**4.2. Correctional setting**

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 setting [40].

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

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

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 the population is sub-optimal [30].

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