You’re only as old as you feel? That timeworn adage certainly holds true for the 50-year-old inmate who, body wracked by years of hard living and neglect of health care, now attends clinics for diabetes and hypertension and can barely move when his angina flares up. If he lives in Florida, the state department of corrections defines him as “elderly,” and that’s exactly how he feels.

And he’s not alone. The statistics are sobering. On January 1, 2001, state and federal prisons housed 113,358 inmates age 50 or older, a 173% jump from 41,586 such inmates in 1992. And the proportion of these older inmates has risen, to 7.9% of the overall prison population in 2001 compared to 5.7% in 1992.

These figures come from a recent report, Correctional Health Care: Addressing the Needs of Elderly, Chronically Ill, and Terminally Ill Inmates, commissioned by the National Institute of Corrections and prepared by the Criminal Justice Institute. (See box at right to learn how to obtain the report.)

Given the national demographic, crime and sentencing trends that have contributed to the increase in elderly prison inmates, their numbers likely will continue to rise. Inevitably, this poses great challenges for correctional systems, not only in determining what services to provide and how, but also how to pay for them.

Accelerated Aging
Who qualifies as elderly? While definitions vary among correctional institutions, a CJI study in 2001 found that, among the 22 state agencies (of 49 responding) that had a working definition of the term, the average first qualifying age was 55. Some states used degree of disability in their definitions rather than chronological age. The NIC report also points out that the elderly population overlaps with two other categories of special needs patients—chronically ill and terminally ill—that also require enhanced services.

Whatever the definition, the transformation to “elderly” is accelerated among prison inmates compared to the general population. According to the NIC report, this faster physiological aging adds 11.5 years, on average, to inmates’ chronological ages after age 50.

Factors behind this phenomenon include the stress that new inmates experience as they try to survive incarceration, avoid confrontation with inmates and staff, and cope with financial pressures related to imprisonment; withdrawal from substance abuse; lifelong histories of high-risk behaviors; and inadequate health care before incarceration.

For those who have lived behind bars awhile, add to that list debilitating stresses related to reduced human interaction, lack of privacy, loss of self-esteem, fear of dying in prison, and even fear of being released from prison.

The most common signs of health deterioration among inmates over age 50 include higher rates of incontinence, sensory impairment, impaired flexibility, respiratory illness, cardiovascular disease and cancer, according to studies cited by the NIC report. As in the free world, the most common chronic diseases are arthritis, high blood pressure, ulcers, prostate problems and heart disease, though these are more concentrated in correctional settings.

Of course, older inmates also experience typical age-related problems: cognitive impairment, reduced vision and hearing, muscle mass loss, incontinence, dietary intolerance and general vulnerability, and, related to the above, collateral emotional and mental health problems.

Not surprisingly, per capita costs of incarcerating elderly inmates have soared, according to the NIC report, to an average of $60,000 or $70,000 per year compared to about $27,000 per inmate in general population. Looking at health care alone, overall spending increased by 27% from 1997 to 2001.

Complex Challenges
So the challenge for prison systems is multifaceted. They must:
• Assess how best to house and manage these special needs inmates (e.g., mainstreaming vs. new construction or remodeling of special units)
• Provide special accommodations, facilities and programs (e.g., aids to geriatric living)
• Weigh epidemiological considerations, given this population’s vulnerability to contagion
• Strive to contain costs
• Train medical and correctional staff to identify and respond to the needs of this population
• Employ the most appropriate and effective functional assessment tools. This, the NIC report says, is the key to addressing all of the challenges above, since it makes clear exactly what accommodations and services will be required.

Functional Assessment
Early and accurate identification of the complex needs of elderly inmates is so important that the authors of the NIC report devote a full chapter to it. As with any newly admission, prison health care staff must perform an intake history or screening exam and when they identify urgent needs, should refer the inmate for assessment or treatment. In all cases a complete medical history and physical exam should occur within seven days. (See NCCHC’s Standards for Health Services Section E, Inmate Care and Treatment, for the requirements for accredited prisons.)

However, pitfalls in this process do arise—for example, the inmate may not disclose health information if the setting does not appear to ensure confidentiality—and can result in a treatment plan that fails to address an inmate’s special needs.

Also, prison classification and screening instruments in use generally weren’t designed with the needs of elderly inmates in mind, say the authors of the NIC report. To prevent negative health outcomes for the inmate—and to avoid serious liability for the prison—the report outlines two strategies that should be considered. In one, the physician lists individual inmates’ specific needs to enable appropriate classification and placement. In the other, a detailed coding system is used to aid decision making.

Even when assessment and placement are done appropriately, problems may arise when a special needs inmate is transferred to another institution. For example, delays may occur when the second prison needs to reorder necessary medical equipment or supplies. A system for tracking inmates with special needs will help to prevent such problems.

Programs, Housing and Treatment
Since the elderly and chronically ill often need ongoing care for multiple conditions, it is important that they be housed in facilities that offer a full range of health services, the NIC report authors advise. These include access to health staff 24/7, specialty medical services and assistance with activities of daily living. In addition, adaptive devices such as walkers, hearing aids, extra blankets, etc., are likely to be needed.

Housing arrangements should be based on need, not age. Clearly, those with serious debilities would be candidates for a nursing home setting or even an infirmary. Older inmates in good health can live in general population, though the NIC report cautions that facilities designed for physically active people may be problematic architecturally. Less tangible difficulties arise, too: Older inmates may not fit in well with younger, aggressive inmates and may even be victimized. Therefore, separate units that provide a more sheltered environment and accommodations such as ramps and hand rails may be worth considering.

Old age need not mean a continual downward spiral. The NIC report notes that programming should strive to help elderly inmates stay physically active and mentally alert, for example, through self-help programs. This will lessen the inevitable difficulties they’ll face if and when they are released to the community.