Significant changes are required in Australian prisons to ensure a growing population of elderly prisoners have adequate access to palliative care, according to a high-profile expert on public health and corrections policy.

Chris Puplick AM, chair of the NSW Justice Health and Forensic Mental Health Network Board, said there had been “staggering” growth in the aged prison population over the past decade.

While there had been a 36% increase in people 65 years and older in the general NSW population, the prison population had experienced a 133% increase. About one third of the NSW prison population will be older than 65 by 2036, which is consistent with national trends.

Speaking at a Leading Age Services Australia conference in Albury, NSW, Mr Puplick said there was an “epidemic” of cardiovascular disease, diabetes, and cancer among older people in prisons, as prisoners were typically in poor health, largely due to being from disadvantaged backgrounds and having inadequate access to screening.

“In terms of mental health, we are dealing with people who have chronic depression, who are becoming demented, who have Parkinson’s, Alzheimer’s and psychologically an increasing fear of dying inside prison walls.”

“There’s no real capacity for any form of palliative care within the prison system."

Mr Puplick said the ageing population and longer sentences were not the only reasons for the change in prison demographics. Over the past decade, there had been a 292% increase in women 65-years-and older in NSW prisons. A large proportion had committed social security fraud. In that time the number of older men convicted of historic sex offences had also increased dramatically, with more charges likely to flow from the Royal Commission in to Institutional Responses to Child Sexual Abuse.

Palliative care inadequate

Mr Puplick told Palliative Matters that people in custodial care were entitled to equivalent health care to that available in the general community.

“A far as palliative care is concerned, we are probably not yet at that level.

“There’s no real capacity for any form of palliative care within the prison system. If someone is in a terminal condition, there is capacity for an application to be made for them to be released early from custody, provided a palliative care place can be found for them.

“There are a number of cases in which people who are clearly terminally ill are transferred to hospital, where they may or may not get the equivalent of palliative care. They may simply be sent to a hospital in the expectation they are about to die.”

Why prisons are behind

Mr Puplick said the need for palliative care hadn’t been adequately addressed because prisons had typically been considered places where young, fit, aggressive people were confined.

“The idea of old, demented people shuffling around corridors in their prison uniforms just didn’t occur to people and so we are playing catch up.”

He said the NSW Justice Health and Forensic Mental Health Network Board had established a working group, which was investigating challenges posed by the ageing prison population and he hoped to be raising issues with the NSW Ministry of Health shortly.

“Palliative care is one of the things that has got to be in the mix. If we are talking about continuation of the trend of longer sentences and older prisoners, then it clearly is going to be a matter of significance.”

However, a more immediate pressure was likely to be providing appropriate care for the increasing proportion of people in prisons who have dementia.

Providing adequate care for prisoners with dementia, particularly women, was also of concern to research fellow at Monash University, Susan Baidawi. Miss Baidawi has authored two reports and several academic research articles on Australia’s ageing prison population and started a PhD looking at distress experienced by people in prisons. She recently completed an international literature review for Justice Health NSW & Forensic Mental Health Network on health care models for older people in prisons.

“Dementia is one of the key problems in Australia, because there are far fewer female prisoners,” she told Palliative Matters.

“Here, there aren’t the resources to manage an older female prisoner with dementia and so they may have to be placed in the male clinical setting. The critical mass is more present for males, so it can be worse for women in prison who have declines in physical, cognitive or functional health.”

Miss Baidawi said cancer, heart disease and respiratory diseases are the primary causes of death in prisons and these natural deaths have started to outnumber unnatural deaths only recently.

“Combine that with an increasing older prisoner population and these deaths are going to increase,” she said.

Living conditions

Mr Puplick said prisons are built for the young and the fit, not for the aged and the frail. Crowding meant some elderly prisoners were required to take the top bed in a bunk. More than 2000 NSW inmates were in prisons built in the 19^th Century, where corridors or cells could not accommodate wheel chairs.

Walking sticks and walking frames were regarded as potential weapons, so “falls are a regular occurrence”. There was also a lack of privacy and unsuitable facilities for people who were incontinent.

“When you are locked in a cell for 16 hours a day with two or three other people and you are suffering from incontinence and what you have in the corner is a steel toilet that everybody is sharing, I invite you to think about conditions in which we are keeping some of these people.”

Mr Puplick said there needed to be serious consideration of whether prison was a valid option for elderly people with complex health conditions. The NSW prison system recently had to accommodate a woman older than 80 who was sentenced for a considerable term for social security fraud.

“Not only did we have to manage her, but she as the sole carer of her husband – frail aged – required us to find accommodation and facilities for him, since his primary carer was now being locked up.”

Changes required

Mr Puplick said more appropriate infrastructure was required, “in the foreseeable future”.

“I do believe that at some stage in NSW, we are going to have to custom build a secure facility, along the lines of an aged-persons home, in which the doors are wide enough for wheelchairs, people don’t have to climb stairs and air-conditioning and ventilation is appropriate,” Mr Puplick said.

Miss Baidawi said a fundamental shift will also be required in terms on issues such as pain management, which is contentious because of high rates of substance abuse among prisoners.

“The accessibility of what we might consider low risk pain medication is highly controlled in a prison environment, which has significant implications for people experiencing chronic pain associated with end of life," Miss Baidawi said.

“Really, what it comes down to is that a lot of the principles that palliative care in the community might be based on – in terms of dignity, choice, autonomy and collaborative decision making – go out the window in a lot of cases in the prison system, because it is structured around security and that dominates everything.

“That doesn’t leave much flexibility in terms of health care models that are effective and humane.”