As the prison population ages, so does the parole population. Between 1990 and 1999, the percentage of new parolees aged 55 and older increased from 1.5% to 2.1% of the total U.S. parolee population and the number of state prisoners aged 55 or older leaving custody on parole nearly doubled from approximately 5000 in 1990 to approximately 9000 in 1999 (http://www.ojp.usdoj.gov/ bjs/pub/pdf/reentry.pdf, 2003). Despite these changing demographics, little research has been done on the care and well-being of older ex-prisoners.
On release, geriatric ex-prisoners may face unique challenges reentering the community. These challenges are social as well as medical, and include: frailty in an unsafe neighborhood; concerns about employability as an older person; multiple chronic illnesses with functional limitations; and/or lack of medical insurance or prescription drug benefits. In addition, serious mental illness and the psychological syndrome of institutionalization cannot be underestimated as challenges to long-term inmates when they are released to the community. With long-term incarcerations, older adults who are to be released may not have made up for opportunities missed in their life such as education, job advancement, and strengthening family relationships (Aday, 2003). Despite this, the Bureau of Justice reports that geriatric parolees have lower recidivism rates (54%) during their parole terms, and increasing age is one of the most reliable predictors of low recidivism as older ex-prisoners are the least likely to return to prison (Turley, 2003).
A series of interviews with elderly male prisoners aged 65 to 84 in England and Wales revealed that inmates commonly had concerns about release. These concerns were predominantly social and medical and centered on discharge planning. They included where they would live, how they would get there, and with whom they would be living. They were also fearful for their personal safety and about where they would get medical care (Crawley & Sparks, 2006).
Ex-prisoners usually reenter communities that are similar to those from which they came (Pogorzelski, Wolff, Pan, & Blitz, 2005). Many of these communities are unsafe. In contrast to when they were young, older ex-prisoners may now be less physically fit and less able to defend themselves. Some may have lost contact with family and friends. There may be no one to turn to for financial, physical, emotional, or economic support; for many older ex-prisoners, family and friends remain in prison (Aday, 2003; Crawley & Sparks, 2006).
When older adults reenter the community, finding employment can be difficult due to their age, especially if they used to work as hard laborers. The stigma of incarceration is a substantial barrier to a smooth reintegration into the community. In addition, job prospects may be further limited by educational attainment; studies show that fewer older probationers have completed high school or a GED than their younger counterparts (Aday, 2003). Also, after being in prison for many years and possibly for the majority of their lives, older adults many have acquired very few independent living skills such as cooking, shopping, and balancing a checkbook and would benefit from "community placement orientation" before release (Aday, 2003; Crawley & Sparks, 2006; Terhune et al., 1999).
Older ex-prisoners frequently have multiple medical conditions and may encounter several obstacles in optimizing their medical care. While older inmates are often on multiple medications at the time of release, many are discharged with little or no medication (Hornung et al., 2002). Insufficient health-related discharge planning may lead to release without a health care appointment. Reinstating Medicare and/or Medicaid can take many weeks to months, so the only health care option for many older parolees with chronic health care needs may be to use high cost emergency services for routine care or after medical decompensation (Hornung et al., 2002). In addition, some older parolees will require discharge to a nursing home or other long term care facility. This entails a special discharge coordination effort to find an accepting location and enrollment in Medicaid to obtain the funds necessary to pay for the care (Terhune et al., 1999).
Older inmates transitioning into the community may also have new health care providers who do not know of their incarceration history. This can pose a significant problem as ex-prisoners are at particularly high risk for certain diseases such as STDs, hepatitis, and HIV (Hornung et al., 2002; http://www. ojp.usdoj.gov/bjs/pub/pdf/reentry.pdf, 2003). Although all older adults should be screened for these diseases, they often are not because health care providers rarely consider older adults at risk (Skiest & Keiser, 1997). Thus, without knowledge of a history of incarceration, many health care providers might fail to screen older ex-prisoners for STDs or infectious disease.
Older parolees are also at higher risk for adverse psychological reactions to prison release. They display high rates of anxiety about release (Crawley & Sparks, 2006), and are also at increased risk for post-release suicide (Pratt, Piper, Appleby, Webb, & Shaw, 2006). Parole officers and health care providers should be familiar with these increased risks so that mental health crises can be avoided or identified early. In addition, older parolees with dementia could violate parole by missing their parole officer meetings, or might intentionally violate parole hoping to be returned to prison due to their inability to function on the outside (Terhune et al., 1999). For these reasons, some advocate changing the role of parole officers to serve as bridges and support systems for older parolees transitioning back into the community (Terhune et al., 1999).
Preventive Measures that Can Be Taken Before Release
Steps can be taken before prison release to smooth the transition back into the community. Prior to release, older adults who have been incarcerated for a long time may benefit greatly from training in independent living skills such as cooking, shopping, banking, and money management. It is imperative that older adults have a transition plan that includes health care and medication access. Ideally, a summary of the individual's medical problems would be provided to their post-release physician. In addition, classes in health care promotion and, for those who have a chronic disease, education about their illness and disease self-management can be valuable.
Intensive case management that links the older inmate to community resources can be a helpful step in promoting a smoother transition. Community-based organizations can also reach out to older adults who are being paroled or released. An example program is the Senior Ex-Offenders Program (SEOP) in San Francisco. SEOP helps the older ex-prisoner identify his or her needs, such as medical or mental health referrals or assistance with Medicare applications, and then mobilizes the necessary resources to meet these needs. Innovative organizations like SEOP also help ex-prisoners identify meaningful contributions that they can make to the community, such as being anger management counselors, HIV test counselors, or soup kitchen volunteers, and train them to develop these skills. In this way, such transition programs can provide purpose and a social network to older individuals as they reenter the community while also having a positive impact on the community to which they return.
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