**6.2. Re-framing of practice to improve quality of life for prisoners**

The development of policies and procedures for health checks, screening and assessment on admission and at regular intervals, along with the use of risk reduction program such as 'Your Brain Matters', will help in supporting and educating healthcare staff to provide quality care to prisoners that matches services provided in the community [1]. The World Health Organisation guide for prison health provides advice around the need for development of health policies in prisons which are integrated into the health policy of the nation [22]. The development of these policies and procedures will provide staff with resources to support decision making around dementia in prisoners and present a structure for initial screening and regular follow up to ensure those with cognitive impairment and dementia do not miss out on early interventions to improve the progress of their health and outcomes. This is supported by Hayton in the World Health Organisation guide for prison health, where it is stated that there need to be regular assessments and screening with prevention strategies and health promotion included [67].

potentially prisoners with cognitive impairment and dementia, strengthens the workforce by ensuring they have the capacity to work safely in this environment with minimal stress.

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There may be the need to redevelop areas of the correctional environment to accommodate older and infirm prisoners. This may mean that organisations need to modify environments in areas where dementia prisoners, those at risk of dementia or cognitive impairment are housed to reduce poor behaviours as well as poor outcomes. If the facility is of a substantial age then modification could be difficult therefore simple actions would be around clear signs and directions, which could assist the prisoner with dementia in identifying their specific cell, where to go for meals and hygiene needs. It may also mean these prisoners are housed in an area with no or minimal stairs and that bunk beds are not used as the old, infirm prisoner who

The World Health Organisation (WHO) was the first to discuss the promotion of health in prisons, for not just prisoners but for correctional and healthcare staff as well [13]. Their 'Health in prisons' publication, developed as a guide to prison health, that there needs to be a focus on 'health promotion' and 'health protection' which can be successful within the correctional environment [13]. The guide provides recommendations on how to develop a healthier correctional environment for both prisoners, staff and the environment which will also reduce the amount of harm in these settings [13]. The guide explains the fundamental steps that need to be included when developing health and health promotion in prisons [13, 68]. It states that all staff need to be involved from senior management down, and to make it sustainable there need to be links between the correctional healthcare service and healthcare in the community [13, 68]. This will then ensure that all interested parties are involved in the process, including prisoners, community healthcare in the local vicinity, politicians, staff and management [13, 68]. There needs to be a shift in perception around corrections and health so that creating

a healthy prison is supporting the public not just those that are incarcerated [68].

the World Health Organisation to guide and direct health internationally [57, 58].

Being able to create a healthy correctional environment using the whole prison approach is not always clear and can be quite difficult in areas that are resource-poor [68]. For example low and middle income countries may not have the resources to manage change in the correctional environment using a whole prison approach to develop health promoting prisons. There are many models for health promotion but there are few publications that provide direction to prison staff and administrators around this process [68]. One model that has been designed to guide correctional organisations in developing healthy prisons is the TECH model. This model was designed following the World Health Organisation guide for health in prisons [13, 68]. The TECH model is described as a way to improve health in any country no matter the level of resources they have and is about health promoting approaches using four domains that move across long term chronic care to short term acute care [68]. The TECH model uses the World Health Organisation guide for prison health as a foundation in its development, and it also meets the requirements of the Primary Health Care principles within the 'Declaration of Alma-Ata' and the Ottawa Charter for Health Promotion with both documents developed by

will have difficulty climbing up onto them.

**6.3. Developing a healthy prisons approach**

Policies and procedures can be developed to identify the specific age group where these screenings should begin and the staff member responsible for the identification. For example the correctional officer may identify that a specific prisoner who did not raise any flags in their admission screen is demonstrating behaviour that may show the early development of cognitive impairment. This correctional officer would then arrange for a referral to the nurses at the health clinic who could undertake a more comprehensive assessment, and then if the prisoner meet certain requirements as per the policy and procedure, they are referred to a geriatrician or medical practitioner who can provide a diagnosis. Once a diagnosis has been made, strategies developed with an individual plan of care for the prisoner to ensure the remainder of their time behind bars is managed in a safe manner free from victimisation.

Cashin et al. [41] states that another option is to develop a facility within a prison that simulates a hostel environment which provides housing for the aged prisoner in a more cost effective environment. These facilities should be developed to be similar to the community aged care centre and use trained younger inmates as care assistants, therefore reducing the staffing costs [41]. These carers would receive formal aged care training which can lead to a formal qualification for use once released from prison [41]. These trained carers would be supervised by qualified healthcare professionals who can observe the standard of care they provide as well as their level of skill development [41]. This provides the older prisoner with personalised care not previously available in a general prison, as well as providing the care assistant with a role within the prison that can translate to employment once released [41].

The older offender who has dementia may not be able to stand trial. However if their crime has been serious or involved violence they need to be placed under supervision in a facility that can accommodate their diminished mental capacity, to protect other prisoners and wider community [38]. It is recommended a secure unit be provided for the older adult with dementia to provide security and appropriate healthcare without the physical restraints imposed in the acute care setting, therefore not compromising safety and providing a comfortable environment [38]. This environment needs to be staffed by people trained in the care of these prisoners and how to address any incidents which may arise [38].

Another strategy is to collaborate with specialists in the field of aged and dementia care for support and education program development (for example Alzheimer's Association, geriatricians, physiotherapists, occupational therapists, carer supports and training). These specialists can help to develop the polices for identification and support for both the prisoners and staff as well as specific staff training programs to skill them in aged and dementia care. Dementia specific training provided to all staff working in the correctional environment where there are potentially prisoners with cognitive impairment and dementia, strengthens the workforce by ensuring they have the capacity to work safely in this environment with minimal stress.

There may be the need to redevelop areas of the correctional environment to accommodate older and infirm prisoners. This may mean that organisations need to modify environments in areas where dementia prisoners, those at risk of dementia or cognitive impairment are housed to reduce poor behaviours as well as poor outcomes. If the facility is of a substantial age then modification could be difficult therefore simple actions would be around clear signs and directions, which could assist the prisoner with dementia in identifying their specific cell, where to go for meals and hygiene needs. It may also mean these prisoners are housed in an area with no or minimal stairs and that bunk beds are not used as the old, infirm prisoner who will have difficulty climbing up onto them.

#### **6.3. Developing a healthy prisons approach**

health policies in prisons which are integrated into the health policy of the nation [22]. The development of these policies and procedures will provide staff with resources to support decision making around dementia in prisoners and present a structure for initial screening and regular follow up to ensure those with cognitive impairment and dementia do not miss out on early interventions to improve the progress of their health and outcomes. This is supported by Hayton in the World Health Organisation guide for prison health, where it is stated that there need to be regular assessments and screening with prevention strategies and health

Policies and procedures can be developed to identify the specific age group where these screenings should begin and the staff member responsible for the identification. For example the correctional officer may identify that a specific prisoner who did not raise any flags in their admission screen is demonstrating behaviour that may show the early development of cognitive impairment. This correctional officer would then arrange for a referral to the nurses at the health clinic who could undertake a more comprehensive assessment, and then if the prisoner meet certain requirements as per the policy and procedure, they are referred to a geriatrician or medical practitioner who can provide a diagnosis. Once a diagnosis has been made, strategies developed with an individual plan of care for the prisoner to ensure the remainder of

Cashin et al. [41] states that another option is to develop a facility within a prison that simulates a hostel environment which provides housing for the aged prisoner in a more cost effective environment. These facilities should be developed to be similar to the community aged care centre and use trained younger inmates as care assistants, therefore reducing the staffing costs [41]. These carers would receive formal aged care training which can lead to a formal qualification for use once released from prison [41]. These trained carers would be supervised by qualified healthcare professionals who can observe the standard of care they provide as well as their level of skill development [41]. This provides the older prisoner with personalised care not previously available in a general prison, as well as providing the care assistant

The older offender who has dementia may not be able to stand trial. However if their crime has been serious or involved violence they need to be placed under supervision in a facility that can accommodate their diminished mental capacity, to protect other prisoners and wider community [38]. It is recommended a secure unit be provided for the older adult with dementia to provide security and appropriate healthcare without the physical restraints imposed in the acute care setting, therefore not compromising safety and providing a comfortable environment [38]. This environment needs to be staffed by people trained in the care of these

Another strategy is to collaborate with specialists in the field of aged and dementia care for support and education program development (for example Alzheimer's Association, geriatricians, physiotherapists, occupational therapists, carer supports and training). These specialists can help to develop the polices for identification and support for both the prisoners and staff as well as specific staff training programs to skill them in aged and dementia care. Dementia specific training provided to all staff working in the correctional environment where there are

their time behind bars is managed in a safe manner free from victimisation.

with a role within the prison that can translate to employment once released [41].

prisoners and how to address any incidents which may arise [38].

promotion included [67].

134 Cognitive Disorders

The World Health Organisation (WHO) was the first to discuss the promotion of health in prisons, for not just prisoners but for correctional and healthcare staff as well [13]. Their 'Health in prisons' publication, developed as a guide to prison health, that there needs to be a focus on 'health promotion' and 'health protection' which can be successful within the correctional environment [13]. The guide provides recommendations on how to develop a healthier correctional environment for both prisoners, staff and the environment which will also reduce the amount of harm in these settings [13]. The guide explains the fundamental steps that need to be included when developing health and health promotion in prisons [13, 68]. It states that all staff need to be involved from senior management down, and to make it sustainable there need to be links between the correctional healthcare service and healthcare in the community [13, 68]. This will then ensure that all interested parties are involved in the process, including prisoners, community healthcare in the local vicinity, politicians, staff and management [13, 68]. There needs to be a shift in perception around corrections and health so that creating a healthy prison is supporting the public not just those that are incarcerated [68].

Being able to create a healthy correctional environment using the whole prison approach is not always clear and can be quite difficult in areas that are resource-poor [68]. For example low and middle income countries may not have the resources to manage change in the correctional environment using a whole prison approach to develop health promoting prisons. There are many models for health promotion but there are few publications that provide direction to prison staff and administrators around this process [68]. One model that has been designed to guide correctional organisations in developing healthy prisons is the TECH model. This model was designed following the World Health Organisation guide for health in prisons [13, 68]. The TECH model is described as a way to improve health in any country no matter the level of resources they have and is about health promoting approaches using four domains that move across long term chronic care to short term acute care [68]. The TECH model uses the World Health Organisation guide for prison health as a foundation in its development, and it also meets the requirements of the Primary Health Care principles within the 'Declaration of Alma-Ata' and the Ottawa Charter for Health Promotion with both documents developed by the World Health Organisation to guide and direct health internationally [57, 58].

The first of the four domains is 'T: test and treat infectious diseases and provide vaccinations, if available'. This guides prisons to screen and treat for infectious diseases [68]. These infectious diseases include sexually transmitted infections and, diseases contracted as a result of substance abuse which has a high incidence in prison populations [68]. Depending on the location of the correctional facility there may be infectious diseases endemic in the location and therefore identifying and treating would provide optimal outcomes, not only for the facility but also the community the prisoners will eventually be released back into [68]. After this initial identification and treatment, arranging childhood vaccinations where appropriate will provide important cover of some conditions which could be transmitted to visitors, children and correctional staff [68]. Once these two actions have been completed undertaking any further immunisation as part of prevention and age specific for the older population will reduce the opportunity of diseases being spread through the correctional population [68].

conditions does not increase in a closed environment such as a correctional setting [68]. Being in close confines with multiple other prisoners means that if there is an infectious disease present it will move through the prisoner population fairly quickly, making it more costly to treat in the long term [68]. This affect both prisoners and the correctional service officers working with them by putting staff at risk of contracting the infectious disease and potentially taking it home to their families [68]. Management incudes education which should be undertaken regularly for both prisoners and staff [68]. Education for prisoners needs to be conducted regularly to ensure those with short sentences do not miss out on important information about health education that will improve their own and community health outcomes [68]. One option is for peer educators within the prisoner population to educate other prisoners in a culturally appropriate way and who, after release, can become community educators [68]. Peer educators are a cost effective way to ensure interested parties receive the correct and

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

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137

This TECH model of four domains provides information to be used by any correctional facility in any country and is not dependent on being in a higher income country. Each of the four domains explains aspects of health that need to be considered with minimal or no financial impact of the facility. It has been designed to develop a 'healthy prison' using the 'World Health Organisation guide to the essentials in prison health' as the foundation, providing whole prison health for prisoners and staff [13]. Providing education and optimal healthcare services in a correctional setting moves the organisation from just thinking about health in

There are many different suggestions around building a healthy prison, ranging from major structural changes to policy development and procedural changes. A 'whole-prison approach' identifies initiatives in other areas of the community and adapts them to the correctional environment [9]. Some of the other programs that could inform this approach are 'Healthy Hospitals', 'Dementia Friendly Community', 'Healthy Cities/Towns' which all have components that could be adapted to the correctional environment [9]. All these programs have provided development across multiple domains to achieve their health outcomes and therefore the approach should be taken across the entire correctional facility [9]. Health promotion is an important aspect of healthcare in any community and if this direction is used in the correctional setting then diseases and disorders will be identified in a timely manner to allow early treatment, as well as support through to and past release from prison. To ensure this approach is successful there must be development of an assessment process which can incorporate all interested parties to ensure it encompasses all needs [9]. This also means there must be a system in place to manage and develop the change that is required to move the correctional facility from its current practices and systems to working with external stakeholders, for example including community and industry partners, to provide a system wide approach to health care and promotion. This is important as it not only focuses on health promotion for the prisoner but is also inclusive of the health of staff to ensure it is underpinned by the core principles of health promotion [35]. This is a systems approach where responsibility is not exclusively given to the healthcare service within the correctional setting but is shared by

other areas of the system working together to provide a healthy prison [35].

timely education where it is needed [68].

their prison to being a healthy prison [13, 68].

The second domain is 'E: Environmental modification to prevent disease transmission' which includes not only the physical environment but also factors such as insects which may cause the transmission of disease [68]. For this there may need to be a program of spraying the area for insects especially if there are areas of stagnant water which is a good breeding area for insects such as mosquitos [68]. A survey of the physical environment is needed to identify if there is anything present that could be a source of infection transmission such as homemade tattoo equipment [68]. Another consideration would be the provision of condoms, and although management may not want to acknowledge it, consensual or non-consensual sexual activity does occur and providing protection will reduce the transmission of sexually transmitted infections [68]. Another environmental impact on health is the move to banning smoking in correctional facilities which will have a long term impact on health, and improved nutrition can improve health without being too costly [68]. Longer term planning for environmental modification should be considered especially where overcrowding will impact both the physical and mental health of the prisoners [68].

The third domain is 'C: Chronic disease identification and treatment'. Because the ageing population in the correctional setting is increasing so is the incidence of chronic disease [68]. Once chronic diseases are identified their treatment can be reasonably low cost and many can be improved by improving the prisoner's nutrition and increasing opportunities for exercise [68]. Mental health problems in this older group in the prison are also higher than the general community population and can worsen in a correctional setting if not identified or treated in a timely manner [68]. Therefore screening when on admittance and early treatment can reduce the impact on prisoners and improve health outcomes [68]. Once screening has identified health issues then a treatment plan can be developed for the individual targeting the specific needs of the prisoner and therefore reducing the potential of increased costs for unmanaged chronic health conditions [68].

The fourth domain is 'H: Health maintenance and health education'. This domain is about maintenance of the actions taken during the previous domains to develop a healthy prison [68]. Therefore this domain is about continuing to provide screening as well as chronic disease management and ongoing management and treatment of infectious diseases [68]. This continued management is required so the incidence of infectious diseases and chronic health conditions does not increase in a closed environment such as a correctional setting [68]. Being in close confines with multiple other prisoners means that if there is an infectious disease present it will move through the prisoner population fairly quickly, making it more costly to treat in the long term [68]. This affect both prisoners and the correctional service officers working with them by putting staff at risk of contracting the infectious disease and potentially taking it home to their families [68]. Management incudes education which should be undertaken regularly for both prisoners and staff [68]. Education for prisoners needs to be conducted regularly to ensure those with short sentences do not miss out on important information about health education that will improve their own and community health outcomes [68]. One option is for peer educators within the prisoner population to educate other prisoners in a culturally appropriate way and who, after release, can become community educators [68]. Peer educators are a cost effective way to ensure interested parties receive the correct and timely education where it is needed [68].

The first of the four domains is 'T: test and treat infectious diseases and provide vaccinations, if available'. This guides prisons to screen and treat for infectious diseases [68]. These infectious diseases include sexually transmitted infections and, diseases contracted as a result of substance abuse which has a high incidence in prison populations [68]. Depending on the location of the correctional facility there may be infectious diseases endemic in the location and therefore identifying and treating would provide optimal outcomes, not only for the facility but also the community the prisoners will eventually be released back into [68]. After this initial identification and treatment, arranging childhood vaccinations where appropriate will provide important cover of some conditions which could be transmitted to visitors, children and correctional staff [68]. Once these two actions have been completed undertaking any further immunisation as part of prevention and age specific for the older population will reduce the opportunity of diseases being spread through the correctional population [68].

The second domain is 'E: Environmental modification to prevent disease transmission' which includes not only the physical environment but also factors such as insects which may cause the transmission of disease [68]. For this there may need to be a program of spraying the area for insects especially if there are areas of stagnant water which is a good breeding area for insects such as mosquitos [68]. A survey of the physical environment is needed to identify if there is anything present that could be a source of infection transmission such as homemade tattoo equipment [68]. Another consideration would be the provision of condoms, and although management may not want to acknowledge it, consensual or non-consensual sexual activity does occur and providing protection will reduce the transmission of sexually transmitted infections [68]. Another environmental impact on health is the move to banning smoking in correctional facilities which will have a long term impact on health, and improved nutrition can improve health without being too costly [68]. Longer term planning for environmental modification should be considered especially where overcrowding will impact both

The third domain is 'C: Chronic disease identification and treatment'. Because the ageing population in the correctional setting is increasing so is the incidence of chronic disease [68]. Once chronic diseases are identified their treatment can be reasonably low cost and many can be improved by improving the prisoner's nutrition and increasing opportunities for exercise [68]. Mental health problems in this older group in the prison are also higher than the general community population and can worsen in a correctional setting if not identified or treated in a timely manner [68]. Therefore screening when on admittance and early treatment can reduce the impact on prisoners and improve health outcomes [68]. Once screening has identified health issues then a treatment plan can be developed for the individual targeting the specific needs of the prisoner and therefore

reducing the potential of increased costs for unmanaged chronic health conditions [68].

The fourth domain is 'H: Health maintenance and health education'. This domain is about maintenance of the actions taken during the previous domains to develop a healthy prison [68]. Therefore this domain is about continuing to provide screening as well as chronic disease management and ongoing management and treatment of infectious diseases [68]. This continued management is required so the incidence of infectious diseases and chronic health

the physical and mental health of the prisoners [68].

136 Cognitive Disorders

This TECH model of four domains provides information to be used by any correctional facility in any country and is not dependent on being in a higher income country. Each of the four domains explains aspects of health that need to be considered with minimal or no financial impact of the facility. It has been designed to develop a 'healthy prison' using the 'World Health Organisation guide to the essentials in prison health' as the foundation, providing whole prison health for prisoners and staff [13]. Providing education and optimal healthcare services in a correctional setting moves the organisation from just thinking about health in their prison to being a healthy prison [13, 68].

There are many different suggestions around building a healthy prison, ranging from major structural changes to policy development and procedural changes. A 'whole-prison approach' identifies initiatives in other areas of the community and adapts them to the correctional environment [9]. Some of the other programs that could inform this approach are 'Healthy Hospitals', 'Dementia Friendly Community', 'Healthy Cities/Towns' which all have components that could be adapted to the correctional environment [9]. All these programs have provided development across multiple domains to achieve their health outcomes and therefore the approach should be taken across the entire correctional facility [9]. Health promotion is an important aspect of healthcare in any community and if this direction is used in the correctional setting then diseases and disorders will be identified in a timely manner to allow early treatment, as well as support through to and past release from prison. To ensure this approach is successful there must be development of an assessment process which can incorporate all interested parties to ensure it encompasses all needs [9]. This also means there must be a system in place to manage and develop the change that is required to move the correctional facility from its current practices and systems to working with external stakeholders, for example including community and industry partners, to provide a system wide approach to health care and promotion. This is important as it not only focuses on health promotion for the prisoner but is also inclusive of the health of staff to ensure it is underpinned by the core principles of health promotion [35]. This is a systems approach where responsibility is not exclusively given to the healthcare service within the correctional setting but is shared by other areas of the system working together to provide a healthy prison [35].
