The Relationship of Death Anxiety With Loneliness and Psychological Well-Being in the Elderly Living in a Nursing Home

Abstract

This descriptive correlational study aimed relationship of death anxiety with loneliness and psychological well-being in the elderly living in a nursing home. The study was conducted on the elderly living in a nursing home in Istanbul, Turkey, between November 2021-February 2022. The study sample included 165 nursing home residents. The Sociodemographic Characteristics Form, Death Anxiety Scale (DAS), Loneliness Scale for the Elderly (LSE) and Psychological Well-Being Scale were used as data collection tools. The elderly participants obtained a mean score of 6.10 ± 3.50 from DAS, a mean score of 9.01 ± 4.08 from LSE, and a mean score of 38.97 ± 10.05 from Psychological Well-Being Scale. When death anxiety scale mean score of the elderly was compared with their mean scores of loneliness scale and psychological well-being scale, a weak and negative correlation was determined between psychological well-being and loneliness (p < 0.001). As the mean score of psychological well-being scale increases, loneliness scale mean score decreases.

Keywords

older adults elderly death anxiety loneliness psychological well-being

Introduction

Throughout human history, death has occupied a large place in art, literature, myths, and cultural and religious practices (Becker, 1977). Beyond differences such as culture, nationality, and sociocultural and life style changes, death constitutes the common point of all humanity. Death, which means the termination of life, can be defined in different ways in various resources (Kasar et al., 2016; Yılmaz, 2018). The individual, who mostly focuses on the phenomenon of growth in earl years of life, starts to perceive loss of life as normal but can consider the death of young individuals as untimely or early. Therefore, those who are closest to death are considered to be elderly individuals (Onur, 2014). Death is a sociocultural event; for this reason, knowing about individuals’ feelings, attitudes, and judgements, and fears, if any, about death can heal individuals’ psychological health in the process towards death. Death is a source of anxiety and worry for all individuals, young and old alike. However, it is a known fact that the rate of death at a young age is lower compared to death at an old age (Say Şahin, 2021; Yilmaz, 2018; Yukay, Gunes, Akdag, 2017). Growing elderly population in the world emphasizes the necessity of focusing on the psychological problems of the elderly such as death anxiety (Mohammadpour et al., 2018).

Death anxiety is a natural and normal experience. It exists in the life of the individual in different degrees. It is affected by factors such as environmental events, age, and gender. Having death anxiety at a low level throughout one’s life is necessary to encourage individuals to carry out positive activities; however, a high level of death anxiety can lead to discordance in the individual. Such anxiety intensifies stressful conditions and may cause the development of a feeling of emptiness related to life and disappointment (Sargent-Cox et al., 2014; Nagaraj & Nithyanandan, 2019). Death anxiety and depression regarding death can lead to the emergence of situations that prevent the individual from feeling psychologically good and may negatively affect the individual’s daily life (Kurt Magrebi & Akcay, 2020)).

Research has demonstrated that death anxiety is more prevalent in the elderly (Cavusoglu et al., 2020; Nal et al., 2016; Zhang et al., 2019). Nal et al. (2016) determined in their study that the elderly experienced death anxiety more in comparison to young individuals due to factors such as loneliness, lack of care, death of the spouse, worry about illness, and treatment costs. In addition, a higher level of death anxiety was determined in the elderly who had a chronic illness such as chronic obstructive disease accompanying this situation (Nal et al., 2016). Zhang et al. (2019) emphasized that death anxiety could affect stress levels. In the study they conducted with the participation of 290 elderly individuals at a nursing home and rehabilitation center, Kurt Magrebi and Akca (2020) found death anxiety in the elderly at a moderate level. Cavusoglu et al. (2020) identified death anxiety in 34% of the participants in the study they conducted on the elderly. In a recent study they conducted on individuals who had myocardial infarction, Yildirim and Kocatepe found death anxiety at a severe level (Yildirim & Kocatepe, 2021).

Loneliness is among the important problems that affect the quality of life in the elderly. Loneliness related to weak social relations and communication skills is observed in the elderly living at institutions (Bilgili et al., 2012). Death anxiety and loneliness are situations that affect the quality of life of the elderly individual. In the study conducted by Aisenberg-Shafran et al. (2021), it was determined that the elderly individuals with high levels of death anxiety had higher levels of loneliness in comparison to other age groups (Aisenberg-Shafran et al., 2021). In a cross-sectional study conducted, higher levels of loneliness in the COVID-19 pandemic period were reported (Bu et al., 2020). Although many studies have been conducted in order to prevent or reduce loneliness in the elderly residing in nursing homes (Joosten-Hagye et al., 2020; Maliga et al., 2019; Siniscarco et al., 2017), little is known about the strategies used daily by the elderly in order to diminish their loneliness. Therefore, it is important to determine how these variables affect one another.

In the study he conducted, Silva et al. (2021) stipulated that the increase in death anxiety in the elderly was associated with lower levels of psychological well-being indicators. Uncontrolled and unregulated death anxiety can lead to an increase in individuals’ anxiety levels and psychological disorders (Pyszczynski et al., 2021). Death anxiety has been associated with negative health results such as decrease in physical functions, psychological stress, disrupted ego integrity, life dissatisfaction, and low endurance (Semenova & Stadtlander, 2016).

Along with the changes and pandemic experienced all over the world in recent years, each individual experiences death anxiety at certain levels. When the studies conducted in the literature are examined, a limited number of studies conducted on only the elderly can be accessed (Cavusoglu et al., 2020; Kurt Magrebi and Akca, 2020; Nal et al., 2016; Zhang et al., 2019). A study in which death anxiety, loneliness, and psychological well-being levels were evaluated together was not encountered, and limited studies where these issues were handled only with sociodemographic variables were accessed (Bassett & Bussard, 2021; Guner et al., 2021; Hajihasani and Naderi, 2021; Rababa et al., 2021; Silva et al., 2021).

Therefore, as a result of the study, it was aimed to determine the elderly individuals’ death anxiety, loneliness status, and psychological well-being levels, and by reducing the psychological burden on the families and healthcare professionals, to help them cope with such situations more easily. Determining the relationship between death anxiety, loneliness, and psychological well-being is also important for the increasingly aging population of the world. Examining the relationship between these concepts is necessary in terms of determining the quality of health services to be provided to the elderly. In the long term, it is aimed to reduce the elderly individuals’ death anxiety and loneliness by developing institutional policies that will help them in coping with these feelings and to increase their psychological well-being levels.

Materials and Methods

Study Sample

The study was conducted on the elderly living in a nursing home in Istanbul, Turkey, between November 2021- February 2022. The study sample included 165 nursing home residents who met the inclusion criteria and agreed to participate in the study. The mean age of the participants was 69.21 ± 9.41, 66.7% were male, and 94.5% were single. 73.3% of the elderly had primary school education, and 67.3% reported their economic status as moderate (Table 1). In the study, the Sociodemographic Characteristics Form, Death Anxiety Scale (DAS), Loneliness Scale for the Elderly (LSE), and Psychological Well-Being Scale were used as data collection tools. The inclusion criteria were determined as follows: being 60 years old and above, volunteering to participate in the study, and being able to communicate in Turkish. The exclusion criterion was determined as follows: not having a neurological or psychiatric disorder that will hamper communication. All participants were informed about the study’s purpose before the study. All of them consented to participate in the present study.

Table 1.

Distribution of the Elderly Individuals’ Sociodemographic Characteristics, Presence of Death Anxiety, and Loneliness Level (n = 165).

Variables	Mean ± SD	Number	%
Age	69.21 ± 9.41
Gender	Female	55	33.3
Gender	Male	110	66.7
Marital status	Single	156	94.5
Marital status	Married	9	5.5
Educational level	Primary school	121	73.3
	High school	36	21.8
	University	8	4.8
Economic status	Low	47	28.5
	Moderate	111	67.3
	High	7	4.2
Presence of a chronic disease	Yes	90	54.5
Presence of a chronic disease	No	75	45.5
Death anxiety	Yes	55	33.3
Death anxiety	No	110	66.7
Loneliness	Not feeling lonely	22	13.3
	Acceptable loneliness	122	73.9
	Very lonely	21	12.7

Data Collection Tools, Sociodemographic Characteristics Form Sociodemographic Characteristics Form consists of 6 questions (age, gender, marital status, educational status, economic status, and presence of a chronic disease) inquiring about the sociodemographic characteristics of the elderly.

Death Anxiety Scale

The scale developed by Templer (1970) was adapted to Turkish by Senol (1989). Senol also included elderly individuals in his study. Later, Akca and Kose (2008) carried out a validity and reliability study in order to improve the scale. The 15-item scale is a 2-point Likert type scale scored as correct and incorrect. Correct answers are scored as 1, and incorrect answers are scored as 0. The last 6 items on the scale are reversely scored. The scores to be obtained from the scale range between 0–15, which means that the minimum score to be obtained from the scale is 0, while the maximum score is 15. A score of 7 and above is interpreted as high level of death anxiety, and a score of 6 and below shows a low level of death anxiety. The Cronbach’s alpha reliability coefficient of the sale was determined as >=0.79 (Akca & Kose, 2008). In the present study, the Cronbach’s alpha reliability coefficient of the Death Anxiety Scale was calculated to be 0.76.

Loneliness Scale for the Elderly

The scale developed by de Jong Gierveld and Kamphuis in 1985 (de Jong Gierveld & Kamphuis, 1985) was revised by van Tilburg and de Jong Gierveld (1999). The 11-item scale has two subscales, which are emotional loneliness and social loneliness. The scale has a 3-point Likert type scoring system (0 = Yes, 1 = maybe, 2 = no). Turkish adaptation study of the scale was conducted by Akgul & Yeşilyaprak, 2015. The scale’s Cronbach’s alpha coefficient is 0.85. In the present study, this coefficient was found to be 0.78.

Psychological Well-Being Scale

The scale was developed by (Diener et al., 2009), and its Turkish adaptation and reliability studies were carried out by Telef (2013). The items on the scale are scored between 1 and 7 as (1) Totally Disagree and (7) Totally Agree. All items on the scale include positive statements. When all items are scored as “totally disagree”, the total score to be obtained is 8, while the total score to be obtained is 56 when all items are scored as “totally agree.” A high score indicates the individual has many psychological resources and power. The Cronbach’s alpha coefficient of the scale was determined as 0.80 (Telef, 2013). In the present study the Cronbach’s alpha coefficient of the scale was found as 0.86.

Data Analysis

The data were analyzed by using descriptive statistics such as number, percentage, mean, and standard deviation (IBM Corp, 2016) Kolmogorov-Smirnov test was used to examine normality. Pearson correlation analysis between the scales was performed (Büyüköztürk et al., 2015). Chi-square analysis was performed between Loneliness Scale for the Elderly and Death Anxiety Scale and sociodemographic data. T-test in independent groups and one-way analysis of variance were performed between Psychological Well-being Scale and sociodemographic data.

Ethical Considerations

Ethical Approval (2021/621) from the Ethics Committee in Istanbul Aydın University in Turkey and the institutional permission from the nursing home where the study was conducted were obtained in order to conduct the study. Participants who volunteered to participate in the study signed consent forms.

Results

Descriptive Statistics

54.5% of the participants reported the presence of a chronic disease. It was determined that 33.3% of the elderly had death anxiety, and that 73.9% had an acceptable level of loneliness.

Mean Scores Obtained from Death Anxiety in the Elderly Scale, Loneliness in the Elderly Scale, and Psychological Well-Being Scale

Mean Scores Obtained from Death Anxiety in the Elderly Scale, Loneliness in the Elderly Scale, and Psychological Well-Being Scale are presented in Table 2. The mean score obtained from Death Anxiety in the Elderly scale was determined to be 6.10 ± 3.50, the mean score obtained from Loneliness in the Elderly scale was found to be 9.01 ± 4.08, and the mean score obtained from Psychological Well-Being Scale was determined as 38.97 ± 10.05 (Table 2).

Table 2.

Mean Scores Obtained from Death Anxiety, Loneliness, and Psychological Well-Being in the Elderly Scales.

	n	Mean ± SD	Min-Max
Death anxiety scale mean score	165	6.10 ± 3.50	0–14
Loneliness scale mean score	165	9.01 ± 4.08	0–16
Psychological well-being scale mean score	165	38.97 ± 10.05	16–56

Correlation Analyses

When the elderly individuals’ mean scores of Death Anxiety in the Elderly Scale, Loneliness in the Elderly Scale, and Psychological Well-Being Scale were compared, it was determined that there was weak negative correlation between psychological well-being mean score and loneliness mean score (r = 0.345; p < 0.001). As psychological well-being mean score increases, loneliness mean score decreases (Table 3).

Table 3.

The Relationship Between the Elderly’s Individuals’ Death Anxiety Scale Mean Score and Loneliness and Psychological Well-Being Scale Mean Scores.

	1	2	3
Death anxiety	1
Loneliness	0.091	1
Psychological well-being	0.009	−0.345*	1

r: Pearson correlation, *p < 0.001.

When the relationship between the elderly individuals’ death anxiety level and their sociodemographic characteristics was examined, no statistically significant relationship was found between the presence of death anxiety in the elderly and their gender (χ² = 0.055, p = 0.815), marital status (χ² = 0.529, p = 0.467), educational level (χ² = 0.015, p = 0.901), economic status (χ² = 0.372, p= 0.542) and presence of a chronic disease (χ² = 0.110, p = 0.740) (Table 4).

Table 4.

The Relationship Between the Elderly Individuals’ Sociodemographic Characteristics and Death Anxiety Levels (n = 165).

		Death Anxiety				Test and Significance Level
		Yes		No
		Number	%	Number	%
Gender	Female	19	34.5	36	65.5	χ² = 0.055p = 0.815
Gender	Male	36	32.7	74	67.3	χ² = 0.055p = 0.815
Marital status	Single	51	32.7	105	67.3	χ² = 0.529p = 0.467
Marital status	Married	4	44.4	5	55.6	χ² = 0.529p = 0.467
Educational status	Primary school	40	33.1	81	66.9	χ² = 0.015p = 0.901
Educational status	High school and above	15	34.1	29	65.9	χ² = 0.015p = 0.901
Economic status	Low	14	29.8	33	70.2	χ² = 0.372p = 0.542
Economic status	Moderate	41	34.7	77	65.3	χ² = 0.372p = 0.542
Presence of a chronic disease	Yes	31	34.4	59	65.6	χ² = 0.110p = 0.740
Presence of a chronic disease	No	24	32.0	51	68.0	χ² = 0.110p = 0.740

When the relationship between the elderly individuals’ sociodemographic characteristics and their loneliness level was examined, no statistically significant relationship was determined between loneliness and gender (χ² = 2.562, p = 0.278), marital status (χ² = 0.074, p = 0.964), educational level (χ² = 0.664, p = 0.718) and the presence of a chronic disease (χ² = 3.281, p = 0.194) (p > 0.05). The examination of the relationship between the elderly individuals’ economic status and loneliness revealed that 59.6% of the elderly with a low economic status experienced loneliness at an acceptable level, 79.7% of those with a moderate economic status experienced an acceptable level of loneliness, and the difference was statistically significant (χ² = 21.992, p = 0.000) (Table 5).

Table 5.

The Relationship between the Elderly Individuals’ Sociodemographic Characteristics and Loneliness Levels (n = 165).

		Loneliness						Test and Significance Level
		Not Feeling Lonely		Acceptable Loneliness		Very Lonely
		Number	%	Number	%	Number	%
Gender	Female	9	16.4	42	76.4	4	7.2	χ² = 2.562 p = 0.278
Gender	Male	13	11.8	80	72.7	17	15.5	χ² = 2.562 p = 0.278
Marital status	Single	21	13.5	115	73.7	20	12.8	χ² = 0.074 p = 0.964
Marital status	Married	1	11.1	7	77.8	1	11.1	χ² = 0.074 p = 0.964
Educational level	Primary school	17	14.0	90	74.4	14	11.6	χ² = 0.664 p = 0.718
Educational level	Highschooland above	5	11.4	32	72.7	7	15.9	χ² = 0.664 p = 0.718
Economic status	Low	4	8.5	28	59.6	15	31.9	χ² = 21.992 p = 0.000
Economic status	Moderate	18	15.3	94	79.7	5.1	5.4	χ² = 21.992 p = 0.000
Presence of a chronic disease	Yes	13	14.4	62	68.9	15	16.7	χ² = 3.281 p = 0.194
Presence of a chronic disease	No	9	12.0	60	80.0	6	8.0	χ² = 3.281 p = 0.194

When the distribution of the elderly individuals’ psychological well-being mean scores was examined according to their sociodemographic characteristics, no statistically significant difference was found between their psychological well-being scores in terms of gender, marital status, educational level, and presence of a chronic disease (p > 0.05). It was found that the difference between the economic status of the elderly individuals and their psychological well-being mean score was statistically significant (p < 0.05), and that the difference resulted from the elderly individuals with low economic status (Table 6).

Table 6.

The Relationship Between the Elderly Individuals’ Sociodemographic Characteristics and Psychological Well-Being Levels.

Variables		Psychological Well-Being Mean ± SD	Test Value p
Gender	Female	39.78 ± 10.29	t = 0.727
Gender	Male	38.57 ± 9.94	p = 0.468
Marital status	Single	39.07 ± 9.98	t = 0.537
Marital status	Married	37.22 ± 11.71	p = 0.592
Educational level	Primary school	38.80 ± 9.60	F = 0.179
	High school	39.08 ± 11.63	p = 0.836
	University	41.00 ± 10.11
Economic status	Low	34.08 ± 9.63*	F = 8.557
	Moderate	40.84 ± 9.71	p = 0.000
	High	42.14 ± 7.42
Presence of a chronic disease	Yes	37.73 ± 10.48	t = −1.750
Presence of a chronic disease	No	40.46 ± 9.35	p = 0.082

The data regarding the correlation between psychological well-being mean score and age were presented. Accordingly, no statistically significant relationship was found between the elderly individuals’ psychological well-being mean score and mean age (r = 0.063; p > 0.05).

Discussion

The study aimed to determine death anxiety, loneliness, and psychological well-being in the elderly living in a nursing home. Variables such as age, gender, marital status, and continuously thinking about death can affect death anxiety in the elderly (Say Şahin, 2021).

The elderly individuals obtained a mean score of 6.10 ± 3.50 from Death Anxiety Scale. Considering that the maximum score is 16, it can be stated that their death anxiety was at a moderate level. In addition, it was determined that 33.3% experienced death anxiety. In a study recently conducted at a nursing home by Kurt Magrebi and Akcay (2020), Death Anxiety Scale mean score was similarly found to be 7.24 ± 2.27. And in another similar study, no relationship was found with gender, marital status, educational status, and presence of a chronic disease (Kurt Magrebi & Akcay, 2020). The study being conducted at a single center and the characteristics of the population investigated may have affected this result. Similarly, in a study conducted by Guner et al. (2021) in the COVID-19 pandemic period, death anxiety in the elderly was found at a moderate level.

In the present study, the mean score obtained by the elderly from the loneliness scale, from which the maximum score to be obtained is 22, was found to be 9.01 ± 4.08. While an acceptable level of loneliness was determined in 73.9% of the elderly, 12.7%, whose loneliness score was above the average, were found to be very lonely. Similarly, in the study conducted by Guner et al. (2021), loneliness mean score in the elderly was found as 11.39 ± 5.31. Similar to the results of the present study, no statistically significant correlation was found between gender and loneliness mean score (Guner et al., 2021). In the present study, one of the outstanding variables was the economic status of the elderly. It was determined that as the economic status improved, a lower level of loneliness was found. More comparative studies are needed in this field. It is thought that improving the economic conditions of individuals in their old age and retirement will have a positive impact on their loneliness level and socialization.

In the present study, the mean score obtained from the psychological well-being scale, the maximum score of which is 56, was found to be 38.97 ± 10.05, which is above the average score. In addition, differently from the sociodemographic variables, the difference between the economic status of the elderly and their psychological well-being mean score was statistically significant. The importance of psychological well-being for healthy aging is known. Similarly, in the study they conducted, Ooi et al. (2021) reported that psychological well-being was one of the significant factors for a healthy life in the elderly. In evaluating active aging, factors such as psychological well-being, social support and creating a network should be reinforced. A detailed examination of psychological well-being, which has an impact on economic status, is all the more necessary than ever (Ooi et al., 2021). In the present study, in support of this situation, it was seen that the difference between the economic status of the elderly and their psychological well-being mean score was statistically significant, and that the difference originated from the elderly with low economic status. Psychological well-being in the elderly is affected by economic status. Accordingly, managers of the community and health system planners and managers should take necessary precautions that will support the elderly in their old age. The negative relationship between psychological well-being mean score and loneliness mean score is an expected result, and it is an important finding that a statistically significant difference was determined between economic status variable and both of these variables.

Conclusion

It is believed that knowing about death anxiety in the elderly will be a guide for the clinical practices of healthcare professionals. Moreover, loneliness and psychological well-being in the elderly are still an important issue. In the light of these results, the necessity to support the elderly socially and economically among the precautions to be taken and interventions to be made specific to old age comes to the foreground. A multi-disciplinary and multi-sector approach is needed in order to reduce the elderly individuals’ experiencing death anxiety, to minimize their feeling of loneliness, and to increase their psychological well-being levels.

Limitations of Study

The study is important in that it evaluated death anxiety, loneliness, and psychological well-being in the elderly together. No study that examined these variables in a nursing home in the pandemic period has been encountered in the literature. A limitation of the study is that it was carried out in a single center, so studies to be conducted in more than one centers and with a larger sample size are recommended. Also, future longitudinal studies with different designs such as mixed method that aim to explain death anxiety and other variables can be conducted.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Emine Ergin

Dilek Yildirım

Author Biographies

Emine Ergin is working as an assistant professor at University of Health Sciences, Hamidiye Faculty of Health Sciences-İstanbul Turkey. Public Health Nursing PhD. Her research areas of interest concern nursing education, older adults, home visits, public health interventions.

Dilek Yildirim is working as an assistant professor at Nursing Department in Istanbul Aydın University, Faculty of Health Sciences-Turkey. Her research areas of interest concern palliative care, cancer, pain, cancer symptoms, intensive care nursing research.

Cennet Ciriş Yildiz is working as an assistant professor at Nursing Department in Istanbul Aydın University, Faculty of Health Sciences-Turkey. Her research areas of interest concern management and care in nursing.

Sevinc Yildirim Usenmez is working Darulaceze Directorate Nursing Home, Istanbul Metropolitan Municipality, Istanbul, Turkey. Her research areas of interest concern older adults.

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