ETHNOGERIATRICS AND SPECIAL POPULATIONS

Being Old and Doing Time: Functional Impairment and Adverse
Experiences of Geriatric Female Prisoners
Brie A. Williams, MD,Ã w Karla Lindquist, MS,Ã Rebecca L. Sudore, MD,Ã w Heidi M. Strupp,z
Donna J. Willmott, MPH,z and Louise C. Walter, MDÃ w

The number of older prisoners is increasing exponentially.
For example, the number of geriatric female prisoners in
California has increased 350% in the past decade. Despite
an increasing population of geriatric female prisoners, the
degree of functional impairment in this population is unknown. Therefore, the goals of this study were to describe
the prevalence and nature of functional impairment in geriatric female prisoners in California and to identify aspects
of the prison environment that may exacerbate functional
impairments.
Questionnaires were analyzed from 120 geriatric women in California state prisons. Functional impairment was
defined as impairment in activities of daily living (ADLs) or
in prison ADLs (PADLs), including dropping to the floor for
alarms, standing for count, getting to meals, hearing orders,
and climbing onto the top bunk. The mean age of participants was 62; 16% were dependent in one ADL, and 69%
reported one PADL impairment. Increasing severity of
functional impairment was associated with worse health
status and more adverse prison experiences. For example,
fall rates ranged from 33% in women without impairment
to 57% with PADL impairment to 63% with ADL dependence (P 5.02). Several prison environmental stressors were
identified that likely exacerbate functional impairment.
For example, 29% of geriatric women were assigned to a
top bunk.
Geriatric female prisoners report high rates of functional impairment. ADL and PADL impairment were associated with worse health status and adverse prison
experiences. Therefore, the evaluation of functional impairment in geriatric female prisoners needs to consider the
unique demands of the prison environment. J Am Geriatr
Soc 2006.
Key words: prisoners; geriatrics; activities of daily living;
women
From the ÃDivision of Geriatrics, University of California, San Francisco,
California; wSan Francisco Veterans Affairs Medical Center, San Francisco,
California; and zLegal Services for Prisoners with Children,
San Francisco, California.
Address correspondence to Brie A. Williams, MD, 4150 Clement Street Box
181-G, San Francisco, CA 94121. E-mail: brie.williams@ucsf.edu
DOI: 10.1111/j.1532-5415.2006.00662.x

JAGS 2006
r 2006, Copyright the Authors
Journal compilation r 2006, The American Geriatrics Society

T

he population of older prisoners in the United States is
increasing exponentially.1–4 California, the largest
state prison system, has 7,150 geriatric prisoners, of whom
353 are women.3 The number of geriatric women in California prisons has increased 350% in the past decade.3,4
Prisoners are defined as ‘‘geriatric’’ at age 55, because they
develop disability and comorbid conditions earlier than
persons in the general U.S. population.2,4–8 It is projected
that by 2030 there will be 33,000 geriatric prisoners in
California alone and that one-third of the U.S. prison population will be geriatric.9 This dramatic aging is, in part,
due to longer sentences, mandatory minimum sentencing
laws, and tighter parole policies.2,10 Because the average
cost for incarcerating a geriatric prisoner is $70,000 per
year, two to three times that of a younger prisoner, the expense of sustaining the prison system is expected to rise
considerably.2,11
Although functional impairment predicts high healthcare costs, future functional decline, and mortality, few
studies have examined the health and functional status of
geriatric prisoners.12,13 In Iowa, 11% of male prisoners
aged 50 and older were found to have limitations in selfcare activities. In the United Kingdom, 10% of male prisoners aged 60 and older reported disability in one or more
activities of daily living (ADLs).7,8 In prison, geriatric
women have higher rates of comorbid conditions than
men, and in the general U.S. population, older women
have higher rates of functional impairment than older
men.6,14–16 During incarceration, female sex and older age
are also the strongest predictors of morbidity and increased
use of medical care,16,17 but no studies to the authors’
knowledge have assessed functional impairment in geriatric
female prisoners. Furthermore, no studies have evaluated
the unique functional demands imposed by the prison
environment.
Therefore, the goals of this study were to describe the
prevalence and nature of functional impairment in geriatric
female prisoners in the California state prison system, to
describe the association between the severity of functional
impairment and health status and adverse experiences, and

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WILLIAMS ET AL.

to explore how aspects of the prison environment might
exacerbate functional impairment.

METHODS
Study Population
In this cross-sectional study, data were analyzed from a
questionnaire of geriatric women in California state prisons. Statistics from the California Department of Corrections and Rehabilitation indicated that there were 353
women prisoners aged 55 and older as of August 2004.3
The only confidential mail sent to prison is that protected by
attorney/client privilege. Therefore, Legal Services for Prisoners with Children (LSPC), a legal aid and advocacy
group, sent questionnaires to 203 geriatric female prisoners
who were known to the organization through prior advocacy work using attorney/client mail. Limiting the sample
to known prisoners allowed LSPC to ensure confidentiality
in questionnaire responses.
Of the 203 questionnaires sent, 29 were not completed
because of parole, and four were sent to the wrong address.
This resulted in 170 questionnaires sent to eligible women,
of which 101 were completed (59% response rate). LSPC
then obtained an additional 19 questionnaires from women
referred by other prisoners who met the age requirement,
resulting in 120 subjects.
A cover letter informed subjects that LSPC was conducting an evaluation to better understand prison conditions for older women, that they had the right not to
complete the questionnaire, and that results would be used
for research. The Committee on Human Research at the
University of California, San Francisco and the San Francisco Veterans Affairs Medical Center approved analyses
and publication of these data.
Questionnaire Design
LSPC designed the questionnaire and developed it in a series
of individual structured, open-ended interviews with 10 key
informants who were geriatric female prisoners and former
prisoners. The 10 women were selected to be a diverse
group representing a spectrum of ages, races, and prison
locations. The interviews contained questions about the
experiences of older women (e.g., ‘‘What are your concerns
about getting older in prison?’’ How do prisoners regard
older prisoners?’’). Results from the structured interviews
were used to generate items for the final questionnaire. The
resulting questionnaire included open- and close-ended
questions and was reviewed by physicians, prison advocates, attorneys, and former and current prisoners before
distribution.
Demographic and Health Status Measures
Demographic questions included age, race/ethnicity, highest grade completed, length of sentence, and whether the
offense was related to domestic violence. Health status
questions included those about medical illnesses, self-rated
health, and number of current medications. Participants
were asked to indicate their illnesses from a list of 23 common conditions such as hypertension, asthma, and diabetes
mellitus. Self-rated health was evaluated by asking participants to rate their health on a 10-point scale. Several

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geriatric conditions were assessed, including difficulty with
vision or hearing, incontinence (loss of bladder control),
and memory loss. Mobility impairment was assessed by
asking women whether they needed help walking or used a
wheelchair.

Functional Measures
ADLs were assessed by asking respondents whether they
currently needed help with any of five ADL (bathing, eating,
toileting, dressing, and transferring (getting in and out of
bed)). Women were classified as having ADL dependence if
they reported needing help with one or more activity.
In addition to traditional ADLs, incarceration introduces daily physical activities that are unique to prison life
and are necessary to independent functioning while in prison. During the pilot interviews, women were asked, ‘‘Are
there prison routines that become more challenging for
prisoners as they get older?’’ Prison experts reviewed the
responses to identify the five activities most commonly required on a daily basis. These prison-specific functional
activities were termed ‘‘prison activities of daily living’’
(PADLs). The five PADLs were dropping to the floor for
alarms, standing for head count, getting to the dining hall
for meals, hearing orders from staff, and climbing on and
off the top bunk. Women were asked to rate each PADL
activity as not difficult, somewhat difficult, or very difficult.
Women were classified as having PADL impairment if they
described one or more activities as very difficult.
Other Outcome Measures
Adverse prison experiences included reporting a fall in the
previous year, feeling depressed, feeling unsafe in one’s
prison cell, and reporting physical abuse by another prisoner. Women were asked about environmental modifications for functional impairment, including the number of
prison hours worked, the type of work required, assignment
to a top bunk, presence of bathroom handrails, and who
provided them with needed assistance.
Statistical Analysis
Descriptive analyses of the women’s demographics, health
status, and functional impairment were performed. Women
were classified into one of three functional groups: those
with no functional impairment, those with PADL impairment but without ADL dependence, and those with ADL
dependence.
The relationship between functional impairment and
health was evaluated to examine the construct validity of
the PADL measurement as an indicator of intermediatelevel functional status. This was done by testing trend associations across the three functional groups in self-rated
health, the presence of mobility impairment, and the presence of three or more comorbid conditions. Regression
analysis was used for self-rated health, and chi-square test
for trend was used for mobility and comorbid conditions.
Rates of adverse prison experiences were also compared
between the three functional groups using chi-square tests
for trend.
Chi-square test for trend was used to examine whether
the prison environment had been modified to meet the needs
of prisoners with functional impairment by assessing the

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2006

association between functional group and job status, assignment to top bunk, and presence of bathroom handrails.
Descriptions of who provided the needed assistance to
women with ADL dependence or mobility impairment were
also reported. Intercooled Stata, version 8.0 (Stata Corp.,
College Station, TX) was used for all statistical analyses.
To further illustrate some of the experiences of geriatric
female prisoners with functional impairments, case vignettes were included. Vignettes were obtained from the
open-ended sections of the questionnaires. Identifying features were omitted to protect the participants.

RESULTS
Characteristics of Geriatric Female Prisoners
The mean age of the 120 respondents was 62 (range 55–82);
12% were aged 70 and older, and 68% were white (Table
1). Sixty percent of women had completed high school.
Fifty-one percent reported that their conviction was related
to domestic violence, and 46% had been in prison for more
than 15 years. Thirty-three percent reported three or more
of the comorbid conditions listed in Table 1, and 78% took
five or more medications. In addition, 58% of women reported impaired vision, 52% reported impaired hearing,
28% had experienced memory loss, and 22% reported incontinence.
Functional Impairment
Sixteen percent of women needed help with one or more
ADLs (Table 1). Sixty-nine percent of women reported that
at least one PADL was very difficult for them to perform,
including 65 women with no reported ADL dependence.
PADL difficulties included hearing orders from staff (59%),
dropping to the floor for alarms (57%), standing for head
count (35%), getting to the dining hall for meals (31%),
and climbing on and off the top bunk (14 of the 35 women
assigned to a top bunk).
Women with worse functional status reported worse
self-rated health (Po.01), more mobility impairment
(Po.01), and higher rates of comorbid conditions
(Po.01) (Table 2). For example, 74% of women with
ADL dependence reported mobility impairment, compared
with 26% with PADL impairment and 5% with no impairment.
Association Between Functional Status and Adverse
Experiences
Increasingly severe functional impairment in geriatric female prisoners was associated with more adverse experiences (Figure 1). For example, 51% of all women reported
falling in the previous year. Fall rates ranged from 33% in
women with no impairment to 63% in women with an ADL
impairment (P for trend 5 .02). For the 33 women with
mobility difficulties, 70% reported a fall within the previous year. Sometimes falls occurred during prison activities
not modified to individuals at risk for falls. For example, an
80-year-old woman with arthritis and visual impairment
described falling and hitting her head on a metal box while
standing for a long time during head count.
Feeling depressed was also associated with increasing
severity of functional impairment. Nineteen percent of

FUNCTIONAL IMPAIRMENT OF OLDER FEMALE PRISONERS

3

Table 1. Characteristics and Functional Impairment of
Geriatric Female Prisoners (N 5 120)
CharacteristicÃ
Demographic
Age
55–59
60–64
65–69
!70
Ethnicity
White
Black
Latina
Mixed or other
Educationohigh school
Health status
Comorbidities
Hypertension
Diabetes mellitus
Asthma/chronic obstructive pulmonary disease
Arthritis
Stroke
Depression
Cancer
Heart disease/heart attack
Other geriatric conditions
Mobility impairmentÃ
Impaired vision
Impaired hearing
Incontinencew
Problems with memory
Functional impairment
Dependence in ADLsz
Bathing
Eating
Toileting
Dressing
Transferring
!1 ADL impairments
!1 ADL or mobility impairments
Impairment in PADLs§
Dropping to the floor for alarms
Standing for head count
Climbing on and off the top bunkk
Getting to the dining hall
Hearing orders from staff
!1 PADL impairments

N (%)

55 (46)
51 (28)
17 (14)
14 (12)
82 (68)
16 (13)
7 (6)
15 (13)
42 (35)

77 (64)
19 (16)
39 (33)
88 (73)
15 (13)
43 (36)
14 (12)
37 (31)
33 (28)
70 (58)
62 (52)
26 (22)
33 (28)

6 (5)
5 (4)
2 (2)
11 (10)
6 (5)
19 (16)
38 (32)
68 (57)
56 (47)
14 (40)
37 (31)
32 (27)
83 (69)

Note: All characteristics were self-reported.
Ã
Defined as needs help with walking or uses a wheelchair.
w
Defined as loss of bladder control.
z
Defined as needing help with activities of daily living (ADLs).
§
Defined as very difficult.
k
For those in a top bunk (n 5 35).
PADL 5 prison activity of daily living.

women with no functional impairment reported having
depression, compared with 40% of women with a PADL
impairment and 53% of women with ADL impairment
(P for trend 5 .01).
Personal safety concerns were more common in women
with functional impairment, although these trends were of

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Table 2. Association Between Physical Function and Health Status

Health Status

No Functional
Impairment
(n 5 36)

Prison Activity
of Daily Living
Impairment Only
(n 5 65)

Activity of Daily
Living Dependence
(n 5 19)

P-valueÃ

5.3 Æ 2.0

3.3 Æ 2.1

2.2 Æ 1.4

o.01

4 (11)
2 (5)

24 (37)
17 (26)

12 (63)
14 (74)

o.01
o.01

Self-rated health, mean Æ
standard deviationw
Three or more comorbidities, n (%)z
Mobility impairment, n (%)§
Ã

P-value calculated using regression analysis for self-rated health and chi-square test for trend for comorbidities and mobility impairment.
Rated on a scale of 1 to 10, with 1 5 the worst health and 10 5 the best health.
z
Self-reported hypertension, diabetes mellitus, asthma/emphysema, arthritis, stroke, depression, cancer, and heart disease/heart attack.
§
Self-reported need help with walking or uses a wheelchair.
w

borderline statistical significance (Figure 1). Twenty-three
percent of geriatric women reported feeling unsafe in their
cells, and 34% reported physical abuse by other prisoners.
One woman described the safety risks for older inmates:
‘‘There are some older women who can’t take care of themselves, so to be in a room with eight women and to be in a
room with aggressive women is not a very safe place for
them to be [living]. . . . What happens is you see a lot of
older women with black eyes.’’

Aspects of the Prison Environment that Likely Exacerbate
Functional Impairment
Many geriatric women reported participation in physically
demanding activities and had no access to environmental
modifications for functional impairment. For example,
70% were required to work full time, including 68% of
women with PADL impairment and 50% of women with
ADL dependence. Sixty-one percent had been assigned to
jobs that were too difficult to perform, including janitorial
positions and yard crew. A 75-year-old woman with ar-

No Functional
Impairment

Impairment in ≥
1 PADLs

Dependence in ≥
1 ADLs

100
P = .02 for
Trend

P = .01 for
Trend

P = .05 for
Trend

P = .17 for
Trend

thritis awaiting hip replacement was assigned to manual
labor on the yard crew when she arrived in prison at age 70.
Eventually her job was changed to porter. She described this
experience: ‘‘I use a brush for the toilet and I bend
overFcarefullyFto clean the tile. I use my leg to clean
the floor because I can’t use a mop.’’ In addition, 29% of
geriatric women were assigned to a top bunk, including two
women with ADL dependence and seven with mobility impairment. Even for many women without functional impairment, getting on and off the top bunk was difficult. For
example, a 57-year-old woman with impaired vision reported breaking her arm and coccyx while climbing onto
her top bunk. Other accommodations, such as bathroom
handrails, were frequently not available. Eighty-two percent of geriatric female prisoners with PADL impairment
and 58% with ADL dependence reported no handrails in
their bathrooms.
The majority of assistance reported was informal, provided by other prisoners rather than prison staff. Of the
38 women needing help with ADLs or mobility, 69% reported that they mostly received help from other prisoners,
and 28% reported that no one helped them. Only one
woman reported that she regularly received help from prison staff. An elderly wheelchair-bound inmate with a history
of stroke explained that she often missed meals, because,
without someone to help her, she could not get to the dining
hall on time.

Percentage

75

50

25

0
Frequent Falls

Feels Depressed

Feels Unsafe
in Cell

Physical Abuse by
Another Prisoner

Figure 1. Self-reported adverse experiences according to functional status. This figure shows the percent of geriatric female
prisoners with no functional impairment, impairment in one or
more prison activities of daily living (PADLs), or dependence in
one or more activities of daily living (ADLs) who reported falls,
felt depressed, felt unsafe, or reported physical abuse by another
prisoner.

DISCUSSION
The prevalence of functional impairment and comorbid
conditions was high among geriatric female prisoners in
California. Sixteen percent of women aged 55 and older
reported needing help with one or more ADLs, twice the
rate of the general U.S. population aged 65 and older.18
Geriatric female prisoners also reported high rates of comorbidities, consistent with other studies showing high
rates of disease burden in older prisoners.2,4,6–8 For example, women prisoners aged 55 and older reported similar
rates of diabetes mellitus and heart disease as women aged
65 and older in the general U.S. population (16% diabetes
mellitus, 31% heart disease), but geriatric female prisoners
reported higher rates of hypertension (64% vs 51%),
asthma/chronic obstructive pulmonary disease (33% vs
19%), and arthritis (73% vs 48%) than older women in the
community.19

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Because functional impairment constitutes a complex
interaction between a person’s physical abilities and her
environment, the ability to perform daily prison activities
was assessed and termed ‘‘prison activities of daily living.’’
When PADLs were measured, functional impairment was
much more common than measures of ADLs would indicate; 69% of women reported an impairment in PADLs
whereas only 16% of women would be identified as functionally impaired based on traditional ADL measures.
Thus, people who are independent in the community might
be impaired in prison.
Women with impairment in ADLs or PADLs were at
greater risk for poor self-rated health, mobility impairment,
and a higher burden of comorbid conditions. These, in turn,
are associated with increased morbidity and mortality.14,20–22
Furthermore, women with ADL or PADL impairment were
more likely to report adverse experiences, including falls,
feeling depressed, feeling unsafe, and physical violence. For
example, 63% of women with ADL impairment and 57% of
women with PADL impairment reported falling in the previous year, compared with 33% with no impairment. In
comparison, an estimated one-third of the U.S. population
aged 65 and older reports falling annually.23
Although functional impairment and the environment’s
functional requirements may be mismatched in the community,24 the mismatch is intensified in prison. Prisons,
which are generally designed for young, healthy inmates
without functional limitations,4,10 often lack assistive devices such as bathroom handrails, which also occurs in the
community.24 However, prisons also raise the physical level
at which older adults must function by requiring activities
such as climbing onto a top bunk and dropping to the floor
for alarms. Using periodic functional assessments to identify women with functional impairment could decrease
these mismatches. For example, women with functional
limitations could be assigned to less physically demanding
jobs and to a bottom bunk. Bathroom handrails could be
installed to decrease falls,25 and a formal caregiver job
could be created in which younger inmates assist geriatric
prisoners with functional impairments.
Some states have initiated interventions to address the
problems of aging in prison. For example, the Project for
Older Prisoners partners law schools and state departments
of corrections to allow early release for nonviolent elderly
inmates. Thus far, the Project for Older Prisoners program
has organized the early release of 100 older prisoners without a single act of recidivism.26 In Texas, a university-based
program has improved chronic disease management in older prisoners through implementation of treatment guidelines.1 A program in Florida trains medical students in
geriatrics by having them care for older prisoners,2 and in
Pennsylvania, prisoner–caregivers assist older prisoners
with ADL impairments after receiving training in the use
of assistive devices (such as wheelchairs).10
This study has limitations inherent in studying a group
of subjects with special confidentiality requirements. To
guarantee confidentiality, the questionnaire was limited to
women previously known to LSPC in order to use attorney/
client mail. Despite this limitation, responses from onethird of all geriatric women in California state prisons were
analyzed, and the sample reflects the racial/ethnic and age
distributions of geriatric women in California prisons.3

FUNCTIONAL IMPAIRMENT OF OLDER FEMALE PRISONERS

5

In addition, all data were self-reported, although self-report
is considered a valid measure of disease burden and functional impairment.18,20,24,27 This study also likely underestimates the severity of functional impairment and disease
burden in geriatric female prisoners. Women had to be well
enough to complete the questionnaire, and only one of the
respondents resided in California’s skilled nursing facility
for prisoners. The questionnaire also may not have been
completed by women with low literacy, a prevalent problem
in prison that is associated with chronic disease and poor
disease self-management.28–30 In addition, the prevalence
of functional impairment would have likely been higher if
this study had assessed difficulty with ADLs rather than
dependence in ADLs. Indeed, the prevalence of difficulty
with any ADL approaches 43% of women of lower socioeconomic status in the general U.S. population.27
In summary, geriatric female prisoners reported high
rates of functional impairment that were associated with
worse health status and adverse experiences and likely contribute to the escalating costs of prison health care. This
study suggests that functional assessment that takes into
account the unique physical demands of the prison environment could identify geriatric women at greater risk for
adverse outcomes with the goal of reducing prison healthcare costs and future disability while increasing safety. Interventions could then be implemented to mitigate some of
the functional demands of prison. Because the law mandates adequate healthcare in prisons,1 functional assessment and environmental modifications are necessary to
provide humane and appropriate medical care to this population.

ACKNOWLEDGMENTS
Financial Disclosure: Dr. Williams and Dr. Sudore are supported by a training grant from the National Institute on
Aging (T32-AG00212). Dr. Walter is a recipient of the
Veterans Affairs Research Career Development Award in
Health Services Research and Development. Ms. Lindquist
is a senior biostatistician employed by University of California, San Francisco. Ms. Strupp and Ms. Willmott are
employees of Legal Services for Prisoners with Children, a
legal aid and advocacy group that sponsored the design of
the health survey and recruitment of the subjects. This relationship did not affect the analysis or interpretation of the
data or preparation of the manuscript, which were performed by Drs. Williams, Sudore, Walter, and by Ms.
Lindquist.
Author Contributions: Dr. Williams, Dr. Sudore, Dr.
Walter, Ms. Strupp, and Ms. Willmott: study concept and
design. Ms. Strupp and Ms. Willmott: acquisition of subjects. Dr. Williams, Dr. Sudore, Dr. Walter, and Ms.
Lindquist: analysis and interpretation of data. Dr. Williams, Dr. Sudore, Dr. Walter, and Ms. Lindquist: preparation of manuscript.
Sponsors’ Role: The funding sources had no role in the
design, conduct, analyses, or decision to publish this study.
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