ressymkoenig09rev.pdf

Religion,SpiritualityandHealthinOlderAdultsReligion,SpiritualityandHealthinOlderAdults

HaroldG.Koenig,MDHaroldG.Koenig,MD

DepartmentsofPsychiatryandMedicineDepartmentsofPsychiatryandMedicine

DukeUniversityMedicalCenterDukeUniversityMedicalCenter

GRECCVAMedicalCenterGRECCVAMedicalCenter

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

Overview

Definitions

Facingthemostdifficultandthornyissuefirst

Religion

Involvesbeliefs,practices,andritualsrelatedtothetranscendent,wherethetranscendent isthatwhichrelatestothemystical,supernatural,orGodinWesternreligioustraditions,ortoDivinities,ultimatetruth/reality,orenlightenmentinEasterntraditions.Religionmayalsoinvolvebeliefsaboutspirits,angels,ordemons.Religionsusuallyhavespecificbeliefsaboutthelifeafterdeathandrulesaboutconductthatguidebehaviorswithinasocialgroup.Religionisoftenorganizedandpracticedwithinacommunity,butitcanalsobepracticedaloneandinprivate,outsideofaninstitution.Centraltoitsdefinition,however,isthatreligionisrootedinanestablishedtraditionthatarisesoutofagroupofpeoplewithcommonbeliefsandpracticesconcerningthetranscendent.Religionisauniqueconstruct,whosedefinitionisgenerallyagreedupon.Itcanbemeasuredandexaminedinrelationshiptomentalandphysicalhealthoutcomes.

Spirituality

Spiritualityisaconceptwhichtodayisviewedasbroaderandmoreinclusivethanreligion.Itisatermmorepopulartoday,muchmoresothanreligion.Spiritualityismoredifficulttodefinethanreligion.Itisconsideredpersonal,somethingindividualsdefineforthemselvesthatmaybefreeoftherules,regulations,andresponsibilitiesassociatedwithreligion.

Thetermspiritualityismostusefulinclinicalsettings,sincethegoalistobewelcomingandinclusive,andforpatientstodefinethetermforthemselvessothatconversationmaybegin.Butbecauseofitsvagueandnebulousnature,itisdifficulttomeasureandquantifyforresearchpurposesespeciallysincethedefinitionofspiritualityhasbeenchangingandexpanding.

Spirituality

Religion

TraditionalHistoricalUnderstanding

Source

Secular

MentalHealth PhysicalHealth

Meaning

Purpose

Connectedness

Peace

Hope

Depression

Anxiety

Addiction

Suicide

CardiovascularDisease

Cancer

Mortality

Psych

oneu

roim

mun

olog

y

vs.Ex.wellbeing

Spirituality

Religion

ModernUnderstanding

Source

Secular


Meaning

Purpose

Connectedness

Peace

Hope

Depression

Anxiety

Addiction

Suicide


Cancer

Mortality

Psych

oneu

roim

mun

olog

y

vs.Ex.wellbeing

Spirituality

Religion

ModernUnderstandingTautologicalVersion

Source

Secular


Meaning

Purpose

Connectedness

Peace

Hope

Depression

Anxiety

Addiction

Suicide


Cancer

Mortality

Psych

oneu

roim

mun

olog

y

vs.

Ex.wellbeing

Spirituality

Religion

ModernUnderstandingClinicalApplicationonly

Source

Secular


Meaning

Purpose

Connectedness

Peace

Hope

Depression

Anxiety

Addiction

Suicide


Cancer

Mortality

Psych

oneu

roim

mun

olog

y

Ex.wellbeing

NotaResearchableModel

Inthistalk,tokeepthingssimpleandclear,Iwillbeaddressingrelationshipswithhealthintermsofreligion.

First,letusexaminehowreligionmightinfluencehealth.Thisisatheoreticalmodelinvolvingcausalpathwaysandintermediaryvariables.TheexampletobeprovidedisbasedintheJudeoChristianIslamictradition,whichviewsGodasseparatefromhumansandcreation,andaspersonal.

ModelslikethisexistforforEasternreligioustraditionsaswell,butmylackofexpertiseinthosetraditionsmakeiteasierformetoillustrateeffectsusingaWesternreligiousmodel.

Godbelief,relation,attachment

Publicprac,rit

Privateprac,rit

Rcommit

Rcoping

Forgiveness

Altruism

Gratefulness

PositiveEmotions*

NegativeEmotions*

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

Socialsup&connections

PhysicalH

ealthandLongevity

Immun

e,End

ocrin

e,Cardiov

ascu

larFun

ctions

Pathway/OrderofEffects

Genetics,Personality,DevelopmentalExperiences

HealthBehaviors,LifestyleChoices,Decisions

SOURCE

Rexp

Let us now examine the circumstances we are facing and the role that religion may play in them, especially for older adults

Increasedstressduetorecenteconomicdownturn

Increaseddepressionduetolosses(jobs,homes)

Increasingdebt,decreasingsavings

Youthfacingmanychoices,withfewerabsolutestoguide

Populationaging,facingincreasinghealthproblems

Fewsavingforretirement(fear)

Stress & Depression Common, Increasing

Myocardialinfarction

Hypertension

Stroke

Susceptibilitytoinfection

Slowwoundhealing

Increaseagingprocess

Increaselengthofhospitalstay,needformedicalservices

Stress & Depression Affect Physical Health, Need for Health Services

93%ofAmericansbelieveinGodorahigherpower

89%reportaffiliationwithareligiousorganization

83%sayreligionisfairlyorveryimportant

62%aremembersofachurch,synagogueormosque

58%prayeveryday(75%atleastweekly)

42%attendreligiousservicesweeklyoralmostweekly

55%attendreligiousservicesatleastmonthly

Religion in widespread in the United States

BeliefinGod Membership Importance Attendance30

40

50

60

70

80

90

100

Percent 1317

1829

30495064

6574

75+

Religiousinvolvementacrossthelifespan(NationalStudyofYouthandReligion20022003GallupPollsoftheUnitedStates20012002)

90%turnedtoreligiontocopewithSeptember11th(NEJM)

90%ofhospitalizedpatientsrelyonreligiontocope

>40%sayitsmostimportantfactorthatkeepsthemgoing

Hundredsofquantitativeandqualitativestudiesreportsimilarfindingsinpersonswithhealthproblems,especiallyinminorities,women,thepoor

Researchontheeffectsofreligiononcopingandhealthisgrowingrapidlyworldwide

Many in U.S. Turn to Religion to Cope with Stress and Illness

1965 1970 1975 1980 1985 1990 1995 2000 2005 2008

Year

0

10

20

30

40

50

60

Thou

sandsofArticles PsychInfo

Medline

Religion/SpiritualityHealthArticles19602008Cumulative

Searchwords:religionorreligiousnessorreligiousorreligiosityorspirituality(2/20/09)

196569 197074 197579 198084 198589 199094 199599 20004 20059

Year

0

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Thou

sandsofArticles

PsychInfo

Medline

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

196569 197074 197579 198084 198589 199094 199599 20004 20059

Year

0

2

4

6

8

10

12

14

Thou

sandsofArticles

PsychInfo

Medline

Religion/SpiritualityHealthArticlesper5YearPeriod(NonCumulative)

Searchwords:religionorreligiousorreligiosityorreligiousnessorspirituality(2/20/09)Searchwords:psychotherapyorpsychoanalysis(forcomparison)

Medline

Religionisrelatedto:

Lowerperceptionsofstress

Lessdepression,fasterrecoveryfromdepression(204of324studiesshowdepressionlessamongreligious)

Greaterwellbeing,happiness,meaning,purpose,hope(278of359studiesshowpositiveemotionshigherinreligious)

Increasedqualityoflife(20of29recentstudiesshowQOLhigheramongreligious)

Religious involvement can buffer stress, reduce depression, enhance quality of life


Lessalcohol/druguse,especiallyamongtheyoung,althoughtrueforallagesgroups(276of324studiesshowsignificantlylowerrates)

Alcohol/drug abuse lower in the religious


Lesscigarettesmoking,especiallyamongtheyoung(102of117studiesshowsignificantlylowerrates)

Moreexercise(4of6studiesshowsignificantlymorelikelytoexercise)

Dietandweight(1of8studiesshowreligiouspersonsweighless)

Lessextramaritalsex,safersexualpractices(fewerpartners)(45of46studiesshowsignificantrelationships)

Religious live healthier lifestyles, have better habits, fewer risky behaviors

Maritalstabilitygreaterlessdivorce,greatersatisfaction(36of39studiespriortoyear2000)

Socialsupportgreater(19of20studiespriortoyear2000)

Thus: Shorterhospitalstays,fewerhospitaldaysperyear

Lesstimespentinnursinghomeafterhospitaldischarge(particularlyforwomenandAfricanAmericans)

Religious persons need and use fewer health care services due to better health and more support from family, community

Religion

MentalHealth

SocialSupport

HealthBehaviors

StressHormones

ImmuneSystem

AutonomicNervousSystem

DiseaseDetection&TreatmentCompliance

SmokingHighRiskBehaviorsAlcohol&DrugUse

Infection

Cancer

HeartDisease

Hypertension

Stomach&BowelDis.

Accidents&STDs*

Geneticsusceptibility,G

ender,Age,R

ace,Edu

cation

,Income

Liver&LungDisease

Stroke

Childho

odTraining

Adu

ltDecisions

Valuesan

dCha

racter

Adu

ltDecisions

*SexuallyTransmittedDiseases

ModelofReligion'sEffectsonHealthHandbookofReligionandHealth(OxfordUniversityPress,2001)

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

Religion related to better physical health, recovery from illness

RecentStudies

ReligiousattendanceassociatedwithslowerprogressionofcognitiveimpairmentwithaginginolderMexicanAmericansHilletal.JournalofGerontology200661B:P3P9ReyesOrtizetal.JournalofGerontology200863:480486

ReligiousbehaviorsassociatedwithslowerprogressionofAlzheimersdis.Kaufmanetal. Neurology200768:15091514

[fordepressioncognitionrelationshipseeArchGenPsychiatry2006AGP63:530538200865(5):542550AGP200865(10):11561165)]

FewersurgicalcomplicationsfollowingcardiacsurgeryContradaetal.HealthPsychology200423:22738

GreaterlongevityifliveinareligiouslyaffiliatedneighborhoodJaffeetal.AnnalsofEpidemiology200515(10):804810

Religiousattendanceassociatedwith>90%reductioninmeningococcaldiseaseinteenagers,equaltoorgreaterthanmeningococcalvaccinationTullyetal. BritishMedicalJournal2006332(7539):445450

RecentStudiesPhysicalHealthOutcomes

HIVpatientswhoshowincreasesinspirituality/religionafterdiagnosisexperiencehigherCD4counts/lowerviralloadandslowerdiseaseprogressionduring4yearfollowupIronsonetal.JournalofGeneralInternalMedicine200621:S6268

Religionandsurvivalinasecularregion.Atwentyyearfollowupof734Danishadultsbornin1914.laCourP,etal.SocialScience&Medicine200662:157164

Nearly2,000Jewsoverage70livinginIsraelfollowedfor7years.Thosewhoattendedsynagogueregularlyweremorelikelythannonattendeestobealive7yearslater(61%morelikelytobealivevs.41%morelikelytobealiveforinfrequentattendees.Gradientofeffect.EuropeanJournalofAgeing20074:7182

Experimentalstudyshowsthatlesspainisexperiencedwhensubjectsviewreligiousvs.secularpaintingsfunctionalMRIscansdocumentsthatpaincircuitsinbrainarereduced(JournalofPain2008,forthcoming)

Over70recentstudieswithpositivefindingssince2004http\\:www.dukespiritualityandhealth.org

ApplicationstoClinicalPractice

SpiritualityinPatientCare,SecondEditionTempletonFoundationPress,2007

ReviewedinJAMA2008299:16081609

Why Address Spirituality in Clinical Practice Why Address Spirituality in Clinical Practice

1.1. Notdependentonresearchaloneevenwithoutresearch,Notdependentonresearchaloneevenwithoutresearch,integratingspiritualityintopatientcarehasvalueintegratingspiritualityintopatientcarehasvalue

2.2.Manypatientsarereligious,wouldlikeitaddressedinhealthcManypatientsarereligious,wouldlikeitaddressedinhealthcareare

3.3.ManypatientshavespiritualneedsrelatedtoillnessthatcouldManypatientshavespiritualneedsrelatedtoillnessthatcouldaffectmentalhealth,butgounmetmentalhealthaffectsphysicaffectmentalhealth,butgounmetmentalhealthaffectsphysicalal

4.4. Patients,particularlywhenhospitalized,areoftenisolatedfroPatients,particularlywhenhospitalized,areoftenisolatedfrommreligiouscommunities(requiringotherstomeetspiritualneeds)religiouscommunities(requiringotherstomeetspiritualneeds)

5.5. Religiousbeliefsaffectmedicaldecisions,mayconflictwithReligiousbeliefsaffectmedicaldecisions,mayconflictwithtreatmentstreatments

6.6. ReligioninfluencessupportandcareinthecommunityReligioninfluencessupportandcareinthecommunity

Take a Spiritual History Take a Spiritual History

1.1. TheThescreeningscreeningspiritualhistoryisbrief(2spiritualhistoryisbrief(24minutes),andisnotthesame4minutes),andisnotthesameasaspiritualasaspiritualassessmentassessment(chaplain)(chaplain)

2.2. ThepurposeoftheSHistoobtaininformationaboutreligiousThepurposeoftheSHistoobtaininformationaboutreligiousbackground,beliefs,andritualsthatarerelevanttohealthcarbackground,beliefs,andritualsthatarerelevanttohealthcaree

3.3. IfpatientsindicatefromthestartthattheyarenotreligiousIfpatientsindicatefromthestartthattheyarenotreligiousorspiritual,orspiritual,thenquestionsshouldberethenquestionsshouldberedirectedtoaskingaboutwhatgiveslifedirectedtoaskingaboutwhatgiveslifemeaning&purposeandhowthiscanbeaddressedintheirhealthmeaning&purposeandhowthiscanbeaddressedintheirhealthcarecare

PhysicianShouldTakePhysicianShouldTakeTheSpiritualHistoryTheSpiritualHistory

1.1. PhysiciandirectsthecareofthepatientPhysiciandirectsthecareofthepatient

2.2. PatientneedstofeelcomfortabletalkingwithphysicianaboutsPatientneedstofeelcomfortabletalkingwithphysicianaboutspiritualpiritualissuesissues

3.3. PatientsPatientsmedicaldecisionsareinfluencedbytheirreligiousbeliefsmedicaldecisionsareinfluencedbytheirreligiousbeliefs

4.4. PatientsPatientscompliancewithtreatmentsareinfluencebyreligiousbeliefscompliancewithtreatmentsareinfluencebyreligiousbeliefs

5.5. TakingspiritualhistoryenhancesdoctorTakingspiritualhistoryenhancesdoctorpatientrelationship&mayitselfpatientrelationship&mayitselfaffecthealthoutcomesaffecthealthoutcomes

6.6. SpiritualstrugglescanadverselyaffecthealthoutcomesSpiritualstrugglescanadverselyaffecthealthoutcomes

Religious Struggle Religious Struggle 444 hospitalized medical patients followed for 2 years 444 hospitalized medical patients followed for 2 years

n n Wondered whether God had abandoned me Wondered whether God had abandoned me

n n Felt punished by God for my lack of devotion Felt punished by God for my lack of devotion

n n Wondered what I did for God to punish me Wondered what I did for God to punish me

n n Questioned the God Questioned the God s love for me s love for me

n n Wondered whether my church had abandoned me Wondered whether my church had abandoned me

n n Decided the Devil made this happen Decided the Devil made this happen

n n Questioned the power of God Questioned the power of God

Eachof7itemsbelowratedona0to3scale,basedonagreement.Forevery1pointincreaseonreligiousstrugglescale(range021),therewasa6%increaseinmortality,independentofphysicalandmentalhealth(ArchInternMed,2001161:18811885)

Contents of the Spiritual History Contents of the Spiritual History

1.1. WhatispatientWhatispatientsreligiousorspiritual(R/S)background(ifany)sreligiousorspiritual(R/S)background(ifany)

2.2. R/Sbeliefsusedtocopewithillness,oralternatively,thatmaR/Sbeliefsusedtocopewithillness,oralternatively,thatmaybeaybeasourceofstressordistresssourceofstressordistress

3.3. R/Sbeliefsthatmightconflictwithmedical(orpsychiatric)caR/Sbeliefsthatmightconflictwithmedical(orpsychiatric)careormightreormightinfluencemedicaldecisionsinfluencemedicaldecisions

4.4. InvolvementinaR/ScommunityandwhetherthatcommunityisInvolvementinaR/Scommunityandwhetherthatcommunityissupportivesupportive

5.5. SpiritualneedsthatmaybepresentandneedtobeaddressedforSpiritualneedsthatmaybepresentandneedtobeaddressedforhealthhealthreasonsreasons

See JAMA 2002 288 (4):487-493

Besides Taking a Spiritual History Besides Taking a Spiritual History

1.1. Supportthereligious/spiritualbeliefsSupportthereligious/spiritualbeliefsofthepatientofthepatient(verbally,non(verbally,nonverbally)verbally)

2.2. EnsurepatienthasresourcestosupporttheirspiritualityEnsurepatienthasresourcestosupporttheirspiritualityreferpatientsreferpatientswithspiritualneedstoCHAPLAINSwithspiritualneedstoCHAPLAINS

3.3. AccommodateenvironmenttomeetspiritualneedsofpatientAccommodateenvironmenttomeetspiritualneedsofpatient

4.4. BewillingtocommunicatewithpatientsaboutspiritualissuesBewillingtocommunicatewithpatientsaboutspiritualissues

5.5. Praywithpatientsifrequested(?)Praywithpatientsifrequested(?)

6.6. Prescribereligiontoimprovehealth(?)Prescribereligiontoimprovehealth(?)

Limitations and Boundaries Limitations and Boundaries

1. Donotprescribereligiontononreligiouspatients

2. Donotforceaspiritualhistoryifpatientnotreligious

3. Donotcoercepatientsinanywaytobelieveorpractice

4. Donotpraywithapatientbeforetakingaspiritualhistoryandunlessthepatientasks

5. Donotspirituallycounselpatients(alwaysrefertotrainedprofessionalchaplainsorpastoralcounselors)

6. Donotdoanyactivitythatisnotpatientcenteredandpatientdirected

Community Applications Community Applications

MiddleSeriesEstimates

ProjectedgrowthoftheU.S.elderlypopulation{>65)

HighSeriesEstimates

X

2000USCensus

ProjectedgrowthoftheelderlyU.S.populationandMedicarespending.MedicaredatafromOfficeoftheActuary&BureauofDataManagement&Strategy,CenterforMedicareandMedicaidServices(CMS),U.S.DepartmentofHealthandHumanServices (March/April2002).

Billions$perYear M

illionsofPeople

MedicareSpending

OlderPopulation

(MiddleSeries)

2001NationalHealthExpenditures=$1.4trillion2011NationalHealthExpenditures=$2.8trillion

TheDilemma:SpendingonFutureHealthCareintheUSAPublicPolicyandAgingReport200232:1319

What do these aging and economic What do these aging and economic trends mean? trends mean?

1. Needofhealthservicesoutstrippingabilitytopayforhealthservices

2. Olderadultsfallingthroughthecracksintermsofmedicalservicesandlongtermcare

3. Olderadultswithoutfamilymemberstocareforthemlivingouttheirlatterdaysoncitystreetsandparks

4. Needtoidentifycommunityresourcestohelpalleviatetheburdenofcareoffthehealthcaresystemandoffofyoungfamilies

PreventionandManagementofDisease

Congregation HealthcareSystem

ParishNurseor

LayLeader

Clergy

PhysicianAdvisor

AcuteCareHospital

Primary,Secondary,andTertiary

Volunteers

OutpatientClinics/Offices

Individu

alm

embe

rs

Layministers

Smallg

roup

lead

ers

LargerCommunity

NursingHomes

ChaplainsSocialworkers

NursesMDs

RunhealthprogramstakeBP's,bloodsugarsCoordinateservicesrespite,homemaker

ProvideservicesPatientadvocateSupporting,calling,visiting

Mob

ilizing

,training

Com

mun

icating

Provideseducation/trainingProvidesspeakersProvides$$support

GovernmentIncentives

motivating

PublicPolicy&AgingReport200212(4):16

Medicine,ReligionandHealth(2008,TempletonPress)

HandbookofReligionandHealth(2001,OxfordUniversityPress)

TheLinkBetweenReligionandHealth(2002,OxfordPress)

FaithintheFuture:Healthcare,Aging,andtheRoleofReligion(2004,TempletonPress)

AgingandGod(1994,HaworthPress)

Religion,HealthandAging(1988,GreenwoodPress)

FurtherInformationWebsite:DukeCenterforSpirituality,TheologyandHealth

Further Reading

SummerResearchWorkshopJulyandAugust2009Durham,NorthCarolina

5dayintensiveresearchworkshopsfocusonwhatweknowabouttherelationshipbetweenreligionandhealth,applications,howtoconductresearchanddevelopanacademiccareerinthisarea(July2024,Aug1721,2009)LeadingreligionhealthresearchersatDuke,UNC,USC,andelsewherewillgivepresentations:

Previousresearchonreligion,spiritualityandhealthStrengthsandweaknessesofpreviousresearchApplyingfindingstoclinicalpracticeTheologicalconsiderationsandconcernsHighestprioritystudiesforfutureresearchStrengthsandweaknessesofreligion/spiritualitymeasuresDesigningdifferenttypesofresearchprojectsCarryingoutandmanagingaresearchprojectWritingagranttoNIHorprivatefoundationsWheretoobtainfundingforresearchinthisareaWritingaresearchpaperforpublicationgettingitpublishedPresentingresearchtoprofessionalandpublicaudiencesworkingwiththemedia

Ifinterested,contactHaroldG.Koenig: [email protected]

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