So it is with their medical care. Prisons have medical personnel and clinics, and some have hospitals, but most health issues are handled through "sick call" — the designated time when inmates show up at the appropriate places to describe their acute symptoms.

The small but rising number of elderly inmates includes men and women with multiple chronic conditions who would be candidates for geriatric care in the world beyond the walls. They are poorly served by the sick-call system, said Dr. Jeffrey Nichols. He is a gerontologist who is vice president for medical services for the Cabrini Eldercare Consortium and medical director of the Cabrini Center for Nursing and Rehabilitation in New York City.

Working with the New York State Department of Correctional Services, the Cabrini Center has developed training programs to help prison medical personnel better care for the older people among their general inmate populations. Nichols and Dr. Robert Kennedy, a Cabrini Center board member and geriatrics specialist, began conducting training sessions last summer inside two of the prison system's five regional medical centers, each of which is inside a larger correctional center. A dozen more sessions are planned at three of the medical centers. To widen the program's reach, the sessions are being videotaped and circulated to medical staffs at the rest of the 62 state prisons.

Nichols and Kennedy also are working to improve health care access for aging inmates reentering society.

Nichols describes the New York prison health system as "remarkably progressive about a lot of things," but, he adds, geriatric care is something that is new to most corrections departments. "As limited as geriatric care can be in our society, it's even more so within a prison system," Nichols said.

Geriatrics, the branch of medicine that focuses on promoting health and the treatment of disease and disability in later life, differentiates between disease and the normal decrepitude associated with aging. Its practitioners recognize that disease and medications can impact the elderly much differently than the middle-aged.

Among other things, Nichols said medical personnel treating the elderly need to understand the difference between the normal wear and tear of aging and symptoms that require medical intervention.

Prison's mini age boom
The New York state system houses more than 58,000 inmates. Each of its medical centers has a long-term care unit. One medical center has a hospice-care unit and another has a 30-bed center for cognitively impaired inmates, including older inmates with dementia. Inmates in the medical centers tend to be older.

Older inmates are part of the patient load at regular "sick call" too. The prison system keeps older inmates in its general prisons unless it's medically necessary to move them to special care, said Dr. Lester N. Wright, deputy corrections commissioner and chief medical officer of the state corrections department.

"Having a mix of young and older inmates in a prison makes it run smoother than a prison with, for instance, all young inmates," Wright said.

Elderly inmates make up a small part of the state's prison population, for which the average age is 37. Wright said almost 7 percent of the inmates are 55 years or older, but only 1.3 percent are 65 or older and only 329 inmates — 0.5 percent — are 70 or older. As of Jan. 10, he said, the oldest inmate was 89 years old.

Wright said the percentage of older inmates is on the rise. In January, 3.1 percent of the total inmate population was 60 or older, up from 2.7 percent in 2009.

There is no threshold chronological age for geriatric care. A patient's lifestyle and medical history factor into the health status that can make a younger senior an appropriate candidate for geriatric care. Wright and Nichols said that, generally speaking, inmates show signs of aging sooner than do people in the outside world. For that reason, the prison system considers inmates who are 55 and older to be seniors. "The (geriatric) population you see in prisons is a lot younger in age than the people we see in geriatric clinics," Nichols said.

Most of the older inmates have been incarcerated for many years. And prior to imprisonment, they tended toward unhealthy lifestyles. "These are people who had a lot of unmet needs before going to prison, and who certainly haven't been getting annual physicals," Nichols said.

Nichols said life inside prison can be hard on health as well. Even though prisons provide healthy diets and opportunities for exercise, prison life can be violent. Inmates sometimes obtain illegal drugs, he said. Additionally, Nichols said, "The stress of incarceration is probably, by itself, a negative health factor."

Age increases medical complexity
In the training sessions, Nichols said that he and the Cabrini Center staff discuss differences in treating younger and older people for illnesses and ways to manage chronic care for elderly inmates. He said one thing they discuss at length is polypharmacy, especially the increased risk of adverse drug interactions in seniors.

"That's the biggest single thing we deal with," he said. "A lot of prisoners take a lot of medications. You have people who end up taking a whole lot of medications that may be appropriate for younger people, but when added together, can have a lot of toxicity for older people."

Wright, the deputy commissioner, said his staff appreciates the training. "Health care staff who work behind the walls and fences of prisons can feel cut off from (the broader health care community)," he said. "Bringing in continuing education by Cabrini and by major medical centers around the state helps keep my staff up to date and feeling connected to mainstream health care."

Pamela E. Guigli, vice president for planning for the Cabrini Eldercare Consortium, said the Cabrini Center will seek grants to continue and expand the work in prison health.

Guigli said the Cabrini Center staff began discussing issues of medical care for aged prisoners several years ago; and, in 2007, it won a program grant of $15,000 from the Adorers of the Blood of Christ, an order of women religious based in St. Louis. That grant is funding the current training program.

The work to improve care of inmates continues the tradition of St. Frances Xavier Cabrini, and the Missionary Sisters of the Sacred Heart of Jesus, the order of women religious she founded. That order sponsors Cabrini Center.

Guigli said, "The mission of Mother Cabrini is to care for the underserved and the forgotten."

Nichols said elderly inmates fit that description."We're talking about a group of people who have been written off in every conceivable way."

Smoothing transitions
Guigli and Nichols said that elderly inmates discharged back into the community often have few or no relatives to help them reenter the outside world and get access to continued medical care. They are bewildered by the little details of contemporary life, such as cell phones and swipe cards to take public transportation. And they don't know how to apply for Medicaid or Medicare.

"What is needed is a comprehensive geriatric assessment prior to release, with referral to care providers, and expedited access to Medicaid," Nichols said.

Nichols said Cabrini staff are working on ways to make those things happen.

Copyright © 2010 by the Catholic Health Association of the United States