No prison demographic is growing as fast as the elderly. Of the 6.7 million people under correctional supervision in 2015 (“more than were enslaved in antebellum America and more than resided in the Gulag Archipelago at the height of Stalin’s misrule,” Adam Gopnik recently pointed out in the New Yorker), over 10 percent were geriatric (55 years or older)—a 400 percent demographic increase since 1993, according to a 2013 report by the Bureau of Justice Statistics. From 2009 to 2014, while the overall prison population shrank by 3 percent, the geriatric prison population doubled. As 1 in 10 state prisoners serve life sentences, this population will only continue to grow.
The trend poses at once a health crisis and an economic crisis. Older prisoners come with a range of complex medical and social demands. Simply walking, eating, and bathing can become complicated undertakings. Though an aging prison population is an inevitable result of harsh sentencing policies combined with an aging population, prisons are often unprepared.
I started to think about aging and ultimately, dying in the criminal justice system.
And yet some of these inmates need critical medical treatment every day. For doctors, prison care often means making more from less. When Brie A. Williams, a geriatrician at the University of California, San Francisco, and an expert in geriatric prison care, began her career, there were only two studies about the needs of older prisoners: “A dated one about older prisoners in a U.S. jail, and one about French prisoners written in French. I thought, it doesn’t look like we know much about the health needs of this growing population.” And so, Williams began amassing a body of medical and sociological data from the ground up.
Williams recently spoke to Nautilus about the distinctive needs of geriatric prisoners, the ambiguous benefits of geriatric prison wards, and her ardent belief that compassionate release is the best solution to the impending geriatric prison crisis.
What is changing in prison geriatric care?
I think the biggest change in the decade plus that I’ve been doing this work is that people are finally talking about this. I cannot tell you how many puzzled looks I’ve gotten when describing my work. The overwhelming response was, “That sounds interesting, but why?” People now have a better sense of what we’ve found in our studies—which is that it costs, on average, four to nine times more to incarcerate an older adult than a young one.
Older adults are the most rapidly growing population in jails and prisons. Because our population is aging, more and more older adults are being arrested. Jails are booking more older adults, so they have to be think about these issues as well. Public defenders are defending them. District attorneys are prosecuting them. Judges are hearing cases about them. The entire criminal justice system is being affected in such a profound way. It’s rare now to have a conversation with any person in any part of the criminal justice system about aging without hearing: “Oh yeah, this is one of the biggest issues that our program is confronting.”
How are enforcement officers adapting?
I’m concerned about police interactions with older adults. My team recently read about one older man who was wandering, and was arrested for being very threatening and disruptive in a building. Long story short, his family told the jail where he was being held that he had a history of dementia. The charges were dropped. He was supposed to be discharged the next morning to a family member. Unfortunately, he was released around 4 o’clock in the morning when no one was there. He wandered, and was killed walking on a highway.
Our communities are having important conversations about mental health and police, but I think that the conversation should expand to include dementia and delirium in older adults. Police are the eyes and ears of the healthcare profession for people with cognitive and mental health problems. We want our police officers to be aware of this issue and knowledgeable about it.
How did you, as a medical professional, decide to focus your efforts on geriatric prisoners?
When I was a medical student, I had a deeply provocative patient experience. A young woman was shackled to her hospital bed. I did her entire medical history without realizing she was shackled until the very end. The single most important health question that was underlying her health, her health care, and her access to healthcare, I didn’t even know until the physical examination. I realized then how ill equipped I was.
Later, during my residency at San Francisco General Hospital, I saw a patient, an older man who had been transferred from the San Francisco County Jail with a very serious medical condition. He had a pericardial tamponade, basically fluid in the casing surrounding his heart, and he was unable to breathe. We performed an emergency medical procedure and saved him, for the time being.
The next day he was assigned to me as my patient. So began two months, really, of taking care of him. I was one of two people who saw him everyday. I got to know him and his story, and began to understand how such an older man was in jail—what behavioral and social health factors has led him to that life. And I started to think about aging and ultimately, dying in the criminal justice system. I think nobody really anticipated the degree to which mass incarceration would create this extremely high-risk, high-need aging population in the criminal justice system.
We began the process of learning how to petition for an early release for him. We reunited him with his very elderly mother, who had not seen him in decades. It was a very meaningful experience. Later, I was invited to participate in a state-wide project to assess the health and healthcare needs of older prisoners across the state of California. I got to visit 11 or 12 of the 30-odd prisons in California and that launched my career.
What did you see in those prisons?
At that time at least, prison was a very difficult place to grow old. California prisons were horribly overcrowded, and people were living in triple bunks. There were some people in their sixth and seventh decades living in the middle or top of a three bunk living arrangement in a room of 200 men and two officers.
None of our training [as medical professionals] prepares us for this environment, where the orienting culture is not healthcare but punishment and control. That is an extraordinarily complicated place to provide quality optimal community standard healthcare. I think what impressed me most was the struggle that environment poses for clinicians. I was stunned by the gravity and the scope and the depth of the problem.
Some prisons are opening new units expressly designed to care for geriatric patients. Should older patients be consigned to these units?
It depends on the facility, and it depends on the individual. Things going for the cohort-ing of geriatric patients are, first of all, that you can develop ADA (American Disability Act) accessible units with only bottom bunks, with grab bars in every shower, with no shower lips, and so on. All the things we do to people’s environments to keep them safe when they have physical disability, we could do to an entire facility. That’s very appealing.
You can also enhance training to the officers who are in that setting, so that they have more awareness of the warning signs of health deterioration in older adults—things like confusion, falls, worsened hearing.
And it’s appealing because many older adults have a real fear of victimization in [a prison] setting.
Cognitive impairments are far more predictive of mortality than a single disease.
But these positive aspects are outweighed by the negative aspects. For one, a lot of older adults don’t want to go to these units because they don’t want to be surrounded by a lot of “old people,” just like in the outside world. They don’t feel old. It could be that they have friends or kin in the mixed age prison who take care of them. If you put a bunch of older adults who are physically impaired into a setting, you lose the informal caregivers in the general population.
There’s a lot of sociology literature that suggests that older adults are a calming influence on the general population. So removing them could potentially have an adverse effect on the rest. Now, from the older person’s perspective, that may not be important, but it is a factor in terms of the population as a whole.
There are ways that you can get around moving people into cohorted facilities. For example, if you have a prison where there’s yard time, you could say, “From noon to 2 will be yard times for everybody; 2 to 4 is yard time just for older adults. You can choose which one you want to go to.” These are strategies that some facilities are taking that allow a little more choice.
You’ve written that when you started, there was a stark lack of data about older prisoners and geriatric care. What does data collection look like in these contexts?
Throughout my career I’ve taken four approaches to data. One is using preexisting data—which is very hard to find. Prisoners are rarely featured or included in national health data. So the next step is going out and collecting your own data. Altogether, I think we’ve collected data on about 350 older adults in the San Francisco County Jail. We’ve followed approximately 125 of them after their release. Collecting your own data is critical in this work.
The third thing we’ve done is write about the data vacuum. We published one paper called “Confined to Ignorance,” about the lack of ability to create a cohort of criminal justice-involved individuals in many national health data sets. After that article, we approached the Health and Retirement Study with our results, and that motivated them to actually add questions into their national health data survey about criminal justice involvement.
The final piece is taking evidence from other sources and applying it to the correctional population. For example, in one of our projects we are working to understand how solitary confinement affects older adults. So, we can apply evidence that we already know—the tried and true evidence from geriatric clinical research—and try to understand what happens when somebody is put in a room the size of a parking spot and left alone 23 hours a day, seven days a week, for years.
What are some of the problems facing compassionate release programs?
Compassionate release is a loose term that refers to a number of different policies or laws. Some of these programs are early medical parole for people with debilitating illness. Some of them are early release for people with serious illness or in the terminal stage of their illness. The basic idea that unites them is that they allow seriously ill individuals to get care and often die outside of the prison system.
Some form of compassionate release is available in almost every state, with a few exceptions. The problem is that, despite their wide availability, they are rarely used.
There are two main steps in compassionate release. The first is medical eligibility. Nobody gets into the program of compassionate release unless they can get a doctor to attest to their medical qualification. The second step is the administrative step. They have to be approved, sometimes by the sentencing courts, sometimes by the prison itself, sometimes by the parole board.
Many of these rules—at least at the time when we wrote our first paper—require the physician to prognosticate that the person has either less than six months or less than 12 months, or sometimes less than 18 months, to live.
Physicians are very reluctant to prognosticate, and when we do, we’re not very good at it. We tend to overestimate prognosis, and often by a pretty big factor. When we know a patient better, or when the stakes are higher, we’re even worse.
What we learned from our analysis is that we need to allow physicians to have prognostic uncertainty. A physician may feel much more comfortable saying, “This person is in the end of life trajectory. They’re dying. I don’t know that it’s going to be in five months, but I know that unless something very unusual happens this medical process is going to be what leads to their death, and it’s going to be soon.”
Another thing we know from geriatrics research is that functional and cognitive impairments are far more predictive of mortality than a single disease. Prognostically, it’s much more powerful to say a person no longer knows their name and cannot bathe themselves than it does to say they have congestive heart failure. We should be using these powerful prognostic scenarios in determining eligibility.
You’ve written that “compassionate release is about more than compassion.” What does that mean?
[Laughs.] We went back and forth about how to word that. My refrain is that compassionate release is not just the right thing to do, it’s the smart thing to do. Prisons facilities were simply not built with the intention to provide health care.
You have severely ill or seriously chronically ill individuals who require a lot of medical attention, sometimes including 24-hour nursing, in facilities that are often very overcrowded. In order to provide the appropriate level of care—which is what prisoners have a constitutional right to—you require many medical providers. That is a significant expense.
When you release somebody or parole somebody with serious illness, if they are impoverished they will go into the Medicaid system. Those systems are much more cost-efficient. They are more developed. Instead of a situation where you have a few very, very high intensity individuals in a system that was never developed expressly for the purpose of taking care of them, you have these few people going into a massive system that is developed expressly to take care of the seriously ill.
Lead photo: Shutterstock
Geriatric Care is a series of articles exploring the work of the Centers of Excellence in Geriatric Medicine and Geriatric Psychiatry, sponsored by the American Federation for Aging Research and The John A. Hartford Foundation.