1. Spirituality and Aging
Andrea Sherman, Ph.D., President, Transitional Keys
Endorsed by The George Washington Institute for Spirituality and Health (GWish). 

2. Learner Objectives
Discuss the vital role of spirituality in older adults, and in patient/caregiver relationships.
Distinguish between spirituality and religion and the impact of culture.
Discuss the relationship of spirituality and chronic disease.
Identify several methods for taking a spiritual history and know when it is appropriate to make such an assessment.

3. Learner Objectives (contd.)
Describe when it is helpful to connect to pastoral care, chaplains, and other spiritual advisors in different settings of care.
Identify and discuss interventions of spiritual care including the arts, story/reminiscence, and other therapies and modalities.
Understand the importance of self-care as a spiritual practice and list techniques that are useful.

4. Hope is an important element of spirituality.
Spirituality has many meanings.
Root-words (Hebrew, Latin and Greek): wind, breath, or air which gives life.
Other word associations: Inspiration, meaning, beliefs and values, nature, connection, transcendent, purpose, journey, pilgrimage.
Hope is an important element of spirituality.

5. Spirituality
“Spirituality is that which allows a person to experience transcendent meaning in life…whatever beliefs and values give a person a sense of meaning and purpose in life.”
(Pulchalski, 2000)
Pulchalski, C. (2000). Taking a Spiritual History Allows Clinicians to Understand Patients More Fully. Journal of Palliative Medicine 3 (1)

6. Spirituality: Relationship to Person/Patient-Centered Care
Need to understand the person who has the disease and not merely the disease that the person has.
Spirituality is integral to the care of the whole person. It is grounded in person/patient-centered care.
Interdisciplinary team approach.
Grounded in the biopsychosocial model of care.

7. Religion
Root-word: Latin, to tie/secure/bind/fasten together to create system of attitudes and beliefs.
Participation in an “organized” religion may involve:
Practices
Adherence to certain beliefs
Participation in a religious community

8. Religion
Most of the research on spirituality and aging has been from a religion-oriented concept. Koenig, McCullough, and Larsen have extensively reviewed 1200 scientific papers and 400 review articles examining the relationship between religion and health outcomes such as depression, suicide, anxiety as well as heart disease, hypertension, cardiovascular disease and the brain, immune system dysfunction, cancer, mortality, pain and other somatic symptoms.
Koening, McCullough, & Larson (2001). Handbook of Religion & Health, NY: Oxford University Press.

9. Spirituality Religion Individual Non-institutional/not organized
Spirituality and Religion Relationship May Change Over the Life-Span
Spirituality
Religion
Individual
Non-institutional/not organized
Where do I find meaning?
Texts have personal meaning
Organizational
Institutional/organized
What is true and right?
Religious text of tradition

10. Spirituality, Religion, and Culture
Culture frames both spirituality and religion, spirituality frames culture and religion, religion frames culture and spirituality.
All three impact one another.

11. Gerotranscendence
Considered the 9th stage of lifecycle development (Erik Erikson developed 8 stages of lifecycle).
Asserts that spiritual development gradually and steadily increases from middle age onward.
3 Dimensions: cosmic (life, death) self-transcendent (personal self no longer center of attention), and social selectivity (focus on close friends and family) elements.
Gerotranscendence was developed by Lars Tornstam -- Gerotranscendence: A developmental theory of positive aging. New York: Springer, 2005.
Erikson, E. , Erikson J, & Kivnik, H. (1994). Vital Involvement in Old Age, W. W. Norton.

12. Teaching Strategies for Students
Make a list of the words that you associate with spirituality, with religion. Compare and discuss. How do you think they relate to each other? What is the difference?
Interview with a partner to learn how your spirituality has changed/grown over time.
Discuss your reactions to the term Spirituality and Healthcare (as a combined term).
Discuss: Have you had experiences where spirituality played a role in your healing, or a patient’s healing? (make sure to define spirituality).

13. Spirituality and Suffering
Suffering: “the state of severe distress associated with events that threaten the intactness of person.”
“We need to learn to stay with suffering without trying to change it or fix it. Only when we are able to be present for our own suffering are we able to be present for the suffering of others.”
(Cassel, 1991)
Cassel, E. (1991). The nature of suffering and the goals of medicine. New York: Oxford University, p. 33).
Halifax, J. (2008). Halifax, Being with Dying, Shambhala, Boston, p. 157.
(Halifax, 2008)
The presence of pain compounds suffering and can result in spiritual distress.

14. Prayer
The MANTRA project, clinical trial of cardiac patients at Duke University demonstrates the positive impact of prayer (prayed for by a religious group or receiving special bedside spiritual therapies, or both interventions) on patient outcomes, such as fewer complications, less medication needed and quicker return to health.
Krucoff, M.W. (1999). The MANTRA Study Project, Alternative Therapies in Health & Medicine, 5(3)
(Krucoff, 1999)

15. Chronic Disease and Quality of Life
In a study examining the role of spirituality in the self-management of chronic illness among older Africans and whites, African American elders were more likely than White elders to endorse a belief in divine intervention. White elders were more likely than African American elders to merge their spirituality (self-efficacy) in various self-management practices. For both chronically ill groups, spirituality played an integral part in their health and well-being. .
Level V:, Harvey, I. S., & Silverman, M. (2007) The Role of Spirituality in the Self-Management of Chronic Illness among Older African and Whites. Journal of Cross- Cultural Gerontology, 22(2)
(Harvey & Silverman, 2007)

16. Levin’s Research Spans Two Decades
Levin’s research suggests that being involved in religious organization, with practices is correlated with improved health outcomes.
For each of the 3 leading causes of death in the US : heart disease, cancer, and hypertension people with religious beliefs have lower rates of illness.
Levin’s Research (each of the following offer specific health benefits):
Religious affiliation
Regular religious fellowship
Religious beliefs
Simple faith
Mystical Experiences
Absent prayer for others (separated from person praying for).
Levin, J., God, Faith & Health: Exploring the Spirituality- Healing Connection, NY: John Wiley and Son 2001.
Older adults who participate in private & congregational religious activities have fewer symptoms, less disability lower rates of depression, chronic anxiety & dementia.
(Levin, 2001)

17. Spirituality, Depression and Acute Heart Failure
In an exploratory study of older persons hospitalized with acute heart failure, where depressive symptoms are often exhibited, there was a significant negative correlation between spiritual well-being and depression: those who had more depressive symptoms had a lower level of spiritual well- being.
Whelen-Gales, Griffin, M.T. Q, Maloni, J., Fitzpatrick J.J. (2009), Geriatric Nursing, 30(5).
(Whelen-Gales, et al., 2009)

18. Dementia and Spirituality
In a study on Cognitive Decline in Alzheimer’s Disease: Impact of Spirituality, Religiosity and Quality of Life, 70 patients with AD were given the MMS to monitor rate of cognitive decline. Religiosity and spirituality were measured. A slower rate of cognitive decline was associated with higher levels of spirituality and private religious practices. The study concluded that higher levels of spirituality and private religious practices, but not quality of life, are associated with slower progression of Alzheimer’s Disease.
Level IV: Kaufman, Y., Anaki,D., Binns, M., & Freedman M.(2007) Cognitive decline in Alzheimer disease: Impact of Spirituality, religiosity, and QOL. Neurology, 68 (18) ).
(Kaufman, et al., 2007)

19. Dementia and Spirituality
“A diagnosis of Alzheimer’s disease calls for even greater attention to be paid to spiritual well-being.”
(Stuckey)
Jon Stuckey, “The Divine is Not Absent in Alzheimer’s Disease”, Aging, Spirituality and Religion, (Second Edition) Kemble, M., McFadden S., (Eds.) Minnesota. Fortress Press, p

20. End-of-Life
This study examined resiliency factors and processes of older adults who experienced positive dying. Based on interviews with hospice patients and their caregivers, core resiliency factors identified: empowering relationships with others, spiritual beliefs and practices, ability to skillfully confront mortality, and a stable caregiving environment. Personal growth, spiritual well-being were interrelated in the dying older adult’s experience of life fulfillment.
Level V: Nakashima, M., & Canda, E.R., (2005) Positive Dying and resiliency in later life: A qualitative study. Journal of Aging Studies, 19(1),
(Nakashima & Canda, 2005)

21. Improving Care for the End-of-Life
Patient and Family Needs:
Being held and comforted by loved ones.
Being Listened to: sharing hopes, dreams, fears and anxiety.
Having the opportunity to pray, meditate, participate in sacred rituals, listen to music.
Receiving blessings form family, friends, clergy.
Seeking Forgiveness form God, family and loved ones.
Being at peace with themselves and others.
Lynn, J., Shuster, J., Kabcenell, A., Improving Care at the End –of- Life: A Sourcebook for Health Care Managers and Clinicians, Oxford University Press, 2000.

22. Teaching Strategies Case studies: Discuss in small groups:
Case study: what would you do if you were asked to pray with a patient? Or to pray for them?
Can you picture yourself helping someone who is dying? How? What do you have to offer that is unique?
What do you fear about death?
What do you think about the statement positive dying?

23. Teaching Strategies Comment and discuss the following:
“Of what use will I be to anyone even to God? (person newly diagnosed with Alzheimer’s Disease).
“I no longer visit my father--it is a waste of time. He doesn’t remember me.”
“Why should I give communion to demented elder? They don’t understand.”
Thibault, J. M Spiritual Counseling of Persons with Dementia, in Aging Spirituality, and Religion (2nd Edition)  Kemble, M., McFadden S., (Eds.). Minnesota: Fortress Press,  
(Thibault, 2003)

24. Taking Spiritual History and Assessment
The models guide the nurse in domains of questions that need to be addressed.
Available tools:
FICA
Three Questions (social, emotional)
HOPE
SPIRIT

25. FICA© Developed by Christina Puchalski, MD
FAITH: Do you have a spiritual belief that helps you cope with stress? With Illness? I
IMPORTANCE: What importance does your faith or belief have in your life? Does It influence how you think about your health & illness and healthcare decisions? C
COMMUNITY: Do you belong to a spiritual community? Do you need to search for another community, would it help you if you found one? A
ADDRESS IN CARE: How do your religious and spiritual beliefs apply to your health? How might we address your spiritual needs in your healthcare.
Puchalski, C. (2006). Spiritual assessment in clinical practice. Psychiatric Annals, 36(3), 150.
Puchalski, C., & Romer, A. L. (2000). Taking a spiritual history allows clinicians to understand patients more fully. Journal of Palliative Medicine, 3(1),

26. Three Questions Model Developed by C. Kinney, PhD, RN
What helps you get through the tough time?
Who do you turn to when you need support?
What meaning does this experience have for you?
Developed by C. Kinney, PhD., RN, Retired UTMB Nursing Faculty, Sierpina, V.S., Boisaubin, E. Complementary Health Practice Review, Vol. 6, No. 2, (2001)

27. HOPE Model Developed by Anadarajah & Hight
Sources of hope, meaning, comfort, strength, peace, O
Organized Religion P
Personal Spirituality E
Effects on medical care and end-of-life issues
Anandarajah, G. & Hight, E Spirituality and Medical Practice: Using the HOPE Questions as a Practical Tool for Spiritual Assessment.
American Family Physician, 63(1):
Printed with permission.

28. Other Sources of Spiritual Assessment
Another model is the Spiritual History Model, developed by Maugans: Maugans, T.A. 1996, The SPIRITual History. Archives of Family Medicine, 5,
(Maugans, T. A. 1996)

29. Teaching Strategies Regarding Assessments
Have students conduct spiritual assessments on each other, discuss with their partner, then in large group.
Students discuss when they might use these assessments.
Based on a particular spiritual assessment of a patient, develop a spiritual plan of care.
Compare and contrast each model. Which one was easier to use?
What is missing from the query/model, i.e. culture, Botanica uses

30. Settings of Care: Spiritual Advisors
Know who is available for spiritual support in all care settings -- from the home to the nursing home. Chaplains, clergy, pastoral care, or other spiritual leaders.

31. Healthcare Chaplains
Chaplains: generic term that refers to any clergy or qualified layperson who assists patients, families and staff in addressing spiritual/religious needs.
Exist in hospitals, prisons, military, mental health institutes.
May come from any religious tradition, they may be certified.

32. When to Refer to Chaplains
Grief
Major Change
Desire for Comfort
Decision-Making
Stress & Distress
Isolation
Difficult Ethical Issues
Desire for Rituals
Desire for “Sacred”
Adapted from Spirituality in Healthcare Curriculum, Center for Spirituality and Healing, University of Minnesota, 2003.
(adapted from Center for Spirituality and Healing, 2003)

33. Community Clergy/Community Support
Can be vital resource for home settings.
Often have the big picture of the older adult and their practical situation.
Support groups may offer support -i.e. breast cancer, grief, Alcoholics Anonymous.
May not have a degree.
May have congregational health ministry, faith community nurse, and parish nurse activities.

34. Teaching Strategies
Discuss the role of clergy as members of an interdisciplinary team.
Case study of community dwelling older adult and referral to spiritual advisor.
Case study of transitioning older adult to another setting and providing continuity of spiritual care.
Discuss clergy as surrogate decision maker.

35. Interventions of Spiritual Care: Overlap with Cultural/Psychosocial Care
Creative/expressive arts
Story/Spiritual Reminiscence
Music
Presence/listening/empathy
Humor

36. Creative/Expressive Arts
Mastery and Control and Social Engagement through engaging arts programs yields better health outcomes.
(Cohen et al., 1994)
The New research on Creativity and Aging demonstrates, “The very act of engaging one’s mind in creative ways affects health directly via the many mind/body connections.” - Dr. Gene Cohen
“Art is like chocolate to the brain.” - Dr. Gene Cohen
Cohen, G., Perlstein, S, Chapline, J., Kelly, J., Firth, K, (2005).The Impact of Professionally Conducted Programs on the Physical Health, Mental Health, and Social Functioning of Older Adults. The Gerontologist 46(6)

37. Creative/Expressive Arts
Art forms:
Dance/Movement
Music
Visual arts
Theatre
Poetry
Writing
Visual Art is viewed as an integral component of spiritual care.
Art heals dis-ease through expression, integration, imagery, symbols and imagination.

38. Music
Studies have shown that a person’s favorite music can be a powerful distraction from pain.
Music can be a bridge to connecting and to companioning.
Assess for older adult’s musical preferences, mood, identification of music that produces happiness, sadness, relaxation, and the importance of music in their life.

39. Story
“The stories people tell have a way of taking care of them. If stories come to you, care for them. And learn to give them away when they are needed. Sometimes a person needs a story more than food to stay alive.”
Jean Shinoda Bolen, Crossing to Avalon, Harper Collins, 1994.
(Bolen, 1994)

40. Spiritual Reminiscence
Focuses on gathering meaning through life story which becomes more significant with frailty, dementia, and disability.
Considers past experiences and stories about: connectedness, faith context, joy, sadness.
Reframes present events through reminiscence, allowing possibility for transcendence and finding hope amidst vulnerability.
MacKinlay, E.B., Trevitt, C. “Spiritual Care and Ageing in a Secular Society.” Medical Journal of Australia, Volume 186, Number 10, May 2007
(MacKinlay & Trevitt, 2007)

41. Compassionate Presence
Deep and attentive listening connects you to the person you are caring for.
“Bearing Witness” to whatever arises.
“Being there” …being fully present in the moment and acknowledging deep belief systems and life world of self and other.
The word compassion means “to suffer with.”
Developed by Jean Watson, Nursing Human Science & Human Care, A Theory of Nursing, Jones & Barlett, MA,
(Watson, 1999)

42. Humor
Humor:
Can be a source of spiritual uplifting and a coping mechanism during difficult times.
Is viewed as transcendent.
Connects and bonds people together-connectedness is a component of spiritual well-being.
Releases endorphins and increases body’s ability to heal and to tolerate pain.
Can reveal the truth about ourselves, melt barriers, and release stress.
Cultural Sensitivity
is an important
consideration
Bennett, M. & Lengacher, C., Humor & Laughter May Influence Health, Evidence-Based Complementary and Alternative Medicine, V. 3 (2) June 2006.

43. Teaching Strategies
Take a moment and think what music, poetry, dance have had an important spiritual meaning for you. Write them down and share.
Ask: What does art mean to you?
Discuss: if you had to bring a patient with dementia to a “place of art” which place/modality would you choose and why. Relate it to spirituality.

44. Self-Care as Spiritual Practice
The ANA Code of Ethics requires self-care.
Know what renews and restores your spirit.
Care for your body, mind and spirit.
Create your home as a place to restore you.
Create an “inner home” that you can go to throughout the day.
Practice resilience throughout the day.

45. Integrating Self-Care Into Your Day
How do you enter the room of your patient? Can you take a moment for yourself beforehand?
How/where do you eat your lunch?
How do you leave the room of your patient?

46. Rituals of Self-Care
Journaling
Meditation
Movement
Music
Nature

47. Journal Topics Journal Topics: Write in the morning or before bedtime.
Write on your birthday.
Add doodles to your journal.
Write a poem, a song.
Write for ten minutes and keep your hand moving!
Journal Topics:
What made me happy today?
I love work because….
When I take care of older people…
I would like to let go of …..
Am I a spiritual person?
I am comfortable with caring for people who are dying because…
What restores me is ……

48. Meditation
Meditation is a quiet turning inward that can create relaxation, inner peace, and harmony.
Stress reduction
Reduce blood pressure, pain
Enhance immune system
Heightened connection to the sacred.

49. Movement, Centering, Relaxation
Breathing is integral to self-care, learning to focus on the inhale and exhale of breath is key.
Do something physical to get your energy moving, yoga, tai chi, dance, aerobics, swimming, walk. Take the time to stir your energies.
Breathe, breathe, breathe

50. Music Reduces pain Lower blood pressure Reduce stress
Increase mood & positive feelings
Release of emotions
Healing effects
American Music Therapy Association,

51. Nature / Putting “Play” Into Your Life
“Letting go” is vital to self-care.
Nature is restorative, inspirational, and refreshing.
Changing your environment is crucial to renewal.
Nature provides a new perspective. Doing something different (known) in your environment.
e.g., walk barefoot!

52. Teaching Strategies
Create an inventory of self-care activities in the last month and evaluate them.
Perform one self-care activity each day and document them in a journal.
Take moments to breathe throughout your day, while you are waiting for the elevator, climbing the stairs, or riding the bus.
Think of one self-care activity/thing that you really like (need) e.g. mashed potatoes. If you had to do without it, what would you put in its place?

53. Teaching Strategies Use your breaks to truly relax.
Discuss the difference between “doing” and “being” as a nurse.
What kind of support group would you start, at work, and why? Discuss.
Distinguish between self-care as a spiritual practice and as basic psychosocial self-care activities.

54. Spirituality and Aging Websites: Curriculum
The George Washington Institute for Spirituality and Health
UTMB, Spirituality and Clinical Care, Course Syllabus 2010,
University of Minnesota, Spirituality in Healthcare

55. Spirituality and Aging Websites

56. Spirituality and Aging Websites (contd.)

57. Recent Studies/Reports
Recent Studies and Resources are found on this slide’s Notes Page.
Improving the Quality of Spiritual Care as a Dimension of Palliative Care: The Report of the Consensus Conference, Puchalski et al. Journal of Palliative Medicine 2009; Volume 12, Number 10.
Religious attendance associated with slower progression of cognitive impairment with aging in older Mexican-Americans Hill et al. Journal of Gerontology 2006; 61B:P3-P9, Reyes-Ortiz et al. Journal of Gerontology 2008; 63:
Religious behaviors associated with slower progression of Alzheimer’s dis. Kaufman et al. Neurology 2007; 68:1509–1514.
For depression-cognition relationship see Arch Gen Psychiatry 2006; AGP 63: ; 2008;65(5): ; AGP 2008; 65(10): )
Fewer surgical complications following cardiac surgery. Contrada et al. Health Psychology 2004;23:
Greater longevity if live in a religiously affiliated neighborhood. Jaffe et al. Annals of Epidemiology 2005;15(10):
Partially Compiled by Harold G. Koenig, MD, Department of Psychiatry and Medicine, Duke University Medical Center, GRECC VA Medical Center