The Effects of Incarceration on Elderly Individuals

NUR 442

October 7, 2015

Courtney Gardell, Tracy Owusu, Tingting Peng & Erica Weiser

Inmates are aging and the older adults are quickly becoming the largest

population in prisons. Due to the long sentences some inmates face, these people are

growing older and frailer behind bars yet they are not receiving the adequate health and

social care that they require (BBC, 2014). In prison, inmates are defined as elderly at age

50 (Abner, 2006). This is due to the fact that inmates are physiologically seven to ten

years older than their true age (Aging Inmates, 2015). Causes of the rapid aging may be

due to the lack of health care services, poor diet, lack of exercise habits and drug and

alcohol abuse (Aging Inmates, 2015). Other contributing factors may also be due to the

high stress in prison due to the environment, the lack of a support system and the lack of

trust between inmates (Abner, 2006). Because many inmates have long sentences and

thus their health deteriorates in prison, they are likely to use the healthcare resources and

expenditures that prisons offer. However, prisons do not offer superior healthcare

services which mean that some prisoners do not receive the proper care they need (At

America’s Expense, 2012). The lack of quality health care services presents an issue to

the views of the health the elderly inmates have which is to be free from disease and to be

physically, mentally, and socially stable.

Health Promotion and Prevention of Disease

Due to the issue that elderly prisoners are a marginalized group and their care

exceed the general population, factors for health promotion are pertinent. This group is

disadvantaged in two ways including advanced age and incarceration. These

disadvantages can lead to more disease and greater need for health promotion. In fact, the

health of elderly prisoners is inferior to that of the general population and their use of

medical services is higher (Tarback, 2011).

A big issue among elderly prisoners is tobacco use (Tarback, 2011). Even though

most correctional facilities have implemented tobacco restrictions in an effort to improve

prisoner’s health it is still an issue, and little has been done in order to evaluate the impact

of these policy changes. Prior to being incarcerated tobacco use was prevalent in this

specific population and increased by around 3% during incarceration. The number of

cigarettes smoked has decreased in prison, but the number of smokers has risen. Also,

tobacco use in prison is higher among elderly prisoners than the general prison

population and the population in general (Kauffman, Ferketick, Murray, Bellair &

Wewers, 2011). This is an important area for a nurse to promote health promotion

because there are numerous risks involved with smoking. In a broad scope, smoking can

lead to heart and lung disease. More specifically, chemicals in tobacco can thicken blood

and make oxygen carrying more difficult, increase blood pressure and heart rate, lower

LDL and raise HDL cholesterol, disturb normal heart rhythm, and damage blood vessel

walls (“What are the Risks of Smoking”, 2011). There are many risks involved from

tobacco use so implementing health promotion and disease prevention models to inhibit

smoking among this population is incredibly important.

It has been found that alcohol dependency appears particularly to affect older

prisoners. A steady increase with age in the amount of prisoners experiencing alcohol

withdrawal symptoms has been reported. In fact, one third of prisoners over the age of 65

had symptoms of alcohol withdrawal. Alcohol withdrawal symptoms include tremors,

anxiety, nausea and vomiting, headache, tachycardia, irritability, and confusion. Acute

withdrawal symptoms and complications including seizures, hallucinations, and delirium

tremors are all medical emergencies and must be dealt with as so. Some complications,

including Wernike Koraskoff Syndrome, may cause permanent damage (Trevisan,

Boutros, Petrakis & Krystal, 2012). It is important to combat this with health promotion

as a nurse. This would be a pertinent area of teaching for a nurse as health promotion

through educational programs within the prisons. Educational programs have been found

to have a long-term impact on alcohol use so it would be important to target this age

group in prisons.

Finally, after studies have been done of health problems and physical or

functional disabilities of this group, it has been found that the set up and design of prisons

can be considered a health promotion focus. For example, elderly prisoners may be more

at risk for violence from other prisoners. It may be health promotion to set up the prison

in a way to keep this group from known prisoners who perpetuate fights. Older prisoners

can be seen as weak and may not be able to defend themselves. Also, an area for concern

is the physical environment that includes numerous stairs and long hallways. These older

prisoners may not be able to physically keep up with the demands of the prison due to

their increasing age (Tarback, 2011). It can be considered health promotion and

prevention of disease by setting up prisons in a way that makes it easier for them to meet

the demands. This will prevent falls and many more health problems.

Plan for Rehabilitation

The ageing of the world population is progressive and rapid and has been

recognized as a major concern in most developed countries. Successful ageing has

resulted in higher expectations in the elderly for maintaining personal independence in

their increased life years (Grundy & Bowling 1999); however, many elderly people may

experience functional disability due to falls, injury, or disease, which result in surgical

procedures. Rehabilitation programmes have been considered best practice for

maintaining and restoring functional ability following orthopaedic surgery (Heitkemper

2005).

According to Young, 1996, Rehabilitation is the process of restoring someone to a

condition of good health to regain maximum independence. The main aim of

rehabilitation is to achieve optimal functioning in interaction with the environment.

Elderly people express that their primary aim of rehabilitation after a disabling event is to

return to their own homes and be able to live there as long as they wish with maximum

independence and a good quality of life (Johansen et al., 2012).

Most elderly people will benefit from rehabilitation programs such as physical

therapy, occupational therapy, speech and language therapy and also mental health

services. Physical therapy treatment focuses on improving a person's function, whether

it's related to bones, joints, muscles or nerves. Generally, a person's function has been

compromised in some manner as a result of an injury, wear and tear, or as part of the

aging process. When treating older patients, physiotherapists treat functional problems

such as pain, balance issues, poor endurance, difficulty walking and poor muscle strength

(Trottman and Pippenger, 2008). Occupational therapy concentrates on helping people

achieve independence in their day- to-day life. Within the older population, occupational

therapists normally focus on the person’s ability to complete everyday activities such as

bathing, dressing, and eating. Occupational therapists are trained to identify problems in

these areas and make recommendations for improvement. At times, equipment

recommendations are made including rolling walkers, tub benches, commodes and

adaptive eating utensils (NHS Choices, 2014) Speech and language therapy treatment

focuses on improving the ability to communicate effectively and eat safely. Within the

geriatric population, Speech and Language therapists focus on speech, language, voice,

cognition, and swallowing. It is their duty to identify problems in these areas and provide

treatment to enhance a person's ability to communicate with family, friends, and doctors,

as well as make safe, competent decisions. (Trottman and Pippenger, 2008). Mental

health services are also provided in rehabilitation. Specialist mental health services for

older people include the assessment, treatment and management of mental health

disorders and severe behavioral disorders. Typically, the service treats older people with

previous mental health issues or with newly diagnosed mental illnesses such as severe

depression or challenging behavior associated with dementia (Aged Care &

Rehabilitation Services - Older Persons Mental Health 2013).

The United States, (U.S.) the United Kingdom (UK) and Finland all view the

increasing older population and increase of life expectancy as a challenge for health and

social care. They all have similar goals and objectives of the care for older people, which

is to respect the elderly peoples autonomy and support them to live in their own homes

for as long as they wish independently. Respect for autonomy and integrity is essential

when dealing with someone’s wellbeing. Empowerment was considered important

because caring for a vulnerable older patient places them at risk of becoming dependent.

In Britain, an estimated 4.3 million people over 60 are disabled; this represents

70% of all disabled people and 46% of all older people. Over 90% of older disabled

people live in their own homes, and most (over 80%) have only “mild” disability, but

many have several types of disability. Disability of all severity grades is strongly related

to age, reflecting the increasing prevalence of the common disabling conditions: stroke,

arthritis, cardiorespiratory diseases, fractured neck of femur, and peripheral vascular

disease (Young, 1996). Consequently, the main focus of rehabilitation in the UK is

physical and occupational therapy. However successful rehabilitation requires a broader

perspective, in which psychological and social problems can be identified and addressed.

Nolan and Nolan (1997) noted that essential components of rehabilitation were patient

participation, family participation and a team approach. Young et al (1999) highlighted

two other essential ingredients; goal setting and the interactive, cyclical process of

comprehensive assessment and intervention. The RCN (2000) outlined the nurses’ role in

rehabilitation as providing psychological and emotional support, enhancing lifestyles and

relationships, facilitating self-expression and ensuring cultural sensitivity. It is also

essential to maximise independence and functional ability and educate the person to aid

in health promotion.

Approximately 71 million people in the year 2030, or 20% of the U.S. population,

will be older than 65 years (Centers for Disease Control and Prevention (CDC) and the

Merck Company Foundation, 2007). According to the recent report The State of Aging

and Health in America, “the aging of the U.S. population is one of the major public

health challenges they will face in the 21st century. One of CDC’s highest priorities as

the nation’s health protection agency is to increase the number of older adults who live

longer, high quality, productive, and independent lives”. These statistics suggest how

important it is for these countries to provide geriatric rehabilitation to accommodate the

growing older population.

One common barrier both countries had were the cost of rehabilitation. In the UK

rehabilitation services are funded by the government making the service available for

everyone, but putting a strain on the government. However, in the US the government

does not fund the costs making rehabilitation unaffordable to many people. People with

disabilities have lower incomes and are often unemployed, so are less likely to be

covered by employer-sponsored health plans or private voluntary health insurance. If they

have limited finances and inadequate public health coverage, access to rehabilitation may

also be limited, compromising activity and participation in society.

Rehabilitation for the global population of the world seems promising. Most

countries have acknowledged the increasing older population and although ageing is

widely seen as one of the most significant risks to global prosperity in the decades ahead

because of its potentially profound economic, social and political implications. Global

ageing, in developed and developing countries alike, will dramatically alter the way that

societies and economies work (Sohn, 2009).

Addressing Community Health Concerns

Elderly inmates in the United States, the United Kingdom, and Finland are

becoming an increasingly high priority on the federal and state government’s list due to

the expenditures that are required to keep these inmates healthy. The 1976 U.S. Supreme

Court case Estelle v. Gamble ruled that the 8th amendment requires that prisoners be

provided with medical care (Rosen et al., 2012). Since most of these individuals have

multiple health problems and require a higher amount of health services to maintain life,

it falls on the government to fund these services. According to the Council of State

Governments (2006), a younger prisoner costs approximately $22,000 to house annually

while an older inmate costs approximately $67,000. The state government is responsible

for providing health service expenditures for all prisoners, but most is being allocated

toward elderly prisoners now.

The health care costs for inmates age 55 and older with a chronic illness is two to

three times that of the cost of other inmates (Vestal, 2013). Inmates are not eligible for

federal health insurance programs such as Medicaid and Medicare, but by law are still

required to receive medical treatment (Metla, 2015). The prisons have to cover all of the

costs and get their funding from taxes paid by state residents. This means that no matter

whose responsibility it is to maintain prisons, taxpayers are the ones who pay for it

(Metla, 2015). There are ways for elderly prisoners to obtain Medicare and Medicaid

eligibility while they are incarcerated, but it does not mean that they will receive those

benefits during their sentence (Healthcare.gov, 2015). Elderly prisoners are able to apply

for federal and state health insurance programs, as well as private insurance programs,

but will not receive the benefits until after they are released. If they choose to do so, they

will most likely be able to receive health care at a faster rate than those who are

uninsured when they are released. Prisoners are not penalized for not having health

insurance during incarceration, but once they are released they have three options: to

obtain health coverage, pay the penalty for being uninsured, or get an exemption

(Healthcare.gov, 2015). Depending on the state of incarceration, the government may

allow an inmate to stay enrolled in Medicaid while enrolled in an institution

(Healthcare.gov, 2015).

State governments have started to develop strategies and cost control measures in

order to reduce the expenditures it takes for these elderly inmates to remain healthy.

These strategies include telemedicine and outsourcing of medical services to state

universities and other providers (Vestal, 2013). Telehealth refers to the use of electronic

information and telecommunications technologies to support long-distance health care

services (The Pew Charitable Trusts, 2014). This strategy provided by the states and

prisons improves prisoners’ access to primary care physicians and specialists while

reducing transportation and security expenses. This is also a benefit to public safety and

health because inmates will need fewer trips off the prison guards for medical care. States

who turn to outsourcing look to partners within the community to provide all or part of

their prison health care services at lower costs while maintaining or even improving the

quality of care (The Pew Charitable Trusts, 2014). While prisoners are not eligible for

holding Medicaid while incarcerated, states can obtain federal Medicaid reimbursement

that covers at least 50 percent of that prisoner’s hospitalization costs (The Pew Charitable

Trusts, 2014). States that have expanded their Medicaid coverage post initiation of the

Affordable Care Act will get the most back on their reimbursement so it is in the best

interest of the state to expand their Medicaid coverage in order to reduce elderly prisoner

health care costs.

A very beneficial and supportive government intervention regarding the health of

elderly prison inmates is the adoption of medical or geriatric parole that allows for the

release of older, terminally ill, or incapacitated inmates who meet certain requirements

(The Pew Charitable Trusts, 2014). These programs, when utilized appropriately, can

achieve notable savings for the state even if the state retains financial responsibility for

the parolees’ health care costs outside of the prison system. This program is not being as

utilized due to narrow eligibility requirements, complicated applications, lengthy review

processes, difficulty in assessing medical conditions, and a shortage of nursing home

spaces for offenders (The Pew Charitable Trusts, 2014). It is especially difficult for older

adults who have committed violent crimes and those who are habitual offenders because

policy makers dispute their early release. Even though these programs are not being

utilized as much as older inmates would like, it is still a potential option that the state

government provides for them.

A nongovernmental organization that is involved in the treatment of elderly

prisoners in the United States is the Release Aging People in Prison campaign stationed

in New York. This group advocates for the release of elders through parole decisions

based on legitimate public safety risk and people’s personal growth while in prison

(Release Aging People in Prison, 2015). They focus on seeking fair and objective

hearings for all individuals who come before parole boards and insist that decisions be

made on a person’s merit and experiences while incarcerated. They believe that the

United States has a “mass incarceration crisis: the reliance on a system of permanent

punishment, a culture of retribution and revenge rather than rehabilitation and healing”

(RAPP, 2015). RAPP encourages the mobilization of currently and formerly incarcerated

older adults, their families and other members of the community that wish to get involved

in the efforts. This group, along with the help of its contributors, can help to raise

awareness throughout the rest of the country on the conditions the inmates face while

incarcerated and could potentially shape the future of health care for older adults in the

prison systems. Other nongovernmental organizations include the American Civil

Liberties Union (ACLU), which works to defend and preserve the individual rights and

liberties guaranteed by the Constitution and laws of the United States (American Civil

Liberties Union, 2015). This group has many major platforms, including mass

incarceration, and works to find alternatives and health-based options to incarceration.

The Washington Post reported in May of this year that the U.S. Sentencing Commission

has made tens of thousands of incarcerated drug offenders eligible for reduced sentences

to begin with to prevent more elderly prisoners from taking up room in facilities

(Horwitz, 2015). Whether looking through the perspective of a governmental or

nongovernmental organization within the United States, it is becoming clear that elderly

prisoners are becoming a high priority and the issue of health care expenditures for these

individuals needs to be addressed immediately.

Prisons within the United Kingdom have a health care policy for their inmates

that is comparable to the United States’ policy. According to the United Kingdom

Government (2015), prisoners get the same health care and treatment as anyone who is

not in prison. The treatment is free for the inmates and has to be approved by a doctor

within the prison systems (Gov.UK, 2015). Their prisons do not have hospitals but may

have in-patient beds for prisoners that need to receive care within the facility. This

system is similar to the United States because all prisoners are required to receive quality

health care while they are incarcerated. Prisoners within the UK can also receive

specialist support if they have drug or alcohol addictions, HIV or AIDS, learning

disabilities, or are disabled (Gov.UK, 2015). Special considerations are given to elderly

individuals that require more health care than a younger inmate, and every inmate will

receive the same quality of care.

Several prisons in the United States hold nearly twice the prison population of

Finland (Larson, 2013). It is clear that the incarceration rate within the U.S. is

significantly higher than in Finland, but it is not the only major difference between the

two country’s prison systems. Finland has adopted an “open” prison system, meaning that

inmates get much more responsibility handed to them and security is not as much of an

issue as within the U.S. Not all prisons are open concept, which means there are some

secured facilities that resemble those in the United States. Like the United States, health

care is mandated for all prisoners within the country. This is done through the National

Prison Health Care Services consisting of two hospitals and five district units (Criminal

Sanctions Agency, n.d.). There are also institutions called The Prison Hospital and the

Prison Mental Hospital that are available to provide services to prisoners in need of

hospitalization and psychiatric treatment.

In comparing the United States to the UK and Finland in regards of organizations

available to help older adults in prison, it is evident that both countries are lacking

resources for helping this population. It appears to be a high priority problem on the

government’s radar for both countries, yet there is little being done about it. Prisoners are

receiving health care but it is costing the governments immense amounts of money and it

is becoming unbearable. If more organizations, both governmental and nongovernmental,

were to become available for older adults, it would be easier for the states to fund health

care for these individuals and their health would become much better. While it is hard to

change the incarceration state of a person due to the ruling made by the courts, simply

advocating for better conditions, especially for older adults, can change their health.

Nursing Theory for Health Promotion

Elderly inmates are one of the fastest growing populations in the Federal Bureau

of Prisons system. As mentioned earlier, the effects of the growing elderly incarcerated

population has increased the financial burden of the prisons because many of the elderly

prisoners have chronic diseases or comorbidities that require more health services.

Unfortunately, the Federal Bureau does not have programming for staff designed to

educate on the needs of the aging population of inmates (OIG, 2015). Many older inmates

require assistance with activities of daily living like getting dressed, but the staff is not

required to help the inmates with these activities.

There are some health services offered by prisons to the older population.

Prisoners are placed in institutions based on their level of care. The care levels are from

1-4 where one is described as little medical attention is needed and four is described as

needing inpatient care. Levels three and four prisoners are put in institutions with better

medical staffing and services. There are only six of these institutions and overcrowding is

an issue with these facilities. Because older inmates have many medical issues, the

facility will take the inmates to medical specialists outside of the prison. Due to a lack of

correctional officers who are able to escort the prisoners to these appointments, medical

care visits to outside health care providers are often delayed (OIG, 2015). Social workers

are qualified to prepare an inmate’s continuity of medical care after release from prison.

But like correctional officers, social workers are also severely understaffed. As of May

2015, there are only 36 social workers for all of the federal institutions in the United

States. Another health service provided by institutions is lower bunks so the older

population has an easier time getting into bed. There are not many services offered to the

elderly incarcerated population but the institutions do provide medical needs and services

like dialysis but the speed of services are delayed due to shortage of staff and supplies.

One of the biggest issues in prisons as mentioned earlier is smoking, especially in

the elderly populations who have nicotine addiction prior to incarceration. Smoking in

prisons was banned in 2014 but tobacco products were taken off the shelves of prison

commissaries in 2006 (Nelson, 2014). Ever since the banning of smoking in prisons,

inmates have been turning to black markets to get cigarettes or any other form of tobacco.

The issue with smoking in the facilities is the lack of ventilation, which easily exposes

those who do not smoke to the perils of second hand smoking. Because the elderly

population already has health issues, the problems smoking causes should not be added to

the list of health issues.

To promote smoking cessation and health in the aging prison population, Betty

Neuman’s Systems Model can be utilized. Primary prevention is to prevent smoking in

those who do not smoke (Primary, Secondary and Tertiary Prevention, n.d). The ban on

smoking in the institutions is a good primary prevention because it prevents the exposure

to the harmful habit. Another way to promote health with primary prevention is to

educate the prisoners about the dangers of smoking. When presenting the information to

older inmates, the information needs to be tailored to the learning preferences of the

elderly. For example, use a few points to get the message across and to avoid the use of

medical jargon. Secondary prevention occurs when an inmate is already a smoker but the

goal is prevent further harm in the body and to quit smoking. In order to achieve

secondary prevention, the individual prisoner needs to be monitored for the diseases and

common problems of smoking like asthma, chronic obstructive pulmonary disease and

high blood pressure. As for the community, smoking cessation groups should be formed

in order to encourage the prisoners to stop smoking, which could reduce many health

issues and medical costs for the institutions. Tertiary prevention is prevention that occurs

when the prisoner successfully quits smoking and the goal is to promote health and

prevent relapse into old habits. The individual may require medical attention to reduce

the impact of smoking over the years on the body. The community of inmates who have

quit smoking may need to rely on each other to remain smoke free. An example of a

tertiary prevention for the community is the formation of a support group to encourage

fellow members to live smoke free. The three types of prevention are helpful ways to

allow for health promotion and better living among the aging population in prison.

In conclusion, each country and each government has a different way of

addressing the health care needs of elderly inmates. Whether it is through health

promotion, services while incarcerated, or those after release, the government is

responsible for making sure inmates receive quality health care throughout their

involvement with the correctional system. This paper explores the different realms of

health care within the correctional systems for elderly individuals and has compared and

contrasted the systems within different countries, including the United States, Finland,

and the United Kingdom. Through these analyses, it is evident that elderly incarceration

is at an all time high and there is a dire need to ensure quality health care for this

vulnerable population.

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