So what is known in the scholarship of religion and spirituality at this point of the 21st century? Definitions of spirituality show a growing understanding of the breadth and content of spirituality, and yet, there remains no firm definition. In one sense, it might be good that spirituality has not been tightly defined. Swinton and Pattison (Reference Swinton and Pattison2010, p231) note, “multiple definitions may be indicative of the necessity and the flexibility of the term to meet particular needs that would otherwise go unmet.” The publication of the paper written by Agli et al. in this edition of the journal, is timely and provides an excellent systematic review of the recent literature. The authors show the wide variety of understanding of the terms spirituality and religion in the current literature. Meaning and relationship or connectedness are obvious in their inclusion. The relationship of religion with spirituality is also attested to, as is the rise of secular spirituality, unrelated to religious faith. Factors of hope and acceptance are also there. A shifting understanding of religion and spirituality and falling adherence to religious practices in developed societies make it difficult to set parameters for this emerging discipline of study.

Yet, interest in the spiritual dimension in particular, is growing with many more papers appearing that purport to describe spirituality in pastoral care, in medicine, nursing, social work, and psychology to name a just a few of the disciplines that are studying and claiming to apply spirituality within their roles. Claims are made as to the efficacy of adopting spiritual practices to healing and coping. Yet, as can be seen in the paper by Agli et al., a systematic review of the literature over the past decade fails to provide credible evidence of the effectiveness of the application of spiritual and religious behaviors via empirical research. Why is this? Several possibilities are suggested, first, the very lack of agreement on definitions presents problems for comparison between studies. This means that it is still very difficult to set variables for research projects – questions of “what are we measuring and why?” are raised. This is shown in the paper of Agli et al., where they note the different parameters used in the various studies making cross study comparisons difficult. Researchers from different disciplines use their own lenses to study spirituality. Second, and importantly, because of the nature of the spiritual and religious dimensions, it is not possible to randomly select subjects into groups. This is because the spiritual dimension is not about the physical or even psychological dimensions that can be relatively easily quantified, and further, unlike the other dimensions of being human, the spiritual and religious dimensions are about beliefs, not facts.

The spiritual dimension lies at the very core of being, perhaps most appropriately called the “heart” of being. These factors set the scene for a range of complex questions related to exploration and examination of the spiritual domain, perhaps even more emphasized in older people and those who have dementia. In a real sense, study of the spiritual dimension, and religion is about the sacred. Agli et al. reviewing the current research in this field rightly state that, “the benefits observed should be considered with caution and included in rigorous experimental research in the future.” Nevertheless they acknowledge that there do seem to be health benefits for those who have spiritual and/or religious beliefs, especially related to hope, meaning, and acceptance. The obvious effects of spirituality and religion related to health of older people make it an important domain for further study.

During the second half of the 20th century with the rise and growing sophistication of scientific study of human biology, and increasing study of the mind, it seemed that scientists would soon be able to readily map the human being – biologically, psychologically, socially, and spiritually. However, the now seemingly well understood methodologies of the biological and behavioral sciences do not seem able to examine matters of the spiritual or religious to the same degree of effectiveness. As yet it is not clear that current research methods are entirely appropriate to capture the nuances of the spiritual dimension. This domain of enquiry calls for sensitive and perhaps even new ways of research. Spirituality is really a matter of the heart, not in a physiological sense, but associated with life meaning and relationship, at the very depths of one's being.

An important factor in research of spirituality and religion is that it is not possible to compare “doses” of prayer, nor frequency of church attendance to find effects of spirituality or religion on health (Sloan, Reference Sloan and Bagiella2002). The underlying critical factor is belief; therefore it is not possible to randomly assign subjects to different conditions of prayer, or to worship style, or to any other measureable variable. Spirituality is about belief, whether this is a humanistic spiritual belief, or practice of a religious faith.

While it is widely accepted that there is potential for spiritual growth and there are changes in the spiritual dimension relating to religious practices in later life, the reasons for these and the processes by which these changes occur are difficult to track and remain illusive at this stage of scholarship in this field.

Caution is needed not to reduce spirituality to a variable such as an activity or a component of lifestyle, as spirituality can too easily become just another variable in a social science study. In this case, it will fail to reach the reality of spirituality that does make a difference in the lives of older people, especially those facing loss, dying, grief, and dementia. In one sense, spirituality is possibly not even a “coping” mechanism as spirituality is actually a whole dimension of human being. However it is acknowledged that study of coping has formed an important aspect of the development of knowledge of spirituality (Pargament, Reference Pargament2001). A concentration on spirituality in coping tends to reduce the spiritual to just another strategy that can be used in care. The problem with this is, spirituality only really functions where there is a depth of associated meaning and belief, and seems heightened during various life crises. It is not possible to give meaning to another person (Frankl, Reference Frankl1984), nor to specify a mode of treatment based on a spirituality that fails to take account of the individual's belief system, either secular or religious.

Research into the spiritual dimension and religion challenges the scientific mode of approach to examining phenomena. There has been a tendency to dismiss anything that does not lend itself to rigorous scientific examination as not being of real importance to health. And yet, it is becoming very apparent that the spiritual and religious dimensions have real and vital effects on human well-being and are of enormous value to many people as they face issues of loss, dementia, grief, and facing their own deaths. Evidence of differences of outcomes for older people who have a religious faith in health matters have been demonstrated, mostly in North American studies (Koenig et al., Reference Koenig, George and Titus2004; Reference Koenig, King and Carson2012). But just why these effects are demonstrated remains unclear, perhaps we could say, it is a mystery. Best recent studies of the effects of spirituality and religion have used mixed methods of study, applying psychometric testing and combining this with participant engagement in trials of various programs. Thus the interventions have been spiritual or religious, while the variables used have been measurable behaviors, for instance, tracking cognition, depression, and morale over time, while the intervention is being run. Qualitative data is more likely to provide the reasons for the findings from psychometric testing.

The nature of dementia, spirituality and religion, and their relationships are vital to understanding the place of spirituality and religion in the lives of people who have dementia. While the much sought for cure for Alzheimer's disease seems as far off as it was ten or more years ago, strategies are needed now for helping people who have dementia and their families to live full and meaningful lives, in the face of dementia. Spirituality and religion seem to provide a means of supporting these vulnerable people.

Future directions in the research of dementia and ageing will necessarily include a search for new and more effective methods of research as it will only be then that the dimensions of spirituality and religion can be better understood. I wonder though if there will remain an area of mystery in this field. Can we live with struggle, with hope, love and acceptance while not knowing?