Shackling in the Hospital.

Hospitalized incarcerated patients are commonly shackled throughout their duration of treatment in community medical centers to prevent escape or harm to others. In the absence of overarching policies guiding the shackling of non-pregnant, incarcerated patients, clinicians rarely unshackle patients during routine care. We provide a medical-legal lens through which to examine inpatient shackling, review the limited evidence supporting the practice, and highlight harms associated with shackling in the hospital. We conclude by offering guidance to advance evidence-based shackling practices that prevent physical harm, reduce prejudice towards incarcerated patients, and relinquish reliance on shackles in favor of tailored security measures.

COVID-19 outbreak in a state prison: a case study on the implementation of key public health recommendations for containment and prevention.

BACKGROUND: People incarcerated in US prisons have been disproportionately harmed by the COVID-19 pandemic. That prisons are such efficient superspreading environments can be attributed to several known factors: small, communal facilities where people are confined for prolonged periods of time; poor ventilation; a lack of non-punitive areas for quarantine/medical isolation; and staggeringly high numbers of people experiencing incarceration, among others. While health organizations have issued guidance on preventing and mitigating COVID-19 infection in carceral settings, little is known about if, when, and how recommendations have been implemented. We examined factors contributing to containment of one of the first California prison COVID-19 outbreaks and remaining vulnerabilities using an adapted multi-level determinants framework to systematically assess infectious disease risk in carceral settings. METHODS: Case study employing administrative data; observation; and informal discussions with: people incarcerated at the prison, staff, and county public health officials. RESULTS: Outbreak mitigation efforts were characterized by pre-planning (e.g., designation of ventilated, single-occupancy quarantine) and a quickly mobilized inter-institutional response that facilitated systematic, voluntary rapid testing. However, several systemic- and institutional-level vulnerabilities were unaddressed hindering efforts and posing significant risk for future outbreaks, including insufficient decarceration, continued inter-facility transfers, incomplete staff cohorting, and incompatibility between built environment features (e.g., dense living conditions) and public health recommendations. CONCLUSIONS: Our adapted framework facilitates systematically assessing prison-based infectious disease outbreaks and multi-level interventions. We find implementing some recommended public health strategies may have contributed to outbreak containment. However, even with a rapidly mobilized, inter-institutional response, failure to decarcerate created an overreliance on chance conditions. This left the facility vulnerable to future catastrophic outbreaks and may render standard public health strategies - including the introduction of effective vaccines - insufficient to prevent or contain those outbreaks.

Medical Multimorbidity, Mental Illness, and Substance Use Disorder among Middle-Aged and Older Justice-Involved Adults in the USA, 2015-2018.

BACKGROUND: Adults age ≥ 50 are among the fastest growing populations in correctional supervision and are medically underserved while experiencing unique health disparities. Community-living older adults, referred to as "justice-involved," are people who have been recently arrested, or are on probation or parole. Although medical complexity is common among incarcerated older adults, the occurrence of medical morbidity, substance use disorder (SUD), and mental illness among justice-involved older adults living in US communities is poorly understood. OBJECTIVE: To estimate the prevalence of medical multimorbidity (≥ 2 chronic medical diseases), SUDs, and mental illness among justice-involved adults age ≥ 50, and the co-occurrence of these conditions. DESIGN: Cross-sectional analysis. PARTICIPANTS: A total of 34,898 adults age ≥ 50 from the 2015 to 2018 administrations of the US National Survey on Drug Use and Health. MAIN MEASURES: Demographic characteristics of justice-involved adults age ≥ 50 were compared with those not justice-involved. We estimated prevalence of mental illness, chronic medical diseases, and SUD among adults age ≥ 50 reporting past-year criminal justice system involvement. Logistic regression was used to estimate the odds of these conditions and co-occurrence of conditions, comparing justice-involved to non-justice-involved adults. KEY RESULTS: An estimated 1.2% (95% confidence interval [CI] = 1.1-1.3) of adults age > 50 experienced criminal justice involvement in the past year. Compared with non-justice-involved adults, justice-involved adults were at increased odds for mental illness (adjusted odds ratio [aOR] = 3.04, 95% CI = 2.09-4.41) and SUD (aOR = 8.10, 95% CI = 6.12-10.73), but not medical multimorbidity (aOR = 1.15, 95% CI = 0.85-1.56). Justice-involved adults were also at increased odds for all combinations of the three outcomes, including having all three simultaneously (aOR = 8.56, 95% CI = 4.10-17.86). CONCLUSIONS: Community-based middle-aged and older adults involved in the criminal justice system are at high risk for experiencing co-occurring medical multimorbidity, mental illness, and SUD. Interventions that address all three social and medical risk factors are needed for this population.

Criminal Justice Reform Is Health Care Reform.

This Viewpoint discusses legal provisions guiding health care delivery for incarcerated individuals, the impact of the First Step Act of 2018, and future federal criminal justice reform.

Differences between incarcerated and non-incarcerated patients who die in community hospitals highlight the need for palliative care services for seriously ill prisoners in correctional facilities and in community hospitals: A cross-sectional study.

BACKGROUND: Incarcerated populations worldwide are aging dramatically; in the United States, prisoner mortality rates have reached an all-time high. Little is known about the incarcerated patients who die in community hospitals. AIM: Compare incarcerated and non-incarcerated hospital decedents in California. DESIGN: Cross-sectional study. SETTING/PARTICIPANTS: All state hospital decedents ( N = 370,831) from 2009 to 2013, decedent age over time examined with additional data (2001-2013). RESULTS: Overall, 745 incarcerated and 370,086 non-incarcerated individuals died in California hospitals. Incarcerated decedents were more often male (93% vs 51%), Black (19% vs 8%) Latino (27% vs 19%), younger (55 vs 73 years), had shorter hospitalizations (13 vs 16 days), and fewer had an advance care plan (23% vs 36%, p < 0.05). Incarcerated decedents had higher rates of cancer, liver disease, HIV/AIDs, and mental health disorders. Cause of death was disproportionately missing for incarcerated decedents. The average age of incarcerated decedents rose between 2001 and 2013, while it remained stable for others. CONCLUSION: Palliative care services in correctional facilities should accommodate the needs of relatively young patients and those with mental illness. Given the simultaneous growth in the older prisoner population with the rising age of incarcerated hospital decedents, community hospital clinicians should be prepared to care for seriously ill, incarcerated patients. Significant epidemiologic differences between incarcerated and non-incarcerated decedents in this study suggest the importance of examining the differential palliative care needs of incarcerated patients in all communities.

Post-traumatic stress disorder symptoms and associated health and social vulnerabilities in older jail inmates.

OBJECTIVES: To examine post-traumatic stress disorder (PTSD) symptoms in older jail inmates, and to determine whether adverse social and health-related characteristics were associated with having PTSD symptoms. METHOD: We performed an exploratory cross-sectional study of 238 older (age ≥55 years) jail inmates from a county jail. PTSD symptoms were determined using the Primary Care PTSD (PC-PTSD) screen. Reporting three or more PTSD symptoms was defined as a positive screen. Descriptive statistics and multiple regression analyses were used to examine the prevalence of a positive PTSD screen and associations with social and health-related characteristics. RESULTS: The mean age was 59 years, 64% were Black, and 82% reported an annual income ≤$15,000. Nearly 40% of older jail inmates had a positive PTSD screen and 10% reported a prior PTSD diagnosis by a physician. Older jail inmates with a positive PTSD screen were significantly more likely than those with a negative PTSD screen to report medication insecurity in the past year, impairment in two or more activities of daily living, traumatic brain injury, pain in the past week, and poor self-rated health. CONCLUSION: Over one in three of the older jail inmates in this study had a positive PTSD screen, though only one in five of those with a positive screen reported a prior PTSD diagnosis. Screening for PTSD in jails may help identify older inmates who would benefit from additional mental health treatment and reentry planning to improve health in this population.

Older jail inmates and community acute care use.

OBJECTIVES: We examined older jail inmates' predetainment acute care use (emergency department or hospitalization in the 3 months before arrest) and their plans for using acute care after release. METHODS: We performed a cross-sectional study of 247 jail inmates aged 55 years or older assessing sociodemographic characteristics, health, and geriatric conditions associated with predetainment and anticipated postrelease acute care use. RESULTS: We found that 52% of older inmates reported predetainment acute care use and 47% planned to use the emergency department after release. In modified Poisson regression, homelessness was independently associated with predetainment use (relative risk = 1.42; 95% confidence interval = 1.10, 1.83) and having a primary care provider was inversely associated with planned use (relative risk = 0.69; 95% confidence interval = 0.53, 0.89). CONCLUSIONS: The Affordable Care Act has expanded Medicaid eligibility to all persons leaving jail in an effort to decrease postrelease acute care use in this high-risk population. Jail-to-community transitional care models that address the health, geriatric, and social factors prevalent in older adults leaving jail, and that focus on linkages to housing and primary care, are needed to enhance the impact of the act on acute care use for this population.

History of Incarceration and Its Association With Geriatric and Chronic Health Outcomes in Older Adulthood.

Importance: Although incarcerated older adults experience higher rates of chronic disease and geriatric syndromes, it is unknown whether community-dwelling older adults with a history of incarceration are also at risk for worse health outcomes. Objective: To evaluate the association between a history of incarceration and health outcomes, including chronic health conditions and geriatric syndromes, in older age. Design, Setting, and Participants: This cross-sectional study using population-based data from the nationally representative Health and Retirement Study included US community-dwelling adults aged 50 years or older who completed the 2012 or 2014 survey waves assessing self-reported history of incarceration. Statistical analysis was completed from December 2021 to July 2022. Exposures: Self-reported history of incarceration. Main Outcomes and Measures: Geriatric health outcomes included cognitive impairment, mobility impairment, vision impairment, hearing impairment, urinary incontinence, and impairment of activities of daily living (ADLs). Chronic health outcomes included high blood pressure, diabetes, chronic lung disease, heart disease, stroke, mental health conditions, heavy alcohol use, and self-reported health. Survey weights were applied to adjust for the survey design. Results: Among 13 462 participants, 946 (7.6%) had experienced incarceration (mean [SD] age, 62.4 [7.8] years); compared with 12 516 people with no prior incarceration (mean [SD] age, 66.7 [10.0] years), previously incarcerated adults were more likely to be male (83.0% vs 42.8%; P < .001) and in the lowest quartile of wealth (44.1% vs 21.4%; overall P < .001). After adjusting for age, sex, race and ethnicity, wealth, educational attainment, and uninsured status, a history of incarceration was associated with a 20% to 80% increased risk of all geriatric syndromes evaluated, including impairment of ADLs (relative risk [RR], 1.62; 95% CI, 1.40-1.88) and hearing impairment (RR, 1.22; 95% CI, 1.04-1.44). Incarceration was also associated with increased risk of some chronic diseases, including chronic lung disease (RR, 1.56; 95% CI, 1.27-1.91), mental health conditions (RR, 1.80; 95% CI, 1.55-2.08), and heavy alcohol use (RR, 2.13; 95% CI, 1.59-2.84). Prior incarceration was not associated with diabetes or cardiovascular conditions. Conclusions and Relevance: In this study, at least 1 in 15 older US adults reported a history of incarceration in their lifetime. Past incarceration was associated with many chronic diseases and geriatric syndromes even after accounting for socioeconomic status. These findings suggest that attention to incarceration history may be an important consideration in understanding and mitigating health risks in older age.

Confined to ignorance: the absence of prisoner information from nationally representative health data sets.

BACKGROUND: Incarceration is associated with poor health and high costs. Given the dramatic growth in the criminal justice system's population and associated expenses, inclusion of questions related to incarceration in national health data sets could provide essential data to researchers, clinicians and policy-makers. OBJECTIVE: To evaluate a representative sample of publically available national health data sets for their ability to be used to study the health of currently or formerly incarcerated persons and to identify opportunities to improve criminal justice questions in health data sets. DESIGN & APPROACH: We reviewed the 36 data sets from the Society of General Internal Medicine Dataset Compendium related to individual health. Through content analysis using incarceration-related keywords, we identified data sets that could be used to study currently or formerly incarcerated persons, and we identified opportunities to improve the availability of relevant data. KEY RESULTS: While 12 (33%) data sets returned keyword matches, none could be used to study incarcerated persons. Three (8%) could be used to study the health of formerly incarcerated individuals, but only one data set included multiple questions such as length of incarceration and age at incarceration. Missed opportunities included: (1) data sets that included current prisoners but did not record their status (10, 28%); (2) data sets that asked questions related to incarceration but did not specifically record a subject's status as formerly incarcerated (8, 22%); and (3) longitudinal studies that dropped and/or failed to record persons who became incarcerated during the study (8, 22%). CONCLUSIONS: Few health data sets can be used to evaluate the association between incarceration and health. Three types of changes to existing national health data sets could substantially expand the available data, including: recording incarceration status for study participants who are incarcerated; recording subjects' history of incarceration when this data is already being collected; and expanding incarceration-related questions in studies that already record incarceration history.

How safe is your neighborhood? Perceived neighborhood safety and functional decline in older adults.

BACKGROUND: Neighborhood characteristics are associated with health and the perception of safety is particularly important to exercise and health among older adults. Little is known about the relationship between perception of neighborhood safety and functional decline in older adults. OBJECTIVE: To determine the relationship between perceived neighborhood safety and functional decline in older adults. DESIGN/SETTING: Longitudinal, community-based. PARTICIPANTS: 18,043 persons, 50 years or older, who participated in the 1998 and 2008 Health and Retirement Study. MAIN MEASURES: The primary outcome was 10-year functional decline (new difficulty or dependence in any Activity of Daily Living, new mobility difficulty, and/or death). The primary predictor was perceived neighborhood safety categorized into three groups: "very safe", "moderately safe", and "unsafe." We evaluated the association between perceived neighborhood safety and 10-year functional decline using a modified Poisson regression to generate unadjusted and adjusted relative risks (ARR). KEY RESULTS: At baseline 11,742 (68.0%) participants perceived their neighborhood to be very safe, 4,477 (23.3%) moderately safe, and 1,824 (8.7%) unsafe. Over 10 years, 10,338 (53.9%) participants experienced functional decline, including 6,266 (50.2%) who had perceived their neighborhood to be very safe, 2,839 (61.2%) moderately safe, and 1,233 (63.6%) unsafe, P < 0.001. For the 11,496 (63.3%) of participants who were functionally independent at baseline, perceived neighborhood safety was associated with 10-year functional decline (moderately safe ARR 1.15 95% CI 1.09-1.20; unsafe ARR 1.21 95% CI: 1.03-1.31 compared to very safe group). The relationship between perceived neighborhood safety and 10-year functional decline was not statistically significant for participants who had baseline functional impairment. CONCLUSION: Asking older adults about their perceived neighborhood safety may provide important information about their risk of future functional decline. These findings also suggest that future studies might focus on assessing whether interventions that promote physical activity while addressing safety concerns help reduce functional decline in older adults.

Subjective social status and functional decline in older adults.

BACKGROUND: It is unknown whether subjective assessment of social status predicts health outcomes in older adults. OBJECTIVE: To describe the relationship between subjective social status and functional decline in older adults. DESIGN: Longitudinal cohort study. SETTING: The Health and Retirement Study, a nationally representative survey of community-dwelling older adults (2004-2008). PARTICIPANTS: Two thousand five hundred and twenty-three community-dwelling older adults. MAIN MEASURES: Self-report of social status (SSS), categorized into three groups, reported by participants who marked a 10-rung ladder to represent where they stand in society. Four-year functional decline (new difficulty in any of five activities of daily living, mobility decline and/or death) KEY RESULTS: Mean age was 64; 46% were male, 85% were white. At baseline, lower SSS was associated with being younger, unmarried, of nonwhite race/ethnicity, higher rates of chronic medical conditions and ADL impairment (P < 0.01). Over 4 years, 50% in the lowest SSS group declined in function, compared to the middle and highest groups (28% and 26%), P-trend <0.001. Those in the lowest rungs of SSS were at increased risk of 4-year functional decline (unadjusted RR = 1.91, CI 1.-9-2.46). The relationship between a subjective belief that one is worse off than others and functional decline persisted after serial adjustment for demographics, objective SES measures, and baseline health and functional status (RR 1.36, CI 1.08-1.73). CONCLUSIONS: In older adults, the belief that one is in the lowest rungs of social status is a measure of socioeconomic distress and of significant risk for functional decline. These findings suggest that self-report of low subjective social status may give clinicians additional information about which older adults are at high risk for future functional decline.

Aging in correctional custody: setting a policy agenda for older prisoner health care.

An exponential rise in the number of older prisoners is creating new and costly challenges for the criminal justice system, state economies, and communities to which older former prisoners return. We convened a meeting of 29 national experts in correctional health care, academic medicine, nursing, and civil rights to identify knowledge gaps and to propose a policy agenda to improve the care of older prisoners. The group identified 9 priority areas to be addressed: definition of the older prisoner, correctional staff training, definition of functional impairment in prison, recognition and assessment of dementia, recognition of the special needs of older women prisoners, geriatric housing units, issues for older adults upon release, medical early release, and prison-based palliative medicine programs.

Balancing punishment and compassion for seriously ill prisoners.

Compassionate release is a program that allows some eligible, seriously ill prisoners to die outside of prison before sentence completion. It became a matter of federal statute in 1984 and has been adopted by most U.S. prison jurisdictions. Incarceration is justified on 4 principles: retribution, rehabilitation, deterrence, and incapacitation. Compassionate release derives from the theory that changes in health status may affect these principles and thus alter justification for incarceration and sentence completion. The medical profession is intricately involved in this process because eligibility for consideration for compassionate release is generally based on medical evidence. Many policy experts are calling for broader use of compassionate release because of many factors, such as an aging prison population, overcrowding, the increasing deaths in custody, and the soaring medical costs of the criminal justice system. Even so, the medical eligibility criteria of many compassionate-release guidelines--which often assume a definitive prognosis--are clinically flawed, and procedural barriers may further limit their rational application. We propose changes to address these flaws.

Lost in translation: the unintended consequences of advance directive law on clinical care.

BACKGROUND: Advance directive law may compromise the clinical effectiveness of advance directives. PURPOSE: To identify unintended legal consequences of advance directive law that may prevent patients from communicating end-of-life preferences. DATA SOURCES: Advance directive legal statutes for all 50 U.S. states and the District of Columbia and English-language searches of LexisNexis, Westlaw, and MEDLINE from 1966 to August 2010. STUDY SELECTION: Two independent reviewers selected 51 advance directive statutes and 20 articles. Three independent legal reviewers selected 105 legal proceedings. DATA EXTRACTION: Two reviewers independently assessed data sources and used critical content analysis to determine legal barriers to the clinical effectiveness of advance directives. Disagreements were resolved by consensus. DATA SYNTHESIS: Legal and content-related barriers included poor readability (that is, laws in all states were written above a 12th-grade reading level), health care agent or surrogate restrictions (for example, 40 states did not include same-sex or domestic partners as default surrogates), and execution requirements needed to make forms legally valid (for example, 35 states did not allow oral advance directives, and 48 states required witness signatures, a notary public, or both). Vulnerable populations most likely to be affected by these barriers included patients with limited literacy, limited English proficiency, or both who cannot read or execute advance directives; same-sex or domestic partners who may be without legally valid and trusted surrogates; and unbefriended, institutionalized, or homeless patients who may be without witnesses and suitable surrogates. LIMITATION: Only appellate-level legal cases were available, which may have excluded relevant cases. CONCLUSION: Unintended negative consequences of advance directive legal restrictions may prevent all patients, and particularly vulnerable patients, from making and communicating their end-of-life wishes and having them honored. These restrictions have rendered advance directives less clinically useful. Recommendations include improving readability, allowing oral advance directives, and eliminating witness or notary requirements. PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs and the Pfizer Foundation.

The Impact Of COVID-19 On The Health Of Incarcerated Older Adults In California State Prisons.

The number of older adults (age fifty-five or older) incarcerated in US prisons reached an all-time high just as COVID-19 entered correctional facilities in 2020. However, little is known about COVID-19's impact on incarcerated older adults. We compared COVID-19 outcomes between older and younger adults in California state prisons from March 1, 2020, to October 9, 2021. Adjusted odds ratios (aORs) revealed an increasing risk for adverse COVID-19 outcomes among older age groups (ages 55-64, 65-74, and 75 or older) compared with younger adults, including for documented infection (aOR, 1.3, 1.4, and 1.4, respectively) and hospitalization with COVID-19 (aOR, 4.6, 8.7, and 15.1, respectively). Moreover, although accounting for 17.3 percent of the California state prison population, older adults represented 85.8 percent of this population's COVID-19-related deaths. Yet a smaller percentage of older adults than younger adults were released from prison during the pandemic. The differential rates of morbidity and mortality experienced by incarcerated older adults should be considered in future pandemic response strategies regarding prisons.