71: Understanding the Effects of Criminal Justice Involvement on Older Adults

Health care providers are increasingly managing the health of older patients who are currently or recently involved in the criminal justice system. These interactions occur in a variety of arenas. Many correctional systems contract with community clinics to provide prisoner-patients with specialty services, such as cardiology, neurology and dialysis. For acute care, prisoners are generally triaged to those hospitals with prison health care contracts, although in urgent or critical situations, a prisoner is brought to the nearest appropriate facility for care. As a result, current and former prisoners are seen daily at community clinics, specialty clinics, hospitals, and emergency departments around the country. Primary care providers are also increasingly taking care of patients who are arrested for the first time, as well as recently released older adults who are reintegrating into the community from prison or jail.

Increased attention from the press, nonprofit advocacy groups, and policymakers has spurred a growing literature in health and criminal justice research aimed at addressing the aging crisis in U.S. correctional systems. Studies suggest that currently and recently incarcerated older adults are a medically vulnerable group and that a history of incarceration is an important life event for health care practitioners to consider when caring for older patients.

Prisoners age 55 years or older (“older prisoners”) are the fastest growing segment of the criminal justice population, both as a result of stricter sentencing policy and an increasing number of older adult arrests. Since 1990, the number of older prisoners in the United States has more than tripled, and it is estimated that older prisoners could comprise up to one-third of the total U.S. prison population by 2030 if current sentencing policies remain unchanged. The percentage of new parolees who are older is also growing. Between 1990 and 1999, the number of state prisoners released to the community on parole nearly doubled and is expected to continue to increase.

Physical Health

In general, older prisoners age prematurely and their physiologic age appears to be about 10–15 years older than their chronologic age. This “accelerated aging” can result from multiple factors—an unhealthy lifestyle prior to prison entry (eg, alcohol abuse, homelessness) and during incarceration (eg, poor diet, minimal exercise), limited lifetime access to preventive health care, and chronic stress during incarceration.

On average, older prisoners tend to have high rates of multimorbidity, geriatric syndromes, and functional impairments. Older prisoners have considerably higher rates of chronic illnesses, such as diabetes, hepatitis C, hypertension, and chronic obstructive pulmonary disease as compared with younger prisoners and age-matched community-living older persons, and they are also likely to take multiple medications. Geriatric syndromes, including vision and hearing impairment, falls, chronic pain, and urinary incontinence are also common in this population and may lead to unique challenges. For example, an older prisoner may be at increased risk for physical confrontation if he fails to respond to another inmate’s request as a result of hearing loss or if he aggravates another inmate in close quarters because of incontinence. The prevalence of disability in traditional activities of daily living (eg, bathing, dressing) is higher in older prisoners than in age-matched older adults in the community. Additionally, disability rates in this population increase even more dramatically when considering unique activities that are necessary for independence in prison. These activities of daily living for prison include dropping to the floor for alarms and climbing on and off the top bunk. The inability to keep up with the fast pace of day-to-day prison life because of disability may make older prisoners more vulnerable to victimization by other inmates and at greater risk of disciplinary action from correctional staff.

Mental Health

The prevalence of mental illness is much higher among prisoners as compared with those in the general population, regardless of age. Compared with younger prisoners, older prisoners have a higher likelihood of previous alcohol abuse, lower rates of personality disorders, and higher rates of depression, the most common mental health condition in this population. Similar to older persons living in the community, depression among older prisoners is often undertreated and frequently goes undetected; it may be misdiagnosed as a seemingly appropriate response to a medical illness or medication, or to the process of aging, in general, and it may be difficult to disentangle from conditions such as bereavement, fatigue, or cognitive impairment. High rates of undertreated and undetected depression likely contribute to the high rate of suicide in this population. In addition, although empirical research is lacking, histories of substance abuse, posttraumatic stress disorder, and traumatic brain injury may contribute to high rates of cognitive impairment in older prisoners, with 1 study reporting prevalence of 40%. Yet, early stages of cognitive impairment and dementia may be difficult to detect in the structured prison or jail environment as a consequence of limited opportunities for prisoners to make decisions, make plans, or initiate complex behaviors.

With the aging of the population, an increasing number of older adults are coming into contact with the criminal justice system as arrestees, detainees in jail or prison, or as recently released members of the community. Clinicians should consider a recent history of criminal justice contact as a potential warning for underlying cognitive impairment, substance abuse, or psychiatric disease. In addition, given the health risks of incarceration, clinicians should screen those recently released for a history of victimization, depression/suicidality and infectious diseases such as hepatitis B and C and HIV. Recognition of the medical vulnerabilities of older adults involved in the criminal justice system is critical to maintaining the health and safety of this growing population. Table 71–1 details specific considerations to guide the clinical encounter when a criminal justice history is identified. These considerations are further discussed in the following sections.

Care of a Patient Arrested or in Custody

In 2009, more than 530,000 persons age 55 years and older were arrested. These individuals include both first-time arrestees and those who are returning to jail or prison in later life, yet typically have been in the criminal justice system sporadically throughout their lives. The majority of persons who are arrested again in later life have multiple health problems resulting from a lifetime of unhealthy behaviors, including substance abuse, poor diet, risky sexual encounters, and substandard health care both prior to and (sometimes) during incarceration. They are also more likely to have been homeless with few family or community ties. These behavioral and physical health factors can adversely affect an older adult’s ability to participate in the legal process or obtain appropriate legal counsel, and can also put them at risk for incarceration and associated decreased safety and worse health. Particularly for those arrested for the first time as an older adult, the event leading to the arrest may be indicative of an underlying medical condition. Clinicians can play a key role in evaluating for diagnoses such as alcohol or drug use, cognitive impairment, dementia, or delirium, which may have contributed to criminal justice involvement or result in implications for sentencing and/or safety during incarceration.

Care of a Patient Returning to the Community from Incarceration

A growing number of persons transitioning from incarceration to the community are older adults. As older prisoners are far less likely to be reincarcerated than younger prisoners, the transition from prison or jail to the community is particularly important. Substantial periods of time away from the community are associated with negative consequences. These include severed relationships with family and friends, and termination of housing and employment. In addition, the reinstatement of cancelled government entitlement programs such as Medicare, Medicaid, Social Security Insurance, and Veterans Health Administration benefits may take several months, thereby causing considerable stress for those returning to the community. Prisonization, or excessive dependence on the institutional routines of prison life, is also common among older inmates who have spent much of their lives in prison and may make it difficult to navigate life outside of prison. Regardless of how long a recently released patient was incarcerated, health problems, which may be exacerbated by the stresses of community reentry, can also lead to additional difficulties with employment, housing, and other important benchmarks of successful reentry. For example, older parolees with dementia could violate parole unintentionally. In general, health care practitioners should know that older adults who are recently released from a jail or prison are at risk for adverse health outcomes including disproportionately high rates of mortality in the immediate post-release period and an increased risk of suicide after reentry into the community.

Ideally, clinicians who treat older adults being released from incarceration should be contacted by jail or prison clinicians during the prerelease planning phase to optimize referral to social services such as reinstitution of government benefits including medical insurance and housing support, and continuing medical and mental health care of these individuals. However, this rarely occurs. It is, therefore, critically important to ask new patients about a recent or remote history of arrest, detainment, or incarceration.