In corrections systems nationwide, officials are grappling with decisions about geriatric units, hospices and medical parole as elderly inmates – with their high rates of illness and infirmity – make up an ever increasing share of the prison population.
At a time of tight state budgets, it's a trend posing difficult dilemmas for policymakers. They must address soaring medical costs for these older inmates and ponder whether some can be safely released before their sentences expire.

The latest available figures from 2010 show that 8 percent of the prison population – 124,400 inmates – was 55 or older, compared to 3 percent in 1995, according to a report being released Friday by Human Rights Watch. This oldest segment grew at six times the rate of the overall prison population between 1995 and 2010, the report says.

"Prisons were never designed to be geriatric facilities," said Jamie Fellner, a Human Rights Watch special adviser who wrote the report. "Yet U.S. corrections officials now operate old age homes behind bars."

The main reasons for the trend, Fellner said, are the long sentences, including life without parole, that have become more common in recent decades, boosting the percentage of inmates unlikely to leave prison before reaching old age, if they leave at all. About one in 10 state inmates is serving a life sentence; an additional 11 percent have sentences longer than 20 years.

The report also notes an increase in the number of offenders entering prison for crimes committed when they were over 50. In Ohio, for example, the number of new prisoners in that age group jumped from 743 in 2000 to 1,815 in 2010, according to the report.
Fellner cited the case of Leonard Hudson, who entered a New York prison at age 68 in 2002 on a murder conviction and will be eligible for parole when he's 88. He's housed in a special unit for men with dementia and other cognitive impairments, Fellner said.

A.T. Wall, director of the Rhode Island Department of Corrections and president of the Association of State Correctional Administrators, said he and his colleagues regularly exchange ideas on how to cope with the surging numbers of older prisoners.
"We are accustomed to managing large numbers of inmates, and it's a challenge to identify particular practices that need to be put into place for a subset," he said. "There are no easy solutions."
Wall said prison officials confront such questions as whether to retrofit some cells with grab bars and handicap toilets, how to accommodate inmates' wheelchairs, and how to deal with inmates who no longer understand instructions.

"Dementia can set in, and an inmate who was formerly easy to manage becomes very difficult to manage," he said.

States are trying to meet the needs.

Some examples:
_Washington state opened an assisted living facility at its Coyote Ridge prison complex in 2010, with a capacity of 74 inmates. It's reserved for inmates with a disability who are deemed to pose little security risk.

The Louisiana State Penitentiary has had a hospice program for more than a decade, staffed by fellow prisoners who provide dying inmates with care ranging from changing diapers to saying prayers.

In Massachusetts, a new corrections master plan proposes one or more new facilities to house aging inmates who need significant help with daily living. Some critics object, saying inmates shouldn't get specialized care that might not be available or affordable for members of the public.

Montana's corrections department is seeking bids for a 120-bed prison that would include assisted-living facilities for some elderly inmates and others who need special care.

In Texas, legislators have been considering several options for addressing the needs of infirm, elderly inmates. State Rep. Jerry Madden, chairman of the House Corrections Committee, said no decisions have been made as the experts try to balance cost factors and public safety.

"You can't just generalize about these prisoners," he said. "Some are still extremely dangerous, some may not be.... Some you wouldn't want in the same assisted living facility with your parents or grandparents."

Fellner, who visited nine states and 20 prisons during her research, said corrections officials often were constrained by tight budgets, lack of support from elected officials, and prison architecture not designed to accommodate the elderly.

She noted that prison policies traditionally were geared to treat all inmates on an equal basis. So it may not be easy for prison officials to consider special accommodations for aging inmates, whether it be extra blankets, shortcuts to reduce walking distance, or sparing them from assignments to upper bunks.

The report said the number of aging prisoners will continue to grow unless there are changes to tough-on-crime policies such as long mandatory sentences and reduced opportunities for parole.

"How are justice and public safety served by the continued incarceration of men and women whose bodies and minds have been whittled away by age?" Fellner asked.

One of the problems facing prisons is that many of their health care staff lack expertise in caring for the elderly, according to Linda Redford, director of the geriatric education center at the University of Kansas Medical Center.

"It's a big struggle for them to keep up," said Redford, who has helped train prison staff and inmates in geriatric care.

"They're used to having to deal with issues of younger prisoners, such as HIV and substance abuse," she said.

Under a Supreme Court ruling, inmates are guaranteed decent medical care, but they lack their own insurance and states must pay the full cost. In Georgia, according to Fellner's report, inmates 65 and older had an average yearly medical cost of $8,565, compared with $961 for those under 65.

Redford said the challenges are compounded because inmates' health tends to decline more rapidly than that of other Americans of the same age due to long-term problems with drug use and poor health care.

"In the general population, 65 doesn't seem that old," Redford said. "In prison, there are 55-year-olds looking like they're 75."

Many states have adopted early release programs targeted at older inmates who are judged to pose little threat to public safety.
However, a 2010 study by the Vera Institute of Justice in New York City found the laws were used infrequently, in part because of political considerations and complex review procedures.

Redford said a common problem is finding nursing homes or other assisted-living facilities that will accept released inmates who have family to live with.

"Nursing homes don't want former felons," she said. "Some states are looking at starting long-term care facilities outside prison for that could take care of parolees."

For inmates who are terminally ill and have no close family on the outside, it's probably more humane to let them die in prison if there's a hospice program available, Redford said.

"The inmates who are volunteering are at those guys' sides when they die – they're really committed to making the last days as comfortable as possible," Redford said. "They're not going to get that on the outside."