Characteristics of Recurrent Visions of the Nonphysical World Among Cognitively Unimpaired Elders of the Ojibwe Tribal Nation

Key Points Question What are the characteristics of Ojibwe culture and spirituality in the context of a standard behavioral neurology evaluation? Findings In this cross-sectional study partnering with an Ojibwe Tribal Nation in Minnesota, 33 cognitively healthy tribal Elders aged 55 years or older were recruited. Sixteen (48%) reported frequent visions of the nonphysical world that generally involved deceased ancestors or human spirits; these visions were transient, nonthreatening, and carried spiritual significance. Meaning This study suggests that, when a diagnosis of a hallucination can disqualify a patient for new Alzheimer disease–modifying therapy, physicians must carefully consider cultural context to avoid misdiagnosis of neuropsychiatric disease.


Introduction
Hallucinations, or a sensory perception in the absence of a corresponding external stimulus, are considered pathologic if they are not a normal part of the patient's culture or belief system. 1 The identification of a hallucination is an integral component of not only primary psychiatric disease but also of neurodegenerative disease.For instance, the presence of early hallucinations with progressive dementia suggests dementia with Lewy bodies and argues against a diagnosis of Alzheimer disease. 2 The identification of hallucinations also has therapeutic implications not only in the consideration of antipsychotic treatment but also for new Alzheimer disease therapy; hallucinations are possible grounds for exclusion from lecanemab treatment, the first clearly beneficial disease-modifying therapy for Alzheimer disease. 3mplicating the interpretation of hallucinations is the patient's culture or belief system.A person seeing children in the kitchen who have no physical basis would likely be interpreted differently than a monastic individual experiencing a transient vision of a divine being. 1 The Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) emphasizes that a visual experience without a physical basis is only pathologic if it is not based on the patient's corresponding culture, religion, or belief system. 1 Little is known regarding how American Indian culture and spirituality can affect the interpretation of hallucinations in the context of a medical or neuropsychiatric evaluation.The heterogeneity among American Indian tribal nations prevents any broad generalizations.The present study focuses on the Ojibwe (sometimes referred to as Chippewa) Tribal Nation in northern Minnesota.The terms Chippewa and Ojibwe are English and French exonyms for the Anishinaabe people.The term Chippewa is used for legal and treaty purposes and is incorporated into the official names for tribal nations of the Anishinaabe people.The term Ojibwe, however, is commonly used to describe the ethnolinguistic and ancestral aspect of the Anishinaabe people and is frequently used interchangeably with the term Anishinaabe, at least in the United States. 4The Ojibwe are the fifth most populous Indigenous people in the US. 5 Our study seeks to characterize spiritual experiences among Ojibwe Elders that can inform physicians' diagnosis of a hallucination.

Methods
This prospective, cross-sectional cognitive aging clinical research study was conducted between August 1, 2021, and August 31, 2022.Each participant (or their legal authorized representative if cognitive loss was to an extent that precluded informed consent) provided written informed consent at the Bois Forte Band of Chippewa (population: 984) Health Services (Nett Lake or Lake Vermilion, Minnesota).Payment of $150 was provided for participation.The Bois Forte Band of Chippewa partnered with the research team, agreed to this work (through a signed, unanimously agreed-on tribal resolution), and agreed to the publication and public dissemination of this article (unanimous agreement at a tribal council meeting).This study was also approved by the University of Minnesota tests, which provide greater cultural sensitivity and offer additional differentiation of retrieval vs recognition memory. 6Despite the CICA's development with Ojibwe First Nation individuals in Canada who have a shared entholinguistic history with the Ojibwe Tribal Nations in Minnesota, cultural heterogeneity between regions exists, which led us to also include the MMSE as a cognitive screening tool. 6,7Mild cognitive impairment due to Alzheimer disease, dementia with Lewy bodies, and vascular dementia were diagnosed according to previously described criteria.Participants underwent blood testing for standard reversible dementia markers, including vitamin B 12 and methylmalonic acid levels; thyroid-stimulating hormone and thyroxine levels; and a comprehensive metabolic panel.A 1.5-T semitruck magnetic resonance imaging (MRI) system was brought to the local clinic, and noncontrast MRI scans were interpreted by a board-certified neuroradiologist (Z.C.) and reviewed by a behavioral neurologist (W.G.M.) to evaluate for any structural brain disease that could explain a participant's cognitive and neuropsychiatric examination.
No statistical tests were performed, as this was a descriptive study.

Results
Forty-four participants contacted the study team for enrollment.Seven were unable to schedule a visit or were unable to attend their scheduled time.Thirty-seven participants underwent the comprehensive neurocognitive evaluation.These 37 participants were a mean (SD) age of 67.1 (8.1) years, 23 (62%) were female, the mean (SD) years of formal school-based education was 13.1 (1.8) years, the mean (SD) MMSE score was 29.0 (1.8), and the mean (SD) CICA score was 36.9 (1.4).Thirtythree participants had normal cognition; these 33 participants were a mean (SD) age of 66.0 (7.5) years, 22 (67%) were female, the mean (SD) years of formal school-based education was 13.2 (1.5) years, the mean (SD) MMSE score was 29.4 (0.8), and the mean (SD) CICA score was 37.1 (1.2).Four participants had mild cognitive impairment or dementia (2 had mild cognitive impairment [1 due to Alzheimer disease and 1 due to sedating medication use], 1 had vascular dementia, and 1 had dementia with Lewy bodies).
A total of 16 cognitively normal participants (48%) reported well-formed visions of the nonmaterial world that generally involved deceased ancestors or human spiritual beings.These 16 participants were a mean (SD) age of 64.5 (7.7) years, 13 (81%) were female, the mean (SD) years of formal school-based education was 13.0 (1.8) years, the mean (SD) MMSE score was 29.4 (0.8), and the mean (SD) CICA score was 37.1 (1.4).Some of these spiritual visions had unwitnessed interactions with the material world, such as opening doors, making noises on a different floor of the house, or changing the direction a bed was facing.These visions were nonthreatening, transient (generally less than several seconds), present since childhood, and were considered by the participant to be a normal part of their culture's spiritual experience.We discussed these visions with an Ojibwe Mide diagnosis of vascular dementia) had similar spiritual visual experiences.Other additional hallmark features of their respective clinical diagnoses were present to the extent that their diagnoses were not based on the presence or misattribution of their spiritual experiences as hallucinations.
None of the participants with normal cognition had dream enactment behavior, parkinsonism, sleep-related hallucinations, dysautonomia, fluctuations in mental status, metabolic derangements beyond mild hyperglycemia or mild hyponatremia, current moderate to severe depression, or psychedelic or recreational substance use.None of the participants had any evidence of disorganized thoughts, delusional thinking, or prior or current severe psychiatric illness or psychiatric hospitalization.Of the 24 participants with normal cognition who underwent MRI (9 did not participate due to scheduling conflicts, claustrophobia, or MRI-incompatible metallic implants or shrapnel), none had any structural lesions or abnormalities on neuroimaging scans beyond mild small vessel disease of the subcortical white matter.There were no interpretation disputes between the interpreting neuroradiologist (Z.C.) and the behavioral neurologist (W.G.M.).

Discussion
Visions of the nonmaterial world are common among cognitively healthy members of an Ojibwe Tribal Nation and reflect normal spiritual experiences.These visions were present since childhood, nonthreatening, transient, generally related to ancestors or human spirits, and carried spiritual significance.Unlike psychiatric features commonly encountered among individuals with neurodegenerative disease, none of our participants (including those with cognitive impairment) had visions accompanied by paranoid, persecutory, grandiose, or personal misidentification thought content. 10Apart from visual spiritual experiences that could be misinterpreted as hallucinations, none of the participants with normal cognition had any core features of dementia with Lewy bodies 2 or psychosis. 1Although the religious beliefs of the Ojibwe are heterogeneous and vary from person to person, a common thread is that animals, plants, and nature are spiritually inhabited and sacred. 11is harmony of spiritual life within the environment is in keeping with the regularly occurring, spiritually meaningful experiences of the participants in this study.

Limitations and Strengths
This study has some limitations.One is generalizability because this study was conducted in 1 Ojibwe Tribal Nation.There are 574 federally recognized tribal nations in the United States with enormous linguistic, cultural, and spiritual heterogeneity. 12Given that other Indigenous peoples in the US and North America have similar epistemologies linking human experience with the spiritual and natural environment, 13 future work is warranted to determine whether the findings herein extend more generally to other Indigenous groups.The second limitation is selection bias; data herein stem from a cognitive aging clinical research study, which may result in recruitment of an unrepresentative sample.Religious psychedelic substance use was not a confounding factor or limitation; as opposed to some American Inidan spiritual practices most prevalent in the southwest US, peyote and religious psychedelics are not used among the Ojibwe people and were not reported by any participant. 14e study's strength is that it was performed at the Ojibwe Tribal Nation clinic with daily in-person assistance of tribal health staff, which created a nonintimidating environment for participants to openly share their spiritual beliefs and helped to promote the recruitment of underrepresented Indigenous people who otherwise might not be part of clinical research.

Conclusions
Today's environment of infrequent or insufficiently short cognitive evalutions, 15,16 a mean 16-minute face-to-face visit with a physician, 17 and increasing use of previsit symptom checklists 18 19 and all the negative ramifications associated with a misdiagnosis of psychiatric disease.Novel biomarkers for dementia with Lewy bodies 20,21 and other neurodegenerative diseases 22,23 represent promising additional safeguards to prevent misdiagnosis among participants with normal cultural spiritual experiences.

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institutional review board.This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.Using radio interviews, fliers, health fair presentations, and a YouTube video posted to the Ojibwe Tribal Nation social media account, we announced that researchers were hoping to include American Indian participants in cognitive aging clinical research.Eligibility criteria included (1) enrollment in 1 of the 6 Minnesota Chippewa (Ojibwe) Tribal Nations, (2) aged 55 years or older, (3) English as a first language, and (4) absence of an unstable medical condition that requires hospitalization.Normal cognition was defined as having no impairment in instrumental activities of daily living, having not delegated tasks to someone else due to cognitive decline, and scoring 27 or more of a possible score of 30 on the Mini-Mental Status Examination (MMSE) or 36 or more of a possible score of 39 on the Canadian Indigenous Cognitive Assessment (CICA).The CICA includes culturally relevant confrontational naming and memory items and also involves recognition memory JAMA Network Open | Equity, Diversity, and Inclusion Recurrent Visions Among Cognitively Unimpaired Elders of the Ojibwe Tribal Nation JAMA Network Open.2023;6(10):e2338221. doi:10.1001/jamanetworkopen.2023.38221(Reprinted) October 18, 2023 2/From: https://jamanetwork.com/ on 10/20/2023