Schizophrenia in Elderly Homeless Individuals: Nursing Management and Interventions

This article discusses the challenges of managing schizophrenia in elderly homeless individuals and the nursing interventions that can be used to improve their care. It also explores the relationship between homelessness and schizophrenia, and the treatment options available.

Assignment 2: Justification
Introduction
Schizophrenia is a mental health problem associated with impairments in manifestation
of reality exhibiting as auditory hallucinations, paranoid illusions in the background of important
social or occupational dysfunction (Susanti et al., 2018; Verhaeghe, 2018). Diagnosis is
dependent on the patient's self-reported experiences and perceived behaviour. According to
Druss et al. (2018), Schizophrenia has been associated with an increased dopamine action in the
brain’s mesolimbic pathway. Globally, the management and treatment of elderly homeless
individuals suffering from mental health illness including schizophrenia is a huge challenge to
the health service providers (Rezansoff et al., 2016; Fazel et al., 2014). According to Gaebel and
Zielasek (2015), an individual experiencing a combination of homellesness and mental disorder
poses a major challenge to public health policy focus globally.
The demographic characteristics of Australian population paints a picture of ageing
population with findings from a survey conducted and released in the year 2017 revealed that 3.8
million representing 15% of the general population of Australian citizens were 65 years and
above (Australian Institute of Health and Welfare [AIHW], 2018). The research findings by
Rezansoff et al. (2016) revealed that 11% of persons with no home suffers from schizophrenia.
However, 5 in 100 persons suffers mental health problem in Australia (AIHW, 2018). At the
same time, 36% of the homeless individuals in Sydney Australia were suffering from
schizophrenia (Mental health services Overview - AIHW", 2018).
Homelessness and schizophrenia
Various studies have established a positive relationship between homeless and low
antipsychotic medication adherence leading to high risk of relapse, patient being in hospital for
1

longer periods, and rise in suicide cases (Rezansoff et al., 2016; Coe et al., 2015). In Australia,
mental health related conditions including schizophrenia are considered a public health issue,
furthermore, it is anticipated that the ratio of mental healthcare service providers such as nurses
who are critical in supporting the homeless aged population will decrease significantly in the
coming years (Allison and Bastiampillai, 2015). At the same time, from economical perspective
the Australian government through treasury has recognized the fact that the aging and homeless
elderly population is a major factor for reduced economic growth due to reduced labor force
(Wilkins, 2017).
The national rate of specialized homeless services data established that there is an
increase elderly persons with mental health problems such as schizophrenia since the beginning
of the data collection and they represent the fastest increasing sub-group within the specialized
homelessness service (SHS) collection ("Mental health services Overview - AIHW", 2018). The
number increased from 23.5% in 2012-2013 to 32.3% in 2016-2017 this represent an average
annual increase of 10.7%. Housing crisis and inappropriate housing conditions have been cited
by the schizophrenic old persons to be the main reason for pursuing help from the SHS and other
community health facilities (AIHW, 2018; Allison and Bastiampillai, 2015).
The precise cause of schizophrenia is not known and the prediction of who will develop
the disease is quite difficult. However, it is believed that factors related to individual’s genetics
plays a major role in the disease development (Conn, 2018). It is believed that chromosome 13
and 6 are involved in predisposition to the development of schizophrenia (Howes et al., 2017).
The other factors include biological factors such excessive dopamine. Diagnosis of schizophrenic
cases may prove difficult, however, there are certain symptoms that can be noticed by the
patients relatives including loss of ability to communicate well coupled with mood fluctuations
2

(Chang et al., 2018). Nurses working in the community home care plays a critical role in the
management of elderly homeless schizophrenic patients. According to ("Mental health services
Overview - AIHW", 2018), in the year 2016 employed specialized psychiatrists were 9.9% of the
all employed specialist medical practitioners, and 58.8% of all employed nurses were aged 45
years and above.
Nursing management and interventions
Nurses managing the schizophrenic patients should understand that early diagnosis and
identification of the risk factors related to the development of schizophrenia among the elderly
homeless results to reduced number of cases (Olfson, 2016). Nurses need to identify
schizophrenia and note the hallmark symptoms including poor social interactions, hallucinations,
thought distortion, and disorganized thinking (Conn, 2018). There are different nursing
intervention approaches nurses deploy to care for schizophrenic patients include the needs to
develop a good rapport and trust between nurses and the patients, assessing the patient’s ability
to carry out daily physical activities, hence, promoting patient’s independence (Carlbo et al.,
2018). At the same time, nurses should introduce themselves and highlight their responsibilities
to the patients and their families. According to Townsend and Morgan (2017), mental health
nurses should ensure that the patient’s family are well informed about the disease and the need
for medical adherence. Nurses should be able be able to recognize the positive symptoms of
schizophrenia including weakened physical movement associated with depression, marked
behavioral changes and suicidal thought due impulsiveness, and risk for injury related to
hallucinations and delusions. There is also risk of poor nutritional status among the homeless
elderly schizophrenic patients due to poor feeding practices relating to self-neglect (Farrer et al.,
2018).
3

The nursing care plan and goals for elderly homeless schizophrenic patients should focus
on achieving reduced patients psychotic symptoms, avert relapse of acute episodes of that could
lead to the readmission, and improve patient’s adherence to therapy and nursing plan (Pinho et
al., 2017). The patient’s level of functioning should be maximized by promoting independence
and only offering help where necessary and rewarding positive behaviour. Nurses should be able
to monitor drug therapy by administering prescribed medication and ensure drug adherence by
the patients in their custody. At the same time, anaphylactic reaction and toxicity due to drugs
are managed well. In the treatment of homeless schizophrenic patient family involvement should
be encouraged and they should be able to identify relapse (Kerkemeyer et al., 2015).
Treatment
According to (Schmidt et al., 2015), pharmacological therapy and psychosocial
intervention offered to schizophrenic patient results to reduced incidence and prevalence of the
disease among the elderly homeless individuals. There is evidence of existing gap for treatment
of individuals in special groups who are also schizophrenic, with emphasis on comorbidities of
depression and suicidal thoughts the knowledge on evidence-based treatment is rare (Hasan et
al., 2015). Therefore, accurate and well-timed diagnosis of schizophrenia among the elderly
homeless individual can positively impact on the treatment attainment, nurses offering the much
needed care should be able to pay special attention to the early signs that might be expressed by
the patients. According to (Moos, 2017), nurse offering mental health services work under very
intense environment in order to deliver services to the homeless elderly schizophrenic patients.
First generation antipsychotics (FGAs), conventional neuroleptics such as
chlorpromazine have been oldest and common form of pharmacotherapy of older patients with
schizophrenia (Solmi et al., 2017). However, FGAs have undesired side effects such as
4

extrapyramidal symptoms (EPS) and tardive dyskinesia (TD), sedation, anticholinergic effects,
and postural hypotension, limiting their usage as the drug of choice for treating older patients
with schizophrenia (Stafford et al., 2015).The use of second generation antipsychotics (SGAs),
such as quetiapine, risperidone, olanzapine have provided relief for the treatment of
schizophrenia in older persons. The SGAs have high safety and tolerability compared with FGA.
However, there are noticeable side effects including weight gain and metabolic disorders (Solmi
et al., 2017). At the same time, Cognitive-Behavioral therapy has been established to provide
clinically important results related to reduction in symptom burden, relapse and improved
recovery in schizophrenic patients (Kuller et al., 2010). There are various health-care
intervention strategies that have been developed to advance the well-being and health of special
group including Programs of All-Inclusive Care for the Elderly (PACE).
Conclusion
Pharmacotherapy and psychosocial interventions directed towards management of
Schizophrenia contribute immensely to the reduction of incidence of the disease. Nursing models
and theories in the care of the elderly homeless schizophrenia has proved important in
management of this disease. The gap in theory-practice in the psychiatric nursing care of
homeless elderly persons suffering from schizophrenia is an area of concern which should be
addressed immediately. Positive diagnosis of schizophrenia may prove difficult at the beginning
of the first episodes, however, the family members may recognize difficulties in communication,
and personality or mood changes. The nurses offering mental health services to the homeless
elderly schizophrenic patients should realize that strategies around early treatment are
encouraged and early identification of risk factors may assist in reducing the incidence and
prevalence of schizophrenia.
5

References
Allison, S., & Bastiampillai, T. (2015). Mental health services reach the tipping point in
Australian acute hospitals. The Medical Journal of Australia, 203(11), 432-434.
Australian Institute of Health and Welfare. (2018). Retrieved from
https://www.aihw.gov.au/reports-statistics/health-welfare-services/mental-health-
services/overview
Carlbo, A., Claesson, H. P., & Åström, S. (2018). Nurses' Experiences in using Physical Activity
as Complementary Treatment in Patients with Schizophrenia. Issues in mental health
nursing, 1-8.
Chang, X., Lima, L. D. A., Liu, Y., Li, J., Sleiman, P., & Hakonarson, H. (2018). Common and
rare genetic risk factors converge in protein interaction networks underlying
schizophrenia. Frontiers in Genetics, 9, 434.
Coe, A. B., Moczygemba, L. R., Gatewood, S. B., Osborn, R. D., Matzke, G. R., & Goode, J. V.
R. (2015). Medication adherence challenges among patients experiencing homelessness
in a behavioral health clinic. Research in Social and Administrative Pharmacy, 11(3),
e110-e120.
Conn, P. J. (2018). 43. Building on Genetics and Pathophysiology Of Schizophrenia To Guide
Discovery Of New Treatments. Schizophrenia Bulletin, 44(Suppl 1), S70.
Druss, B. G., Chwastiak, L., Kern, J., Parks, J. J., Ward, M. C., & Raney, L. E. (2018).
Psychiatry’s Role in Improving the Physical Health of Patients with Serious Mental
Illness: A Report from the American Psychiatric Association. Psychiatric Services, 69(3),
254-256.
Farrer, L. M., Walker, J., Harrison, C., & Banfield, M. (2018). Primary care access for mental
illness in Australia: Patterns of access to general practice from 2006 to 2016. PloS one,
13(6), e0198400.
6

Fazel, S., Geddes, J. R., & Kushel, M. (2014). The health of homeless people in high-income
countries: descriptive epidemiology, health consequences, and clinical and policy
recommendations. The Lancet, 384(9953), 1529-1540.
Gaebel, W., & Zielasek, J. (2015). Homeless and mentally ill–a mental healthcare challenge for
Europe. Acta Psychiatrica Scandinavica, 131(4), 236-238.
Hasan, A., Falkai, P., Wobrock, T., Lieberman, J., Glenthøj, B., Gattaz, W. F., ... & WFSBP
Task Force on Treatment Guidelines for Schizophrenia. (2015). World Federation of
Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of
schizophrenia part 3: update 2015 management of special circumstances: depression,
suicidality, substance use disorders and pregnancy and lactation. The World Journal of
Biological Psychiatry, 16(3), 142-170.
Howes, O. D., McCutcheon, R., Owen, M. J., & Murray, R. M. (2017). The role of genes, stress,
and dopamine in the development of schizophrenia. Biological psychiatry, 81(1), 9-20.
Kerkemeyer, L., Mostardt, S., Biermann, J., Wasem, J., Neumann, A., Walendzik, A., ... &
Breunig-Lyriti, V. (2015). Evaluation of an integrated care program for schizophrenia:
concept and study design. European archives of psychiatry and clinical neuroscience,
265(2), 155-162.
Kuller, A. M., Ott, B. D., Goisman, R. M., Wainwright, L. D., & Rabin, R. J. (2010). Cognitive
behavioral therapy and schizophrenia: A survey of clinical practices and views on
efficacy in the United States and United Kingdom. Community mental health journal,
46(1), 2-9.
Moos, R. H. (2017). Evaluating treatment environments: The quality of psychiatric and
substance abuse programs. Routledge.
Olfson, M. (2016). Building the mental health workforce capacity needed to treat adults with
serious mental illnesses. Health Affairs, 35(6), 983-990.
Pinho, L. G. D., Pereira, A., & Chaves, C. (2017). Nursing Interventions in Schizophrenia: The
Importance of Therapeutic Relationship. Nurse Care Open Acces J, 3(6), 00090.
7

Rezansoff, S. N., Moniruzzaman, A., Fazel, S., Procyshyn, R., & Somers, J. M. (2016).
Adherence to antipsychotic medication among homeless adults in Vancouver, Canada: a
15-year retrospective cohort study. Social psychiatry and psychiatric epidemiology,
51(12), 1623-1632.
Schmidt, S. J., Schultze-Lutter, F., Schimmelmann, B. G., Maric, N. P., Salokangas, R. K. R.,
Riecher-Rössler, A., ... & Morrison, A. (2015). EPA guidance on the early intervention in
clinical high risk states of psychoses. European psychiatry, 30(3), 388-404.
Solmi, M., Murru, A., Pacchiarotti, I., Undurraga, J., Veronese, N., Fornaro, M., … Carvalho, A.
F. (2017). Safety, tolerability, and risks associated with first- and second-generation
antipsychotics: a state-of-the-art clinical review. Therapeutics and Clinical Risk
Management, 13, 757–777. http://doi.org/10.2147/TCRM.S117321
Stafford, M. R., Mayo-Wilson, E., Loucas, C. E., James, A., Hollis, C., Birchwood, M., &
Kendall, T. (2015). Efficacy and safety of pharmacological and psychological
interventions for the treatment of psychosis and schizophrenia in children, adolescents
and young adults: a systematic review and meta-analysis. PloS one, 10(2), e0117166.
Susanti, H., Lovell, K., & Mairs, H. (2018). What does the literature suggest about what carers
need from mental health services for their own wellbeing? A Systematic Review.
Enfermeria clinica, 28, 102-111.
Townsend, M. C., & Morgan, K. I. (2017). Psychiatric mental health nursing: Concepts of care
in evidence-based practice. FA Davis.
Verhaeghe, P. (2018). On being normal and other disorders: A manual for clinical psych
diagnostics. Routledge.
Wilkins, P. (2017). Monitoring and Evaluation of a Multi-Agency Response to Homelessness:
An Australian Case Study. In evaluating the complex (pp. 157-180). Routledge.
8