The functional health needs of older persons in custody: A rapid review

Abstract

Introduction:

The number of older persons in custody is increasing and older incarcerated individuals have higher functional healthcare needs and higher healthcare costs. Consideration of available measures and interventions to address functional decline, are therefore imperative given the importance of disability to healthcare spending.

Purpose:

To identify the existing literature describing the functional health needs of older incarcerated individuals.

Methods:

This rapid review synthesized existing literature on the functional health of older incarcerated individuals. Three electronic databases and two correctional service health-related journals were searched. Bibliographic searches of seminal articles and key authors were conducted for thoroughness.

Results:

Fifteen articles were retained in the final analysis. The methods of the included studies were heterogenous. Consideration of basic self-care (activities of daily living) and functional mobility were the primary ways of capturing functional health. The concept of ‘Prison ADLs’ emerged and measured the unique aspects of correction-specific functional activities.

Conclusions:

This review identified the existing literature on how the functional health of older incarcerated persons is operationalized and measured, and how it is considered within this unique context. The concept of ‘Prison ADLs’ provides insight into the functional experiences of this population. Additionally, performance across PADLs typically declines before abilities across traditional ADLs.

1. Introduction

Approximately 20% of the global population that is incarcerated is concentrated in North America.¹ More than two million people are incarcerated in North America and 98% of these individuals are in the United States (US). The US also has the highest global prison population rate of 629 per 100,000 residents. Comparatively, Canada has a prison population rate of 104 per 100,000 residents.¹ Despite the marked correctional system-level differences between these countries, there is evidence to support that the population of older persons in custody is increasing as a whole. In the US, there was a 400% increase among those aged 55 years and older between 1993 and 2013.² These include those sentenced for more than one year, which may underrepresent the magnitude of growth in this cohort. In Canada, there was a 50% increase among those aged 50 years and older, and this demographic group represents 25% of Canada’s total federal prison population.³ Despite increasing proportions of incarcerated older adults, this population remains understudied when compared to older adults in the population as a whole.

It is common to see older persons in custody defined by using a younger chronological age as the cut point. A chronological age of 50–55 years is often used because of the accelerated aging process often observed and experienced by those in custody.^4–6 This accelerated aging can be attributed to a myriad of co-occurring risk factors, including lower socioeconomic status, healthcare access, associated lifestyle factors, and the negative consequences of incarceration.⁷ Additionally, other factors including longer, and late-life sentencing contribute to the growing population of older persons in custody.⁸ A Canadian report highlighted that health care costs for older persons in custody are 2–4 times higher than that of younger incarcerated individuals.³ Given the evolving aging trajectory among incarcerated populations, better consideration must be given to how aging, and the aging process in custody, will influence the overall functional health and healthcare needs of these populations, especially as functional decline is an established driver of higher healthcare costs within this population.⁹

A person’s ‘functional health’ broadly refers to their ability to engage in, and range of abilities related to, performing their basic activities of daily living (ADLs) such as bathing, eating, dressing, and mobility.¹⁰ ADLs are fundamental functional aspects of health that span across multiple domains related to living independently. Existing literature highlights that there are unique daily activities that should be considered within prison settings such as: dropping to the floor for alarms, climbing on/off the top bunk, standing for a head count, and getting to the dining hall for meals.¹⁰ These prison-specific ADLs are referred to as Prison ADLs (PADLs), and were developed using the input of incarcerated females living in Californian prisons.¹⁰ This rapid review aims to identify the existing literature describing the functional needs of older persons in custody more broadly to include incarcerated males and persons in custody across varying facility types (including community settings and inpatient forensic psychiatry settings) and levels (including facilities with minimum, medium, and maximum levels of security).

2. Methods

This knowledge synthesis aligned methodologically with the rapid review process. However, there is little consensus on the definition of what constitutes a rapid review. This type of review is typically conducted within a shorter timeframe, and as such employs a more streamlined search strategy. This review method was chosen because this literature synthesis is the initial step in a larger study. The larger study will aim to develop a screening assessment that captures the broader determinants of health. The goal is to implement and trial this assessment nationally. The new screening assessment will have an emphasis on the functional needs of older persons in custody. In this rapid review, stricter delimiters and more specific search terms were used to address a clinically emergent research question. The ambiguity in this type of knowledge synthesis stems from what aspects of the knowledge synthesis process are condensed or even eliminated to satisfy the timeline of this type of review.^11–13 In the current study, one author completed the title, abstract and full article review for inclusion (A.M.). As with a scoping review methodology, the quality of the study was not assessed for the inclusion into this synthesis because the aim of this study was to map the existing literature related to the functional health needs of older persons in custody.¹⁴ The types of studies reviewed included quantitative, qualitative, knowledge syntheses, and other types of academic and grey literature. Garrard’s Matrix method was used to consolidate the relevant information from each included article.¹⁵ This consolidative step provides the foundation for identifying the current state of evidence on this topic, analyzing current trends in the literature, and identifying remaining gaps.

2.1. Search strategy

The search strategy for this review occurred in two phases. Phase one involved searching the following databases: Ovid MEDLINE, CINAHL and Ovid PsycINFO. In consultation with an academic librarian, two additional health related correctional services journals were searched simultaneously using Web of Science, namely: Journal of Correctional Healthcare and International Journal of Prisoner Health. The search terms and medical subheadings used included variations of the following terms across the different databases: prisons, incarceration, correctional service, forensic psychiatry, prisoners, older adult, middle aged, adult or aged, geriatric assessment, disability, functional assessment, activities of daily living, self-care, and functional status.

The second phase involved a manual bibliographic search of the reference lists of the key articles retained in this rapid review.^7,10,16 Additionally, the list of publications by the author of the seminal article identifying and outlining PADLs was searched. An additional four articles were fully reviewed, and two of these were included in this rapid review from using these additional search methods.

2.2. Inclusion and exclusion criteria

Literature was included if it satisfied the following criteria: 1) the context was a correctional service facility, prison, jail, or inpatient forensic psychiatry unit; 2) the study included adults (aged 45 years and older) to capture the accelerated rate of aging in the prison system; 3) were written in English; and 4) considered functional health needs. More specifically, functional health needs could include ADLs, PADLs, and/or other measures of function or experiences related to functional status as defined by the authors. Studies were excluded if they were commentaries or editorials; however, these types of articles provided valuable background information for framing the context and broadly detailing the landscape of the prison system.

3. Results

3.1. Study selection process

Initially, 101 articles were title screened and were reduced to 30 articles for abstract screening. After reviewing the abstracts, 21 articles were retained for full text review. Reasons for exclusion at each of these stages included: 1) duplication; 2) no consideration of functional health; and 3) the articles were non-English (French and German). The reference lists of key articles were also searched and yielded four additional articles for consideration in the full text review. After full text review, fifteen articles were retained for analysis in the final review. Articles were excluded from the final analysis if they did not consider the functional health needs of older persons in custody. Further details of the process of article selection can be found in Fig. 1.

Fig. 1.

Flow chart of articles identified at each stage of the review.

3.2. Summary of findings

There were no limitations on the types of studies included in this review, and therefore the final articles retained were heterogenous. The methods across these studies included qualitative studies (n = 2), quantitative studies (n = 10), mixed and other methods (n = 1), and knowledge syntheses (n = 2). Results across the types of studies also varied, including descriptive analyses of functional impairment, exploring how functional health was related to other aspects of health and well-being, prevalence studies, and subject matter expert analyses regarding aspects of functional health within the broader correctional services context (Table 1).

Table 1.

Summary of study characteristics included in the review.

Authors, year, and Location	Study design and context	Participants (age, sex, number)	How function is operationalized, considered, and/or assessed (i.e., self-report vs. externally rated)	Corrections-specific functional measure(s)	Outcomes/Results/Interventions
Colsher, Wallace, Loeffelholz, & Sales19 1992 USA	Cross-sectional (survey) Context: seven state correctional facilities	50+ Male N = 119	Aspects of functional health measured: gross physical function, self-care, instrumental activities of daily living, making isolated movements, hearing impairment items, cognition, reading normal newsprint. Function was self-rated (along with other measures of health)	Not considered	11.2% of the study participants were dependent with self-care, and 20.7% were dependent for IADLs.
Harris & Lovell20 2001 USA	Cross-sectional study State prison	20+ Males N = 61	- Functional Assessment of Residents: ADLs, medical problems, social behaviour, vocational activities, and mental health issues. FAR captures knowledge held by corrections officers Functional health evaluated by corrections officers.	Not considered	ADLs (mean/max score) as captured by the FAR: Bathing: 4.8/5 Feeding: 3.9/4 Toileting: 2.9/3 Caring for own property: 2.9/3 Ambulation: 3.9/4 Overall, minimal difficulty across ADLs. Mental health measures: Participation: 1.6/3
Williams, Lindquist, Sudore, Strupp, Willmott, & Walter10 2006 USA	Cross-sectional study Context: state prisons	55+ Females N = 120	- ADL (bathing, eating, toileting, dressing, and transferring (getting in and out of bed); ADL dependent if needed help with any one ADL - PADLs: 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 of the top bunk. PADLs were rated as not difficult to very difficult. Individuals were considered to experience impairment if an individual reported ‘very difficult’ on at least one PADL. Self-report of functional health	- PADLs	Outcome measures: adverse events (e.g., falls within the last year), feeling depressed, feeling unsafe in one’s cell, physical abuse by another prisoner More than 50% of those who experienced ADL/PADL impairment had no access to environmental modifications. Results: ADLs: –16% with ≥ 1 ADL impairment –32% with ≥ 1ADL or mobility impairment PADL Impairment: Dropping to the floor for alarms - 57% Standing for head counts - 47% Climbing on and off the top bunk – 40% Getting to the dining hall – 31% Hearing orders from staff - 27% ≥1 PADL impairments 69% Relationship between functional dependence and adverse outcomes: Falls: 63% of females experiencing ADL dependence fell within the last year. Feelings of depression: 40% of women with PADL impairment and 53% with ADL impairment felt depressed.
Williams, Lindquist, Hill, Baillargeon, Mellow, Greifinger, & Waleter21 2009 USA	Cross-sectional (questionnaires completed with correctional service officers about their geriatric population) California Department of Corrections & Rehabilitation (CDCR) prison	Age 55+ for prisoners; age of corrections officers not disclosed Male/Female prisoners; sex of corrections officers not disclosed. N = 71 correctional officers assigned to random sample of N = 618 prisoners	- ADLs (feeding, bathing, dressing, toileting, and transferring); if required supervision or higher levels of assistance then they were classified as having ADL impairment. - As outlined by Williams et al.,21 The California Department of Corrections and Rehabilitation reports ‘Armstrong disability criteria’ which capture the following: wheelchair dependence, sensory impairment (vision, hearing, and speech), and mobility impairment. - Geriatric disability: falls in previous year, daily incontinence, memory deficits. - Questions regarding safety concerns in current housing arrangement, and if the officer anticipated the need for a move to a facility with a higher level of care. Correctional officer reported on level of function.	Not considered	Results: most common ADL impairments were bathing (4%) and transferring (3.2%). Those at ‘high risk” for adverse events: were older (66.7 years vs. 61.7 years); were more likely to experience impairment in ADLs (22% vs. 5%) and were more likely to experience a fall.
Ross, Reed, Fontao, & Pfafflin22 2012 Europe (Germany, Norway, Netherlands, UK: England and Scotland)	Longitudinal cohort study Context: forensic psychiatry	20–53 Male/Female N = 231	BEST-Index23,24 - self-and family-care subscale considered: hygiene, meal preparation, group/family relationships, health precautions, money management, personal grooming). BEST Index: completed by trained assessors that know their clients well (for at least 3 months).	Not considered	Prevalence estimates for ADLs/IADLs were not reported. This study provided evidence of the validity of the BEST-Index with patients in forensic psychiatry. The tool was reported to be sensitive to changes in behaviour over time. The internal consistency of the Self-and Family-care subscale, which focuses on aspects of ADLs and IADLs: Cronbach α was 0.67.
Williams, Stern, Mellow, Safer, & Greifinger6 2012 USA	Roundtable of experts to develop consensus recommendations for policy improvement (qualitative – focus group) Unspecified context: included a range of experts. 9 chief medical officers, 5 independent medical or psychiatric/psychology expert; 2 prison advocates; 2 foundation officers. There were 14 physicians, 2 psychologists, 1 nurse, and 3 lawyers.	Males/Females N = 29 experts (19 men and 10 women) employed in correctional health care	- Recommendations from consensus table regarding the definition of functional impairment: 1. Develop prison specific daily functional requirements list. 2. Each housing unit should outline functional daily tasks required for independence in that environment. 3. Use the developed list of functional requirements as a way to capture and screen for functional impairment at baseline and annually for both older adults (55+) and younger individuals with disabilities. 4. Sensory impairment screening (vision and hearing) for all ages. Unspecified whether the measures of functional impairment should be self-report, observational, or both.	PADLs	Operationalizing prison specific functional requirements is crucial in early identification of functional decline (i.e., need of baseline assessments and follow-up assessments to follow trajectory of functional performance across activities specific to facility).
Hayes, Burns, Turnbull, & Shaw25 2013 Northwest England	Cross-sectional Twelve prisons	50+ Male N = 262	- Camberwell Assessment of Need Forensic Short Version scale (items related to function: self-care, living environment, physical health, safety to self, safety to others, telephone, transport, money).26 Self-report of their met/unmet needs.	Not considered	Reported met and unmet needs across health and functional domains (as a percentage). Met need: self-care: 4.2% physical health: 50.3% safety to self: 1.1% safety to others: 1.1% telephone: 1.1% transportation: 0.7% money: 2.2% Unmet needs: self-care: 6.5% physical health: 32.6% safety to self: 3.3% safety to others:2.2% telephone: 10% transportation: 0.7% money: 10.2%
Barry, Ford, & Trestman27 2014 Connecticut, USA	Prevalence study Context: local jails	18–64 Male/female N = 315	Two questions on Physical Functioning subscale of the Medical Outcomes Study Short-Form health survey28 related to climbing stairs and engaging in moderate activities (example: bowling) Measured on a scale-whether health limits them ‘a lot’, ‘a little’, or ‘not at all’ Self-report	Not considered	Those in the older age category (40+) were 5.21 times more likely to have poor health compared to those aged 1824. When stratified by sex, increased age was associated with poorer function: [males 40+ OR = 7.41 (95% CI: 2.37–23.17) and females 40+ OR = 4.07 (95% CI = 1.4–11.79) compared to those males and females 18–24 respectively].
Filison17 2014 USA	Cross-sectional Study Medium security prison	55–88 Male N = 67	- PADLs, mobility, ADLs were also reported as being measured however, the author does not report on these individuals. Self-reported, although the authors didn’t explicitly state how these measures of function were assessed.	-PADLs	Overall, 60% of participants had no problems with PADLs; 21% only had difficulty with one PADL. Difficulty with getting off of floor for alarms: > 20% Difficulty with standing for head count: 11% Difficulty getting to the dining hall: 8% Only 8 participants had a top bunk and 1/8 reported difficulty with this PADL; one participant reported difficulty with having a bottom bunk. Incarcerated individuals with PADL difficulty were also more likely to have sensory impairment (vision or hearing) and limitations with ADLs and mobility, and a greater number of health conditions.
Bedard, Metzger, & Williams9 2016 Predominantly USA	Knowledge synthesis Context: unspecified	Not applicable.	Activities of Daily Living (ADLs): toileting, feeding, dressing - Instrumental ADLs (IADLs)–shopping, cooking, and managing finances. IADLs were mentioned because they are not often completed by an inmate independently; but other tasks unique to the setting may be completed such as: head count, etc.) functional ability directly related to the interaction between their “cognitive and physical abilities and the environment in which they live.”9(p921) Walking with restraints and decreased opportunities to exercise both increased falls risk.	Standing for a long time for head count and climbing onto an assigned top bunk. Daily activities varied within and between facilities.	Suggestions for interventions: environmental modifications to lessen the impact of impairment (e.g., grab bars) use of trained staff to accommodate for functional loss across ADLs (e.g., shower assist) age-segregated settings. Females were reported to have disproportionately higher functional impairment in the existing body of literature.
Barry, Wakefield, Trestman, & Conwell29 2017 USA	Cross-sectional study Context: Department of Justice facilities	50+ Male/Female N = 167	Basic activities of daily living (BADLs) and Prison ADLs (PADLs) Self-rated on both measures: the Katz,30 and PADLs	PADLs were defined as including the following: dropping to the floor for alarms, climbing to access the top bunk, hearing orders, walking while handcuffed, standing in line for medications, ambulation to chow.	55.7% (n = 93) experienced PADL disability. 7.8% (n = 13) or study participants experienced ADL disability. PADL and ADL disability were reported if an individual stated that they had difficulty with and/or could not do one or more PADLs and/or ADLs respectively. PADL disability was associated with depression and suicidal ideation severity. The association between PADL and depression was stronger in males (OR = 6.66; 95% CI = 1.80–24.70) than females (OR = 0.58; 95% CI = 0.09–3.84).
Magaletta, Perskaudas, Conners, Patry, Reisweber, & MacLearen18 2018 USA	Pilot test: Daily activities list for inmates Context: Subject matter experts (SME): Majority (12) worked at institution security levels (minimum, low, medium, high and administrative security levels); the other 3 had varied experience: 1 worked at only low security institutions; 1 worked at all levels except low security and lastly, one worked only at medium and minimum security.	Male/Female N = 15 Subject Matter Experts that were employed in correction services roles	Classified daily activities into three categories based on location of activity: In cell; either in or out of cell; out of cell. 227 items from a list of 403 potential items SME compiled and classified daily activities	Crossover between ADLs and PADLs in the list of 227 activities as well as inclusion of leisure and programming items.	- Content validity of the items were retained.
Skarupski, Gross, Schrack, Deal, & Eber16 2018 Multiple locations for primary articles (across multiple states in the USA)	Comprehensive review over the last 10 years Context: state or federal prison (excluding jails and civilly detained populations)	50+ Male/Female 20 studies included Male/Female	The authors classified ADLs and PADLs under the broader ‘measure’ of mobility function. Aspects of ADLs that were reported included: bathing, feeding, dressing, toileting, and transferring from bed to chair. Aspects of PADLs captured in the review included: dropping to the floor for alarms, standing for count, walking while handcuffed, getting to dining hall for meals, hearing orders from staff, and climbing on and off top bunk.	PADLs	Prevalence estimates of functional impairment vary (depending on location and how function was defined). In this review, the range of functional impairment was from 7.8% to 21%. Females were more likely to report difficulty with PADLs compared to males. The efforts to prevent disability were relatively non-existent. Interfacility accommodations varied. Older adults with PADL deficits also tend to report hearing and vision impairments.
Chatterjee, Chatterjee, & Bhattacharyya31 2019 India: West Bengal	Qualitative: “Ethnographically oriented narrative research” Context: three prisons – now termed correctional homes	20+ Female N = 90	Self-care activities were defined broadly into the following categories: hygiene, nutrition, lifestyle, environmental factors, socioeconomic factors, and self-medication. The prison architecture and regimented time present barriers to self-care. Functional definitions were not formally measured but were noted during the interviews.	Different environmental barriers to self-care (social, institutional, and physical).	Broad themes included: Constricted architecture is a barrier to self-care (over-crowding restricts mobility). Lack of meaningful/purposeful activities. Link between nutrition/food and health; there was the belief that food was being manipulated by prison authorities to control health; cultural links to food preparation as a meaningful activity and lack of participation in food preparation was culturally incongruent with their roles. Relationships – transfers to other prisons and differences between how and when seeing children impacted self-care and their role and relationship with family. Relationships between staff and those imprisoned can be a barrier or facilitator to self-care.
Prost, Archuleta, & Golder32 2021 USA	Cross-sectional (survey) Context: Medium security state prison	45+ Male N = 186	Older Americans Resources and Services (OARS) Multidimensional Functional Assessment Questionnaire33 Self-Care Capacity measured on 3-point scale: 0–2 (can do without help to unable to do) Both self-report: data were collected by interviews	Not considered	Functional impairment increases with age; older adults (65–85) experienced high ratings in functional impairment (OARS-ADL = 5.04) compared to other groups. Middle aged (55–64) group experienced less functional impairment (OARS-ADL: 2.54) than the youngest group (45–54) (OARS-ADL: 2.63).

Nearly half (46%) of the studies (excluding reviews) included both male and female persons in custody in their analysis, and 38% of the studies (excluding reviews) included only males. The objectives of the knowledge syntheses were to identify and describe health care challenges for older persons in custody⁹ and to provide an overview of the health care status of this cohort.¹⁶ Functional health was one aspect of health explored in each of these reviews. Within these reviews, functional health and mobility were operationalized and explored within the context of ADLs and PADLs. Bedard et al.⁹ outlined the environmental barriers that aging individuals in custody may experience and ways in which these barriers have been addressed. Examples of some barriers included: uneven flooring, poor lighting, and lack of adaptive equipment (e.g., grab bars). They suggested that age-specific units could address some of these environmental needs among the incarcerated older adult cohort. Skarupski et al.¹⁶, outlined the variations in reporting PADL impairment across multiple studies which contributes to variations in disability prevalence among this cohort. Furthermore, Skarupski et al.¹⁶ reported that incarcerated females were more likely to report experiencing impairment across functional measures.^16,17

Heterogeneity of findings was found amongst the remainder of the studies with respect to purpose and how functional health among older persons in custody was considered or emerged. The purpose of the studies included in this review ranged from specific objectives pertaining to function and aspects of self-care to broad research questions addressing health, healthcare, and health care interventions among older persons in custody. The current review synthesized aspects of these articles that pertained specifically to the functional health domain. One seminal article by Williams et al.¹⁰ focused specifically on the unique aspects of PADLs that differed from ADLs outside of the prison context. The most common way that function was measured across the included studies was in terms of ADLs, PADLs, and a combination of ADLs and/or PADLs. One study expanded this list to consider more than 220 daily activities that were categorized into one of three groups: activities conducted in one’s cell, activities conducted out of one’s cell, and activities that could be done either in or out of one’s cell.¹⁸ Across the studies included in this rapid review, mobility was considered in one of two ways: independent from the list of ADLs or as a measure of function along with ADLs. Irrespective of how mobility was operationalized, it was considered an essential daily activity.

3.3. Understanding functional health concerns in correctional services

There are two main areas of functional health within the correctional services literature. There is the traditional approach to operationalizing functional health by examining it within the context of ADLs; alternatively, prison activities of daily living (PADLs) emerged in the literature in the mid 2000s. PADLs focus on aspects of day-to-day life within the institutional context of the prison system, and include five unique domains of function: “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 of the top bunk” ^10(p703) (refer to Table 2 for a summary of functional health concepts).

Table 2.

Most commonly considered and accepted aspects of ADLs, IADLs, and PADLs.

Activities of Daily Living	Instrumental Activities of Daily Living	Prison Activities of Daily Living10
- dressing	- transportation	- dropping to the floor for alarms
- bathing	- meal preparation	- standing for head count
- toileting	- managing medications	- getting to and from the dining hall
- eating	- shopping	- hearing orders from staff
amobility	- financial management	- climbing onto and off of the top bunk

^aMobility is sometimes included in ADL lists and other times it is considered as a separate activity. Mobility can be considered a core component in successfully completing ADLs and IADLs.

Environmental context was also emphasized as an important consideration in the performance of functional health.^{6,9,16,17,25,34} The environment plays a significant role as either a facilitator or a barrier to functional performance and level of independence across functional indicators (ADLs and PADLs). There are two main environmental considerations within the correctional services context across the articles retained in this rapid review: the individuals’ living space and spaces that they interact with daily (physical), and the type of facility and level of security (institutional). Specifically, the type of activity, the environment in which it is performed, and the level of security that defines the settings will all influence what modifications can and need to be made to minimize (or eliminate) the impact of underlying functional impairments.

4. Discussion

This rapid review examined the health of older persons in custody from a functional lens and how this is operationalized within the unique environmental, institutional, and social context of incarceration. The majority of the studies were conducted in North America (specifically the USA). Given the size of the incarcerated population in the USA, this finding is not unexpected. However, it further emphasizes the dearth of international evidence in this area of health and health care. Another gap in the correctional literature emerged with respect to the types of correctional settings that functional health was measured. Forensic inpatient units were explicitly identified as the primary group of interest in one study.²² The study conducted in inpatient forensic units considered some traditional and adapted areas of ADLs and IADLs embedded within the BEST-Index, however the purpose of the study was to capture behaviour change among inpatients and how workers on the unit appraised the clinical utility of the tool. A future area of research could involve the implementation of a cross-sectoral functional assessment including individuals from unique units within the broader correctional setting, like forensic inpatient units. This work would provide important insights into whether functional health needs should be operationalized differently in these areas and whether existing functional measures maintain clinical utility.

Irrespective of how functional health has been considered thus far, those who are incarcerated experience functional decline at a younger age and more rapidly within this setting.^4–7 The studies included in this rapid review were heterogeneous with respect to how functional health issues were examined. Regardless of the number and types of daily activities included, aspects of self-care and mobilization were always noted to be essential functional health domains being considered. There is limited evidence with respect to differences across males and females; often due to limited sample sizes and/or responses from incarcerated females. Proportionately, females who are incarcerated account for approximately 7% of the prison population worldwide.³⁵ Some evidence suggests that incarcerated females are more likely to experience difficulty performing PADLs.¹⁶ Foundational work conducted to develop PADLs was conducted within a cohort of incarcerated females, which may be why PADLs are discussed more often among women in the existing literature.¹⁰

While the majority of the studies included in this rapid review acknowledged both essential self-care activities (within the context of imprisonment) and other basic ADLs experienced by these individuals,^{6,9,10,16–18,20,29} issues related to performing instrumental activities of daily living (IADLs) were rarely reported or considered within the context of incarceration. IADLs are functional activities deemed essential for one to interact and engage within a given community environment and broadly consider: organizing transportation, preparing meals, managing medications, shopping, and managing one’s finances. PADLs, however, appear to operate in a similar way as IADLs do within the context of living in the community. PADLs tend to represent activities that are essential to aspects of community engagement and participation within the context of correctional settings. Further, engagement in PADLs extends beyond the individual because they are conducted within the larger ‘community’ context of the corrections environment, and these activities are often conducted with or alongside other individuals.

ADLs and PADLs are mutually exclusive ‘lists’ of activities, however, there are underlying commonalities with respect to muscular strength, muscular endurance, and motor requirements for optimal performance and independence. Impairment across ADLs and PADLs appear to progress in a way that is similar to how functional impairment progresses between IADLs and ADLs in the broader community context. Individuals typically experience difficulty with performing their PADLs before their performance across their ADLs is impacted.^9,10,36 Williams et al.¹⁰ conducted foundational work to identify and measure key aspects of daily function that were unique to the correctional services environment(s) and important considerations as one ages within this environment. Skarupski et al.¹⁶ expanded on the work by Williams et al.¹⁰ to highlight that impairment across these PADLs is experienced in this order: 1) hearing orders from staff, 2) dropping to the floor for alarms, 3) standing for head counts, and 4) getting to and from the dining hall.

The existing literature has outlined that PADLs are measured using a self-reported three-point difficulty scale.^{10,16,17,29,37} How PADLs are currently measured and reported presents an opportunity to extend our understanding of functional performance within this context to consider a multi-pronged approach to functional measurement. These measurements could include both self-reported capacity and performance-based measures that can be observed and intervened upon to optimize engagement and foster independence. For example, those activities that are completed daily (e.g., ability to get to and from the dining hall) may be an area where performance-based measurement could be completed during any one mealtime, and across multiple correctional service configurations. Conversely, the PADL that considers dropping to the floor for alarms may not be a daily occurrence, and therefore not observable on the day in which it is assessed. In this scenario, consideration of either assessing performance during a simulated event and/or self-reported capacity could be considered. Additionally, consideration should be given to the diversity of experiences across different correctional service environments, wherein some PADLs may not occur. In this case, there should also be an option to convey that a particular activity does not apply to the experience of an individual.

Another factor that affects performance across ADLs, IADLs, and PADLs is the environment in which they are conducted. Some studies included in this rapid review considered the impact of the environment on functional health and independence; however, many studies broadly mention the environment.^{6,9,16,17,25,37} The physical environment is influenced by both the institutional environment and the social environment and context, and as such is complex to navigate. There are person-level characteristics, environmental attributes, and the type of functional activity that an older person in custody participates in, that collectively contribute to their level of performance and subsequently level of independence.³⁸ Considering this within the context of a corrections environment adds an additional layer of complexity, in that traditional community- or care setting-based interventions and adaptations may or may not be possible. Factors affecting feasibility include: the health status of the current cohort, level of security, and staffing. These considerations could offer an opportunity to optimize performance and foster independence.

Environment will not only influence performance across basic activities of daily living but may also change the relevance and importance of the activities that are assessed. Depending on the facility and level of security, participation or capacity in broader IADLs may become more meaningful, such as managing finances. For example, employment and financial management may become necessary aspects of a functional assessment in community corrections settings and lower-level security units where some individuals work multiple paid shifts within a given timeframe. Similarly, if transitioning from corrections facilities to the community, assessing capacity across these broader IADLs may become more important than they are depicted or currently considered within the existing literature.

Overall, functional performance across ADLs declines as individuals age, and how functional performance is defined and measured differs based on the environmental context within which functional activities are performed. Three key findings emerged from this review: 1) ADLs are performed within and outside of the prison context and how performance and independence are optimized and facilitated differs based on the environmental context; 2) because IADLs are often deemed irrelevant within the context of incarceration, PADLs highlight unique aspects of function within the ‘community’ created within this setting; and 3) Assessing IADLs should be reconsidered in the context of similar activities across the corrections setting environments (examples include: paid employment and managing finances, and shopping at the canteen or commissary). Future research endeavours in this field should consider how variations across different correctional environments and transitions between these environments influence the relevance and importance of each activity.

4.1. Limitations

The primary limitation with a rapid review is the potential to exclude or omit articles. This is a more significant risk with rapid reviews because: a) there is only one reviewer conducting the screening and data extraction, and b) the search restrictions and inclusion/exclusion criteria imposed are more stringent to facilitate a review within a more rapid timeframe. These restrictions and potential study omission can therefore increase the potential for bias during the article selection process. The authors mitigated these risks by conducting additional bibliographic searches of reference lists for seminal articles, key authors, and key reviews. Additionally, the authors consulted a reference librarian to ensure important databases/journals were included and stakeholders within correction services were consulted to ensure key studies and domains of functional health were captured. There were targeted efforts to scan the grey literature with an emphasis on the North American landscape because of the higher proportion of those in custody, specifically in the US, and this presents another opportunity to have missed literature. The emphasis on functional health domains may have also factored into potential article omissions.

5. Conclusions

The existing research exploring the functional health of incarcerated persons consistently includes aspects of self-care (ADLs) but inconsistently defines the broader aspects of functional health (PADLs and IADLs). The existing research on PADLs captures the uniqueness of the institutional, social, and physical environments of prisons and the correctional system as a whole. Collectively, ADLs and PADLs both provide essential information with respect to the evolving functional health and needs within this particular population. The existing literature is beginning to provide insight into how functional health should be conceptualized and measured in a similar way within the context of correctional settings; however, the lens with which these concepts are explored needs to be more appropriately contextualized through further research as well.