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As the inmate population ages, dementia will become increasingly common in our jails and prisons. In the community, the rate of new cases of dementia is expected to double in the next four decades. Although we don’t really know what the prevalence of dementia is among inmates, there is no reason to think it is less than in the community.

Tip of the Iceberg:
40 Year Forecast

See the current prevalence rate and projections for 2030 and 2050. Table »

In fact, there is reason to think it may be two to three times more frequent in corrections than in the community: Inmates have fewer protective factors and more risk factors; increasing numbers are being incarcerated into late age or for life; and inmates may grow physiologically older faster than people in the community due to high risk lifestyles and poor health care prior to incarceration. Base rates for serious mental disorders are two to four times greater in corrections than in the community. Dementia is unlikely to be an exception.

Dementia is not a good thing. The gateway symptom is impairment in memory for old information and learning of new information. There also must be at least one additional cognitive impairment. This impairment may be:

Dementia is usually progressive. Symptoms increase and functioning declines with time, ultimately resulting in death. There are no cures, no vaccines and no treatments that are effective in halting the decline. On average, people live about six years after being diagnosed with dementia. Between diagnosis and death, approximately 90% eventually require full-time nursing care in an institution.

Dementia causes not only increasing cognitive problems, but also increasing psychiatric and behavioral problems. For the inmate, the loss of memory and other cognitive problems may be the most pressing. For our institutions and staff, the behavioral and psychiatric problems may be the most concerning. Agitation, wandering, aggression, depression, impulsivity, catastrophic emotional reactions, paranoia, delusions, hallucinations, self-neglect and incontinence commonly occur at some point in the course of dementia. Individuals with dementia have, on average, two or three additional medical conditions, further complicating their treatment and management.

Addressing the Problem
What steps can the correctional health care community take to address these challenges? We present five recommendations, along with a closing caution.

1. We need to do better at early detection
Early signs of dementia include regular forgetfulness, confusion, indecisiveness, loss of judgment, disorientation to time or place, wandering, loss of initiative, new handwriting problems, changes in mood and personality, and difficulty completing once-familiar tasks. Typically, these signs do not trigger referrals to medical or mental health services, and inmates may be unlikely to submit sick call slips for these problems.

We need to be alert to the signs. This won’t help stop dementia, but it will help manage the dementing inmate and facilitate treatment of co-occurring medical or mental health conditions. Noncompliance with treatment and treatment complications are common in dementia.

Detecting dementia early requires obtaining a good history. Because insight and memory are impaired with dementia, inmate self-report is unlikely to be the best source of information. Consulting with correctional officers, other staff and family members can be crucial. They can identify personality changes, embarrassing behaviors (e.g., self-neglect, incontinence) and impairments that represent unmistakable changes from the inmate’s previous levels of functioning. Physical examination, laboratory tests and brief cognitive tests can also be helpful in making the correct diagnosis. Many of the newest cognitive screening instruments, such as the Montreal Cognitive Test or the DemTect, are readily accessible on the Internet.

2. Once dementia is diagnosed, the inmate needs to know
Disclosing the diagnosis requires planning, multidisciplinary collaboration and sensitivity. When possible, family members should be included in the disclosure process with the inmate. While there may be a few inmates whose dementia will be identified so late that there is no meaningful way for them to appreciate the diagnosis, in most cases we need to respect the inmate’s need to know what is wrong and what is likely to happen. Disclosure and acceptance of the diagnosis will be a process, not an event, for the inmate.

Staff also need to know, because loss of functioning in most dementias is not reversible. Treatment should support and prolong functioning as long as possible. It cannot restore previous levels of functioning. Staff expectations need to be realistic and to be focused on aspects of treatment and management that have real meaning for the inmate’s experience and quality of life. As with the inmate, disclosure and acceptance of the diagnosis will likely be a process, not an event.

3. We need to structure the environment for success
Environmental features reduce the potential for confusion and agitation in an inmate with dementia. Unless we plan ahead, institutional operations and inmate management will become increasingly difficult. Environments should be well-lit and quiet; contrasting colors to delineate bathrooms should be used, mirrors should be removed; and simple signs including pictures as well as words should be posted. Handrails and wheelchair- accessible showers are also recommended. In the community, the research supports the use of locked units, the absence of rugs or carpeting with edges and consistent daily routines. In these areas, jails and prisons are ahead of the curve.

Hearing aids and eyeglasses can be critical for inmates who need them. When perceptual acuity is diminished, our brains strain to make sense of things and often come up with misinterpretations. Reducing this “brain strain” helps reduce dependency on others and proneness to agitation.

Clothing that is easy to get on and off (Velcro and elastic design) also helps support an inmate’s functioning. There are three major reasons for incontinence among individuals with dementia: not knowing where the bathroom is, not being able to get clothing off and not being able to control bodily functions. The good news is that the first two can often be addressed relatively easily through environmental interventions.

4. We need to train our staff
Research indicates that staff training has the greatest effect on dementia treatment outcomes. Much of the training is focused on communication. It is critical to treat inmates with dementia as adults, to take their perspective seriously and to avoid trying to argue them out of delusions or confusion. A nonjudgmental perspective is required: Blaming the inmate for a shrinking brain will only harden staff and alienate the inmate.

Patience, discipline and flexibility are also required; dementing inmates cannot be expected to remember or follow multistep directions. Directing their attention to the function of an item may work better than giving directions. For example, telling an inmate, “Here’s the toothbrush for your teeth” may feel less childish or threatening than “Time to brush your teeth.” Putting toothpaste on the toothbrush and placing it on the sink may be even more effective. It is critical to support the inmate’s sense of personal autonomy while keeping choices simple and manageable. This strategy helps prevent confusion, shame, anger, agitation and behavioral crises.

Due to the inmate’s memory problems, it may be necessary to reintroduce yourself each time you start a conversation. Dementia also impacts the inmate’s ability to pay attention, so it is important to make sure you have the inmate’s full attention before you begin communicating. Talking slowly, using gestures and allowing the inmate enough time to process and respond are essential. Most importantly, staff need to remember that, for an inmate with dementia, life is always like coming into the middle of a movie. They need to spend a lot of effort making sense of things as they go along. If staff can keep this perspective in mind, a great deal of the inmate’s behavior will make sense and empathic and effective communication is more likely to occur.

5. We need to develop nonpharmacological interventions to support the highest levels of functioning
Praising inmates for positive behaviors can increase the likelihood of the same positive behaviors in the future. Relaxation training, support of specific skills, physical exercise and some group and individual treatment interventions have shown positive effects. Aromatherapy, massage, music therapy, pet therapy and day programming have also demonstrated positive effects. While some of these latter interventions may be challenging to implement in corrections, they are important to consider. Inmates, like the rest of us, require holistic treatment.

Even with the best of treatments, however, most inmates with dementia are eventually going to require round-the-clock nursing care in a protected environment.

— About the authors: John Wilson, PhD, is clinical operations specialist and Sharen Barboza, PhD, is senior clinical operations specialist for MHM Services, Inc., Vienna, VA. They presented a half-day seminar on this topic in April at NCCHC’s Updates in Correctional Health Care conference in Nashville. An interview with Dr. Wilson on this topic is available online at NCCHC Right Now.