including spirituality in comprehensive geriatric assessment

Julie Whitney looks at the role of spiritual assessment in caring for those in the last years of life and how Christians can be helped to see Jesus’ passion as a template for spiritual growth as they face declining health.

Introduction

In health and social care contexts, while the term ‘frailty’ is disliked by older people,1 it has gained currency in helping to distinguish those who need more support and care to remain independent and live well. The term frailty is defined as ‘a multidimensional syndrome characterised by decreased reserve and diminished resistance to stressors’.2 The pathophysiology of frailty is complex and likely to be a combination of genetic, epigenetic, and environmental factors.3 Older people living with frailty have higher health and social care needs4,5 and as a result of this vulnerability and dependency, they are also at higher risk of isolation and loneliness.6

The cornerstone of the care and management of the frail older person is Comprehensive Geriatric Assessment (CGA), which consists of a multidimensional holistic assessment and formulation of a plan to address what matters most to the older person living with frailty. It has been found to decrease hospital and care home admissions.7,8 While the underpinning principle of CGA is holistic, the model proposed by the British Geriatrics Society does not include the assessment of spirituality, an important mediator of wellbeing.

Spirituality in frailty

The definition of spirituality to be used here is ‘That which lies at the core of each person’s being, an essential dimension which brings meaning to life. It is acknowledged that spiritualty is not constituted only by religious practices, but must be understood more broadly, as relationship with God, however God or ultimate meaning is perceived by the person, and in relationship with other people.’9

MacKinlay interviewed older people to develop a model of ‘Spirituality in Ageing’. She divided her findings into the ‘third’ and ‘fourth age’. Third age describes people aged over 65 who remain independent, whereas fourth age relates to older people who have become dependent on others and will be the focus of this work. This model consists of six themes with related spiritual tasks:

1). The ultimate meaning in life – Task: to find ultimate meaning,

2). Response to ultimate meaning – The task: to respond to ultimate meaning,

3). Self-sufficiency /vulnerability – The task: to transcend disabilities and loss,

4). Wisdom – The task: to search for final meanings,

5.). Relationship/isolation – The task: to find intimacy with God and/or others, and

6). Hope/Fear/Despair – The task: to find hope.10

The concept of ‘gerotranscendence’, as in MacKinlay’s theme 3, suggests something radically different to a biomedical model of frailty based on degeneration and loss, instead, proposing that with the right support, the onset of frailty could trigger a time of spiritual growth.11 Moreover, the contribution of healthy spirituality to wellbeing may be more important in the context of severe frailty.

Spirituality in CGA

Ellingson concluded that CGA offers many opportunities for affirming and exploring what is needed for good spiritual health, but also that health and social care practitioners (HSCPs) lack the time, skill and confidence to engage in such discussions. She concluded that the term ‘comprehensive’ in CGA implies the inclusion of spirituality.12

Given the importance of a healthy spirituality to overall wellbeing, there is an argument that spirituality should be considered part of CGA. However, it is unclear how HSCPs delivering such interventions feel about this.

This study aimed to better understand how HSCPs understand and incorporate spirituality into CGA undertaken with frail older people living in community settings. The views of Anna chaplains, whose role is to offer spiritual support to and promote the spiritual welfare of older people living in care homes, sheltered housing, and the wider community, were also sought.

Methods

HSCPs with at least two years’ experience of undertaking CGA in community settings and Anna Chaplains with at least two years’ experience were invited to participate in semi-structured online interviews which were analysed using thematic analysis.13 The project was approved by the Common Awards Ethics Committee (St Augustine’s). All participants provided informed written consent.

Findings

Four interviews were undertaken, two with Anna Chaplains and two with healthcare practitioners (HCPs), one of whom was an occupational therapist, while another interview included two nurses. The HCPs had more than 20 years’ experience and the Anna Chaplains had been ordained chaplains for decades before moving into Anna Chaplaincy in the past few years.

Themes

Three themes emerged from the analysis:

1). spiritual assessment needs time, trust and skill,

2). supporting spirituality is focused on sustaining identity, fostering hope and encouraging spiritual growth and,

3). health care professionals lack confidence in how to recognise and address spiritual needs.

 

Theme 1: Spiritual assessment needs time, trust and skill

All interviewees described the importance of time when exploring spirituality. The use of tick box checklists or questionnaires were not thought to be helpful by the chaplains and not brought up as a possibility by the HCPs.

Suggestions made as to what questions to ask as part of a spiritual assessment are listed in Table 1.

Table 1. Suggested Questions/conversation points to use in the assessment of spirituality

Question

Interview participant
Have a general chat about the day, where they come from, bring it around to family. Anna Chaplain 1
What is it that really matters to you? Anna Chaplain 2
Is there anything worrying or scaring you? Anna Chaplain 2
In a broader sense, a bigger sense just so that we can make sure that all of your needs are addressed. So do you mind me asking you, what is it you believe? Anna Chaplain 2
Would you like to see the chaplain (when they are on the wards). Nurse 1
What’s important to you in terms of meaning? Nurse 2
Are you religious at all? Nurse 2
What drives you, what gives you meaning and purpose? Occupational therapist
Ask them about their day, what they do and what do they enjoy doing and what’s important to them. Occupational therapist
How have they coped with adversity in the past? Occupational therapist
Ask people about their life history. Occupational therapist
Any specific achievements, favourite pets or favourite places to visit. Occupational therapist

Theme 2: Supporting spirituality is focused on sustaining identity, fostering hope and encouraging spiritual growth

There were many ways in which chaplains and HCPs discussed supporting older people to meet spiritual needs. HCPs tended to describe functional ways to support people to meet spiritual needs. For example, providing a mobility aid to help a person access religious worship or alleviate social isolation. All participants discussed the importance of upholding identity for frail older people, where they may have lost the status bestowed by participation in roles such as paid employment or voluntary work. It was recognised that a frail older person is often dependent on someone else to support them with the task of sustaining their identity. The HCPs did not discuss hope or despair spontaneously but referred to resilience. When asked specifically about how the psychological construct of resilience might relate to the more spiritual terms of hope and despair, all HCPs recognised the presence of hope and despair in patients or family members and the influence of these experiences on wellbeing. Both chaplains describe how supporting a frail older person to find hope in their situation was a key part of their role. The two chaplains raised the possibility that older people experiencing frailty may in fact find it is a time for spiritual growth.

Theme 3: Healthcare professionals lack confidence in how to recognise and address spiritual needs

The HCPs, particularly, felt that spirituality was not assessed effectively or confidently within the context of CGA despite unanimous expression of its importance to a holistic assessment.

Discussion

The findings from this study should be interpreted with caution due to the small numbers of interviews undertaken, and which did not include the full breadth of practitioners involved in CGA.

The interviews with two Anna Chaplains and three HCPs suggest that assessment of spirituality should not be a tick-box exercise and provided helpful suggestions on assessment questions that map well onto MacKinlay’s model of Christian spirituality in the fourth age (frailty) as illustrated in Figure 1.

Figure 1. Potential assessment questions mapped onto MacKinlay’s model of spirituality in the fourth age

 

What is apparent, when considering the interview findings in this way, is that there were no questions specifically probing the domain of transcendence. Given the growing body of evidence supporting a relationship between self or gerotranscendence and wellbeing in the presence of disability towards the end of life,14 further exploration of this is required.

Looking at Christian Scripture for examples of successful ageing and transcendence, there are differences in the general messages from the Old and the New Testaments. While the Old Testament provides positive examples of ageing in the Patriarchs, Abraham, Jacob, and David, who lived to a great age, amassed considerable wisdom, and died of natural causes, the New Testament tells the story of Jesus of Nazareth, who was executed at a young age after only a short period of active ministry.15 In The Stature of Waiting, Vanstone argued that there are two distinct episodes in the life of Jesus, both of which offer a model for living.16 He described a life of activity relating to the years of ministry, which involved travelling, teaching, debating, healing and performing miracles. However, there was another episode where Jesus was powerless and lacked agency over what happened to him. Vanstone described this as the point at which Jesus was ‘handed over’, after which, he was inactive and completely at the behest of the actions of others. The conclusion of Vanstone’s thesis related Jesus’ passion to those who also find themselves in a position of utter powerlessness or inaction including those who can no longer participate in meaningful occupation and those impacted by disability. If the only model that Jesus presented in the New Testament was one of activity, this would present a bleak outlook for those living with frailty. Jesus’ passion, when interpreted through Vanstone’s lens offers a model for frail older people. Transcendence comes into this model in that when one is powerless and entirely dependent, the process of waiting enhances the meaning of the actions of others and the effects of creation. There is, of course, a risk of dualism in considering spiritual growth in frailty in this way. However, Vanstone’s model does not seem to suggest a retreat to the inside of the mind, but an acceptance of powerlessness and vulnerability in the inability to influence outcomes.

Conclusions and recommendations for praxis

The interview findings, applied to models of spirituality in frailty, suggest the following conclusions and recommendations:

  1. Spirituality should be a domain of CGA.
  2. There are open-ended questions that can help a clinician assess spirituality as represented in MacKinlay’s model of spirituality in the fourth age.
  3. There is a gap in how to assess and support frail older people with the process of transcending physical limitations.
  4. Christian older people experiencing frailty and dependency have a model in the passion of Christ as to how they might transcend their condition and grow spiritually. There is the possibility for this to be a fruitful season for faithful frail older people.
  5. Health and social care practitioners conducting CGA would benefit from further training and direction in assessing spirituality.
  6. Community chaplains, particularly Anna Chaplains are essential to support the spiritual wellbeing of frail community-dwelling older people and could be considered a part of the multi-disciplinary team.

 

Appendix

From MacKinlay’s spirituality in the fourth age model [10]

 The ultimate meaning in life – Task: to find ultimate meaning.

Frailty drastically impacts on the capacity for ‘doing’. A frail person may lack the energy and ability to participate in activities ranging from volunteering or caring roles to managing their own personal care. This can be an important trigger for spiritual growth as physical limitations lead to the latter part of life becoming a ‘natural monastery’. In those who had faith, this resulted in greater intimacy with God and for those who did not find meaning from God, this came through relationships with others. However, in those without faith or meaningful relationships, this internment could lead to despair.

Response to ultimate meaning – The task: to respond to ultimate meaning.

Physical impairments may constrain the ways in which frail older people are able respond to God as ultimate meaning. Church attendance may be less feasible with the focus needing to shift to scripture, prayer or meditation or meaning mediated through music, art or the environment. Moreover, the ability to engage in scripture and discussion may be limited by sensory impairments (vision or hearing loss) and may need to be facilitated by others. Those who find ultimate meaning in relationship with others may be impacted by the death of a spouse, siblings or friends and disability may further accelerate social isolation.

Self-sufficiency /vulnerability – The task: to transcend disabilities and loss

Frailty leads to dependency on others which threatens self-sufficiency. MacKinlay found that self-transcendence was an important contributor to wellbeing. Those who were able to move from self to other centredness were able to move beyond the physical constraints and find enjoyment in life, suggesting this process is a key task in ensuring spiritual wellbeing in frailty.

Wisdom – The task: to search for final meanings

Becoming frail is a prompt to move to final meanings. As described above, frailty may open time for the reminiscence required to generate a whole life story.

 Relationship/isolation – The task: to find intimacy with God and/or others

There are many factors that contribute to isolation in frailty. However, MacKinlay found in frail older people, relationship becomes more and not less important in the search for meaning. In fact, all the facets of this model of spirituality become more reliant on the support of others as frailty progresses. In some cases, formal carers may be the only means of relationship, and only source of love and affirmation that nourishes the soul.

 Hope/Fear/Despair – The task: to find hope Wisdom

In the interviews with frail older people, MacKinlay found that the state of hope or despair was dependent on the other areas of the model such as self-transcendence and finding final meanings.

 

Author details

Related Publication

Key Points

■      While those in the last years of life may become increasingly frail and dependent, it can also be a time of great spiritual meaning and growth, which can add significantly to their wellbeing.

■      To better understand how spiritual assessment and care factored into a Comprehensive Geriatric Assessment, the author interviewed several health and social care practitioners and Anna Chaplains to assess their experiences and perceptions.

■      The findings suggest that spiritual assessment needs time, trust, and skill. While supporting spirituality in older people is focused on sustaining identity, fostering hope, and encouraging spiritual growth, healthcare professionals lack confidence in their ability to recognise and address spiritual needs.

■      Jesus’s arrest and crucifixion offer a model for exploring spiritual transcendence at a time of life marked by increasing vulnerability.

 

References

References (accessed March 2025)

 

  1. Age UK BGS. Britain Thinks. Frailty: Language and Perceptions A report prepared by Britain Thinks on behalf of Age UK and the British Geriatrics Society. 2015. bit.ly/4j3XrJp
  2. Rodríguez-Mañas L. et al. Searching for an operational definition of frailty: a Delphi method-based consensus statement: the frailty operative definition-consensus conference project. J Gerontol A Biol Sci Med Sci. 2013;68(1):62-7.
  3. Clegg A. et al. Frailty in elderly people. Lancet. 2013;381(9868):752-62.
  4. Han L. et al. The impact of frailty on healthcare resource use: a longitudinal analysis using the Clinical Practice Research Datalink in England. Age Ageing. 2019;48(5):665-71.
  5. Nikolova S. et al. Social care costs for community-dwelling older people living with frailty. Health Soc Care Community. 2022;30(3):e804-e11.
  6. Kojima G. et al . Associations Between Social Isolation and Physical Frailty in Older Adults: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc. 2022;23(11):e3-e6.
  7. Ellis G. et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. 2017;9(9):Cd006211.
  8. Briggs R. et al. Comprehensive Geriatric Assessment for community-dwelling, high-risk, frail, older people. Cochrane Database Syst Rev. 2022;5(5):Cd012705.
  9. MacKinlay E. The Spiritual Dimension of Ageing. Second Edition ed. London: Jessica Kingsley Publishers; 2017.
  10. MacKinlay E. Spiritual Growth and Care in the Fourth Age of Life. London: Jessica Kingsley Publishers; 2006.
  11. Tornstam L. Gerotranscendence: The contemplative dimension of aging. Journal of Aging Studies. 1997;11:143-54.
  12. Ellingson LL. Spirituality within the comprehensive geriatric assessment process. In: Wills M, editor. Spirituality and health communication. Cresskill NJ: Hampton Press. 2009.
  13. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3(2):77-101.
  14. Flood MT, editor A Mid-Range Nursing Theory of Successful Aging. 2005.
  15. Collicutt J. Personal correspondence. 2022.
  16. Vanstone WH. The Stature of Waiting. London: Darton Longman and Todd.; 1982.

  • 6 Marshalsea Road, London SE1 1HL