Download The Graying of the US Prisoner Population

The Graying of the
U.S. Prisoner Population
Journal of Correctional
Health Care
Volume 14 Number 3
July 2008 202-208
© 2008 NCCHC
10.1177/1078345808318123
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Glenda Reimer, PhD, RN, CCHP
Correctional systems and health care providers are facing multiple challenges in providing care
for an increasing population of older and sicker inmates. The dramatically changing demographics of the incarcerated population mandate greater attention to and understanding of the
particular health care and health maintenance needs of older inmates, as well as the ways in
which these needs can best be met by U.S. correctional systems and institutions. This article discusses the growth of prison populations and the characteristic of aging and elderly prisoners. The
health status and health care of older inmates are addressed, followed by an overview of
approaches being implemented in caring for the aging prison population nationwide.
Keywords:
aging; correctional health care; prisoners; geriatrics
Unprecedented Growth of the Incarcerated Population
The total number of sentenced inmates in state and federal prisons rose 35% between 1995
and 2005. On December 31, 2005, a total of 1,446,269 inmates were in the custody of state
and federal prison authorities, and 747,529 were in the custody of local jail authorities. At
year-end 2005, state prisons were operating at between 1% below and 14% above capacity,
and federal prisons were operating at 34% above capacity (Bureau of Justice Statistics,
2006c). This unprecedented growth in incarcerated populations is related to changes in sentencing and parole practices; recidivism rates; and increasing incarceration rates in several
major offense categories.
In the 1980s, many states abolished parole and passed “three strikes you’re out” laws.
At the federal level, Congress imposed mandatory sentencing guidelines. In the decade from
1980 to 1990, average sentences tripled from 20 months to 57 months. Of the factors
affecting increases in incarcerated populations, legislation on sentencing has been a major
contributor. Enactment of three strikes state laws across the United States has placed correctional systems in a crisis of overcrowding as more individuals face longer sentences without parole. The average age nationally of three strikes legislation is 31 years. In the state of
Colorado, for example, where sentences previously convicted felons to 25 years, legislation
in the 1980s mandated a number of sentencing changes, including (a) changing sentencing
From Beth El College of Nursing and Health Sciences, University of Colorado at Colorado Springs, Colorado.
The author declares no conflict of interest. For information about JCHC’s disclosure policy, please see the Self-Study Exam.
Address correspondence to: Glenda Reimer, PhD, RN, CCHP, Beth El College of Nursing and Health Sciences, University
of Colorado at Colorado Springs, 1420 Austin Bluffs Parkway, P.O. Box 7150-UH-1, Colorado Springs, CO 80933-7150;
e-mail: [email protected].
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from indeterminate to determinate terms; (b) requiring courts to apply a maximum sentence
for crimes of violence; and (c) doubling maximum penalties for all felony classes. Such sentencing legislation has dramatically increased prison populations across the United States.
Recidivism (defined here as a new criminal activity or technical violation of parole, probation, or nondepartmental community placement within 3 years of release) is another
important factor in growing prison populations. The average recidivism rate for males in
Colorado, for example, is 53.1% and for females is 51.1%. This means that for every two
people released from prison, one will return within the next 3 years. Recidivism has contributed substantially to the 5.7% increase in Colorado’s incarcerated population between
2004 and 2005 (Bureau of Justice Statistics, 2006c).
Prisoners sentenced for drug offenses constituted the largest group of federal inmates
(55%) in 2003. Between 1995 and 2003, the number of federal inmates held for publicorder offenses increased 170%, most of which was accounted for by the increase in immigration offenses (up 394%). The number of weapons offenders held in federal prisons
increased about 120% between 1995 and 2003, and violent offenders under federal jurisdiction increased 46% from 1995 to 2003. Homicide offenders increased 146%. While the
number of offenders in each of these major offense categories increased, the number incarcerated for a drug offense accounted for the largest percentage of the total growth (49%),
followed by public-order offenders (38%; Bureau of Justice Statistics, 2006c).
Who Are the Elderly Incarcerated?
The National Institute of Corrections defines “elderly” among the incarcerated population
as any inmate above the age of 50 years, because the average prisoner has a reduced health
status approximating the health condition of nonincarcerated people who are 10 to 15 years
older (Duckett, Fox, Harsha, & Vish, 2000; Falter, 2006).
Ronald Aday (2003), in Aging Prisoners: Crisis in American Corrections, emphasizes that
the increase in the proportion of elderly is having far-reaching effects on the criminal justice system. Wheeler, Connelly, and Wheeler noted in 1995 that the aging of the large baby
boom population (born between 1946 and 1964) would be a significant factor in the growing numbers of incarcerated elderly. In 2003, prisoners 45 years and older accounted for
17.8% of sentenced inmates, up from 13% in 1995 (Fields, 2005). Inmates 50 and older are
now the fastest-growing portion of the prison population (Associated Press, 2005), increasing at a rate three times faster than the general prison population.
Geriatric correctional specialists Craig-Moreland and McLaurine (Neeley, Addison, &
Craig-Moreland, 1997) identify four categories of elderly offenders: (a) first offenders who
were sentenced to prison after the age of 50; (b) juveniles who entered the prison system at
a young age and grow old in prison as a result of a life sentence; (c) prison recidivists who
have served multiple sentences; and (d) chronic offenders who have the propensity for criminal activity but have never been incarcerated.
Conditions of poverty, isolation, and abandonment may contribute to anger and depression in the aging population in general as well as in the aging incarcerated population.
Developmental theorist Daniel Levinson (Levinson, Darrow, Klein, Levinson, & McKee,
1978) states that midlife issues as well as the social and psychological effects of retirement
often precipitate crises that may lead to criminal behavior with possible incarceration.
Researchers Kratcoski and Pownall (1989) suggest that violent crimes committed by older
people typically focus on victims who are family members, relatives, or close acquaintances.
Older inmates who are in prison for the first time are usually serving a sentence for a violent crime, often alcohol related (Falter, 2006). Florida corrections officials reported that
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Journal of Correctional Health Care / Vol. 14, No. 3, July 2008
74% of elderly state inmates were incarcerated for violent offenses such as sex crimes or
murder, with about 30% serving life sentences (Jones, Connelly, & Wagner, 2001).
Health Status of Elderly Prisoners
The aging of the prison population is increasingly becoming a major health care issue. Health
care providers in the correctional setting have become increasingly concerned with the challenges of caring for the growing population of aging prisoners. These prisoners experience the
common effects of aging, including chronic health conditions, sensory decline, and cognitive
and emotional disorders (Aday, 2003) and may experience these effects at earlier ages than the
general population due to conditions of incarceration and difficult lives prior to incarceration
(Falter, 2006). Correctional health care typically addresses not only the concerns that normally
accompany aging, such as nutrition, hydration, mobility, vision, and hearing, but also conditions related to chronic and acute physical and mental illnesses and end-of-life care.
Age-related conditions that correctional staff must address in working with the aging
incarcerated population are also inherent in the general population but are often more
severe in the inmate population. As an example, elderly inmates may be extremely sensitive
to changes in ambient temperatures; however, jails and prisons are not well equipped to regulate facility temperatures. Most facilities are enclosed, providing little outside ventilation,
and inmates have limited exposure to outside air. In addition, chronic respiratory diseases
are typically present, subjecting inmates to contaminated airflow in their living spaces.
Asthma and upper respiratory infections are thus a common health hazard in such environments. Reduced lung capacity typically accompanies aging, with inmates aged 80 and older
having about one third the lung capacity of younger inmates. Many older inmates suffer
from chronic respiratory infections such as pneumonia, tuberculosis, persistent bronchitis,
asthma, and emphysema, which may be aggravated by anxiety, fear, extreme temperature
changes, exertion, and/or smoke.
Normal aging of the circulatory system includes the enlargement of the heart and
decrease in elasticity of blood vessels, resulting in slower pulse rates and decreased oxygenation of all organs and tissues. Aging inmates often have shortness of breath, high blood
pressure, and obstructive pulmonary disease. Exercise routines for the aging inmate population in the current correctional systems typically do not correspond to requirements for
maintaining or increasing cardiovascular health. Older female prisoners, a very small percentage of the prison population, are at risk of not having their particular health needs met.
Anger, confusion, and the inability to sustain a peaceful demeanor are often evident
among inmates. Symptoms of posttraumatic stress disorder are ever present in the incarcerated population and many elderly inmates exhibit behaviors attributable to long-term
manifestation ofposttraumatic stress disorder. Based on data from personal interviews with
state and federal prisoners in 2004 and local jail inmates in 2002, at midyear 2005 more
than half of all prison and jail inmates had a mental health problem. Among those 55 years
or older, 40% of state prison inmates, 36% of federal prison inmates, and 52% of local jail
inmates had mental health problems (Bureau of Justice Statistics, 2006b).
There is growing evidence of widespread elder abuse in the United States, including
physical, emotional, and sexual abuse, abandonment, exploitation, and neglect. In prison systems, abuse of elderly inmates has also been documented. The state of Oklahoma considers
some of its older inmates open to exploitation and therefore houses them in single-person
cells (McMahon, 2003). Findings from the Bureau of Justice Statistics’ (2006a) Survey of
Inmates in Local Jails showed that 7.8% of inmates 45 years or older had been injured while
incarcerated, and the likelihood of injury increased with the length of incarceration.
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In this same study of inmates in local jails, about 61% of inmates age 45 or older
reported having a current medical problem, and 44% reported impairment. Among inmates
who were homeless in the year before their arrest, 49% reported a current medical problem,
compared to 35% of those who were not homeless. Medical problems and physical or mental impairments were also more prevalent among inmates who reported being unemployed
before their arrest or receiving government assistance.
A Bureau of Justice Statistics (2007) study revealed that 12,129 inmates in the nation’s
state prisons died while in custody during a 4-year period from 2001 through 2004. Of these
deaths, 89% were attributed to medical conditions including heart disease (27%), cancer
(23%), liver disease (10%), and AIDS-related causes (7%). Inmates who were 45 years or
older represented 14% of state prisoners but 67% of the prisoner deaths during this period.
More than half (59%) of inmates age 65 or older who died in state prisons were at least 55
or older when admitted to prison. Only 15% of elderly inmates who died were younger than
45 at the time of their admission to prison.
Health Care for Aging Prisoners
A study by Walsh (1992) revealed that elderly inmates 55 years or older have different health
care needs than younger inmates. Morton (1992) discusses many ways in which most prisons, designed for younger, more physically active inmates, are not well adapted for the needs
of older inmates. Essentially, this research demonstrated that elderly inmates need additional preventive care, orderly conditions, safety, and emotional support.
Pain management is a significant challenge in caring for the aging inmate population.
Given the mental and physical stresses of incarceration, compounded by chronic diseases,
the presence of both real and imaginary pain is common among inmates. Assessing and
managing pain in elder inmates requires specialized health care knowledge and skills.
The economics of caring for the aging in prison is a critical issue. Foster (1990) found
that the annual average cost for health care and maintenance of inmates older than 50 years
was as much as $60,000, whereas the cost of incarcerating younger inmates averaged
$21,000 yearly. At one state correctional facility in Pennsylvania, costs for one of the 111
inmates receiving 24-hour nursing care are about $62,000 per year (Associated Press,
2005). Much recent literature suggests that the cost of caring for an older person in prison
is three times the average inmate health care cost (Duckett et al., 2000). The National
Center of Institutions and Alternatives estimated annual incarceration costs for an elderly
inmate at $69,000, compared with an average of $22,000 for all inmates (McMahon, 2003).
Generally, aging prisoners are not eligible for Medicare and Medicaid benefits.
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.
A report on 50 departments of corrections across the United States indicated that only 16
provided special training for security staff working with chronically ill, terminally ill, or
elderly inmates (LIS, 1997). The same survey indicated that many correctional agencies did
provide specialized medical care to elderly inmates either throughout their systems or consolidated at specific sites (Falter, 2006). Iowa reported mainstreaming its elderly inmates
within the overall prison population and providing specialized care based on specific needs
rather than age. Tennessee reported housing inmates with special medical needs in a health
care center. Maine reported using nursing home beds for frail and medically compromised
elderly inmates. Colorado reported providing specialized medical care such as hospice for
elderly inmates at several sites, and housing inmates who needed moderate assistance at two
specific facilities (Falter, 2006).
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Journal of Correctional Health Care / Vol. 14, No. 3, July 2008
In its Clinical Practice Guidelines: Preventive Health Care, the Federal Bureau of
Prisons (2005) recommends the following screening procedures annually for federal prison
inmates 50 years of age and older, noting that the frequency of monitoring patients should
be patient-specific and adjusted as clinically necessary to monitor significant changes in a
parameter, such as increases or decreases in weight or blood pressure.
•
•
•
•
•
•
•
•
•
•
Counsel on nutrition, exercise, substance abuse, and infectious disease transmission
Measure weight, body mass index (schedule reevaluation based on trend)
Measure blood pressure (schedule reevaluation based on trend)
Screen for latent tuberculosis infection with annual tuberculin skin test (unless
previously positive)
Screen for tuberculosis disease with chest radiographs for certain inmates who
refuse isoniazid treatment
Screen for hearing loss with annual audiograms for those at occupational risk
Screen for breast, cervical, and colon cancers per established parameters/clinical
indications
Screen for cardiovascular risk (aspirin need), diabetes, and hypercholesterolemia per
criteria
Screen for osteoporosis in females 65 years of age and older
Screen for abdominal aortic aneurysms in male smokers 65 to 75 years of age
Universal screening for certain diseases, such as glaucoma and ovarian or prostate cancer, is not recommended in these clinical practice guidelines but may be indicated for certain inmates based on risk factors or clinical concerns. Although the courts have mandated
that all prisoners must receive health care comparable to care available in the community,
evidence has not revealed that all prisoners receive such care on a consistent basis.
Approaches to Caring for Aging Inmates
As early as 1988, Johnson recommended that aged inmates should receive special attention
reflecting the physiological, psychological, and sociological effects of aging. Johnson further
advises correctional systems to look at the whole person when assessing and classifying inmates
to best meet their needs. In 1992, Flynn recommended that corrections officials pursue a
number of strategies to address the health care of elderly inmates, including the following:
• Collect baseline data on each elderly inmate;
• Modify inmate classification systems to facilitate mainstreaming of elderly inmates
if this is consistent with their needs and inmate safety;
• Adapt existing facilities to ensure equitable treatment of the elderly;
• Modify existing work and education programs to include health care education, preventive medicine, and counseling of the elderly;
• Establish special geriatric units for inmates requiring specialized care.
Geriatric corrections expert Ronald Aday recommends the immediate step of increasing
preventive care and educating older prisoners in strategies for maintaining and monitoring
their own health (Pfeffer, 2002). Longer-term strategies include developing long-term care
facilities for aging inmates similar to nursing homes or hospices, or other alternative
arrangements such as halfway houses or house arrest for nonviolent older offenders.
Herbert Rosefield, a consultant and former geriatric prison superintendent in North
Carolina, believes that geriatrics can produce cost savings for states that choose to group older
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inmates by risk (personal communication, Annual Symposium of the Colorado Department of
Corrections, 2004). This practice of putting similar inmates together has also been shown to
have a calming effect. A number of states currently house high-risk inmates in geriatric units or
stand-alone prisons that are staffed by specialists in detecting and treating gerontological conditions. Minimum-security facilities and correctional nursing homes require fewer guards,
which reduces budgets. Inmates convicted of nonviolent crimes long past might be moved into
supervised forms of release (Pfeffer, 2002). Prisoner advocates and hospice groups estimate that
about 100 ill inmates are released each year under some form of compassionate release program
(Fields, 2005). Requests for such releases are increasing with the aging of inmate populations.
Court rulings compel prisons to provide health care comparable with what is available
in the community, and many corrections systems are providing hospice care as part of a continuum of care. Health care workers in a prison hospice provide the same kinds of care they
would in any hospice. The first prison hospices were opened in 1987. In 2001, 19 states had
hospice programs, another 14 states were developing programs, and 9 states were planning
to expand their programs. Reports from prison hospice programs reveal a number of benefits, such as improved behavior and greater respect for care givers, including other inmates
who volunteer to help care for the terminally ill and dying (Domrose, 2004).
Summary
Unprecedented growth in incarcerated populations is related to changes in sentencing and
parole practices, recidivism rates, and increasing incarceration rates in several major offense
categories. Inmates age 50 and older are now the fastest-growing portion of the prison population, increasing at a rate three times faster than the general prison population. This
increasing proportion of elderly is having far-reaching effects on the criminal justice system.
Elderly inmates have different health care needs than younger inmates, and experts agree
that older inmates should receive special attention reflecting the physiological, psychological,
and sociological effects of aging. Among those 55 years or older, 40% of state prison inmates,
36% of federal prison inmates, and 52% of local jail inmates had mental health problems.
About 61% of jail inmates age 45 or older reported having a current medical problem, and
44% reported impairment. In the nation’s state prisons, 12,129 inmates died while in custody
during a 4-year period from 2001 through 2004. Of these deaths, 89% were attributed to
medical conditions.
Correctional systems are struggling to treat not only conditions that normally accompany
aging but also conditions related to chronic and acute physical and mental illnesses and endof-life care. Much recent literature suggests that the cost of caring for an older person in
prison is three times the average inmate health care cost. Several approaches recommended
by experts appear to provide more satisfactory health care while reducing costs. Experts recommend increasing preventive care and educating older prisoners in strategies for maintaining and monitoring their own health. Longer-term strategies include developing long-term
care facilities for aging inmates similar to nursing homes or hospices, or other alternative
arrangements such as halfway houses or house arrest for nonviolent older offenders.
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