Older imprisoned persons

People grow old, even in prison. This has always been the case, but today, it happens more often because many people are imprisoned for longer, and some are never released. Due to this stricter prison policy, there are more people who age and die in prison.

Prisons are usually alien to us - because they are hidden behind walls and barbed wire. For this reason, incarcerated adults often belong to a forgotten group. With this exhibition, we want to foster discussion of this neglected topic and spread knowledge about those who live in our country but are invisible.

Over the past fifteen years, the Institute of Biomedical Ethics at the University of Basel has gathered comprehensive data and new findings on older incarcerated adults in Swiss penal and forensic psychiatric institutions. During two large-scale projects funded by the SNSF, "Agequake 1" and "Agequake 2", the phenomenon of ‘ageing in prison’ was investigated. This webpage is now part of the public relations work to make the findings accessible to the general public.

Accommodation and care

How, where and with whom do we want to live in old age? This question arises both outside and inside prisons. One particular feature of imprisonment is that inmates are not allowed to decide and determine their 'living situation' themselves but are dependent on the conditions in prison. At the same time, prisons are generally designed for younger and physically active people and are not adapted to the needs of older incarcerated adults.

With the increase in the number of older incarcerated adults, the question of accommodation and care for this group is becoming increasingly urgent. Should older people live separately in separate facilities or integrated into existing prisons? One advantage of separation is the more efficient use of resources and the possibility of staff specialising in the typical needs and health problems of the elderly. In addition, segregation is sometimes necessary to ensure the protection of older incarcerated adults from abuse by younger and stronger individuals who are higher up in the prison hierarchy. Specialised units within existing prisons are important to prevent older people with mobility problems from having to climb stairs, for example. However, ensuring contact with younger people and access to general care structures is also essential. Many older people appreciate socialising with younger generations but want more privacy, peace, and quiet.

There are currently three such specialised departments in Switzerland. In other countries, there are similar solutions for the care of older people, but there are also special features: In Canada, for example, there are so-called 'peer interventions', where younger incarcerated adults support older people in coping with everyday life. These have great potential to cover the high need for care and, at the same time, promote dialogue between the generations. It is also a method to reduce loneliness and isolation among older people and to give younger people a meaningful and responsible task during their imprisonment.

Old from 50?

Older incarcerated adults have high health burdens. Their state of health is not only worse compared to younger incarcerated adults but also to people of the same age in the general population. They are classified as old from the age of 50, as the burden of disease and healthcare system utilisation increases sharply from this age.

In the general population, age 65 is often used as a threshold for differentiating between old and young. Behind bars, people over 50 are already considered older. The reason for this is that a drastic increase in the disease burden and utilisation of health services is already noticeable from age 50. From this age onwards, there is a clear decline in health and the ability to perform activities of daily living. Prison health services are under great strain as they are geared towards treating younger people with acute illnesses and injuries. However, older people often require constant care due to their increasing chronic health problems, such as high blood pressure, rheumatoid diseases and depressive moods.

The difference in health between the general population and the prison population can be attributed to the fact that incarcerated adults are more likely to belong to a group that is exposed to unfavourable influences that can have a negative impact on their health and the ageing process. These factors include, for example, diet, sleep, exercise, chronic stress, substance use, housing situation, level of education and the social and family environment.

With regard to imprisoned persons, this difference is attributed to two main reasons: the lifestyle of the imprisoned persons prior to imprisonment and the influences of imprisonment itself. It has been shown that imprisoned persons tend to come from disadvantaged backgrounds with a lower socio-economic status. In addition, they often have a history of excessive drug and alcohol use, poor diet and eating habits, personal neglect, inadequate access to medical care, stressful life experiences and a general tendency towards risky behaviour. Furthermore, imprisonment itself is also thought to have an impact on incarcerated adults' health through separation from family, the risk of isolation and loneliness, fear of violence from other incarcerated adults and poorer access to healthcare during imprisonment.

Healthy ageing

Health promotion benefits both the individual and society as a whole. We should see prisons as an opportunity to engage with an otherwise hard-to-reach population because the well-being of the individual increases the well-being of the population as a whole.

Prisons represent an opportunity to promote healthy ageing. People in prison usually come from socially disadvantaged backgrounds, which increases their risk of illness. Through targeted measures, prisons can help to make ageing healthier. This is important for the individual’s well-being, for reducing the risk of recidivism as well as relieving the burden on the healthcare system. To this end, it is of great importance that prison health services shift their focus from treating acute illnesses such as infections and injuries to caring for chronic health problems such as diabetes, high blood pressure and depression. In addition to comprehensive medical care, a balanced diet and regular physical activity are also crucial for maintaining and promoting quality of life and good health.

Many prisons in Switzerland have a canteen system. This means that all incarcerated adults in an institution receive the same meal at the same time. This food is often perceived as repetitive and not particularly healthy. People who have been in prison for a long time find the weekly repetition of the menu as an unnecessary punishment. Adapting the diet to chronic illnesses such as diabetes and kidney disease poses a particular challenge for the system. Older people report that they are often not given an alternative specifically tailored to their health needs but have to pick and choose from the general menu. An elderly detainee with chewing problems described the following: "The problem is that I can't bite. So they took the meat, took the vegetables, put everything in a pot and sh-sh-sh [imitates the sound of a blender]. Well, it looked like vomit.".

People in prison tend to lead a sedentary lifestyle, largely centred around their bed. There are opportunities for exercise and sport within prisons, but older people, in particular, often avoid these. This is because they cannot keep up with younger people's sports due to health problems or declining fitness. For example, they don't want to pump in the fitness room with techno music blasting or potentially injure themselves playing football. One Swiss Prison has responded to this need and created a sports and exercise programme that is specially adapted to the interests of older incarcerated adults. A step in the right direction.

Risk and reintegration

How many fences, walls and locks should murderers and sex offenders be locked up behind? Preferably as much as possible! - says our zero-risk society. What looks like more security at first glance brings with it many problems and raises questions.

Crime rates fall with increasing age. This means, the older, the fewer offences, the less dangerous. Nonetheless, most older incarcerated adults are inadequately housed in terms of their dangerousness and are over-secured. This is partly due to the social expectation of zero risk but also to a lack of prisons with lower security levels. In addition, there are too few public facilities offering long-term care to which formerly incarcerated persons could transfer after their time in prison.

Every prison sentence should end with successful reintegration, but what prospects do older incarcerated adults have? They often have few financial resources and little prospect of returning to work. They have small social networks but need a lot of support. They need close-knit healthcare, and some need support in everyday life. They have often served long prison sentences and show the effects of institutionalisation, such as dependence on institutional structures, social alienation and withdrawal. Some have never seen a smartphone and are unfamiliar with the digital world. Unsurprisingly, many older incarcerated adults report fears about being released but also fears of dying in prison and never being able to experience the outside world again. However, due to their declining capacity and increasing health problems, many feel unable to build an independent life. Therefore, the majority are ambivalent: they want more personal freedom and to move about in the world outside the walls but have concerns about their ability to live independently.

There is no such thing as zero risk-nowhere. This raises the question of whether such superficial security measures with many walls and fences make sense. Many of the older people in prison may not be able to return to an independent life, but they no longer need this strong security. Most need facilities that provide long-term care in public institutions or prisons with little security. Walls, fences, and security staff cost a lot of money. Our zero-risk society should reconsider whether these resources are being properly utilised. 

End of life and death

"These people who will end their days in prison with an incurable disease - I think that's worse than a death sentence. It's a death sentence, indirectly. He's going to die in prison, so he's sentenced to death."

The topic of ‘end of life in prison’ was previously mostly dealt with in connection with suicide or killings by fellow incarcerated adults. Due to the increase in the number of older incarcerated adults, more people will die of natural causes in prison. These deaths require different interventions, care and psychosocial support. However, the care of incarcerated adults at the end of life is often complicated by the restrictive environment and the conflicting goals of providing care and ensuring security.

The proximity to their own finiteness and the possibility of dying in bondage trigger fears. They long to experience freedom once again. Many elderly or sick people fear dying alone and unnoticed in their cells due to strict confinement practices. They want to say goodbye to their families and friends, resolve conflicts and settle financial issues. Some want to avoid the added stigma of dying in prison to protect their families. The restrictive visiting hours and lack of information sharing are perceived as unnecessary punishment for relatives.

People in prison cannot choose where they want to die. Most wish to spend their last days outside of prison. The early release of seriously ill and elderly people is possible, but this rarely happens. Additionally, public institutions such as hospices often refuse to care for incarcerated individuals, mainly due to stigma and fear of the unknown. If a person's health deteriorates, they can be transferred to a special ward for incarcerated adults at the Inselspital in Bern. This offers acute care that prison health services cannot provide. For some long-term incarcerated adults who have largely lost contact with the outside world and whose social environment is mainly within the prison, the question arises as to whether they would prefer to die within the prison, which has become their permanent place of residence. This is now possible in a specialized unit of one Swiss prison.

Isolation and loneliness

Older people in prison are particularly at risk of experiencing loneliness and isolation. The prison environment poses a challenge to forming and maintaining close relationships.

A lack of social networks and the experience of isolation and loneliness can affect not only mental and physical health but also successful reintegration into society. Contact with society outside and inside the walls is severely restricted, as this imprisoned person summarises: "No more relationships with society, no more romantic relationships with the opposite sex, with women, none of that. No more meetings with people who could enrich us. None of that exists anymore."

Older incarcerated adults usually have long periods of imprisonment behind them. For this reason, many have lost contact with people outside prison over time. Perhaps their parents have died, their extended family hardly seeks contact, or their intimate relationship has broken up. The rules on visiting times are highly regulated and become increasingly difficult for friends, acquaintances and family members who are also getting older. Long journeys and complex security checks are stressful. A few contacts may remain, but the social support network is small.

Because older people, in particular, have spent many years in prison, social relationships within prisons are very important. Socialising with other incarcerated adults is essential but is restricted by security measures, as they cannot move freely between departments. Furthermore, there are often language barriers, as people from many nations and, therefore, different languages are imprisoned together. Some older people report that they appreciate the exchange with younger people, as their advice is appreciated. In addition, the importance of interactions with healthcare staff is increasing, especially among older people. Some of them need health care and support in everyday life and develop a close relationship with the nursing staff. Others describe their psychotherapist as their main confidant within the institution. Loneliness increases the risk of physical and mental health problems. Therefore, there should be a stronger focus on helping incarcerated adults to build and maintain close relationships. Prisons have the potential to create an environment that fosters the development of intimate relationships. We should use this opportunity.