The NYSPA Report: The Mentally Ill Elderly in Prison: A Behavioral Health Crisis

A recent editorial in the New York Times titled: “Nursing Homes Behind Bars” notes that “after declining for three years in a row, the nation’s stubbornly huge prison population has crept back up again” and “aging inmates make up the largest and fastest-growing segment of the American prison population.” “It is no surprise” the editorial stated, “that a nation addicted to imprisonment is quickly approaching a crisis of elderly inmates.”

However, it is very disappointing that there is not even a mention, in this lengthy editorial, of elderly inmates with mental illness.

Nor is it acknowledged that many of these mentally ill elderly adults had been hit with the “one/two punches” of “deinstitutionalization” followed by “transinstitutionalization” i.e., they were kicked out of Psychiatric Hospitals and ended up in Prisons.

So, to make this less abstract and more personal try to imagine yourself as an inmate in a prison – “doing time.” The boredom, the gruesome surroundings, the claustrophobia causing bare walls and iron bars, the clang of the gates. But then try to imagine what it would be like if you were elderly and mentally ill.

It sounds terrible, but in truth, for older persons with mental illness in the criminal justice system – that is in jails or prisons or under arrest or on probation or parole, these times are both the worst of times but also the best of times.

The “worst of times” hardly needs elaborating: the overcrowding, the violence, the gangs, the victimization, the isolation and the inadequate behavioral health care and treatment.

But what is meant by the “best of times?” It is that these are times of many dramatic reforms. In recent years, (often because of the advocacy and hard work of good and concerned people) there are significant reforms at the “front door” and the “back door” of our prison system. At the “front door” there are many types of “diversion” programs, and mental health courts are being rapidly established all over the country. These efforts may keep a particular defendant out of the correctional system entirely. And, at the “back door’ there are increasingly effective programs for “reentry” which at best may provide the inmate being released with housing, work, behavioral health treatment and benefits such as Medicaid.

But for those still in prison, The American Psychiatric Association’s publication “Psychiatric Services in Jails and Prisons” assets very strongly that “effective provision of access to mental health services for older inmates in jails or prisons requires recognition of a variety of special challenges facing both inmates and mental health professionals.”

And, parenthetically, few know that The National Institute of Corrections states that it may be useful to consider an inmate who is over the age of 50 as statistically more likely to have more common problems of “aging” even though the standard in the community is usually 65. This relatively “young” definition for the geriatric inmate population arguably may be supported by the relatively high “biological age” of such an inmate due to substance abuse including smoking, poor nutrition, lack of prior care, and generally a lower socioeconomic life in the community. And, the number of inmates over age 50 is increasing rapidly. (The number of prisoners in the United States age 50 and older has increased 330 percent in the past ten years.)

It is well known that elderly inmates have special medical needs that may present with behavioral health symptoms that will complicate interventions in various ways: the housing for the inmate, the structure of programming, the relevance of counseling, even the choice of medication. And these problems are not only more likely to be expensive, chronic, permanent and progressive but may also present the possibility of dying in custody.

But most older inmates face serious psycho-social concerns that include estrangement from or lack of connection to other inmates in the general population, given the relatively small (though increasing) percentage of older inmates; physical vulnerability to more serious consequences of assault and a greater possibility of dying during incarceration.

Older inmates suffer a higher incidence of loss of external supports, e.g., spouse, parents, friends, and other external supports which leads to a profound sense of isolation. The sense of isolation may be expressed in a variety of ways, and when extreme, may exacerbate or create mental illness or psychiatric crises and result in a higher rate of completed suicide.

Other issues related to isolation are the concerns about acceptance after release from prison, providing for food, shelter, and clothing after release, assault and potential greater sequelae of injury, and isolation from older “free” relatives and friends who themselves may be unable to travel to visit, etc. Some of these issues may benefit from mental health intervention, including group or peer counseling.

As for the older inmates with terminal Illnesses “dying with dignity” is more difficult to achieve in a prison. Caring for inmates with terminal illnesses may need to involve the use of a “hospice” inside the prison. Training and written policies must be developed to address the in-custody hospice dying inmate-patient, because a hospice inmate-patient may change in his or her ability to function physically and mentally, and may become less oriented and behave more inappropriately as the disease and deterioration progress. It is worth noting that some facilities use inmate volunteers in such hospices who are familiar with basic health issues such as universal precautions, and mobility management. t has been reported that this innovation may reduce the dying inmate-patient’s (or his or her family’s) perception that “the prison isn’t doing enough.”

Finally, another approach is “compassionate release” which in addition to being, in selected, appropriate cases, the most suitable alternative, has a number of advantages, including cost-savings for the prison health care system itself.

For those who would like more detailed information about and discussion of this Behavioral Health Crisis, there are a number of publications that address these complicated and difficult issues. I have found the most thorough and up to date to be the 2012 book “Old Behind Bars: The Aging Prison Population in the United States.

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