**4.3. Case studies (globally)**

Baldwin and Leete [31] acknowledge that a person with dementia in the correctional setting is vulnerable to abuse and bullying from other prisoners. Cognitive impairment is an early identifier for dementia, and failure to identify cognitive impairment early in prisoners could lead to adverse health outcomes including victimisation, the inability to conform with complex instructions, and poor judgement resulting in disciplinary actions [30, 32]. This is supported by other studies which acknowledge that older prisoners who have dementia are at a greater

Prisons exist for three reasons; to provide safety for the community by removing someone who has demonstrated criminal activity from society, as a form of punishment for these activities and lastly for rehabilitation prior to returning to the community [39]. Prisons therefore have not been developed for a person's healthcare, or for management of the declining cognitive function which occurs with dementia [39, 40]. This leaves the older prisoner with cognitive impairment and dementia vulnerable to poorer health outcomes in a correctional

Prisons have not been designed to accommodate older or infirm prisoners, therefore inflicting further punishment if the prisoner is unable to navigate the facility due to cognitive impairment or dementia [30, 31, 41]. Older prisoners are not able to easily access bathroom facilities, climb up to top bunks or attend some exercise sessions [31, 41]. Equipment to support the older, frail prisoner is not generally available in this setting and activities are not structured for the older person with reduced cognitive or physical abilities [18, 41]. The inflexible environment of the correctional setting could also intensify the loss of independence and functional ability of the older prisoner [41]. The older prisoner may present with multiple and complex healthcare needs, which are difficult to manage in an unprepared setting [41]. Prisoners are at increased risk of developing depression which can be exacerbated by the lack

In Australian prisons, the rate of older prisoners is increasing faster than the same age in the general population, and there has been a substantial increase in the number of older prisoners in the correctional system during the decade between 2000 and 2010 [10, 25]. This increase in the number of older prisoners has been identified across the world [27]. For example, England and Wales report a 74% increase in older prisoners in the past decade and the United States

United States citizens 65 years and older who have dementia represent about 13% of the general population, and the prisoner representation can be as high as 44% [30]. In the United Kingdom a survey on prison inmates provided evidence that 15% of those surveyed exhibited signs of cognitive impairment that had not been previously identified. These findings were then used as an indication that there could be many unrecognised instances of dementia in prisons [31]. In the United States there are prisoners with dementia who have been neglected, due to being incarcerated in facilities where medical and mental health care for this group of

risk of becoming victims of violence, bullying and victimisation [5, 38].

of stimulation and distance from family and support networks [31].

reports the number has tripled in the same time period [7].

the population is sub-optimal [30].

**4.2. Correctional setting**

setting [40].

124 Cognitive Disorders

There is minimal research around dementia screening and management in the correctional environment, however some prisons have implemented or are developing processes for older prisoners.

Fishkill, in New York (United States of America) has created a dementia specific unit to provide accommodation for dementia prisoners from the state's prisons, which is attached to the prison's medical centre [10, 25]. Staff are required to attend 40 hours of training, designed by the Alzheimer's Association, to assist them in working with prisoners in this unit [10]. The supposition is that dementia-specific staff training provides a way to create knowledgeable staff and reduce the occurrence of confusion or anxiety in prisoners with dementia [10].

The California Men's Colony (Unites States of America) was developed for any prisoner with a severe cognitive impairment to reduce the incidence of victimisation, and meet the needs of this group of prisoners [10]. Prisoners need to meet special requirements for entry into this facility, with dementia being one of the requirements [10]. The facility offers a 'Special Needs Program for Inmate-Patients with Dementia (SNPID)' which supports prisoners by modifying either their social or physical environment [10, 45]. This program includes the use of specially selected prisoners to provide support to the prisoner with dementia and ultimately improving their quality of life [10, 45].

**5. Healthcare in correctional settings**

into society [31].

vices [48, 49].

needs cannot be met, in prison [31].

**5.1. Prisoners access to healthcare is a human right**

The question has been raised about whether it is appropriate to continue to hold someone in prison if they no longer remember their criminal act due to dementia [47]. Dementia can contribute to a prisoner having no knowledge about his/her wrong doing and the loss of the ability to understand this [31]. There is also the situation where a prisoner was initially aware of their guilt when admitted to the correctional facility, however in time they no longer have an understanding of this or their surroundings [31]. In all of these situations there is no opportunity for rehabilitation, which is the main reason for incarceration prior to release back

Re-Framing and Re-Thinking Dementia in the Correctional Setting

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Compassionate release from prison revolves around four different points: 'the chance of recidivism, the rights of the victim, the costs involved in continued incarceration versus the cost of external healthcare, and the continued welfare of the prisoner with dementia' [31]. This raised the question of the ethics of keeping a prisoner, whose psychological and physical

Older prisoners are more costly as they require resources that are more expensive compared to prisoners who are younger and generally healthier [48]. One of the increased resources needed is increased healthcare generally due to a lack of healthcare throughout their lives [48]. Older prisoners have a higher incidence of physical and mental health issues than those in the community who are the same age and therefore need ready access to healthcare ser-

Prisons were initially designed for young people, with narrow staircases and cement buildings and floors which can be harsh on old bodies [50]. Prison healthcare systems were initially designed for young and healthy men, therefore older females and males from marginalised backgrounds and/or minority groups, who have higher incidences of chronic conditions, have

Many older prisoners have chronic medical conditions. Approximately 95% of prisoners will eventually be released back into society, therefore proper management of these conditions in the correctional setting will reduce the costs and the impact on communities when prisoners are released [32]. Even though being incarcerated could be the optimal time to identify and mange health problems, this is not occurring adequately or consistently across correctional facilities internationally [49]. The guidelines of many countries state that healthcare provision to prisoners should be to the same standard as the general population, however this has not

As the correctional population is becoming older, increasingly release is through death, and therefore there is a growing need for end of life options in this environment, making it difficult for correctional services to meet the special needs of the ageing population while remaining humane [52]. In some countries there is a movement toward penal harm which means that disciplinary measures, which extend to the healthcare clinic, are the focus in correctional

different healthcare needs which can challenge the traditional models of care [51].

occurred in many prison healthcare services, with frequent lapses in care [19, 49].

Training of prisoners to become carers has been used as a strategy in Queensland (Australia) by providing Carers Certificate 2 training to selected prisoners to assist with older prisoner care [46]. This provides extended care for the prisoner with cognitive impairment when needed, while also providing the prisoner carer with a potential career on discharge from prison [46]. These carers work under the direction of a registered nurse to ensure safe and quality healthcare is provided.

Long Bay Correctional Complex in Sydney (Australia) is developing access to allied health professionals who specialise in areas of need for prisoners with dementia [10]. They will provide long term supported care in the correctional health service, which will include an '…aged-care offender's independent living in segregation from the mainstream prison, with support from a disability service…' [10] (p. 15).

#### **4.4. Community settings**

There have been various strategies for early identification and support for people in the general community with cognitive impairment and dementia for some time, however this has not translated into the prison setting. Specialised tools are used in the community to assess a person's functional abilities as these skills are the first ones affected by cognitive impairment and dementia [5]. Two of the community tools are 'activities of daily living' (ADLs) and 'instrumental activities of daily living' (IADLs). A person in a correctional environment would not be responsible for developing or using these skills so an alternative tool has been developed in the United States of America called 'prison activities of daily living' (PADLs) [5]. Although this tool has been identified by a couple of authors it does not appear to have been picked up in other countries. Each country and each correctional facility will have slightly different processes and these could be used to modify the PADLs to suit their specific facility.

In Australia, 'The National Framework for Action on Dementia', which aimed to make dementia a national priority, was developed to support communities to provide assistance to carers and those in the community with dementia [23]. A national framework for action was agreed upon by Australian Health Ministers and this framework listed five priority areas [3]. These priority action areas were: 'care and support services, access and equality, information and education, research and workforce and training strategies' [3]. Even though this was developed for the general Australian population, the correctional setting is yet to follow these recommendations [10]. In England a national dementia strategy was developed to provide support for early diagnosis and intervention, and Scotland developed a dementia strategy to achieve similar outcomes [23]. In the United States of America preventing and reducing dementia has been identified as a 'national public health priority' [30].
