Dementia in <scp>UK</scp> prisons: Failings and solutions?

Prison is a place built for the young, fit offender (Newcomen, 2016a), yet older people make up the fastest growing demographic in prisons in the United Kingdom (O'Moore, Czachorowski, Leaman, Peden, & Sturup-Toft, 2018) and in other developed countries (Psick, Ahalt, Brown, & Simon, 2017). When paired with the fact that dementia is one of the most pressing healthcare issues in the United Kingdom (Moll, 2013), it is unsurprising that facing dementia is a serious issue for prisons too. The age change in prisons in part reflects changes in average age of the general population in most developed countries. In 2016, people of over 65 years made up 18% of the total U.K. population, and it is projected that they will account for over a quarter of it within the next 40 years (Storey, 2018). In March 2018, 16% of the adult prison population in England and Wales was over 50 years old compared with 7% in 2002 (Sturge, 2019). Generally increased life expectancy is not, however, the only explanation among prisoners. There has also been a rise in historical sex offence proceedings and prison sentences have been getting longer (Di Lorito, Völlm, & Dening, 2018; Ministry of Justice, 2018; Munday, Leaman, & O'Moore, 2017). To compound this, ‘old’ in prison comes, on average, around 10–15 years earlier than in the general population (Di Lorito et al., 2018; Enggist, Møller, Galea, & Udesen, 2014; Munday et al., 2017). This is attributed to reasons including poverty, inadequate access to healthcare, alcohol, smoking, illicit drug use, as well as psycho-social factors including familial separation and the contemplation of long periods of time in incarceration (Moll, 2013). A widely used figure to demarcate ‘old age’ in prison is 50 years (Enggist et al., 2014; Munday et al., 2017). Older prisoners, therefore, are probably even more likely than general population peers to have complex physical and mental health needs (Di Lorito et al., 2018; Enggist et al., 2014), including dementia related needs. How well can prisons cope with all this? It is difficult to get an accurate figure for the prevalence of dementia in prison due to likely underdiagnosis (Munday et al., 2017; Newcomen, 2017). Estimates suggest that approximately 5% of prisoners over 50 years-old are suffering with dementia (Munday et al., 2017), which is close to the general population figure of 7% of those over 65 (NHS, 2017). When, however, one prison in England (HMP Bronzefield) undertook pilot cognitive screening (Addenbrooke's Cognitive Examination-III) of all prisoners over 55s, a quarter received a provisional diagnosis of dementia for the first time (Chao, 2019). Others have also suggested higher dementia rates in prisons than in general population (Newcomen, 2017; Sindano, 2016). If the higher estimate is closer to the truth, what could account for this apparent excess over the general population? Heavy alcohol consumption can lead to reduction in the brain's white matter and increase the risk of dementia (Alzheimer's Society, 2019). Heavy alcohol use and/or dependence are widely recognised as affecting around 18–30% male prisoners and 10–24% in female prisoners (Enggist et al., 2014), although, again, if formal screening is undertaken figures may be even higher (Kissell et al., 2014). Either way, figures are a great deal larger than the 9% of men and 3% of women in the general population with drinking problems (Drinkaware, 2019). Depression has a complex relationship with dementia. Whilst depression-dementia comorbidity is common, there is emerging evidence that depression, particularly in earlier life, carries at least twice the risk of dementia than never having had it (Byers & Yaffe, 2011). Studies on later life depression have been inconclusive, partly because it is difficult to tell whether the depression was indeed a risk factor, a prodrome, or a co-occurrence (Byers & Yaffe, 2011), but some kind of association is undoubted (Li et al., 2011). The national occurrence of depression in the United Kingdom is around 3.3% (Mind, 2017), however the prevalence of depression in UK prisons is estimated to be around 10 times higher (Moll, 2013; Newcomen, 2016b), a possible alert to higher risk of dementia among prisoners. Adequate responses to any substantial health problem pose a challenge, but even more so when the governing body is not primarily tasked with healthcare and not even in a place to assess its true prevalence. Common early signs and symptoms of dementia are memory loss, difficulty concentrating, struggling to carry out familiar tasks, not being orientated to time and place, and mood changes (NHS, 2017). These are typically changes that friends and family members would identify in their loved one, and bring it to the attention of their GP. So, who is there to spot these signs in older inmates? At an extreme level, such signs may be picked up on reception screens, but the nature of living in prison means that mental health conditions are often missed or ignored if they are not causing the prisoner to demand help or pose a threat to security (Moll, 2013). Furthermore, the prison population in England and Wales is so large and prisons so understaffed that often no single person is spending enough time with each prisoner to notice subtle functional difficulties (Moll, 2013). In UK prisons, 95% of inmates are male (Sturge, 2019), so other factors making recognition of dementia-related needs difficult include a lower likelihood of older people and men reporting their health difficulties or changes in mood (Moore, Grime, Campbell, & Richardson, 2012). In addition, the rather basic levels of routine which currently prevail in prisons in England and Wales (O'Connor, Bezeczky, Moriarty, Kalebic, & Taylor, 2020) may make it harder to notice those in the early stages of dementia (Moll, 2013), thereby making it more difficult to slow the progression of the disease at a more independently functional stage. It is arguable that prison officers are best placed to flag up concerns about a prisoner with cognitive decline, but, even if they have time, do they have the skills? Prisoner officers' level of knowledge about dementia is generally low, and the symptoms or signs are often not noticed or attributed to other conditions (Sindano, 2016). Given their centrality to prisoner care as well as containment, the Alzheimer's Society has made efforts to improve prison officers' training in this respect (Sindano, 2016), however more recent studies have still identified significant gaps in such training and skills (Brooke, Diaz-Gil, & Jackson, 2018). A possible solution may lie in the regular cognitive screening of older prisoners. It can, however, be difficult to ascertain whether any signs, like disorientation to time, are due to dementia or the disorientating nature of being in prison (Brooke et al., 2018), so even currently validated screening tools, such as the Mini-Mental State Examination, may have limited value for a prison setting; they have yet to be validated for such use (Brooke et al., 2018). They are, however, only screening tools – flagging possible problems that need more expert evaluation, so should be considered. There is currently no comprehensive screening policy for dementia in prison in the United Kingdom. People with dementia require progressively more support and modifications to their environment in order to survive. Early on, provision of calm, bright environments and gentle reorientation may be sufficient, later more extensive assistance with communication, feeding and dressing will be required (NHS, 2017). Such support is often provided by family members acting as unpaid carers, which as a collective, save the NHS £132 billion a year (Carers UK, 2015). The remaining costs outside of unpaid care total £26 billion per year, two thirds of which is met by those affected and their families (Hutchings, Carter, & Bennett, 2018). Even in the wider community state-funded dementia care is heavily rationed in the United Kingdom (Hutchings et al., 2018), but this is accentuated in prisons. One of the biggest challenges in providing adequate support for dementia in prison is the lack of money – there can be no offsetting of costs by families. Health services in prisons are commissioned from the NHS and other healthcare providers and have long been suffering budget pressures. Furthermore, the prison staff budgets were significantly cut from 2010, resulting in a loss of at least a quarter of the prison workforce (Treacy, Haggith, Wickramasinghe, & Van Bortel, 2019). Lack of specific support in prison for a condition as common as dementia has been described as ‘institutional thoughtlessness’ (Di Lorito et al., 2018). The many risks to the prisoner with dementia include victimisation by other prisoners, disciplinary action if undiagnosed dementia is incorrectly viewed as disobedience, and distress due to a lack of a calm, well-signposted environment (Brooke et al., 2018; Grierson, 2018; Newcomen, 2016a; Treacy et al., 2019). There are examples of emerging good practice with regard to dementia care in prisons, for example dementia awareness training on offer to both prisoners and staff at HMP Dartmoor and HMP Exeter, and regular multidisciplinary team meetings for older prisoners held at HMP Whatton (Moll, 2013; Newcomen, 2016a). Yet the intense financial pressures mean that there is not currently enough of this standard-level healthcare, resulting in a ‘postcode lottery’ effect. According to the Prisons & Probation Ombudsman, whilst some prisons are beginning to move in the right direction when it comes to caring and providing for prisoners with dementia, systemically, prisons are still ill-prepared (Newcomen, 2016a). The purposes of prison are commonly accepted as some combination of punishment, incapacitation, deterrence and rehabilitation, to protect the public, although there is disagreement on the importance and efficacy of each of these functions (Scottish Centre for Crime & Justice Research, 1996). There is little evidence supporting the idea that imprisonment or longer sentences serve as a criminal deterrent (Burnett & Maruna, 2004; Lufkin, 2018; National Institute of Justice, 2016; Robinson & Darley, 2004), but how anyway do you punish or deter somebody who has forgotten where or why they are in prison, and to what end (Fazel, McMillan, & O'Donnell, 2002)? How do you rehabilitate someone who is inevitably cognitively declining until death? Is it legally or ethically defensible to keep people incarcerated in unfit conditions? If protection of the public remains an issue in an individual case, are there better alternative options, such as secure care homes? Care homes for people with dementia already include strategies for prevention of ‘wandering off’. Imprisonment of people with dementia raises a question to do with one of the core pillars of medical ethics: justice (Beauchamp & Childress, 2001). In order to be just with regards to health and social care, it is the U.K. government's national policy that there is an obligation to provide the same standard of care inside prisons as that provided for the general population (House of Commons Health and Social Care Committee, 2018). If this basic standard of care cannot be provided as well in prison as outside, then it is in frank discord with the principles of justice. Provisions for prisoners will never be high on the public's list of political demands (Moll, 2013), but that does not make current practice right. Furthermore, not only is it ethically unsound not to provide equivalence of care, it is arguably illegal. Lack of appropriate healthcare for ill prisoners has been declared to be in violation of Article 3 of the Human Rights Act 1998, as a form of inhuman or degrading treatment (Fazel et al., 2002). There is still no national strategy for management of dementia in prison in the United Kingdom, although it is desperately needed, and it is national policy that people in prison should receive a standard of care that is the same as that in the community. Despite a few areas of good practice, the government is not yet delivering on this. As the situation stands, there is no accurate assessment of the true scope of the problem. Then, even within the cohort of correctly diagnosed prisoners, it is often not possible to provide the right environment for them, although a select number of forward-thinking prisons may have adequate provisions and could be taken as models for dissemination and further evaluation. There are several serious ethical issues raised by the incarceration of people with dementia; a re-examination of the purpose of their imprisonment becomes more and more relevant, the more they cognitively decline. There is also the matter of other aspects of justice if prisoners are not receiving equivalent treatment and care for their dementia as they might if they were a free citizen. There is no shortage of recommendations for the future of healthcare for dementia in prisons – for all countries by the World Health Organisation (WHO; Enggist et al., 2014) and, in England and Wales, the Prison & Probation Ombudsman (Newcomen, 2016a) among others. The vision will need at least a short-term injection of funding for new personnel, further training and more purpose designed accommodation inside and outside prisons. Furthermore, changes will need research evaluation. Immediate projects could include validation of dementia screening in prisons, a more accurate estimate of current needs and measurement of economic parameters. It is entirely plausible that, after a period of initial investment, service costs could actually be lowered by more appropriate assessment care within prisons and better provision of community alternatives. The current situation with regard to dementia in UK prisons is completely unacceptable and a governmental failing. There needs to be a cohesive, national drive to put in place a plan for this ever-growing problem of dementia in our older prison population. This editorial started life as the winning essay in the 2019 commission of medical student essays by the Forensic Psychiatry Faculty of the UK's Royal College of Psychiatrists. I am grateful to the College and particularly to Dr. Aideen O'Halloran who has overseen this competition for several years. I am also incredibly grateful to Dr. Thomas Hewson and Dr. Nikki Thomas for guiding and supporting me from the earliest stages of my career in psychiatry. Data sharing is not applicable to this article as no new data were created or analysed in this study.

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