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.
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.
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.