Like many other developed countries, Australia has an ageing population. The proportion of people over the age of 65 is projected to increase from 12% in 1997 to 18% in 2021 and about 26% in 2051. The number of people over the age of 85 has also increased sharply — by 69% in the decade 1991–2001.1,2 Improvements in health care have led to increased longevity, but the extra years are wasted unless people can find hope and meaning in life.
There are different views of ageing in our society. One view sees ageing as a period of physical decline that includes illness and disability, with an emphasis on the “burden” of an ageing population. Government policy has concentrated on the cost of this ageing population, exemplified by the Intergenerational Report.3 A second view is of “successful ageing”.4 This promotes continued engagement with the wider community and pursuit of physical and psychosocial activities as a means of ageing successfully. However, this view begs the question of what happens to people who are not “successful” — older people who live with multiple chronic health problems, who are depressed or live with dementia. The reality is that the later years in life may frequently be accompanied by chronic illness requiring special care.
Therefore, an alternative view is needed. We propose a third view that sees ageing as a “spiritual journey”, with challenges that continue across the later years of life. This is a journey that searches to find meaning in one’s life and, therefore, reason for continued life and hope. This view accepts the possibility of death, while living life to the full. Taking this third view allows people living with increasing disability to find hope and to flourish, even in the face of uncertainty.5
The concept of spirituality is about core meaning and connectedness, and it is from this that we respond to all of life. Anger, hate, love, forgiveness and hope come from this core. For some older people, spirituality may be expressed in a relationship with God or a higher being, while for others it may be expressed through family and friends, nature, and/or the environment. When we talk about spirituality, we are not specifically talking of religiousness, although for people who have a religious faith, religiousness is part of their spirituality.6 A better way to think about spirituality is to imagine it as an umbrella. Religion, being one way to express spirituality, comes under this umbrella.
Describing the spiritual domain has always been difficult. It is deeply related to hope and is the spark that enlivens human beings. Essential elements of spirituality seem to revolve around a relationship with self, others and God, a sense of meaning and purpose, hope, connectedness and beliefs.7 Issues of spirituality appear more urgent when people face situational and developmental crises of life, such as coming to terms with a terminal illness and the rising awareness of one’s own mortality.8
That which lies at the core of each person’s being, an essential dimension which brings meaning to life. Constituted not only by religious practices, but understood more broadly, as relationship with God, however God or ultimate meaning is perceived by the person, and in relationship with other people.8
There has recently been an increasing interest in studying the spiritual dimension. US studies have often revolved around religiousness or religious practices.9 However, Australia is largely a secular country. Although 80% of Australians affirm a belief in God or a higher being, only 20% attend church at least monthly — well down on the 45% of attendees in the 1950s.10 A 1999 study by Hughes and Black11 found that two-thirds of Australians felt that a spiritual life was important. Respondents sought meaning and a sense of peace and wellbeing in their lives through their relationships, family, work, nature and music. As a consequence, in Australia, the term “spirituality” appears to elicit more useful information than the terms “religion” or “religiousness”. In spite of the widespread view that some form of spirituality is important, many people who care for older people do not see spiritual care as a priority because the person does not declare a religion or go to church.
As people grow older, especially from middle age onwards, they often become more introspective.12 Erikson et al13 have described a series of psychosocial developmental stages of ageing, the final stage being to move towards integrity or despair, the outcome of which is wisdom. The development of a model of spirituality in ageing described here came about from many hours of interviewing, listening to and analysing the stories of older people. One study explored and mapped the spiritual journeys of independent older people: Where did they find meaning in life? Were they conscious of being on a journey? What was it like? What were the possibilities? Was there still hope in growing older and frailer?8 Other studies have concentrated on frail elderly people6 and those with dementia.14 Each of these studies has sought to explore the spiritual dimension of ageing.
The model shown in the Box is based on qualitative analysis, using grounded theory, of data obtained from in-depth interviews with older people.8,15 It has been refined and affirmed in subsequent studies.6,15 In this model, the central core of spirituality is what the person perceives as ultimate meaning in life. The person responds to life from what lies at the heart or deepest core of their being, and this will vary with the individual. The model is dynamic, with interactions shown by arrows.
At developmental stages of our lives or during critical life experiences, we assign meanings to our experiences. These “provisional meanings” are subject to change at a later point. Changes later in life, such as the diagnosis of a terminal illness or an increasing awareness of one’s own mortality, may be triggers to examine provisional life meanings and move towards assigning “final meanings”. Reminiscence therapy (see below) has been used in such circumstances to help people resolve past issues, including traumatic experiences. Coleman has used reminiscence therapy effectively with older people traumatised by their experiences of World War II.16
A study of independent-living older people showed that all of them feared future vulnerability or losing control of their lives.8 In a similar study of frail elderly nursing home residents, 55% of participants said they had no fears.6 Yet, the latter group had many more disabling conditions than the independent-living group. The precarious balance between vulnerability and self-sufficiency was an important theme for these older people. As vulnerability increased, the move from “doing” (being active) to “being” (having little energy or ability to engage in activities) was more frequently observed. These changes, associated with self-transcendence (the move from self-centredness to other-centredness), are spiritual changes and were present regardless of religious and spiritual background. However, not all of the people studied had progressed along a continuum towards self-transcendence. While some very frail older people seemed at peace and expressed a deep sense of joy in their lives, others experienced despair. A sense of despair may lead to failure to thrive, a concept much studied recently in the broader context of frailty.17 It is contended that one aspect of failure to thrive may be a lack of nourishment of the soul, or lack of love and spiritual care, similar to the failure to thrive concept in paediatrics. My work of mapping the spiritual dimension with frail elderly nursing home residents indicated a possible link between frailty, failure to thrive and lack of hope.
In a review by Levers et al17 of the literature on frailty in older people, in which the multidimensional nature of frailty was acknowledged, only one study was found that included spirituality in a theoretical framework, and none considered it in a research framework. The authors of the review noted that, while the three most common factors contributing to frailty were physical activity, ageing and disease, confusion exists about the relationship between frailty and the multiple identified factors. Considering that only one study included spirituality at all, this is an area for further study.
Reminiscence work was presented first in the early 1960s by Butler as “life review”.18 In many cases, life review gives people an opportunity to reflect on their accomplishments and a chance to right old wrongs, reconcile with enemies and become ready to die.18 Butler felt that this process is not always encouraged. Older people have been told that this type of nostalgia is “living in the past and a preoccupation with self”.18 He counters this attitude with the proposition that life review should be considered as part of a natural healing process.
There has been much written about reminiscence and life story in relation to older people.16,18-20 Haight and Webster18 differentiate between the concepts of life review and reminiscence. They propose that reminiscence has little structure and may jump from event to event as memories are triggered, whereas life review is a more sequential telling of a life. However these concepts are defined, they are both ways of recalling the past.
Spiritual reminiscence6 differs from reminiscence in that it focuses on the meaning of life through the life story, including connectedness, and the faith context (where this is part of the person’s story), and on what has given joy or brought sadness. The process of spiritual reminiscence may identify events that caused anger, guilt or regret. Expressing some of these issues in later life may help people to reframe events and come to a new understanding of how their life was lived.21 Spiritual reminiscence helps people find meaning in life in the present and develop strategies to accept changes of later life, including losses of significant relationships and increasing disability. It offers people with dementia the chance to talk about their fears and hopes and where they find meaning. Outcomes of spiritual reminiscence work include facilitating transcendence and finding hope in the face of increasing vulnerability.8,14
- Elizabeth B MacKinlay1
- Corinne Trevitt2
- School of Theology, Charles Sturt University, Barton, ACT.
Part of the research for this article was funded by Australian Research Council Linkage Grant #LP0214980. We acknowledge the support of Charles Sturt University and industry partners Anglican Retirement Community Services, Wesley Gardens Aged Care and Mirinjani Village Aged Care in our work.
None identified.
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Abstract
Providing spiritual care is about tapping into the concept of spirituality: core meaning, deepest life meaning, hope and connectedness.
The search for meaning, connectedness and hope becomes more significant as older people are faced with the possibilities of frailty, disability and dementia.
Spirituality, ageing and meaning in life can be discussed in the context of an alternative view of “successful ageing”.
A model of spiritual tasks in older age can help explain the spiritual dimension and provide a starting point for spiritual assessment.