Hidden psychiatric morbidity in elderly prisoners

Sociodemographic, psychiatric and criminal characteristics of elderly offenders under evaluation for criminal responsibility in Turkey

OBJECTIVE

The aim of this study was to examine a sample (n = 150) of elderly offenders to analyse the psychiatric, medical, demographic, criminal and if available neuropsychological test characteristics and criminal responsibility.

METHOD

Data were gathered through a retrospective chart review of applicants aged 65 and over who were referred for determination of criminal responsibility from 2014 to 2019 at the Observation Department of Council of Forensic Medicine (Adli Tip Kurumu Baskanligi, Gözlem İhtisas Dairesi) who were evaluated under inpatient status by law.

RESULTS

There were 150 forensic cases aged 65 and over. The majority of the crimes were homicide (25.3%), homicide attempt (10%), and sexual offence (26%). The majority of sexual offence victims were children (34 of 39 cases). The percentages of decisions on criminal liability were as follows: 76% (n = 114) had full criminal liability, 21.3% of them (n = 32) had no criminal liability, 2.7% of them (n = 4) had reduced criminal liability. For the reduced/no criminal liability group, diagnoses were as follows: 37.1% dementia syndromes, 31.4% schizophrenia, 11.5% delusional disorder and 2.8% bipolar disorder manic episode.

CONCLUSION

When the findings in our study and current literature data are examined, it is seen that certain crime groups such as murder and attempted murder, and sexual crimes against children are high in elderly forensic psychiatric evaluations.

Dementia in the incarcerated population: a retrospective study using the South Carolina Alzheimer's disease registry, USA

PURPOSE

Research about the prevalence of dementia among older adults in the incarceration system is currently lacking, and further investigation is warranted. Considering the high level of healthcare needs, unique behavioural issues and difficulty to rehabilitate within the system due to its punitive approach and lack of effective rehabilitation programs, further investigation is warranted to characterize and determine the number of incarcerated older adults with dementia. The purpose of this study is to estimate the prevalence of individuals with dementia in the prison system while also describing the incarceration, demographic and offence-related characteristics of this unique population.

DESIGN/METHODOLOGY/APPROACH

South Carolina (SC) Alzheimer's Disease and Related Dementias Registry (1992-2016) and South Carolina Department of Corrections (SCDC) data (Fiscal years 1992-2019) were cross-referenced. The prevalence of Alzheimer's disease and related dementias (ADRD) cases in the corrections system was calculated using South Carolina Alzheimer's Disease (SC AD) SC ADRD Registry and SCDC data. Pearson's correlation coefficients were calculated to determine strength and direction of relationships between year of incarceration and frequency of ADRD cases both prior to and after incarcerations, respectively. Significant differences by age group, race, gender and dementia type were determined using a two-tailed pooled t-test and Bonferroni approach where appropriate. Count data for types of crimes committed are also presented.

FINDINGS

The linkage showed that there were 2,171 individuals within the SC AD Registry who have been in the corrections system, about 1% of those in the Registry. Of these individuals, 1,930 cases were diagnosed with ADRD after incarceration and 241 prior to incarceration. In 2016, 317 individuals with ADRD were incarcerated. For ages 55 and above in South Carolina, the prevalence of ADRD is 6.7% in the general, non-incarcerated population compared to 14.4% in the incarcerated population. Additional results showed that those diagnosed with ADRD between 55 and 65 years of age had a significantly lower mean age at first incarceration (34.6 years of age) than those diagnosed between 66 and 74 years of age (55.9 years of age), indicating that those incarcerated earlier in life had an earlier dementia diagnosis. Additionally, African Americans had a significantly lower mean age at first incarceration (43.4 years of age) than Whites (46.2 years of age) and females had significantly lower mean age at first incarceration (42.9 years of age) than males (45 years of age). When investigating trends, results showed a significant positive linear association between year and frequency of ADRD diagnoses (p-value < 0.05) for those with ADRD diagnosis prior to incarceration and a significant decreasing linear association (p-value < 0.0001) in the number of individuals with an ADRD diagnosis after corrections. Findings also showed that a large percentage of older adults with ADRD in prison did not commit a violence offence.

ORIGINALITY/VALUE

This study links a population-based Alzheimer's disease registry and state-wide corrections data to estimate the prevalence of individuals with dementia in the prison system. This linkage presents an opportunity to fill in significant gaps and contribute to the body of literature on dementia among people in prison in the USA.

A comparison of older and younger offenders with delusional jealousy

We sought to determine whether or not there were differences in medical, criminological and legal factors between older and younger offenders with diagnoses of delusional jealousy by undertaking a retrospective case-file search of Australian legal databases. Our results demonstrate that older offenders were more likely to have comorbid dementia whereas younger offenders were more likely to have comorbid substance use and chronic psychotic conditions. A history of domestic violence frequently predated the index offence but we were unable to determine if this was due to psychosis or a pre-existing tendency for violence. Despite a common diagnosis, the older offenders were more likely to be made forensic patients rather than sentenced prisoners when compared with the younger offenders. Consequently, different factors might mediate the pathway to violence in older and younger people suffering from delusional jealousy and could be additional targets for clinical intervention.

Standardized outcome measures of mental health in research with older adults who are incarcerated

PURPOSE

The targeted use of standardized outcome measures (SOMs) of mental health in research with older adults who are incarcerated promotes a common language that enables interdisciplinary dialogue, contributes to the identification of disparities and supports data harmonization and subsequent synthesis. This paper aims to provide researchers with rationale for using "gold-standard" measures used in research with community-dwelling older adults, reporting associated study sample psychometric indexes, and detailing alterations in the approach or measure.

DESIGN/METHODOLOGY/APPROACH

The authors highlight the mental health of older adults who are incarcerated. They also discuss the benefits of SOMs in practice and research and then identify gold-standard measures of mental health used in research with community-dwelling older adults and measures used in research with older adults who are incarcerated. Finally, the authors provide several recommendations related to the use of SOMs of mental health in research with this population.

FINDINGS

Depression, anxiety and post-traumatic stress disorder are common among older adults who are incarcerated. Researchers have used a variety of measures to capture these mental health problems, some parallel to those used with community-dwelling samples. However, a more targeted use of SOMs of mental health in research with this population will contribute to important strides in this burgeoning field.

ORIGINALITY/VALUE

This review offers several practical recommendations related to SOMs of mental health in research with older adults who are incarcerated to contribute to a rigorous evidence base and thus inform practice and potentially improve the health and well-being of this population.

Older Individuals Convicted of Sexual Offenses: A Literature Review

The population of older individuals convicted of sexual offenses (OSOs) is rapidly increasing. However, we have little understanding of their characteristics (e.g., demographic, psychological, individual, offense, and risk) and needs. To identify any similarities or differences that are unique to older individuals convicted of sexual offending, it is important to compare such characteristics across the adult lifespan. Therefore, the aim of this systematic review was to specify and synthesize the current knowledge of characteristics across the adult lifespan of the population of individuals convicted of sexual offenses. Five databases were searched and 10,680 results were screened, resulting in 100 studies included in the final review. The findings were grouped into four emergent themes: age of onset and prevalence; offender and offense characteristics; age and the risk of reoffending; and treatment. Implications of the findings from this review are discussed in relation to future research and clinical practice.

Older people in custody in a forensic psychiatric facility, prevalence of dementia, and community reintegration needs: an exploratory analysis

BACKGROUND

Across much of the developed world, the number of older people in custody has been increasing, which presents challenges for correctional systems due to the complex social, medical and mental health needs of this subgroup, especially those living with dementia. The present study therefore aimed to increase insight into the extent to which older people in custody are (a) potentially living with dementia and (b) receiving appropriate supports/services (particularly, with respect to community reintegration).

RESULTS

Cross-sectional data were drawn from a sample of 29 older people in custody and 20 correctional health care professionals at a regional forensic psychiatric hospital in a medium-sized Canadian city. In general, analyses revealed that: (a) scores from a modified version of the Community Screening Instrument for Dementia (CSI'D') suggest that 45% of older individuals screened positive for dementia; (b) 35% of Social Workers and 25% of Primary Nurses (i.e., RNs/RPNs) suspected that at least one older individual on their caseload has dementia, and there was adequate agreement between health staffs' perception of the presence or absence of dementia and the CSI'D' assessment; (c) varying supports/services may be required for older individuals' successful community reintegration and living; and (d) Social Workers and Primary Nurses generally lack training/education to adequately support older people in custody.

CONCLUSIONS

A substantial number of older people in custody may experience age-related challenges, including dementia. This necessitates the development and implementation of programming to effectively address older individuals' needs during incarceration and community reintegration and living.

The older prisoner health and social care assessment and plan (OHSCAP) versus treatment as usual: a randomised controlled trial

Background

Older people are the fastest-growing demographic group among prisoners in England and Wales and they have complex health and social care needs. Their care is frequently ad hoc and uncoordinated. No previous research has explored how to identify and appropriately address the needs of older adults in prison. We hypothesised that the Older prisoner Health and Social Care Assessment and Plan (OHSCAP) would significantly increase the proportion of met health and social care needs 3 months after prison entry, compared to treatment as usual (TAU).

Methods

The study was a parallel randomised controlled trial (RCT) recruiting male prisoners aged 50 and over from 10 prisons in northern England. Participants received the OHSCAP or TAU. A clinical trials unit used minimisation with a random element as the allocation procedure. Data analysis was conducted blind to allocation status. The intervention group had their needs assessed using the OHSCAP tool and care plans were devised; processes that lasted approximately 30 min in total per prisoner. TAU included the standard prison health assessment and care. The intention to treat principle was followed. The trial was registered with the UK Clinical Research Network Portfolio (ISRCTN ID: 11841493) and was closed on 30 November 2016.

Results

Data were collected between 28 January 2014 and 06 April 2016. Two hundred and forty nine older prisoners were assigned TAU of which 32 transferred prison; 12 were released; 2 withdrew and 1 was deemed unsafe to interview. Two hundred and fifty three 3 prisoners were assigned the OHSCAP of which 33 transferred prison; 11 were released; 6 withdrew and 1 was deemed unsafe to interview. Consequently, data from 202 participants were analysed in each of the two groups. There were no significant differences in the number of unmet needs as measured by the Camberwell Assessment of Needs – Forensic Short Version (CANFOR-S). The mean number of unmet needs for the OHSCAP group at follow-up was 2.03 (SD = 2.07) and 2.06 (SD = 2.11) for the TAU group (mean difference = 0.088; 95% CI − 0.276 to 0.449, p = 0.621).

No adverse events were reported.

Conclusion

The OHSCAP was fundamentally not implemented as planned, partly due to the national prison staffing crisis that ensued during the study period. Therefore, those receiving the OHSCAP did not experience improved outcomes compared to those who received TAU.

Trial registration

Current Controlled Trials: ISRCTN11841493, 25/10/2012.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11965-5.

The mental and physical health of older offenders: A systematic review and meta-analysis

A systematic review with meta-analysis was performed to: 1) estimate the prevalence of both mental and physical health problems in older offenders; 2) calculate relative risks for the health conditions in relation to non-offender older adults and; 3) explore the potential confounding role of several variables. We searched five databases up to August 2019. Studies involving offenders older than 50 years old were included. Fifty-five publications met criteria. The pooled prevalence for 18 mental and 28 physical health problems was calculated. In comparison with non-offender older adults, older offenders showed significantly higher risk for Hypertension (RR = 1.16, CI = 1.1, 1.2), Cardiovascular Diseases (RR = 1.24, CI = 1.09, 1.41), Respiratory diseases (RR = 1.75, CI = 1.29, 2.35), and Arthritis (RR = 1.19, CI = 1.12, 1.25). Heterogeneity was significant for all meta-analyses and partially explained by the confounding effect of country, the diagnosis assessment method, and the sample characteristics. Future research should include comparison groups of non-offender older adults and use longitudinal study designs to identify risk factors that can be targeted in preventive programmes.

Dementia and mild cognitive impairment in prisoners aged over 50 years in England and Wales: a mixed-methods study

Background

People aged ≥ 50 years constitute the fastest-growing group in the prison population of England and Wales. This population has complex health and social care needs. There is currently no national strategy to guide the development of the many-faceted services required for this vulnerable population; therefore, prisons are responding to the issue with a range of local initiatives that are untested and often susceptible to failure if they are not fully embedded in and securely funded as part of commissioned services.

Objectives

The objectives were to establish the prevalence of dementia and mild cognitive impairment in prisoners in England and Wales and their health and social care needs; validate the six-item cognitive impairment test for routine use in prisons to aid early and consistent identification of older prisoners with possible dementia or mild cognitive impairment; identify gaps in current service provision; understand the first-hand experiences of prisoners living with dementia and mild cognitive impairment; develop a care pathway for prisoners with dementia and mild cognitive impairment; develop dementia and mild cognitive impairment training packages for staff and prisoners; and produce health economic costings for the care pathway and training packages.

Design

This was a mixed-methods study.

Setting

The study setting was prisons in England and Wales.

Participants

Prisoners aged ≥ 50 years and multiagency staff working in prison discipline and health and social care services took part.

Results

Quantitative research estimated that the prevalence rate of suspected dementia and mild cognitive impairment in the prison population of England and Wales is 8%. This equates to 1090 individuals. Only two people (3%) in our sample had a relevant diagnosis in their health-care notes, suggesting current under-recognition of these conditions. The prevalence rate in prisons was approximately two times higher among individuals aged 60–69 years and four times higher among those aged ≥ 70 years than among those in the same age groups living in the community. The Montreal Cognitive Assessment screening test was found to be more effective than the six-item cognitive impairment test assessment in the older prisoner population. Qualitative research determined that staff and prisoners lacked training in knowledge and awareness of dementia and mild cognitive impairment, and this leads to problematic behaviour being viewed as a disciplinary issue rather than a health issue. Local initiatives to improve the lives of prisoners with dementia and mild cognitive impairment are often disadvantaged by not being part of commissioned services, making them difficult to sustain. Multidisciplinary working is hampered by agencies continuing to work in silos, with inadequate communication across professional boundaries. A step-by-step care pathway for prisoners with dementia and mild cognitive impairment was developed, and two tiers of training materials were produced for staff and prisoners.

Limitations

Our prevalence rate was based on the results of a standardised assessment tool, rather than on clinical diagnosis by a mental health professional, and therefore it may represent an overestimation. Furthermore, we were unable to distinguish subcategories of dementia. We were also unable to distinguish between a likely diagnosis of dementia and other conditions presenting with mild cognitive impairment, including learning disability, severe depression and hearing impairment. Questionnaires regarding current service provision were collected over an extended period of time, so they do not reflect a ‘snapshot’ of service provision at a particular point.

Conclusions

We hypothesise that implementing the step-by-step care pathway and the training resources developed in this study will improve the care of older prisoners with dementia and mild cognitive impairment.

Future work

The care pathway and training materials should be evaluated in situ. Alternatives to prison for those with dementia or mild cognitive impairment should be developed and evaluated.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 27. See the NIHR Journals Library website for further project information.

Global Estimates of the Prevalence of Depression among Prisoners: A Systematic Review and Meta-analysis

BACKGROUND

Prison populations tend to be marginalized and disadvantaged of the rights and freedoms that other people in the community benefit from. Their separation from families, a narrow room and lack of privacy in the prison, violence between prisoners, and the uncertainty about the future result in psychological distress, for example, depression. The review has synthesized previous studies conducted on the topic and summarized to formulate recommendations for future prison health care services.

METHODS

We systematically searched the databases: PubMed, Psych Info, and SCOPUS, as well as manual Google Scholar searches, were conducted to retrieve published literature globally. We have included observational studies, written in English language. Estimates were pooled using a random-effects model. The study protocol was registered in PROSPERO with protocol number CRD42020156108. Subgroup and sensitivity analysis was conducted, and heterogeneity across the studies was evaluated using Q and the I ²-test. Publication bias was assessed by inspection of the funnel plot and Egger's regression test.

RESULT

A total of 1313 studies were initially identified through the electronic database; among these, a total of 73 full-text articles were retrieved for further appraisal. Further, 32 full-text articles were included in the final systematic review and meta-analysis. In this meta-analysis, the pooled prevalence of depression among prisoners was 36.9% (95% CI; 27.3-47.6). The pooled prevalence of depression among prisoners in the developing and developed countries was 39.2% and 33.1%, respectively. Moreover, the prevalence of depression was 19.1% and 54% for the studies that used diagnostic and screen tools to diagnose or screen depression, respectively. A leave-one-out analysis revealed that the pooled prevalence of depression among prisoners was not dependent on a single study removal or addition. Thus, the pooled prevalence of depression ranges between 35.3 and 38.0%.

CONCLUSION

The prevalence of depression among prisoners was high. Therefore, regular and continuous screening of depressive symptoms for prisoners along with its appropriate management is highly recommended.

The prevalence of major mental illness, substance misuse and homelessness in Irish prisoners: systematic review and meta-analyses

AimsTo systematically review studies from Irish prisons that estimate the prevalence of major mental illness, alcohol and substance misuse, and homelessness at the time of committal.

METHODS

Healthcare databases were searched for studies quantifying the point prevalence for each outcome of interest. Searches were augmented by scanning of bibliographies and searches of governmental and non-governmental websites. Proportional meta-analyses were completed for each outcome.

RESULTS

We found eight, six and five studies quantifying the point prevalence of major mental illness, substance misuse, and homelessness respectively. Considerable heterogeneity was found for each subgroup (except psychosis where substantial heterogeneity was observed) and random effects models were used to calculate pooled percentages. The pooled percentage for psychotic disorder was 3.6% [95% confidence interval (CI) 3.0-4.2%], for affective disorder 4.3% (95% CI 2.1-7.1%), for alcohol use disorder 28.3% (95% CI 19.9-37.4%), for substance use disorder 50.9% (95% CI 37.6-64.2%) and for those who were homeless on committal 17.4% (95% CI 8.7-28.4%).

CONCLUSIONS

Estimates for the prevalence of psychotic illness and substance abuse amongst Irish prisoners are in keeping with international estimates of morbidity in prisons, whilst those for affective disorders are lower. The prevalence of homelessness in committal to Irish prisons is higher than some international estimates. Rates for psychoses, alcohol and substance misuse as well as homelessness in Irish prisons are significantly higher than the general population prevalence of these vulnerabilities. A need for service development is discussed.

Mental health and offending in older people: Future directions for research

BACKGROUND

The number of older people and their proportion of the prison population in high-income countries is increasing substantially. This pattern is mirrored by the age profile in forensic hospital services, and both trends seem counter to the age-crime curve concept. How do we understand this and what are the mental health needs of this growing group?

AIM

The aim of this review is to identify existing research robust enough to inform policy and practice in relation to mental health in older offenders and the knowledge gaps that should drive future research.

METHODS

A keyword-based search strategy of the databases Embase, PsychINFO, Medline, and grey literature 2008-2018. Article selection was limited to empirical research with the potential to inform policy or practice and findings synthesised narratively.

RESULTS

Much of the research in this field focuses on prevalence and the increased psychiatric morbidity of the older offender population. Older prisoners and those older patients in secure hospitals have needs that differ in some respects from their younger counterparts and community-dwelling older people. There are few studies of interventions for mental health in older prisoners or into the challenges of timely release given their complex needs. Discharge of older individuals from secure settings is also an area where further research is required in order to inform policy and service provision.

CONCLUSIONS

The older population in prisons and secure settings is growing, and there is much concern as to how far facilities and services have been able to identify and meet the mental health needs of those of older age. Cooperation between researchers and services and between disciplines will be essential if we are to secure a more robust evidence base in this respect. Engaging service users in such research and considering the whole criminal justice pathway including diversion remains a priority.

Looking from the outside: No substitute for rigorous evaluation

Looking in from the outside, what would the ordinary person expect of forensic mental health services? I suggest that there are three questions he or she would ask: (a) Are there public health measures that can be introduced to prevent those with mental disorder going on to commit crimes? (b) Can we identify in advance the individual who is likely to go on and commit a violent act because of his or her mental health difficulties, and prevent that or limit damage? (c) If a seriously harmful act has already been committed, what interventions might prevent a repetition? All of these questions are about prevention of an untoward event in the future and anticipate knowledge. How secure can we be that current forensic mental health practitioners can make adequately evidenced responses? I fear that examination of current literature would indicate that they and their academic colleagues would fall short of these expectations. Reasons for this are undoubtedly numerous. The issues are complex, with the interplay of many variables from the vagaries of human nature through varying presentations of disorders, still often classified rather than diagnosed, to widely differing environments which, further, may suddenly change in a critical way. The impact of a serious offence can be so catastrophic that officialdom often decides that "something must be done." Yet, without a good evidence base, such decision-making is often ineffective and wasteful of resources. The limited evidence base has not been helped by the virtual extinction of an academic forensic psychiatry infrastructure and funding within British universities and the National Health Service. This does not bode well for the future.

The Health of America's Aging Prison Population

Older incarcerated individuals comprise the fastest growing demographic in the US prison system. Unhealthy lifestyles among incarcerated individuals and inadequate health care lead to earlier onset and more rapid progression of many chronic conditions that are prevalent among community-living older adults. There are limited peer-reviewed epidemiologic data in this area; however, there is growing interest in identifying strategies for housing aging incarcerated individuals, delivering appropriate health care in prisons, and coordinating after-release health care. In this systematic review, we summarize the epidemiologic evidence of the health challenges facing the aging US prison population. Our comprehensive literature search focused on health outcomes, including diseases, comorbid conditions, mental health, cognition, and mobility. From 12,486 articles identified from the literature search, we reviewed 21 studies published between 2007 and 2017. All the studies were observational and cross-sectional, and most (n = 17) were based on regional samples. Sample sizes varied widely, ranging from 25 to 14,499 incarcerated people (median, 258). In general, compared with their younger counterparts, older incarcerated individuals reported high rates of diabetes mellitus, cardiovascular conditions, and liver disease. Mental health problems were common, especially anxiety, fear of desire for death or suicide, and depression. Activities of daily living were challenging for up to one-fifth of the population. We found no empirical data on cognition among older incarcerated individuals. The findings of this review reveal few empirical data in this area and highlight the need for new data to drive policy and practice patterns that address critical health issues related to the aging prison population.

Psychiatric disorders, substance use, and executive functioning in older probationers

BACKGROUND

Although the number of older people serving community sentences (probation) after conviction for a criminal offence in England and Wales has increased rapidly since about 2006, this population has received little research attention.

AIM

To examine the mental health, substance use, and executive functioning of older probationers.

METHODS

Thirty‐two male probationers aged 50 years and older were recruited from probation services in the Thames Valley, England, and administered validated semistructured interviews for psychiatric disorders, symptom checklists for depression and substance use, cognitive impairment screens, and neuropsychological tests of executive functioning (examining verbal fluency and response inhibition).

RESULTS

We found that older probationers presented with a high prevalence of mental health difficulties (overall caseness n = 22; 69%, 95% CI [53–85]) that exceed estimates in the older general population. Prevalences of depression (25%) or alcohol abuse or dependence (19%) were found to be high. In comparison with normative data, however, older probationers did not present with deficits in tested executive functioning.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Mental health and substance use problems were more prominent than cognitive deficits in this sample of older probationers. Further work should include older community controls to inform service planning and to determine how these mental health factors interact with offending.

The impact of dementia in the prison setting: A systematic review

Older prisoners are the fastest growing group in the prison population, with an accelerated aging process they are at a high risk of developing dementia. However, no systematic review has explored the impact of dementia in the prison setting. The objectives of this review were to identify the prevalence of dementia in the prison setting and how prison, health and social care providers assess, diagnose, treat, support and care for prisoners with dementia. A systematic search of the literature from the following databases was undertaken: CINHAL, PubMed, BNI, PsychINFO, and MEDLINE. Search strategies were tailored for each database and included recognised Medical Subject Headings. Hand searching of prominent journals in correctional services and dementia, as well as reference lists of included papers was completed. Open Grey website was searched to identify relevant government, local council and charity publications regarding dementia in the prison setting. The appropriate Critical Appraisal Skills Programmes Checklist for all included studies was completed. Following the application of inclusion and exclusion criteria, 10 studies were included in the review. Due to the nature of the data extracted, a meta-synthesis was not possible; therefore, a thematic synthesis was completed. Three themes emerged: prevalence of dementia in the prison population, identification of older prisoner's needs, and knowledge of correctional officers and legal professionals. The prevalence and incidence of dementia in prison populations remain largely unknown. There is a need for national policies and local strategies that support a multi-disciplinary approach to early detection, screening and diagnosis of cognitive impairment and dementia across prison settings. Alongside the development of structured prison environments, non-pharmacological interventions, continued assessment of prisoners with a dynamic care plan, and training for health, social and prison staff and prisoners.

What are the characteristics of first time older sexual offenders?

ABSTRACTBackground:Our objective was to examine and describe the common socio-demographic and clinical characteristics of first time older sex offenders.

METHODS

Research papers published in MEDLINE, PsycINFO, and EMBASE were searched systematically. Following removal of duplicates and irrelevant papers, a total of 423 papers were reviewed to determine whether the selection criteria were met. A total of seven publications were included and evaluated by two researchers.

RESULTS

Of the seven publications, there were two retrospective research studies and five case reports. There was a higher proportion of neurocognitive disorder in this offender group and the victims were usually vulnerable individuals. Yet, cognitive assessments were rarely done or reported. Two subtypes of older sex offenders were identified: (i) offenders who had offended in the past but were not previously detected; (ii) first-time offenders with a high proportion of neurocognitive disorder.

CONCLUSION

There is a paucity of research in first time sex offending by older people. This review has highlighted a need for better designed studies to explore the characteristics of older sex offenders. Better collaboration between forensic and old-age psychiatric services is required for improved assessment and management of older sex offenders.

Cognitive impairment, self-perceived health and quality of life of older prisoners

BACKGROUND

There is a wealth of studies of somatic and mental illness among prisoners, but little on older prisoners and their cognitive aging.

AIMS

Our study examines the cognitive performance of older male prisoners and its effect on their perceived health and quality of life.

METHODS

A total of 138 men aged 50 or over were recruited in seven French prisons and 138 men of similar ages from the general population. Two assessments of executive cognitive functions - the mini-mental state examination and the frontal assessment battery - were administered to each participant, together with self rating schedules of health (Nottingham Health Profile), subjective state of mental health and quality of life (the brief World Health Organisation Quality of Life Questionnaire).

RESULTS

There were very significant differences between the two groups in terms of cognitive performance, perceived health and quality of life. There was, however, no significant association between cognitive impairment and perceived health or quality of life.

CONCLUSIONS

We found evidence that about a fifth of male prisoners in France had executive function test scores suggestive of at least moderately severe dementia and many others some evidence of cognitive impairments. Prisoners suffering from cognitive impairment do not necessarily seek help, perhaps not even considering that their health or quality of life to be affected. Communication deficits may also prevent their participation in prison activities which could prevent, slow or halt cognitive decline. Consequently, it is important that systematic screening for cognitive disorders is offered to men over 50 in prison. Copyright © 2017 John Wiley & Sons, Ltd.

Ethical, Legal and Forensic Issues in Geriatric Psychiatry

PURPOSE OF THE REVIEW

To evaluate the ethical, legal and forensic issues that is faced by the older adult population.

RECENT FINDINGS

Many older individuals will face a host of ethical, medical and legal issues associated with their care. Most prominent among these issues are the maintenance of autonomy while ensuring their safety and the safety of individuals who care for them. Decisions regarding end of life including the formulation of advance directives add to the complexity of care for these older adults. A significant portion of individuals in the criminal justice system are aging and many of these individuals have psychiatric disorders. Their care is compromised due to the lack of appropriate services within criminal justice system for providing care for these individuals.

CONCLUSIONS

Ethical, legal and forensic issues among older are not uncommon and complicate the care of these vulnerable individuals.

New horizons: Forensic mental health services for older people

Although the older adult population makes up only a small percentage of mentally disordered offenders, there is a clear need for forensic mental health services for older people. However, these services to date have developed ad hoc and with no coordination. In this article we discuss the evolution, current provision, future direction and therapeutic implications of such services. Although the epidemiology, criminology and clinical characteristics of older people are sufficiently different from those of younger people to warrant such service specificity, we suggest that the provision of care should be geared to services based on older people's multiple and complex needs, rather than on arbitrary age cut-offs.

Learning Objectives

• Be able to use an understanding of epidemiology, criminology and clinical characteristics of older people in the provision of forensic mental healthcare

• Understand the forensic mental healthcare needs of older people

• Be able to develop forensic mental health services for older people

Psychiatric disorders among older prisoners: a systematic review and comparison study against older people in the community

OBJECTIVES

Despite emerging evidence that older prisoners experience poor mental health, literature in this area is still limited. In the present systematic review and meta-analysis, we report on the prevalence of psychiatric disorders among older prisoners and compare our findings against community studies on older people.

METHODS

We searched on Assia, PsycInfo, MedLine, Embase, Web of Science, Google and Gov.uk. We carried out bias assessments, rated studies for quality and ran a heterogeneity test. We meta-analysed prevalence rates of psychiatric disorders through an aggregate weighted mean and calculated relative risk (RR) and statistical significance against community studies. Sensitivity analyses were further performed.

RESULTS

We reviewed nine studies and obtained the following prevalence: 'Any psychiatric disorder' 38.4%, depression 28.3%, schizophrenia/psychoses 5.5%, bipolar disorder 4.5%, dementia 3.3%, cognitive impairment 11.8%, personality disorder 22.9%, alcohol abuse 15.9%, anxiety disorders 14.2%, PTSD 6.2%. Older prisoners were found to have higher RR for every single psychiatric disorder against older people in the community, with the sole exception of alcohol abuse (RR = 1) and dementia (RR = .75). The prevalence rates were statistically significantly higher (p < .05) among the prisoners for 'Any psychiatric disorder', depression and personality disorder. Overall, the sensitivity analyses confirmed our original results.

CONCLUSION

Our findings point at a high prevalence of every single psychiatric disorder among older prisoners, who also experience rates of dementia and alcohol abuse comparable to those reported in the community. Our results have relevant implications for policy and practice in this area. Further research is crucial to confirm findings from this study.

The effectiveness of the Older prisoner Health and Social Care Assessment and Plan (OHSCAP): a randomised controlled trial

Background

Older people are the fastest-growing group in prisons in England and Wales and have complex health and social care needs that often remain unmet.

Objectives

(1) Evaluate the efficacy of the Older prisoner Health and Social Care Assessment and Plan (OHSCAP) in improving (i) the ability to meet older male prisoners’ health and social care needs, (ii) health-related quality of life (HRQoL), (iii) depressive symptoms and (iv) functional health and well-being and activities of daily living; (2) assess the quality of care plans produced; (3) explore the experiences of older prisoners receiving, and staff conducting, the OHSCAP; and (4) evaluate the cost-effectiveness of the OHSCAP compared with treatment as usual (TAU).

Design

Multicentre, parallel-group randomised controlled trial (RCT) with follow-up at 3 months, with a nested qualitative study and quality audit of care plans (n = 150, 68%).

Setting

Ten English prisons.

Participants

Four hundred and ninety-seven newly arrived male prisoners aged ≥ 50 years with a discharge date at least 3 months from recruitment. A total of 14 prisoners and 11 staff participated in qualitative interviews.

Intervention

Randomisation to OHSCAP or TAU. The OHSCAP group had health and social needs assessed by a trained health-care worker or prison officer. Care plans were devised and subsequent actions included professional support and appropriate referrals.

Main outcome measures

Primary outcome measure – mean number of unmet health and social care needs as measured by the Camberwell Assessment of Need – Short Forensic Version. Secondary outcome measures – measures of functional health and well-being, depressive symptoms and HRQoL. A health economic evaluation was undertaken using service contact between baseline and follow-up and appropriate unit cost information.

Results

A total of 497 prisoners were recruited (248 to OHSCAP and 249 to TAU). The 404 completed follow-ups were split evenly between the trial arms. No significant differences were observed between the intervention and TAU groups in relation to the primary outcome measure. The OHSCAP did not demonstrate convincing benefits in HRQoL over TAU, and there were no significant differences in relation to costs. Audit and qualitative data suggest that the intervention was not implemented as planned.

Limitations

As a result of the limited follow-up period, potential long-term gains of the intervention were not measured. Some of the standardised tools had limited applicability in prison settings. Cost-effectiveness data were limited by unavailability of relevant unit cost data.

Conclusions

The OHSCAP failed in its primary objective but, fundamentally, was not implemented as planned. This appears to have been attributable, in some part, to wider difficulties currently affecting the prison landscape, including reduced levels of staffing, the loss of specialist support roles for such initiatives and increased prevalence of regime disruption.

Future work

Partnership working and information sharing across disciplines within prison settings require improvement. Research should explore the potential involvement of other prisoners and third-sector organisations in identifying and addressing older prisoners’ health and social care needs to better match community provision. Further examination should be undertaken of how the prison regime and system affects the well-being of older prisoners. Future prison-based RCTs should carefully balance the fidelity of initiatives being evaluated and testing in a ‘real-life’ setting.

Trial registration

Current Controlled Trials ISRCTN11841493.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 5, No. 31. See the NIHR Journals Library website for further project information.

Disability in prison activities of daily living and likelihood of depression and suicidal ideation in older prisoners

OBJECTIVE

The study objective was to determine if disability in activities of daily living specific to prison, prison activities of daily living (PADLs), is associated with depression and severity of suicidal ideation (SI) in older prisoners, a rapidly growing population at high risk of suicide.

METHODS

Cross-sectional design using data from a study of prisoners age ≥50 years (N = 167). Depression was operationalized as a score of ≥15 on the 9-item Physician Health Questionnaire (PHQ-9). SI severity was assessed using the Geriatric Suicide Ideation Scale (GSIS). Participants were considered to have PADL disability if they reported any of the following as "very difficult" or "cannot do:" dropping to the floor for alarms, climbing on/off the top bunk, hearing orders, walking while wearing handcuffs, standing in line for medications, and walking to chow. Associations were examined with bivariate tests and with multivariable logistic and linear regression models, and the interaction term gender × PADL disability was tested.

RESULTS

PADL disability was associated with depression and SI severity. There was no main effect of gender on either depression or SI, yet the association between PADL disability and depression was considerably stronger in male than in female older prisoners.

CONCLUSIONS

Identifying older prisoners who have difficulty performing PADLs may help distinguish prisoners who may also be likely to be depressed or experience more severe SI. Furthermore, the association between PADL disability and depression may be particularly salient in older male prisoners. Longitudinal studies are needed as causal inferences are limited by the cross-sectional design. Copyright © 2016 John Wiley & Sons, Ltd.

"Teach-to-Goal" to Better Assess Informed Consent Comprehension among Incarcerated Clinical Research Participants

Correctional health research requires important safeguards to ensure that research participation is ethically conducted. In addition to having disproportionately low educational attainment and low literacy, incarcerated people suffer from health-related conditions that can affect cognition (e.g., traumatic brain injury, substance use disorders, mental illness). Yet modified informed consent processes that assess participants' comprehension of the risks and benefits of participation are not required by relevant federal guidelines. A push to assess comprehension of informed consent documents is particularly timely given an increase in demand for correctional health research in the context of criminal justice reform. We argue that comprehension assessments can identify persons who should be excluded from research and help those who will ultimately participate in studies better understand the risks and benefits of their participation.

Old and dangerous: Prison and dementia

Older prisoners are the fastest growing group of prisoners in many countries. The purpose of this study is to explore the phenomenon of detention of persons suffering from dementia. Medline searches were conducted for relevant articles, chapters and books published until August 2016. Search terms included dementia, elderly, prison and criminal. Publications found through this indexed search were reviewed for further relevant references. As results, there is a lack of data about elderly with dementia in prisons. Given the rise in the average age, it is reasonable to hypothesize that the number of older prisoners is growing. Moreover, some elderly are imprisoned with a concomitant cognitive impairment or psychiatric disorder while others will develop such diseases once incarcerated. At the present time, legal and social systems seem unprepared to handle the phenomenon of dementia in prison. As proposal, health assessments for older first time offenders should become a practice inside the correctional facilities and include an evaluation for specific health issues, such as psychiatric comorbidity and cognitive impairment.

Older prisoners: psychological distress and associations with mental health history, cognitive functioning, socio-demographic, and criminal justice factors

BACKGROUND

The growth among older prisoner populations, including in Australia, necessitates an understanding of this group in order to generate effective management strategies. One particular concern is the mental well-being of older prisoners. This study aimed to determine the level of psychological distress among sentenced prisoners aged 50 years and older, to compare this level to that seen among younger prisoners and older people in the community, and to investigate which mental health history, cognitive functioning, socio-demographic, and criminal justice characteristics were associated with psychological distress.

METHODS

A cross-sectional survey of 173 older (M = 63 years) and 60 younger prisoners (M = 34 years) in two Australian jurisdictions was conducted. The Kessler Psychological Distress (K10) scale was administered with prisoners and additional data were collected from interviews and participant health and corrections files. K10 scores were compared to community norms using data from the Australian Health Survey.

RESULTS

Average K10 scores of the older prisoners were significantly lower than the younger prisoners' (p = 0.04), though the effect size was small (r = 0.1). Significantly, higher distress levels were observed in comparison to the general population (p < 0.001), with older prisoners being three times more likely to display very high levels of distress (12.3% vs. 3.7%). Higher psychological distress scores among older prisoners were significantly associated with female gender (p = 0.002) and a history of mental health issues (p = 0.002).

CONCLUSIONS

While the levels of distress seen among older prisoners were significantly lower than that of younger prisoners, their higher levels of distress in comparison to community norms demonstrate a need for correctional services to be attuned to the mental health of the expanding older prisoner population.

Links between depressive symptoms and unmet health and social care needs among older prisoners

BACKGROUND

absolute numbers of older prisoners and their proportion of the total prison population are increasing. They have multiple health and social care needs that are prominent on entry into prison. No previous studies have identified older prisoners' health and social care needs at this crucial point.

OBJECTIVE

to examine unmet health and social care needs among older men entering prison and their links with depressive symptoms.

METHODS

a cross-sectional survey across nine prisons in the North of England was completed. One hundred male prisoners aged between 60 and 81 were interviewed, using the Camberwell Assessment of Need-Forensic short version (CANFOR-S) and Geriatric Depression Scale-Short Form (GDS-15). Descriptive statistics were generated and χ(2) tests performed.

RESULTS

participants reported high levels of unmet needs as measured with the CANFOR-S, notably in the domains of knowledge about their condition and treatment (38%); psychological distress (34%); daytime activities (29%); benefits (28%); food (22%) and physical health (21%). The mean total number of unmet needs was 2.74, with a median of 2.0. More than half the sample (56%, 95% CI 45-66%) exhibited clinical signs of depression. A significant association between depressive symptomology and an unmet physical health need, as measured by the CANFOR-S, was detected (χ(2) = 6.76, df = 1, P < 0.01).

CONCLUSIONS

high levels of depressive symptoms were experienced by older prisoners on entry into prison. Personalised health and social care needs assessment and discrete depression screening are required on prison entry to facilitate effective management of unmet needs.

Disease profiles of detainees in the Canton of Vaud in Switzerland: gender and age differences in substance abuse, mental health and chronic health conditions

BACKGROUND

Literature on the disease profile of prisoners that differentiates by age and gender remains sparse. This study aimed to describe the health of correctional inmates in terms of substance abuse problems and mental and somatic health conditions, and compare it by gender and age.

METHODS

This study examined cross-sectional data from the Canton of Vaud in Switzerland on the health conditions of detainees who were in prison on January 1, 2011 or entered prison in 2011. Health conditions validated by physician examination were reported using the International Classification of Diseases (ICD) version 10. The analyses were descriptive by groups of prisoners: the entire sample (All), Men, Older adults and Women.

RESULTS

A total of 1,664 individuals were included in the analysis. Men comprised 91.5 % of the sample and had a mean age of 33 years. The other 8.5 % were women and had an average age of 39. Older adults (i.e., age 50 and older) represented 7 % of the total sample. Overall, 80 % of inmates were non-Swiss citizens, but the proportion of Swiss prisoners was higher among the older adults (51 %) and women (29 %). Overall, 41 % of inmates self-reported substance abuse problems. Of those, 27 % were being treated by psychiatrists for behavioral disorders related to substance abuse. Chronic infectious diseases were found in 9 % of the prison population. In addition, 27 % of detainees suffered from serious mental health conditions. Gender and age had an influence on the disease profile of this sample: compared to the entire prison population, the older inmates were less likely to misuse illegal drugs and to suffer from communicable infections but exhibited more problems with alcohol and a higher burden of chronic health conditions. Female prisoners were more disposed to mental health problems (including drug abuse) and infectious diseases. In terms of chronic diseases, women suffered from the same conditions as men, but the diseases were more prevalent in women.

CONCLUSION

It is important to understand the different disease profiles of prisoners by gender and age, as it helps identify the needs of different groups and tailor age-and gender-specific interventions.

Aging Prisoners in Switzerland

Objective: This study assessed health care utilization of aging prisoners and compared it with that of younger prisoners. Method: Health care utilization comprised visits to general practitioners (GPs), nurses, and mental health professionals (MHPs) for a period of 6 months. Using retrospective study design, data were extracted from medical records of 190 older prisoners (50 years and older) and 190 younger inmates (18-49 years). Age group was a dichotomous predictor variable with type of sentencing and time spent in prison as covariates. Descriptive statistics and generalized linear mixed models (GLMMs) were performed. Results: For each of the three outcome variables, two GLMMs were constructed. The first model only included age group as the predictor variable (3 × Unadjusted models). The second included the two covariates in addition to the predictor variable (3 × Adjusted model). Results from the adjusted model indicate that visits to GPs significantly differed between the two age groups ( p = .022). Older prisoners visited GPs 1.43 times more often than younger prisoners over the 6-month period (adjusted risk ratio [RR] = 1.43, 95% confidence interval [CI] = [1.05, 1.94]). The finding for visits to nurses was not statistically significant ( p = .080). However, older prisoners visited nurses 1.36 times more frequently (adjusted RR = 1.36, 95% CI = [0.96, 1.91]). Finally, older prisoners visited MHPs 1.24 times more often than younger prisoners (adjusted RR = 1.24, 95% CI = [.95, 1.61]) and this finding was also not statistically significant ( p = .11). Discussion: Study findings underline that older prisoners utilized health care more often than younger prisoners although in most models the finding did not reach statistical significance. The prison system must develop solutions to address the needs of an aging population, particularly those with physical and mental health problems.

Pre- and post-sentence mental health service use by a population cohort of older offenders (≥45 years) in Western Australia

PURPOSE

Information on older offenders' mental health service (MHS) used before and after sentence is sparse. We therefore aimed to determine the 1-year prevalence of MHS use before sentence, and the likelihood and predictors of MHS use in the 5-year post-sentence period by first-time older adult offenders (≥45 years).

METHODS

Pre- and post-sentence MHS use by a cohort of 1,853 first-time offenders over 45 years in Western Australia was determined through whole-population linked administrative data. Logistic regression models compared the 1-year pre-sentence MHS contacts between offenders and matched non-offenders. Cox proportional hazards regression models identified the socio-demographic, offending and pre-sentence health service variables that determined post-sentence MHS use.

RESULTS

Older offenders were six times more likely to have used MHSs than non-offenders before sentence. Substance use was the most commonly treated disorder. Non-custodial offenders were twice more likely than prisoners to have been treated for any mental disorder and substance use disorders, and violent offenders were four times more likely to have attempted self-harm than non-violent offenders before being sentenced. The strongest predictors of post-sentence MHS contact were past psychiatric diagnosis in offenders with a pre-sentence MHS contact, and pre-sentence hospitalisation for attempted self-harm or physical illness, or being a male in those without. Discontinuity in MHS use after sentence by over half of the offenders with a prior contact was prominent.

CONCLUSION

Better detection and treatment of mental disorders in older offenders to ensure continuity of care at all transition points through age-sensitive correctional and community-based MHSs is needed.

Prevalence of chronic non-cancer pain in a UK prison environment

Chronic non-cancer pain (CNCP) is significant global health issue, accounting for a substantial increase in prescription analgesics worldwide, in recent decades. This clinical burden is evident in the UK prison population, where the prevalence of CNCP has never previously been determined. This study, conducted in June/July 2013, used prescribing data and a systematic review of clinical records from two UK prison establishments to derive a figure for point-prevalence of CNCP. Results showed that 20% of the total aggregated prisoner rolls (N = 1944) described CNCP and had been in receipt of treatment with daily analgesia, for a period of at least 3 months prior to observation date. This prevalence of CNCP was related to increasing age group (Spearman's rank correlation 0.94). Of those on continuous analgesic therapy (CAT), 44% were taking continuous opioid therapy (COT) of any sort. Prisoners with a diagnosis of opioid-type drug dependence (OTDD) were more than twice as likely to complain of CNCP and be on continuous medication for it (odds ratio 2.3). The issues relating to CNCP in prisons are discussed. Further research is recommended, identifying factors influencing CNCP prevalence in prisons, and enabling comparisons to CNCP prevalence in the UK general population.

Older men and older women remand prisoners: mental illness, physical illness, offending patterns and needs

BACKGROUND

Older prisoners are the fastest growing group of prisoners in most countries. They have high rates of physical and psychiatric co-morbidity, compared to community dwelling older persons and also compared with other prisoner groups. Very high rates of mental illness have been found in remand (pre-trial) prisoners when compared with other prisoner groups; however to date there have been no studies examining older male and female remand prisoners.

METHODS

A retrospective chart review was conducted of all remands, to a male and a female prison, over a six and half-year period. Demographic data were collected pertaining to psychiatric and medical diagnoses and seriousness of offending.

RESULTS

We found rising numbers of older prisoners amongst male remand prisoners. Older remand prisoners had very high rates of affective disorder and alcohol misuse. They had rates of psychotic illnesses and deliberate self-harm comparable to younger remand prisoners. High rates of vulnerability were found among older prisoners and older prisoners had a greater need for general medical and psychiatric services than younger prisoners. We also found comparable offending patterns with younger prisoners and high rates of sexual offending among the older male prisoner group.

CONCLUSIONS

Given the ageing population of many countries it is likely the numbers of older prisoners will continue to grow and given their high levels of both physical and psychiatric illness this will have implications for future service delivery.

Why is it important to consider so-called “invisible” older people in UK healthcare?

Purpose

– The purpose of this paper is to start a debate about older people who are in groups that are not readily visible to policy makers and practitioners.

Design/methodology/approach

– The paper is based on information obtained from academic literature, government statistics and other publications from relevant organisations. The authors investigated one “invisible” group each and comparisons and conclusions were then made collaboratively.

Findings

– Many groups of older people seem to be absent from statistics and from policy making. The paper suggests that there needs to be more research to identify the scale of any problems and how they may be solved.

Research limitations/implications

– This is not a systematic review but a preliminary account of the problem.

Practical implications

– There are practical implications for health and social care professionals if they do not recognise that there are groups in society about whom little is known. Lack of knowledge and empathy may affect their approach to these groups.

Social implications

– There are implications for society if these groups are not taken into account in decision making and especially over the allocation of resources.

Originality/value

– There is little written which brings together the lack of attention paid to these groups as a whole.

New directions for the study of incarcerated older adults: using social capital theory

As the population of older adults continues to rise, so, too, does the population of older adults in prison. The body of literature on older adults in corrections is scant, particularly with regard to health and social functioning. Past studies of aging inmates primarily focus on health care and related costs. The purpose of this article is twofold: (a) outline and synthesize the research on older adults living in prison; and (b) propose a framework for future research and intervention development based on social capital theory. Recommendations for social work practice, programs, and research are discussed.

‘They just throw you out’: release planning for older prisoners

Older prisoners are the fastest growing incarcerated sub-group. They have more complex health and social care needs than both younger prisoners and their age-matched peers living in the community. Prisoners who have been recently released are at enhanced risk in terms of their physical and mental health. Consequently, there is a need for timely, multi-disciplinary release planning. The aim of this study was to explore the health and social care needs of older male adults discharged from prison into the community. Qualitative interviews were carried out with prisoners with four weeks left to serve (N=62), with follow-up interviews conducted four weeks after release (N=45). Participants were selected from nine prisons in the North of England. The constant comparison method was used to analyse the data. Older prisoners perceived release planning to be non-existent. There was a reported lack of formal communication and continuity of care, causing high levels of anxiety. Older prisoners experienced high levels of anxiety about the prospect of living in probation-approved premises; however, those who did go on to live in probation-approved premises had their immediate health and social care needs better met than those who did not move into such accommodation. Release planning for older prisoners is generally inadequate and there is currently a missed opportunity to address the needs of this vulnerable group.

Psychosocial and reincarceration risks among older adults in mental health courts

OBJECTIVE

Older adults are increasingly involved in the criminal justice system, yet there is limited research regarding their needs and experiences. This study examined differences in psychosocial experiences and reincarceration between older and younger adults with psychiatric disorders involved in the criminal justice system.

METHODS

Participants (N = 80) were recruited from two mental health courts in the midwestern United States. Bivariate analyses examined age-related differences in psychosocial experiences and reincarceration between younger and older participants.

RESULTS

Older adults, on average, experienced more treatment adherence and fewer probation violations than younger adults during the 6-month follow-up; however, they experienced comparable risk for reincarceration. Older adults' substance use, service use, housing instability, and program retention were similar to their younger counterparts.

CONCLUSION

Despite older mental health court participants' treatment adherence and reduced probation violations, they are at risk for incarceration, substance use, and housing instability.

Prison prescribing practice: practitioners' perspectives on why prison is different

The current prison population in England and Wales has multiple, complex healthcare needs, presenting unique challenges to those caring for prisoners. Prison numbers have increased dramatically in the last 10 years. There are now approximately 84,000 prisoners in England and Wales and 120,000 new episodes of imprisonment each year . The authors all contribute to prison healthcare. Below, we discuss a key issue arising from first-hand experience of prisoners' health and social care needs, the prescription of psycho-active drugs by primary and secondary care practitioners. This is a core medical task, but beset with difficulties. These difficulties are not necessarily encountered in other areas of prison healthcare. However, they do illustrate how providing healthcare to prisoners is complex, often lacking a research base and can have pitfalls that are not obvious to the outsider.

Paying the price: the pressing need for quality, cost, and outcomes data to improve correctional health care for older prisoners

Despite a recent decline in the U.S. prison population, the older prisoner population is growing rapidly. U.S. prisons are constitutionally required to provide health care to prisoners. As the population ages, healthcare costs rise, states are forced to cut spending, and many correctional agencies struggle to meet this legal standard of care. Failure to meet the healthcare needs of older prisoners, who now account for nearly 10% of the prison population, can cause avoidable suffering in a medically vulnerable population and violation of the constitutional mandate for timely access to an appropriate level of care while incarcerated. Older prisoners who cannot access adequate health care in prison also affect community healthcare systems because more than 95% of prisoners are eventually released, many to urban communities where healthcare disparities are common and acute healthcare resources are overused. A lack of uniform quality and cost data has significantly hampered innovations in policy and practice to improve value in correctional health care (achieving desired health outcomes at sustainable costs). With their unique knowledge of complex chronic disease management, experts in geriatrics are positioned to help address the aging crisis in correctional health care. This article delineates the basic health, cost, and outcomes data that geriatricians and gerontologists need to respond to this crisis, identifies gaps in the available data, and anticipates barriers to data collection that, if addressed, could enable clinicians and policy-makers to evaluate and improve the value of geriatric prison health care.

Social and custodial needs of older adults in prison

BACKGROUND

older prisoners are a fast-growing group but there is limited evidence for how well their needs are being met.

OBJECTIVES

to quantify the social and custodial needs of older prisoners and suggest improvements for service provision.

DESIGN

cross-sectional study.

SETTING

twelve prisons holding adult males in North West England.

SUBJECTS

two hundred and sixty-two prisoners; 97 aged between 50 and 59, 165 aged 60 and over.

METHODS

interview and case-note review for issues of social and custodial need and quality of life in prison, including Forensic Camberwell Assessment of Need and Lubben Scale for social networks.

RESULTS

many had problems mixing with younger prisoners, accommodation and activities, and limited contact with friends and family. A small group had personal care needs which were not well managed in prison.

CONCLUSION

older prisoners have distinct social and custodial needs which need to be addressed by a national strategy for their care and management.

Health and social care services for older male adults in prison: the identification of current service provision and piloting of an assessment and care planning model

Background

Older prisoners are the fastest growing subgroup in the English and Welsh prison estate. Existing research highlights that older prisoners have high health and social care needs and that, currently, these needs routinely remain unmet.

Objectives

(1) To explore the needs of men entering and leaving prison; (2) to describe current provision of services, including integration between health and social care services; and (3) to develop and pilot an intervention for identifying health and social care needs on reception into prison, ensuring that these are systematically addressed during custody.

Methods

The research programme was a mixed-methods study comprising four parts: (1) a study of all prisons in England and Wales housing older adult men, establishing current availability and degree of integration between health and social care services through a national survey and qualitative interviews; (2) establishing the health and social care needs of older men entering prison, including experiences of reception into custody, through structured (n = 100) and semistructured (n = 27) interviews; (3) the development and implementation of an intervention to identify and manage the health, social care and custodial needs of older men entering prison; and (4) exploration of the health and social care needs of older men released from prison into the community through qualitative interviews with older prisoners prior to and following discharge from prison. Descriptive statistics were produced for all quantitative data, and qualitative data were analysed using the constant comparison method.

Results

The number of older prisoner leads has increased in recent years but they do not all appear always to be active in their roles, nor in receipt of specialist training. Nearly half (44%) of establishments do not have an older prisoner policy. There is a lack of integration between health and social care services because of ambiguity regarding responsibility for older prisoners' social care. The responsible social service may be located a considerable distance from where the prisoner is held; in such instances, local social services do not co-ordinate their care. The most frequent unmet need on prison entry was the provision of information about care and treatment. Release planning for older prisoners was frequently non-existent.

Limitations

The study used a cut-off age of 60 years as the lower limit for the definition of an older prisoner; evidence has emerged that supports a redefinition of that cut-off to 50 years. Our study examined the care provided for men and this should be considered if contemplating using the Older prisoner Health and Social Care Assessment and Plan (OHSCAP) with older women in prison.

Conclusion

The OHSCAP, developed as part of this study, provided a feasible and acceptable means of identifying and systematically addressing older prisoners' health and social care needs. Future work will include the conduct of a randomised controlled trial to examine the impact of the OHSCAP in terms of improving a range of outcomes, including economic impact.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The case for human agency, well-being, and community reintegration for people aging in prison: a statewide case analysis

This study profiled 2,913 adults aged 50 and older sentenced to a statewide correctional system and their parole eligibility status with implications for community reintegration, resettlement, and recovery needs. The research team developed the Correctional Tracking Data Extraction Tool to gather official data and personal and legal characteristics from a state department of corrections website. The majority of older prisoners were men from racial/ethnic minorities between the ages of 50 and 59 with a range of minor to serious offenses. Time served in prison ranged from 1 month to 45 years; more than 40% were eligible for parole within 5 years. These findings underscore the need for an intervention that can address the differing typologies and individual-level and systemic issues that gave rise to the aging prisoner population. Promising practices that address elements of a conceptual model in prison and community reintegration and recovery for older adult prisoners are reviewed.

The health and social needs of older male prisoners

OBJECTIVES

This study aimed to quantify the health and social needs of older male prisoners in the North West of England, to determine whether their needs were being met, and to explore an age cut-off for this group.

METHODS

Data were collected by interview and case note review. Areas covered included physical health, mental health, personality disorder, cognitive impairment and social need.

RESULTS

A total of 262 prisoners were included in the study. Over 90% had a physical health disorder, most commonly hypertension and osteoarthritis. A total of 61% had a mental disorder, most commonly major depressive disorder and alcohol misuse disorder. There were few differences within age bands for physical health problem or health/social need, but those aged 50-59 years had more mental disorder, including mental illness, substance misuse disorder and personality disorder.

CONCLUSIONS

Older prisoners have a high level of health need and a different profile to the rest of the prison population. Fifty appears to be a useful age over which to define this group, and service provision should reflect this in a national management strategy.