**5.4. Case study (international initiatives)**

Correctional healthcare services are responsible for the provision of care to prisoners and are the key personnel to support those with cognitive impairment and dementia [62]. The increase in the numbers of older prisoners, and their higher incidence of chronic disease and disability, are challenging and place a burden on correctional healthcare service providers who are generally not educated in aged care [40]. Therefore, where there are prisoners with multiple comorbidities, and especially for prisoners with mental health or cognitive impairment such as dementia and who have a reduced capacity to articulate their health problems, this can lead to under diagnosis of conditions/illness.. This is compounded by the key system issue of the regime in the correctional setting. Furthermore, as these regimes have not been developed with consideration of older prisoners with frailer and poorer health, many conditions and illnesses go unrecognised. More recently, overcrowding within correctional settings has compounded the complexities in delivering best practice healthcare, service provision

Correctional healthcare services have a strong focus on acute healthcare issues rather than long term preventive measures [33]. In fact, correctional healthcare services are in an optimal position to deliver primary healthcare services that can be a disease prevention and health promotion service that is equivalent to that received on the outside [9]. If this style of healthcare is delivered within the correctional setting not only will it reduce the impact on communities once prisoners have been released, it will also provide optimal care within the national

It has been identified that prisoner's healthcare needs can be complex, and many are too extensive for prison healthcare services to manage [33]. In Australia, this leads to the health system performance in the correctional setting not meeting the requirements of the National Health Performance Framework [54]. This causes inequity across the range of patient care needs because the service provided within the correctional environment is vastly different to

Correctional facilities were not designed for prisoners who are dependent on others for care, creating challenges for correctional healthcare services in identifying and supporting those with cognitive impairment and dementia [63]. This leads to incidences where care needs have gone unrecognised and health needs have been unmet [63]. There is very little information in the literature about early screening, identification and support of prisoners with cognitive impairments or dementia, and as a consequence there is little evidence to direct practice

Effective healthcare provision in the correctional environment can be obstructed due to the routine of the prison, correctional staff unavailability, time constraints and demands from prisoners [62]. There are barriers for nurses to develop therapeutic relationships with those they are caring for due to correctional requirements and the physical environment which can affect nurse-patient relationship building [64]. Correctional health clinic attendance is dependent on prisoners being able to attend, and this can be restricted by correctional services procedures and constraints [34, 62]. This creates a competition between the custody aspects of the correctional environment and the caring aspects, at times providing barriers to care and limiting nurse's autonomy [64]. A key point from the World Health Organisation

health performance framework and provide equivalent care to the community [9, 54].

and diagnosis of people with cognitive impairment [19].

that in the general community [18, 54].

130 Cognitive Disorders

around this vulnerable group in the correctional setting.

California Men's Colony (CMC) provides an environment with areas specifically for those inmates with moderate to severe dementia and provides tailored programs for those with cognitive impairment [7]. This prison identified that there was a need to assist prisoners with severe cognitive impairment in order to reduce the incidence of victimisation and meet the needs of this group of prisoners [10]. The outcome of these programs has provided evidence that there is an improvement in social skills, attention levels and depression [7]. They also have a program where they buddy a prisoner without dementia with one that has dementia [7]. The prisoner buddies need to have a record of good behaviour, and receive training from the Alzheimer's Association so they can provide care for those with dementia and protect them from victimisation and bullying [7, 10].

Onomichi prison has a ward for older prisoners which provides nutritional support, and they changed the requirement that prisoners march in formation so that it wasn't as strict as other areas in the prison [65]. This environment was designed for prisoners who are not very mobile, with ramps and hand rails being provided instead of stairs, and they have customised their wash rooms to accommodate the less mobile [7].

Framework by addressing Health System Performance to provide improved 'effectiveness, safety, responsiveness, continuity of care, accessibility, efficiency and sustainability' [54].

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

http://dx.doi.org/10.5772/intechopen.73161

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Best practice management recognises early identification of dementia as being important, and also specific training in dementia care and support for correctional staff [10]. It is suggested that dementia training should incorporate information on helping staff to understand what dementia is and signs of its development, as well as how it can impact the person with dementia and those they are living with [10]. If staff are adequately informed and trained this could lead to early identification of the person with dementia, which can ultimately lead to early interventions and support being provided [10]. Feczko [5] supports this by acknowledging that correctional staff need to be trained in identifying the early stages of dementia, and how to recognise a prisoner's inability to undertake basic tasks rather than staff focusing on behaviour problems. It has also been identified that correctional officers need education and training to help them understand that if a prisoner is not following an order or direction it may not mean they are deliberately being disobedient, rather it may be due to their deteriorating cognitive abilities through the dementia process [52]. Prison health staff are not trained in aged care or early identification and care support for those with cognitive impairment and dementia, therefore specific training will assist those predominantly responsible for prisoner

The other aspect of training and support for correctional and healthcare staff is to ensure those working closely with people who have dementia are provided regular debrief sessions to safeguard their own wellbeing [10]. This will then link into the World Health Organisation prison health guide where health promotion and management is needed for correctional staff to reduce stress and to maintain the workforce [66]. Developing resources for health promotion should not only encompass prisoner care, it should also develop a partnership to provide for staff across the facility [66]. There can be high sick leave in some correctional settings and if staff members feel that they have a health promotion service available to them through work this could lead to them feeling more fulfilled in their employment and therefore lead to

Other strategies to improve workforce capacity within the correctional setting are modifications or adaptions in the correctional environment which can help to avoid disruptive or unacceptable behaviour from a person with dementia. Meanwhile, if prisoner behaviour becomes easier to manage, the staff will have a reduced burden within their work shifts [10]. This modification could be as simple as a process change to provide carers within corrections by training selected prisoners to be support people for the prisoner with dementia [10].

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

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

health to care for this vulnerable group [32].

reduced sick days [66].

Fishkill Correctional facility in New York provides a unit for inmates who have been identified with cognitive impairment, and once admitted to the unit, there is a policy of regular assessment [7]. Apart from the commonly used assessment tools for cognitive impairment they also use 'Early Warning Signs' and 'Dementia Symptoms and Behaviour Triggers' [7]. All staff working in this facility are chosen from a pool of people who want to work there rather than being allocated to this facility, and they all must complete a 40-hour program of training developed and delivered by the Alzheimer's Association [7, 10].

Long Bay Correctional Complex in Sydney provides a program that collaborates with agencies specialising in dementia care to deliver better services to prisoners with dementia and cognitive impairment [10]. Some of these are the provision of access to allied health professionals who specialise in areas of need for these prisoners, long term supported care in the hospital facility, an aged-care offender's area of independent living that is separate to the mainstream prison with support from disability services [10]. A program is being developed to support appropriate aged care placement within the correctional setting, and collaboration on the development of processes for identification and assessment of prisoners with dementia as well as their management [10].

The state of Texas in the United States of America has geriatric units that have been designed for prisoners who are 60 years and older to provide more support for these prisoners with the activities of daily living [18]. They also have a geriatric unit for prisoners that is higher level and arranges access for the prisoners in this unit to specialist services for their higher acuity health needs such as dialysis and physiotherapy [18].
