Introduction
Older adults constitute one of the largest social groups in the world [1]. Death anxiety is one of the most common mental health disorders in these people. Death anxiety refers to thoughts, fears and feelings about the final event of life [2]. Death anxiety can increase negative attitudes towards aging and even lead to anxiety and fear of aging [3]. The level of death anxiety in the elderly and the related factors can be different due to individual differences, social and environmental factors, and views on death [4, 5]. Although Khalvati et al. reported a low death anxiety in Iranian elderly [6], studies showed that the COVID-19 pandemic caused an increase in death anxiety [7]. Many studies in Iran have investigated various factors related to death anxiety in the elderly, but their results are contradictory. Therefore, this study aims to investigate death anxiety and factors related to it in Iranian elderly people.

Methods
This is a descriptive-analytical study with a cross-sectional design that was conducted on the elderly aged 60 or older in Iran. Sampling was done using a convenience sampling method. The inclusion criteria were the ability to read and write in Farsi and access to common social networks in Iran. The exclusion criterion was the return of incomplete questionnaire. Sampling was done form among those covered by the foundations for the elderly and retirement centers in Iran. The Templer death anxiety scale was used to collect data. Its online Persian version was prepared in Porsline website and the link was sent to people on social media applications. In total, 3841 questionnaires were distributed online, of which 712 were excluded due to incompleteness, and finally the data of 3129 questionnaires were examined. The data were analyzed using descriptive statistics (frequency, Mean±SD) and inferential statistics (Kolmogorov-Smirnov test, independent t-test, one-way ANOVA, multiple linear regression analysis) in SPSS software, version 22. 

Results
Among 3129 participants, 1271 (40.3%) were women and 1858(59.7%) were male, whose age range was 60-80 years. Most of them (67.8%) were in the age group of 60-64 years while a few of them had age of 75 years or older (n=51, 1.7%). Also, 88.1% were married, 74.58% were living in their own houses and 86.4% were living with their spouses and children. Regarding the educational level, 57.6% had and education higher than high school diploma. Also, 96.6% were city residents, 78% were retired, and 92.3% had insurance coverage. Furthermore, 49.8% were of Fars ethnicity, 21.3% of Turkish ethnicity and 28.9% of other ethnicities. Regarding the religion, 81% were Shia Muslims. 
The death anxiety score of the participants ranged from 5 to 15, with a mean score of 8.5±3.44. The results showed that 1325 (42.5%) had severe death anxiety, 531(16.9%) had moderate death anxiety, and 1273(40.7%) had mild anxiety. A significant difference was observed in death anxiety in terms of age, gender, marital status, household living arrangements, occupation, religion, and insurance coverage (P≤0.05), but no significant difference was observed in terms of housing conditions, the place of residence (urban or rural), educational level and ethnicity (P>0.05). 
With multiple linear regression analysis using the backward method, the variables of age, sex, marital status, occupation, religion, insurance coverage, household living arrangements, were entered into the model. The multiple regression model showed that the variables of age, sex, marital status, household living arrangements, occupation, insurance coverage, and religion predicted 22.5% of the variance of death anxiety in the elderly (Table 1).




Conclusion
The results of this study showed that most elderly people in Iran had moderate or severe death anxiety. According to our results, death anxiety in Iranian elderly can be predicted by age, sex, religion, marital status, occupation, household living arrangements, and insurance coverage. The limitation of this study was the online sampling method, which was done due to the restrictions created by the COVID-19 pandemic. This led to difference in the characteristics of samples such as age and literacy level.

Ethical Considerations

Compliance with ethical guidelines
This study was approved by the Ethics Committee of the Iran National Science Foundation (INSF) (No.: 99012960). and was conducted according to the principles of the Declaration of Helsinki. Informed consent was obtained from all individual participants included in the study.

Funding
This article was extracted from a research project, funded by Iran National Science Foundation (INSF).

Authors' contributions
All authors contributed to the writing of the article

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
We gratefully acknowledge the support of the INSF and extend our sincere thanks to all the researchers who provided their valuable assistance and cooperation in the execution of this research.


 

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