The issue of aging in recent years as has attracted the attention of experts, policymakers and even public. Reports show that, by the next 30 years, the percentage of aged population will reach approximately 26% of the total population [1]. One of the most common mental disorders in old age is death anxiety. Death anxiety refers to the thoughts, fears and feelings about the last days of life that a person experiences throughout life [2]. Death anxiety includes awareness of the importance of death and the types of beliefs, attitudes, images, and thoughts about death and what happens after death [4]. Given that during the past years, several studies have been conducted in the field of death anxiety of the elderly, this systematic review study aims to identify the death anxiety prevalence and effective interventions in reducing death anxiety in the Iranian elderly.

The present study is a systematic review of studies related to death anxiety of the elderly in Iran published in Persian from 2011-2019. In this regard, a search was conducted in national online databases including SID, Irandoc, Iranmedex, Magiran, IDML, ElmNet, and Civilica as well as Google Scholar using the keywords: “Death anxiety”, “older adult”, “fear of death” “elderly” and “Iran” in Persian. The target population included the entire aged population in Iran both men and women. The studies that had a standard structure covering type of service or intervention, aspect of service (living in nursing homes, community, daycare centers), client groups (older adults, retired adults), and professional role or task (death anxiety); and studies that were correlated, cross-sectional or had psychological interventions using behavioral therapy or spiritual therapy with and without a control group published from 2011 to 2019 were included in the study. Studies conducted in other fields (not on older people), theoretical studies, unpublished studies, and those published in other languages were excluded from the study.
Qualitative evaluation was used for interventional studies using the Cochrane modified checklist. For correlational and cross-sectional studies, the STROBE Checklist was used. First the data were saved in “dta” format. Then, the metan command of STATA software was used for meta-analysis. In order to check the publication bias, Begg’s test was used. In correlational studies, the significance level was P>0.05 and the confidence interval was -302.38 to -328.68, indicating the absence of publication bias. In quasi-experimental studies, P value was also greater than 0.05 and the confidence interval was in range of -0.083 to -0.0089. Due to the significance of Kendall’s tau value, there was a significant relationship between the estimated value and the sample size. This indicates the existence of publication bias. In order to find the heterogeneity factor, meta-analysis of subgroups was performed. For this purpose, studies were divided into two groups; the first group measures the effect of behavioral therapies on reducing death anxiety and the second group measures the effect of spiritual therapy on reducing death anxiety. For data analysis, SPSS v. 22 software and STATA v. 14 software were used.

Thirty three articles were included in the study and evaluated. Findings were divided into three sections: comparison (3 articles), intervention (11 articles) and factors affecting death anxiety in Iranian elderly (18 articles). In these articles, 40.35% of the participants were female and the rest were male with a Mean±SD age of 67.80±6.44 years. The interquartile range of death anxiety was greater in men than in women, and the elderly living in nursing homes had the highest mean score of death anxiety (11.8). In correlational studies, death anxiety in the elderly had no statistically significant relationship with demographic variables, depression, social support, religious attitude and social intelligence. It had a significant positive relationship with external control, cognitive fusion, mental disorders and cognitive avoidance, while had a significant negative relationship with spiritual health, perception of aging, religious orientation, emotional intelligence, thanksgiving, external religious orientation, internal religious orientation, spiritual intelligence, spiritual well-being, social support, source of internal control, problem-focused coping, emotion-focused avoidance coping, quality of life, mental well-being, spiritual health, mindfulness, resilience, attachment to god, psychological well-being, religiosity, meaning of life, and aging. The results of comparative studies showed that death anxiety was significantly different between single and married older men, but there was no significant difference between single and married older women. Death anxiety scores of the elderly with pessimistic life orientation were significantly higher than that of those with optimistic life orientation. In 7 studies, the association between spiritual therapy and the reduction of death anxiety was reported. Although there was no heterogeneity between studies, but due to the lack of a significant level (P=0.919), the results showed that there was no positive and significant relationship bet ween spiritual therapy and reduction of death anxiety in the elderly.

Although different tools report different levels of death anxiety in the elderly, it seems that the death anxiety in the elderly in Iran is low. Older women are more likely to have death anxiety than older men, and the elderly living in nursing homes have more death anxiety than the elderly living at own home. Behavioral therapies have significant effect on reducing death anxiety in the elderly. Numerous variables are effective in reducing the anxiety of death in the elderly. By being aware of it, policymakers can reduce the phenomenon of death anxiety in the elderly in Iran. It is recommended that a review of studies published in other languages in the field of death anxiety in the elderly and its results be compared with the results of the present study.

This study was approved by the Research Committee of Mashhad University of Medical Sciences.

This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

All authors contributed equally in preparing this article.
Conflicts of interest
The authors declare no conflict of interest.

 

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