Mental Health and Death Anxiety among Community- Dwelling Elderly: A Cross-Sectional Study

Dhafer Ameen Al-Mossawy1, Ohood A. Radhi2*, Fatima Wanas Khudair2, Hassam M. Al- Amarei2, Intisar Albandar3

1Faculty of Nursing, University of Warith Al-Anbiyaa, Karbala, Iraq

2Faculty of Nursing, University of Kufa, Najaf Governorate, Iraq

3Department of Biology, College of Sciences, University of Basra, Basrah, Iraq

*Corresponding Author’s Email: ohouda.radhi@uokufa.edu.iq

ABSTRACT

Background: Elderly individuals, while representing a vital part of society, often experience psychological challenges associated with ageing. Among these, mental health problems and death anxiety are particularly significant, as they directly affect quality of life and social contribution. Identifying their psychological status and related factors is therefore essential to support the well-being of this vulnerable group. Objectives: This study aimed to assess the mental status and death anxiety level of elderly people in Najaf city and to find out the relationship between death anxiety and mental status with socio-demographic data among elderly people. Methods: A descriptive cross-sectional study was carried out from 15th October 2023 to 1st April 2024 on a sample of 200 community-dwelling elderly participants in Al-Najaf Al-Ashraf province. Results: Most of the study participants exhibited death anxiety and abnormal mental status, indicating possible cognitive impairment. A highly significant relationship was observed between mental status and age, marital status, and economic status (p < 0.01), whereas number of children and place of residence showed no significant effect. The study also found a non-significant correlation between mental status and death anxiety. Conclusion: The study concluded that most of the study samples had abnormal mental status, indicating possible cognitive impairment and the presence of death anxiety. Hence, the study recommends encouraging elderly people to do many simple daily activities to distract them from thinking about death and enhance their mental state, such as worship, reading, and housework.

Keywords: Death Anxiety; Disorder; Elderly; Mental Status

INTRODUCTION

Elderly people encounter numerous challenges in their daily lives due to the inescapable and unavoidable process of age-related decline (Adelirad et al., 2021; Lu, Yang & Ma, 2025). Ageing is one of the most significant stages of life, accompanied by changes in the body’s organs and systems, as well as declines in physical and cognitive performance (Ebrahimi, Hosseini & Rashedi, 2018; Hajihasani & Naderi, 2021; Karaman et al., 2025). Although ageing is a natural stage of life rather than a disease, the needs and concerns related to this period must be taken into account (Taghiabadi et al., 2017; Gürbüz & Yorulmaz, 2024). Globally, the proportion of elderly individuals has gradually increased due to higher life expectancy and declining birth rates (Mohammadpour et al., 2018). Anxiety is one of the most common mental health challenges in older adults, arising from various physical, social, and psychological changes associated with ageing. Reduced self-confidence, decreased mobility and activity, the loss of friends, declines in financial and physical independence, and chronic illnesses all contribute to heightened anxiety among the elderly (Mohammadpour et al., 2018; Hong et al., 2022). Death, sickness, and ageing are uncontrollable events, and among them, death is inevitable. While some individuals perceive death as a transition to a new existence due to beliefs in life after death, others view it as extinction, which can lead to psychological distress (Adelirad et al., 2021; Bakan, Arli & Yıldız, 2019; Zhou et al., 2024).

Death anxiety is the most common form of anxiety among older adults. Although death is a biological and psychological reality, thinking about it can be distressing, and individuals often attempt to avoid such thoughts. The degree of death anxiety varies among individuals depending on personal beliefs, health perception, and worldview (Mohammadpour et al., 2018; Turan & Dural, 2025). Mental health plays a critical role in predicting death anxiety, as those who perceive themselves as unhealthy are more conscious of mortality and thus more prone to death-related anxiety (Adelirad et al., 2021; Jazaiery et al., 2022). The worldwide pandemic of dementia can no longer be ignored and should be considered a public health priority in all countries, particularly since death anxiety may intensify when it is associated with pain, loss of independence, separation from loved ones, or the physical disintegration of the body (Assari & Lankarani, 2016; Zan, Adea & Abd, 2018). To cope with these uncontrollable circumstances, elderly individuals often rely on philosophical or spiritual beliefs, emotional suppression, or religious practices to find meaning and alleviate distress (Taghiabadi et al., 2017; Hajihasani & Naderi, 2021). The elderly tend to measure life not by the years lived but by the time remaining, making them acutely aware of personal losses and mortality (Hajihasani & Naderi, 2021). Religion and worldview significantly influence how individuals perceive death. Strong religious beliefs can provide meaning, reduce hopelessness, and help individuals confront death directly, while others may adopt psychological avoidance strategies (Bakan, Arli & Yıldız, 2019; Afrashteh et al., 2024; Jemal et al., 2021). Overall, anxiety is the most pressing emotional challenge for older adults, stemming from losses in physical, cognitive, and social domains.

METHODOLOGY

Study Design: A descriptive cross-sectional study was conducted to assess mental health and death anxiety among the elderly. The study was carried out from October 15th, 2023, to 1st April 2024.

Study Setting: This study was conducted in Al-Najaf Al-Ashraf province among elderly individuals from nursing home residents, primary health care centres, and local hospitals.

Sampling: A non-probability convenience sampling technique was used, and a total of 200 participants were selected.

Study Instrument: An Arabic questionnaire is constructed by the researcher to assess mental health and death anxiety among elderly people (Karaman et al., 2025). The complete instrument of study consists of 3 parts.

Part 1: Socio-demographic Data: This part consists of (7) items, which include age, marital status, number of children, residency, economic status and chronic diseases.

Part 2: Mental status examination: The Mental Status Examination used in this study comprises 11 items assessing cognitive and psychological functions, including orientation, memory, attention, language, and mood. Items are mainly direct observation and short-answer questions, scored on a standardised scale, with higher scores indicating normal mental status and lower scores suggesting possible cognitive impairment (Kurlowicz & Wallace, 1999).

Part 3: Death Anxiety Scale: The Death Anxiety Scale consists of 88 items with yes/no responses. The scale is divided into several sections, each assessing different aspects of death anxiety, such as fear of the dying process, fear of the dead, fear of losing loved ones, and fear of the unknown after death. Each section is scored by summing the number of 'yes' responses, with higher scores indicating greater levels of death anxiety (Templer, 1970).

Data Collection

Data collection was conducted using the constructed Arabic version of the questionnaire. Participants completed the questionnaire through individual interviews, which were held at hospitals, primary health care centres, and nursing homes. The data collection process took place from January 15th 2024 to February 17th 2024.

Data Analysis

All data collected in this study were entered into SPSS software (version 20). Descriptive statistics, including minimum and maximum values, means, and standard deviations, were computed. Inferential statistical tests, namely Pearson’s correlation coefficient, one-way analysis of variance (ANOVA), and the independent samples t-test, were applied to quantitative data, contingent upon meeting the required assumptions for each test. A p-value of ≤ 0.05 was considered statistically significantt.

Ethical Consideration

This article received ethical approval from the Nursing Specialities Branch, Faculty of Nursing, University of Kufa, Iraq with reference number 51 on 8th January, 2023.

RESULTS

Table 1: Distribution of Demographic Data for the Study Sample (n=200)

%= percentage, F = frequency.

Table 1 summarises the frequency distribution of the study sample by their demographic data. This table explains that most of the participants (39%) were those in the age group of 66years and up. In addition. In addition, the participants were mostly married and had three or more children (65% and 67%, respectively). In addition, the table shows that the majority of the participants (85.50%) were residents in urban areas. Regarding income, the table shows that 53.50% of the participants had not enough income.

Table 2: Distribution of Clinical Characteristics for the Study Sample (n=200)

Table 2 summarises the frequency distribution of the study sample by their clinical data. This table explains that an equal percentage of the participants (50%) were with diabetes from those without. In addition, the table shows that high percentages of the participants did not suffer from heart disease, asthma, or kidney and liver diseases (70.50%, 91%, 94%, and 97.50%, respectively), while more than half of the participants suffered from blood pressure (58.5%).

Table 3: Assessment of the Mental Status Overall Items of the Study Sample (n=200)

%= percentage, F = frequency, Sum of score, Abnormal (sum of scores <=24), Normal (sum of scores >=25).

Table 3 demonstrates the sum of scores and assessment of mental status overall items of the study sample. This table shows that the mental status recorded 110 participants as abnormal, indicating possible cognitive impairment, while 90 participants were normal mental status.This assessment is based on the statistical scoring system that indicates the total sum of scores: abnormal (sum of scores <=24) and normal (sum of scores >=25).

Table 4: Assessment of the Death Anxiety Overall Items of the Study Sample (n=200)

%= percentage, F= frequency, M.S: Mean of score, No death anxiety (mean of scores <=1.5), Death anxiety (mean of scores >1.5), Assess.: Assessment.

Table 4 demonstrates the means of scores and assessment of items of the participant's death anxiety. The table shows that the participant's death anxiety recorded No Anxiety for items (5- 8, 10, 12, 16, 18, 19, 21, 24-26, 28, 30-32, 37, 39, 41, 43, 45, 47, 48, 50-52, 56, 58, 60, 61, 66, 68, 71-77, 81, 83, 84, 86, and 88), while all other items were recorded as death anxiety. This assessment is based on the statistical scoring system that indicates no death anxiety (mean of scores <=1.5) or death anxiety (mean of scores >1.5).

Table 5: Relationship between Mental Status of the Participants and their Demographic Characteristics.

# Statistics was done using One Way ANOVA, ψ: Statistics were done using independent t test, NS: non-significant, S: significant, HS: high significant

Table 5 shows a highly significant difference in the mental status of the participants and their demographic characteristics, at a p-value of less than 0.05, except for the number of children and residence; the p-value was more than 0.05.

Table 6: Relationship between Death Anxiety of the Participants and Their Demographic Characteristics

# Statistics was done using One Way ANOVA, ψ: Statistics were done using independent t test, NS: non-significant, S: significant, HS: high significant.

Table 6 shows a non-significant difference in death anxiety of the participants and their demographic characteristics, at a p-value of more than 0.05, except for residence; the p-value was less than 0.05.

Table 7: Correlation between Mental Status and Death Anxiety

Table 7 The correlation analysis between mental status and death anxiety revealed a weak negative relationship (r = -0.084), which was not statistically significant (p = 0.234). This indicates that, within this sample, mental status is not meaningfully associated with levels of death anxiety among the elderly participants.

DISCUSSION

Most of the study sample age is between 56 and 65 years old (38.5%); these ages were the ages most interested in the topic of the research, so the majority of participants were among them. This result goes with the Ghasemi, Atarodi and Hosseini (2020) study that found the majority of their study sample age range between 60 and 69 years (53.5%). This is due to the fact that most of the elderly in Iraq, during their youthful stages, suffered many wars and weak economic conditions that did not allow them to complete their studies. This result does not agree with Yang et al. (2018) study that found most of them completed their middle school. In the matter of their marital status, many of them were married (65%) and had three or more children (67%). This is a positive indicator because they lived a long life, which led a large percentage of them to marriage, and the majority of them are still married to this day. The result is similar to Mohammadpour et al. (2018) study results that found most of them are married (59.1%) and have 1-5 children (60.6%). The majority of the study participants live in urban residency areas (85.5%). This is because of the large residential cities and the tendency of people to live in them and leave the rural areas in order to provide needed services, and because the samples were collected from the elderly home, they are located within the city. From the study of Li, Jia and Yang (2018), it is also evident that most elderly people live in urban areas.

Regarding monthly income, the study shows 53.5% of the participants did not have enough income. This is because most of them have grown too old to work and are not as physically strong as they were in their youth. Also, most of them have retired, so their monthly income is mostly weak. The result is different in the study by Bakan, Arli and Yıldız (2019) most of them have middle economic income. The current result shows that an equal percentage of the participants (50%) were with diabetes compared to those without, while more than half of the participants suffer from blood pressure (58.5%). Many studies have proven that increasing age is a risk factor for developing blood pressure and diabetes mellitus. However, it is not considered a very high percentage or a small percentage, as most percentages are equal. In addition, the results show that high percentages of the participants did not suffer from heart disease, asthma, or kidney and liver diseases (70.50%, 91%, 94%, and 97.50% respectively). These are rare diseases, unlike what was mentioned above about high blood pressure and diabetes. According to the Li, Jia and Yang (2018) study, most of the participants have hypertension (65.93%) and coronary heart disease (42.72%). In the previously mentioned results, mental status for the study participants recorded 110 participants as abnormal, indicating possible cognitive impairment, while 90 participants were normal mental status. Which is most of them have impaired mental status; it’s linked to several factors that will be discussed later. The result is consistent with the Alagiakrishnan et al. (2013) study. According to the study findings, the participant's death anxiety results recorded the presence of anxiety for most of them (55%). This is a common occurrence, according to many previous studies, and the results have proven its presence in the current study.

Meanwhile, the study of Adelirad et al. (2021) revealed low death anxiety among the study participants, and they stated that spiritual belief and good mental health were associated with low levels of death anxiety. The current study result shows a statistically high significant relationship between elderly mental status and their age (p-value less than 0.0001). The researcher believes that the older a person is, the more mental problems he has, which may indicate possible cognitive impairment that negatively affects his life. Also, the same result has been found in the studies by Li, Jia & Yang (2018); İnci and Sözen (2024). Also, elderly marital status is a highly significant factor related to their mental status. The authors believe that people who are currently married are less likely to suffer from these problems, unlike separated, divorced, widowed, and single people. The result is in line with the Zhang, Zheng and Li (2024) study that found marital status is a potentially essential factor for cognitive impairment. The study indicated that older people with a spouse exhibited higher cognitive functioning. According to the relationship table presented in the study results, it is found that economic status is also a highly significant variable affecting elderly mental status.

Whereas people who suffer from a weak economic level are not like those whose economic level is high, as the other are less vulnerable. A study by Zhang et al. (2022) found that economic status significantly affects the physical and mental health of the elderly. The current study findings reveal that only place of residence among elderly people affects their level of death anxiety. The area in which a person lives greatly affects his thinking about death. The result agrees with the Ebrahimi, Hosseini & Rashedi (2018) study that mentioned the same relationship.

Limitation

The study has some limitations. The cross-sectional design prevents establishing causal relationships. The use of convenience sampling from one province and a relatively small sample size may limit generalizability. Self-reported data could be influenced by recall or social desirability bias. In addition, some confounding factors such as education and social support were not considered

CONCLUSION

The study found that most of the study sample had abnormal mental status, indicating possible cognitive impairment. Moreover, the study found that the majority of elderly participants recorded the presence of death anxiety. Further, there are highly significant differences between the mental status of the participants and their age, marital status, and economic status, and there are highly significant differences in death anxiety of the participants and their residence. Finally, the study found a non-significant correlation between mental status and death anxiety. Based on the study conclusions, the study recommends further studies that should be conducted regarding elderly mental status and death anxiety in a greater range and larger area. In addition to encouraging the elderly to do many simple and daily activities to distract them from thinking about death and enhance their mental state, such as worship, reading, and doing housework.

The future scope of this study suggests the need for research on larger and more diverse populations to gain deeper insights into the variations in mental health and death anxiety among the elderly across different cultural and socio-economic contexts. Longitudinal investigations are also essential to examine the causal relationships and track changes in these psychological factors over time. Moreover, interventional studies focusing on the effectiveness of social, spiritual, and therapeutic programmes are recommended to develop evidence-based strategies that can reduce death anxiety and promote better psychological well-being in older adults. Furthermore, the Ministry of Labour and Social Affairs must provide job opportunities suitable for their ages.

Conflict of Interest

The authors declare that they have no competing interests.

ACKNOWLEDGEMENT

The authors would like to thank the Faculty of Nursing, University of Kufa, Al-Najaf Al- Ashraf, Iraq for providing the facilities necessary to conduct this study.

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