Perhaps one of the most overlooked populations in U.S is the elderly; even more so, the elderly prisoner. Why does this population matter and why should we care? Although there have been many revisions to the health care elderly prisoners receive, there is an absence of a protocol of what happens when prisoners become too old to take care of themselves. While states fumble around for different solutions to this constant debate, there is no concise measurement of how effective any of these solutions are because there is no universal starting point to measure the progress of this ever-growing dilemma.
From an economic perspective, the average cost to fund a prisoner’s healthcare for one year is $18,570 that number skyrockets to $67,000 a year for prisoners over the age of 55. (McDonald, 1999, p. 88) . Furthermore, “despite the costly age redistribution, little is known about geriatric disability or health care in prison,” (Williams M.D., Lindquist MS., Sudore M.D., Strupp, Willmott, & Walter MD, 2006, p. 703) . From a humanitarian perspective many of the officers, who are also the inmate’s primary source of assistance, are not even aware of an inmate’s disability and therefore are unable to get them any of the help they need for daily living activities. “Disability, a strong predictor of healthcare costs, morbidity, and mortality in older adults is common in older prisoners, but officers are rarely trained to recognize geriatric disability and overcrowding can impede familiarity with assigned prisoners needs,” (Williams, et al., 2009, p. 1290) . For prisoners who are released into the community, many are released with highly communicable diseases such as AIDS and tuberculosis and without any means of income or housing. In 1996 it was found that the prevalence of tuberculosis among inmates was six times greater than in the community, (Stojkovic Ph.D, 2007, p. 48) . In addition to the many untreated diseases, an elderly released prisoner also faces a great amount of emotional and psychological trauma in transition back into community life.
Despite many of the problems elderly prisoners face, the argument continues that elderly prisoners actually receive too much health care compared to what they would receive in the community. “Prison medical care is consequently being pulled by two opposing tensions. One is to expand access and care, the other is to limit it. Prisoners are the only persons in the United States who have a constitutionally protected right to health care, and the courts show no sign of extinguishing that right,” (Ornduff, 1996, p. 177) . However there are many prisoners who also take advantage of this right “Libby Marsh, a social worker at McCain, recalled an elderly inmate who, while in prison, had a cataract removed from his eye. The next year, the same elderly man threw a brick through the window of a department store so that he could come back to prison to get a cataract removed from the other eye,” (Ornduff, 1996, p.182). Cases like these cause many people to dismiss much of the help that elderly prisoners need.
“Despite increasing numbers of geriatric prisoners, little is known about geriatric disability or healthcare in prison,” (Williams, et al., 2009, p. 1286) . In 2005, California Department of Corrections and Rehabilitation randomly interviewed 71 correctional officers who were assigned to 618 geriatric prisoners from 11 of the states facilities. The study assessed how well an inmate was able to perform their Activities of Daily Living (ADLs) such as eating, bathing, dressing, transferring, and toileting. 22% of the population was determined to be high risk and requiring a higher level of care by the officers. This 22% was a sharp contrast to the 5% identified by the state’s definition for needing higher level of care as defined by the Armstrong Criteria. The Armstrong Criteria bases its definition of high risk on an inmate’s sensory ability and mobility.
Of the 618 elderly prisoners examined 211 of them were completely unknown to the officers including 20 inmates over the age of 70. Of the unknown prisoners, one was a 78 year-old female with dementia and hearing loss and a 73 year-old man assigned to the top bunk. Officers reflected on how imprisonment was actually contributing to an inmate’s disability or was placing them in physical danger. A 63 year-old man was able to walk but required assistance when walking while handcuffed to prevent falls. Another officer reflected on a 70 year-old inmate with dementia, “He forgets his medications, he loses his way to the cell, and he forgets that his is in prison. He gets into fights because he ends up in the wrong cell. He forgets he is incontinent and accuses others of throwing urine on him… He is unsafe and needs more care,” (Williams, et al., MD 2009, p. 1284).
These conditions are a vast improvement over the state of prisons before the 1960’s. “Thomas Murton, the superintendent of an Arkansas prison reported that a convict doctor lacking medical or nursing training was responsible for most of the primary care at the Tucker Prison Farm. This doctor not only ran an illegal drug program and sold medical leaves of absence but also tortured the prisoners by means of a hand-cranked electrical generator,” (McDonald, 1999, p. 92) . Alabama was found to hire personnel without any medical training to extract inmate’s teeth, dispense drugs, perform X-rays, and perform minor surgeries. Medical services were often withheld from prisoners as a form of disciplinary action. “Provisions for psychiatric care were highly inadequate. For example, prisoners who tried to hang themselves were simply cut down, given medication, and returned to their cells without psychiatric evaluation,” (Mcdonald 1999, p. 92). So why was prisoner medical and psychiatric care reformed after the 1960’s? The proliferation of lawsuits.
The Tucker Prison Farm in Arkansas was subject to multiple lawsuits in the 1960’s such as Holt vs. Sarver where the prison was tried for depriving inmates of:
the right not to be imprisoned without meaningful rehabilitative opportunities, the right to be free from cruel and unusual punishment, the right to be free from arbitrary and capricious denial of rehabilitation opportunities, the right to minimal due process safeguards in decisions determining fundamental liberties, the right to be fed, housed, and clothed so as not to be subjected to loss of health and life, the right to unhampered access to counsel and the courts, the right to be free from abuses of fellow prisoners in all aspects of daily life, the right to be free from racial segregation, the right to be free from forced labor, and the right to be free from the brutality of being guarded by fellow inmates (Sterns, Lax, Sed, Keochane, & Sterns, 2008, pp. 74-75) . The state was found guilty on all charges its prisons classified as cruel and inhumane punishment.
In Newman vs. State, all the prison systems in Arkansas were sued for multiple reasons including understaffed facilities, outdated medical techniques and deficiencies such as no ambulance on site at the prison and a lack of resources for geriatric care. One quadriplegic inmate testified that his wound had become maggot infested because of unchanged dressings and spent an additional 20 days after the problem was reported. In the case of a geriatric inmate who suffered a stroke and was partially incontinent who was required to sit on a wooden bench beside the bed in order to ‘keep his bed clean.’ The inmate ultimately died from the chair breaking, causing amputations to his leg, and not having a surgeon on staff that day (Thivierge-Rikard & Thompson Ph.D, 2007, p. 48) . “The court characterized these conditions as barbarous and found the prisons to be in violation of the Eighth Amendment’s prohibition of cruel and unusual punishment,” (Lawrence & Cox, 2010, p. 55) .
In response to these horrific conditions, many states were placed under federal court supervision and were required to make dramatic changes in their health care procedures. By January 1996, thirty six states and three outlying territories were under court order to decrease the prison population and increase health care available in prison. By this point only three states had never been involved in any major litigations concerning conditions or overcrowding. “These and subsequent rulings have incompletely defined the medical services to be provided in a healthcare system. No single federal court decision, applicable to all prisoners, has detailed all the specific services that must be provided,” (Snyder, van Wormer, Chadha, & Jaggers, 2009, pp. 118-119) .
The problem to this current day is what happens to our elderly prisoners if there is no set system? And what is the best way to deal with this problem? A couple of solutions are available. We can a) release them into the community, with the thought that if they are deconditioned they pose no threat to the public, b) build special geriatric facilities that are able to provide long term care, c) do nothing and let them stay in jail without any special adaptations made to suit their needs or d) let them stay in jail with hospice care.
Upon examining these options, I thought that options A and C were unrealistic. The first option essentially sets a prisoner up for failure. “The majority of older inmates test at a sixth-grade level and over one- third of the older female population tests at an IQ level below 70. Few inmates have marketable employment skills or sufficient literacy to maintain gainful employment upon release. Social isolation is compounded by the fact that many of the older inmates friends and family members typically cease being an source of support… and community- based programs are often unwilling to accept older multi-problem inmates with health-related limitations,” (Snyder, van Wormer, Chadha, & Jaggers, 2009, pp. 120-123) .
Although there are arguments against early release, the situation is not completely hopeless. In 1989 Professor Jonathon Turley created the Project for Older Prisoners (POPS) in Louisiana. The program’s goal was to help prisoners who were unlikely or physically incapable of committing additional crimes seek early release from their sentence. This program so far, has had a 100% success rate with the 60 elderly inmates it has released. POPS is active in six states, including Illinois, (Ornduff, 1996, p. 177) . A reason for the program’s profound success rate is the support it gives its clients. The program helps to set up social security payments, find a job, and establish housing. However the program is extremely selective in the clientele they help and only 10% of the prisoners who interview for the program are accepted. All applicants must be at least 55 years old, have served the average time for their offense, have been evaluated as unlikely to commit further crimes, and the victim/victims family must agree to the early release. So why is POPS not the universal solution to the elderly prisoner dilemma? “Releasing any criminals back into society can be politically dangerous and if an early release programs grow, the public may become even more frustrated with governments it perceives to be soft on crime,” (Ornduff, 1996, p. 190).
A secondary option to releasing the elderly prisoner back into the community is the option of medical parole. However medical parole is typically only considered in the case of the terminally ill patient. Because of this, there is normally no negative consequence to releasing the prisoner since they are no longer viewed as a danger to society. Currently, Maine, Kansas, and the District of Columbia are the only states that do not allow medical parole. Parole can be revoked if the prisoner’s medical condition improves. “Conversely, medical parole is only an option for inmates who will not live long, so the benefits from medical parole are short-lived,” (Thivierge-Rikard & Thompson Ph.D, 2007, p. 43) . The elderly inmate, whose health has begun to deteriorate but is not incapacitated are not included in this population.
It would appear that with so much controversy over releasing prisoners that perhaps just building additional facilities for inmates would be a better solution. So far only six states have dedicated facilities for older prisoners and 13 states have dedicated units, (Sterns, Lax, Sed, Keochane, & Sterns, 2008, p. 70) . These estimates are a very inaccurate display of such facilities because so many states differ on what they define as a “dedicated facility.” In these segregated facilities, inmates have access to specialized medical services, substance abuse programs, psychological counseling on death and dying issues, and re-integrative programs, (Thivierge-Rikard & Thompson Ph.D, 2007, p. 39) “In the segregated management model, one central unit is adapted for an age-friendly physical environment, including reducing numbers of stairwells, lower bunk assignments, quiet, well-lit communal areas, and non-waxed floors to reduce falls,” (Thivierge-Rikard & Thompson Ph.D, 2007, p. 42) . Other services provided on site include kidney dialysis and access to oxygen therapy for inmates with kidney failure and COPD. However some fear that centralized units for the aging would take away from the focus on physical and psychological care that non-elderly prisoners would receive. This is not true. In two studies done concerning the care elderly and non-elderly prisoners received, the level of care actually went up in institutions where there were centralized units. However centralized units are expensive and would drastically increase the nation’s already tremendous deficit.
One study done examined data from the Bureau of Justice Statistics Census of State and Federal Adult Correctional Facilities in 2007 and studied their ability to treat for both age populations. Of the 1668 prisons the 2% that had segregated geriatric facilities also had a higher number of work programs, officers, educational programs, and mental health services for its counterpart population. “When medical services are centralized, it benefits all inmates, not just the elderly. In terms of the consolidation versus segregation debate and correctional policy, our results suggest that institutions that consolidate their aging inmates into the general prison population are associated with more non-geriatric mental health services, (Thivierge-Rikard & Thompson Ph.D, 2007, p. 52) .
In 2006 a cross-sectional study was done to examine the appropriateness of the medications given to the elderly prisoner population. This study consisted of the prisoners in the Texas Prison System. The Texas Prison System has the nation’s largest prison population and has an academic-based managed care system through the University of Texas Medical Branch and has been proposed as a “nationwide model,” (Williams M.D., et al., 2010, p. 758) .The Texas Prison System falls into that meager 2% of prison systems with a centralized geriatric facility. The study found that about 32% of older prisoners were given wrong medications such as antihistamines and that this number was similar to “that of older community adults,” (Williams M.D., et al., 2010, p. 759) .
Although it may seem barbaric to simply leave elderly prisoners in jail without any level of care, is there still a possibility of leaving elderly prisoners to die behind bars without medical treatment? Yes and No. Louisiana State Penitentiary at Angola has created a patient-friendly hospice program. Inmates are trained to care for their elderly prisoners in hospice. The program has gotten enthusiastic reviews. “A significant unanticipated consequence of the prison community care provided at Angola is that it has transformed the lives of many hospice volunteers. Often at the end of life, hospice social workers from outside the prison, and fellow inmate volunteers help make up for the absence of family members,” (Snyder, van Wormer, Chadha, & Jaggers, 2009, p. 122) . In the past it was thought that aging inmates had a higher status in the prison hierarchy because they were considered more experienced and knowledgeable in crime, but this has also changed.” Over the past few decades, the increase of gangs has eroded the older inmate’s quality of life because of the perceived and real threat of victimization by stronger, younger inmates,” (Snyder, van Wormer, Chadha, & Jaggers, 2009, p. 124) . This real fear isolates the prisoner from daily activities and even correctional staff will frequently deny access to programs that were originally intended for older inmates. (Snyder, van Wormer, Chadha, & Jaggers, 2009, p. 124) .
Although there are many advantages and disadvantages to all the solutions stated there remains a lack of universal consensus regarding how to care for our elderly prisoners. Medical release and the POPs program appear to make the most sense both financially and in terms of compassionate care. It leaves the responsibility of medical care in the hands of the inmate and hence causes no further financial burden onto the prison system. Both POPs and medical release allow the prisoner die with palliative care and in peace outside cell walls. However these programs still allow some of its elderly prisoners to fall through the cracks and still leave them without care. For this reason, and many others, further research and universal standards are vital to the progress and well-being of this forgotten population.
References
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McDonald, D. C. (1999). Medical Care in Prisons. Chicago: The University of Chicago.
Ornduff, J. S. (1996). Releasing the Elderly Inmate: A Solution to Prison Overcrowding. The Elderly Law Journal , 173-192.
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Williams, M. B., Lindquist MS, ,. K., Hill MD., T., Baillargeon Ph.D, J., Mellow Ph.D, J., Greifinger MD, R., et al. (2009). Caregiving Behind Bars: Correctional Officer Reports of Disability in Geriatric Prisoners. JAGS , 1286-1292.
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