1. Introduction
One aspect of old age is existential anxiety. Although it is a sincere response to ignorance and a consequence of consciousness, if one fails to give a meaningful response, it can lead to Demoralization Syndrome (DS) [1, 2]. This syndrome can cause mental distress, reduced quality of life and even severe depression. The formation of adaptive or maladaptive responses to existential anxieties is influenced by several factors, including living place. Most seniors prefer to stay at home rather than moving to a nursing home [3]. However, the increase in the elderly population along with social, economic, personal and family lifestyle changes have increased the number of nursing homes [4]. The purpose of this study was to investigate the association between place of residence and the incidence of DS in the elderly. The main question is whether there is a difference in DS prevalence among elderly residents of nursing home, community-dwelling elderly people, and the elderlies receiving day care services from rehabilitation centers.
2. Materials and Methods
This is a descriptive comparative study. The study population consisted of all elderly residents of nursing home, community-dwelling elderly people, and the elderlies receiving day care services from rehabilitation centers in Tehran, Iran in 2017. Given that the population variance was not available for estimating the sample size, the method of minimum sample size estimation for variance analysis tables 2×3 (two genders and three groups) was used which was obtained 25 for each group [5], but in all groups, more samples were taken. In the end, by using a convenience sampling method, 110 nursing home residents, 100 day-care receivers, and 115 community dwellers were selected. Inclusion criteria were having age 60-80 years, ability to speak and willingness to answer the questions. On the other hand, exclusion criteria were having severe and disabling physical and motor disorders, severe mind and brain problems such as Parkinson’s and dementia diseases, and inability to perform the personal tasks that make them in need of a permanent nurse. In order to ensure the absence of cognitive impairment in participants, Abbreviated Mental Test was used [7].
Data collection tool was a demographic form (for surveying age, sex, and place of residence), and the Demoralization Scale of Kissane (2004). It has 5 subscales of loss of meaning (5 items), dysphoria (5 items), disheartenment (6 items), helplessness (4 items), and sense of failure (4 items). Kissane et al. reported a Cronbach’s alpha of 0.94. The psychometric properties of its Persian version was examined by Naghiay et al. [6]. They reported a Cronbach’s alpha of 0.86. The questionnaires were completed by researchers through face-to-face interviewing with participants. Collected data were analyzed in SPSS V. 20 software using descriptive statistics (mean and standard deviation) and one-way ANOVA.
3. Results
Participants were 325 older adults aged 60-80 years, 110 nursing home residents with a mean age of 73 years, 100 day-care receivers with a mean age of 69 years, and 115 community dwellers with a mean age of 70 years. The mean overall level of DS in the residents of nursing homes (69.60±17.41) was higher compared to the community dwellers (45.40±21.47), and those receiving day care services from the rehabilitation centers (31.90±17.59), and this difference was significant (P≤0.05). In terms of DS dimensions, the mean DS level in nursing home residents was 21.96 for loss of meaning, 16.39 for dysphoria, 17.66 for disheartenment, 9.09 for helplessness, and 6.64 for sense of failure. For the community dwellers, these mean values were 11.99, 12.78, 11.06, 6.36, and 4.62, and for the day-care receivers, they were 7.5, 10.96, 8.46, 3.59, and 2.56, respectively. As can be seen, the elderly residents of nursing homes had the highest ES level and the day-care receivers had the lowest level.
According to Table 1, there was significant difference between three groups in terms of overall ES level and its five dimensions, where the highest mean difference was observed between community dwellers and day-care receivers (-37.70), and the lowest difference between residents of nursing homes and day-care receivers (-13.50). Regarding ES dimensions, the highest mean difference between residents of nursing homes and day-care receivers was related to the loss of meaning (-14.46), and the lowest difference was related to the sense of failure (-4.0.8). Moreover, the highest difference between community dwellers and day-care receivers was related to the loss of meaning (-4.49), and the lowest difference was related to dysphoria (-1.82). Finally, the highest mean difference between residents of nursing homes and community dwellers was related to the loss of meaning (9.97), and the lowest difference was related to the sense of failure (2.02).
4. Conclusion
This study aimed to investigate the relationship between ES level and housing status among the elderly people. The results showed that the overall ES level was higher among residents of nursing homes, followed by community dwellers and day-care receivers. Obviously, staying away from home and family, reduced emotional communication, and problem in the evaluation of past life have made it more difficult for seniors living in nursing homes to rebuild the meaning and have positive outlook on the future, compared to other two groups. Moreover, the elderly people who live at home and receive day care from the rehabilitation centers can have better psychological/social conditions than the elderly living at home and receive no health care services. In terms of variables affecting ES, the elderly ‘primary need is to be present in a psychologically, socially, emotionally active context in which feelings of being efficient, respectful, and belonging are daily confirmed.

Ethical Considerations
Compliance with ethical guidelines
This study has an ethical approval (Code: IR.USWR.REC.1396.371).
Funding
This study was extracted from a research proposal approved by Iranian Research Center On Aging of the University of Social Welfare and Rehabilitation Sciences.
Authors' contributions
All authors contributed equally to this study.

Conflicts of interest
According to the authors, there is no conflict of interest between them.
Acknowledgements
We are grateful to the respected personnel of the Center under review and to the appropriate assistance provided by the Welfare Organization of Tehran. From Tohid, Mehrgol, Omid, Mehraban and Kamal elderly homes for their well-deserved assistance in accessing samples, from the Yas Elderly Rehabilitation Center for their relentless and good-natured assistance in providing opportunities for interviewing the elderly and to all the elderly participants Thanks for reading.