The mental and physical health of older offenders: A systematic review and meta-analysis

Utilising survey data and qualitative information to inform a logic model to support older people in custody with common mental and physical health problems: Addressing the physical and mental health needs of older prisoners (the PAMHOP study)

A growing number of older people remain in custody each year resulting in an increasing number of common mental and physical health concerns. No prior evidenced-based targeted psychological interventions support this group of people, and little is known about their needs, current activities, and health-related problems. We addressed these gaps through a project involving older prisoners, prison staff and a project advisory group in one male and one female prison site in the North of England. Systematic review evidence supports the development of an implementation tool kit addressing strategies to develop and deliver interventions that are sustainable, acceptable, and feasible in the prison environment. Prison strategies need to specifically address the needs of older people in custody. Relatively inexpensive activities, with some thought to delivery and flexibility have the potential to benefit common mental and physical health, increasing quality of life, reducing high economic and social cost, mortality, and reoffending in this age group.

Multi-sector stakeholder consensus on tackling the complex health and social needs of the growing population of people leaving prison in older age

BACKGROUND

As populations age globally, cooperation across multi-sector stakeholders is increasingly important to service older persons, particularly those with high and complex health and social needs. One such population is older people entering society after a period of incarceration in prison. The 'ageing epidemic' in prisons worldwide has caught the attention of researchers, governments and community organisations, who identify challenges in servicing this group as they re-enter the community. Challenges lie across multiple sectors, with inadequate support leading to dire consequences for public health, social welfare and recidivism. This is the first study to bring together multi-sector stakeholders from Australia to form recommendations for improving health and social outcomes for older people re-entering community after imprisonment.

RESULTS

A modified nominal group technique was used to produce recommendations from N = 15 key stakeholders across prison health, corrections, research, advocacy, aged care, community services, via online workshops. The importance and priority of these recommendations was validated by a broader sample of N = 44 stakeholders, using an online survey. Thirty-six recommendations for improving outcomes for this population were strongly supported. The key issues underlying the recommendations included: improved multi-stakeholder systems and services, targeted release preparation and practices that ensure continuity of care, advocacy-focused initiatives in the community, and extended funding for effective programs.

CONCLUSIONS

There is consensus across stakeholders on ways forward, with intervention and policy updates required at the individual, systems and community levels. These recommendations entail two important findings about this population: (1) They are a high-needs, unique, and underserved group at risk of significant health and social inequity in the community, (2) Multi-sector stakeholder cooperation will be crucial to service this growing group.

Population ageing, incarceration and the growing digital divide: Understanding the effects of digital literacy inequity experienced by older people leaving prison

BACKGROUND

Digital inequity refers to the inequality and exclusion experienced by those who lack the same opportunities or circumstances to support the development of digital skills as the rest of modern society. One rapidly growing and highly vulnerable group to digital inequity is older people attempting to reintegrate into society after release from prison, where technology access is limited. Inadequate support for digital skills in this population entails widespread consequences for public health, human rights, social welfare and recidivism. This qualitative study is the first to: examine digital inequity experienced by older people who have been incarcerated, understand the effects of this on reintegration to society, and begin informing appropriate solutions.

METHOD

Semi-structured interviews were conducted with N = 15 older people (mean age = 57) who had been released from an Australian prison in the last two years, regarding their experiences of digital literacy since leaving prison. Reflexive thematic analysis was conducted under a critical realist lens.

RESULTS

The analysis resulted in six themes that illustrated the extent of digital inequity experienced by this population, and key challenges for improving digital literacy: 'surviving in a digital world', 'stranger in a foreign world', 'questioning the digital divide', 'overcoming your "old" self', 'don't like what you don't know', and 'seeking versus finding help'.

CONCLUSIONS

The digital inequity that older people experience during and after incarceration creates additional challenges for a growing group who are already medically and socially marginalised. Prioritisation of this group for digital literacy initiatives both during incarceration and in the community will have benefits for their health, social and financial reintegration. Their unique life experiences should be considered in designing and delivering these programs. Simultaneously, prisons should be cognizant of the potential detrimental effects of technology restriction on reintegration and criminogenic outcomes.

Criminal behavior in alcohol-related dementia and Wernicke-Korsakoff syndrome: a Nationwide Register Study

BACKGROUND

Chronic heavy alcohol use may lead to permanent brain damage, cognitive impairment, and dementia. While the link between alcohol use and crime is strong, virtually no research exists on the criminal behavior of patients with the alcohol-related neurocognitive disorders of Wernicke-Korsakoff syndrome (WKS) and alcohol-related dementia (ARD).

METHODS

The study population included all persons diagnosed with WKS (n = 1149) or ARD (n = 2432) in Finland in 1998-2015. Data on diagnoses, mortality, and crime were obtained from Finnish nationwide registers. Crime incidences were calculated 4 years before and after diagnosis. Crime types, incidences, and mortality were compared between disorders and with the general population.

RESULTS

Altogether 35.6% of WKS patients and 23.6% of ARD patients had committed crimes in the 4 years preceding diagnosis, most commonly property and traffic crimes, followed by violent crimes. The incidence of criminal behavior decreased significantly after diagnosis; in WKS patients, the standardized criminality ratio (SCR), the ratio of observed to expected number of crimes (95% CI), was 3.91 (3.72-4.10) in 4 years before and 2.80 (2.61-3.00) in 4 years after diagnosis. Likewise, in ARD patients, the SCRs were 2.63 (2.51-2.75) before and 0.84 (0.75-0.92) after diagnosis. No significant difference emerged in mortality between persons with and without a criminal history.

CONCLUSIONS

Persons with alcohol-related neurocognitive disorders frequently engage in criminal behavior prior to diagnosis, especially multiple offending. In the 4 years before and after diagnosis, crime rates declined in a linear fashion, with a marked reduction after diagnosis.

Mental and physical health morbidity among people in prisons: an umbrella review

BACKGROUND

People who experience incarceration are characterised by poor health profiles. Clarification of the disease burden in the prison population can inform service and policy development. We aimed to synthesise and assess the evidence regarding the epidemiology of mental and physical health conditions among people in prisons worldwide.

METHODS

In this umbrella review, five bibliographic databases (Web of Science, PubMed, PsycINFO, Embase, and Global Health) were systematically searched from inception to identify meta-analyses published up to Oct 31, 2023, which examined the prevalence or incidence of mental and physical health conditions in general prison populations. We excluded meta-analyses that examined health conditions in selected or clinical prison populations. Prevalence data were extracted from published reports and study authors were contacted for additional information. Estimates were synthesised and stratified by sex, age, and country income level. The robustness of the findings was assessed in terms of heterogeneity, excess significance bias, small-study effects, and review quality. The study protocol was pre-registered with PROSPERO, CRD42023404827.

FINDINGS

Our search of the literature yielded 1909 records eligible for screening. 1736 articles were excluded and 173 full-text reports were examined for eligibility. 144 articles were then excluded due to not meeting inclusion criteria, which resulted in 29 meta-analyses eligible for inclusion. 12 of these were further excluded because they examined the same health condition. We included data from 17 meta-analyses published between 2002 and 2023. In adult men and women combined, the 6-month prevalence was 11·4% (95% CI 9·9-12·8) for major depression, 9·8% (6·8-13·2) for post-traumatic stress disorder, and 3·7% (3·2-4·1) for psychotic illness. On arrival to prison, 23·8% (95% CI 21·0-26·7) of people met diagnostic criteria for alcohol use disorder and 38·9% (31·5-46·2) for drug use disorder. Half of those with major depression or psychotic illness had a comorbid substance use disorder. Infectious diseases were also common; 17·7% (95% CI 15·0-20·7) of people were antibody-positive for hepatitis C virus, with lower estimates (ranging between 2·6% and 5·2%) found for hepatitis B virus, HIV, and tuberculosis. Meta-regression analyses indicated significant differences in prevalence by sex and country income level, albeit not consistent across health conditions. The burden of non-communicable chronic diseases was only examined in adults aged 50 years and older. Overall, the quality of the evidence was limited by high heterogeneity and small-study effects.

INTERPRETATION

People in prisons have a specific pattern of morbidity that represents an opportunity for public health to address. In particular, integrating prison health within the national public health system, adequately resourcing primary care and mental health services, and improving linkage with post-release health services could affect public health and safety. Population-based longitudinal studies are needed to clarify the extent to which incarceration affects health.

FUNDING

Research Foundation-Flanders, Wellcome Trust, National Institutes of Health.

The Multiple Punishment of Being an Older Adult Coping With Health Problems in Prison

BACKGROUND AND OBJECTIVES

Studies have examined the vulnerabilities and the extent of health problems experienced by the older adult population in prison. However, reports about the subjective experiences of incarcerated older adults who are coping with health problems are scarce. This is alarming since older adults comprise the fastest-growing demographic in the prison systems of the United States and Europe. The aim of the current study was to bring forth the voices of older adults who are living with diseases in prison and to outline the landscape of struggling with everyday health care management.

RESEARCH DESIGN AND METHODS

An interpretive phenomenological analysis was used to analyze the narratives of 23 individuals aged 60-88 who were coping with health problems in prison.

RESULTS

The narratives revealed 3 major themes: (1) living day to day with illness in prison: fighting prison bureaucracy and public humiliation; (2) coping with complex medical issues: lack of professional medical care and cumulative problems, and (3) what does the future hold? Fear of living with illness out of prison.

DISCUSSION AND IMPLICATIONS

Intersectionality was used as a conceptual framework for understanding the participants' narratives. The cumulative effect of belonging to systematically oppressed and marginalized groups is discussed. The research findings point to issues and experiences that are unique to older adults coping with health problems in prison and can serve as a framework for developing tailored interventions for these individuals.

Effects of interventions on depression and anxiety in older people with physical health problems in the criminal justice system: a systematic review

The demand for health care in older people involved in the criminal justice system is high. The prevalence of mental and physical health conditions for people living in prison is greater than in community populations. After systematically searching 21 databases, we found no targeted interventions to support depression or anxiety for this group of people. 24 studies (including interventions of yoga, creative-arts-based programmes, positive psychology, or mindfulness-based interventions and psychotherapy) did contain people older than 50 years, but this only represented a minority (10%) of the overall study population. No single study reported outcomes of physical health. Future interventions need to consider the needs and views of this vulnerable group. Specific gendered and coproduced interventions are required to enhance the implementation, feasibility, and acceptability of interventions that are delivered in prisons.

The role of substance use in the lives of incarcerated older adults: A qualitative study

Background

The prevalence of drug abuse among older adults has grown over the last decade. Despite the expanding development of a body of research dedicated to studying this phenomenon, drug abuse by incarcerated older adults has been marginalized. Thus, the aim of the present study was to explore drug abuse patterns in the lives of incarcerated older adults.

Method

Semi-structured interviews were conducted with 28 incarcerated older adults, and an interpretive analysis was used to analyze the participants’ narratives.

Findings

Four themes emerged: (1) Growing up around drugs; (2) Prison onset; (3) Professionals, and (4) Lifelong substance abuse.

Conclusion

The study findings reveal a unique typology of drug-related themes in the lives of incarcerated older adults. This typology sheds light on the interplay between aging, drug use, and incarceration and the way these three socially marginalized positions may intersect.

Risk of dementia and mild cognitive impairment in older adults with a criminal background: a population-based register study in Sweden

Criminal behaviour has previously been associated with an increased risk for several mental health problems, but little is known about the association between criminal behaviour and dementia. We aimed to examine how the criminal background (type of crime, number of convictions, length of the sentence) is associated with dementia and mild cognitive impairment (MCI), and how mental and physical health disorders and educational attainment influenced these associations. A nationwide cohort of 3,617,028 individuals born between 1932 and 1962 were linked with criminal and medical records using Swedish national registers. We used Cox regression models to examine the associations. Increased risks for dementia (Hazard ratios (HRs) 1.54, 95% confidence interval (CI) 1.50-1.57) and MCI (1.55, 1.50-1.61) were found in individuals with criminal background, particularly among those who committed violent or several crimes, or with long sentences. After full adjustment of covariates, the associations attenuated but remained statistically significant for dementia (1.25, 1.22-1.28) and MCI (1.27, 1.22-1.32). The attenuation was mostly explained by mental health problems -depression, anxiety, schizophrenia spectrum disorders, substance use disorder (SUD), and bipolar disorder- (dementia: 1.34, 1.31-1.37; MCI: 1.35, 1.30-1.40). SUD contributed the most to attenuate the associations. Our results may provide important insights to health and penal systems by showing the importance of considering the severity of the criminal background and life-course mental health when assessing the risk of neurodegenerative disorders.

The ageing prisoner population: demographic shifts in Australia and implications for the economic and social costs of health care

PURPOSE

The Australian prisoner population has experienced a dramatic increase in the number of older inmates over the past decade, consistent with the greying of the prisoner population that is being observed worldwide. Reviews suggest the need for further evidence and practice outside of the USA. This paper aims to review and discuss the cost and social implications of the rising health-care needs of this population in Australia.

DESIGN/METHODOLOGY/APPROACH

A review of international research and policies is presented, as well as the results of basic economic modelling relating to the expected rise in health-care costs of the ageing prisoner population in Australia.

FINDINGS

Taking into consideration the continued rise in incarceration rates, the calculations show that the health costs of prisoners could increase by anywhere between 17% and 90% depending on whether the increase of older prisoners continues as it has in the past decade. These trends are likely to continue over the next decade and will result in higher health costs of prisons under a number of different imprisonment scenarios. Policy responses in Australia have been slow so far, with most initiatives being undertaken in the USA with promising results.

PRACTICAL IMPLICATIONS

The authors suggest that in the absence of a coordinated policy response, covering a range of interventions, costs will continue to increase, particularly as this population continues to age more rapidly than the general population due to an accumulation of risk factors. Well-conceived interventions would be a worthwhile investment from both financial and social perspectives.

ORIGINALITY/VALUE

To the best of the authors' knowledge, this is the first commentary to acknowledge this rising public health issue and to both review and model its implications for the future.

Life-Course Persistent Antisocial Behavior and Accelerated Biological Aging in a Longitudinal Birth Cohort

Prior research shows that individuals who have exhibited antisocial behavior are in poorer health than their same-aged peers. A major driver of poor health is aging itself, yet research has not investigated relationships between offending trajectories and biological aging. We tested the hypothesis that individuals following a life-course persistent (LCP) antisocial trajectory show accelerated aging in midlife. Trajectories of antisocial behavior from age 7 to 26 years were studied in the Dunedin Multidisciplinary Health and Development Study, a population-representative birth cohort (N = 1037). Signs of aging were assessed at age 45 years using previously validated measures including biomarkers, clinical tests, and self-reports. First, we tested whether the association between antisocial behavior trajectories and midlife signs of faster aging represented a decline from initial childhood health. We then tested whether decline was attributable to tobacco smoking, antipsychotic medication use, debilitating illnesses in adulthood, adverse exposures in childhood (maltreatment, socioeconomic disadvantage) and adulthood (incarceration), and to childhood self-control difficulties. Study members with a history of antisocial behavior had a significantly faster pace of biological aging by midlife, and this was most evident among individuals following the LCP trajectory (β, 0.22, 95%CI, 0.14, 0.28, p ≤ 0.001). This amounted to 4.3 extra years of biological aging between ages 25-45 years for Study members following the LCP trajectory compared to low-antisocial trajectory individuals. LCP offenders also experienced more midlife difficulties with hearing (β, -0.14, 95%CI, -0.21, -0.08, p ≤ 0.001), balance (β, -0.13, 95%CI, -0.18, -0.06, p ≤ 0.001), gait speed (β, -0.18, 95%CI, -0.24, -0.10, p ≤ 0.001), and cognitive functioning (β, -0.25, 95%CI, -0.31, -0.18, p ≤ 0.001). Associations represented a decline from childhood health. Associations persisted after controlling individually for tobacco smoking, antipsychotic medication use, midlife illnesses, maltreatment, socioeconomic status, incarceration, and childhood self-control difficulties. However, the cumulative effect of these lifestyle characteristics together explained why LCP offenders have a faster Pace of Aging than their peers. While older adults typically age-out of crime, LCP offenders will likely age-into the healthcare system earlier than their chronologically same-aged peers. Preventing young people from offending is likely to have substantial benefits for health, and people engaging in a LCP trajectory of antisocial behaviors might be the most in need of health promotion programs. We offer prevention and intervention strategies to reduce the financial burden of offenders on healthcare systems and improve their wellbeing.

Older forensic mental healthcare patients in England: demographics, physical health, mental wellbeing, cognitive ability and quality of life

Background

Older individuals (e.g., 55 years and over) constitute a growing proportion of the forensic mental health patient population. As a group, they are vulnerable to health outcomes similar to other individuals with serious mental disorders of the same age; however, these concerns can be compounded by complex forensic-related care backgrounds and clinical presentations, lengthy periods of time spent in prison or psychiatric hospitals, substance use histories, and crime perpetration or victimisation. The healthcare needs and strengths of this group are not well understood.The aim of this study was to identify and describe the demographic, physical health, mental wellbeing, cognitive ability, and quality of life profiles of older forensic patients in community, low, medium, and high security settings in England.

Methods

A cross-sectional quantitative study design was used. N=37 forensic patients aged 55 years and over completed six questionnaires. Data were also collected from patient records.

Results

Most patients were male and were diagnosed with psychosis. The most frequently committed index offence types were violent offences. Patients were prescribed 7.6 medications on average and had average anticholinergic effect on cognition scores of 2.4. Nearly half the sample had diabetes, with an average BMI score of 31.7 (indicating obesity). Possible cognitive impairment was identified in 65% of the sample. Patients' assessments of their recovery-related quality of life and mental wellbeing were comparable to published UK general population values. Assessments of quality of life were positively correlated with the ability to undertake everyday activities and cognitive performance.

Conclusions

We suggest that forensic services are well-placed to provide holistic mental and physical care to this group but that they should co-develop with patients a greater range of age-appropriate meaningful activities that are mindful of mobility issues and consider implementing more cognition-based and physical health interventions.

Substance Misuse and the Older Offender

Substance misuse is prevalent among older adults involved in the criminal justice system. The different classes of older offenders, primarily defined as individuals 50 years and older, as well as their offending behaviors vary in their association with substance misuse. Most prison health care systems do not adequately integrate substance use services. Screening for and treatment of substance misuse should be part of comprehensive mental health programs tailored to older offenders. This article reviews different types of offenses among older offenders, their association with substance misuse, and available treatment services.