The Effect of Psychotropic Medications on Vulnerable Populations

The purpose of my capstone project was to explore the effect of psychotropic medications on vulnerable populations and identify potential side effects that could be caused by previous traumatic events. For this purpose, I have chosen elderly African Americans living in one of the most violent areas of Chicago. Considering family, environment, and home risks, it was decided to administer small dosages of haloperidol eventually increasing them as well as consider patient-centered interventions, such as the use of cultural support of family members and elements of faith nursing. Overall, the intervention was seen as successful in several areas, but it requires further patient-centered nursing efforts to justify the chosen methods as a strategic care plan.

Description of the Aggregate

The selected aggregate for the capstone project are elderly patients undergoing treatment in Ridgeview nursing home located in Rogers Park, Chicago. All people are African-Americans from Englewood, one of the most dangerous official community areas in Chicago owing to increasing rates of gun violence and homicides, highest poverty rates, and progressive cases of mental instability (Todman, Hricisak, Fay, & Taylor, 2012). Such living conditions could be also traced back to the period of Great Migration of 20th century, which enforced the development of segregated African-American communities in Chicago South Side, including Englewood. As people were living in isolation, they have expected a lack of city authorities’ support, hence resulting into poor housing conditions that require essential repairs, absence of safe recreational areas, presence of offensive-looking people on the streets, and limited or no access to public transportation. Apart from that, there is a lack of stores and pharmacies due to the housing foreclosure problem and cut or broken utilities, which prevents vulnerable community members, such as elderly patients, from accessing healthcare and utility services. The elderly in Englewood still have some access to the places of worship (mostly churches), where the level of safety and immediate care is generally higher. The presence of police patrols in Englewood is high, which has eventually supported to lower crime rates in the last two years. However, high suicide levels owing to mental instability and deaths of family members in shootings remain significant for Englewood and its neighborhoods.

Strengths and Weaknesses

Despite the progressive poverty levels and decreasing population, elderly community in Englewood keeps receiving substantial assistance from volunteering efforts that attempt to connect low-income adults across various community areas, provide access to food, assist in finding jobs, and even perform essential home repairs. Englewood Village is one of these volunteer groups that use various ways to gently reach low-income elderly people by distributing flyers, directing them to medical centers, and matching their skills to available jobs in the area. The younger family members of the chosen aggregate also receive support from ‘village networks’ by enrolling them to classes and courses to obtain required qualification for higher paid jobs. Another community strength is a strong bond to the family and spiritual traditions, which is mostly considered by adults and older people African-American cultural heritage. It allows them to form friendly and caring community relationships, which is observed by high involvement of adults who assist their parents, their willingness to listen to the recommendations of nurses and physicians, as well as support faith nursing efforts in local churches.

However, it is worth admitting the community weaknesses are stronger and could not be completely mitigated by its strengths. On top of the gun violence and losses of significant others in homicides, the adults and older people in Englewood tend to consume marijuana, opioids, and alcohol as substances to ease their negative emotions and delusional effects. Having progressive mental issues in this case could only worsen the condition, while it would be hard for nurses or physicians to identify the organic way to prescribe psychotropic medications. Second, the agencies and nursing homes restrict the number of nurses allowed to provide community support in Englewood due to the high crime rates, which, combined with previously mentioned housing issues and utility access, leads to further patient isolation and unequal access to care. Finally, elderly African-Americans experience issues communicating with white nurses feeling deprives and perceiving racial intolerance, which makes it complex to find sufficient number of nurses of the same race to maintain personal contact.

Risk Assessment

The risk assessment for the selected aggregate has been performed in several dimensions. Family assessment has been performed by conducting short interviews with caregivers who visit the patients if available or congregation leaders in churches, which patients have reported to visit or being an active member in the past. Home assessment was performed through the windshield survey outside the housing and subsequent questioning patients about what improvement their houses need. Windshield survey also contributed to results of environmental assessment, while collecting secondary data from news reports and academic research helped formulate its results. Additional data was collected from the official databases that record mortality rates and reasons of deaths of African-Americans in Englewood. Overall, it was found that community risks are eased by family factor, while environmental risks, such as street violence, access to care, and housing problems, significantly increase health risks.

Identified Diagnoses

The actual diagnosis identified for the aggregate is schizoaffective disorder that is observed in multiple forms, from continuous depression to frequent hallucinations and aggressive behaviors. The severity of actual diagnosis varies on the aggregate level and is a direct outcome of past traumatic events, attempts to treat observed mental issues, and age at which the culmination of depression signs has been recorded. The lack of systematic community support, aggressive external environment, and closure of mental clinics in Chicago have also negatively affected the progressive of schizoaffective disorders.

The risk diagnosis identified for the aggregate is a probability of committing a suicide owing to the continuous depression, acknowledging the progressive violence and racial intolerance, and absence of qualified support from mental care facilities to control schizophrenic symptoms. Suicidal ideation was previously reported being observed for more than 40% of patients with schizophrenia, with even higher chances observed for people consuming alcohol or other substances (Luckhoff, Koen, Jordaan, & Niehaus, 2014). The severity of the identified risk diagnosis could increase if the patient tends to demonstrate bizarre or aggressive behaviors, eventually considering the tendency to both homicide and suicide a mean to commit a revenge on gangs or police accusing them of street violence or persistent environmental problems.

Care Plan

Since the chosen aggregate represents elderly patients, the proposed care plan is primarily based on tertiary intervention. It is proposed to focus at administering the haloperidol as an accepted antipsychotic drug. It is a first-generation medication with comparable psychotropic efficiency and possible comparative medication to consider the use of alternative medications. To control possible extrapyramidal symptoms (EPS), regular anticholinergic agents, such as Cogentin, were considered. At the planning stage, it was decided not to consider alternative medications for several reasons. First, while there were controversial observations about the between-group differences when administering haloperidol and effectiveness of alternative medications, such as nemonapride, for the small trials, haloperidol still appeared effective if the dosage is gradually optimized (Dold et al., 2016). Second, since patients are from the vulnerable communities and have not been regularly monitored for disease progression, it is complex to predict possible comorbidity effects and would require observing behavioral changes to vote for alternative medication.

Another aspect of the care plan is to consider community intervention. On the first stage, care plan assumes establishing partnering relationships with family members, thus encouraging them to assist the patient and act as mediums between nurse and patient. It includes training on the correct approach to observe delusional effects, choose the appropriate dosage, and monitor the patient for excessive alcohol abuse or consumption of other substances. Community intervention also assumes extending nursing activities to churches through faith nursing to further train community leaders in mental support as well as collaborating with recently established police units in the area, who are trained to provide basic mental support for Englewood residents on top of their main peacekeeping duties.

Finally, the last aspect of the care plan is to consider the probability of sporadic growth of violence in Englewood area, which would eventually lead to more strict rules for isolation and police or military operations. The nursing home administration should considering strengthening its internal security by assigning police officers to patrol its premises. Nurses should conduct individual sessions with patients and caregivers to explain the importance of staying home under such disasters. Finally, it is advised considering sheltering opportunity in alternative locations where nurses could stay with patients during violence on the streets.

Evaluation of the Implementation Plan

For the intervention of the implementation plan, one patient out of the group of five elderly patients from Englewood was chosen to closely monitor the effect of haloperidol and establish a systematic nursing and community support to treat schizoaffective disorder. The patient is a female who could be differentiated from others in the chosen aggregate by violent behaviors, the use of rude words towards both peers and personnel, and noticed of secretly consuming alcohol. Administering small dosages of haloperidol combined with Cogentin for the cases of observed EPS has been considered to find whether it has positive effect on decreasing signs of violence over time. It was also planned to engage a family caregiver as a source of comfort while making regular visits to decrease patient’s hostility of receiving nursing services by talking about patient’s experiences more frequently.

Overall, while the intervention was implemented as planned and outlined in the initial proposal, some planned effects were not achieved in full. The patient still demonstrates violence towards some of her peers, but she feels more confident to talk about past experiences without demonstrating as much aggression as she did before. It was also eventually confirmed that the dosage of haloperidol could be increased, while the patient still hallucinates and recalls about her being a witness of shootings and deaths occurring in her neighborhood. It is assumed that the main barrier to achieve better outcomes is in the initial attitude to the personnel and unwillingness to undergo treatment, thus preferring to stay at home and having rare but frightening thoughts of committing a suicide, which was the main trigger for family caregiver. However, since the patient is now more willing to accept the reality and attempts to share feelings, it is worth to continue with care plan implementation.

To compare the projected plan effectiveness, two members of the aggregate were interviewed to compare the impact of the interventions made using the same approach of administering the increasing dosage of haloperidol (transcripts are provided below, the wording is adjusted to guide common understanding).

Patient A, 66-year-old male: “I have seen many violence in my life, from war to the way how young boys shooting each other two blocks near my house. Englewood is a dangerous area, and it is hard to find happiness here. In my age, I cannot support happiness there already. However, I think that I want to change and find some rest, find some ease in my life, and get away from these visions that I have in my head. Maybe, I will manage to do this by talking with others, who share the same thoughts and desire to change.”

Patient B, 65-year-old female: “I do feel better here. I still have these memories of my dead beloved in my head, and I hate people who make me live as an outcast, but I think nothing could be done already. I hope somebody will punish them one time, but for me, it is better to stay here and pray for their souls, rather than live in that fear and close doors and windows when I hear police sirens approaching our street again.”

According to the feedback, it could be concluded that intervention certainly had some positive results, as the interviewees admitted their acknowledgement of safety and developing vision for relief as a part of their staying in the nursing home, talking with peers, and receiving support from family members. The obvious sign of success is that the patients feel the positive difference between past and current events and can describe feelings and expectations from the future. The effectiveness is also confirmed for engaging parents, caregivers, and community leaders in churches to be willing to share their experiences that would guide support needs planning per patient. However, the side effects of haloperidol still yet to be tested, considering that treating schizoaffective disorders and preventive suicidal intentions could not be done in such short period. To fulfill my commitment as a nurse, I will keep working with my selected patient, thus aiming to reduce signs of violent behavior and explore possible alternatives and strategies for my future career as a nurse.