Religion and Spirituality in the Elderly

Religion and spirituality are similar but not identical concepts. Religion is often viewed as more institutionally based, more structured, and more traditional and may be associated with organized, well-established beliefs. Spirituality refers to the intangible and immaterial and thus may be considered a more general term, not associated with a particular group or organization, It can refer to feelings, thoughts, experiences, and behaviors related to the soul or to a search for the sacred (eg, a Divine Being, Ultimate Reality, Ultimate Truth). Traditional religion involves accountability and responsibility; spirituality has fewer requirements. People may reject traditional religion but consider themselves spiritual. In the US, > 90% of elderly people consider themselves religious and spiritual; about 5% consider themselves spiritual but not religious. Most research assesses religion, not spirituality, using measures such as attendance at religious services, frequency of private religious practices, use of religious coping mechanisms (eg, praying, trusting in God, turning problems over to God, receiving support from the clergy), and intrinsic religiosity (internalized religious commitment). For most of the elderly in the US, religion has a major role in their life:

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96% believe in God or a universal spirit > 90% pray > 50% attend religious services weekly or more often

The elderly's level of religious participation is greater than that in any other age group. For the elderly, the religious community is the largest source of social support outside of the family, and involvement in religious organizations is the most common type of voluntary social activity more common than all other forms of voluntary social activity combined.

Benefits
Religion correlates with improved physical and mental health. However, experts cannot determine whether religion contributes to health or whether psychologically or physically healthier people are attracted to religious groups. If religion is helpful, the reasonwhether it is the religious beliefs themselves or other factors is not clear. Many such factors (eg, psychologic benefits, encouragement of healthful practices, social support) have been proposed. Psychologic benefits: Religion may provide the following psychologic benefits:

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A positive and hopeful attitude about life and illness, which predicts improved health outcomes and lower mortality rates A sense of meaning and purpose in life, which affects health behaviors and social and family relationships A greater ability to cope with illness and disability

Many elderly people report that religion is the most important factor enabling them to cope with physical health problems and life stresses (eg, declining financial resources, loss of a spouse or partner). In one study, > 90% of elderly patients relied on religion, at least to a moderate degree, when coping with health problems and difficult social circumstances. For example, having a hopeful, positive attitude about the future helps people with physical problems remain motivated to recover. People who use religious coping mechanisms are less likely to develop depression and anxiety than those who do not; this inverse association is strongest among people with greater physical disability. Even the perception of disability appears to be altered by the degree of religiousness. Of elderly women with hip fractures, the most religious had the lowest rates of depression and were able to walk significantly further when discharged from the hospital than those who were less religious. Religious people also tend to recover from depression more quickly. In the elderly, active involvement in a religious community correlates with better maintained physical functioning and health. Elderly people who attend religious services are more likely to stop smoking, exercise more, increase social contacts, stay married, and live longer. In one study, the mortality rate of patients with low levels of comfort from religion and of social support was 14 times that of patients with higher levels of both. Also, better mental health may improve physical health because depression and anxiety may aggravate coronary artery disease, hypertension, stroke, and psychosomatic disorders. Levels of IL-6 are significantly lower among people who attend religious services regularly than among those who do not. Health-promoting practices: Some religious groups (eg, Mormons, Seventh-Day Adventists) advocate behaviors that enhance health, such as avoidance of tobacco and heavy alcohol use. Members of these groups are less likely to develop substance-related disorders, and they live longer than the general population. Social benefits: Religious beliefs and practices often foster the development of community and broad social support networks. Increased social contact for the elderly increases the likelihood that disease will be detected early and that elderly people will comply with treatment regimens because members of their community interact with them and ask them questions about their health and medical care. Elderly people who have such community networks are less likely to

neglect themselves. Caregivers: Religious faith also benefits caregivers. In a study of caregivers of patients with Alzheimer's disease or terminal cancer, caregivers with a strong personal religious faith and many social contacts were better able to cope with the stresses of caregiving during a 2-yr period.

Harmful Effects
Religion is not always beneficial to the elderly. Religious devotion may promote excessive guilt, narrow-mindedness, inflexibility, and anxiety. Religious preoccupations and delusions may develop in patients with obsessive-compulsive disorder, bipolar disorder, schizophrenia, or psychoses. Certain religious groups discourage necessary mental and physical health care, including lifesaving therapies (eg, blood transfusions, treatment of life-threatening infections, insulin

therapy), and may substitute religious rituals (eg, praying, chanting, lighting candles). Religious cults may isolate and alienate elderly people from family members and the broader social community; some cults sometimes encourage self-destruction.

Role of the Health Care Practitioner

Talking to elderly patients about their religious beliefs and practices helps health care practitioners provide care because these beliefs can affect the patients' mental and physical health. Inquiring about religious issues during a medical visit is appropriate under certain circumstances, including the following:

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When patients are severely ill, under substantial stress, or near death and ask or suggest that a practitioner talk about religious issues When patients tell a practitioner that they are religious and that religion helps them cope with illness When religious needs are evident and may be affecting patients' health or health behaviors

The elderly often have distinct spiritual needs that may overlap with but are not the same as psychologic needs. Ascertaining a patient's spiritual needs can help mobilize the necessary resources (eg, spiritual counseling or support groups, participation in religious activities, social contacts from members of a religious community). Spiritual history: Taking a spiritual history shows elderly patients that the health care practitioner is willing to discuss spiritual topics. Practitioners may ask patients whether their

spiritual beliefs are an important part of their life, how these beliefs influence the way they take care of themselves, whether they are a part of a religious or spiritual community, and how they would like the health care practitioner to handle their spiritual needs. Alternatively, a practitioner may ask patients to describe their most important coping mechanism. If the response is not a religious one, patients may be asked whether religious or spiritual resources are of any help. If the response is no, patients may be sensitively asked about barriers to those activities (eg, transportation problems, hearing difficulties, lack of financial resources, depression, lack of motivation, unresolved conflicts) to determine whether the reason is circumstances or their choice. However, practitioners should not force religious beliefs or opinions on patients or intrude if patients do not want help. Referral to clergy: Many clergy members provide counseling services to the elderly at home and in the hospital, often free of charge. Many elderly patients prefer such counseling to that from a mental health care practitioner because they are more satisfied with the results and because they believe such counseling does not have the stigma that mental health care does. However, many clergy members do not have extensive training in mental health counseling and may not recognize when elderly patients need professional mental health care. In contrast, many hospital clergy have extensive training in the mental, social, and spiritual needs of the elderly. Thus, including hospital clergy as part of the health care team can be helpful. They can often bridge the gap between hospital care and care in the community by communicating with clergy in the community. For example, when a patient is discharged from the hospital, the hospital clergy may call the patient's clergy, so that support teams in the patient's religious community can be mobilized to help during the patient's convalescence (eg, by providing housekeeping services, meals, or transportation, by visiting the patient or caregiver). Support of patients' religious beliefs and practices: Health care practitioners should support the patient's religious involvement as long as it does not interfere with necessary medical care because such involvement may contribute to good health. People who are actively involved in religious groups, particularly those in major religious traditions, tend to be healthier. Religious interventions: Some practitioners pray with patients, read religious scriptures to them, or make sure patients have the religious materials (eg, large-print scriptures, religious audiotapes) they want. However, practitioners should not feel obligated to do anything that violates their own beliefs. Recommendation of religious activities: Health care practitioners may suggest that patients consider religious activities if patients seem receptive and may benefit from such activities, which

can provide social contact, reduce alienation and isolation, and increase a sense of belonging, of meaning, and of life purpose. These activities may also help the elderly focus on positive activities rather than on their own problems. However, some activities are appropriate only for more religious patients. If patients are not already involved in religious activities, suggesting such activities requires sensitivity. Patients seek medical care for health-related reasons, not religious ones. Patient and family information: Health care practitioners can provide information about the health benefits of religious beliefs and practices for the elderly and about local religious resources (eg, support groups at local churches, health promotion programs, volunteer activity programs).
Last full review/revision September 2009 by Barbara J. Berkman, DSW/PhD; Daniel B. Kaplan, MSW Content last modified September 2009