1. Religion, Spirituality, and Health in Medically Ill Hospitalized
Older Patients
Harold G. Koenig, MD,Ã wz Linda K. George, PhD,Ã § and Patricia Titus, RN, CÃ k
OBJECTIVES: To examine the effect of religion and CONCLUSION: Religious activities, attitudes, and spiri-
spirituality on social support, psychological functioning, tual experiences are prevalent in older hospitalized patients
and physical health in medically ill hospitalized older and are associated with greater social support, better
adults. psychological health, and to some extent, better physical
DESIGN: Cross-sectional survey. health. Awareness of these relationships may improve
SETTING: Duke University Medical Center. health care. J Am Geriatr Soc 52:554–562, 2004.
PARTICIPANTS: A research nurse interviewed 838 con- Key words: religion; spirituality; social support; depres-
secutively admitted patients aged 50 and older to a general sion; coping
medical service.
MEASUREMENTS: Measures of religion included orga-
nizational religious activity (ORA), nonorganizational
religious activity, intrinsic religiosity (IR), self-rated reli-
giousness, and observer-rated religiousness (ORR). Mea-
sures of spirituality were self-rated spirituality, observer-
rated spirituality (ORS), and daily spiritual experiences. R eligious beliefs and practices are common in the United
States, especially among older adults. According to
Gallup polls conducted in 2000 and 2001, religion was
Social support, depressive symptoms, cognitive status,
cooperativeness, and physical health (self-rated and ob- noted as ‘‘very important’’ by 60% of Americans aged 50 to
server-rated) were the dependent variables. Regression 64, 67% of those aged 65 to 74, and 75% of those aged 75
models controlled for age, sex, race, and education. and older.1 Church or synagogue attendance was also
RESULTS: Religiousness and spirituality consistently pre- common, with 44% of persons aged 50 to 64, 50% of those
dicted greater social support, fewer depressive symptoms, aged 65 to 74, and 60% of aged 75 and older attending
better cognitive function, and greater cooperativeness services within the past 7 days.
(Po.01 to Po.0001). Relationships with physical health When physical illness strikes, religion and spirituality
were weaker, although similar in direction. ORA predicted can become important for coping.2 This may be particularly
better physical functioning and observer-rated health and true for hospitalized patients, who must cope not only with
less-severe illness. IR tended to be associated with better unpleasant physical symptoms but also with the stress of
physical functioning, and ORR and ORS with less-severe being hospitalized.3 Hospital admission often underscores
illness and less medical comorbidity (all Po.05). Patients the seriousness of the condition and nearness to death.
categorizing themselves as neither spiritual nor religious Patients must abandon their usual roles in society, take
tended to have worse self-rated and observer-rated health on a more dependent role, and confront the unknown.
and greater medical comorbidity. In contrast, religious Hospitalization can trigger underlying conflicts regarding
television or radio was associated with worse physical separation and loss and threaten one’s sense of control
functioning and greater medical comorbidity. and adequacy. Likewise, confinement to a hospital bed and
hospital routines restrict mobility, limit stimulation, and
often assault the patient’s sense of competence. Religious or
spiritual beliefs may help patients to cope with these
From the Departments of ÃPsychiatry and wMedicine, §Center for Aging, and stressful experiences.
k
Rehabilitation Institute, Duke University Medical Center, Durham, North What do the terms religious and spiritual mean, how
Carolina; and zGeriatric Research, Education and Clinical Center, VA are they distinguished from each other, and does their value
Medical Center, Durham, North Carolina.
in coping with stress differ? Religion is an organized system
Funding provided by the John Templeton Foundation, Radnor, Pennsylvania;
of beliefs, practices, and symbols designed to facilitate
the Arthur Vining Davis Foundation, Jacksonville, Florida; the Fetzer
Institute, Kalamazoo, Michigan; and the Mary Biddle Duke Foundation, closeness to a higher power and includes the understanding
Durham, North Carolina. of one’s relationship with and responsibility to others.4
Address correspondence to Dr. Koenig, Box 3400, Duke University Medical Religiousness involves three major dimensions: (1) organi-
Center, Durham, NC 27710. E-mail: koenig@geri.duke.edu zational religious activity (ORA), (2) nonorganizational
JAGS 52:554–562, 2004
r 2004 by the American Geriatrics Society 0002-8614/04/$15.00

2. JAGS APRIL 2004–VOL. 52, NO. 4 RELIGION, SPIRITUALITY, AND HEALTH IN THE MEDICALLY ILL ELDERLY 555
religious activity (NORA), and (3) subjective or intrinsic University Medical Center were identified for study
religiosity (IR).5 ORA includes attending church or participation using lists of daily admissions. After obtaining
synagogue, participating in prayer or Bible study groups, written informed consent from the patient, a research nurse
and going to other church/synagogue functions. This is the conducted a 60- to 90-minute interview in the patient’s
social, other-directed dimension of religiousness. NORA room, completed a brief physical examination, and
consists of more private and personal religious behaviors. reviewed the medical record. The research nurse was
These include prayer or meditation, reading the Bible or retrained every 6 months throughout the study period to
other religious literature, and listening to religious radio or avoid drift in data collection.
watching religious television. These activities are typically
done alone and do not necessarily involve relating to other Measures
people. Finally, IR reflects the extent to which religion is the Demographics
primary motivating factor in people’s lives, drives behavior,
and influences decision-making. Age, sex, race, and education were determined.
NORA and IR are the two private dimensions of Social Support
religiousness that can be relied on regardless of health status
The 11-item version of the Duke Social Support Index
and may be preferred over ORA during times of illness.
examines two major components of social supportFsocial
Persons heavily involved in such expressions of religion may
network and subjective support.7 This version was devel-
cope better with changes in physical health because their self-
oped specifically for use in older patients.
esteem and sense of well-being are not as tied to their physical
circumstances. At least one prospective study has shown that Depression
medically ill older hospitalized patients recover more quickly The 11-item Brief Depression Scale is a self-rated depression
from depression if they are more intrinsically religious.6 scale that was specifically developed and validated for use in
Although religiousness is an important construct, most medically ill hospitalized patients.8 The ‘‘yes-no’’ response
would agree that there is something more that needs to be format allows easy use in even the sickest patients.
assessed. Spirituality is the quest for understanding life’s
ultimate questions and the meaning and purpose of living, Cognitive Status
which often leads to the development of rituals and a shared An abbreviated version of the Mini-Mental State Examina-
religious community, but not necessarily.4 Many persons tion, developed and validated specifically for use in
may not be formally affiliated with a religious tradition or medically ill, frail patients,9,10 was administered. Scores
even believe in God, yet still be involved in a spiritual quest, on this version range from 0 to 18; scores of 13 or lower
seeking meaning in something outside of their own personal indicate significant impairment.
egos. Spirituality, though, means different things to different
people. Spirituality has been difficult to capture by measur- Level of Cooperativeness
ing observed activities or even questions about beliefs. At the completion of the interview, the research nurse rated
People themselves define what being spiritual means to them. the patient’s overall cooperativeness during the interview on
a 6-point Likert scale ranging from not cooperative (0) to
very cooperative (5).
Study Hypotheses
First, it was hypothesized that religious or spiritual Physical Illness
practices, attitudes, and experiences would be widespread, To measure physical illness burden, two self-rated and three
given their possible role in coping. Second, greater observer-rated measures of physical health status were used.
religiousness and spirituality would be associated with The Duke Activity Status Index is a 12-item self-report
greater social support, fewer depressive symptoms, better questionnaire designed to measure current level of physical
cognitive functioning, and greater cooperation during the functioning (ability to perform activities of daily living
interview process (reflecting less mistrust). Third, religious- (ADLs)).11 The 12 items assess personal care, ambulation,
ness and spirituality would be correlated with better household tasks, and recreational activities, with response
physical health and overall functioning, but turning to categories ranging from unable to perform ADL (1) to easy
religion to cope as illness advanced might partially offset a to perform (3).
positive association with better health. Fourth, those who Self-rated physical health was assessed by asking,
considered themselves both religious and spiritual would ‘‘How would you rate your overall physical health?’’12
have the best psychological, social, and physical health, Responses ranged from very poor (1) to excellent (6).
whereas those who considered themselves neither spiritual The American Society of Anesthesiologists (ASA)
nor religious would have the worst, and those who Severity of Illness Scale consists of a single item based on
considered themselves spiritual but not religious or religious the observer’s overall rating of the patient’s severity of
but not spiritual would have intermediate health. Finally, medical illness,13 with options ranging from not at all ill (1)
associations would be strongest in older patients (!75). to very severe illness (5).
The Cumulative Illness Rating Scale involves an
METHODS observer-rated assessment of the severity of impairment of
12 major organ systems (e.g., cardiac, vascular, respira-
Procedure tory).14 Each organ system is rated on a scale of 0 to 4, with
Between August 1998 and April 2002, patients consecu- 0 indicating no impairment and 4 indicating very severe
tively admitted to the general medicine service at Duke impairment.

3. 556 KOENIG ET AL. APRIL 2004–VOL. 52, NO. 4 JAGS
The Charlson Comorbidity Index measures overall responses ranging from ‘‘I am not spiritual at all’’ (1) to ‘‘I
illness burden based on number and severity of comorbid am very spiritual’’ (5). For self-rated religiousness (SRR),
illnesses15 using 31 diagnostic categories of illness based on patients were asked to rate their religiousness from ‘‘I am
the International Classification of Diseases, Ninth Revi- not religious at all’’ (1) to ‘‘I am very religious’’ (5).
sion. Each active medical diagnosis was assigned standar-
dized weights and then summed to create an overall Self-Categorizations of Spirituality and Religiousness
comorbidity score. Patients were asked to place themselves into one of four
categories: religious but not spiritual, spiritual but not
Religion religious, both religious and spiritual (BRS), or neither
religious nor spiritual (NRS).
Religious Affiliation
Religious affiliation was dichotomized into any affiliation Observer-Rated Spirituality and Religiousness
versus none (no affiliation, agnostic, or atheist). Patients were asked to define the terms spirituality and
religiousness as they understood them. The interviewer
Organizational Religious Activity
recorded the patient’s responses verbatim for each term.
ORA was measured by assessing frequency of attendance at Based on the patient’s definition of spirituality, three health
church or religious meetings, with responses ranging from professionals independently rated how spiritual they judged
never (1) to more than once a week (6), and frequency of the patient to be based on their definition. Ratings were
participation in other religious group activities such as adult based on the definition of spirituality described in the
Sunday school classes, Bible study groups, and prayer introduction of this paper. A five-point Likert scale was used
groups, with similar response categories. Summing these for rating, with responses ranging from not spiritual at all
two items created an ORA scale. (1) to very spiritual (5). The same procedure was followed
Nonorganizational Religious Activity for scoring observer-rated religiousness ((ORR) not reli-
gious at all to very religious). For spirituality ratings, as
NORA was measured by assessing frequency of private
expected, interrater reliability coefficients were relatively
prayer other than at meal times, with responses ranging
low, averaging r 5 0.39, whereas interrater coefficients for
from not at all (1) to three or more times per day (6), and by
religiousness ratings averaged higher at r 5 0.47.
frequency of reading the Bible or other religious literature,
The observer-rated spirituality (ORS) ratings by the
with responses ranging from not at all (1) to several times
three raters were summed to produce the ORS scale, which
per day (6). Summing these two items created a NORA
ranged from 3 to 15. Similarly, the ORR scale was created
scale.
ranging from 3 to 15. For both scales, if one of the three
Religious Television and Radio ratings was missing (2% of cases), the average of the other
Religious television and radio (RTV) was assessed using a two was used as the replacement value. The ORS and ORR
single question, with responses ranging from not at all (1) to scales (excluding cases where replacement values were
several times per day (6). This variable is usually considered used) correlated with one another at r 5 0.75.
a type of NORA, but because previous research has shown a Daily Spiritual Experiences
different relationship with health than private prayer or
scripture reading, this variable was examined separately. Finally, spiritual experiences were measured using the 16-
The questions constituting the ORA, NORA, and RTV item daily spiritual experience (DSE) scale.19 This scale
scales were taken from the Springfield Religiosity Sched- seeks to assess the perception of the transcendent (e.g., God)
ule.16 and interactions with the transcendent in daily life. Items
focus on experience rather than beliefs or behaviors, and the
Intrinsic Religiosity scale developers claim it is applicable to persons from any
IR was measured using Hoge’s 10-item intrinsic religiosity religious background. Test-retest, interrater, and internal
scale,17 which contains statements about religious motiva- consistency reliability (Cronbach alpha40.93) are all
tion. Patients were asked to note the extent to which they acceptable. Response options range from never or almost
felt the statement was true for them, from definitely not true never (1) to many times a day (5).
(1) to definitely true (5).
Statistical Analysis
Spirituality Frequency distributions were examined for all variables.
There is no widely accepted measure of spirituality. Pearson correlations with age were examined for all
Research that purports to measure spirituality usually religious and spiritual variables. Relationships between
measures religiousness. In the present study, spirituality religious and spiritual factors, psychosocial characteristics
was assessed in four ways. The first three measures used an (social support, depression, cognitive functioning, and
approach in which patients were allowed to define for cooperativeness), and physical health were examined using
themselves what the term ‘‘spiritual’’ meant to them, least squares linear regression. All analyses were controlled
contrasting it with ‘‘religious’’.18 The fourth measure for age, sex, ethnicity, and education. Standardized betas
assessed spiritual experiences using a standard scale. and level of statistical significance were calculated. Because
of multiple statistical comparisons and the exploratory
Self-Rated Spirituality and Religiousness nature of this study; Po.01 was considered statistically
Patients were asked to rate their own spirituality (self-rated significant, whereas 0.10oP4.01 was considered a trend.
spirituality (SRS)) on a five-point Likert scale, with For statistically significant associations, analyses were

4. JAGS APRIL 2004–VOL. 52, NO. 4 RELIGION, SPIRITUALITY, AND HEALTH IN THE MEDICALLY ILL ELDERLY 557
repeated for each age group (50–64, 65–74, and !75); (71.1 vs 64.3; Po.0001) and have chronic pulmonary or
betas without P-values are reported because these are infectious diseases (49% vs 29%; Po.01) and less likely to
secondary analyses. have cardiovascular disease (15% vs 31%; Po.01).
Sample Characteristics
RESULTS
The average age of the final sample was 64.3 (54% aged 50–
Sample 64, 28% aged 65–74, and 18% aged !75), the average
A total of 2,477 consecutive patients aged 50 and older education level Æ standard deviation was 11.9 Æ 3.9 years,
were admitted to the general medical service during the and 53.1% were women and 61.2% Caucasian. Psychoso-
screening period. Patients did not participate in the study cial, physical health, and religious characteristics are
for the following reasons: discharged before seen (n 5 456); described in Table 1. Approximately one-third of patients
delirium or dementia precluding psychological testing (31.1%) had a primary diagnosis of heart or circulatory
(n 5 269); severe physical illness (n 5 239); inability to system disease, whereas 19.3% had gastrointestinal disease,
communicate because of aphasia, tracheostomy, or severe 15.0% chronic pulmonary disease, 13.5% infectious
hearing loss (n 5 203); gone for a medical or surgical disease, and the remaining 12.6% a range of other medical
procedure, transferred to another service, died, could not be conditions. Medical comorbidity was common, with the
located or otherwise could not be interviewed (n 5 38); and average patient having more than five concurrent medical
family or health professional failed to give consent or conditions. Most patients had severe illness (ASA
prevented the interview (n 5 27). Of the 1,245 patients that score 5 4.2), and poor physical functioning as measured
could be interviewed, 407 refused to participate or stopped using the Duke Activity Status Index (average 18.7, range
the interview before it was completed, yielding a final 12–36, where 12 represents inability to perform any of the
sample of 838 (67% adjusted response rate). 12 ADLs assessed). Depressive symptoms were likewise
A computer program randomly selected approximately common, with an average of 3.9 on the Brief Depression
one of every 20 nonparticipants (n 5 72) on whom age, sex, Scale (!3 indicates significant depression.)
race, insurance status, and medical diagnosis were collected Hypothesis 1: Religious and spiritual attitudes and
and compared with those of participants. Nonparticipants practices will be widespread in medically ill older patients
did not differ from participants on race (35% vs 39% given their role in coping with physical illness.
nonwhite), sex (49% vs 53% female), or medical insurance Most patients (97.6%) were religiously affiliated. The
(50% vs 47% private) but were more likely to be older predominant religious groups represented in the sample
Table 1. Psychosocial, Physical Health, and Religious Characteristics of Sample (N 5 838)
Characteristic Value
Psychosocial, mean Æ SD
Abbreviated Duke Social Support Index (range 11–33) 27.4 Æ 3.5
Brief Depression Scale (range 0–11) 3.9 Æ 2.9
Abbreviated Mini-Mental State Examination (range 0–18) 15.2 Æ 2.7
Physical health, mean Æ SD
Duke Activity Status Index (range 12–36) 18.7 Æ 5.2
Observer-rated illness severity (range 1–5) 4.2 Æ 0.7
Self-rated health (range 1–6) 3.2 Æ 1.1
Cumulative Illness Rating scale (range 0–48) 10.1 Æ 4.0
Charlson Comorbidity Index (range 0–49) 7.9 Æ 3.7
Religious
Organizational religious activity, mean Æ SD (range 2–12) 5.6 Æ 2.6
Nonorganizational religious activity, mean Æ SD (range 2–12) 7.6 Æ 2.2
Religious television/radio, mean Æ SD (range 1–6) 3.2 Æ 1.3
Intrinsic religiosity, mean Æ SD (range 10–50) 39.9 Æ 6.8
Self-rated spirituality, mean Æ SD (range 1–5) 3.8 Æ 0.9
Self-rated religiousness, mean Æ SD (range 1–5) 3.6 Æ 1.0
Spiritual-religious categories, %
Religious, not spiritual 2.4
Spiritual, not religious 6.9
Spiritual and religious 87.5
Neither spiritual nor religious 2.5
Observer-rated spirituality, mean Æ SD (range 3–15) 9.7 Æ 2.6
Observer-rated religiousness, mean Æ SD (range 3–15) 9.0 Æ 2.8
Daily spiritual experiences, mean Æ SD (range 16–80) 61.0 Æ 12.1
Note: n may vary by up to 1%.
SD 5 standard deviation.

5. 558 KOENIG ET AL. APRIL 2004–VOL. 52, NO. 4 JAGS
Table 2. Religion and Psychosocial Characteristics (N 5 838)
Psychosocial Characteristic
Social Support Depressive Symptoms Cognitive Function Degree of Cooperation
Religious Characteristic Standardized BetaÃ
Any religious affiliation 0.10k À 0.01 0.04 0.11k
Organizational religious activity 0.23# À 0.12z 0.02 0.12z
Nonorganizational religious activity 0.22# À 0.07z 0.11z 0.21#
Religious TV/radio 0.07 0.01 À 0.01 0.07z
Intrinsic religiosity 0.16# À 0.10k 0.02 0.08§
Self-rated spirituality 0.19# À 0.08§ À 0.05 0.04
Self-rated religiousness 0.16# À 0.05 À 0.06§ 0.01
Spiritual-religious categoriesw
Religious, not spiritual À 0.02 0.00 0.00 À 0.05
Spiritual, not religious À 0.07§ À 0.02 0.02 0.03
Spiritual and religious 0.13z À 0.01 0.01 0.01
Neither spiritual nor religious À 0.12z 0.06z À 0.05 À 0.02
Observed-rated spirituality 0.11k À 0.05 0.12# 0.25#
Observer-rated religiousness 0.13# À 0.08§ 0.13# 0.25#
Daily spiritual experiences 0.28# À 0.12z 0.06z 0.21#
Note: n may vary by up to 1%.
Ã
Standardized estimate from regression model.
w
Each category compared with all others as reference group.
z
0.104P4.05; §Po.05; kPo.01; zPo.001; #Po.0001 (controlled for age, sex, race, and education).
were Baptist or Southern Baptist (47.1%), Methodist such as prayer or Bible study, for those who rated
(10.7%), Pentecostal Holiness (9.6%), Catholic (5.0%), themselves more spiritual, and for those rated by observers
Presbyterian (3.0%), and Episcopal (2.3%). Religious as more religious. Associations were particularly strong for
attendance was common (37.3% weekly or more), as were ORA in patients aged 75 and older (b 5 À 0.22), for IR in
private prayer (80.8% at least once daily) and reading the those aged 65 to 74 (b 5 À 0.16), and for DSEs in those
Bible or other religious literature (50.7% at least several aged 50 to 64 (b 5 À 0.12).
times per week). Patients indicated that such religious Cognitive functioning was better in those more
activities were frequently used to help cope with health involved in private religious activities such as prayer or
problems. DSEs were likewise prevalent, with an average Bible study and those who observers rated as more spiritual
score on the DSE scale of 61.0, far surpassing the average or religious; all associations were strongest in persons aged
scores of middle-age women and college students found in 65 and older. There was also a trend towards better
other studies19 of 46 to 49. Fifty-five percent of patients cognitive functioning in those having more DSEs. In
considered themselves quite or very religious, whereas 61% contrast, those rating themselves more religious tended to
considered themselves quite or very spiritual. There was no have worse cognition.
correlation (P4.05) between age and any religious or Degree of cooperativeness was uniformly related to
spiritual variables except for self-rated religiousness greater religiousness and spirituality. Patients who prayed
(r 5 0.11; P 5.001) and self-categorization as spiritual but or read the Bible more often and those who had more DSEs
not religious (r 5 À 0.13; P 5.0002). were significantly more cooperative during the interview
Hypothesis 2: Religious and spiritual attitudes and process (Po.0001). Similarly, those rated by observers as
practices will be related to greater social support, fewer more spiritual or more religious were also more cooperative
depressive symptoms, better cognitive functioning, and as were those more involved in ORA. All associations were
greater cooperation. stronger in patients aged 65 and older.
Measures of religiousness and spirituality were asso- Hypothesis 3: Religiousness and spirituality will be
ciated with greater social support, with RTV being the only correlated with better physical health and functioning.
exception (Table 2). Social support was most strongly Although generally true, the findings for physical
related to DSEs, ORA, and NORA (b ranging from 0.22 to health were much weaker than for psychosocial outcomes
0.28; Po.0001); this effect was particularly strong for (as expected if health benefits were offset by patients
persons aged 75 and older (b ranging from 0.30 to 0.38, turning to religion as they became sicker) (Table 3).
analyses not shown). Associations varied depending on how religiousness or
Depressive symptoms were significantly less common spirituality was measured. Patients more involved in ORA
in those more involved in ORA, those with greater IR, and reported better physical functioning (ADLs) and were rated
those with more DSEs. There was also a trend toward fewer as less severely ill on two measures (ASA and Cumulative
depressive symptoms for those more involved in activities Illness Rating Scale); associations were strongest in patients

6. JAGS APRIL 2004–VOL. 52, NO. 4 RELIGION, SPIRITUALITY, AND HEALTH IN THE MEDICALLY ILL ELDERLY 559
Table 3. Religion and Physical Health (N 5 838)
Activities of Self-Rated Observer-Rated Cumulative Charlson
Daily Living Health Health Illness Rating Comorbidity Index
Religious Characteristic Standardized BetaÃ
Any religious affiliation À 0.00 0.01 À 0.03 0.04 0.02
Organizational religious activity 0.11§ 0.04 À 0.11§ À 0.13k À 0.06
Nonorganizational religious activity À 0.03 À 0.03 0.02 À 0.01 0.03
Religious television/radio À 0.08z À 0.04 À 0.01 0.04 0.11§
Intrinsic religiosity À 0.08z 0.03 0.00 0.01 0.00
Self-rated spirituality À 0.03 0.00 À 0.01 À 0.03 À 0.03
Self-rated religiousness À 0.04 À 0.04 0.05 0.01 À 0.02
Spiritual-religious categories
Religious, not spiritual 0.06w 0.10§ À 0.11§ 0.04 0.00
Spiritual, not religious 0.04 0.01 À 0.05 À 0.03 0.02
Spiritual and religious À 0.06w À 0.02 0.05 0.01 À 0.05
Neither spiritual nor religious À 0.01 À 0.07z 0.08z 0.00 0.07z
Observer-rated spirituality 0.02 À 0.05 À 0.08z À 0.03 À 0.07z
Observer-rated religiousness 0.00 À 0.05 À 0.07z À 0.04 À 0.06w
Daily spiritual experiences À 0.05 0.01 0.00 0.01 À 0.04
Note: n may vary by up to 1%. Higher scores on activities of daily living and self-rated health indicate better health, whereas higher scores on observer-rated health,
Cumulative Illness Rating Scale, and Charlson Index indicate worse health.
Ã
Standardized estimate from regression model. w0.104P4.05; zPo.05; §Po.01; kPo.001 (controlled for age, sex, race, and education).
younger than 75. There was no relationship with private DISCUSSION
religious activities such as prayer or Bible study. Those with This is the largest and most detailed study reported thus far
higher ORS and ORR tended to receive higher health on the religious and spiritual characteristics of medically ill
ratings and experience fewer comorbid illnesses. In hospitalized patients and their relationships to social,
contrast, patients reporting more RTV tended to have psychological, and physical health factors. These are among
worse physical functioning and were significantly more the sickest patients that medical practitioners treat and the
likely to have multiple comorbid illnesses on the Charlson ones most likely to have their coping abilities challenged by
Comorbidity Index; these associations were strongest in illness and disability. As expected, religious/spiritual beliefs
patients aged 50 to 64. and practices were widespread (true for all age groups) and,
Hypothesis 4: Patients categorizing themselves as BRS not surprisingly, were frequently used to cope with illness.
will have the best psychosocial and physical health out- This confirms the findings from other samples of medically
comes, and those as NRS will have the worst. ill patients in North Carolina20–22 and elsewhere.23–26
This hypothesis was confirmed most strongly for social Religious beliefs help patients make sense of their medical
support, and there were trends in the expected direction for conditions and may enable them to better integrate health
physical health (Tables 2 and 3). Social support was changes into their lives. Religious practices can help to
inversely related to being NRS (b 5 À 0.12, Po.001), relax, distract, and counteract the effects of loneliness and
especially in patients aged 50 to 64 (b 5 À 0.16), and isolation that are so prevalent.
spiritual not religious (b 5 À 0.07, 0.104P4.01), espe-
cially in patients aged 75 and older (b 5 À 0.26). In
contrast, those who indicated they were BRS reported Social Support
significantly greater support (b 5 0.13, Po.001), especially Not only are religious and spiritual practices prevalent, they
if aged 75 and older (b 5 0.23). With regard to depressive are also associated with measurably better psychosocial
symptoms, those categorizing themselves as NRS tended to functioning. Most evident was the relationship with social
experience more depressive symptoms, although the rela- support, a variable known to have strong links to well-being
tionship was weak (b 5 0.06). and better health status.27,28 A recent review of the
Concerning physical health, patients categorizing literature on religion and social support reported that 19
themselves as BRS tended to report fewer impaired ADLs of 20 studies found significant associations between the
(b 5 À 0.06). In contrast, those who categorized themselves two.29 Although it is understandable that social religious
as NRS tended to rate themselves as less healthy activities (attending church and other religious meetings)
(b 5 À 0.07), to be rated by the research nurse as more might be correlated with higher support, it is less clear why
severely ill (b 5 0.08), and to experience more comorbid involvement in private religious activities (prayer and Bible
medical illness (b 5 0.07) (all Po.05). Interestingly, study), IR, or DSEs was so strongly correlated with social
although somewhat puzzling, patients who categorized network size and satisfaction with social relationships here.
themselves as religious but not spiritual had significantly One possibility is that, when religion becomes internalized
better scores on self-rated and observer-rated health so that it affects private life and experiences, it influences
measures, particularly those younger than 75. sociability and perhaps perception of relationships.

7. 560 KOENIG ET AL. APRIL 2004–VOL. 52, NO. 4 JAGS
The relationship between social support and almost all The first study involving 586 older medical inpatients found
measures of religiousness and spirituality represents the that greater religiousness was related to greater coopera-
most striking and consistent finding in this study, especially tiveness, with betas ranging from 0.20 to 0.25,36 similar in
because the effect was strongest in patients aged 75 and magnitude to those seen in the present study. Although it
older. Although direction of causation cannot be deter- was perhaps not surprising that religious subjects were
mined here, longitudinal research over nearly 3 decades has more cooperative than nonreligious subjects in a survey
shown that greater religious involvement predicts future about religion, the strong relationship between coopera-
nonreligious group memberships, contacts with close tiveness and private activities and DSEs suggests that, when
friends, and marital stability.30 If greater religiousness or religion becomes personalized and associated with mean-
spirituality enhances social support, then the findings of the ingful spiritual experiences, it might also lead to a greater
present study are relevant for geriatricians treating older desire to help others and facilitate the interview process.
medical patients, given the importance of adequate social Whether religiousness or spirituality also predicts greater
support in predicting health outcomes and ensuring cooperativeness in healthcare settings or greater likelihood
compliance once patients return home.31–33 of participating in clinical research is unknown.
Depressive Symptoms
Physical Health
Depressive symptoms are widespread in older medical
inpatients and predict worse health outcomes and greater Relationships with physical health were less frequent and
use of health services.34 In the present study, depressive weaker than with psychosocial factors. This was partly
symptoms were less common in patients who were more expected, because religious beliefs and practices are often
religious. Inverse associations with depressive symptoms used to help cope with medical illness, and as severity of
were most evident for ORA, IR, and DSEs, especially in illness increases, religious activities, especially private ones,
those aged 65 and older. These findings build on previous likewise increase. Thus, even if religious factors helped to
work in medical and community settings. Religious prevent disability and limit the severity of medical illness,
attendance has been inversely related to depressive symp- this would be difficult to demonstrate in a cross-sectional
toms in elderly patients recovering from hip surgery,35 older study, in which sicker patients turning to religion could
medical patients,36 and community-dwelling older adults in neutralize such effects.
the United States37 and Europe.38 In longitudinal studies, Nevertheless, ORA was related to better physical
religiousness predicts faster remission from depression in functioning and less-severe medical illness, particularly in
older medical inpatients6 and community-dwelling el- those younger than 75. Whether such religious activity led
derly,39 but this is the first study in medical patients to to better functioning and physical health status, or whether
examine the relationship between depressive symptoms and better functioning and health status led to greater ability
DSEs.19 Overall, these findings suggest that religious to participate in ORA, cannot be determined here, but a
activities, personal religiousness, and spiritual experiences 12-year prospective study of nearly 3,000 older adults
are not only common in older patients, but that they are found evidence that religious attendance may forestall the
also often used successfully to cope with illness and ward development of functional disability and that, although
off depression. physical disability also affects religious attendance, that
effect is usually short term and does not offset the long-term
effect of religious activity on preventing disability.40 With
Cognitive Function
regard to the present study, it may be that ORA enhances
Cognitive functioning was positively related to ORS and physical health by keeping chronically ill older adults
ORR, especially in patients aged 75 and older. Those with active and involved in the religious community and by
better cognitive functioning may have been more articulate providing meaningful activities and social support that
in their feelings about spirituality and religion, thereby enhance coping and maintain positive attitudes toward self-
leading to higher ratings by outside observers, but the care, compliance, and motivation to recover. Few other
positive association with private religious activities religious characteristics predicted better physical health
(NORA) is less easily dismissed as a methodological than ORA.
artifact. NORA was related to significantly better cognitive A more interesting and robust association was found
function (b 5 0.11, Po.001), especially for those aged 65 between physical health status and RTV, although not in the
and older. An earlier study of 850 hospitalized male same direction as other religious measures. Those who
veterans also found religious coping positively correlated engaged more frequently in that activity had significantly
with better cognitive function (b 5 0.10, Po.01).20 Re- more comorbid medical illnesses and tended to report
ligious coping activities such as prayer or scripture reading worse physical functioning, an association found primarily
may lead to better cognitive functioning, or perhaps more in younger patients (aged 50–64). Frequency of RTV has
likely, better cognitive function may facilitate private also been correlated with higher blood pressure,41 worse
religious activities (given the highly cognitive nature of overall health and more depressive symptoms42 in studies of
such practices). community-dwelling elderly and with more generalized
anxiety43 in younger populations. It is difficult to imagine
Cooperativeness why frequent RTV would cause a worsening of physical
This is the second study of medical patients in which high health status, except perhaps by fostering physical inactiv-
levels of religiousness or spirituality predicted patient ity, but it could be that poorer physical functioning and
cooperativeness, particularly in those aged 65 and older. more comorbid medical illness made it difficult for such

8. JAGS APRIL 2004–VOL. 52, NO. 4 RELIGION, SPIRITUALITY, AND HEALTH IN THE MEDICALLY ILL ELDERLY 561
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