Spirituality and Aging

Helen Lavretsky

Aging Health. 2010;6(6):749-769.

Abstract and Introduction

Abstract

Interest in spirituality and aging has increased recently, owing to overwhelming evidence of positive health outcomes linked to spirituality and religious participation. Increasing longevity in modern society puts spiritual needs of older adults at the forefront of societal priorities. Understanding individual spiritual perspectives becomes increasingly important, given the issues of loss, physical illness and mortality that are confronted in old age. There are multiple barriers to the proper assessment of spirituality in clinical practice and research (e.g., the lack of professional training for healthcare professionals, shortage of time and comfort for healthcare providers when discussing spiritual issues and needs). Integrating an individual's spiritual practice into their healthcare can help shape personalized medical care for older adults and improve health outcomes. This article reviews literature and research on spirituality, as well as spiritual interventions and their putative neurobiological mechanisms in relation to aging, mental and physical health, and coping with death and dying.

Introduction

Interest in spirituality and aging has increased recently, primarily owing to empirical research overwhelmingly demonstrating the various health benefits of spirituality and religious participation.^[1,2] Studies have also shown that spirituality tends to increase during later adulthood.^[3–5] Interestingly, this trend of increased spiritual growth and religious activities in older age people continues in modern society, despite significant secularization of the society compared with 50 years ago. Spirituality moderates positive relationships with various measures of life satisfaction, psychosocial wellbeing, both physical and mental health, and is helpful in the quest for meaning and purpose in life.^[6] Understanding an individual's spiritual perspective becomes increasingly important, given the issues of loss, physical illness, disability and mortality that are confronted in old age.^[2] In this broad review of the topic, the trends for spiritual development in older age in the modern society will be discussed, as well as gerontological theories of resurgence of spirituality in old age, the existing evidence of close relationships between spirituality and mental health, physical health and successful aging, the objectives for professional training in spirituality assessment in clinical settings, research findings in neurobiology of spirituality, and the efficacy of spiritual interventions in aging adults. This article presents a perspective on the importance of understanding individual spirituality as a way of developing personalized patient-centered healthcare according to modern societal priorities.

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Table 1. Examples of commonly used religiosity/spirituality assessment instruments.
Rating scales	Conceptual model	Reliability		Validity	Responsiveness	Interpretability	Properties			Ref.
Rating scales	Conceptual model	Cronbach's α	Test–retest	Validity	Responsiveness	Interpretability	Burden	Alternative forms	Cultural adaptations	Ref.
*Commonly used assessment instruments*
SWB	20 items: 10 (RWB)^† 10 (EWB)^‡	0.89 (SWB) 0.87 (RWB)^† 0.78 (EWB)^‡	0.93 (SWB) 0.96 (RWB)^† 0.86 (EWB)^‡	SWB, RWB and EWB all correlated positively with the purpose-in-life test	Higher scores indicate SWB	Higher scores indicate SWB and correlated with less loneliness	No difficulty	None	None	[149]
MMRS	88 items divided into sections: daily spiritual experiences (16), meaning (20), beliefs (7), forgiveness (10), religious practices (4), religious coping (11), religious spiritual history (5), organizational religiousness (7), commitment (2), religious preference (1), values (3), overall ranking (2)	0.72–0.96 range for all subsections	0.61–0.84 range for all subsections	Positively correlated with the SWB scale	In most subsets, higher scores indicate higher religiosity/spirituality, except guilt	Correlated with physical and mental health	Long self-report scale	Brief version has been validated	None	[147]
DSES	16 item full scale, 2 factors: SG and SD	0.98 (SG) 0.86 (SD)	0.85 (SG)	Correlations with positive effect subscale of PANSS	Higher scores indicate higher spirituality	Positive correlations with decreased alcohol use, quality of life, social status	No difficulties	Short version, 6 items used in the MMRS	None	[153]
SPS	10 items: understanding of spirituality Likert 1–6, where 6 is a greater spiritual perspective	0.93 hospitalized 0.95 hospitalized terminal patients	0.57–0.68	Evidence for construct validity; having a religious background indicated higher scores on SPS; open-ended questions indicated the validity of the SPS for participants in the study	Adequate for terminally ill, healthy and nonseriously ill adults. Terminally ill adults indicated greater spirituality than both hospitalized nonterminally ill adults and healthy adults	Terminally ill adults indicated change toward increased spirituality (p = 0.01); change in spiritual views correlated positively with SPS scores	20–26 min to complete	None	None	[150, 151]
*Scales proposed for future research*
DAP	21 items; self-administered, Likert-type scale, four dimensions: fear of death, escape, acceptance, approach acceptance and neutral acceptance	Not addressed	Not addressed	Negatively related to happiness (p < 0.001) and positively related to hopelessness (p = 0.05). Failed to support the predicted relationship between approach-oriented death acceptance, happiness and hopelessness. Escape-oriented death acceptance was positively related to hopelessness but unrelated to happiness. Neutral acceptance was unrelated to hopelessness but positively related to happiness; not used in a terminally ill population	Not used as an outcome measure to date; used to assess differences in death attitudes across the lifespan	Not used in clinical settings; young and middle-aged adults may have a harder time accepting the reality of death	Not addressed	None	None	[154]
HHI	12-items: 1–4 Likert scale three dimensions: temporality and future, positive readiness and expectancy, interconnectedness	0.88	Not addressed	Negative correlation with depression and positive relationship to self-esteem, both significant (p = 0.001). Statistically significantly affected the hope scores, education and the patterns of worship. Educated and attending worship more frequently scored higher on the HHI; has not been used in a terminally ill population to date	Hope scores decreased in the hospital group that had increased depression; higher self-esteem scores scored higher on HHI; pastoral caregivers may increase hopefulness by encouraging self-esteem	Clinical setting not in a terminally ill population; no significant variation in scores based on age, gender, marital stature or religious background	Useful in chronically ill and terminally ill populations; short and easy to administer; good for respondents with limited stamina or concentration	None	None	[156]

^†Religious wellbeing scales.
^‡Existential wellbeing scales.
DAP: Death Attitude Profile; DSES: Daily Spiritual Experience Scale; EWB: Existential wellbeing (sub) scale; HHI: Herth Hope Index; MMRS: Multidimensional Measurement of Religiousness/Spirituality Instrument; RWB: Religious wellbeing (sub) scale; SD: Spiritual decline; SG: Spiritual growth; SPS: Spiritual Perspective Scale; SWB: Spiritual Wellbeing Scale.

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Executive Summary

Interest in spirituality and aging has increased recently, owing to overwhelming evidence of positive health outcomes linked to spirituality and religious participation.
Psychological and gerontological theories from a broad range of perspectives provide the idea that there is an increased spirituality in late life. Increasing longevity in the modern society puts the spiritual needs of older adults at the forefront of immediate societal needs. Given the issues of loss, physical illness and mortality confronted in old age, understanding an individual's spiritual perspective becomes increasingly important.
There are multiple barriers to the proper assessment of spirituality (e.g., the lack of professional training for healthcare professionals, shortage of time, and discomfort in healthcare providers in discussing spiritual issues and needs) in clinical practice and research.
Improved understanding and respect for an individual's spiritual practice can help shape personalized medical care for older adults, and improve health outcomes.
The definitions of spirituality have been changing over time and are increasingly considered a construct related to mental and physical health. The National Interfaith Coalition on Aging was organized in 1971, and defined spiritual wellbeing as the affirmation of life in a relationship with God, the self, the community and the environment that nurtures and celebrates wholeness.
Various systematic reviews and meta-analyses have demonstrated that religious involvement correlates with decreased morbidity and mortality, and increased survival in a variety of medical illnesses.
The impact of religion and spirituality on mental health has been studied more extensively than the impact on physical health. Much of the research in spirituality and aging has studied at the relationship between spiritual or religious coping and health. There is abundant evidence that spirituality and religious participation are associated with positive mental health outcomes.
A few systematic studies have shown that religious involvement and spirituality are associated with negative physical and mental health outcomes. Religious beliefs can affect a person's health by encouraging avoidance or discontinuation of traditional treatments, or leading to a delay or failure to seek timely medical care, leading to higher mortality. In addition, religions can stigmatize those with certain diseases and prevent those from seeking proper medical care.
Spiritual practices can change one's attitude toward death and dying. Developing interventions will raise awareness of the dying process and, ultimately, result in a more peaceful experience. These interventions will likely improve the experience of death and dying for the patient and their families in various medical settings, such as palliative care, hospice, long-term care and in primary care settings.
The guidelines of the Joint Commission on Accreditation of Healthcare Organizations require hospitals to meet the spiritual needs of patients. An effort should be made to train healthcare providers in appropriate assessment and integration of patient's spiritual beliefs in healthcare decisions.
The challenges with spirituality and religion research include logistical and funding limitations, but also the ambiguity of defining and measuring the concept of spirituality and religiosity.
There are very few well-designed large-scale studies.
Religious or spiritual activities can be practiced to help treat or prevent illnesses. These may include prayer, meditation, bibliotherapy, meditation, yoga and many others. Mind–body interventions can help enhance mental and physical wellbeing, and improve outcomes of psychiatric and physical illnesses.
Despite modest progress to date, the evidence point to the intricate neurobiological mechanisms underlying meditative practices that have revealed a significant increase in α and τ activity during meditation, and low frequency activation of τ and α bands that have been suggested to reflect enhanced and sustained attention to internal events.
Although most modern functional imaging studies have typically been conducted in very small subject numbers and without the use of control conditions, the findings support the evidence that meditation leads to increased activation in frontal and subcortical brain regions, which are important for sustained attention and emotion regulation. Fronto–parietal and fronto–limbic brain networks seem to be activated in the attention practices that lead to meditation, reflecting processes of internalized and sustained attention and emotion regulation. The findings of dopamine release in limbic brain regions are comparable with previously reported activation findings in left-frontal and limbic areas during the abstract sense of joy using the same meditation technique. All of the findings point to the potential benefit to offset deleterious effects of aging on the brain and body.
Future studies of the neurobiology of spiritual interventions and individualized spiritual treatment should include neuroimaging, an assessment of individual genetic, psychosocial and biological vulnerability factors, which can lead to the development of more effective preventive interventions for depression and anxiety, and stress-reduction in older adults.
Integrated use of spiritual interventions enhancing individual resilience to stress, and the mind–body approaches to stress reduction (e.g., meditation, yoga, mindfulness and Tai Chi) are likely to improve the overall functioning and wellbeing in older adults.

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