Ageing behind bars: what are the healthcare challenges
Between 2008 and 2014 there was a 75% increase in the over-50s prison population
As the prison population ages worldwide, it is expected that more prisoners will die of natural causes in prisons and have active palliative care needs. Photograph: Cyril Byrne
The relatively recent phenomenon of ageing prison populations brings unique healthcare challenges for prison services worldwide. These include accommodating the needs of frail older prisoners and the provision of end-of-life care.
Due to the accelerated ageing process caused by prison life and other factors, prisoners are usually referred to as “older” if they are over the age of 50.
In July 2014 this category of “older prisoners” made up 10 per cent of the prison population in Ireland and between 2008 and 2014 there was a 75 per cent increase in the Irish daily prison population aged over 50.
The latest figures from the Irish Prison Service (IPS), from April 2016, show there are 404 male and 12 female prisoners over the age of 50 in Irish prisons. Among these are 61 male prisoners aged between 60 and 64; 30 between 70 and 74; 18 aged 74 to 79; four aged 79 to 84; and two aged over 85. The oldest female prisoner is aged between 64 and 69.
Fastest-growing age groupAccording to UK data from the Penal Reform Trust’s Bromley Briefings, the over- 60s are the fastest growing age group in prisons in England and Wales, with this group seeing a 164 per cent rise between 2002 and 2015.
There are about 12,000 prisoners over the age of 50 in England and Wales and that number is projected to increase to more than 15,000 by 2020.
As the prison population ages worldwide, it is expected that more prisoners will die of natural causes in prisons and have active palliative care needs.
In Irish prisons when a prisoner needs palliative care “all prisoners are treated on the basis of equivalence of care in the community”, says the IPS. “As far as possible all services that are required by a prisoner are facilitated in the prison.
“When the care requirements exceed that available in the prison, the prisoner is transferred to the appropriate clinical setting. This will be based on clinical factors and influenced only by clinical requirements.
“The most appropriate clinical setting is based on the clinical advice from the treating physician and it is not uncommon for prisoners to be moved to a hospice setting for a peaceful and dignified death,” says the IPS.
“Prisoners released to hospital or another care facility can either be escorted, electronically tagged or granted temporary release. Each case is unique and decisions are made on a case-by-case basis,” the IPS says.
A number of UK prisons have developed special hospice suites to accommodate dying prisoners and allow their families to be with them at the end of life.
In 2014, 107 people aged 50 or over died of natural causes in UK prisons; this represents an almost 50 per cent increase in the last decade. There were 148 deaths from natural causes in prisons in England and Wales in 2015, the highest number on record.
ProfilesThe Penal Reform Trust Bromley Briefings in the UK describe four main profiles of older prisoners. These are repeat prisoners, people who have been in and out of prison for less serious offences and have returned to prison at an older age; those who have grown old in prison; short-term, first-time prisoners; and long-term first-time prisoners, those convicted possibly for historic sexual or violent offences.
One of the reasons for the relatively recent increase in the age profile of prisoners is the rise in the number of older people being convicted of historic offences. UK data also shows that 42 per cent of male prisoners over the age of 50 are sex offenders.
A study presented at the European Association of Palliative Care (EAPC) World Research Congress, which took place in Dublin earlier this month, looked at palliative care in prisons and the healthcare needs of older prisoners.
Organised by the Irish Association of Palliative Care, the event was attended by more than 1,200 delegates from 47 countries.
The older prisoner survey by Dr Mary Turner, research fellow at Lancaster University in the UK, forms part of a larger three-year study entitled Both sides of the Fence, which aims to improve palliative care for prisoners in the UK.
The study comprised a survey of 127 prisoners in a prison in northwest England ranging in age from 55 to 91, a quarter of who were over 70. The data from this study suggested that three-quarters or 75 per cent of the prisoners in this survey were in prison for the first time.
According to the survey, a significant minority or 28 per cent of prisoners rated their health as “poor” or “very poor” and more than half reported having three or more concurrent health conditions, the most common being arthritis, high blood pressure, respiratory problems, anxiety and depression.
Half of those surveyed reported to be taking five or more medications and almost two-thirds reported having difficulty with at least one aspect of daily living such as washing, going to the bathroom or feeding themselves.
The survey also found that 26 per cent of older prisoners could not walk more than 100 metres, 11.8 per cent had very poor mobility, a few were wheelchair users, 43.3 per cent used a medical aid such as a Zimmer frame or hearing aid, and almost a third had experienced a fall during the previous two years.
Drug accessAccording to Turner, access to and safety around medication was one of the main concerns expressed by older prisoners with a number fearing intimidation and bullying by younger prisoners for their prescribed drugs.
One older prisoner quoted in the study stated: “When you go to the hatch, people hang about looking what med you are on, so they can tell people. Then they’re able to buy them from you.”
The survey also found that oldest prisoners’ greatest concerns were that they would deteriorate and die alone in prison.
According to Turner, the study found that older prisoners have multiple, complex health and social care needs, as well as high levels of frailty and vulnerability.
It also found that palliative care in prison needed to be considered in the wider context of healthcare and the issues that impact on it such as ageing, frailty and disability.
Turner says a dearth of data on the provision of palliative care in prisons and the wide variation in prisoner populations in terms of ages, meant that people could potentially slip through the net in terms of their palliative care needs.
“People are not necessarily thinking palliative care in prison,” she says.
However, she says there was “a huge willingness” among prison staff to make improvements in this area.
The Irish Penal Reform Trust (IPRT) is due to publish a report later this year entitled the Rights and Needs of Older People in Prison.
According to the report, the Inspector of Prisons in Ireland has recommended that when it is apparent that a prisoner is reaching the end of his/her life, a case conference involving a palliative care team should be convened to formulate a care plan.
Palliative careThe report also notes that while the IPS attempts to meet the individual preferences of terminally ill people, palliative care is often best provided in a hospital or hospice setting.
The IPRT report is expected to recommend that older people with significant medical problems whose care cannot be adequately catered for in prison should be released on health grounds.
“The decision to grant temporary release on health grounds should be based on the particular circumstances of each case and should not be influenced by policies regarding the nature of the offence committed,” the IPRT notes.
According to Deirdre Malone, executive director of the IPRT, “When it is apparent that a prisoner is reaching the end of his or her life, a case conference involving a palliative care team should be convened to formulate a care plan.
“As prisons provide primary care health services only, care for people in advanced stages of ill-health, including palliative care, is more often best provided in a hospital or hospice setting.”
In a statement, the IPS said “all care is provided and co-ordinated in conjunction with the local palliative care specialist teams, as would happen in any other setting. The Irish Prison Service wholly engage with these specialist services, the prisoner themselves and families/significant others, so that the prisoner’s dignity and preferences are met as far as possible at this time.
“This approach is echoed throughout the care pathway, from the point of initial diagnosis, through treatment and up to the point of death.
“As there are many considerations, healthcare and otherwise, in the provision of palliative care for a prisoner, regular meetings are held with the multi-agency team to plan and facilitate this process as sensitively and compassionately as possible.
“All prisoners who may be affected by the death of a fellow prisoner, have access to supportive counselling and psychology services, if and when required,” the IPS added.