High Occurrence of Dementia in Older Adults Returning to Community From Prison

Abstract

Introduction Given minimum sentencing laws, more arrests in later age, and population aging, the US incarcerated population is aging, with adults 50+ projected to account for 1/3 of this population by 2030. As most incarcerated persons are released, the number of those being released in mid- to late-life is growing. Evidence indicates accelerated aging (e.g., higher prevalence of geriatric conditions and ADL disability) among those 50+ with incarceration histories as compared to their never-incarcerated (NI) peers. Moreover, those reentering the community following incarceration are likely to have many risk factors for Alzheimer's disease and related dementias (AD/ADRD), such as PTSD and low education attainment. However, the burden of AD/ADRD, mild cognitive impairment (MCI), and other related diseases in this population is largely unknown. Our objective was to characterize the prevalence of these conditions in the 50+ reentry population using a national sample. Understanding this burden is a crucial first step to developing evidence-based policies that support their healthcare and reentry needs. Methods We estimated the prevalence of dementia (AD/ADRD and MCI) and other related diseases in 28,267 veterans aged 50+, who were Medicare beneficiaries and reentered the community from incarceration between October 1, 2007 and December 31, 2017 (referred to as “reentry veterans”). In addition, we created a 1:5 matched comparison cohort of 141,335 never-incarcerated veterans (referred to as “NI veterans”) matched on age, year of release/Medicare eligibility year, and sex. To create these cohorts, we linked two national databases: (1) Centers for Medicare & Medicaid Services (CMS), for medical claims/diagnoses and incarceration release date; and (2) National Patient Care Database (NPCD), for VA inpatient and outpatient services. To characterize the prevalence of dementia and related diseases, we used ICD-9 clinical diagnosis codes in inpatient and outpatient medical records from October 1, 2007 to September 30, 2015, and ICD-10 codes through study end. The 10-year prevalence of dementia diagnoses include MCI and AD/ADRD diagnoses: Alzheimer's disease, Frontotemporal dementia, Lewy body dementia, vascular dementia, mixed dementia (2+ dementias), dementia associated with Parkinson's disease, senile dementia, dementia not otherwise specified, and dementia associated with HIV/AIDS. The 10-year prevalence of dementia related diseases included Parkinson's disease, Huntington's disease, and multiple sclerosis. Both 10-year prevalence estimates were determined by reentry and NI status across age groups 50-64, 65-74, 75-84, and 85+. Differences between reentry and NI cohorts age groups were evaluated with chi-square tests. We examined the potential differing trend across age groups by statistically testing the interaction of age groups and reentry status for each disorder using logistic regression. Statistical significance was defined as p <.05. Results Both cohorts had an average age of 63 (SD 8) and were 97% male. The reentry cohort was 66% white, 30% black, and 4% other. The never incarcerated cohort was 77% white, 18% black, and 4% other. Figure 1 presents the 10-year prevalence of dementia diagnoses according to age group for both reentry and NI cohorts. The reentry cohort had, on average, a 32% higher 10-year prevalence of dementia diagnosis than the NI cohort (Figure 1), with greatest differences at ages 65-74. At ages 65+, 18% of reentry veterans had an AD/ADRD diagnosis, versus 12% in the NI cohort. The estimates go up to >50% for reentry veterans 85+ versus 43% for NI (p-interaction < .001). Conversely, Figure 2 shows the reentry cohort had, on average, a 17% lower 10-year prevalence of dementia related disease diagnoses than the NI cohort (p-interaction < .001). However, at ages 85+, reentry veterans had a slightly higher prevalence of dementia related disease (8.0%) than those never incarcerated (7.3%). Conclusions These findings indicate that reentering community after incarceration aged 50+ is associated with higher occurrences of AD/ADRD and MCI, but not necessarily with dementia related diseases. Because we did not have access to the reentry group's incarceration medical records, we were unable to obtain diagnoses during incarceration. This is the first study to characterize the burden of AD/ADRD and related diseases among those with a recent history of incarceration. The higher prevalence of AD/ADRD and MCI in the reentry cohort across age groups may indicate accelerated cognitive aging among those with a history of incarceration. Our findings highlight the importance of identifying those with MCI during incarceration so reentry care transition services can be put into place to slow the progression of cognitive decline. Funding This work was supported by RF1 MH117604 from the National Institute of Mental Health (principal investigators: Lisa C. Barry, Ph.D., M.P.H. and Amy L. Byers, Ph.D., M.P.H.). Given minimum sentencing laws, more arrests in later age, and population aging, the US incarcerated population is aging, with adults 50+ projected to account for 1/3 of this population by 2030. As most incarcerated persons are released, the number of those being released in mid- to late-life is growing. Evidence indicates accelerated aging (e.g., higher prevalence of geriatric conditions and ADL disability) among those 50+ with incarceration histories as compared to their never-incarcerated (NI) peers. Moreover, those reentering the community following incarceration are likely to have many risk factors for Alzheimer's disease and related dementias (AD/ADRD), such as PTSD and low education attainment. However, the burden of AD/ADRD, mild cognitive impairment (MCI), and other related diseases in this population is largely unknown. Our objective was to characterize the prevalence of these conditions in the 50+ reentry population using a national sample. Understanding this burden is a crucial first step to developing evidence-based policies that support their healthcare and reentry needs. We estimated the prevalence of dementia (AD/ADRD and MCI) and other related diseases in 28,267 veterans aged 50+, who were Medicare beneficiaries and reentered the community from incarceration between October 1, 2007 and December 31, 2017 (referred to as “reentry veterans”). In addition, we created a 1:5 matched comparison cohort of 141,335 never-incarcerated veterans (referred to as “NI veterans”) matched on age, year of release/Medicare eligibility year, and sex. To create these cohorts, we linked two national databases: (1) Centers for Medicare & Medicaid Services (CMS), for medical claims/diagnoses and incarceration release date; and (2) National Patient Care Database (NPCD), for VA inpatient and outpatient services. To characterize the prevalence of dementia and related diseases, we used ICD-9 clinical diagnosis codes in inpatient and outpatient medical records from October 1, 2007 to September 30, 2015, and ICD-10 codes through study end. The 10-year prevalence of dementia diagnoses include MCI and AD/ADRD diagnoses: Alzheimer's disease, Frontotemporal dementia, Lewy body dementia, vascular dementia, mixed dementia (2+ dementias), dementia associated with Parkinson's disease, senile dementia, dementia not otherwise specified, and dementia associated with HIV/AIDS. The 10-year prevalence of dementia related diseases included Parkinson's disease, Huntington's disease, and multiple sclerosis. Both 10-year prevalence estimates were determined by reentry and NI status across age groups 50-64, 65-74, 75-84, and 85+. Differences between reentry and NI cohorts age groups were evaluated with chi-square tests. We examined the potential differing trend across age groups by statistically testing the interaction of age groups and reentry status for each disorder using logistic regression. Statistical significance was defined as p <.05. Both cohorts had an average age of 63 (SD 8) and were 97% male. The reentry cohort was 66% white, 30% black, and 4% other. The never incarcerated cohort was 77% white, 18% black, and 4% other. Figure 1 presents the 10-year prevalence of dementia diagnoses according to age group for both reentry and NI cohorts. The reentry cohort had, on average, a 32% higher 10-year prevalence of dementia diagnosis than the NI cohort (Figure 1), with greatest differences at ages 65-74. At ages 65+, 18% of reentry veterans had an AD/ADRD diagnosis, versus 12% in the NI cohort. The estimates go up to >50% for reentry veterans 85+ versus 43% for NI (p-interaction < .001). Conversely, Figure 2 shows the reentry cohort had, on average, a 17% lower 10-year prevalence of dementia related disease diagnoses than the NI cohort (p-interaction < .001). However, at ages 85+, reentry veterans had a slightly higher prevalence of dementia related disease (8.0%) than those never incarcerated (7.3%). These findings indicate that reentering community after incarceration aged 50+ is associated with higher occurrences of AD/ADRD and MCI, but not necessarily with dementia related diseases. Because we did not have access to the reentry group's incarceration medical records, we were unable to obtain diagnoses during incarceration. This is the first study to characterize the burden of AD/ADRD and related diseases among those with a recent history of incarceration. The higher prevalence of AD/ADRD and MCI in the reentry cohort across age groups may indicate accelerated cognitive aging among those with a history of incarceration. Our findings highlight the importance of identifying those with MCI during incarceration so reentry care transition services can be put into place to slow the progression of cognitive decline.