Mohammed T. Abou-Saleh

642 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYFUNCTIONAL PSYCHOSESPsychotic symptoms and signs appear similar in form across awide variety of settings 26 , although the content, e.g. ofdelusions, will be influenced by culture. Also, of course, thepatient and his family’s explanation for the illness will dependon their cultural framework 27 . Hence, someone from Zambiamay explain his/her schizophrenia as he/she might explain astroke, depression or a burglary—as due to bewitchment or tohaving angered a spirit.Culturally-supported dissociative states and altered states ofconsciousness can be misleading 6 . Pseudohallucinatory phenomenahave been described in non-psychotic depression, anxiety anddistress states 13,28 .An apparently unusual idea, such as believing oneself to bebewitched, is only a delusion if it is out of keeping with the beliefsof others in the culture. This must be checked by asking someonewith appropriate knowledge. If faced with the patient alone, askhow he/she came to believe this, and if others close to him/heragree. If a traditional healer told him/her so, and his/her peersagree, then it is at least likely that this is a culturally sanctionedbelief. Another error is to assume that a belief is culturally normalwhen it is actually abnormal.DEMENTIADSM-IV criteria 29 for dementia require the demonstration ofcognitive impairment of sufficient severity to interfere with theactivities of daily living. However, cultures vary in the extent towhich they expect older people to take responsibility, e.g. fordomestic activities. Also, impairment from physical conditionsis commoner in socially disadvantaged people and will bedifficult to distinguish from that due to dementia, requiringgreater emphasis on physical examination and tests 6,30 . Manycognitive tests include items affected by education (e.g.requiring reading, writing or arithmetic skills) and/or whichmay have little relevance in certain cultures (e.g. ‘‘Who is thePresident?’’, ‘‘Take 7 from 100’’). When testing those unfamiliarwith such approaches, be courteous, encouraging (without‘‘helping’’), give explicit instructions and some dummy tasksto allay anxiety 30 . Rather than doggedly adhering to theoriginal version of instruments, it is appropriate either tomake rational adaptations (as described for the MMSE 35 )ortodevelop new instruments 31 . Novel adaptations will, of course,require translation, back-translation and pre-testing 33 . Suitableinformants should be screened for any decline in function oftheir close contact 32 . The Community Screening Instrument forDementia 31,33 combines culture-fair cognitive testing with astructured informant interview. This approach should becomemore routinely applied, both in primary and secondary care.REFERENCES1. Bahl V. 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