Death distress in Iranian older adults.
By increasing of population of elders, consider to physical and mental health problems of them is expanding. It is anticipated that population of elders will be more than 26 million by 2050 . Iran SCO (2006) reported that population over 60 years was 6/6% in 2006 and it will be increase to 10% in Iran by 2020 . Aging is a process associated with changes in physiological, psychological and sociological dimensions. In addition to downward trend of biological processes, quantitative and qualitative increasing of stress related to aging, facing with inevitable death and anxiety associated with death, have an important role in development of mental disorders in aging as well. On the basis plurality and diversity of stressors that elderly people are faced with them, regarding to mental health of old age is a necessity. Fear of death only does not occur in the elderly, but rising of age may increase such phobias and death fear increases to possible highest rate in old age. Even it is possible that anxiety due to death causes a mental disorder in the elderly .
Changes in old age are including decline in physical abilities, changes in the body's response to drugs, experience of life events such as retirement, stay in elderly homes, reduction of income and opportunities for social connection that are causing loneliness in the elderly. Depression, anxiety and death anxiety are common in elders . Elders have to tolerate grief, several losses, changes in job status, loss of physical strength and health . Tse  reported that elders who were living in nursing home experienced undesirable emotions and feelings such as insecurity, abandonment, loneliness, lack of privacy, and they considered there as a prison for themselves.
In the eighth and final stage of Erik Erikson's theory of psychosocial development, psychosocial conflict is integrity versus despair, major question is "Did I live a meaningful life?" basic virtue is wisdom and important event is reflecting back on life. Dealing with task related to eighth stage of life is as a part of critical developmental period. During this period of time, elders who feel proud of their accomplishments will feel an integrity sense, look back with few regrets and feel satisfaction. These elders will attain wisdom, even when they confront with death. Wisdom enables a person to look back on their life with a sense of closure and completeness, and also accept death without fear. Elders who are unsuccessful during this stage willfeel their life has been wasted and will experience many regrets, will not confront with death and will avoidant and fear to death .
There are four major concerns in human existence including freedom, loneliness, meaninglessness and death . Dimensions of death are including death anxiety, death depression and death obsession that were introduced as death distress by Abdel--Khalek . Death anxiety includes thoughts, fears and emotions associated with the end of life [10, 11]. This type of anxiety is a multidimensional concept. In view of Halter and Halter (1987) there were eight dimensions for death anxiety including: fear of the dying process, fear of premature death, fear of object ones, phobias of death, fear of destruction, fear of the body after death, fear of being unknown of death and fear of the dead . In the middle and late life, fear of death is common phenomenon . Wu, Tang, and Kwok  reported that in Chinese elderly people, level of death anxiety was associated with younger. In Japanese older there were socio- cultural components related to death anxiety . Ozturk, Karakus, and Tamam  reported a significant increase in death anxiety among elderly cases that had frequent death thoughts in last month.
Nouhi, Karimi, and Iranmanesh  reported that elderly group inhabited in houses had significantly higher total score on the Collett-Lester Fear of Death than elderly group settled in the elderly home. Having kind, compassionate and more relatives was increased fear of death in elders . More attachment to family, friends, and relatives increased more death fears in elders . Death depression is a psychological and conceptual phenomenon related to death . Anxiety level and death distress are related to depression . Almostadi  indicated that significant correlation between death anxiety and death depression. Death obsession includes ruminations, repetitive, intrusive thoughts or images about death . There is a significant positive relationship between death rumination, death dominance and death idea [23, 24]. Despite of the growth of the elderly population is not still focused on needs of them. Death fear, death of friends, family members, and pets, the loss of a spouse or partner are one of factors of depression in elderly. Feeling of loneliness, isolation and despair, lacks of aging and approaching to the reality of death may, propel them into meaningless and death distress in life . The aim of the present study was to examine death distress in Iranian older adults and to compare this distress among women and men older adults.
MATERIALS AND METHODS
The participants were 74 older adults (44 men and 30 women) who were living in the community and they selected from public places. Available sampling was used. They were participated voluntary in the study and administered a demographic information sheet, Templer's Death Anxiety Scale (TDAS), Death Depression Scale (DDS), and Death Obsession Scale (DOS) for measuring death distress. The demographic information sheet were asked for age, sex, level of education, marital and job status, number of children, history of physical illness, psychiatric disorder, and take medication and also types of them.
Templer's Death Anxiety Scale (TDAS) is a self-administered scale, with 15 items. It is answered to false = 0 and true =1. Items of 2, 5, 6, 7, and 15 were scored reversely. Range of total scores is 0-15. Death Depression Scale (DDS) has 17 items and six elements including death despair, death loneliness, death fear, death sadness, death depression and death end. It is answered to false = 0 and true =1. Items of 11 and 12 were scored reversely. Range of total scores is 0-17. Death Obsession Scale (DOS) has 15 items and is answered to No = 1, A little = 2, A fair amount = 3, Much = 4 and Very much = 5on a 5-point Likert-type rating scale. Range of total scores is 15-75. Good psychometric properties, desirable validity and reliability have been reported for TDAS by Conte, Weiner, & Plutchik , Rajabi, & Bahrani , Naderi, & Esmaili , Roshani, & Naderi , Tavakoli, & Ahmadzadeh , Bashi, & Lester , for DDS by Templer, Lavoie, Chalgujian, et al , Abdel-Khalek , and for DOS by Abdel-Khalek , Maltby & Day , Tomas--Sabado, & Gomez--Benito , Mohammadzadeh, Asgharnejad Farid, & Ashouri , Rajabi , Rajabi , and Moripe, & Mashegoane .
RESULTS AND DISCUSSION
Results showed that age means of participants was 65.72, SD 5.60. 41% of them were female and 59% male, 36% diploma and over, 73% married, 53% retired and 93% had child with mean 3.78, SD 1.72. History of physical illness, psychiatric disorder, and take medication were 57%, 7%, and 55% respectively (see Table 1). Types of physical illness were including diabetes, fat, BP, TBI, renal, thyroid, heart disease, brain tumor, lung, digestion, eye, ear, leg pain, headache and back pain (1%-22%). Psychiatric disorders were including depression, phobia and epilepsy each of them 1%. Medications were including Fat, Insulin, blood pressure, thyroid, cardiac, and psychiatric drugs (1%-22%).
Findings showed that older adults indicated death distress on TDAS (mean 7.48, SD 3.32), DDS (mean 7.69, SD 4.34), and DOS (mean 27.95, SD 11.94). Women older adults had higher death distress than men older adults on TDAS (7.8 vs.7.2), DDS (8.7vs.7.7), and DOS (7.7 vs. 27.6), but these differences were no statistically significant (see Table 2).
Present study showed that older adults showed death distress on TDAS, DDS, and DOS. These findings are according to results of Cicirelli , Fountoulakis, Siamouli, & Magiria, et al , Ron , Kawano  and Ozturk, Karakus, & Tamam . Suhail and Akram  found that elders obtained higher scores in death anxiety. Depaola, Griffin, Young, et al  reported that Caucasian subjects showed higher fear of the dying process than older African American subjects and they reported higher levels of death anxiety on three subscales of the MFODS (fear of the unknown, fear of conscious death, and fear for the body after death) than older Caucasian subjects. Azaiza, Ron, Shoham, et al  reported that elderly Arab Muslims living in the nursing home, showed more death anxiety than elderly living in the community. Missler, Stroebe, Geurtsen, et al  explored that there were limited studies focuses on death anxiety among the elderly, particularly those who were resident in institutions. Also elderly had higher scores of fear for others that it was associated with poor physical health, and also fear of the dying process that it was associated with low self-esteem, little purpose in life, and poor mental well-being. Harrawood, White and Benshoff , Demuthova  reported that age is connected with death fear levels and older shower less death fear than younger. Chuin and Choo  found that there were no different on levels of death anxiety scale in young adults compare to older adults.
Present study showed that women older adults had higher death distress than men older adults but this difference was no statistically significant. Fortner and Neimeyer  found that gender does not predict death anxiety in elderly. According to findings of other studies, Suhail & Akram , Abdel-Khalek , Lester, Templer, and Abdel-Khalek  indicated that women showed more death anxiety than men. Sarvandian, and Hasan Pour  reported that there was a relationship between loneliness and fear of death in elderly men and women living in elderly home. Findings of Depaola, Griffin, Young, et al  showed that older women reported higher scores on the Fear of the Dead subscale of the Multidimensional Fear of Death Scale (MFODS) than older men. Abdel-Khalek  declared that relation between love of life and death distress scales were not significant, except death depression and one pertaining to love of life that was negative in women. Azaiza, Ron, Shoham, et al  indicated that death anxiety was related to gender and education for elderly living in the community and elderly women and uneducated persons showed more of death fear levels than other elders. Missler, Stroebe, Geurtsen, et al  reported that elder women showed more death fear of loved ones and also consequences of their own death on these loved ones. But Wu, Tang, & Kwok  declared that there was no difference between Chinese elderly women and men in death anxiety. Chuin and Choo  reported that women subjects had lower death anxiety. Differences in sample size, used instruments, stay place, religious and cultural differences can justify results present study with findings of other studies.
One of the undeniable facts in aging is coming to true of death . Religion is one of the spiritual intelligence domains that can reduce death anxiety in elders . Findings have shown that faith and believe to life after death is related to less fear of death. Persons, who were more religious, reported more less fear of death. In fact religious attitudes make persons overcome to their fear, feel more comfortable in their life and more cope with fact of death fear [52-55]. Ali Akbari Dehkordi, Oraki, and Barghilrani  reported that there was a negative correlation between internal religious orientations and death anxiety, and a significant positive solidarity between external religious orientations and death anxiety. Paimanfar, Ali Akbari Dehkordi, and Mohammadi  found that elderly who had stronger faith and religious attitude, reported a more sense of meaning in life, also less feel of lonely compare to other older adults. Religion can have a main role in mental health of elderly [58, 59]. Elders for religious beliefs and behaviors are placed great value, religion is important in their lives and they think to the deeper meaning of religious symbols and rituals. Religious activity is associated with several positive outcomes such as prevention and reduction of mental disorders for instance anxiety and depression in elders . Bahrami, Dadfar, and Dadfar  reported that religious teachings were effective in decreasing depression and dysfunctional attitudes in elders. Maintain of spiritual issues and strengthen of religious or spiritual beliefs help to alleviate depression in elderly. Among coping strategies of elderly, religion plays an important role and has a positive valuable load for filling blank space of life, social support of elderly, dealing with stress, appropriate adjustment with situations and meaning of life and death . A sense of meaning in life related to religion and religious attitudes . Religion is one of spiritual intelligence domains that can reduce death anxiety in elders . Ellis, Wahab, and Ratnasingan  found that religiosity is positively correlated with increase of death fear and meaning and more religious persons, showed more fear from the death in the US, Turkey, and Malaysia.
Overall, the source of anxiety and stress in aging is different from other life stages. In aging, the origin of these factors is focused on death anxiety and the anxiety of lack of change and compensation in the life. Elders reviewing of their life experiences and memories conclude that there is no chance to compensate of their mistakes. Therefore fear of death concerns them. Awareness of death increases a sense of responsibility towards life. Elders with knowledge of death are used all their efforts for responsibility to their life. Also information and awareness of death increases motivation in the facing with high risk activities. Knowledge about inescapable death gives an opportunity to elders to live bravely regardless aware of their defects. Since, death distress can effect on physical and mental health of older adults, and can interfere in their health care, therefore death education program for coping of them with issues related to death, is necessary. Wass and Myers , Cicirelli , Dadfar, Lester, & Kolivand  reported that elders need to learn about different aspects of death and dying including psychosocial components, therefore helping to them for coping with concerns related to death and dying, is necessary. Furer and Walker  developed an approach for treatment of death anxiety that its components were including exposure to feared themes related to death, reduction of safety behaviors, cognitive reappraisal, increased focus on life goals and life enjoyment, and relapse prevention. Ghorban Alipour, and Esmaieli  reported that logo therapy reduced death anxiety in the elderly who lived at home.
In present study religious attitudes of elders were not measured. Since religious attitudes are a preventive agent to reduce of problems of elderly about death issues, considering of these attitudes in future research, is recommended. Longitudinal studies to examine levels and fluctuations of death distress (death anxiety, death depression and death obsession) in across life span, is suggested. This research was carried on Iranian Muslim older adults, therefore generalizability of the present findings to older adults who are resident in elderly and nursing homes, other population, culture, and religion merits further investigation.
Received 15 April 2014
Received in revised form 22 May 2014
Accepted 25 May 2014
Available online 15 June 2014
This paper is based on a research that financially was supported by University of Social Welfare and Rehabilitation Sciences in Tehran, Iran. The researchers have no conflicts of interest. We thank all of subjects who participated in the study.
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(1) Fazel Bahrami, (2) Mahboubeh Dadfar, (3) David Lester, (4) Ahmed M. Abdel-Khalek
(1) PhD. Faculty Member in University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
(2) PhD Student in Clinical Psychology, International Campus-Iran University of Medical Sciences (IC-IUMS), Tehran, Iran
(3) PhD, Psychology Program, the Richard Stockton College of New Jersey, USA
(4) PhD, Department of Psychology, College of Social Sciences, Kuwait University, Kuwait
Corresponding Author: Mahboubeh Dadfar, PhD Student in Clinical Psychology, International Campus-Iran University of Medical Sciences (IC-IUMS), Tehran, Iran, E-mail: email@example.com
Table 1: Means, standard deviation, frequency, and percent of demographic characteristics of older adults. Demographic M SD Demographic F (%) characteristics characteristics Age 65.72 5.60 Having of child 69 93 Sex F (%) Number of M SD Female 30 41 children 6.72 5.60 Male 44 59 Level of education Physical illness F (%) Under diploma 25 34 history 42 57 Diploma and over 27 36 BA and over 22 30 Marital status Psychiatric 5 7 Single 3 4 disorder history Married 54 73 Divorced 2 3 Widowed 15 20 Job status Take medication 41 55 Retired 38 53 history Tradesman 6 9 Housewife 12 18 Other 15 20 Table 2: Means, standard deviation and t-tests for total score on the TDAS, DDS and DOS for older adults and gender. Scales M SD Templer's Death 7.48 3.32 Anxiety Scale (TDAS) Death Depression 7.69 4.34 Scale (DDS) Death Obsession 27.95 11.94 Scale (DOS) Older adults Older T p women adults men M SD M SD df = 72 Templer's Death 7.8 3.06 7.2 3.50 .66 - Anxiety Scale (TDAS) Death Depression 8.7 4.71 7.7 4.19 .19 - Scale (DDS) Death Obsession 27.7 12.24 27.6 11.82 .22 - Scale(DOS)