January 27, 2012

III. Conditions of Confinement

In general, the older people are, the more barriers they have to an active, independent life, the greater their physical and mental health needs, and the harder it is for them to live and function with dignity. The difficulties can be even greater for those elderly who are in prison. Prisons are primarily designed for the young and able-bodied; it takes additional effort on the part of corrections officials to meet the needs and respect the rights of the old and infirm.

Older prisoners, 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.[83]

While age does not change the rights of people who are incarcerated, it may change what prison officials must do to ensure those rights are respected in particular cases. More precisely, it is not so much age in the abstract that determines how officials should treat individual prisoners, but their physical and mental conditions. A certain decline in general physical and mental capabilities is highly correlated with advancing years. There is also considerable overlap between persons who are aging and those who are chronically, seriously, or terminally ill or incapacitated. As persons age, they are at increasing risk of developing various illnesses and disabilities (see discussion below in Chapter IV).[84] Officials confronting an aging and frail inmate, or one who is old and riddled with disease, cannot treat him the same as they would a healthy 25-year-old.

During our visits to state prison systems, corrections personnel—including high-ranking central office staff, wardens, corrections officers, doctors, and nurses—insisted they were committed to ensuring the older men and women in their charge received the care and treatment they needed, albeit within the limitation of what is possible and permissible in prison. While this report does not evaluate the extent to which the human rights of older prisoners were respected in any given facility, there is no doubt that many older prisoners suffer from violations of their rights. Our conversations with corrections professionals, advocates, and prison experts nationwide leads us to believe the problems in the states we visited are replicated to a greater or lesser degree throughout the country. Limited resources, resistance to changing longstanding rules and policies, lack of support from elected officials, as well as insufficient internal attention to the unique needs and vulnerabilities of older prisoners, all lead to inadequate protection for the rights of the elderly.

As prison professionals themselves acknowledged to Human Rights Watch, individual incidents of neglect, mistreatment, and even cavalier disregard for the well-being of aging and vulnerable inmates occur. Prisons can also be plagued by systemic problems that leave the elderly—and younger prisoners as well —suffering acutely.[85]

US prisons are usually overcrowded warehouses that are hard places to live in, regardless of age.[86] Those who are older in prison, like their younger counterparts, must cope with the lack of privacy, extensive and intrusive controls over every aspect of life, severe limitations on connections with family and community, the paucity of opportunities for education, meaningful work, or other productive, purposeful programs or activities, and threats of violence and exploitation. They have to cope with correctional and even medical staff who not infrequently view them with animosity, anger, and distaste because they are “felons,” attitudes which can influence how such staff exercise their responsibilities.[87] They have to cope with medical staff and treatment facilities that may be insufficient in quantity and inadequate in quality. As corrections medical expert Dr. Robert Greifinger explained to Human Rights Watch, “The quality of medical care and disability accommodation in U.S. prisons varies considerably. Young and old alike suffer from poor quality care just as they benefit similarly from higher quality care.”[88] Older inmates, like younger inmates, struggle to maintain their self-respect and emotional equilibrium in this difficult environment while also confronting the physical, emotional, social, and spiritual challenges that accompany aging.

Older prisoners, even if they are not suffering illness, can find the ordinary rigors of prison particularly difficult because of a general decline in physical and often mental functioning which affects how they live in their environments and what they need to be healthy, safe, and have a sense of well-being. In addition to the memory loss and other ordinary cognitive impairments that can come with aging, older prisoners sooner or later will develop:

[D]ecreased sensory acuity, muscle mass loss, intolerance of adverse environmental conditions, dietary intolerance and general vulnerability [which] precipitate collateral emotional and mental health problems.[89]

As a senior official with the California Prison Health Care Services explained to Human Rights Watch:

Age by itself is not the same as disability, but the end result of an accumulation of diseases and injuries, causing decreased ability to safely interact with our surroundings. In elders, hearing, vision and balance progressively decrease; foot speed slows; and muscle loss occurs. All of which make climbing up stairs or into upper bunks difficult if not dangerous.[90]

Older persons are more likely to develop disabilities that require the use of assistive devices such as glasses, hearing aids, wheelchairs, walkers, and canes. As in the community, the elderly in prison suffer from falls, which contribute to hip fractures and high health costs. One California study found that 51 percent of geriatric women prisoners age 55 or over reported a fall in the past year.[91] In the community, falls are associated with poor lighting, uneven or icy pavement, loose rugs, and lack of handrails. In prison, there are additional potential hazards, including top bunk assignments and crowds of quickly moving young inmates oblivious to the slower, more fragile older inmates among them.[92]

For someone who is old and frail or infirm, the right to safe conditions of confinement means not being required to live in a dorm with younger persons prone to violence and extortion and not being required to sleep on a top bunk. The right to decent conditions of confinement means older persons should be given extra blankets and clothing in the winter because it is harder for them to stay warm and they should not have to stand outside in harsh weather waiting to receive medication. They may need more time to eat. Inmates have a right to activities to promote rehabilitation, and older incarcerated persons should be provided age-appropriate educational, recreational, and vocational opportunities. For the prisoner whose mental capacities are weakening or who may have dementia, disciplinary procedures should be adjusted to reflect the diminished culpability. Ensuring an older offender who cannot care for himself is treated with respect for his humanity means ensuring the availability of staff or inmate aides who can help him change his clothes and clean up his cell when he has had an “accident” and soils himself.

Geriatric incontinence puts unique demands on older prisoners. It puts them at risk of social isolation, depression, diminished independence, and even harassment and physical confrontations from inmates offended when an older person urinates or defecates in her clothes.[93]Prison bathrooms typically lack privacy; individuals who need to change their soiled clothes or diapers must endure the humiliation of doing so in public. Preserving dignity in this context is difficult.

Mobility impairments are common in older populations, and they are particularly problematic in the prison context. Even when provided canes, walkers, and wheelchairs, many of the elderly confront facilities that were not designed with the structural or programmatic needs of mobility-impaired individuals in mind.

Buildings may be scattered throughout the prison complex, requiring inmates to walk a distance to access healthcare, meals, and additional services and activities. Architectural impediments such as steps, narrow doorways, and absence of grab bars and handrails can present problems for inmates needing long term care.[94]

Mobility-impaired older inmates often confront a shortage of wheelchair-accessible bathrooms, including showers with seats, bars, and no shower lip to step over; and too few rooms on a first floor so they are not required to climb stairs. They confront the long distances that exist between housing units and prison services and programs, and may need assistance getting from one place to another. Retrofitting old facilities and construction of new facilities are hampered by budget realities.[95]

Some prisons have changed their rules and created special programs to respond to some of the needs of the elderly. Women age 55 or over who are incarcerated at Central California Women’s Facility (CCWF) benefit from a Silver Fox program which gives them certain privileges, such as being able to take shortcuts when walking from one place to the next, extra pillows and blankets, and extra time for doing laundry. In August 2011, extensive organizing and advocacy efforts by older women at CCWF seeking to improve their conditions of confinement were rewarded with the initiation of a new component of the Silver Fox program, a Senior Living Unit (SLU), to be located in an existing facility designed to “address the emotional and physical needs of the older inmate population” who choose to live in it.[96] The women in the SLU will have privileges otherwise not available to CCWF inmates: additional mattresses upon request, unlimited access to the phone, designated space in the dayroom for small plants, and the ability to purchase a fan and not have it count towards the maximum number of appliances permitted. In addition, plans for the SLU include special age-sensitive programs and support groups. On the other hand, some rules were not modified. Whether or not a prisoner is geriatric, infirm, or has disciplinary violations, she will be put in cuffs and shackles when taken offsite to a medical visit, even though such restraints can be painful for persons with older bones.

Housing for the Elderly

Corrections departments do not typically make housing assignments for inmates solely based on age.[97] When it comes to housing the elderly, prison systems support “mainstreaming,” that is, keeping older inmates in the “general population” as long as possible, consistent with their particular physical and mental needs and vulnerabilities. Housing decisions take into account frailty, disabilities, illness, and the “culture” of particular facilities—some are known to be more violent and dangerous than others—in addition to the security classification of the inmates. Space permitting, aging inmates who have serious physical or mental conditions or limitations on their ability to independently manage the activities of daily living will be placed in a facility that has the capacity to meet those particular needs. As older incarcerated persons develop increased needs for medical services and assistance, officials often place them in facilities in which the aging and/or infirm predominate.[98] For this report, Human Rights Watch conducted many of our site visits in facilities with high proportions of elderly and infirm inmates.

Cedric McDonald, age 65, has been in prison in Mississippi since 1998 serving a 20-year sentence for a second degree manslaughter conviction for killing his wife. He was a truck driver all his life and had never been in prison before. He has a transplanted kidney and is on dialysis three times a week. When we interviewed him he was toothless. He told us he had dentures, but could not afford the denture cream so did not use his dentures. “Chews pretty good without them.” he said. Because of his dialysis he cannot get a prison job, and relies on money his sister sends him every so often so he can buy cereal and coke from the commissary. Older people often have a difficult time coping with extremes in temperature, whether heat or cold. There was record-breaking heat when Human Rights Watch visited the prison, and McDonald’s principal complaint was the heat in the un-air conditioned building in which he lived. “It’s so hot in the building. I want to cool off. Fans don’t do much. It cools in the evening. You get one cup of ice after 12, none in the morning, and two cups in the evening.”[99]

For example, at Ohio’s Hocking Correctional Facility, large dormitories house predominantly older men; the average age is 66, and 84 percent of the population there is over 60. The oldest man is 89 years old. The men can stay at Hocking until they cannot take care of their daily living needs (for example going to the bathroom by themselves) or become so ill they need greater access to specialized medical care.

Some prison systems are developing special housing units that provide higher levels of care than in the general population, but short of assisted living or skilled nursing care. These units are not limited to the elderly but are used for any confined person who needs greater medical care or assistance with daily living activities. As the Missouri Department of Corrections Aging Offenders Management Team noted, aging offenders with mild to moderate levels of need for health services can “do well in a ‘modified’ general population setting where they have reasonable accommodations for their mobility, medical and mental health needs.”[100] The team recommended the development of Enhanced Care Units which would have no top bunks, daily rounds by health services staff, organized activities to keep offenders busy and oriented, assistance from other offenders trained to be helpers, and special assistance with meals.[101] In response to this recommendation, the department has piloted its first Enhanced Care Unit “to keep offenders as functional as possible while providing appropriate health and housing services to accommodate their special needs.”[102]

At Mississippi State Penitentiary, men who, whether due to age or for other reasons, need more support and assistance than is available in regular general population units are housed in Unit 31, a special housing unit.[103] Prisoners can stay there until they deteriorate to the point at which they can no longer care for themselves, even with the help of other inmates. They are then moved to the hospital.

The Texas Department of Criminal Justice has special geriatric units, located in different state prisons, to provide accommodations for offenders who are age 60 or older and who have specific difficulties with daily activities. In these units, the prisoners have longer periods of time to dress, eat, move from place to place, and shower. Texas also provides a higher level geriatric facility for male inmates located at the Estelle Unit next to the Estelle Regional Medical Facility to ensure accessibility to clinical staff. This unit provides “access to multiple special medical services, such as physical, occupational, and respiratory therapy; special wheelchair accommodations; temperature-adjusted environments; dialysis; and services for inmates with hearing and vision impairments.”[104]

Many of the elderly in prison, as in the community, eventually develop a diminished capacity for self-care and require assistance with daily living activities as well as increased medical care. The range of specialized housing for such inmates includes assisted living care units where help with activities of daily living is offered; convalescent care with nursing assistance during the day; skilled care with nursing provided day and night (as in a nursing home); and hospice care for the dying. As of 2008, at least 13 states had responded to the needs of older offenders by creating specialized units, six had dedicated prisons, nine had dedicated medical facilities, five had dedicated secure nursing-home facilities, and eight had dedicated hospice facilities.[105]

Older individuals may end up in long term care in facilities that provide the necessary care and access to medical treatment, but which are not set up to provide non-medical programs for the elderly. For example, in the long term care unit at the Correctional Medical Center (CMC) in Ohio, which has a high proportion of older prisoners, there are no communal spaces or programs. Unlike a nursing home in the community which will have age-appropriate activities, at CMC there is little for the individuals incarcerated there to do to keep them from “simply wasting away” as one staff member told Human Rights Watch.[106]

Meeting the housing needs of the current aging population is an ad hoc process in which officials juggle many factors including the nature and severity of an inmate’s illness or disability, the availability of beds in facilities with requisite levels of medical care, security levels, and risks for victimization or predatory behavior, among others. Housing the elderly is a daily game of musical chairs that can shortchange individual elderly persons while it bedevils corrections officials. Prison officials struggle every day to find enough lower bunks for inmates who cannot climb to the upper ones. They move inmates in and out of hospital beds because they lack sufficient numbers of nursing facility beds. Sometimes the only available housing option is to put those who can no longer take sufficient care of themselves in infirmaries or hospitals, even though those settings provide intensive levels of care in highly restrictive settings that may exceed what the individual requires. In some systems, old and infirm individuals end up in administrative segregation beds—with all the restrictions of segregation—due to the lack of alternative housing options.

Officials in many states acknowledged to Human Rights Watch they are struggling to keep their heads above water with regard to housing the elderly. Their ability to properly house and provide treatment for older inmates is frustrated by lack of resources, inappropriate physical plants, insufficient support from elected officials and the demands of more immediately pressing priorities. They also acknowledged to us they do not see how they can meet the needs of the growing number of older prisoners projected for the future absent new resources, new construction and enhanced staffing. In every state we visited, for example, officials stressed the need to develop additional assisted living care and skilled nursing care capacity to respond to the growing population of the elderly.

Housing for inmates with dementia

We could write her up for verbal abuse but what’s the point.
—Correctional officer

Prison officials were not able to provide us with good data on the number of inmates they confine with age-related dementia, but they told us the numbers are growing.

Prisons do not ordinarily screen for age-related cognitive decline. In the circumscribed world of prisons with limited opportunities for prisoners to make decisions about how to manage their days, or to plan, initiate, or carry out complex behavior, early stages of dementia may not be seen in how a prisoner handles the incidents of daily life. Dementia usually becomes observed by staff or other inmates (who alert staff) when a prisoner exhibits bizarre or erratic conduct, for example, by refusing to bathe or clean up after himself.

Other inmates often contribute to the ability of the aging who are developing dementia (as well as those who have other mental or physical impairments) to stay in general population facilities. Such assistance may be ad hoc—one cellmate helping another because he chooses to—or formalized through offender aide programs in which carefully selected and trained inmates are given the responsibility of assisting inmates who, because of their cognitive decline, need help with daily living activities.

Homer Edmunds was not able to tell Human Rights Watch his age or how long he has been in prison in Mississippi. According to staff, he is 87 years old and has been in prison convicted of homicide since 1984. For the last 21 years he has been in Unit B at Central Mississippi Correctional Facility, a unit for inmates who have special needs, whether due to age or other reasons. He can hardly walk, and was brought to the interview with Human Rights Watch in a wheelchair, but could not explain to Human Rights Watch why he was in it. According to the staff, he needs help with showering, and has severe cognitive issues including little memory, but the staff and other inmates help him get through the days because he does not want to go to the hospital. He has also been diagnosed as a paranoid schizophrenic.[107]

At some point, cognitive problems can grow so severe that remaining in the general population is no longer an option. While many prison systems incorporate offenders with dementia in special medical settings, a few have special units for inmates with dementia, including California, New York, and Ohio.

New York’s Fishkill Correctional Facility has a Unit for the Cognitively Impaired (UCI) within its Regional Medical Unit (RMU). In December 2011, when Human Rights Watch visited it, the UCI housed 25 men with dementia or other progressive cognitive impairments,[108] 17 of whom were age 70 years or older. The UCI provides long term care in an infirmary-type setting. Many of the men in the UCI are likely to die behind bars, as their earliest possible release date will not occur until they are in their eighties; 11 have life sentences.[109] When Fishkill opened the UCI, all of the staff—from janitors to corrections officers to doctors—trained together to understand how the unit would operate and how the nature of the prisoners there would differ from the general population. Senior officials thought it was particularly important for the corrections officers to “buy into the concept that the cognitively impaired have special issues, and you don’t have to get in their face just because they get into yours…. You don’t have to respond to aggression with aggression,” the way an officer might in a regular unit.[110] Security staff have to bid for assignment to the unit and receive 40 hours of special training; security staff are also part of the team, including the medical and psychiatric staff, that periodically review patient conditions and progress. During our visit, we were told that despite the violent histories of some of the men, misconduct is relatively rare in the unit. In addition to psychological and psychiatric treatment, the men in the UCI are offered diverse structured programs that are supposed to be tailored to their particular needs; they can also participate in programs offered to RMU inmates generally. The staff seek to overcome the tendency of UCI residents to isolate themselves in their rooms, encouraging them to participate in group activities, such as bingo.

California Men’s Colony (CMC) contains a special unit which houses inmates with moderate to severe dementia along with those who have developmental disabilities. In the past, CMC did not provide therapeutic interventions tailored to the needs of inmates with serious age-related cognitive decline, but it has recently been testing a special needs program for inmates with dementia that targets their physical environment (for example by providing visual prompts to compensate for memory problems and poor judgment), social environment (by providing training for custody and nursing staff), and the individual inmate himself (through recreational activities and groups to address various needs, like how to manage emotions and compensate for cognitive impairments). The initial results show that prisoners with dementia who participated in the program significantly improved in terms of irritability, social skills, depression, and attention.[111]

Other states are developing plans for special housing for offenders with dementia. In Georgia, for example, the Department of Corrections is working on plans for a geriatric supportive living unit for those with dementia and mild to moderate cognitive impairment. The unit would have treatment teams, including psychiatrists, psychologists, and nurses, and provide therapy groups targeted to the offender’s special needs. It would not, however, be for the more extreme cases; offenders who have major difficulties managing their daily living activities would be moved into a skilled nursing facility.[112]

Whatever the merits of existing or planned facilities for prisoners with dementia and other progressive cognitive impairments, there is one problem that plagues them all: their capacity is too small for predicted need in the near future. Given that one in eight persons age 65 or over develops Alzheimer’s,[113] it is clear that the number of prisoners with progressive cognitive impairment is going to increase markedly in the future.

Segregating the Older from the Younger?

Young guys will do stupid stuff.
—Chad Summers (pseudonym), California Substance Abuse Treatment Facility and State Prison, April 13, 2011

Our research suggests that while older men and women who are in prison have plenty of complaints about younger inmates, they do not want to spend all of their time solely among other old inmates. Corrections officials we interviewed found many advantages in keeping older inmates living with younger inmates as long as possible.[114]

Many of the elderly incarcerated men and women we interviewed expressed the view that younger inmates tended to be rowdy, noisy, and disrespectful. Older incarcerated individuals by and large did not want to have to share cells or dormitories with “gangbangers” and “knuckleheads” who are “still wild.” Older male offenders also told Human Rights Watch that the younger ones tend to be more defiant and engage in misconduct, which prompts a tougher attitude on the part of correctional staff, which can carry over into their treatment of the older inmates.

If a guy in a wheelchair stands up to get ready to fight, by the time he’s standing up he’ll have forgotten what he was going to do.

A 68-year-old man at Hocking explained to Human Rights Watch why he preferred being in a facility with mostly older men:

We don’t have the fights, stealing, getting beat up. We do have arguments, but if a guy in a wheelchair stands up to get ready to fight, by the time he’s standing up he’ll have forgotten what he was going to do.[115]

But older inmates do not want to spend all of their time with people their age. The older men and women we interviewed appreciated the stimulation, activities, and ability to “stay young” that come from interacting with a mixed age group. A recent study of older inmates in Rhode Island found that only 9 percent of interviewed older inmates suggested the aged should be in a separate unit. The older inmates reported that they had quiet places to go to avoid engaging with other inmates when they chose not to, and most did not interact exclusively with similarly aged inmates. “[Like] their counterparts outside of prison, older inmates often did not want to classify themselves as old, seeing themselves as acting younger than their age.”[116]

There are other benefits for aging prisoners in having at least somewhat younger or at least less infirm prisoners about. More capable inmates will help “cover” for increasingly frail or infirm inmates, by helping them with some of their daily activities, so that they will not be moved into an infirmary or hospital. Prisoners of all ages told us the elderly want to avoid such places because the conditions can be more restrictive (for example extremely limited out-of-cell or outside time), because they do not want to be removed from their prison “family,” and because they are seen as places to go to die.

Older offenders also sometimes take on the role of guide or mentor to younger ones, which can be deeply satisfying. Some women told us they liked living with younger inmates because they were able to take on the role of “mother” for the younger ones. As one young man told Human Rights Watch, older guys “taught me how to do my time, so I don’t cause problems.”[117] In his view, younger inmates would be at a disadvantage if older guys were kept away. On the other hand, other inmates told us young inmates resent any efforts by older ones to give them advice. It is important, however, not to lose sight of the fact that older inmates, like younger ones, are a heterogeneous lot. Some may want to offer good counsel and support to those who are younger; some may have no interest in doing so; and some may have little or no tolerance for younger ones.

Correctional staff members we interviewed see advantages to mixed age populations. They pointed out that because the older offenders are more stable and mature, and want to do time as easily as possible, they can be a calming, stabilizing influence on younger ones and can help convince them to “go along with the program.” As William Connelly, the superintendent of Fishkill Correctional Facility in New York, told Human Rights Watch, older prisoners teach younger ones how to behave. Moreover, he strongly believes, “if you rest you rust,” that is, keeping the older inmates active in a mixed age group population promotes their own physical and mental well-being.[118] He insists that in New York, at least, the needs of individual aging offenders can be met on an individual basis, without clustering them by age into designated units. We are not in a position to say whether New York—or other states that take the same position—is in fact able to meet the needs of older offenders on an individual basis. But there is little doubt that ensuring elderly offenders are incarcerated in a manner that respects their human dignity may require transfer from regular general population units at some point during their incarceration. The question will become increasingly urgent as to whether correctional systems have or will be able to develop the capacity to meet the needs of older offenders for different kinds of housing and care.

Victimization

It’s terrible to come here as a 70-year-old. You lose all your family, your home. You’re here with all these kids, noisy, disrespectful, they steal from you, take whatever you got from canteen.
— Lawrence Alexander (pseudonym), California Substance Abuse Treatment Facility and State Prison, April 13, 2011

Corrections officials have the responsibility to protect the safety of those they confine, and people who have been deprived of their liberty have the right to be kept safe. Nevertheless, US prisons can be extremely dangerous places; inmate-on-inmate violence and staff-on-inmate violence jeopardize inmate well-being as well as rehabilitation. Victimization can range in gravity from homicide, severe physical assaults, and vicious rapes to more minor acts of harassment, extortion, theft, or humiliation. Certain types of inmates seem to be more frequently targeted for abuse, especially those who are small, weak, and vulnerable. Older and frail inmates may also be at higher risk of victimization if housed with much younger inmates. For someone who is old and frail, the right to safe conditions of confinement may mean not being required to live in a dorm with younger persons prone to violence and extortion.

Most correctional systems do not track assaults or other forms of victimization by age. Statistics measuring physical or sexual victimization of older inmates—whether by other inmates or by staff—is hard to come by. Data from a quality of life survey of thousands of New Jersey inmates by Dr. Nancy Wolff indicates that both male and female offenders over age 50 report lower rates of victimization by staff and other inmates than do younger offenders. Nevertheless, one in five inmates surveyed who was older than 50 reported some form of physical victimization, primarily inmate-on-inmate.[119]

In a much smaller study of 65 male prisoners age 50 or older, 10.8 percent reported physical attacks and assaults without weapons, 1.5 percent reported physical attacks and assaults with weapons, 6.2 percent reported being robbed, and 1.5 percent reported being raped, with the perpetrators primarily being younger prisoners.[120] California women inmates in mixed-age, general population prisons who responded to a questionnaire expressed concern about the risk of abuse from other women. For example, one woman in her seventies described how her cellmate “[got] right up in my face, and she kept saying she was gonna hit me. She went on that just because I was old and then she went on describing all my wrinkles … She didn’t hit me that day but I expect it will happen sometime. If you start telling the officers what happens they turn right around and go to that person and say, ‘she said such and such’ and ‘what’s this about?’ and you’re in worse shape.”[121] On the other hand, in Rhode Island, a survey of 67 inmates ages 55 to 88 in a medium security prison suggested that older inmates did not see themselves at risk for victimization.[122]

Human Rights Watch did not find a consensus among corrections officials or inmates we interviewed regarding the victimization of older inmates when they are housed with younger inmates. Some officials believe that victimization of the elderly is infrequent, and that when it occurs it typically involves annoyance and harassment or minor theft; serious physical confrontations are rare. Some said that younger inmates protect the elderly ones, insisting that everyone respect them. Others believe that older inmates are at high risk of victimization at the hands of younger inmates. Officials who believe the elderly can be “easy prey” emphasize the importance of placing them in facilities whose inmate population and culture are known to be safer, which in practice can mean facilities with higher proportions of more mature inmates, including those who are elderly, or disabled inmates.

Inmates who are incontinent and urinate or defecate in their clothes—which is not uncommon among the very elderly—may be ostracized and even physically assaulted by other inmates who are offended by the smell. Dr. Joseph Bick, the chief medical officer at California Medical Facility in California, explained to Human Rights Watch that if an old man living in a dormitory with younger offenders has an “accident,” such as a bowel movement in his pants, or if he “smells like pee all the time” because he’s incontinent, he may end up being attacked by annoyed younger inmates.[123]

According to correctional officials and inmates themselves, older inmates generally try to avoid conflict and “do their time” as quietly and easily as possible. This stance may also be a strategy to protect themselves if they are living in dangerous prisons. Whereas younger persons in prison tend to protect themselves by proving their capacity to be aggressive and dangerous, the older inmates tend to use “passive precautionary behaviors such as keeping more to oneself, avoiding certain areas of the prison, spending more time in one’s cell, and avoiding activities.”[124]

Our research suggests that victimization is not a significant problem for the elderly who are confined in “safer” facilities with a high proportion of older or infirm inmates. To the extent the elderly in such facilities were victimized, it tended to be through verbal threats, insults, and being cut in front of by other inmates in food or medical lines. More infrequently, the elderly faced theft or extortion of property or goods from the commissary. The inmates we interviewed also suggested that while the elderly do have things taken from them, this did not happen at a greater rate than that suffered by other inmates.

In terms of safety, there may be a difference between the elderly who have grown old in the prison system and those who arrive old as newcomers to incarceration. Three women we interviewed in a California facility told us they felt relatively safe because as “old timers” they had established relationships and felt protected by other inmates. (Still, they also complained, as did many other inmates both male and female, that younger inmates today have less respect for their elders than inmates did in the past). They thought, however, that older women who were new to prison may be at a higher risk of victimization. Like other inmates and corrections officials suggested to us, people who have been in prison a long time, or who have prior experience with incarceration, tend to “know the ropes,” and can see trouble coming and avoid problems more readily than newcomers.

Prison Rules

I don’t mess with staff. I may be old, but I’m not crazy.
— Gerald Brown (pseudonym), Denver Reception and Diagnostic Center, March 23, 2011
When you’re young you’re willing to jump in the flames; when you’re older you realize the flames are hot.
— Mark Donaldson (pseudonym), California Substance Abuse Treatment Facility and State Prison, April 13, 2011

The likelihood that a person living behind bars will engage in violence, extortion, escape attempts, or other violent or dangerous behavior diminishes with age. Corrections officials and incarcerated men and women we interviewed agreed that the elderly as a group are far less likely to cause trouble than younger inmates. They don’t “mess with staff,” they “just want to be left alone,” and they “get along better with each other than younger guys.”

Nevertheless, older prisoners are a heterogeneous group and prison officials insist on the importance of remaining attentive to the actual conduct and risks posed by each individual. A lieutenant at Ohio’s Correctional Medical Facility told Human Rights Watch: “Don’t let the wheelchairs fool you. They steal, argue, trade, fight, try to kick.”[125]

An 84-year-old offender was in disciplinary segregation at the time of a Human Rights Watch visit to a prison in Washington state because he had engaged in sex with a 72-year-old inmate to pay off a debt he said he owed the younger man. Indeed, staff told us that this particular offender repeatedly engaged in sexual conduct with other inmates, and apparently not always consensually. During our visits to prisons in different states we were told of old inmates swinging at others with their canes, of two old men fighting in their wheelchairs, and of old men who are still active gang members. We heard accounts of elderly who hide and barter medication and other property (like the extra blankets they obtained to protect against the cold). Even the terminally ill can break the rules. We were told of one offender with liver cancer in a prison hospice who arranged for his visitors to bring him contraband; another hospice inmate was allegedly stealing drugs from his fellow hospice mates.

In general, however, it appears that when older inmates do engage in misconduct it typically involves relatively minor rule breaking. The older are far less likely than younger inmates to engage in predatory behavior, be physically aggressive, get into physical fights, keep weapons, or exploit other inmates. We were not able to obtain system-wide data on rule violations by type and by age of offender at any of the facilities we visited. Nevertheless, staff suggested that disrespect to staff and being somewhere without authorization were the most typical rule violations.

Wilma Collins (not her real name) is an 82-year-old woman who was incarcerated in a Colorado prison 16 years ago with a three-decade-long sentence for a violent crime. She refused to be interviewed by Human Rights Watch. Because of multiple physical problems, she is housed in a prison infirmary where she essentially receives nursing home patient care, for example, assistance with eating, moving, and bathing. She is widely regarded by other inmates and staff as ornery and difficult. She is also increasingly confused, sometimes insisting, for example, that she has a pet rabbit in her bed. According to a correctional officer, she is “erratic, demented, and sometimes so abusive she puts aides to tears.” Nevertheless, recognizing her condition he asks, rhetorically, “what would be the point of writing her up for verbal abuse?”[126]

Correctional staff have the responsibility to enforce rules fairly and uniformly, but common sense and basic decency require treating a frail and infirm 80-year-old differently than a boisterous and fit 25-year-old. At least in units or facilities with high proportions of elderly and infirm inmates that we visited, the response of correctional staff to rule-breaking by older inmates tends to be somewhat flexible, accommodating the realities of aging bodies and minds. For example, inmates are supposed to stand for count. Bedridden inmates cannot do that, so they are permitted to satisfy the requirements of count by sitting up in bed, or simply by being awake. Linen is changed on a set schedule, but an offender who wets his bed will be given clean sheets regardless of that schedule. Staff are more likely to try to talk to an elderly offender who is breaking the rules or give him a verbal reprimand rather than to write up a ticket. If an old inmate is having problems getting to chow on time or cleaning his cell, the corrections officer may try to help find a solution or alert medical staff. When they do write up a ticket, unless the offense is quite serious, a disciplinary hearing may never be held. Officials pointed out also that while some rules may have to be “bent” a little to accommodate an offender’s infirmities or disabilities, staff also want to avoid decisions that will leave other offenders thinking they can get away with whatever they want to do. This may be particularly true in facilities with high proportions of younger inmates, who pay close attention to staff behavior and adjust theirs accordingly. Balancing fairness to the elderly with consistency and firmness can be a difficult balance and in any given situation, the older prisoner may end up with his legitimate needs not being satisfied.

California corrections officer describing a 70-year-old man: “He forgets his medications, he loses his way to the cell, and he forgets that he is in prison. He gets into fights because he ends up in the wrong cell. He is unsafe and needs more care.” [127]

Prison Staff and the Elderly

Learning how to identify and meet the needs of the aging population or how to understand geriatric behavior is not part of the training most corrections officers receive.[128] Few if any corrections departments provide training in the academy (before employment begins) or in-service training that addresses the special needs of aging offenders, including how to recognize physical and cognitive deterioration. As one California corrections officer who works in a unit with offenders with dementia and developmental disabilities told us, he came to the unit with no understanding of dementia, or even any training in how to communicate with those have it. He is “just learning it as [he goes] along.”

Trained or not, corrections officers are the eyes and ears of a corrections department, and they are on the front lines of prison geriatric care. Working day in and day out with inmates, they may be the first to know when one of them begins to behave in a strange way, starts having difficulty with regular activities, or develops symptoms that require attention. Mental health and medical staff rely on the corrections officers to notify them of such developments which might otherwise go unobserved until a scheduled medical visit. (Other inmates will also notify staff if one of their fellow inmates seems to be having trouble.) Corrections officers are also sometimes aware of inmate disabilities and impairments that have escaped tracking in the health system.

Even though corrections officers may be aware of limitations that offenders may have in their ability to function in their living environment, assessing functional skills and capabilities of offenders is not one of their formal responsibilities, it is not something they are trained to do, and overcrowding may make it impossible to do it sufficiently in any event. A study in the notoriously overcrowded California prison system found that nearly one-third of geriatric prisoners were unknown to their assigned officers.[129]

Prison facilities have their own cultures which are reflected in staff as well as inmate behavior. Staff and inmates we interviewed agreed that the culture in facilities with large proportions of the elderly and the infirm tend to be more “laid back,” less rigid, and “more peaceable” than in other prisons. The inmates we interviewed in such facilities generally gave good marks to correctional staff and told Human Rights Watch that “with the exception of a few jerks,” most of the staff do not hassle them and seem understanding of the limitations of aging bodies.[130] They said staff were generally helpful to older inmates and informally accommodated behavior from an older inmate that would not be acceptable from a younger inmate. We cannot conclude, however, that these same attitudes toward the elderly prevail when they constitute but a fraction of a facility’s population.

Even in prisons with high proportions of older prisoners, staff do not consistently treat them (or any others) with respect. We were told that sometimes custody staff see the older inmates as a “hassle” and get frustrated, responding with an impatient, “Oh, go take an aspirin,” to an inmate complaint. Some inmates we interviewed told us about particular instances of staff neglect, impatience, or abuse. For example, men in a California prison claimed custody staff mocked an inmate who had both urinary and bowel incontinence, calling him “despicable,” and that staff called another inmate who wore a protective helmet on his head, “helmet head.”[131] A 61-year-old woman in prison in Colorado who is in a wheelchair told Human Rights Watch some nurses are good, but “some are rude” when they give her the help she needs with toileting. “I’m trying to be fair but [I’m not always] treated like a human being.”[132] Women in a California prison pointed out to Human Rights Watch that “there’s always a couple of women in their unit who are incontinent and need help bathing, but there is no one to help them bathe so they don’t.”[133] In every prison we visited, older inmates also expressed views similar to the following from an older prisoner in Colorado: “If you file a grievance, you’ll be treated worse. People young and old are scared to grieve.”[134] We were also told by many inmates in different states that if an elder prisoner is particularly “obnoxious”, then staff may well be as hard on him as if he were younger. We should also note that a number of inmates described to us particular incidents they believed revealed medical neglect or malpractice.[135]

Bonnie Frampton entered prison in Colorado when she was 65, sentenced to more than 100 years for conspiracy for murder. She said the first year behind bars was a culture shock, and that she “still doesn’t truly accept it.” She thinks the staff is “OK.” A few are “the sort you’d never want to deal with” but most leave her alone. They “know she’ll stand up for her rights.” She has filed grievances even though that “risks retaliation because staff get even.” She filed a grievance against an officer who she claims then put a razor blade under her desk so she’d get written up when it was found. When she first came to prison, she had to have a mammogram. Because she has very tender breasts, she put her hands up to stop the mammography and the officer said, “If you touch me, it’s assault,” and she was written up. She has various physical problems, including limited mobility (she uses a walker or a cane), is blind in one eye, has arthritis and asthma, and other “old age medical problems.” She believes corrections officials mistreat the elderly by requiring them to stand outside in the pill line even when there is bad weather. She asks, “Why can’t the elderly and handicapped be given preference in line, so [they] can get their medications first?” She also notes that no extra blankets are provided in the winter even though it is cold. Since she wears her coat inside because of the cold, when she goes outside she has no extra protection. [136]

Many prison officials told Human Rights Watch that working in facilities with sizable populations of elderly prisoners is quite different than working in others.

William Hannah, a sergeant at Hocking Correctional Facility in Ohio, described his experience for Human Rights Watch:

It was a big culture shock for me when I came here in 1994 because of the age of the offenders. Older guys are needier, need help with everyday living. They are lonely, scared, have the disabilities that come with age. Older guys can be stubborn, cranky. How do you handle grumpy men? We give them a little more leeway. We know they’re hard of hearing, can’t see well, can’t perform like younger guys. Staff who come here from tougher prisons have to learn a different culture. You have to slow down, practice your patience. You can’t talk to these guys the way you would with younger ones. The younger offenders are still wild, still trying to prove something. Older guys just live day by day; they just want to do their time. You need to think about your grandparents. It’s a whole different relationship if the offender is 40 or 50 years older than you. You try not to get upset with them but have to be firm. This is an old age home with bars.[137]

Officers who have experience working in prisons with a lot of younger, more violent inmates may also have to adjust when working with a geriatric population. Having become used to thinking that “violence is just around the corner” and that a hard, firm hand is necessary to avert the ever-present potential for danger, it is a big change for them to develop a more “caring” approach for the aged and infirm. Correctional officials also emphasized to Human Rights Watch, however, that it was a challenge for staff to show empathy and compassion for geriatric offenders without crossing the line into doing things that jeopardize security and safety. According to these officials, just because an inmate is getting on in years, for example, does not mean he is not capable of being manipulative, of seeking to entangle staff in a relationship in which favors will be granted (for example contraband) despite the rules.[138] Corrections and medical staff can view requests from older prisoners for additional services or equipment with the same “default” attitude of distrust and wariness they often bring to requests from younger ones. They ask themselves, for example, does this older man really need an extra blanket because he is cold or is he trying to “game” the system and get an extra blanket for bartering purposes (bartering and trading are prohibited in prison).

To be an officer in this environment [a prison assisted living unit] you have to have a different attitude…. Staff don’t receive special training, except how to put the handicapped into a van. But officers come to understand that you can’t yell at [older inmates] like you might to a 25-year-old…. Patience, understanding, tolerance [are] needed from the officers…. You can’t and needn’t assume that if someone raises a hand that danger is imminent. They [older inmates] may not know what they’re doing…. [An officer is] not an aide because you still have a security role, but the shape of that role is quite different because of the context.[139]

Experts strongly urge training for prison staff who will be working with older prisoners on the normal processes of aging.[140] Training should also include “the communication skills needed with older adult inmates as the process of aging can affect the clarity and the speed of speech as well as thought processes.”[141] According to an Oklahoma Department of Corrections report on the aging prison population, a “comprehensive educational program for all corrections personnel should be required. Training should include the knowledge and skills that are required to meet the specialized needs of older offenders as well as an increased sensitivity to their needs and limitations, and the patience to deal with them.”[142] The problem is one of resources: corrections officials lack the budgets to expand academy or in-service training to add geriatric information.

Training aside, some corrections officers will not have the personal qualities and aptitudes for working with geriatric offenders. As one warden told Human Rights Watch, “the academy doesn’t teach patience.”[143] Corrections staff learn rules at the academy and in training, but applying the rules and regulations to old and infirm prisoners is a very different matter. Senior staff also told Human Rights Watch that new officers fresh from the academy may not be comfortable demonstrating any flexibility with regard to the rules; they need some “seasoning” before they realize they have options other than “writing up a ticket” for an elderly inmate who is not following orders or abiding by the rules.

I’ve got one guy in a diaper, one who’s frail. I can only give so much extra attention because I have to watch 70 other guys.[144]

Inmates had views similar to those of correctional officials regarding the difference between new and more seasoned corrections officers. As one California female inmate said, new officers straight from the academy are too strict, zealous, quick to punish, and “like the gestapo.”[145] Another California inmate at a men’s facility agreed, “the newer the officers, the worse they are.”[146] Yet another said that younger corrections officers tend to be “badge heavy.” It takes a while before they get seasoned and learn that respect begets respect.

Programs, Recreation, and Work

Always seen as a privilege or luxury rather than an essential component of corrections, programs have been slashed in US prisons because of budget crises. Aging prisoners have suffered like all others from cuts to programs. Even when programs are available, however, they are rarely designed specifically for the educational, physical, psychological, social, and rehabilitative needs of older persons. Older individuals in prison, for example, rarely have the benefit of programs to address the realities of aging or to help them understand and protect their health in later years. Many of the older prisoners we interviewed have little to do besides read, watch television, or talk to each other.

Ohio was once nationally recognized for the numerous special programs its prisons had for the incarcerated elderly.[147] Many of those programs have fallen by the wayside because of budget-related staff shortages. Thus, for example, Hocking Correctional Facility—in which men over 60 constitute the preponderance of the population—no longer offers programs designed to help offenders understand or cope with numerous physical and mental changes associated with aging. The elderly are also shortchanged because available educational and social programming targets offenders who will be released within three years and most of the older men at Hocking have far more years to go before they near release. Human Rights Watch interviewed Warden Francisco Pineda, who was keenly aware of the lack of programs for the older inmates. In an unpublished paper he wrote that he provided to Human Rights Watch, Pineda expressed his belief that a study is needed to assess the needs of older inmates in Ohio to “help to determine not only programming, but also institution designs or policy recommendations that will address age-specific activities and other types of treatment” that will both help older offenders transition back to the community and enhance staff performance managing them.[148] In Georgia, too, correctional officials acknowledge that they lack the resources to provide much programming for older persons. Because of budget limitations, programming in Georgia prisons is targeted at reentry skills that typically exclude older inmates.

Recreational programs for young and old alike have been slashed because of budgets. Where they exist, physical recreation programs are rarely tailored to older, frailer bodies. Older inmates must also compete with younger ones for access to gym and other recreational equipment. There are exceptions. Colorado Territorial Correctional Facility (CTFC), for example, has a special recreation hour limited to offenders age 50 or over as well as younger offenders with mobility impairments or developmental disabilities. Staff try to provide special activities, like football toss, and tournaments for the less able and active inmates. The effort at CTFC to create recreational opportunities for geriatric and infirm prisoners was not, however, replicated at other prisons we visited.

Older inmates typically are able to work in prison, assuming they are physically and mentally capable. Indeed, they may have to work regardless of whether they want to: there is no retirement age in prison and some prison work is mandatory. While prisons in theory try to match jobs with individual inmates’ capabilities, inmates complain that older inmates are given inappropriate job assignments and required to work under conditions that are dangerous for them. According to a California inmate, “There’s no consideration because of their age that maybe it’s time for them to stop working. You know, they just work till they parole or drop dead.”[149]

Officials say offenders want to work; it helps them stay busy and active, can be a source of pride, and can provide some much needed income. Human Rights Watch visited the license plate manufacturing facility at CTFC, where we saw older men in their wheelchairs next to men in their thirties. Human Rights Watch talked with one man in the factory who was 76 years old and had worked there for 19 years; another inmate, who was 69, had worked there for 13 years, becoming the lead man for embossing; and another, who was 65, who had spent 11 years in the shop. All three expressed pleasure in their work, but the conversations were not private and we have no way of knowing whether different views would have been expressed if they had been.

Planning for the Elderly

Although senior corrections officials know their population of elderly individuals is growing, few corrections systems have undertaken a thorough analysis of their existing and projected elderly populations or have a comprehensive strategy for addressing the needs of the elderly with regard to the built environment and facilities, the programs and activities, healthcare, and preparation for release. Without such studies, it is difficult to make sound policy and programmatic decisions for the future.

North Carolina undertook an Aging Inmate Population Study in 2006 that had the following goals:

  • To examine the factors that have accelerated the growth in the elderly inmate population;
  • To examine the demographics of the elderly inmates;
  • To explore avenues taken by other states in addressing the issues of an aging inmate population;
  • To analyze the costs of providing care to an aging inmate population;
  • To explore possible resources to help the Division in dealing with the aging inmate population;
  • To investigate innovative approaches for dealing with health and mental health issues of aging inmates;
  • To recommend possible solutions to the overwhelming expenses of housing and caring for elderly inmates; and
  • To increase Division knowledge regarding the needs of aging inmates.[150]

The North Carolina study concluded with a number of recommendations, but we do not know how many were implemented.

Obviously, studies accomplish little if officials do not act on them. In California, for example, despite numerous reports by consultants documenting the needs of a growing population of aging prisoners, the California Department of Corrections and Rehabilitation (CDCR) implemented few of the report’s recommendations.[151] As Clark Kelso, the medical receiver for the California Department of Corrections and Rehabilitation, told Human Rights Watch, “you need to listen to your experts who are projecting population demographics and bed needs and then prepare accordingly.”[152]

Even the best of plans—as well as existing programs—can be wrecked by budget crises. Attention to the rising numbers of elderly behind bars can also be sabotaged by changes in correctional leadership, shifting legislative and executive branch priorities, the daunting effort to manage prison populations that still exceed optimal capacity, and the challenges of day-to-day operations. Another problem lies with the absence of staff specifically tasked with supervising the needs and treatment of older inmates. The needs of older men and women cross multiple departments within corrections systems such as custody, operations, medical, and program departments. We know of no correctional system in which a senior official has been assigned the specific responsibility to assess conditions of confinement for older prisoners from a cross-cutting and integrative perspective and to press for the changes needed to improve those conditions.

[83]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; International Covenant on Economic, Social and Cultural Rights (ICESCR), adopted December 16, 1966, G.A. Res. 2200A (XXI), 21 U.N. GAOR Supp. (No. 16) at 49, U.N. Doc. A/6316 (1966), 993 U.N.T.S. 3, entered into force January 3, 1976, art. 12; Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (Convention against Torture), adopted December 10, 1984, G.A. res. 39/46, annex, 39 U.N. GAOR Supp. (No. 51) at 197, U.N. Doc. A/39/51 (1984), entered into force June 26, 1987, art. 16; 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 May 3, 2008.

[84] On the other hand, many chronically and terminally ill inmates are not elderly. Regardless of age, any prisoner who has serious medical conditions requires different conditions of confinement than those provided a healthy prisoner.

[85] In the course of research for this report, Human Rights Watch did not visit any prisons that, for example, approximated the “deplorable” conditions of overcrowding and substandard medical care alleged to have occurred at Alabama’s Hamilton Aged and Infirm Correctional Facility. According to the class action complaint filed by the Southern Center for Human Rights, the Hamilton facility was severely overcrowded and lacked appropriate medical staff to care for a population of elderly, disabled, and severely ill men. The facility lacked adequate emergency or acute medical care; prisoners experienced lengthy delays in receiving medical care for serious medical conditions; and prisoners with disabilities, “including those suffering from Alzheimer’s, dementia, or blindness” as well as mobility impairments were denied the necessary accommodations and assisted living. Aris v. Campbell, First Amended Complaint, Civil Action No. 05-PWG-396-e, June 2005. In February 2007, the court ruled plaintiffs had failed to establish violations of their constitutional rights. The First Amended Complaint and judgment are on file at Human Rights Watch.

[86]The United States does not have an official set of specific principles or rules for prison operations. The principles and outlines for such a regime are more fully developed—in theory at least—in Europe. See, Dirk van Zyl Smit and Sonja Snacken, Principles of European Prison Law and Policy: Penology and Human Rights (New York: Oxford University Press, 2009). See also United Nations Standard Minimum Rules for the Treatment of Prisoners (Standard Minimum Rules), adopted by the First 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 by its resolution 663 C (XXIV) of July 31, 1957, and 2076 (LXII) of May 13, 1977; European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment, “The CPT Standards, ‘Substantive’ sections of the CPT’s General Reports,” CPT/Inf/E (2002) 1, Strasbourg, October 2006.

[87]Medical staff can have negative attitudes towards incarcerated persons as well as security staff. In a well-documented example, 40 or so nurses signed a document protesting the care a quadriplegic inmate was receiving in a California prison. The nurses objected to what they felt were inappropriate special care and treatments the prisoner, Steven Martinez, received, and insisted he did not deserve them because of his offense as well as his hostility to them. They noted, “His offense was against women, and he continues to offend, only now it’s psychological rape and the staff is victims. As management continues to support the special and extra treatments demands by this inmate, it sustains a hostile work environment…. It’s time that all special and unnecessary treatment be stopped immediately. It is unethical and irresponsible to have allowed the many special and far-reaching treatments to have gone on for so many years … No prisoner in the state, county or world should ever receive the special treatment this inmate receives….” quoted by Presiding Commissioner Peck, Board of Parole Hearings, California State Prison, “Medical Parole Consideration Hearing of Steven Martinez,” May 24, 2011, pp. 58-60.

[88]Human Rights Watch email correspondence with Robert Greifinger, MD, December 20, 2011. Dr. Greifinger is a medical expert with extensive experience in complex community and correctional health care systems.

[89] Anno et al., “Correctional Healthcare,” p. 10.

[90]Information provided in “Response to Questions from Human Rights Watch Program,” Human Right Watch email correspondence with David Runnels, California Correctional Health Care Services, May 6, 2011, p.3.

[91] Williams and Abraldes, “Growing Older.”

[92] Ibid.

[93] Williams and Abraldes, “Growing Older,” p. 62.

[94] Cynthia Massie Mara, “Expansion of Long-Term Care in the Prison System: an Aging Inmate Population Poses Policy and Programmatic Questions,” Journal of Aging & Social Policy, vol. 14(2), 2002, pp. 54-55. The Americans with Disabilities Act does not require retrofitting of prisons architecturally, although physical access for people with disabilities must be provided so that inmates are not denied access to activities or services because of a disability.

[95]The Disability Rights Section of the Civil Rights Division of the US Department of Justice has conducted numerous investigations into the failure of prisons to comply with the requirements of the Americans with Disabilities Act; most of the prisons they have investigated have high proportions of geriatric prisoners, a high percentage of whom have mobility, visual, or hearing disabilities. For example, the section is currently working with the Alabama Department of Corrections to eliminate architectural barriers to movement for inmates with mobility impairments at the Hamilton Aged and Infirm Correctional Facility. Human Rights Watch interview (name withheld at request), US Department of Justice, November 29, 2011.

[96]Criteria for inclusion in the Senior Living Unit include: individual must be 55 years or older, have no history of elder abuse or victimization, and no in-custody history of predatory behavior. Central California Women’s Facility Housing Division, “Operational Procedure P-054,” August 2011, on file at Human Rights Watch.

[97]A survey by the Criminal Justice Institute in 2001 asked correctional systems if they designated special housing areas or facilities for elderly inmates. While many answered “yes,” the question did not ask if age was the sole criteria for the facilities. Indeed, we know that some states answered “yes” to the questions even though age by itself would not suffice to place an elderly inmate in the specialized facility. For example, in Texas, there is a special facility for geriatric prisoners over 60 but if they are fit and healthy, they will not be housed there. See Anno et al., “Correctional Healthcare,” Appendix A: Criminal Justice Institute Survey, pp. 66-69. A list of facilities for inmates who are old and infirm developed in 2005 is available at http://answers.google.com/answers/threadview/id/536333.html.

[98]R.V. Thivierge-Rikard and Maxine S. Thompson, “The Association between Aging Inmate Housing Management Models and Non-Geriatric Health Services in State Correctional Institutions,” Journal of Aging & Social Policy, vol. 19(4), 2007; John J. Kerbs and Jennifer M. Jolley, “A Commentary on Age Segregation for Older Prisoners: Philosophical and Pragmatic Considerations for Correctional Systems,” Criminal Justice Review, vol. 34(1), March 2009.

[99]Human Rights Watch interview with Cedric McDonald (pseudonym), Central Mississippi Correctional Facility, Rankin county, Mississippi, June 14, 2011.

[100]Missouri Department of Corrections, “Aging Offenders Management Team Report,” p. 5.

[101]Ibid.

[102]Missouri Department of Corrections, “Annual Report 2010.”

[103] Human Rights Watch visited Mississippi State Penitentiary, including Unit 31, on June 15, 2011.

[104] Ibid.

[105] Anthony A. Sterns et al., “The Growing Wave of Older Prisoners: A National Survey of Older Prisoner Health, Mental Health and Programming,” Corrections Today, October 2008, http://www.aca.org/fileupload/177/ahaidar/Stern_Keohame.pdf (accessed December 13, 2011). While older prisoners may predominate in these facilities, they also house younger inmates with certain medical conditions.

[106] Human Rights Watch visited Ohio’s Correctional Medical Center on May 17, 2011.

[107]Human Rights Watch interview with Homer Edmunds (pseudonym) and nursing staff, Mississippi State Penitentiary, Parchman, Mississippi, June 15, 2011.

[108] Ten of the men in the UCI have diagnoses of dementia; nine have diagnoses of “cognitive impairment-NOS,” a diagnosis used internally at the UCI “to convey the sense that the patients with that diagnosis are not afflicted with dementia as understood medically and/or psychiatrically, but have a significant level of impairment of social/intellectual/physical functioning which impedes/impairs their ability to remain in general population. This does not include those patients with pre-existing uncontrolled psychiatric disorders, mental impairment (mental retardation with/without developmental disability) although we have been called to assess these types of patients for suitability for our unit.” Human Rights Watch email correspondence with Dr. Joseph Avanzato, Fishkill Correctional Center, New York Department of Corrections and Supervision, December 5, 2011.

[109]Information provided to Human Rights Watch in email correspondence with Paula Butler, deputy superintendent health services, Fishkill Correctional Facility, New York Department of Corrections and Community Supervision, November 2, 2011.

[110]Human Rights Watch interview with William Connelly, superintendent, Fishkill Correctional Facility, Beacon, New York, December 2, 2011.

[111]Bettina Hodel and Heriberto G. Sanchez, “A Psycho-Social Intervention Program Provided in the Prison System for Inmate-Patients with Serious Cognitive Problems,” PowerPoint presentation of February 27, 2009, provided to Human Rights Watch by David Runnels, CDCR, May 17, 2011.

[112]Human Rights Watch interview with Dennis Brown, warden, Augusta State Medical Prison, Grovetown, Georgia, June 28, 2011.

[113]See for example, Alzheimer’s Association, “2011 Alzheimer’s Disease Facts and Figures,” http://www.alz.org/alzheimers_disease_facts_and_figures (accessed January 6 2011).

[114]Some academics disagree. See for example, Kerbs and Jolley, “A Commentary on Age Segregation for Older Prisoners,” pp. 119-139. Kerbs and Jolley believe the benefits of age-segregated living arrangements for older inmates include the promotion of rehabilitation and increased safety.

[115]Human Rights Watch interview with Roger Storey (pseudonym), Hocking Correctional Facility, Nelsonville, Ohio, May 16, 2011.

[116]Rachel Filinson, “Survey of inmates aged 55+, Rhode Island Adult Correctional Institution (Medium Security) Overview of Findings,” spring 2011, unpublished document on file at Human Rights Watch.

[117]Human Rights Watch interview with John Burke (pseudonym), California Men’s Colony, San Luis Obispo, California, April 14, 2011.

[118]Human Rights Watch interview with William Connelly, superintendent, Fishkill Correctional Facility, Beacon, New York, December 2, 2011.

[119]Data provided to Human Rights Watch in email correspondence with Dr. Nancy Wolff, June 27, 2011, based on survey of 7,113 male and 562 female inmates. Men were far more likely to report staff-on-inmate victimization than women (10.6 versus 2.5 percent).

[120]Kerbs and Jolley, “A Commentary on Age Segregation for Older Prisoners,” pp. 124-127.

[121] Quoted in Heidi Strupp and Donna Willmott, Legal Services for Prisoners with Children, “Dignity Denied: The Price of Imprisoning Older Women in California,” http://www.prisonerswithchildren.org/publications/reports (accessed January 6, 2011), p.36.

[122] Filinson, “Survey of inmates aged 55+,” unpublished document on file at Human Rights Watch.

[123] Human Rights Watch interview with Dr. Joseph Bick, chief medical executive, California Medical Facility, Vacaville, California, April 11, 2011. Bick also pointed out that no one will acknowledge the incident, neither the victim nor observers. The inmate will claim his black eye was from slipping in his cell, or some such excuse.

[124]Kerbs and Jolley, “A Commentary on Age Segregation for Older Prisoners,” p. 129.

[125]Human Rights Watch interview with correctional officer (name withheld), Correctional Medical Center, Columbus, Ohio, May 17, 2011.

[126]Human Rights Watch interviews with various inmates and correctional officer, Denver Reception and Diagnostic Center, Denver, Colorado, March 23, 2011.

[127]Brie A. Williams et al., “Caregiving Behind Bars: Correctional Officer Reports of Disability I Geriatric Prisoners,” Journal of the American Geriatric Society, vol. 57 no. 7, July 2009.

[128]As a consequence of litigation under the Americans with Disabilities Act (ADA), some prison systems, including Colorado’s, provide training in disability at the academy and in annual refreshers.

[129]Ibid.

[130]Human Rights Watch

[131]Human Rights Watch interviews with inmates, California Substance Abuse Treatment Facility and State Prison, Corcoran, California, April 13, 2011.

[132]Human Rights Watch interview with Constance Wooster, Denver Women’s Correctional Facility, Denver Colorado, March 23, 2011.

[133]Human Rights Watch interview with Joanne Brown (pseudonym) and Sarah James (pseudonym), Central California Women’s Facility, Chowchilla, California, April 12, 2011.

[134]Human Rights Watch interview with Hannah Bonner (pseudonym), Denver Reception and Diagnostic Center, Denver, Colorado, March 23, 2011.

[135] Because we did not set out to assess medical care, these incidents are not included in this report, and we have no basis, in any event, for assessing whether the medical treatment provided to elderly inmates is any better or worse than that provided to inmates of different ages.

[136] Interview with Bonnie Frampton (pseudonym), Denver Women’s Correctional Facility, Denver, Colorado, March 23, 2011.

[137]Human Rights Watch interview with William Hannah, Hocking Correctional Facility, Nelsonville, Ohio, May 16, 2011.

[138]Human Rights Watch interview with Dr. Joseph Bick, chief medical executive, California Medical Facility, Vacaville, California, April 11, 2011.

[139]Quotes compiled from Human Rights Watch group interview with staff, Coyote Ridge Corrections Center, Connell, Washington, August 8, 2011.

[140]Williams et al., “Caregiving Behind Bars.”

[141]Cindy Snyder et al., “Older Adult Inmates: The Challenge for Social Work,” Social Work, vol. 54 no. 2, April 2009, p. 121.

[142]Oklahoma Department of Corrections, “Managing Increasing Aging Inmate Populations,” October 2008, http://www.doc.state.ok.us/adminservices/ea/aging%20white%20paper.pdf (accessed November 29, 2011).

[143]Human Rights Watch interview with Vimal Singh, warden, California Medical Facility, Vacaville, California, April 4, 2011.

[144]Human Rights Watch interview with corrections officer (name withheld), John J. Moran Medium Security Facility, Cranston, Rhode Island, July 15, 2011.

[145]Human Rights Watch interview Joanne Brown (pseudonym), Central California Women’s Facility, Chowchilla, California, April 12, 2011.

[146]Human Rights Watch interview with Carols Ruiz (pseudonym), California Substance Abuse Treatment Facility and State Prison, Corcoran, California, April 13, 2011.

[147]Anno et al., “Correctional Healthcare.”

[148]Human Rights Watch interview with Francisco Pineda, warden, Hocking Correctional Facility, Nelsonville, Ohio, May 16, 2011. Warden Pineda provided Human Rights Watch with an unpublished paper he authored titled “The Older Offender in DRC,” on file at Human Rights Watch.

[149]Quoted in Strupp and Willmott, “Dignity Denied,” p. 27.

[150]Price, “Aging Inmate Population Study.”

[151]Admittedly, the grotesquely overcrowded California prison system was unable to meet the medical and mental health needs of its prisoners regardless of age. The deadly dysfunction finally resulted in a May 2011 Supreme Court decision ordering state officials to reduce the prison population. Brown v. Plata, United States Supreme Court, 131 S. Ct. 1910 (2011).

[152]Human Rights Watch interview with J. Clark Kelso, receiver, California Correctional Health Care Services, Sacramento, California, April 19, 2011.