A Primary Care Guide to Addressing Spirituality
in Midlife or Older Persons as a Component to
Successful Cognitive Aging
1. Issues of Incorporating Faith Issues into Medical Practice
Physicians are often hesitant to discuss spiritual matters or religion with patients
for ethical and personal reasons (1). Some physicians may perceive questions
about religion or spirituality as intrusive or a violation of physician-patient
relationship; however, recent trends in medical education have caused 70% of
medical schools to include course work on spirituality in clinical practice (2).
Physicians are trained to treat patients regardless of the patient’s ethnic or
religious background. The lack of quantitative methodologies to measure
spiritual or religious activity limits the value of correlative studies that compare
health outcomes to “spirituality”. This lack of clinical data reduces certainty
among physicians about any demonstrated beneficial effect from personal faith
as professed by the patient. Some physicians may doubt the existence of a
higher power and some may harbor negative feelings towards religious or
spiritual beliefs, as well as organized worship (3).
2. Defining The Measurement of Spirituality and Religion
Spirituality can be defined based on the HOPE paradigm. The HOPE spiritual
assessment follows the acronym with “H” representing sources of hope or
strength; “O” represents the role of organized religion; “P” represents personal
spirituality and practices; and “E” depicts the effect on medical care and end of
life decisions. Some longitudinal studies with specific diseases, such as HIV
infection suggest that patient survival is related to frequency of prayer and
inversely proportional to the patient’s judgmental attitudes (4). The intensity
and quality of a patient’s spiritual life is difficult to measure (18).
The measurement of religion and spirituality may not provide equal prediction
for outcomes. Several studies indicate that greater spirituality but not greater
religiosity are more likely to predict good health in an older individual (5), (6).
3. The Link Between Spiritual and Physical Vitality in Older Persons
Spirituality appears correlated to health outcomes and quality of life in older
individuals. For hospitalized older individuals, increased spirituality predicts
fewer depressive episodes and better cognitive function (7), (8). Longitudinal
A Primary Care Guide to Addressing Spirituality in Midlife or Older Persons
as a Component to Successful Cognitive Aging
 Richard E. Powers, MD (2006) - Bureau of Geriatric Psychiatry/Dementia Education & Training
Program – 1-800-457-5679
5/24/07
1
studies suggest that increased lifetime organized religious activity may predict
decreased likelihood for prolonged, utilization of long-term care services by the
older patient. Likewise, the magnitude of intrinsic, self-described spirituality
appears correlated to outcomes of health and pain management (9).
Individuals with active, spiritual and religious lives demonstrate a diminished
risk of developing depression in later life, as well as severe functional
impairment produced by the psychiatric disability (10), (11), (19), (20). The
relationship between spirituality, religion, and health outcomes may be related
to stress coping and maintenance of mood. Individuals with active spiritual
lives appear to enjoy diminished levels of stress and less evidence for
depression producing better outcomes for chronic health problems or hospital
care. The role of formalized religious activity is less clear; however, some
studies do support the relationship between organized activity and reduced
long-term medical morbidity (12), (13).
4. Conclusion About the Role of Spiritual Vitality in Maintaining Cognitive
Vitality
Older individuals can become marginalized in spiritual communities. Pastors
may not recognize the positive impact of spiritual activity on the quality of an
elder’s life and longevity. No data exists to compare spiritual activity with risks
for developing cognitive decline.
Spirituality may enhance psychosocial
function (22). Depression, chronic stress, and diminished activity are potential
risk factors for cognitive decline in later life that may be mitigated by active,
personal spirituality (CLICK HERE FOR MORE INFORMATION –
2513.31, 2513.51). A growing body of medical literature defines the role of
spirituality in clinical practice (14), (15), (16). Physicians are encouraged to
promote spiritual and religious activity in those patients who have selected to
achieve these internal goals. Each physician must determine their level of
comfort in discussing this matter with mid-aged and older individuals.
Physicians should avoid proselytizing or attempts at convincing patients who
hold contrary beliefs (13). Older persons often serve as caregivers and
spirituality improves their overall outcome (20) (21).
Recommendations to Primary Care Physicians
1. Recognize that any active spiritual life may promote successful aging.
2. Consider the individual spiritual needs of each patient.
3. Encourage an active spiritual life in appropriate patients.
4. Respect those patients who do not maintain or value an internal spiritual
life.
A Primary Care Guide to Addressing Spirituality in Midlife or Older Persons
as a Component to Successful Cognitive Aging
 Richard E. Powers, MD (2006) - Bureau of Geriatric Psychiatry/Dementia Education & Training
Program – 1-800-457-5679
5/24/07
2
5. Empower patients to expect that their spiritual community will include
them in all aspects of a faith life.
A Primary Care Guide to Addressing Spirituality in Midlife or Older Persons
as a Component to Successful Cognitive Aging
 Richard E. Powers, MD (2006) - Bureau of Geriatric Psychiatry/Dementia Education & Training
Program – 1-800-457-5679
5/24/07
3
References:
1. Post SG, Puchalski CM, Larson DB. Physicians and patient spirituality: professional boundaries,
competency, and ethics. Ann. Intern. Med. 2000;132(7):578-83.
2. Puchalski C. Spiritual assessment in clinical practice. Psych Annals 2006;36(3):150-156.
3. Powell LH, Shahabi L, Thoresen CE. Religion and spirituality. Linkages to physical health. Am.
Psychol 2003;58(1):36-52.
4. Anandarajah G, Hight E. Spirituality and medical practice: using the HOPE questions as a practical
tool for spiritual assessment. Am. Fam. Physician 2001;63(1):81-9.
5. Daaleman TP, Perera S, Studenski SA. Religion, spirituality, and health status in geriatric
outpatients. Ann. Fam. Med. 2004;2(1):49-53.
6. Curlin FA, Roach CJ, Gorawara-Bhat R, et al. How are religion and spirituality related to health? A
study of physicians’ perspectives. South Med. J. 2005;98(8):761-6.
7. Ironson G, Solomon GF, Balbin EG, et al. The Ironson-Woods spirituality/religiousness index is
associated with long survival, health behaviors, less distress, and low cortisol in people with
HIV/AIDS. Ann Behav Med. 2002;24(1):34-48.
8. Koenig HG, George LK, Titus P. Religion, spirituality, and health in medically ill hospitalized older
patients. J. Am. Geriatr Soc. 2004;52(4):554-62.
9. McBride JL, Arthur G, Brooks R, Pilkington L. The relationship between a patient’s spirituality and
health experiences. Fam. Med. 1998;30(2):122-6.
10. Baetz M, Griffin R, Bowen R, et al. The association between spiritual and religious involvement and
depressive symptoms in a Canadian population. J. Nerv. Ment. Dis. 2004;192(12):818-22.
11. Bosworth HB, Park KS, McQuoid DR, et al. The impact of religious practice and religious coping on
geriatric depression. Int J. Geriatr Psychiatry 2003;18(10):905-14.
12. Koenig HG, Pargament KI, Neilsen J. Religious coping and health status in medically ill hospitalized
older adults. J. Nerv. Ment. Dis. 1998;186(9):513-21.
13. Koenig HG, George LK, Titus P, Meador KG. Religion, spirituality, and acute care hospitalization
and long-term care use by older patients. Arch Intern Med. 2004;164(14):1579-85.
14. Yang CP, Lukoff D. Working with spiritual issues. Psychiatric Annals 2006;36:3.
15. Sperry L. Working with spiritual issues of the elderly and their caregivers. Psychiatric Annals
2006;36:3.
16. Cloninger CR. Fostering spirituality and well-being in clinical practice. Psychiatric Annals
2006;36:3.
17. McKee DD, Chappel JN. Spirituality and medical practice. J. Fam. Pract. 1992;35(6):617-8.
18. Nelson-Becker H, Nakashima M, Canda ER. Spiritual assessment in aging: a framework for
clinicians. J Gerontol Soc Work 2007;48(3-4):331-47.
19. Yoon DP, Lee EK. The impact of religiousness, spirituality, and social support on psychological
well-being among older adults in rural areas. J. Gerontol Soc Work 2007;48(3-4):281-98.
20. Hebert RS, Dang Q, Schulz R. Religious beliefs and practices are associated with better mental
health in family caregivers of patients with dementia: findings from the REACH study. Am J Geriatr
Psychiatry 2006 Dec 8.
A Primary Care Guide to Addressing Spirituality in Midlife or Older Persons
as a Component to Successful Cognitive Aging
 Richard E. Powers, MD (2006) - Bureau of Geriatric Psychiatry/Dementia Education & Training
Program – 1-800-457-5679
5/24/07
4
21. Haley WE, Gitlin LN, Wisniewski SR, et al. Well-being, appraisal, and coping in African-American
and Caucasian dementia caregivers: findings from the REACH study. Aging Ment. Health
2004;8(4):316-29.
22. King DE, Cummings D, Whetstone L. Attendance at religious services and subsequent mental health
in midlife women. Int. J. Psychiatry Med 2005;35(3):287-97.
A Primary Care Guide to Addressing Spirituality in Midlife or Older Persons
as a Component to Successful Cognitive Aging
 Richard E. Powers, MD (2006) - Bureau of Geriatric Psychiatry/Dementia Education & Training
Program – 1-800-457-5679
5/24/07
5