Religion,SpiritualityandHealthinOlderAdults

HaroldG.Koenig,MD
DepartmentsofPsychiatryandMedicine
DukeUniversityMedicalCenter
GRECCVAMedicalCenter
GRECCVAMedicalCenter

Overview

Definitions
ReligionintheU.S.
Stressanddepression:commonandincreasing
Stressaffectsphysicalhealth&needforhealthcareservices
Useofreligiontocopewithstress,sickness,anddisability
Religion,depression,andqualityoflife
Religion,alcohol/drugabuse,andcrime/delinquency
Religion,healthbehaviors,andhealthierlifestyles
Religion,physicalhealth,andfasterrecovery
Religion,andneedforhealthcareservices
Particularlyrelevantinolderpersons
Clinicalandcommunityapplications

Definitions
Facingthemostdifficultandthornyissuefirst

Religion
Involvesbeliefs,practices,andritualsrelatedtothe
transcendent,wherethetranscendent isthatwhichrelates
tothemystical,supernatural,orGodinWesternreligious
traditions,ortoDivinities,ultimatetruth/reality,or
enlightenmentinEasterntraditions.Religionmayalsoinvolve
beliefsaboutspirits,angels,ordemons.Religionsusually
havespecificbeliefsaboutthelifeafterdeathandrulesabout
conductthatguidebehaviorswithinasocialgroup.Religionis
oftenorganizedandpracticedwithinacommunity,butitcan
alsobepracticedaloneandinprivate,outsideofaninstitution.
Centraltoitsdefinition,however,isthatreligionisrootedin
anestablishedtraditionthatarisesoutofagroupofpeople
withcommonbeliefsandpracticesconcerningthe
transcendent.Religionisauniqueconstruct,whosedefinition
isgenerallyagreedupon.Itcanbemeasuredandexamined
inrelationshiptomentalandphysicalhealthoutcomes.

Spirituality
Spiritualityisaconceptwhichtodayisviewedasbroader
andmoreinclusivethanreligion.Itisatermmorepopular
today,muchmoresothanreligion.Spiritualityismore
difficulttodefinethanreligion.Itisconsideredpersonal,
somethingindividualsdefineforthemselvesthatmaybefree
oftherules,regulations,andresponsibilitiesassociatedwith
religion.
Thetermspiritualityismostusefulinclinicalsettings,since
thegoalistobewelcomingandinclusive,andforpatientsto
definethetermforthemselvessothatconversationmay
begin.Butbecauseofitsvagueandnebulousnature,itis
difficulttomeasureandquantifyforresearchpurposes
especiallysincethedefinitionofspiritualityhasbeen
changingandexpanding.

TraditionalHistoricalUnderstanding
Source

MentalHealth

PhysicalHealth

Religion
Meaning

Purpose

Connectedness

Suicide

Ex.wellbeing
Anxiety
Peace

Secular

Hope

Psychoneuroimmunology

Depression

Spirituality

vs.

Cardiovascular
Disease

Cancer

Addiction
Mortality

ModernUnderstanding
Source

MentalHealth

PhysicalHealth

Spirituality
Meaning

Cardiovascular
Disease

Religion
Purpose
Suicide
Connectedness

vs.

Ex.wellbeing

Anxiety

Peace
Addiction

Secular

Hope

Psychoneuroimmunology

Depression

Cancer

Mortality

ModernUnderstandingTautologicalVersion
MentalHealth

Meaning

Purpose

Connectedness

Suicide

Ex.wellbeing
Anxiety
Peace

vs.
Hope

Secular

Cardiovascular
Disease

Depression

Religion

Spirituality

PhysicalHealth

Psychoneuroimmunology

Source

Cancer

Addiction
Mortality

ModernUnderstandingClinicalApplicationonly
MentalHealth

Meaning

Purpose

Spirituality

Ex.wellbeing

Suicide

Anxiety

Peace

Secular

Hope

Cardiovascular
Disease

Depression

Religion

Connectedness

PhysicalHealth

Psychoneuroimmunology

Source

Cancer

Addiction
Mortality

NotaResearchableModel

Inthistalk,tokeepthingssimpleandclear,Iwillbe
addressingrelationshipswithhealthintermsof
religion.
First,letusexaminehowreligionmightinfluence
health.Thisisatheoreticalmodelinvolvingcausal
pathwaysandintermediaryvariables.Theexample
tobeprovidedisbasedintheJudeoChristian
Islamictradition,whichviewsGodasseparatefrom
humansandcreation,andaspersonal.
ModelslikethisexistforforEasternreligious
traditionsaswell,butmylackofexpertiseinthose
traditionsmakeiteasierformetoillustrateeffects
usingaWesternreligiousmodel.

Pathway/OrderofEffects

Privateprac,rit

SOURCE
God
belief,relation,
attachment

Rcommit

Rexp

PositiveEmotions*

Forgiveness

Altruism

Socialsup&
connections

Gratefulness
NegativeEmotions*

Rcoping

PhysicalHealthandLongevity

Publicprac,rit

Immune,Endocrine,CardiovascularFunctions

HealthBehaviors,LifestyleChoices,Decisions

Genetics,Personality,DevelopmentalExperiences
*Positiveemotions:peace,harmony,existentialwellbeing,happiness,hope/optimism,meaning,purpose
*Negativeemotions:depression,anxiety,emotionaldistress,loneliness,lowselfesteem

Let us now examine the circumstances we

are facing and the role that religion may
play in them, especially for older adults

Stress & Depression Common, Increasing

Increasedstressduetorecenteconomicdownturn
Increaseddepressionduetolosses(jobs,homes)
Increasingdebt,decreasingsavings
Youthfacingmanychoices,withfewerabsolutestoguide
Populationaging,facingincreasinghealthproblems
Fewsavingforretirement(fear)

Stress & Depression Affect Physical Health,

Need for Health Services
Myocardialinfarction
Hypertension
Stroke
Susceptibilitytoinfection
Slowwoundhealing
Increaseagingprocess
Increaselengthofhospitalstay,needformedicalservices

Religion in widespread in the United States

93%ofAmericansbelieveinGodorahigherpower
89%reportaffiliationwithareligiousorganization
83%sayreligionisfairlyorveryimportant
62%aremembersofachurch,synagogueormosque
58%prayeveryday(75%atleastweekly)
42%attendreligiousservicesweeklyoralmostweekly
55%attendreligiousservicesatleastmonthly

Religiousinvolvementacrossthelifespan(NationalStudyofYouthand
Religion20022003GallupPollsoftheUnitedStates20012002)
100
90

Percent

80
1317

70

1829
3049
5064

60

6574
75+

50
40
30

BeliefinGod

Membership

Importance

Attendance

Many in U.S. Turn to Religion to Cope

with Stress and Illness
90%turnedtoreligiontocopewithSeptember11th (NEJM)
90%ofhospitalizedpatientsrelyonreligiontocope
>40%sayitsmostimportantfactorthatkeepsthemgoing
Hundredsofquantitativeandqualitativestudiesreportsimilar
findingsinpersonswithhealthproblems,especiallyin
minorities,women,thepoor
Researchontheeffectsofreligiononcopingandhealthis
growingrapidlyworldwide

Religion/SpiritualityHealthArticles19602008Cumulative
60

Searchwords:religionorreligiousnessorreligiousorreligiosityorspirituality(2/20/09)

ThousandsofArticles

50
PsychInfo

40

30
Medline

20

10

0
1965

1970

1975

1980

1985
Year

1990

1995

2000

2005 2008

Religion/SpirtualityHealthArticlesper5YearPeriod
(NonCumulative)
Searchwords:religionorreligiousorreligiosityorreligiousnessorspirituality(2/20/09)

14
12
ThousandsofArticles

PsychInfo

10
8
Medline

6
4
2
0
196569 197074 197579 198084 198589 199094 199599 20004
Year

20059

Religion/SpiritualityHealthArticlesper5YearPeriod
(NonCumulative)
14 Searchwords:religionorreligiousorreligiosityorreligiousnessorspirituality(2/20/09)
Searchwords:psychotherapyorpsychoanalysis(forcomparison)

12
ThousandsofArticles

PsychInfo

10
Medline

Medline

6
4
2
0
196569 197074 197579 198084 198589 199094 199599 20004
Year

20059

Religious involvement can buffer stress,

reduce depression, enhance quality of life
Religionisrelatedto:
Lowerperceptionsofstress
Lessdepression,fasterrecoveryfromdepression
(204of324studiesshowdepressionlessamongreligious)
Greaterwellbeing,happiness,meaning,purpose,hope
(278of359studiesshowpositiveemotionshigherinreligious)
Increasedqualityoflife
(20of29recentstudiesshowQOLhigheramongreligious)

Alcohol/drug abuse lower in the religious

Religionisrelatedto:
Lessalcohol/druguse,especiallyamongtheyoung,
althoughtrueforallagesgroups(276of324studiesshow
significantlylowerrates)

Religious live healthier lifestyles, have

better habits, fewer risky behaviors
Religionisrelatedto:
Lesscigarettesmoking,especiallyamongtheyoung
(102of117studiesshowsignificantlylowerrates)
Moreexercise
(4of6studiesshowsignificantlymorelikelytoexercise)
Dietandweight
(1of8studiesshowreligiouspersonsweighless)
Lessextramaritalsex,safersexualpractices(fewerpartners)
(45of46studiesshowsignificantrelationships)

Religious persons need and use fewer

health care services due to better health
and more support from family, community
Maritalstabilitygreaterlessdivorce,greatersatisfaction
(36of39studiespriortoyear2000)
Socialsupportgreater
(19of20studiespriortoyear2000)
Thus:
Shorterhospitalstays,fewerhospitaldaysperyear
Lesstimespentinnursinghomeafterhospitaldischarge
(particularlyforwomenandAfricanAmericans)

ModelofReligion'sEffectsonHealth
HandbookofReligionandHealth(OxfordUniversityPress,2001)

AdultDecisions

ChildhoodTraining

Mental
Health

Stress
Hormones
Cancer

HeartDisease
Immune
System
Hypertension

AdultDecisions

Religion

ValuesandCharacter

Geneticsusceptibility,Gender,Age,Race,Education,Income

Infection

Social
Support

Health
Behaviors

Autonomic
Nervous
System

Disease
Detection&
Treatment
Compliance

Smoking
HighRiskBehaviors
Alcohol&DrugUse

Stroke

Stomach&
BowelDis.

Liver&Lung
Disease
Accidents
&STDs*
*SexuallyTransmittedDiseases

Religion related to better physical health,

recovery from illness

Fewerheartattacks,fewerdeathsfromCAD
Betterrecoveryfollowingcardiacsurgery,fewercomplications
Lowercardiovascularreactivitytolaboratoryinducedstress
Lowerbloodpressure
Lessstroke
Fewermetabolicproblems
Betterimmunefunctioning
Lowerstresshormonelevels
Lesscancer,longersurvivalwithcancer
Lesssusceptibilitytoinfection
Greaterlongevity
Slowercognitivedeclinewithaging,Alzheimersdisease
Lessfunctionaldisabilitywithincreasingage

RecentStudies
Religiousattendanceassociatedwithslowerprogressionofcognitive
impairmentwithaginginolderMexicanAmericans
Hilletal.JournalofGerontology200661B:P3P9
ReyesOrtizetal.JournalofGerontology200863:480486
ReligiousbehaviorsassociatedwithslowerprogressionofAlzheimersdis.
Kaufmanetal. Neurology200768:15091514
[fordepressioncognitionrelationshipseeArchGenPsychiatry2006AGP
63:530538200865(5):542550AGP200865(10):11561165)]
Fewersurgicalcomplicationsfollowingcardiacsurgery
Contradaetal.HealthPsychology200423:22738
Greaterlongevityifliveinareligiouslyaffiliatedneighborhood
Jaffeetal.AnnalsofEpidemiology200515(10):804810
Religiousattendanceassociatedwith>90%reductioninmeningococcal
diseaseinteenagers,equaltoorgreaterthanmeningococcalvaccination
Tullyetal. BritishMedicalJournal2006332(7539):445450

RecentStudiesPhysicalHealthOutcomes
HIVpatientswhoshowincreasesinspirituality/religionafterdiagnosis
experiencehigherCD4counts/lowerviralloadandslowerdisease
progressionduring4yearfollowup
Ironsonetal.JournalofGeneralInternalMedicine200621:S6268
Religionandsurvivalinasecularregion.Atwentyyearfollowupof734
Danishadultsbornin1914.
laCourP,etal.SocialScience&Medicine200662:157164
Nearly2,000Jewsoverage70livinginIsraelfollowedfor7years.Those
whoattendedsynagogueregularlyweremorelikelythannonattendeesto
bealive7yearslater(61%morelikelytobealivevs.41%morelikelyto
bealiveforinfrequentattendees.Gradientofeffect.
EuropeanJournalofAgeing20074:7182
Experimentalstudyshowsthatlesspainisexperiencedwhensubjects
viewreligiousvs.secularpaintingsfunctionalMRIscansdocumentsthat
paincircuitsinbrainarereduced(JournalofPain2008,forthcoming)

Over70recentstudieswithpositivefindingssince2004
http\\:www.dukespiritualityandhealth.org

ApplicationstoClinicalPractice
SpiritualityinPatientCare,SecondEdition
TempletonFoundationPress,2007
ReviewedinJAMA2008299:16081609

Why Address Spirituality in Clinical Practice

Practice
1. Notdependentonresearchaloneevenwithoutresearch,
integratingspiritualityintopatientcarehasvalue
2. Manypatientsarereligious,wouldlikeitaddressedinhealthc
Manypatientsarereligious,wouldlikeitaddressedinhealthcare
3. Manypatientshavespiritualneedsrelatedtoillnessthatcould
affectmentalhealth,butgounmetmentalhealthaffectsphysic
affectmentalhealth,butgounmetmentalhealthaffectsphysical
4. Patients,particularlywhenhospitalized,areoftenisolatedfro
Patients,particularlywhenhospitalized,areoftenisolatedfrom
religiouscommunities(requiringotherstomeetspiritualneeds)
5. Religiousbeliefsaffectmedicaldecisions,mayconflictwith
treatments
6. Religioninfluencessupportandcareinthecommunity
Religioninfluencessupportandcareinthecommunity

Take a Spiritual History

History

1. Thescreeningspiritualhistoryisbrief(2
spiritualhistoryisbrief(24minutes),andisnotthesame
asaspiritualassessment(chaplain)
2. ThepurposeoftheSHistoobtaininformationaboutreligious
background,beliefs,andritualsthatarerelevanttohealthcar
background,beliefs,andritualsthatarerelevanttohealthcare
3. Ifpatientsindicatefromthestartthattheyarenotreligiousorspiritual,
thenquestionsshouldbere
thenquestionsshouldberedirectedtoaskingaboutwhatgiveslife
meaning&purposeandhowthiscanbeaddressedintheirhealthcare
care

PhysicianShouldTake
TheSpiritualHistory
1. Physiciandirectsthecareofthepatient
2. Patientneedstofeelcomfortabletalkingwithphysicianabouts
Patientneedstofeelcomfortabletalkingwithphysicianaboutspiritual
issues
3. Patients
Patientsmedicaldecisionsareinfluencedbytheirreligiousbeliefs
4. Patients
Patientscompliancewithtreatmentsareinfluencebyreligiousbeliefs
5. Takingspiritualhistoryenhancesdoctor
Takingspiritualhistoryenhancesdoctorpatientrelationship&mayitself
affecthealthoutcomes
6. Spiritualstrugglescanadverselyaffecthealthoutcomes
Spiritualstrugglescanadverselyaffecthealthoutcomes

Religious Struggle
444 hospitalized medical patients followed for 2 years
Eachof7itemsbelowratedona0to3scale,basedonagreement.
Forevery1pointincreaseonreligiousstruggle
scale(range021),therewasa6%increaseinmortality,
independentofphysicalandmentalhealth
(ArchInternMed,2001161:18811885)

n
n
n
n
n
n
n

Wondered whether God had abandoned me

Felt punished by God for my lack of devotion
Wondered what I did for God to punish me
Questioned the Gods love for me
Wondered whether my church had abandoned me
Decided the Devil made this happen
Questioned the power of God

Contents of the Spiritual History

History
See JAMA 2002 288 (4):487-493

1. Whatispatient
Whatispatientsreligiousorspiritual(R/S)background(ifany)
2. R/Sbeliefsusedtocopewithillness,oralternatively,thatma
R/Sbeliefsusedtocopewithillness,oralternatively,thatmaybea
sourceofstressordistress
3. R/Sbeliefsthatmightconflictwithmedical(orpsychiatric)ca
R/Sbeliefsthatmightconflictwithmedical(orpsychiatric)careormight
influencemedicaldecisions
4. InvolvementinaR/Scommunityandwhetherthatcommunityis
supportive
5. Spiritualneedsthatmaybepresentandneedtobeaddressedforhealth
reasons

Besides Taking a Spiritual History

1. Supportthereligious/spiritualbeliefsofthepatient(verbally,non
(verbally,nonverbally)
2. Ensurepatienthasresourcestosupporttheirspiritualityreferpatients
withspiritualneedstoCHAPLAINS
3. Accommodateenvironmenttomeetspiritualneedsofpatient
4. Bewillingtocommunicatewithpatientsaboutspiritualissues
5. Praywithpatientsifrequested(?)
6. Prescribereligiontoimprovehealth(?)
Prescribereligiontoimprovehealth(?)

Limitations and Boundaries

1. Donotprescribereligiontononreligiouspatients
2. Donotforceaspiritualhistoryifpatientnotreligious
3. Donotcoercepatientsinanywaytobelieveorpractice
4. Donotpraywithapatientbeforetakingaspiritualhistory
andunlessthepatientasks
5. Donotspirituallycounselpatients(alwaysrefertotrained
professionalchaplainsorpastoralcounselors)
6. Donotdoanyactivitythatisnotpatientcenteredand
patientdirected

Community Applications

ProjectedgrowthoftheU.S.elderlypopulation{>65)

M
X

s
ma
te

E
sti

le
Se
rie
s

idd

Hi
gh
Se

rie
sE
s

tim
ate

2000USCensus

TheDilemma:SpendingonFutureHealthCareintheUSA
PublicPolicyandAgingReport200232:1319

eri ulat
es) ion

leS

Old
(M er
idd Po

areS
p
Med
ic

ProjectedgrowthoftheelderlyU.S.populationandMedicarespending.Medicaredatafrom
OfficeoftheActuary&BureauofDataManagement&Strategy,CenterforMedicareand
MedicaidServices(CMS),U.S.DepartmentofHealthandHumanServices (March/April2002).

MillionsofPeople

Billions$perYear

endi

n g

2001NationalHealthExpenditures=$1.4trillion
2011NationalHealthExpenditures=$2.8trillion

What do these aging and economic

trends mean?
1. Needofhealthservicesoutstrippingabilitytopayforhealth
services
2. Olderadultsfallingthroughthecracksintermsofmedical
servicesandlongtermcare
3. Olderadultswithoutfamilymemberstocareforthemliving
outtheirlatterdaysoncitystreetsandparks
4. Needtoidentifycommunityresourcestohelpalleviatethe
burdenofcareoffthehealthcaresystemandoffofyoung
families

PreventionandManagementofDisease
Primary,Secondary,andTertiary
PublicPolicy&AgingReport200212(4):16

Congregation

HealthcareSystem

Clergy
motivating

Outpatient
Clinics/Offices

ParishNurse
or
LayLeader

Communicating

Mobilizing,training

Volunteers

RunhealthprogramstakeBP's,bloodsugars
Coordinateservicesrespite,homemaker

Chaplains
Socialworkers

AcuteCare
Hospital
Nursing
Homes

Smallgroupleaders

Layministers

Individualmembers

Physician
Advisor

Larger
Community

Provideservices
Patientadvocate
Supporting,calling,visiting

Nurses
MDs

Government
Incentives
Provideseducation/training
Providesspeakers
Provides$$support

Further Reading
Medicine,ReligionandHealth(2008,TempletonPress)
HandbookofReligionandHealth(2001,OxfordUniversityPress)
TheLinkBetweenReligionandHealth(2002,OxfordPress)
FaithintheFuture:Healthcare,Aging,andtheRoleofReligion(2004,
TempletonPress)
AgingandGod(1994,HaworthPress)
Religion,HealthandAging(1988,GreenwoodPress)

FurtherInformation
Website:DukeCenterforSpirituality,TheologyandHealth

SummerResearchWorkshop
JulyandAugust2009
Durham,NorthCarolina

5dayintensiveresearchworkshopsfocusonwhatweknowabouttherelationshipbetween
religionandhealth,applications,howtoconductresearchanddevelopanacademiccareerin
thisarea(July2024,Aug1721,2009)LeadingreligionhealthresearchersatDuke,UNC,
USC,andelsewherewillgivepresentations:
Previousresearchonreligion,spiritualityandhealth
Strengthsandweaknessesofpreviousresearch
Applyingfindingstoclinicalpractice
Theologicalconsiderationsandconcerns
Highestprioritystudiesforfutureresearch
Strengthsandweaknessesofreligion/spiritualitymeasures
Designingdifferenttypesofresearchprojects
Carryingoutandmanagingaresearchproject
WritingagranttoNIHorprivatefoundations
Wheretoobtainfundingforresearchinthisarea
Writingaresearchpaperforpublicationgettingitpublished
Presentingresearchtoprofessionalandpublicaudiencesworkingwiththemedia

Ifinterested,contactHaroldG.Koenig: koenig@geri.duke.edu