Incarceration affects many aspects of health care. By 2030, older adults are projected to comprise about 30% of the total prison population. These older adults are at risk for “accelerated aging” due to environmental stressors, predisposing and preexisting medical conditions, lack of access to health care, cognitive problems, and functional limitations (e.g., mobility, sensory deficits). 

Incarcerated adults, defined by the US sentencing commission as “older” offenders (those aged > 50 years) and “elderly” offenders (those aged > 65 years), are at increased risk for multiple conditions including infectious diseases, chronic health problems (e.g., hypertension, diabetes, heart disease, malignancy), chronic pain, mental health problems including trauma and substance use disorders, as well as injury (e.g., traumatic brain injury, concussions).

There is insufficient education for healthcare professionals to effectively care for older incarcerated adults living in environments that are not designed for needs of aging people. Raising awareness and education about this unique population can help clinicians best meet these health care needs.

Medical issues which may be heightened in the prison environment include:  

• Delirium/dementia: Cognitive decline may be more difficult to identify due to prison-related factors such as the confined environment and regimented schedules. Additionally, behavioral symptoms of dementia may be misinterpreted and misdiagnosed as either other mental health conditions or as “normal aging”.
• Falls: The prison environment may increase fall risk due to muscle deconditioning and arthritis, limited assistive devices and adaptive equipment, poor lightning, uneven floors, steep staircases, high bunk beds, low toilets, confined environments, and shackles.
• Mental health conditions: Chronic mental health diagnoses may be increased or joined by anxiety related to reentry to society, thoughts of death, mistrust, and insomnia.
• Nutritional problems: Poor access to oral care may worsen dentition, leading to tooth pain and loss.
• Pain control: Inadequate pain control may occur due to clinician bias, history of opioid/substance use/abuse, or from decreased mobilization caused by shackles or other restraints.
• Polypharmacy: Gaps in care providers may increase polypharmacy (inmates take, on average, 9 medications) and the prescribing of potentially inappropriate medications for older adults.
• Sensory deficits: Vision and hearing impairment can lead to falls, social isolation, and decreased ability to respond to others, including responding to orders from prison officials.
• Urinary and fecal incontinence: The inability to control bowel and bladder function (complicated by limitations in the supply of incontinence pads), may lead to embarrassment and victimization.

Functional requirements in prisons are different from other settings and include:

• PADLs (Prison Activities of Daily Living).  These activities include dropping to the floor for alarms, standing for counts/presence, walking while handcuffed, hearing orders from facility staff, and climbing on and off upper bunk beds.

Palliative and hospice care may be different in the prison environment:

• Advance Directives: Incarcerated adults may not have advance directives or an identified surrogate decision-maker.  In some cases, there is estrangement from family and friends and designating a surrogate decision-maker can be difficult.
• Some correctional facilities have trained volunteers to care for terminally ill older adults. The compassionate release process might take longer than the life expectancy of the older adult.
• Barriers to re-entry into the community may include:
  • Distrust of people and community systems
  • Decline in functional and cognitive abilities 
  • Decreased social network and isolation
  • Housing problems/homelessness
  • Lack of health insurance
  • Low health literacy
  • Unemployment