By Lynn F. Sander, MD, MPH
Posted on January 4, 2010 – The 2009 annual conference of the Society of Correctional Physicians entitled Health Promotion and Disease Prevention in the Aging Inmate was held on October 18, in Orlando, Florida. Dr. Joe Paris, DeKalb County Board of Health and DeKalb (GA) County Jail began the session with a lively case-based discussion on administrative dilemmas. The first case dealt with MRSA. The second case was about a missed cancer diagnosis due to a combination of factors including inadequate initial evaluation and poor follow up. This highlighted the fact that unexpected negative outcomes are rarely due to a single error, but occur because of a confluence of errors.
Next, a talk outlining the demographics of the aging incarcerated population was presented by William Sabol, PhD, Chief of the Corrections Statistics Unit of the Bureau of Justice Statistics. Although still a small percentage of the total inmate population, the elderly are the fastest growing age group due to a variety of factors. In prisons, a higher percentage of these inmates tend to be incarcerated for violent crimes, primarily murder (25%) and sexual assault on a child (25%). In jails, they are held for serious offences and DUI.
The impact of the above statistics was discussed by Dr. Brie Williams, a UCSF gerontologist. Elderly inmates are a major contributor to escalating correctional health care expenses as the cost of their care is three times that of younger inmates. She also stated that the best prognosticator for morbidity in the elderly (more than any diseases a patient may have) is functional impairment, i.e., loss of one ADL or Independence ADL. Dr. Paula Frantz, Chief Medical Officer for the Colorado Department of Corrections, followed with a talk and demonstration of objective tests to assess mobility impairment. Few appreciate the complexity of mobility which includes muscle strength, range of motion, balance, coordination of the anatomy of the skeleton, muscles, tendons and ligaments, cognition and vision. Dr. Frantz emphasized that, in addition to the objective tests presented, it is important to observe the patient upon entry into the clinic area, the exam room and while disrobing. It is also important to perform a physical exam which includes measurement of muscle strength, range of motion, knee ligaments, skin integrity, joint and muscle tenderness, effusions and edema, and vascular integrity.
Next, Dr. Terry Hill discussed the need to appropriately assess inmates for infirmary placement since these beds are a limited resource. Many infirmary beds are filled with younger patients and for reasons other than medical management, e.g., CPAP, inability to store clean nephrostomy supplies, indwelling catheters. To be efficient and appropriately allocate these limited resources, systems should find other ways to manage these nonmedical needs. Dr. Hill also noted that in corrections level of care depends on more than clinical characteristics.
Next was a talk on special accommodations for inmates with disabilities ranging from modest physical impairment to behavioral impairment, including both mental illness and dementia, by Dr. Nick Scharff, Chief of Clinical Services, Pennsylvania DOC. He also discussed hospice care and the special management units that Pennsylvania has created and the criteria and procedures for transfer into these units. After a much-needed lunch break, Dr. Mike Puerini, Chief Medical Officer, Oregon State Correctional Institution, moderated a discussion about use of restraints during pregnancy. The topic was timely as SCP and NCCHC are finalizing a position statement on the subject.
Dr. Richard Kosierowski, Director of Oncology Services for Prison Health Services (PA), followed with a discussion on prostate cancer, the most common malignancy in the aging prison population. Although using PSA for screening is still recommended through age 75, studies have shown malignancy can be present in those with a low PSA. And those with a high PSA may be cancer free. Additionally one should take into account racial differences as the normal PSA in African-American men is higher than that of Caucasians, whereas Chinese men have a lower average PSA. According to Dr. Kosierowski, the best predictor of poor outcomes is the Gleason grade on biopsy: those with grade six or less generally die of other causes. Recent studies have shown that in these low-risk patients, there is no difference in mortality from prostate cancer amongst the treatment options of watchful waiting, radiation and surgery.
Next, Drs. Natalie Needham, Ob-Gyn Consultant, and Don Kern, Chief Medical Officer, NaphCare, discussed care of the aging female inmate. Recommended screenings include yearly breast exams and mammograms until age 75, and pap smears every one to three years until age 70, as long as there is a cervix. It is also important to check for osteoporosis in postmenopausal women and those with myriad other risk factors.
The final talk on psychiatric treatment of elderly inmates was delivered by Dr. Daniel Comiskey of MHM Services. Psychiatric medication management in this population becomes more complex because of various physiological changes associated with aging. These include delayed absorption of oral medications, such that next day side effects are common; lower muscle and higher body fat composition, creating a smaller volume distribution which increases the risk of toxicity of hydrophilic medications like lithium; decreased amounts of circulating proteins, so there may be increased circulating levels of protein-bound medications such as Depakote and Tegretol; and decreased function of the liver and kidneys, delaying clearance of many medications. Because of these factors it is important to carefully monitor these patients, decreasing doses and obtaining blood levels. Another factor that complicates treatment is interaction with other medications, as the elderly tend to be on more medications than younger patients.
At the end of the day, all participants headed out to an informal networking dinner which provided a good time for all who attended.
