriatric syndromes in a nationally representative sample of community-dwelling US adults aged 50 years or older.

Study Design and Population
We performed a cross-sectional study of data from the 2012 and 2014 survey waves of the Health and Retirement Study (HRS).The HRS is a nationally representative longitudinal survey of adults aged 50 years or older that is conducted by the University of Michigan and sponsored by the National Institute on Aging. 156][17] Institutionalized persons, including those residing in carceral facilities, are excluded from enrollment in the HRS.
Participants complete interviews every 2 years about their economic, health, and psychosocial information.Our study included all participants who completed the 2012 or 2014 psychosocial leavebehind questionnaire, the only survey waves that assessed self-reported incarceration history.The questionnaire was left with participants to return by mail and was administered to a random 50% of all HRS respondents in 2012 and the other 50% in 2014. 18Approval for this data analysis was obtained from the institutional review board at the University of California, San Francisco, which waived the patient consent requirement because the data are deidentified.We followed the

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Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Measures Incarceration
Our exposure variable was self-reported incarceration, defined as ever having spent time in juvenile detention, jail, or prison.Participants reported whether the total time spent incarcerated was less than 1 month, less than 1 year, between 1 and 5 years, more than 5 years, or unknown.In some analyses, we dichotomized incarceration length (<1 month vs Ն1 month) due to small sample sizes.

Sociodemographic Characteristics
Sociodemographic characteristics included self-reported age, sex, race and ethnicity (Black/African American, Hispanic/Latino[a], White, and other [Asian, American Indian, Alaska Native, Native Hawaiian, and other Pacific Islander]), educational attainment, veteran status, and a history of ever experiencing homelessness.All variables were drawn from the survey year corresponding to the completed questionnaire.
We assessed socioeconomic status using wealth (an assessment of all assets and debts) since it is the most comprehensive measurement of socioeconomic status in older adults. 19We categorized wealth into 4 quartiles from lowest (quartile 1) to highest (quartile 4).

Health Outcomes
The HRS assesses self-reported physical health outcomes, which have been well validated in older US adults. 20Chronic health conditions included ever having been told by a physician that you have a health condition, including high blood pressure or hypertension, diabetes or high blood glucose level, chronic lung disease, stroke, and heart disease (myocardial infarction, coronary heart disease, angina, congestive heart problems, or other heart problems).A history of mental health conditions was defined as being told by a physician that you have any emotional, nervous, or psychiatric problem.
We categorized self-reported heavy alcohol use as drinking more than 4 alcoholic drinks daily.We categorized self-rated health as excellent, very good, or good vs fair or poor.
The HRS also collected information about geriatric conditions.Cognitive impairment was defined as ever being told by a physician that you have Alzheimer disease, dementia, senility, or serious memory impairment.We defined mobility impairment as using an assistive device (cane, walker, or wheelchair) or difficulty walking several blocks.Vision and hearing impairment were defined as reporting fair or poor vision or hearing.Urinary incontinence was defined as having experienced loss of control of urine in the past 12 months.Impairment in ADLs was defined as having difficulty with bathing, dressing, feeding, toileting, or transferring; impairment in instrumental ADLs (IADLs) was defined as having difficulty with meal preparation, grocery shopping, taking medications, making telephone calls, or managing money.

Statistical Analysis
Data were analyzed from December 2021 to July 2022.We conducted a descriptive analysis of sociodemographic factors, health care utilization, and health outcomes stratified by history of incarceration.To compare individuals with and without a history of incarceration, we used a Rao-Scott χ 2 test for categorical variables and a nonparametric test for equality of medians for continuous variables.We applied survey weights to adjust for the survey design.
To compare the prevalence of health outcomes among those with and without a history of incarceration, we used modified Poisson regression and controlled for age, sex, race and ethnicity, wealth quartiles, educational attainment, and uninsured status.To better understand the association of biological vs social factors with health outcomes, we also performed a minimally adjusted analysis, adjusting for age and sex.In a combined analysis, we evaluated the risk of having any geriatric syndrome and any chronic health condition.We identified potential confounders a priori based on

JAMA Network Open | Geriatrics
Association of Incarceration History With Chronic Health Outcomes in Older Adulthood existing literature and controlled for variables that might confound the variable-outcome association.
We did not adjust for variables that are also potential mediators between history of incarceration and adverse health outcomes, including homelessness, substance use, or mental illness.We performed regression analyses using a complete case analysis given the low rates of missingness for included variables (<0.4%).
Next, we assessed the impact of length of incarceration.Participants who were incarcerated for an unknown duration (n = 30) were excluded from this analysis.We used descriptive statistics and a trend analysis to compare health outcomes among participants with no incarceration history, those who had been incarcerated for less than 1 month, and those who had been incarcerated for 1 month or more.To evaluate whether there was a difference in health outcomes among those with shorter vs longer periods of incarceration, we repeated the modified Poisson regression, controlling for the same variables, and compared individuals with 1-to 30-day incarceration durations vs 1 month or more.We used a 2-sided a priori significance threshold of P < .05.We completed our analyses using Stata, version 17.0 (StataCorp LLC) and SAS, version 9.4 (SAS Institute, Inc).
Previously incarcerated participants were more likely to report having General Educational Development or not graduating from high school (31.9% vs 16.8%; overall P < .001), to have ever experienced homelessness (27.7% vs 3.1%; P < .001),and to be a veteran (31.7% vs 16.7%; P < .001).

Incarceration History
Among those who had ever been incarcerated (n = 946), the majority were incarcerated for less than 1 month (60.9%).One-fifth (20.5%) were incarcerated for 1 to 12 months, 11.7% for 1 to 5 years, and 4.0% for more than 5 years.

Incarceration Length
Despite small absolute numbers, all health outcomes that were associated with a history of incarceration except cognitive impairment also had a statistically significant test of trend across length of incarceration, suggesting that longer incarceration periods may be associated with an increased risk of these health outcomes (Figure).However, in our adjusted Poisson regression model, there were no significant differences between individuals who were incarcerated for 1 month or more vs less than 1 month (eTable in Supplement 1).

Discussion
In a nationally representative sample of older US adults, we found that at least 1 in 15 adults (7.6%) aged 50 years or older had experienced incarceration during their lifetime.This is likely an underestimate of the actual experience of older US adults since the HRS does not include people who were unhoused, did not have a telephone, or were incarcerated at the time of study enrollment.As there is a profound lack of data about US adults with a criminal legal history, this study is among the first to estimate self-reported history of incarceration among community-dwelling older US adults.
There is a critical need to improve data collection and transparency to generate accurate estimates of lifetime incarceration in the US. 7,8,21Nevertheless, our findings indicate that incarceration is so prevalent in the US that an older adult's likelihood of having a history of incarceration is higher than their lifetime risk of developing colorectal cancer. 22Yet, despite the ubiquity of criminal legal system involvement in the US, there has been relatively little funding and research dedicated to understanding the downstream health outcomes and needs of this population. 21,23 our knowledge, this is the first published study to demonstrate that a lifetime history of incarceration was associated with increased risk of geriatric syndromes and several chronic health conditions among community-dwelling older adults.We found that older adults with any incarceration history (even of short duration) had a 20% to 80% increased risk of experiencing geriatric syndromes even after controlling for socioeconomic factors.These findings are consistent with prior research demonstrating a high prevalence of chronic health conditions and geriatric syndromes at relatively young ages among older adults who were currently incarcerated (rather than living in the community) 10,11 and support the notion of accelerated aging in this population.
Our results regarding chronic health outcomes were variable.People who had been incarcerated had an increased risk of fair or poor self-rated health in addition to health outcomes related to substance use or mental health concerns, including chronic lung disease, mental health

Figure .
Figure.Prevalence of Geriatric Syndromes and Chronic Health Conditions, Stratified by History and Length of Incarceration Association of Incarceration History With Chronic Health Outcomes in Older Adulthood 0% vs 75.1%;P < .001).When controlling for the same aforementioned factors, an incarceration history was associated with increased risk of any geriatric syndrome (RR, 1.20; 95% CI, 1.12-1.28;P < .001)and any chronic health condition (RR, 1.09; 95% CI, 1.04-1.13;P < .001).

Table 1 .
Participant Characteristics and Health Outcomes Stratified by History of Incarceration c Represents 4 625 413 adults.d Includes Asian, American Indian, Alaska Native, Native Hawaiian, and other Pacific Islander.e Wealth was categorized into 4 quartiles from lowest wealth (quartile 1) to highest wealth (quartile 4).

Table 2 .
Health Outcomes Associated With History of Incarceration Among Older Adults a Absolute numbers with weighted percentages are shown.bAdjustedforage, sex, race and ethnicity, wealth, educational attainment, and uninsured status.cDifficulty with bathing, dressing, feeding, toileting, or transferring.dDifficulty with meal preparation, grocery shopping, taking medications, making telephone calls, or managing money.eIncludes history of myocardial infarction, coronary heart disease, angina, or congestive heart failure.fDefined as more than 4 drinks per day.