Improving the care of older persons in Australian ...

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Improving the care of older persons in Australian prisons using the Policy Delphi method

Dementia 0(0) 1–15 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1471301214557531 dem.sagepub.com

Karen Patterson Justice Health & Forensic Mental Health Network, Practice Development Unit, Malabar, New South Wales, Australia

Claire Newman Justice Health & Forensic Mental Health Network, Practice Development Unit, Malabar, New South Wales, Australia

Katherine Doona Justice Health & Forensic Mental Health Network, Long Bay Hospital, Malabar, New South Wales, Australia

Abstract There are currently no internationally recognised and approved processes relating to the care of older persons with dementia in prison. This research aimed to develop tools and procedures related to managing the care of, including the identification and assessment of, older persons with dementia who are imprisoned in New South Wales, Australia. A modified approach to the Policy Delphi method, using both surveys and facilitated discussion groups, enabled experts to come together to discuss improving the quality of care provision for older persons with dementia in prison and achieve research aims. Keywords correctional health, Delphi method, dementia, prison, older person

Background Traditionally, the prison environment is not designed to cater for older persons, particularly individuals living with dementia. Prisons have historically been designed to be secure, rather than ensuring they are equipped with the appropriate facilities or qualified staff to treat Corresponding author: Claire Newman, Justice Health & Forensic Mental Health Network, Practice Development Unit, The Roundhouse, Long Bay Complex, 1300 Anzac Parade, Malabar, New South Wales 2036, Australia. Email: [email protected]

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prisoners with psychiatric concerns (Hancl, 2008). From a social and psychological perspective, older persons with dementia in prison may experience confusion regarding social hierarchies and prison etiquettes, making them more susceptible to intimidation and placing them at risk of harm (Baidawi et al., 2011; Gross, 2007). In addition, as the disorder progresses, older persons with dementia in prison are likely to have trouble accessing shower and toilet facilities, upper bunk beds, recognising common objects, or participating in social, educational, or exercise programs, many of which are typically designed for younger prisoners (Baidawi et al., 2011). It is likely that an incarcerated person suffering from dementia may also be limited in their ability to comply with prison rules, procedures and routines. This may be misunderstood as defiance, or they may exhibit disruptive or aggressive behaviour (e.g. wandering, hallucinations, and impulsivity). Such behaviours are likely to attract penalties within the prison system including segregation which can further deteriorate an individual’s psychological state (Moll, 2013). Whilst there is a lack of agreement among researchers, policymakers and correctional administrators in how to define an ‘older offender’, the use of 50 years of age and older has been deemed appropriate and commonly used (Baidawi et al., 2011; Grant, 1999). It has been suggested that the ageing process is accelerated among prisoners creating a 10-year difference in their health compared to the general population (Grant, 1999). This difference is largely attributed to the typical profile of an offender entering custody (i.e. poor nutrition, substance misuse, lack of medical care, stressful life events, economic disadvantage) and environmental constraints within prison (i.e. prison layout and surroundings, lack resources to manage chronic illness, unaccommodating programs) (Baidawi et al., 2011; Carlisle, 2006; Grant, 1999; Potter, Cashin, Chenoweth, & Jeon, 2007; Stojkovic, 2007). In addition, Indigenous Australians are over-represented within the prison system (26% of the total population), and are likely to be affected by age-related diseases at a younger age with the median age of death lower among Indigenous compared to non-Indigenous Australians (Baidawi et al., 2011). Australian prison census data suggest the number of incarcerated older persons has increased by 84% over the past decade. For example, in 2000, 8.3% of imprisoned persons were aged 50 years or older, whereas in 2011, 11.7% of imprisoned persons were aged 50 years or older (Australia Bureau of Statistics (ABS), 2001, 2011; Baidawi et al., 2011). Moreover, of imprisoned persons aged over 50, the largest increase was noted among those aged 65 years or older, where the number of such individuals rose by 140% (Baidawi et al., 2011). It has been suggested that changes in sentencing laws, including mandatory minimum sentencing and reduced options for early release, as well as the higher proportion of older persons convicted of violent offences, may have contributed to the rise in the number of older persons in prison (Baidawi et al., 2011; Grant, 1999; Potter et al., 2007). For example, proportionally older offenders are imprisoned 1.5–3 times more often for a sexual offence, a homicide or a drug offence, each attracting longer sentences (Grant, 1999). Whilst there is increasing attention in the older person, there are no current estimates of the number of people with dementia in Australian prisons. A recent study from the United Kingdom found physical and psychiatric morbidity was common among imprisoned persons aged 50 years and over (Kingston, Le Mesurier, Yorston, Wardle, & Heath, 2011). Half of the prisoners surveyed had a mental health disorder, with depression diagnosed among 83% of the sample, and signs of cognitive impairment apparent in 12% (Kingston et al., 2011). Of concern was the finding that less than a quarter (18%) of participants with a psychiatric diagnosis were prescribed appropriate medication, and very few (7%) psychiatric conditions were noted in the patients’ medical records. Other studies from the United States suggest the



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prevalence of dementia among the prison population is likely to range from 1% to 44%, depending on the size and nature of the correctional facility (Maschi, Kwak, Ko, & Morrissey, 2012). This research suggests that there is likely to be a significant, and growing population of imprisoned persons with dementia in Australia. It is also suggested that there is opportunity for improving the quality of care and thereby quality of life for people with dementia in prison. There have been a number of innovative practices, reported by Moll (2013), aimed at addressing the needs of incarcerated persons with dementia in eight UK prisons, four US prisons, and individual facilities in Japan and Belgium. These practices included improving health staff and prison staff awareness of dementia, modifications to the physical environment, introducing screening tools to improve diagnosis, implementing pathways to address early intervention and initiatives targeting social and cognitive well-being for older persons with dementia in prison including prisoner carer schemes and recreational activities (Moll, 2013). Similarly, reported dementia specific services or programs being introduced into US prisons include the introduction of units purposively build to suit cognitively impaired prisoners, activity based programs for older prisoners, peer support programs providing social and practical support for older prisoners and prisoners with dementia (Hodel & Sańchez, 2012; Maschi et al., 2012). Establishing targeted training for correctional officers in one US Department of Corrections to assist in meeting the need of imprisoned individuals with dementia has also been reported (Coleman, Crews, Hall, Ita, & Williams, 2012). It is of note however, that the formal evaluation of such initiatives is lacking in the international literature. There are currently no internationally recognised and approved processes relating to the care of older persons with dementia in prison. The need for research focusing on screening practices for older persons with dementia in prison, as a health policy priority, has been highlighted in the international literature (Moll, 2013; Williams, Stern, Mellow, Safer, & Greifinger, 2012). Further to this, there is paucity in the literature relating to dementia and dementia care practices for older persons imprisoned in Australia. This research aimed to develop tools and procedures related to managing the care of, including the identification and assessment of, older persons with dementia who are imprisoned in New South Wales (NSW), Australia.

Method Research design The project aim was achieved through the use of a Policy Delphi study. The Delphi method, which is commonly used in health research, involves an iterative process to gain consensus among a group of experts regarding a defined issue or topic (Keeney, Hasson, & McKenna, 2011). The Delphi Method is a multi-staged approach, with each stage building on the results from the previous stage. The classical approach to a Delphi study involves the use of anonymous based surveys that focus on iteration and controlled feedback with the objective of achieving convergence and consensus of responses (Crisp, Pelletier, & Duffield, 1999; de Meyrick, 2003). The Policy Delphi is a modified version of the original Delphi technique and has been defined as ‘‘a systematic method for obtaining, exchanging, and developing informed opinion on an issue’’ (Rayens & Hahn, 2000, p. 308). The purpose of a Policy Delphi study is not to achieve consensus but rather to generate ideas about a defined topic and to explore the divergence of views held by experts (Crisp et al., 1999;



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Franklin & Hart, 2007). The research used a modified approach to the Policy Delphi method, using both surveys and facilitated discussion groups to enable a purposive sample of topic-specific experts to come together to discuss improving the quality of care provision for people with dementia in prison. Experts systematically discussed how best to adapt, modify and develop existing materials, including assessment tools and procedures, to treat and support people with dementia in the prison system.

Context There are almost 10,000 adults currently incarcerated in NSW prisons with almost 20% of these being aged over 45 years (Correctional Services New South Wales (CSNSW), 2013). Across NSW, services for adult prisoners are provided in 30 publicly, and 2 privately, operated correctional centres. These correctional centres range from large metropolitan centres that accommodate more than 900 adults, to rural and remote centres that accommodate less than 100 adults. Statewide healthcare services to incarcerated adults in NSW are provided by Justice Health & Forensic Mental Health Network (JH&FMHN).

Procedures The Policy Delphi approach for the current study consisted of four rounds. The first round was conducted online to survey registered nurses (RNs) regarding their perception of the suitability for identifying persons with dementia of the current Screening Assessment tool applied to all new prisoners on reception to a correctional centre. Round 1 participants were identified using a list provided by Nursing Unit Managers at each correctional centre that received new prisoners. All RNs (n ¼ 108) based across NSW who undertake the initial screening of persons on entry to the prison system were invited via email to participate in an online survey. The survey asked participants to respond to statements regarding the suitability of the Reception Screening Assessment tool in identifying dementia in people entering prison. Participants were sent an email reminder to complete the survey after one week. The final three rounds were conducted using a combination of surveys and facilitated discussion groups. All nursing (n ¼ 17), medical (n ¼ 1), health service manager (n ¼ 2) and allied health (n ¼ 2) staff who were identified as being currently involved in the assessment and management of older persons with dementia in prison were invited to participate. Discussion group participants were purposively selected based on their knowledge of, and involvement with, patients with dementia in the prison system. The first discussion group focussed on the identification process of older persons in prison who may have dementia. The second discussion group focussed on the assessment of persons who had been identified as potentially having dementia. The final discussion group focussed on how the care of individuals who had been assessed and diagnosed with dementia could be managed. More specifically in Round 2, the first discussion group, participants were provided with a summary of findings from the RN online survey conducted in Round 1, together with a copy of the Reception Screening Assessment tool, for consideration and discussion in small groups. They then participated in a discussion facilitated by researcher KP regarding the modification of this tool, and related process, to aid in the identification of older persons with dementia. Comments were collated by researcher CN and used to amend the Reception Screening Assessment tool and to create an algorithm representing the discussed



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identification process. These were provided to participants for their final comment in Round 3. Participants were also provided with a NSW Health recommended dementia assessment tool, the Global Deterioration Scale (GDS), and asked to complete a paperbased survey regarding the suitability and improvability of this tool for the assessment of people with dementia in prison. In Round 3, the second discussion group, participants were provided with a summary of findings from the survey conducted in Round 2 for consideration and discussion in small groups. They then participated in a discussion facilitated by researcher KP relating to the process of assessing older persons with dementia in prison and the appropriateness of the GDS for the defined patient population. Comments were collated by researcher CN and used to create an algorithm representing the discussed assessment process, and a modified version of the GDS, both of which were provided to participants for final comment in Round 4. In the final round, the third discussion group, attendees participated in a discussion facilitated by researcher KP relating to how the care of persons with dementia in prison could be managed. Comments were collated by researcher CN and used to create an algorithm representing the discussed process for managing the care of persons who had been through the assessment process.

Participants A total of 36 RNs participated in Round 1, the online survey. This represents a 33% response rate of all RNs who screen prisoners on entry to the prison system across NSW. In total, 18 health staff participated in rounds 2 to 4, the discussion groups. This represents an 82% response rate. Attendees were representative of prison-based clinicians from aged care, mental health and primary health based services. Whilst these clinicians included nursing, medical and allied health, representatives from the specialist mental health services for older persons and the drug and alcohol service declined to participate due to time constraints. Of those participating, seven (n ¼ 39%) attended all three discussion groups, eight (n ¼ 44%) attended two groups and three (17%) attended one of the three discussion groups. Discussion group participants included nursing, medical, health service manager and allied health staff who worked in aged care, mental health, primary health and chronic care services within the health service (see Table 1).

Table 1. Discussion group participants by position and service area. Position

Service area

Number of participants

Registered nurse Nursing unit manager Nurse practitioner Clinical nurse consultant Clinical nurse educator Health service manager Geriatrician Occupational therapist Total

Aged care Aged care & mental health Primary health Mental health & chronic care Mental health & primary health Chronic care Aged care Aged care

N¼5 N¼2 N¼2 N¼2 N¼2 N¼2 N¼1 N¼2 N ¼ 18



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Ethical considerations Participation in the project was voluntary and written consent was obtained from participants. Ethical approval for this study was received from the Justice Health Human Research Ethics Committee.

Findings Round 1: Online survey The majority (64.3%, n ¼ 18) of survey respondents indicated that the current Screening Assessment tool used to complete a health assessment on persons newly received into the prison system, was either ‘sometimes unsuitable’ (42.9%, n ¼ 12) or ‘very unsuitable’ (21.4%, n ¼ 6) as a means to identify individuals who may have dementia. Reasons provided by respondents relating to the unsuitability of the tool included: the tool does not specifically test cognitive function or memory skills; the tool does not contain prompts for the completing nurse to consider or comment on a possibility of dementia; and the ability for dementia to be detected using the tool will be dependent on the severity of dementia and experience of completing nurse. Only two respondents (7.1%) indicated that the tool was ‘very suitable’ and eight respondents (28.6%) indicated that the tool was ‘sometimes suitable’ in screening for dementia in people entering prison. Reasons provided by these respondents included: ability to identify would be dependent on severity of dementia; and memory loss or confusion would be detected by the completing nurse during the process. Respondents were also asked if the tool could be improved in order to increase the likelihood of identifying new reception prisoners who have dementia. The majority of respondents (60.7%, n ¼ 17) indicated ‘yes’ to this question. Suggested amendments to the tool to improve its effectiveness in screening for dementia in people entering prison included: including a Mini-mental State Examination (MMSE), and incorporating questions relating to cognitive function, memory loss and activities of daily living into the tool. Round 2: First discussion group Discussion group participants in Round 2 were presented with the findings from Round 1 and participated in a facilitated discussion regarding the suitability and improvability of the assessment tool in screening for dementia in people entering prison. There was a shared view among group participants that the process for identifying older persons with dementia could be improved. Participants discussed modifications to the screening tool that would be used in combination with a new process for identifying older persons who potentially have dementia. Modifications to the tool recommended by the group were to include a simple memory test (asking the patient to remember three words) and cognition test (asking the patient to draw a clock face) to be completed by persons who were aged over 50 years, or over 40 years if Indigenous. A prompt would be included in the summary page of the screening tool for the individual to be referred to the Primary Health Nurse for cognitive screening if they failed either or both of these tests. Cognitive screening would be undertaken using the MMSE for those whose first language is English or the Rowland Universal Dementia Assessment (RUDAS) for those whose first language is not English. Individuals who scored highly on these cognitive screening assessments were considered to most likely have dementia and would therefore warrant further assessment. This process was reviewed



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by discussion group participants during Round 3 for final comment and editing. The agreed process for identifying older persons with dementia entering prison is illustrated in Figure 1. Round 3: Second discussion group Discussion group participants in Round 3 were presented with the findings from the survey regarding the suitability and improvability of the GDS for the assessment of whether an individual has cognitive impairments consistent with dementia within the prison context. Discussion group participants completed this survey at the end of Round 2, or via email for those who did not attend the first discussion group. The survey was completed by 77.8% (n ¼ 14) discussion group participants. Survey results indicated that whilst the GDS was a suitable tool for the assessment of incarcerated persons with dementia (n ¼ 13, 92.9%), it could be improved to suit the prison context (n ¼ 12, 85.7%). During the discussion group participants discussed minor modifications to the GDS to make the

Du uring Recepon Screening Ass essment Paent failed cognitive screening test

Refer paent to Primary Health Nurse (who has been trained to complete t he MMSE and RU DAS) for Cognive Screening

The paen t’s first languaage is English

Yes

No

Co omplete Mini M ental State Exam (M MSE)

Complete Rowland C Universal Demena Assessment (RUDAS)

Scorred less than 24

Score d more th an 24

Go to process for asssessing persons with deme na in prison

ored less Sco than 22

Scored more than 22

o further acon required No

Figure 1. Process for identifying older persons with dementia entering prison.



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wording of some criteria relate specifically to the prison context, i.e. changing being able to recall the names of family to name of cell mate, changing being able to recall telephone number to their individually assigned prison identification number, changing decreased ability to travel and handle finances to decreased ability to negotiate buy-up (prison grocery service) and visits. The focus of the discussion was on the complete assessment process. This process involved undertaking an initial assessment of referred individuals to determine whether further assessment was required and at what level this assessment would be (i.e. ongoing or immediate comprehensive assessment required). The group identified that the assessment process should be undertaken by a multidisciplinary team, specifically created for this purpose, based locally at each centre. This process was reviewed by group participants during Round 4 for final comment and edit. The agreed process for assessing the older person with dementia is illustrated in Figure 2. Round 4: Final discussion group Discussion group participants in Round 4 engaged in a facilitated discussion regarding how the care of older persons with dementia should be managed in prison. Participants identified that individuals or older persons who had required comprehensive assessment during the assessment stage also required their health care to be planned. Care planning would initially be overseen by the locally based multidisciplinary team who undertook the assessment process. A number of strategies would be employed by the team to enable the person to remain in their current accommodation within the prison system. These strategies include buddying the person with another incarcerated individual and engaging other services, such as referring them to the Geriatrician and the CSNSW Disability Service. Older persons who, despite strategies employed, were unable to be safely and effectively managed in their current location would be transferred to a more appropriate setting (i.e. an aged care unit within the prison system or community facility) and an individualised care plan would then be implemented by local multidisciplinary teams. How the care of older persons with dementia in prison can be managed, as recommended by group participants, is illustrated in Figure 3.

Discussion The research used a modified Policy Delphi approach, using both surveys and facilitated discussion groups, to enable topic-specific experts to come together to discuss how best to adapt, modify and develop assessment tools and procedures related to the care of older persons with dementia in the prison system. The online survey-based first round enabled the opportunity for frontline nursing staff who assess newly received prisoners over a geographic area of more than 800,000 km2, to voice their opinion regarding the identification of persons with dementia entering prison. Findings from this survey were then used to initiate discussion among experts, who were bought together for the final three rounds, related to the use of the assessment tool in the process of identifying persons with dementia newly received into prison. It was considered important to capture the views of clinicians in this way as it was recognised that the experts participating in the final rounds, whilst were responsible for assessing and managing older persons with dementia in prison, did not undertake this initial screening process. The use of discussion groups in the final three rounds enabled the group of experts to discuss face-to-face how the quality of care of older persons with dementia in the prison



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Flagged at reccepon via MMSE or RUDAS

Refer paent to the specifical ly trained, and locally based, demena care team

Inial assessm ment:

• Basic Aged Ca re Assessment Tool (BACAT) • Global Deterio raon Scale (contextualised version) • Comprehensiv e medical assessment

Acute medical reason r idenfied for symptoms

Refer to appropriate clinical pathway • Mental Health • Drug & Alcohol • Populattion Health • Primaryy Health

Paent managing in cu rrent locaon without intervenon

Ongo ing Assessmen nt (3 or 6 mont hly intervals ass required) • M MSE/RUDAS • B ACAT • G lobal Deterioraaon Scale (c ontextualised version)

Paent requ ires comprehens ive assessment an d care manageme nt

Comprehensi ve Assessment: • Cogniv e funcon Com municaon and lang uage Soc ial interacon Pro blem solving Memory • Risk ass essment Safe ty Env ironmental risk

Go to proce ss for managing the care o f persons with dement ia in prison

Figure 2. Process for assessing the older person with dementia in prison.

system could be improved; specifically in relation to the identification, assessment and care management of these persons. This method of obtaining expert opinion was employed to promote participant engagement in the process and to facilitate discussion among experts regarding the topic in a timely manner. Face-to-face approaches in Delphi-based research have been suggested to increase participation especially among participants whose time is limited, such as those in leadership positions (Rayens & Hahn, 2000). Incorporation of survey feedback, related to existing tools, into the discussion groups not only aided initiation of discussion but also enabled the opportunity for participants to voice their opinion anonymously. Anonymity when providing personal viewpoints encourages



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Comprehen sive assessment undertaken

Is the paent a ble to manage in current locaon?

Yes

Ongoing Assessment by local demena care team (interval of assessmen ts determined by local dem ena care team)

No

Employ strategies to enable the paent to stay in current locaon: • Inform/Educate CSNSW Off icers and Nursing Unit Manager (NUM ) • Inform CSNSW Disability Service • Refer to Aged Care Bed Dem and meeng • Refer to Specialist Mental H ealth Services for Older People (SMHOPS) • Refer to Geriatrician • Add Dementia Alert to Pae nt Administraon System (PAS ) • Add paent to paent of co ncern list • Buddy with another incarce rated individual • Ongoing monitoring and rev iew by local demena care team

Is the paent managing in cur rent locaon?

Yes

No

Ongoing ass essment and revie w by demena c are team

Move paent to more appropr iate seng (i.e. specifically equipped aged-ca re units within JH&FMHN, community facility) and implement individualised care plan

Figure 3. Process illustrating how the care of older persons with dementia in prison can be managed.

openness and truthfulness whilst minimising pressure felt by participants’ to confirm to the group’s view (Keeney et al., 2011). It was a challenge for discussion group participants to develop a dementia screening process that would work within the constrictions of assessing older persons newly received



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into a correctional centre. Identified constrictions discussed included limited time available to conduct cognitive screening during reception, limited experience of reception nurses completing the initial screening in the area of cognitive testing and dementia and the high incidence of individuals being unsuitable to undergo cognitive screening for dementia on reception to prison due to being under the influence of alcohol or illicit substances. To address these constraints, the discussion group participants recommended a screening process that entailed a second stage where older persons who failed the initial cognitive screening tests were referred to an appropriate clinician, such as a specifically trained Primary Health Nurse, for more in-depth cognitive screening to be conducted at a later date using validated cognition tests. An outcome of this study was the development of a new process for assessing older persons for dementia who have been identified through the screening process undertaken on entry to prison. Discussions held centred on ensuring minimal disruption to the older person’s social environment, recommending an assessment process that would also be applicable to rural correctional centres in order to avoid the need for an older person to be transferred to a metropolitan correctional centre for assessment purposes. Furthermore, the discussion group participants recommended the development of a multidisciplinary team consisting of a nurse, general practitioner and a representative from CSNSW, based locally at each correctional centre, to undertake the dementia assessment process. It is of interest to note that all discussion group participants were metropolitan based. This was because, despite being a statewide service, only clinicians in metro locations were identified as being currently involved in the assessment or management of the health of prisoners with dementia in prison. The need for specifically trained clinicians to be based locally at rural and remote centres in order to improve the provision of care for older persons with dementia was therefore highlighted by participants. It was determined by participants that a CSNSW representative being included in locally based multidisciplinary teams was essential as correctional services staff have a significant role in the assessment of a prisoner’s cognitive functioning on a day-to-day basis due to being the personnel who spends most time with this individual. Health staff therefore often rely on prison officers to detect early symptoms of dementia in imprisoned older persons (Coleman et al., 2012; Moll, 2013). However, it is recognised that this method of detecting imprisoned persons with potential dementia symptoms is often ineffective due to limited training opportunities for correctional staff resulting in poor awareness of the disorder (Coleman et al., 2012; Moll, 2013). This factor was taken into consideration by discussion group participants by stipulating that all members of the assessment team, including the CSNSW representative, would be specifically trained and networked with like teams in other centres for support. Networking of teams was considered an important factor to not only facilitate awareness through information sharing but to reduce the impact of isolation known to be experience by prison staff. Health staff working in the prison environment have reported experiencing a profound sense of isolation as the result of confining prison architecture, working in geographically isolated locations, and being professionally isolated from mainstream health services (Doyle, 1998). The facilitation and enhancement of partnerships between prison health and correctional services through the inclusion of CSNSW in the assessment process may arguably promote the achievement of best patient outcomes. Historically, operational priorities, such as security, discipline, compliance and order, have overridden health care needs of imprisoned persons and conflict with the values of prison based health services (Doyle, 2001;



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Meave, 1997; Meave & Vaughn, 2001; Powell, Harris, Condon, & Kemple, 2010). Actions by health staff often need to be negotiated with, or are compromised and undermined by, correctional staff in order to oblige with correctional mandate (Meave, 1997; PeterneljTaylor, 2004). Therefore, collaborative partnerships between the two organisations may reduce the impact of differing priorities that may exist between the organisations and ultimately improve the quality of patient care. The identification of early symptoms of dementia is also likely to be hindered by the potential for early symptomatic indicators being masked by prison regimentation (Coleman et al., 2012; Moll, 2013). For example, cognitive impairment may be difficult to detect and assess in the prison environment due to not having to do daily tasks such as manage finances, cook, etc. (Williams et al., 2012). During the study process, discussion group participants therefore made minor modifications to the GDS in order for it to be a suitable assessment tool to be used within the prison context. Modifications related to the wording used in the assessment. It was recognised by participants that this tool would form a part of the assessment process in conjunction with a number of other assessment processes including a comprehensive medical assessment and aged care assessment. The third outcome of this study was the development of a new process for how the care of older persons with dementia, who had required comprehensive assessment in the previous phase, should be managed. Prisons in general are ill-equipped to provide dementia related services that are equal to community based dementia care services (Peate, 2013). The majority of existing prisons were not built to accommodate older offenders who have physical or cognitive impairments. Adaptions to existing prison structures, or the building of new purpose-built structures would be an impracticable possibility due to the limitations of the associated resources that would be required. Through participant discussion it was therefore deemed priority for the older person to be managed locally, and not immediately transferred to a specialised unit. Strategies to support the older person staying in their current prison accommodation were similar to those being reported as innovative practices in the literature, for example, education and training for staff (Coleman et al., 2012), and introducing a prisoner-based buddying system (Hodel & Sańchez, 2012). It was recommended by discussion group participants that a person whose dementia was deemed too advanced for them to be safely cared for locally in the correctional centre, should be transferred to a specialised unit within the prison system or a community facility. At present however, the number of such placements is limited. Currently in the NSW prison system there is a 15-bed inpatient facility for aged-care patients, and a 15-bed CSNSW operated unit for the housing of persons (not exclusive to older persons) with cognitive functioning difficulties. Whilst transfer from prison to a community facility has been possible for a small number of older persons, the organisation of such is fraught with both legal and social obligation challenges.

Conclusion and recommendations The Policy Delphi technique adopted in this study enabled the opportunity for individuals considered to hold expert experience and opinions regarding the care of older persons with dementia in NSW prisons to come together to discuss ideas and opinions, and to develop tools and procedures related to the identification, assessment and health management of incarcerated persons with dementia. The inclusion of surveys to obtain participant opinion, that was subsequently feedback to the discussion group participants, provided the



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opportunity for participants to reconsider their own opinions after knowing the opinions of other experts. This iterative process is a key component of the Delphi approach. The facilitated discussion groups enabled an inclusive environment, whereby staff could express their opinions and experiences in a forum which they felt comfortable doing so. Whilst all discussion group participants were involved in the care of persons with dementia, it was the first time that this group of experts had been brought together for an in-person meeting. The research process enabled participants to develop tools and procedures related to the identification and assessment of, and management of care for, older persons with dementia in prison. This research provides a framework to support future research. An evaluation of the tools and procedures that were an outcome of this research is recommended. Research to determine the prevalence of dementia among the older offender population in Australia would also be of benefit to health and correctional organisations attempting to address service provision for people with dementia in prison. Further development in the area of care provision for older persons with dementia in the prison system is also required. Care provision should be inclusive of accessibility of staff trained in dementia care at rural and remote correctional centres, discharge planning/post release service provision and partnerships with community providers. Acknowledgements We would like to acknowledge Dr Catherine Hungerford, University of Canberra, for her advice and direction throughout the research regarding the Delphi Method; Dr Elizabeth Moore, Ministry of Health New South Wales, for her assistance in the early stages of this research; Prof Richard Fleming and Dr Lorna Moxham, University of Wollongong, for sharing their insights in developing dementia education and training materials for healthcare professionals; Shirley O’Keefe, Service Director, Long Bay Hospital for her leadership and Justice Health & Forensic Mental Health Network clinicians and managers for their commitment to evidence based, patient centred healthcare within the prison setting.

Declaration of conflicting interests The authors declare that there is no conflict of interest.

Funding This research was part funded by the New South Wales and Australian Capital Territory Dementia Training Study Centre, an initiative of the Australian Government, Department of Social Services.

References Australia Bureau of Statistics (ABS). (2011). Prisoners in Australia. Cat. No. 4517. Canberra: ABS. Australia Bureau of Statistics (ABS). (2001). Prisoners in Australia. Cat. No. 4517. Canberra: ABS. Baidawi, S., Turner, S., Trotter, C., Browning, C., Collier, P., O’Connor, D., . . . Sheehan, R. (2011). Older prisoners – A challenge for Australian corrections. Trends and issues in crime and criminal justice, No. 426. Canberra: Australian Institute of Criminology. Carlisle, D. (2006). So far, so bleak: Increasing numbers of older prisoners in a prison estate, designed essentially for fit young men, pose a problem for health service providers. Nursing Older People, 18(7), 20–23.



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Karen Patterson has held the position of Head, Practice Development Unit with Justice Health & Forensic Mental Health Network, NSW, Australia, since 2010. Karen provides



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leadership in enabling scholarly based practice, engaging clinicians in critical inquiry and in the translation of evidence into practice and policy. Karen is passionate about research and person centred care with a background in qualitative and mixed methods research. Recent research includes: a case study of patient centred care practices in the correctional environment; a support and challenge framework for nursing managers working in high secure environments; and defining the role of the forensic hospital registered nurse and prioritising their core capabilities using the Delphi Method. Karen works collaboratively across disciplines, agencies and sectors. She holds a Clinical Senior Lecturer post with The University of Sydney and an Honorary Associate Professor at the University of Wollongong. Claire Newman has been the Research Officer with the Practice Development Unit at Justice Health and Forensic Mental Health Network since 2008. Claire has lead and influenced a range of research projects during this time with roles as principle researcher and investigator. Claire also provides expert advice and research supervision to clinicians and managers engaging in research and evidence based inquiry. Claire completed her Masters by research and has published and researched in the areas of qualitative and mixed methods. Her work includes: evaluation of the implementation of a new nursing model of care across custodial health sites; a phenomenological examination of the lived experience of incarceration of those with autism; and evaluation of the Justice Health Mentoring Program. Katherine Doona has worked with Justice Health & Forensic Mental Health Network since 2009, holding positions as a registered nurse, nursing unit manager-aged care and rehabilitation unit and currently as a business analyst. Katherine is committed to patient centred care and to building her research capabilities to enhance her ability to provide effective nursing clinical leadership. Katherine’s qualifications include BSc (General Nursing) and Diploma in Management.
