MANAGING THE ELDERLY IN CORRECTIONSFrank J. Porporino, Ph.D.

“
Well, I done got old,
I canʼ
t do the things I used to do,ʻCause I done got old,
I canʼ
t see like I used to,Canʼt walk like I used to,Canʼt love like I used to,1ʻ
Cause Iʼm an old man.”
Buddy GuyʻLife in prison can challenge anyone,but it can be particularly hard for people whose bodies andminds are being whittled away by age. Prisons in the United States contain an ever growing
number of aging men and women who cannot readily climb stairs, haul themselves to the top
bunk,or walk long distances to meals or the pill line;whose old bones suffer from thin mattresses
and winterʼs cold;who need wheelchairs,walkers,canes,portable oxygen,and hearing aids;who
cannot get dressed,go to the bathroom,or bathe without help;and who are incontinent,forgetful,
suffering chronic illnesses, extremely ill, and dying.ʼ
Human Rights Watch, Old Behind Bars, 2012 p. 4

I. INTRODUCTION
There are few benefits to growing old. As we age, we inevitably deteriorate both physically andmentally,perhaps gradually if we are fortunate,but nonetheless steadily. Social psychological studies
tell us that the happiest elderly people are those who can remain active, with close connections withfamily and friends and other social supports, and who can still feel they are contributing in somemeaningful fashion. We clearly live in an ʻ
ageistʼsociety and none of us particularly looks forward togetting old,but old age can be negotiated more or less effectively when there is quality healthcare wecan access, some level of financial stability we can enjoy, and supportive social networks we can bepart of.
Aging in prisons is another experience all together. Most elderly offenders will have lost touch with
their families and friends, who are either dead, too old to visit, or have simply moved on with theirlives. Health concerns are a daily preoccupation and fear of death,alone in a small cell,the fodder fornightmares. Opportunity to enjoy the small things in life, that become very important things as wegrow older,is lost in prison;looking forward to our favorite meal,that special cup oftea,the calla lilies
in our garden, or playing peek-a-boo with our grandchild. Aging in prison instead becomes an
unceasing grind where one is forced to endure a boring, austere, routinized, noisy and foul smelling
enclosed environment. There is no ʻ
choiceʼto learn to age gracefully in prison. You simply get old,quickly and mostly invisibly.
The issue of managing the elderly in prisons has emerged as one of the most significant andunplanned-for crises in corrections. Though it may be of most concern in developed nations,where life
expectancy has steadily and significantly increased, the problem is growing quickly in developing
nations where long prison sentences are becoming a matter of course. For many jurisdictions
Board M ember, International Corrections and Prisons Association and Senior Partner, T3 Associates Inc. E-mailcontact at fporporino＠rogers.com. A version of this paper was presented in May 2014 to participants of the 157th
International Training Course of the United Nations Asia and Far East Institute for the Prevention of Crime and theTreatment of Offenders (UNAFEI).
1Blues Ballad by Buddy Guy, “Done Got Old Lyrics”, from the Album Sweet Tea, 2001.

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157TH INTERNATIONAL TRAINING COURSE
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worldwide, it is an issue that has simply caught them by surprise as the aging of their prisoner
population has begun to be noticed. It is clearly a situation that obliges action in accordance withnumerous declarations of respect for human rights endorsed by most nations of the world. The elderly
in prison, like all prisoners, have the right to be treated with respect for their humanity and inherent
human dignity; to not be subjected to torture or other cruel, inhuman, or degrading treatment or
punishment;to receive appropriate medical and mental healthcare;to have reasonable accommodation
for their disabilities;and to be provided activities and programs to support their rehabilitation.2 This
paper will attempt to:
Outline the scope of the problem of the elderly offender in corrections;
Discuss what might be causing this problem;and finally,
Assess what some of the most significant consequences might be for the delivery of correctional services to this population, and what possible responses (policies, programs orservices)might be helpful.
A. The Scope of the Problem
Although there is some inconsistency both across countries and in the literature in terms of how theʻolderʼor ʻ
elderlyʼoffender is defined,typically it is accepted that this should refer to offenders who areat least 50 years old or over (Aday,1994;Gallagher,2001).3 A useful distinction is to categorize older
offenders as falling into one of three groups (Goetting,1984). The first is those offenders incarcerated
after the age of 50, often for the first time, and often described as the later-life offender. These
offenders will most often be charged with either minor economic offences (i.e., shoplifting or theft),fraud,or as far as serious offences are concerned,either a sex offence(e.g.,pedophilia)or murder (e.g.,of a spouse). A second category of older offenders is the relatively small proportion of ʻ
careercriminalsʼwho consistently continue to offend and get imprisoned well past the peak age for offending(Aday, 2003). Typically, these offenders would be serving sentences for a whole variety of serious
crimes,including possibly organized crime,drug trafficking,or robbery. Finally,the last category ofolder offenders,which is clearly the largest group within prisons and jails today,are theʻlong-termersʼ
who were incarcerated prior to age 50 but who have aged in prison because of their long sentences.
It has been documented that approximately 13% of sentenced prisoners in America are aged 50 andolder (Guerino et al., 2011). This constitutes the fastest-growing sector of the prisoner population,
which is now at least 5 to 8 times as large as it was in 1990 (Human Rights Watch, 2012). As an
example,although the population in New York State prisons decreased by over 20% in the last decade,the population of incarcerated individuals aged 50 or older increased by 64% (Bernstein, 2011).
Between 1995 and 2010, the number of state and federal prisoners in America age 55 or older nearlyquadrupled (Human Rights Watch, 2012). Over a period of only a few years, from 2007 to 2010, theprisoner population older than 65 in America grew at 94 times the rate of the overall prison population(see Figure 1 below).

2See for example,the United Nations Standard M inimum Rules for the Treatment of Prisoners,adopted bytheFirst United

Nations Congress on the Prevention of Crime and the Treatment of Offenders,held at Geneva in 1955,and approved by
the Economic and Social Council byits resolution 663 C (XXIV)ofJuly31,1957,and 2076(LXII)ofM ay13,1977;European
Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment, “The CPT Standards,
ʻ
Substantiveʼsections of the CPTʼs General Reports,”CPT/Inf/E (2002) 1, Strasbourg, October 2006; International
Covenant on Civil and Political Rights(ICCPR),adopted December 16,1966,G.A. Res. 2200A (XXI),21 U.N. GAOR Supp.
(No. 16)at 52,U.N. Doc. A/6316(1966),999 U.N.T.S. 171,entered into force March 23,1976,arts. 7 and 10;Convention
on the Rights of Persons with Disabilities (CRPD),adopted December 13,2006,G.A. Res. 61/106,Annex I,U.N. GAOR,
61st Sess., Supp. (No. 49)at 65, U.N. Doc. A/61/49 (2006), entered into force M ay 3, 2008.
3Following convention in the literature, reference to the ʻolderʼoffender will be for those aged 50 or older, whereasʻelderlyʼoffender will refer to those aged 65 or older.

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RESOURCE MATERIAL SERIES No. 94
Figure 14

Strikingly, it has been noted that the rate of incarceration for men age 65 and over in America is
142 per 100,000 male US residents of that age,a rate that exceeds the total rate ofincarceration for menof any age in most countries (Human Rights Watch,2012). By the year 2030,it has been forecasted thatolder inmates will represent over one-third of the U.S.prisoner population (Durham,1994;Neeley et al.,1997), an increase of 4,400% since 1981 (American Civil Liberties Union, 2012)(see Figure 2).
Figure 2

Figures from Canada in the mid-90s suggested that about 8% of offenders in federal institutions
were 50 years of age or older (Grant & Lefebvre, 1994) and that the growth in the concentration of
offenders 65 years of age or older had been outpacing all other age groups (i.e.,an increase of 49% over
only a 3 year period from 1990-93). By 2011-12,it was reported that 20.6% of the incarcerated federal
offender population was now aged 50 and over (over 1 in 5). Moreover,the population under community supervision was even older, with 32.6% of offenders in the community aged 50 and over (Public
Safety Canada, 2012). Interestingly, almost three quarters (72%)of the offenders 60 years of age and

4Taken from Human Rights Watch, Old Behind Bars, 2012.

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157TH INTERNATIONAL TRAINING COURSE
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older were found to be serving their first prison term, mostly for either homicide or sexual offences(70.3%)(Grant & Lefebvre, 1994).
Similar concerns about a quickly aging prisoner population have been noted in England and Wales
where it was reported recently to the House of Commons that 12% of prisoners were aged 50 and older
and the proportion in this age grouping had more than doubled since 2002,significantly outpacing allother age categories (Berman & Dar, 2013). In Australia the proportion of prisoners over 50 has also
been reported as more than doubling in the last several decades(Dawes,2005). And in Japan it has beenreported that the number of prisoners age 65 and over increased by160% between 2000 and 2006,mostly
for non-violent offences such as shoplifting and petty theft,a phenomenon attributed to the breakdownof the traditional family that has led to older persons turning to crime due to poverty and isolation.
B. So What Is Causing This Problem of the Graying of the Prisoner Population?
“
The increasing warehousing of aging prisoners for low-level crimes and longer sentences isa nefarious outgrowth of the “tough on crime”and “
war on drugs”policies of the 1980s and1990s.”
ACLU, ʻThe M ass Incarceration of the Elderlyʼ, 2012, p. 2
M any parts of the world are facing what has been dubbed a ʻsilver tsunamiʼ― a growing trend
towards aging of the general population. Between 2000 and 2010,for example,the elderly populationin America (65 years and over)increased at a much faster rate(15.1%)than the total population (9.7%),
a trend that is expected to accelerate. People 65 or older represented only 4% of Americans in 1900,
increasing to 12.4% of the population by the year 2000, and are expected to grow to close to 20% by
the year 2030(Administration of Aging,2014). This same pattern is occurring in many countries where
the demographic bulge known as the ʻboomerʼgeneration is now moving into old age. It might seemsensible,therefore,to suggest that the graying of the prisoner population is simply a reflection of thismore general phenomenon. However,the facts present quite a different story. Looking at who these
aging prisoners actually are makes it quite clear that the aging of the prisoner population is not beingcaused by the well-established shift in demographics of the general population.
A recent thorough analysis of the trends and patterns of offences committed by the elderly in
America over a 25-year period (1980-2004) confirms that demographics alone cannot account for thedisproportionate growth of the elderly prisoner population (Feldmeyer & Steffensmeier, 2007).
First,it was found that older offenders (i.e.,aged 55 or older)actually contribute only modestly tothe nationʼ
s total arrest rate. The elderly show the lowest rate of arrests of any age group and theirshare of crime accounts for less than 4% of total arrests and less than 3% of ʻseriousʼor Index crimearrests.
Second, elderly crime rates have not increased in level or seriousness in recent decades and therelative criminal involvement of the elderly is about the same as 25 years ago. For almost all offencesthat were examined, arrest rates for the elderly had either remained stable or had fallen over time.
Third, the analysis confirmed the stability over time of the well-known age-crime curve that has
been observed in criminology for over a century.5 This burn out theory of crime has become one of themost well-known observations in criminology (M aruna,2000;Steffensmeier et al.,1989),and we know,for example, that arrest rates drop dramatically to just over 2% at age 50 and are almost 0% at age
5The agecrime curve, which seems to be stable across both cultures and historical periods,shows rates of involvementin crime rising rapidly in early adolescence,peaking in the late teens or early twenties,and then declining. The dramatic
drop off in criminal involvement with age has been related to numerous factors that contribute to an “
aging out”of crimeat later stages in life. This has been attributed to the biological process of aging as well as the changing roles andperspectives of the elderly. There is a decline in physical strength,energy,and psychological drive with age. The elderly
are likely to have fewer opportunities for crime and criminal sanctions and possible incarceration will represent as a more
serious threat (i.e.,more to lose with less time to death). Finally,aspirations and goals change with age and the elderly
may no longer strive for the same level of material fulfillment and recognition as when theywere younger. M ajor sourcesof reinforcement for crime (e.g.,money,sex,status,and antisocial peer pressure)may be absent or relatively weak in old
age.

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65 (ACLU, 2012).
And finally, the findings showed that there was very little change in the profile of the elderly
offender who is arrested, with elder arrests continuing to be overwhelmingly for minor offences (e.g.,theft) or alcohol-related offences. The authors concluded that the law-violating behavior of older
adults was not more of a pressing problem todaythan a generation ago,and that indeed there was someevidence suggesting it was less so.
We can conclude that despite the obvious aging of the population in the wider community, theelderly are not committing crimes, being arrested or ending up in prison in significantly larger
numbers.6 But if that is the case then what explains the rather dramatic and disproportionate growthin the concentration of older and elderly offenders in prisons? Arguably,the main culprits are,on the
one hand, punitive sentencing policies and practices that send more offenders to prison for longer
terms, and on the other hand, severely restrictive release policies for long-term offenders, either forparole, or even for offenders who are infirm or quite disabled and dying.
The well-documented recent report from the American Civil Liberties Union, Mass Incarceration of
the Elderly (2012), highlights the following:
The elderly prison population is increasingly made up of individuals who were sentenced when
they were younger but given lengthy prison terms (20 years or more)that effectively lead totheir remaining in prison well into old age. In 1979, only 2% of aging prisoners fell into thiscategory nationwide. Data shows that this percentage has increased up to ten fold in many
American jurisdictions.
M any older individuals who would have been sentenced to short periods of incarceration for
repeat crimes of a minor nature are now caught in the net of ʻ
habitual offenderʼand threestrikes legislation.
The percentage of aging prisoners who were first imprisoned after they turned 50 is actually
declining.
Over a 25-year period, from 1984 to 2008, the number of offenders serving life sentences in federal
prisons in America increased tenfold. Even in the more recent decade from 1998 to 2008, the numberof state and federal prisoners serving life sentences in America more than quadrupled (ACLU, 2012).
The Sentencing Project7, a well respected non-governmental research and advocacy group, has
documented that 1 out of every 9 prisoners in America are currently serving life sentences, and evensince just 2008, the rise in sentences of life without parole has been much steeper than for life withparole (22.1% rise in LWOP; 7.6% rise in LWP). The ACLU review summarizes the situation as
follows: “Our prison population has not grown so old by accident. The proliferation of severe
sentencing policies―the enactment of mandatory minimum,three-strikes,and truth-in-sentencing laws
along with the general increase in sentence lengths―has led to a massive explosion in the aging
prisoner population”(p. 45).
The deterrent effect of these severe sentencing practices has been seriously questioned repeatedly(Wright, 2010). Nonetheless, all over the world, political mileage continues to be had with ʻtough oncrimeʼrhetoric and the common refrain of calling for lengthier prison terms in the supposed interestof increased public safety. But the reality is that punitive sentencing is only of chimeric value in termsof public safety. In Canada,for example,our Conservative government recently saw fit to pass a ʻ
Safe
Streets & Communities Actʼembracing a range of American-like practices to lengthen prison terms for
6It is generally recognized that demographically the highest crimerisk group is males from their teens through to theirlate 20s. Crime rates began to increase in North America as the large wave of a so-called ʻboomerʼgeneration passed
through their high crime-risk years from about 1960 to the mid-90s. As this boomer generation aged,crime rates began
dropping steadily since the early 1990s, particularly since the follow on demographic groupings entering their highcrime-risk years (i.e., the baby bust and boomer echo)are much smaller in size than was the boomer generation.
7See http://www.sentencingproject.org>.

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many offenders. This occurred despite the fact that crime rates had steadily decreased to the lowest
level in over forty years. When challenged about the need for such measures, our Justice Minister
dismissively declared that:“We donʼt use statistics as an excuse not to get tough on criminals”.8
Getting tough on criminals has led to many perhaps unintended consequences;the perpetuation of
institutionalized racial discrimination on a grand scale in America and elsewhere (Alexander, 2010),
inhumane conditions of overcrowding, and skyrocketing costs of incarceration that deplete publicfunds that could be allocated to education and/or other essential social or health care services (Vera
Institute of Justice,2012;Sentencing Project,2013). More or less globally,corrections is now struggling
as well with how to deal with a growing wave of elderly adults, many of whom are in need of
specialized care, in facilities that were not at all designed for that purpose (Stone et al., 2011).
The next section of this paper attempts to summarize a number ofthe most significant consequences
for correctional services and outline some possible ways for corrections to respond more humanely andeffectively.
C. The Aging Prisoner Population:Significant Consequences and Possible Reponses
As the proportion of older and elderly offenders grows steadily, correctional services confront adifficult dilemma. With correctional budgets already stretched to the limit, do they more or less let
things be and thereby run the risk of not only seriously disadvantaging this group of individuals, butviolating their fundamental human rights. Or,do they further stretch these strained budgets to develop
specialized programs and services for these older offenders and possibly disadvantage younger
offenders as a result.
It has been estimated that taxpayers pay more than twice as much per year to incarcerate an aging
prisoner compared to a younger one (ACLU, 2012). The estimated 16 billion dollars required toincarcerate older offenders in America,for example,is more than the Federal Department ofEducation
funding for state elementary and secondary school improvements. While there is clearly an imperative
to look at sentencing reforms and diversion strategies for stemming the growth ofthe number ofelderly
in prisons (HRW, 2012;ACLU, 2012), the fact remains that corrections will need to attend, for theforeseeable future, to managing, and finding ways to reduce the cost, for at least the most essential
services for humane treatment of an increasingly aging prisoner population.
1. M anaging the Health Care Needs of the Elderly Prisoner
Even only the most basic and minimal level of care for elderly prisoners has been estimated to costroughly two to three times that for a younger prisoner (ACLU,2012). Aging prisoners are more likely
to suffer from a variety of medical conditions, require more contacts with healthcare providers, andwill typically need longer and more frequent hospitalizations. In America, a Bureau of Justice
Statistics national survey of prisonersʼmedical problems indicated that more than two-thirds ofprisoners age 45 and older were experiencing medical problems and over 20% had undergone surgery
after they were incarcerated (Maruschak, 2008). Loeb & Steffensmeier (2006) have nicely outlined abroad range of conditions that can lead to physical deterioration of the elderly prisoner.
―
―
―
―
―
―
―

Decreased sensitivity to heat, cold and pain (so they may need extra clothing and bedding);
Disinclination to eat (no taste, bad teeth and/or denture problems, swallowing problems andgastrointestinal difficulties, decreased sense of smell and taste)leading to weight loss;
Pressure injuries and falls which may be exacerbated by stairs, slippery floors and mats;
Increased problems with heart disease,either related to high blood pressure or to age relatedchanges in the heart muscle, lungs or blood vessels;
Decreased amount of activity;
Increased amount of medications they will be consuming;
Age related changes in the nervous system (for example,tremor or shaking of the hands andbody, dementia, stroke, parkinsonism);

8Our Public Safety Minister was also quoted as saying he didnʼ
t believe crime statistics because he knew that ʻ
unreportedʼ

crime was on the increase ― rather humorous if it wasnʼ
t also sadly reflective of how ʻfactsʼcan be so totally dismissedby politicians.

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―
―
―
―
―
―

Decreased circulation in the extremities,which can result from illnesses such as diabetes or life
style choices like smoking;
Poor sight and hearing;
Decreased muscular strength and physical fitness;
Bone and joint related disorders such as arthritis and osteoporosis;
Urinary tract problems ranging from infections to prostate problems to incontinence (either
bladder or bowel);Cancers of various types.

Several factors in particular stand out in accounting for the much higher cost of health care for theelderly in prisons, most of which are beyond the control of correctional agencies.
It is well established that the elderly in prison suffer more rapid decline in cognitive andfunctional capacity,or what is often referred to as ʻ
accelerated agingʼ(Fattah & Sacco,1989;
Human Rights Watch, 2012;Williams et al., 2012). This can be attributed to multiple causes
including a tendency to pursue unhealthy lifestyles (poor diets, little exercise)and engage inhigh-risk behaviors prior to imprisonment (smoking,drug and alcohol use);inadequate preventive health care; a greater rate of infectious disease; and the compounding effects of thedeprivations and stressors of prison life.
Prisons in general are designed for the young and able-bodied and not for individuals requiring
various special services and devices, such as walkers, wheelchairs, and hearing or breathing
aids. Without access to these medical aids, health conditions deteriorate even more quickly.
M ore so than in the community,the elderlyin prison also suffer from falls,accidents or various
kinds of victimizations, which also add to high health costs.
Correctional and healthcare professionals in prisons are under-trained vis-a-vis geriatric careand lack the technical expertise for early intervention of various age-related illnesses.
Problems such as hearing loss,vision problems,arthritis,diabetes,asthma,hypertension,and
dementia consequently exacerbate unnecessarily during confinement and costs to address
them increase.
Prisons often have to send aging prisoners to outside hospitals for emergency or specialized
medical treatment and this incurs the added costs of transportation,the specialized treatment
itself, and the salary costs of the officers (often with overtime) to supervise the prisoners
undergoing treatment. It has been estimated that these ʻexternal care expendituresʼcanconstitute up to 70% of total health care costs for the elderly offender.
And finally,at the extreme,taking care of some aging prisoners with chronic conditions (e.g.,
heart disease,emphysema),as well as hospice care for the dying,will require substantial costs
simply to meet even very basic needs.
Correctional agencies increasingly need to pursue innovative strategies to deal with these spiraling
costs of health care for the elderly offender. M any jurisdictions are turning to the establishment ofgeriatric or nursing-home type programs ranging from specially designed facilities for the aged andinfirm to special units within a larger prison setting. Grouping prisoners with similar health care needs
is not only more cost effective but it allows for the design of a more age-sensitive,safer and healthierenvironment for the elderly that can help avoid further deterioration and encourage preventive
self-care(e.g.,special diets,access to appropriate medications,geriatric walking programs,low-impact
sports activitiesetc.). With an interdisciplinary staff compliment trained in geriatric-specificcorrectional care,these specialized units often also make very effective use of family and prisoner peer
supports, and community in-reach and advocacy group volunteers and mentors (M aschi et al., 2013).
Programs are offered as well to help prisoners deal with their emotional reactions to health issues,thestrain of prison life, and conflicts or disengagement with family and children that can be a powerful
additional strain on physical health.
As long as sentencing practices continue to resort to lengthy prison terms despite the limited gains
for public safety, the aging of our prisoner population will press on, and the concomitant costs ofproviding essential health care services will present a growing challenge to corrections. A double-sided
strategy is needed where on the one hand,correctional environments for the elderly are created where
physical and mental health is not exacerbated (i.e., prevention), and on the other hand, practical40

157TH INTERNATIONAL TRAINING COURSE
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solutions are found where care can be provided in a cost-effective manner(i.e.,intervention). A numberof examples of these kinds of double-sided and integrated models of practice for managing the elderly
in corrections will be outlined later in this paper.
2. Coping and Adaptation to Prison Life for the Elderlyʻ
We assert that the poor social and environmental conditions of confinement,particularly for
older persons, are in fact a type of elder abuse and neglect.ʼ
Maschi et al., 2014, p. 56
There has been considerable criminological and psychological focus on the causes and consequencesofʻ
prisonizationʼ,and the challenges of coping with,or adapting to imprisonment. This dates back to
the early, classic sociologic studies of prison life (Clemmer, 1940;Sykes, 1958)and other more recent
and more psychologically attuned studies of the impact of imprisonment (see for example;Cohen andTaylor, 1972;Liebling & Maruna, 2005;Zamble & Porporino, 1988). Adjustment or maladjustment inprison is clearly multiply determined by both individual and setting characteristics. However,there isalso some significant degree of continuity in coping from community to prison,where those individuals
who are relatively well adjusted (socially and psychologically)in the community prior to incarceration
continue to cope relatively well during imprisonment (Zamble & Porporino, 1988). There has beenrather limited study of the psychological impact of imprisonment on the elderlyin particular. But whatevidence does exist suggests that there is no continuity in adjustment or coping for the elderly prisoner.
Regardless of how well they may have coped with life prior to imprisonment,the prison experience forthe elderly(and especially when it is lengthy)has profound and pervasive psychological repercussions.
As we have already noted, elderly prisoners are a heterogeneous group where some have aged inprison, others have been incarcerated late in life, and yet others are recidivists who may have had
numerous terms of imprisonment and may now be facing either a lengthy or relatively short prison
sentence in old age. Some will have histories of victimization or co-occurring mental heath and alcoholor substance abuse issues to contend with, while others may be mostly concerned only with healthissues. M any long-termers will have a respected position within the prison sub-culture,while the newly
incarcerated may feel alienated and out of place. Some individuals who have aged in prison may haveadapted,and even over-adapted,to the routines and depersonalization of the prison experience,falling
into institutional dependency (Aday, 2003). Others may be experiencing the early trauma of enteringa strange world where fear of violence and loss of control is persistent. A recent thematic analysis ofsome of the varied types ofʻ
psychologicalʼstressors experienced by the elderly in prison is informative,
based on an extensive survey of close to 700 elderly prisoners in one American state jurisdiction (seeTable 1;from M aschi et al., 2014).
Table 1. Types of Stressors for the Elderly in Confinement

Indisputably,the physical environment of most prisons will be similarly oppressive for most elderly
prisoners,especially if they are also frail or disabled (e.g.,poor lighting and ventilation,being housed

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too far away from dining rooms and toilet facilities,sleeping in bunk beds,limited recreational or work
opportunities). But the emotional and psychological coping and adaptation needs of the elderly
prisoner will vary substantially depending on how much time they may have served, how much timethey may have remaining to serve,their health conditions,available social support networks,and theirstatus within the prison hierarchy. By necessity,an effective correctional response to these differences
requires some level of individualized case management and sensitivity to the particular needs of theperson, both in time and place. Yet the elderly in prisons, particularly if they are relatively few innumber,can tend to be forgotten and ignored,both by correctional officers in their day-to-day interactions, and in terms of the design of more general institutional regimes and operations (i.e., routines,
regulations,time-tables,etc.). Some groundbreaking ethnographic research of the elderliesʼexperienceof imprisonment in the UK has coined the phrase ʻ
institutional thoughtlessnessʼto refer to this reality(Crawley & Sparks, 2005).
At the institutional level,there is typicallya requirement for the elderlyto fit into and accommodate
to existing routines and practices, not the other way around. Because they are generally less of aproblem, more cooperative and less disruptive, the needs of older prisoners are left inadvertently
unattended. Even in some very subtle ways,this can significantly add to the elderly prisonerʼs feelingsof helplessness,dependency and indignity.Crawley& Sparks (2005;2005a)give some examples that arecommonplace in correctional environments.
―
―
―
―
―
―
―
―

Not being allowed sufficient time to complete activities or to get to and from specific locations;
Forced to watch communal television in the corridor while sitting on hard, un-upholsteredchairs;Being denied additional clothing or bedding in cold weather;
Having to queue for long periods to obtain medication;
Having to climb stairs while carrying food trays;
No access to toilet facilities during exercise periods;
Having to shower in slippery,tiled cubicles that were not equipped with grab-rails or anti-slip
mats;Feeling abandoned or discarded because of limited access to unit officers.

Suffering through the indignities of prison life is a special challenge for the elderly offender. But
perhaps even of more fundamental impact is what Crawley & Sparks (2005) refer to as the need to
manage a ʻ
spoiled identityʼ
;the loss of a sense of purpose or coherence in life which for many can lead
ultimately to ʻa disengagement with all social activities and routines,including personal careʼ(Crawley,2005, p. 360). Crawley (2005) comments eloquently on this particular pain of imprisonment for theelderly offender.
“
The fact of being in prison at this point in oneʼs life is seen as making a failure,or fraud,ofthe whole of that life. This can be experienced as irreparable―there is not enough time left
to make good or start again
We found that many prisoners are very much engaged withreminiscence, seeking solace in the recollection of happier, more successful times
Forothers,however,retrospection offers few consolations. The gulf between the old life and theprison life is too great, the loss of status, position, and identity too complete. In such cases,
prisoners speak of their previous life as having been erased.”(p. 359)
Working to prevent psychological harm and deterioration for the elderly prisoner has to follow a
number of fronts. We know that prisons will generally function more humanely(and effectively)when
there is a proper balance of some key dimensions
an orderly, safe, and fair internal environment;
an active regime with provision of opportunities for personal development (＋ moral growth);respectful and courteous staff-staff and staff-prisoner interactions;timely response to prisoner concerns,and
decent treatment by highly motivated staff(Liebling,2011). The same principles apply in managing theelderly prisoner. But uniquely in caring for the elderly,there is need for other practice innovations andspecial focus. The following are a few examples.
Social work and psychology practice in corrections needs to become more geriatric-specialized42

157TH INTERNATIONAL TRAINING COURSE
VISITING EXPERTSʼPAPERS(Kratcoski, 2000) and more actively involved in advocacy to address the special needs of the elderly
offender (Maschi et al., 2014). Closer attention should be paid to critical periods in the lives of theelderly prisoner, when despondency and depression can set in even more acutely (e.g., the earlytransition into the prison subculture for the late-life offender;pre-release panic for the long-termer;
following the death of a fellow prisoneretc.). M onitoring the changing moods and patterns ofadjustment of the elderly can allow for early supportive intervention,perhaps exploring the benefits ofless change-oriented and more acceptance-oriented therapeutic models. For example, therapeutic
approaches could focus on alleviating the internal struggle of thoughts and feelings related to theinevitability of life in prison (Ruiz, 2010).9
Rather than slotting the elderly into existing educational and recreational programming, newprograms should be developed that are focused more particularly on the needs and interests of elderly
prisoners (e.g., rather than literacy or traditional upgrading, educational programs that focus on
fostering new life interests or hobbies or help explore latent artistic or creative talents;recreational
programs that allow for ease ofparticipation ofthe elderlysuch as geriatric walking programs and low
impact sports activities; reliance on community volunteers to engage the elderly prisoner in ageappropriate arts and crafts activities, theatre, literature or music appreciationetc.).
Self-help and mentoring or peer-support groups for the elderly can be re-motivating,validating andempowering, where common and long-standing concerns of life in prison can be shared and exploredwith peers who ʻ
see and feelʼthe same things (the pain of reminiscing,loss of freedom,health,energy,
work roles, identity, familyetc.). Powerful interpersonal bonds can be created that may last for
years.
For the long-termer,the notion of the prison career can be more fruitfully explored (a life-long job
in prison)and forecasting that an individual will be serving a lengthy prison term should invoke earlycase planning and training for that prison career to take shape. M any of these offenders can findmeaning and identity in their work in prison ― in vocational training shops or arts and crafts classes
as instructors, as literacy promoters or teachers, in prison maintenance work, as librarians, bookkeepers,clerks,and a variety of other prison jobs. Other late-life elderly offenders may already havepursued careers (e.g., accomplished perhaps as teachers, attorneys, accountants, priests,
businessmenetc.), and may bring with them various talents (e.g., as musicians, artists, gardeners,
educators). Not capitalizing on these capabilities and talents in some fashion within the correctional
environment is a sad waste of available resources.
Not all staff members will have the sensitivity, patience and compassion to deal with the elderly
prisoner. Rather than forcing staff to deal reluctantly with the elderly, selection and training forspecialized roles should be developed, line correctional staff working in special units for the elderly
should be carefully screened and other staff can be developed as ʻ
gerontologyʼspecialists.
Correctional environments that can deal more effectively with the elderly prisoner will not emerge
by accident. They need to be planned for and carefully designed and pay respect to the evidence wehave about how imprisonment can affect the elderly. Not all older prisoners will want to be surrounded
only by other older individuals. Some may resist being located in specialized facilities that may begeographically distant from families. There are also some well-accepted correctional advantages tomixed housing of offenders,where older offenders,for example,can serve as a ʻcalmingʼinfluence overyounger ones. But giving ʻ
choiceʼto the elderly offender may be what is most empowering.
It may not be possible to make prison environments actually healthy for the elderly,but at least we
can mitigate some of the impact and make them less unhealthy. Resources will continue to be a
problem but examples of specialized housing and programs for the elderly offender are growing. As
of 2008, for example, at least 13 US states had responded to the needs of older offenders by creating
9 For example, Acceptance Commitment Therapy (ACT)differs from traditional cognitive behavioral therapy (CBT)in

that rather than trying to teach people to better control their thoughts,feelings,sensations,memories and other private
events,ACT teaches them to simply focus on the present and ʻ
just noticeʼ,accept,and embrace the coming and going of
their thinking, especially anxious or traumatic events, but without struggling with them.

43

RESOURCE MATERIAL SERIES No. 94
specialized units, six had dedicated prisons, nine had dedicated medical facilities, five had dedicatedsecure nursing-home facilities,and quite a significant number had developed hospiceprograms(Sterns etal.,2008). One ofthesespecialized,multi-faceted and verygeriatric-sensitiveprograms is described in moredetail in Appendix A of this paper,the ʻTrue Gritʼprogram near Reno,Nevada (Harrison et al.,2012).
3. Supporting the Terminally Ill and Dying Elderly in Prisons
Between 2001 and 2009,illness-related deaths accounted for 9 out of 10 prison deaths in America andprisoners age 55 or older accounted for over 40% of all prison deaths (Noonan & Carson,2011). It has
been estimated that more prisoners on death row will soon be dying each year of natural causes in
America than will be actually executed.10 In Canada over the 10-year period 2003-2013,536 offenders
died in federal custody and two-thirds of these deaths were attributed to natural causes (OCIC,2013).
In the UK, the number of prisoners dying of natural causes was recently reported as reaching record
numbers.11
Issues surrounding the management ofthe severelyand terminallyill offender will continueto posea
significant challenge for correctional services,both in terms ofmaintaining communityand human rights
standards for ʻ
quality of careʼof prisoners before they succumb to death, and ultimately, in finding
ways to provide adequate and humane hospice care for the dying prisoner (Linder & Meyers, 2009).
Even in well-resourced correctional jurisdictions,concerns are raised routinely about the quality ofcare provided to seriouslyailing prisoners,often leaving unanswered the question as to whether a death
was preventable or premature. A recent study by the Office ofthe Correctional Investigator in Canada,
for example, concluded that the M ortality Review Process followed by Corrections Canada wasinadequate and that in numerous cases of death by natural causes there were questionable diagnostic
practices, incomplete records, lax information-sharing, and delays or lack of follow-up on referral ortreatment recommendations. Typically,correctional officials did not investigate the circumstances ofnatural deaths beyond recording the cause as either unexpected or sudden,and these in-custody deaths
failed to generate significant findings or recommendations for a ʻlessons-learnedʼexercise that could be
conducted to improve practice (OCIC, 2013).
Correctional services obviously need to work steadily to raise health care provision to communityequivalent standards. Two conditions that are at least somewhat treatable,heart disease and cancer,
account for close to 50% of illness-related deaths in prisons in America. Some elderly offenders will
die unexpectedly regardless of the quality of care they receive(e.g.,from heart attacks or strokes). Butothers will linger into slow deaths where hospice care becomes the onlyalternative. And this is an area
where some quite innovative ʻbest practiceʼhas emerged in recent years.
There is,of course,the alternative ofʻcompassionate releaseʼfor the terminally ill offender. But in
America,as in many other nations,the restrictions are considerable. In addition to requiring difficult
to obtain medical confirmation of near death prognosis, to be considered for compassionate leave
offenders have to be of low security classification,demonstrate future financial stability,and have an
established dwelling to return to. Aging relatives are often unreceptive about caring for a dying
offender and nursing homes are unwilling to assume the liability for accommodating ex-offenders.
Prison Hospice programs have become the only alternative for many offenders and though thetragedy of unnaturally dying in prison in pain and suffering has at times become the focus of media
sensationalism, other thoughtful presentations highlight the ways in which these programs can quite
deeply affect and benefit both the dying prisoner and the living caregiver.12
The first prison hospice programs were established in America in the late 80s in the states ofM issouri and California (Ratcliff, 2000). Ten years later, the National Institute of Corrections (NIC)
10 Seehttp://www.economist.com/blogs/economist-explains/2014/02/economist-explains-0>.
http://www.telegraph.co.uk/news/uknews/lawandorder/9544445/Recordnumberofprisonersdyinginoldage.html>.
12 See, for example, the recent quite touching academy award nominated documentary “Prison Terminal:
The Last Days of Prisoner Jack Hall” following the final months in the life of a terminally ill prisoner
http://www.prisonterminal.com/index.html＝>.
11 See44

157TH INTERNATIONAL TRAINING COURSE
VISITING EXPERTSʼPAPERS
identified 28 prison hospice programs (NIC,1998). More recently,the National Hospice and Palliative
Care Organization (NHPCO)in America estimated that 75 state and federal prisons and county jails
were offering a formal prison hospice program (Hoffmann & Dickinson, 2011). The National Prison
Hospice Association (NPHA) and the Guiding Responsive Action for Corrections in End-of-Life(GRACE)Project have also developed ʻstandards of practiceʼand ʻ
operational guidelinesʼrespectively,
to facilitate the implementation of hospice in prisons.13
A recent survey of 69 well established prison hospices in America noted that these programs havevarying capacity for hospice care of anywhere from one to 50 prisoners and that the programs operate
quite closely in accordance with community standards;typically managing patient care with Interdisciplinary Teams of a physician, nurse, mental health worker and chaplain who meet regularly toreevaluate the patientʼs care plan;providing hospice care to prisoners from various security classification levels;providing extensive hospice-specific training to caregivers,medical staff,and correctional
officers;and permitting frequent visits by incarcerated and non-incarcerated family members.Uniqueto prison hospice programs,however,is the extensive use of fellow prisoners as caregivers. Over 95%
of these prison hospices reported employing trained inmate caregivers.Acknowledged generally as the
backbone of the prison hospice movement, compared to their volunteer counterparts in community
hospices, these inmate caregivers are screened more intensely, go through more stringent training
requirements, perform a wider variety of duties, and work much longer hours. Table 2 below is ofinterest in documenting the variety of ways that inmate caregivers actually contribute (Hoffmann &Dickinson, 2011).
Table 2:Duties Regularly Performed by Inmate Caregivers

There are clearly some challenges to contend with in expanding the use of prison hospices (Hoffmann & Dickinson, 2011). First, managing the pain of dying patients can be seen as conflicting withsecurity concerns about prisonersʼabuse of drugs in the prison black market. Careful monitoring has
to be instituted to ensure that medication is actually consumed by hospice patients. A second challenge
relates to a central tenet of hospice care which is that family members should be actively involved in
the care-delivery process. Ways to involve families, and community volunteers, as much as possible
and/or desired have to be found. A third challenge is the paradigm shift required to reconcile theseemingly contradictory philosophies of corrections and hospice (i.e., punishment vs. care). Hospiceprograms may have to struggle to gain the support and trust needed from correctional administrators,
correctional officers and other prison staff, to effectively deliver care to terminally ill inmates. And
finally, a particular issue faced by prison hospices is whether offenders will agree to the cessation of
curative treatment as a condition of admission, considering that the incarcerated individual may
seriously doubt whether the prison administration and medical staff have their best interests at heart.
The prison hospice is an innovation born out of necessity that is now accepted internationally notjust as ʻ
goodʼpractice but also as humane and ethical practice. It is rare that correctional programs
can serve the dual purpose of care and support for the client as well as personal growth and both
rehabilitative and redemptive potential for the caregiver (M aull, 2005;Wright & Bronstein, 2007).
13 See National Prison Hospice Association. Prison hospice operational guidelines.

http://npha.org/resources-2/downloads/>;and Guiding Responsive Action for Corrections in End-of-Life.
http://www2.edc.org/lastacts/archives/archivesM ay00/standards.asp>.

45

RESOURCE MATERIAL SERIES No. 94
4. Reintegration of the Elderly Offender Back to the Community
Some elderly offenders will unfortunately die in prison. But the majoritywill eventuallybe released
even if quite late in their lives and quite ill or disabled. There are some rather unique issues forcorrectional services to deal with in this regard. Unlike with younger offenders, where re-entry
programming and community supervision has to focus quite deliberately on ʻ
risk managementʼ(i.e.,tominimize the risk of reoffending), the issue of risk management with the elderly is of a completely
different nature. It is well established that the elderly ex-offender is only very minimally at risk for
re-offending, and even when it does occur, it is typically of a rather minor nature (e.g., violation of aparole condition). One study of offenders released from New York state prisons, for example, foundthat only a very small percentage of elderly offenders were returned to prison within three years fora violent offence(only 3.4% of those who were between 55 and 64 when released and none of those who
were 65 or older)(Human Rights Watch, 2012).
Risk management for the elderly ex-offender is more a matter of preventing risk for homelessness,loneliness and depression, suicide, return to alcohol or substance abuse, unhealthy lifestyles and lackof access to medical care that will shorten life,and a host of other personal and social issues that will
make for a rather sad quality of life in old age.
Older offenders, especially those well past the age for typical employment potential, and often
lacking living family members to assist them upon release, will need to secure some level of social
assistance and/or specialized housing (e.g., assisted living). Long termers may need practical assistance in finding housing or employment after release, but more importantly in many ways, they willneed to learn to negotiate the new world around them,a world quite different from the one they mightremember. They may lack important social and practical skills for living,express nervousness about
re-establishing ties with family, feel disconnected and unwelcomed in the communities they return to,
and generally see little meaning or purpose for living.
Successful community reintegration for the older offender can be excruciatingly challenging when
there is a compounding of factors, like one grenade after another tossed their way ― serious healthand/or mental health issues to contend with,lack of any family or peer support,no financial resources,
inability to access social welfare benefits, no available transportation, and no place to live.
Fundamentally,it is unlikely that the varied needs of the typical elderly offender can be met as an
adjunct or afterthought in the normal course of most community corrections programs. It has beenreferred to as a ʻ
mission seemingly impossibleʼ(Haberman, 2001). Some level of specialization andfocus is required and there are now some growing examples of a more geriatric-sensitive approach forreintegration of the elderly offender. The following is a sampling of some of these in a number ofdifferent countries.
Hocking Correctional Facility (Ohio, USA). The Hocking Correctional Facility(HCF)in Ohio wasestablished specifically to addresses the prison and community reintegration needs of older prisoners.
Offering one-stop wrap-around services,it includes a pre-release program that provides offenders withinformation on social security or welfare benefits, job-seeking skills, housing-placement services,
employment training, property maintenance, self-care and gero-informed psycho-educational classes,
and general education courses. Staff members are trained to deal effectively with geriatric populations, including chronic illnesses and death and dying issues. Community reintegration is focused on
ensuring that older offenders have the necessary resources for living,including an approved placement
in a nursing home if necessitated by declining health.
SEOP (San Francisco, USA). Funded by the U.S.Office on Aging,the program is located in a seniorcenter for adults aged 50 and older who are incarcerated or about to be released.It provides medical,
financial, social, mental health, and employment services. Wraparound services are provided that
include basic needs,health literature,pre-and post-release counseling,case management,and counseling and support groups (Maschi et al., 2013).
RECOOP (England). This UK program specializes in the care,resettlement,and rehabilitation ofolder offenders and ex-offenders. Program components include support services,advocacy,advice on

46

157TH INTERNATIONAL TRAINING COURSE
VISITING EXPERTSʼPAPERS
financial, housing, employment and health care needs, life skills and mentoring (Davies, 2011).
RESTORE 50 plus Program (England). This is an innovative approach for community reintegration of the elderly offender that adopts a supportive ʻ
offender responsibility modelʼmanaged by older
ex-prisoners in collaboration with correctional staff, where peers provide mentoring and extensivesocial support services (Davies, 2011).
RELIEF (Canada). Established in 1999,this program grew out of a collaborative initiative among
offenders, community volunteers and corrections staff in British Columbia, Canada. The ʻ
Reintegration Effort for Long-term Infirm and Elderly Federal Offendersʼprogram was designed to facilitate thetransition of elderly and infirm older adults from prison to the community. Six self-contained,
six-bedroom houses are dedicated to housing clients and caregivers of the RELIEF program, and allliving, recreational and programming space is at ground level and walker and wheelchair accessible.
The program goes further in adopting an innovative peer support model in that ex-prisoners arescreened to receive hospice training and subsequently serve as caregivers for elderly and infirm
offenders (Stewart, 2000). Supervision, general care, and access to medical care is provided by thesetrained offenders working together with other professional staff and specialized community medical
services. Similar initiatives, and other assisted housing projects, are now being pursued in otherlocations throughout Canada.

II. CONCLUSION
Perhaps a good place to end this review of the issues surrounding management of the elderly incorrections is to briefly summarize some of the major recommendations that have flowed out of recent
thorough analyses of the problem. The American Civil Liberties Union report ʻ
Mass Incarceration of
the Elderlyʼ(2012) highlighted the need for a broad revision of harsh sentencing practices that havecaused the problem in the first instance, including recommending the presumptive granting of conditional release to elderly offenders who pose little risk to public safety. The Human Rights Watch
report ʻ
Old Behind Barsʼimplores correctional officials to pursue a range of strategies, including:
―

―
―
―
―

Undertaking a comprehensive analysis of older prison populations to determine whether,andto what extent, they are being provided with adequate housing, medical care, and programs
that respond to their unique needs and vulnerabilities;
In consultation with older incarcerated men and women,review custody and securityrules andtheir implementation to ascertain which impose unnecessary hardship on older inmates;
Providing training for corrections officers working with older persons, including training inchanging physical and mental conditions, and appropriate means of communication;
Routinely monitor older prisoners to ensure they are not being victimized, and take thepotential for victimization into consideration in their housing decisions;andEnsure that a senior official has the specific responsibility for monitoring, assessing, andpressing for improvements in confinement conditions for older prisoners.

And finally, a recent UNODC report, the ʻ
Handbook on Prisoners With Special Needsʼ, offers an
exhaustive set of recommendations for management of the elderly prisoner within the correctional
environment (Atabay,2009). The report should be required reading for all correctional officials and therecommendations dealing with the elderly offender are reproduced in Appendix B to this paper.
It is undoubtedly the case that limited resources, resistance to changing longstanding policies andprocedures,lack of government support,as well as insufficient ʻurgencyʼregarding the need to address
the particular vulnerabilities of older prisoners, will all lead to some stalling of efforts in developing
a set of geriatric-informed correctional practices.
The elderly offender is still treated as distinctly marginal and remains more or less peripheral topolicy and advocacy within most correctional jurisdictions. Where innovative practices have emerged,
it is typically because of the local efforts of determined correctional professionals,often in partnershipwith the voluntary sector. Despite their increasing numbers, elderly offenders have not yet attained
visibility as a national or international policy issue in corrections. But the evidence is now available

47

RESOURCE MATERIAL SERIES No. 94
and the issues have now been well formulated and presented by numerous researchers (Aday, 2003;
Crawley & Sparks, 2005, 2005a; Lemieux et al., 2002; Maschi et al., 2014), the media (http://www.
prisonterminal.com/index.html＝), high profile human rights groups (HRW, 2012; ACLU, 2013), andeven government reports (Atabay, 2009;Kennedy, 2008).
M aschi et al. (2013)present a useful model for thinking about the kind of differentiated approachand areas of focus required to deal more effectively with the elderly offender in corrections (see Figure
3 below). As with other complicated issues facing correctional services, however, sporadic or spotty
innovation that occurs here and there will not be able to address fully the challenge of managing theelderly in corrections. An overarching and integrated framework is needed,supported by politicians,
policymakers,practitioners,researchers,the non-governmental sector and the public at large. Reforms
are needed both for reasons of humanity and cost-effectiveness in supporting public safety. They
should encompasses needed legislative change in sentencing practices,new policyformulation,development of geriatric-sensitive programming and services, prison design, staff training initiatives, andcommunity partnerships to aid in the very real challenge of reintegration of the elderly offender. The
evidence on which to base all this is now there. All that is needed is for the sense ofʻurgencyʼto deal
with the issue to begin spreading.
Figure 3:A Framework for Best Practice Programming for the Elderly Offender48

157TH INTERNATIONAL TRAINING COURSE
VISITING EXPERTSʼPAPERSREFERENCES
Aday, R. H. (1994). Aging in prison:A case study of new elderly offenders. International Journal of
Offender Therapy and Comparative Criminology, 38, 79-91.
Aday, R. H. (2003). Aging prisoners:Crisis in American corrections. Westport, CT:Praeger.
Administration on Aging. (2014). Projected future growth of the older population. Retrieved fromhttp://www:aoa.gov/AoARoot/Aging Statistics/future growth/>.
Alexander,M.(2010). The new Jim Crow: Mass incarceration in the age of colorblindness,New York:New Press.
American Civil Liberties Union.(2012). At Americaʼ
s Expense:The mass incarceration of the elderly.
New York:ACLU.
Atabay, T. (2009). Handbook on Prisoners with Special Needs. New York:United Nations Office On
Drugs and Crime.
Berman, G. & Dar, A. (2013). Prison Population Statistics. London:House of Commons Library.
Bernstein, D. (2011). Under Custody Report:Profile of Inmate Population Under Custody on January
1, 2011. Statistical Reports on Offender Population. State of New York Department of Corrections
and Community Supervision, Apr. 2011.
Clemmer, D. (1940). The Prison Community. Boston:Christopher.
Cohen, S., & Taylor, L. (1972). Psychological Survival. Harmondsworth, UK:Penguin.
Corrections Yearbook (2003). Middletown, CT:Criminal Justice Institute.
Crawley, E. (2005). Institutional thoughtlessness in prisons and its impacts on the day-to-day prison
lives of elderly men. Journal of Contemporary Criminal Justice, 21:350-363.
Crawley,E.and Sparks,R.(2005).Hidden injuries? Researching the experiences ofolder men in English
prisons. The Howard Journal of Criminal Justice, Vol. 44 No. 4, pp. 345-56.
Crawley, E., & Sparks, R. (2005a). Older men in prison:Survival, coping and identity. In A. Liebling& S. M aruna (Eds.), The effects of imprisonment (pp. 343-365). Cullompton, UK:Willan.
Davies,M .(2011). The integration of elderly prisoners:An exploration of services provided in Englandand Wales. International Journal of Criminology, 1, 1-32.
Durham, A. M. (1994). Crisis and reform: Current issues in American punishment. New York:Little
Brown.
Dawes, J. (2005). M anaging an aging prison population. In S. E. Oʼ
Toole, S. (Ed.), Corrections
Criminology. Annandale:Hawkins Press.
Falter,R.G.(2006).Elderly inmates:An emerging correctional population. Correctional Health Today
Journal, 1, 52-69.
Fattah, E.A., & Sacco, V.F. (1989). Crime and Victimization of the Elderly. New York: SpringerVerlag.
Feldmeyer, B. & Steffensmeier, D. (2007). Elder Crime: Patterns and Current Trends, 1980-2004.
Research on Aging, Vol. 29 , #4:297-322.

49

RESOURCE MATERIAL SERIES No. 94
Gallagher,E.(2001).Elders in prison:Health and wellbeing of older inmates. International Journal of
Law & Psychiatry, 24, 325-333.
Goetting, A. (1984). The elderly in prison:a profile. Criminal Justice Review, Vol. 9 No. 14, pp. 14-24.
Grant, B. & Lefebvre L., (1994). Older offenders in the Correctional Service of Canada. Forum on
Corrections Research, Vol. 6, #2.
Guerino,P.,Harrison,P.M.,& Sabol,W.(2011). Prisoners in 2010.Washington,DC:U.S.Departmentof Justice. Washington:Office of Justice Programs, Bureau of Justice Statistics.
Haberman,E.L.(2001).M ission seemingly impossible:community placement of chronic care inmates.
Corrections Today, 63(5), 115-118.
Harrison, M .T., Kopera-Frye, K. and Harrison, W.O. (2012). A promising practice ― True Grit: A
structured living program for older adults in prison, in Maschi, T.,M orrissey,M.,Immagieron,R.
and Sutfin,S.(Eds),Aging Prisoners: A Crisis in Need of Intervention,New York,NY,pp.99-109.
Hoffman, H.C., & Dickinson, G.E. (2011). Characteristics of prison hospice programs in the UnitedStates. American Journal of Hospice & Palliative Medicine, 28(4), 245-252.
Human Rights Watch. (2012). Old Behind Bars. Retrieved fromhttp://www.hrw.org/reports/2012/01/27/old-behind-bars>.
Kennedy, T. (2008). The greying of the offender population: The implications for New South Wales
Corrections in 2021. Sydney:New South Wales Department of Corrective Services.
Kratcoski, P.C. (2000). Older inmates: Special programming concerns. In P.C. Kratcoski (Ed.),
Correctional Counseling and Treatment. Prospect Heights, Il.:Waveland Press.
Lemieux, C.M ., Dyeson, T.B., & Castiglione, B. (2002).Revisiting the Literature on Prisoners who areOlder:Are we Wiser?The Prison Journal, 82:4, 440-458.
Liebling,A (2011).Moral performance,inhuman and degrading treatment,and prison painʼ.Punishment
and Society, 13(5):530-550.
Liebling, A. & M aruna, S. (2005)(Eds.), The Effects of imprisonment. Cullompton, UK:Willan.
Linder,J.F.& M eyers,F.J.(2009).Palliative and End-of-Life Care in Correctional Settings,Journal ofSocial Work in End-of-Life & Palliative Care, vol. 5 issue 1-2, pp. 7-33.
Loeb, S.J. & Steffensmeier, D. (2006). Older male prisoners: health status, self-efficacy beliefs andhealth-promoting behaviors. Journal of Correctional Health Care, 12(4), 269-278.
M aruna, S. (2000). Making Good: How Ex-Convicts Reform and Re-Build Their Lives.Washington,D.
C.:American Psychological Association.
M aruschuk,L.M.(2008).The Medical Problems of Prisoners.Washington:Bureau of Justice Statistics;
NCJ 221740.
M aschi,T.,Morrisey,M .B.,& Leigey,M .(2013).The case for human agency,wellbeing,and community
reintegration for people aging in prison:A statewide case analysis. Journal of Correctional HealthCare, 19(3), 194-210.
M aschi, T., Viola, D., Harrison, M.T., Harrison, W., Koskinen, L. & Bellusa, S. (2014). Bridging
community and prison for older adults: Invoking human rights and elder and intergenerationalfamily justice. International Journal of Prisoner Health, Vol. 10, No.1, pp. 55-73.

50

157TH INTERNATIONAL TRAINING COURSE
VISITING EXPERTSʼPAPERS
M aull, F. (2005). The prison hospice movement. Explore. 1(6):477-479.
National Institute of Corrections (1998). Hospice and palliative care in prisons. Longmont, CO.
Neeley, C. L., Addison, L., & Craig-Moreland, D. (1997). Addressing the needs of elderly offenders.
Corrections Today, 59(5), 120-123.
Noonan,M .E.& Carson,E.A. (2011).Prison and Jail Deaths in Custody, 2000-2009 ― Statistical Tables.
Washington:Bureau of Justice Statistics (NCJ 236219).
OCIC (2013). An Investigation of the Correctional Service of Canadaʼs Mortality Review Process.
Ottawa:Office of the Correctional Investigator of Canada.
Public Safety Canada (2012). Corrections and Conditional Release Statistical Overview.Ottawa:Public
Safety Canada.
Ratcliff M. (2000). Dying inside the walls. Journal of Palliative Medicine, 3(4):509-511.
Ruiz, F. J. (2010). A review of Acceptance and Commitment Therapy (ACT) empirical evidence:
Correlational, experimental psychopathology, component and outcome studies. International
Journal of Psychology and Psychological Therapy 10 (1):125-62.
Sentencing Project (2013). Ending mass incarceration: Charting a new Justice Reinvestment, Washington:The Sentencing Project.
Steffensmeier, D., Allan, E. A., Harer, M . D., & Streifel, C. (1989). Age and the distribution of crime.
American Journal of Sociology 94:803-31.
Sterns,A.A.,Lax,G.,Sed,S.,Keohane,P.,& Sterns,R.S.(2008).Growing wave of older prisoners:A
national survey of older prisonerʼs health, mental health, and programming. Corrections Today,
70(4), 70-72, 74-76.
Stewart, J. (2000). The Reintegration Effort for Long-Term Infirm and Elderly Federal Offenders(RELIEF)Program. Forum on Corrections Research, Vol. 12, No. 3.
Stone, K., Papadopoulosi, I., & Kelly, D. (2011). Establishing hospice care for prison populations:An
integrative review assessing the UK and USA perspective. Palliative Medicine, Oct (12).
Sykes, G. (1958). The society of captives. Princeton, NJ:Princeton University Press.
Vera Institute of Justice (2012). The Price of Prisons:What Incarceration Costs Taxpayers. available
at http://www.vera.org/download?file＝3495/the-price-of-prisons-updated.pdf>.
Williams, B.A., Stern, M .F., Mellow, J., Safer, M., & Greifinger, R.B. (2012). Aging in correctionalcustody:setting a policy agenda for older prisoner health care.American Journal of Public Health,102(8), 1475-1481.
Wright K.N., & Bronstein L. (2007). Creating decent prisons: a serendipitous finding about prison
hospice. Journal of Offender Rehabilitation;44(4):1-16.
Wright, V. (2010). Deterrence in Criminal Justice:Evaluating Certainty vs. Severity of Punishment.
Washington DC:The Sentencing Project.
Zamble, E. & Porporino, F. (1988) Coping, Behavior, and Adaptation in Prison Inmates. New York:
Springer-Verlag.

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APPENDIX AʻTRUE GRITʼ
:DESCRIPTION OF A M ODEL CORRECTIONAL PROGRAM FOR THE ELDERLY
OFFENDER
Because the problem of the elderly in prison is perhaps most severe in America,a number of US states
have recently revamped their policies and approaches for dealing with this population. The state of
M issouri, for example,has designed Enhanced Care Units ʻ
to keep offenders as functional as possible
while providing appropriate health and housing services to accommodate their special needsʼ
. The
units have only single level bunks,organized activities to keep offenders busy and oriented,assistancefrom other offenders trained as helpers, special assistance with meals, and daily rounds by healthservices staff. In the state ofTexas,there are special geriatric units in different state prisons to provide
accommodations for offenders who are age 60 or older. The units allow for longer periods of time todress,eat,move from place to place,and shower. A specialized medical facility for the elderly is alsoavailable that provides physical, occupational, and respiratory therapy,special wheelchair accommodations, temperature-adjusted environments, dialysis, and services for prisoners with hearing andvision impairments (HRW, 2012).
The following description of a model correctional response for dealing with the elderly in prison isborrowed from the work of Tina M aschi and her colleagues (2014), a group of American researchers
who have both studied and advocated extensively for a more humane response to the plight of theelderly in corrections.
The ʻ
True Gritʼprogram in the State of Nevada in America offers an excellent example of a wellintegrated and focused correctional response to the management of the elderly prisonerʼs physical andmental health. The program was established to deal with the entire range of issues confronting theelderly in prison;including physical disabilities, chronic health problems, substance abuse, sexuallydeviant behavior,post-traumatic stress disorder,depression,terminal illness,chronic pain,and end-oflife issues, and/or concerns with community reintegration. It admits select offenders age 55 or older
who are exposed to a structured living environment (SLP)where there is “a comprehensive programof structured physical, mental, emotional and spiritual activities with a set routine and within which
each member is required to participate,to the best of his abilities,on a regular basis”(Harrison et al.,2012).
The True Grit Program components ― The SLP has a variety of interactive modules or aspects thattie it together. An important facet of the program is that all members are housed together in a separate
unit;younger inmates are excluded. When medically necessary,program members may be transferred
to at Regional M edical Facility but return to the SLP upon medical discharge. As necessary, dying
inmates are afforded end-of-life care in the infirmary,provided by staff,volunteers,and compassionate
care visits from other SLP members. Recreational activities are a major segment of the program.
Crocheting,knitting,beading,and latch-hook rug-making provide activity that is not only cognitively
stimulating,but affords excellent physical therapy for arthritic hands and fingers. Beginning with noresources, the programʼs musical activities have expanded to include five vocal ensembles and four
instrumental groups. Recent donation of guitars and sound amplification equipment by a prisonerrehabilitation organization (Jail Guitar Doors)allows former professional musicians in the program toenable amateurs to improve their skills. The Do-Wop Band,True Grit Choir,Spanish ensemble,True
Grit Pops, and Country/Western groups rehearse regularly, and perform whenever the opportunity
presents itself. Because a busy mind may not decline as rapidly as an idle one, True Grit has many
cognitive therapy activities, including an ethno-drama theater arts group;a creative writing group;acultural arts group;and a Spanish language study group. Literary skills are enhanced by productionof True Grit Notes, written and edited by members,and an extensive microwave cookbook featuring
meals that can be prepared using limited supplies available in prison. Most of the performances by the
ethno-drama group deal with problems unique to aging in prison. Unchained Verse is an on-goinganthology of poetry created by the members and mentored by a volunteer retired college professor.
This exercise enables men to express thoughts and emotions that they might otherwise never verbalize.
A Navy veteran volunteer works with inmate veterans to write memoirs or produce artwork relating
to their military experiences.

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Substance abuse/addictions groups ― Traditional 12-step groups including Alcoholics Anonymous,
Narcotics Anonymous, and Sexual Compulsives Anonymous meet regularly, facilitated by volunteer
sponsors.
Wellness and life skills/activities of daily living ― Once each week SLP members gather for seminars
on various aspects of health and wellness, life skills such as cooking, menu-planning and healthy life
choices,or other relevant activities. Group members present a laypersonʼs view of a medical condition
or discuss topics such as human sexuality and the aging process.
Pet therapy/end-of-life care ― Pet therapy plays an extensive role within True Grit. Volunteers fromIntermountain Therapy Animals visit the prison on a weekly basis, providing the members with theopportunity to experience unconditional affection. The volunteers from this organization provide
animal-assisted therapy in the areas of physical,occupational,speech and psychotherapies,as well as
special education. The dogs assist regularly in the pain management group;several have been in theinfirmary with dying inmates during their last days.
Physical fitness ― The men assemble regularly in the gymnasium or ball field for group and individual
physical activities. Depending on the weather these may include wheelchair softball, basketball, orvolleyball; aerobics, tennis, measured-distance walking, weight lifting, stationary bicycle, billiards,
Ping-Pong,horseshoes,or dancing. The latter is usually combined with one or more musical sessions.
Although no credentialed music or dance therapist conducts these sessions, they achieve the desired
goal of enhancing the menʼs physical and mental fitness.
Peer support groups/Vet-to-Vet ― More than half of True Gritʼ
s members are veterans. Volunteers
from chapters of the Vietnam Veterans Association,both within and outside the prison,conduct weekly
peer support groups with elderly veterans,modeled on the Department of Veterans Affairs Vet-to-Vet
program. Volunteers assist members with writing their combat-related memoirs, and a number are
producing sketches and paintings related to their military experience.
Spiritual activities ― In addition to institutional religious activities conducted by prison staff andvolunteers,there are a number of lay leaders within True Grit. They carry out various spiritual rituals
on a regular basis. One particularly moving ceremony is the memorial service conducted after an SLP
member dies in prison.
Correctional mental health activities ― Formal correctional programs facilitated by both staff andcommunity volunteers are available to members of True Grit. These programs include victim
awareness, stress management, anger management, conflict resolution, relationship skills, healthrelated recovery, commitment to change, trauma and recovery, addictions prevention education, sex
offender treatment of prisoners (STOP),Inside/Outside Dads,and special populations programs. M anyof these programs,when completed successfully,provide the members with meritorious credit toward
reducing the length of their sentence.
Discharge planning ― Volunteers provide members with information and referrals concerning theireventual release from prison. This includes collaboration with non-profit organizations, halfway
houses, resources for potential employment, and other assistance. Organizations such as the Department of Veterans Affairs have also been helpful in preparing SLP members for release and successful
return to the community.
Maintaining True Grit in the face of diminishing resources:
In Nevada,the Department of Corrections continues to face a significant budget crisis,resulting in the
reduction of non-correctional staff,such as mental health professionals,as well as lack of funding for
new projects. Despite this,True Grit has grown and been successful because the costs for the state havebeen minimal. This is due primarily to extensive use of volunteers and generous donations of supplies
and material from community organizations. The first volunteers were a group of dogs and theirhandlers, part of the Intermountain Therapy Animal organization. Volunteers now include college
professors and other educators, psychologists, nurses, and retired military personnel. Community

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organizations and private donors also enable diversion activities, cognitive-behavioral interventions,musical activities, the library, the physical fitness program, and the wheelchair repair program tooperate successfully. As an example,a community service organization in Reno regularlydonates used
durable medical equipment, including wheelchairs, to True Grit.
Preliminary evaluation results:
The program is currently being evaluated for its impact. Preliminary analysis of the qualitative datafrom True Grit participants suggests that they view the program as an invaluable part of their lives,
helping them cope with daily prison stress while allowing them to offer restitution for their crimes.
Preliminary quantitative analysis suggests that participants who were released have a 0% recidivism
rate.
Caveats and pitfalls:
True Grit is a multi-faceted, multi-disciplinary programmatic approach to meet the bio-psycho-socialand spiritual needs of older adult prisoners, with the primary goal of rehabilitation of the individual
and assistance with reentry into society. However, despite being broadly recognized and promoted,
True Grit has not been without problems. First and foremost,not all security or correctional officers
or professional staff support or agree with the program. There has been resistance in some quarters
to fully implementing True Grit. Uninformed members of the general public tend to resist what somehave labeled “coddling”of prisoners. Unless a cadre of volunteers and an outside support system ofdonors are organized,funding for older adult prisoner programs may be difficult to implement. With
support from administration and continued educational efforts, both inside and outside prison, however, most resistance for True Grit has been diminished54

157TH INTERNATIONAL TRAINING COURSE
VISITING EXPERTSʼPAPERS
APPENDIX B
UNODC RECOMM ENDATIONS:HANDBOOK ON PRISONERS WITH SPECIAL NEEDS
1. To Sentencing Authorities―――

To pursue a criminal justice policy under which long-term sentences are imposed only if they arenecessary for the protection of society.
To take into account the age of offenders,their mental and physical health,prospects of receiving
adequate care in prison, when passing judgment, to ensure that sentences do not comprise disproportionately harsh punishments.
To consider older prisoners who have committed non-violent offences for non-custodial sanctions
and measures as a matter of principle, as their care can much better be provided for in thecommunity.

2. To Prison Authorities, Probation and/or other Social Welfare Services
M anagement policies and strategies― To develop special policies and strategies to address the needs of this vulnerable group of
prisoners.
― To involve the input of a multidisciplinary team of prison specialists,working in coordination withspecialists and service providers from the community, particularly in the area of medical care.
― To include issues such as staff training, placement of older prisoners within the prison system,
improvement of services, coordination with civil society, early conditional release, release on
compassionate grounds and resettlement in the policies and strategies to be developed.
Staff― To ensure that all staff that has any involvement in the supervision and care of older prisoners
receive training to enable them to work constructively and effectively with this group of prisoners.
― To encourage prison service staff to work with organizations of civil society,as well as health andwelfare services,in order to cover all the needs of older prisoners,while laying the basis for theircontinuum of care in the community following release.
Access to justice― To assist older prisoners in accessing legal counsel, legal and paralegal aid services from theoutset of their detention and to provide additional support to older prisoners with mental or
physical disabilities,as required,to ensure that they are not discriminated against in their accessto justice and treatment in the criminal justice system.
Assessment and allocation― To ensure that a proper assessment is undertaken to determine the very varied needs of older
prisoners on admission, taking into account the low risk status of most older offenders;― Due to the rapidly changing status of older prisoners,particularly in terms of health,to undertake
reviews on a regular basis to modify programmes,as well as to reconsider security classificationlevels.
Accommodation― To place the majority of older prisoners in the general prison population,taking into account their
special accommodation requirements and their need for tranquillity and association with peers.
― To accommodate a small number in special units,only if absolutely necessary to provide specialists care on an ongoing basis, and if it is in the interest of the prisonersʼmental well-being andhealth care. Preference should be given to releasing such prisoners on compassionate grounds tobe treated in the community, wherever possible (see below).
Health care
― To ensure that the medical,nutritional and psychological health care needs of older prisoners aremet, with the engagement of a multidisciplinary team of specialist staff.

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To establish close cooperation with community health services to ensure that specialist care isprovided by outside medical services,as necessary,and that prisoners whose needs cannot be met
in prison are transferred to civilian hospitals.
To provide special programmes addressing mental disabilities, such as depression and fear of
dying, as well as individual counselling, as necessary.

Contact with the outside world― To place older prisoners as close as possible to home in order to help them maintain contacts withfamily members. In addition, where resources allow, to organize family visits for those who are
too old to travel.
― To grant regular prison leave as an integral element of prison regime,enabling older prisoners tospend time with their families and thereby to maintain contact and reduce the sense of isolation.
― To encourage organizations of civil society which work with older persons to include prison visits
and projects in prisons within their programmes.
Prisoner programmes― Where older prisoners are integrated with the general prison population,to make modification toexisting programmes to enable all groups of prisoners,including older prisoners,to participate,aswell as to introduce special programmes that address the needs of older prisoners.
― Special vocational training programmes may include skills training in a selection of arts andcrafts, while areas can be set aside in prisons for older prisoners to read, play cards and board
games or just to associate with each other.
― Other special programmes could include instruction on health care for older prisoners,counselling
related to growing old,fear of death,isolation and substance abuse,tailored physical activity andspecial education courses that meet the needs of this age group. Specialized counselling may also
include those designed for prisoners with terminal illness and those who have received life
sentences without parole.
― To be guided by older prisonersʼown wishes and abilities in determining the level of outdoor
exercise they participate in,and to provide some support and flexibility,as necessary,in arrangements in order to enable older prisoners to take exercise or participate in outdoor recreational
activities.
― Other prisonersʼassistance in helping care for older prisoners may be sought, after careful
screening, assessment and training.
― To take steps to engage community services and NGOs working with older persons in thecommunity in designing and delivering programmes and activities for older prisoners.
Preparation for release and post-release support― To develop individualized preparation for release programmes taking into account the special
needs of prisoners who have grown old in prison and those who have no family support,in orderto help re-establish links with the community, including with health and welfare agencies.
― To work in close coordination with probation services where they exist and with other agenciesof civil society and NGOs,to ensure that maximum possible support is provided to older prisoners
during the difficult period of re-entry into society.
Early conditional release, compassionate release and amnesties― To consider developing a different set of parole eligibility criteria relevant to the needs oflong-term and older prisoners, to minimize the disadvantages they face in the consideration forearly conditional release.
― To release on compassionate grounds older prisoners who are in need of constant specialist
nursing care,and who do not pose a risk to society,transferring them to an appropriate institution
in the community.
― To encourage and facilitate contacts between older prisoners and legal aid services at theappropriate stage,in order to assist such prisoners in gaining early conditional and compassionate
release.
― To ensure that older prisoners, and particularly older women, are one of the groups of prisoners
prioritized for release under amnesty laws, following a careful risk assessment.

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