**4.1. Individual (national framework and health status)**

A high proportion of those people who enter the correctional environment are from disadvantaged and/or minority groups in society, with the majority of the marginalised being well represented and generally from a particular socioeconomic quintile [35]. Those people who become involved in the criminal justice system have a higher incidence of health problems, such as untreated chronic conditions and mental illness, than the general population [35, 36]. It is well documented that people from low socioeconomic lifestyles have a high incidence of unhealthy behaviours such as alcohol and substance misuse, smoking, poor nutrition and living conditions and they rarely visit healthcare services [35, 37]. Health conditions such as mental illness and some unhealthy choices and behaviours, for example alcohol and illicit substance misuse place people at greater risk of arrest and once they are incarcerated, they sometimes enter an overcrowded and at times violent environment [36]. These lifestyle factors prior to incarceration and then within the correctional environment creates negative effects on the mental health of the prisoners due to overcrowding, isolation, lack of mental stimulation, lack of privacy, and separation from family or supports, which in turn puts prisoners at greater risk of developing dementia [17, 35].

Prisoners who have early stages of dementia are treated the same as the rest of the inmates within the correctional environment which causes additional problems. For example, a person with dementia is unable to follow simple instructions or directions from correctional staff which can result in or to lead punishment for non-compliance [31]. This subsequently increases the prisoner's confusion, leading to an exacerbation of the dementia symptoms and processes [5, 31]. It was also identified that the dementia process could cause confusion for a prisoner around social standards or customs in the correctional setting.

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

Due to the structured routine of life in a correctional facility, a person with dementia may not be identified early or easily and the routines in the correctional setting can mask the signs and symptoms of dementia [10, 18]. Prisoners are not expected to coordinate their daily routine or act independently and the inability to do this, because of the dementia process, may not be recognised [10]. They may therefore not be identified as having any cognitive impairment until their behaviour begins to clash with expectations of the correctional environment [10]. Not being identified as having dementia until the late stages means that strategies or treatment cannot be put in place during the early stages to slow or relieve symptoms [10]. As the disease progresses the older prisoner will develop problems following instructions which could lead to punishment which will in turn further impact on their health [10]. As the process of the disease advances the affected person will also develop problems with being able to socialise with others and undertaking general activities of daily living such as performing hygiene needs [10]. The inability to understand and perform general tasks could also lead to being reprimanded or punished and therefore will adversely impact on the physical and mental health of the person [10]. Failure to identify cognitive impairment and dementia in prisoners could lead to such adverse outcomes as victimisation, the inability to conform to complex instructions, and poor judgement resulting in disciplinary actions [30, 32]. This is further supported by other authors who state this lack in understanding may lead to the older prisoner with dementia becoming vulnerable to abuse and bullying from younger prisoners [18, 38]. If the correctional environment is not designed for prisoners with cognitive impairment and dementia, they will find it takes a greater effort to navigate their way around it, and they will be at greater risk of confusion and becoming lost in their surroundings [42–44]. This suggests the reduced independence caused by confusion has an impact on the person's sense of identity and can lead to an exacerbation of the progress of dementia [42–44]. Those with dementia have been identified as 'among the most marginalised, socially excluded and highly stigmatised groups in society' [42] (p. 188). Prisoners are a marginalised and socially excluded group because they are placed in an environment which has been developed to disempower, control

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

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

and put the prisoner in a submissive position [33].

**4.3. Case studies (globally)**

prisoners.
