Religious Attendance Reduces Cognitive Decline Among Older Women With High Levels of Depressive Symptoms

A growing body of literature has documented the salutary effects of religious involvement on various health outcomes. Specifically, compared with individuals who attend religious functions less frequently, individuals who often attend religious services have lower levels of functional disability (1,2), lower prevalence of hypertension (3), and better functional recovery following an acute myocardial infarction (4). The association between religious involvement and lower mortality is robust (5), with weekly attendance at religious services accounting for an additional 2–3 years of life (6). Notable, of all the religious and spiritual measures available (e.g., private religious practice, religious affiliation, spirituality), it is religious attendance that has consistently demonstrated to be the most beneficial to a wide array of health outcomes. Surprisingly, few studies have investigated the relationship between religious attendance and cognitive decline (CD). Cognitive impairment is an important health outcome affecting many elderly individuals, with the prevalence of dementia climbing from approximately 5% among those in their 70s to 24% for those in their 80s (7). A longitudinal study using data from the New Haven Established Populations for the Epidemiologic Studies of the Elderly (EPESE) Survey found that people who attended religious services once a week or more experienced less CD 3 years later than those who attended less than once a week (8). This effect remained significant after controlling for other forms of social engagement. The authors suggest that religious attendance, as a religious form of social engagement, has a unique influence on cognitive functioning. The effect of regular religious attendance on CD has been replicated in other epidemiological studies using samples of older Mexican Americans (9,10) and older adults from Taiwan (11). Because research on the association of religious attendance to CD is limited, explanations for possible mechanisms that may account for this relationship are not yet well developed. Social elements of religious activities may promote mental stimulation that protects against CD. Indeed, research has found that social disengagement is a risk factor for CD among elderly individuals (12,13). Stimulating activities have been shown to help build cognitive reserve capacity that delays the manifestation of cognitive difficulties (14). Religious attendance may increase sensory stimulation through activities such as prayer, scripture reading, singing, sermons, philosophical discussions, and socializing. Another explanation is that engagement in religious activities provides lessons for coping that, in turn, reduce levels of stress, anxiety, and depression. High levels of stress can lead to increased glucocorticoid production, which may damage the hippocampus and affect learning and memory (15). A third explanation is that religious involvement encourages health-enhancing behaviors and discourages risky behaviors. For example, more frequent religious attendance is strongly associated with greater preventive care use, higher levels of exercise, less alcohol use, and never smoking (2,16). Hill (17) suggested in a Guest Editorial in the Journal of Gerontology: Medical Sciences that additional research is needed to test whether this association extends to other regions and other racial–ethnic populations because the current research from the United States only applies to specific populations. Hill also stated that previous research has overemphasized main effects, and little is known about potential indirect effects of religious involvement on CD. Moreover, there is a need for adequate control of baseline mental and physical health because the healthiest elderly persons may have self-selected into religious attendance. The present study attempted to address Hill’s recommendations using data from the Duke EPESE, which consisted of a large biracial sample of community-dwelling adults from the southeastern United States. Cognitive functioning was assessed both at baseline and at follow-up; therefore, we were able to measure change in cognitive functioning over time. We also controlled for variables associated with both religious attendance and CD, including age, health problems, physical functioning, literacy, and education. Importantly, this is one of the first studies to directly control for the potential effects of social support on CD to help determine whether religious attendance influences CD above and beyond general supportive functions. We expected those who more frequently attended religious services to have less CD than less frequent attendees. Lastly, we examined potential moderators of the relationship between religious attendance and CD, specifically gender and depression. Gender differences have been reported between religious attendance and other important health outcomes such as mortality (5,18), psychological distress (19), disability (1), and depression (20), with the protective effect of religious attendance stronger among women. One explanation for these results is that men and women may express their religious faith differently. For example, women pray more frequently than men (21). Therefore, in our study, we expected religious attendance to have a greater influence on women than on men in reducing CD. Nevertheless, other studies have found no gender differences in the relationship between religious attendance and CD (8,9). We were also interested in whether depressive symptoms moderated the religious attendance–CD relationship. There is growing evidence to support the link between higher levels of depression and faster CD (22–27). We hypothesized that individuals with higher levels of depressive symptoms, those at greater risk for CD, would experience more benefit cognitively from attending religious services regularly than those with lower levels of depressive symptoms. Indeed, a recent study found that among those with depression, the inverse relationship between church attendance and cognitive functioning was particularly strong (10). We also examined whether the proposed interaction between depressive symptoms and religious attendance would be influenced by gender. Individuals at highest risk for CD may derive a unique benefit from activities that reduce CD. Given that individuals with higher levels of depressive symptoms are at greater risk for CD as compared with individuals with lower levels of depressive symptoms, and given that religious attendance has been shown to confer greater health benefits to women as compared with men, we hypothesized that the effect of religious attendance on CD would be particularly strong among women with high levels of depressive symptoms. Specifically, more frequent religious attendance would be uniquely beneficial for women with more depressive symptoms than those with fewer depressive symptoms.