Religion and Spirituality

Religion and spirituality are similar but not identical concepts. Religion is often viewed as more institutionally based, more structured, and more traditional. Spirituality involves feelings, thoughts, experiences, and behaviors that arise from a search for the sacred (a Divine Being, Ultimate Reality, or Ultimate Truth).

Religion involves accountability and responsibility, whereas spirituality has fewer requirements. Persons may reject traditional religion but consider themselves spiritual. In the USA, > 90% of elderly persons 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 clergy persons), and intrinsic religiosity (internalized religious commitment).

For most elderly persons in the USA, religion plays a major role in their lives: 96% of persons >= 65 years believe in God or a universal spirit, > 90% pray, and > 50% attend religious services weekly or more often. This 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

A positive and hopeful attitude about life and illness improves health outcomes and mortality rates. Although organized religions generally emphasize a positive attitude, a positive attitude is not the only factor that accounts for the health benefits of religion. The social aspects of the religious community are also involved, as are the meaning and purpose of life that religious beliefs convey and the effect of those beliefs on health behaviors and on the decisions persons make concerning relationships with friends, family members, and colleagues. Evidence indicates that religion is generally associated with better mental health and a greater ability to cope with illness and disability among the elderly and their caregivers. For example, persons who use religious coping mechanisms are less likely to develop depression and anxiety than those who do not; this inverse association is strongest among persons 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 persons also tend to recover from depression more quickly. In a study of caregivers of patients with Alzheimer's disease or terminal cancer, those with a strong personal religious faith and many social contacts were better able to cope with the stresses of caregiving during a 2-year period.

Many elderly persons report that religion is the most important factor in 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.

Religion that improves mental health may improve physical health, because depression and anxiety may aggravate coronary artery disease, hypertension, stroke, and psychosomatic disorders. Furthermore, having a hopeful, positive attitude about the future helps persons who have physical problems and disabilities remain motivated to recover.

Active involvement in a religious community appears to help elderly persons maintain their physical functioning and health status. Levels of interleukin-6 are significantly lower among persons who attend religious services regularly than among those who do not. Elderly persons 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 those with higher levels of both.

Some religious groups (eg, Mormons, Seventh-Day Adventists) advocate avoidance of tobacco and heavy alcohol use, which is linked to the development of coronary artery disease, chronic obstructive pulmonary disease, lung cancer, disorders of the liver and pancreas, and, to some extent, multiple other disorders. Members of these groups are less likely to develop these disorders, and they live longer than the general population.

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 persons will comply with treatment regimens, because members of their community interact with them, asking them questions about their health and medical care. As a result, the elderly with such community networks are less likely to neglect themselves.

Disadvantages

Religion is not always beneficial to the elderly. Devout religiousness may promote excessive guilt, narrow-mindedness, inflexibility, and anxiety. Religious preoccupations and delusions may develop among patients with obsessive-compulsive disorder, bipolar disorder, schizophrenia, or psychoses. Certain religious groups discourage necessary mental and physical health care, such as immunization of children, prenatal care, and lifesaving therapies (eg, blood transfusions, treatment of life-threatening infections, taking insulin). Instead, they substitute religious rituals (eg, praying, chanting, lighting candles). Religious cults may isolate and alienate elderly persons from family members and the broader social community and, in some cases, may encourage self-destruction.

Role of the Health Care Practitioner

The religious beliefs and practices of the elderly are relevant to geriatric health care practitioners because of the potential effect on their patients' mental and physical health. Most health care practitioners believe that inquiring about religious issues during a medical visit is appropriate under certain circumstances, including

• When a patient is severely ill, under significant stress, or near death and there is a specific request or an implied request to the physician to address religious issues
• When a patient tells the physician that he is religious and that religion helps him cope with illness
• When religious needs are evident and may be affecting a patient's health or health behaviors

The elderly often have distinct spiritual needs that may overlap but are not the same as psychologic needs. Ascertaining a patient's spiritual needs can lead to mobilization of the necessary resources.

Spiritual history: Taking a spiritual history shows elderly patients that the health care practitioner is willing to discuss spiritual topics. Patients may be asked if their faith is an important part of their life, how their faith influences the way they take care of themselves, if they are a part of a religious or spiritual community, and how they would like the health care practitioner to address their spiritual needs.

Alternatively, patients may be asked 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, they may be sensitively asked about barriers to those activities (eg, transportation problems, hearing difficulties, lack of financial resources, depression, lack of motivation, unresolved conflicts). However, forcing religious beliefs or opinions on patients or intruding if patients do not want help may be counterproductive.

Referral to clergy: Many clergy members provide counseling services to the elderly at home and in the hospital, often free of charge. Many elderly persons prefer counseling from a clergy member rather than 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 seeing a mental health care practitioner does. However, many clergy members do not have extensive training in mental health counseling and may not recognize when elderly persons need professional mental health care. In contrast, hospital clergy are more likely to have extensive training in the mental, social, and spiritual needs of the elderly. Thus, including hospital clergy as part of the health care team is 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 or by visiting the patient or caregiver).

Support of patients' religious beliefs and practices: Because most religious beliefs and practices, particularly those rooted in major religious traditions, are not harmful to health and probably are beneficial, health care practitioners should support the patient's religious beliefs as long as they do not interfere with necessary medical care.

Spiritual interventions: Interventions include praying with patients, reading religious scriptures to them, and determining whether patients have the religious materials they need (eg, large-print scriptures, religious audiotapes).

Recommendation of religious activities: Health care practitioners may recommend religious activities that can increase socialization, reduce alienation and isolation, and increase a sense of belonging, of meaning, and of life purpose. These activities may also help the elderly to focus on positive activities rather than on their own problems. However, some activities are appropriate only for more religious patients. Suggesting religious activities to patients who are not already involved in them, if done, 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).