Int
ern
at
i
onal
Journ
al
of
P
u
bli
c Hea
lt
h S
c
ie
nce (IJPH
S)
Vo
l.
8
, No
.
4,
Dec
2019
, p
p.
4
1
9
~
4
2
6
IS
S
N: 22
52
-
8806, DO
I: 10
.11
591/ij
phs.
v8
i
4.203
59
419
Journ
al
home
page
: htt
ps://
ww
w.i
aesco
re
.c
om
/j
our
nals/
ind
ex.
php/IJP
H
S
The best
predi
ctor of anxi
ety, stres
s, and d
ep
re
ssi
on
amon
g
i
nstitu
tion
alize
d
eld
er
ly
Ni Pu
tu
Wula
n Pu
rn
am
a Sa
ri
1
, Maria M
anun
gkali
t
2
1
Depa
rtment of
Pall
iative Nursin
g,
W
id
y
a
Manda
la
C
at
hol
ic Univ
ersity
Surab
a
y
a
,
Indone
sia
2
Depa
rtment of
Medic
a
l
-
Surgical
Nurs
ing, Wid
y
a
Manda
la Ca
th
oli
c
Univer
sit
y
S
ura
ba
y
a
,
Indon
e
sia
Art
ic
le
In
f
o
ABSTR
A
CT
Art
ic
le
history:
Re
cei
ved
A
gt
2
1
, 201
9
Re
vised
Oct
28
, 2
01
9
Accepte
d
Nov
11
, 201
9
Anxiety
,
stress,
and
d
epr
essio
n
are
th
e
thr
e
e
m
ost
comm
on
negative
emotiona
l
const
ruc
ts
found
in
t
he
el
d
erly
.
Evi
d
enc
es
av
ai
l
able
worldwide
about
how
ps
ychol
ogi
ca
l
probl
em
coul
d
b
e
re
sulte
d
in
m
ent
a
l
disorder
,
and
the
r
e
is
sign
ifi
c
ant
diff
ere
n
c
e
in
th
e
context
of
li
ving
in
the
n
ursing
hom
e
and
in
comm
unity
setting.
Thi
s
stud
y
ai
m
ed
to
det
ermine
the
b
est
pre
d
ic
tor
of
anxi
ety
,
stre
ss
,
and
depr
ession
in
el
der
l
y
living
in
the
nur
sing
hom
e,
useful
for
future
m
odifi
c
at
ion
and
i
nte
rve
n
ti
on
d
eve
lopment
.
Thi
s
cro
ss
-
sec
t
io
nal
stud
y
invol
v
ed
145
e
lde
r
l
y
i
n
a
priv
at
e
nursi
ng
hom
e
in
Suraba
y
a,
Indo
nesia
.
HA
RS
,
SP
ST
-
20,
and
GD
S
were
used
in
data
col
l
ec
t
ion.
Li
ne
ar
reg
r
ession
an
d
one
wa
y
AN
OV
A
te
sts
were
used
in
d
ata
ana
l
y
sis
(α
<0.
0
5).
Result
s
sh
owed
tha
t
m
o
stl
y
in
old
i
ndivi
dual
s
,
m
il
d
anxiet
y
and
stress,
and
unde
pre
ss
ed
state
we
re
found.
Sensor
y
prob
le
m
s
and
con
ce
ntr
atio
n
difficulties
we
re
th
e
best
pre
d
ic
tor
o
f
anx
ie
t
y
and
stress
respe
ctively
,
w
hic
h
were
acco
unte
d
for
61.
2
%
and
65.
6%
var
ia
n
ce
s
of
anxi
e
t
y
and
stres
s
in
nursing
home
reside
nts
respe
ct
iv
ely
.
Spiri
ts,
l
ife
energ
y
,
happi
ness,
and
fee
l
ing
wonderf
ul
to
be
alive
c
ould
not
pre
dict
depr
ession
signifi
c
ant
l
y
.
Fe
el
ing
inf
eri
or
to
othe
rs
is
the
best
pre
dictor
of
depr
ession
,
which
was
a
cc
o
unte
d
for
25.
9%
var
i
anc
e
of
d
e
pre
ss
ion
in
th
is
popula
ti
on
.
Low
self
-
est
ee
m
leads t
o
depr
ession
in
nursing
ho
m
e
reside
nts
.
Ke
yw
or
d
s
:
Anxiet
y
Depressi
on
Elderly
Pr
e
dictor
Stress
Copyright
©
201
9
Instit
ut
e
o
f Ad
vanc
ed
Engi
n
ee
r
ing
and
S
cienc
e
.
Al
l
rights re
serv
ed
.
Corres
pond
in
g
Aut
h
or
:
Ni P
utu
Wu
la
n Pu
rnam
a Sari,
Dep
a
rt
m
ent o
f Pal
li
at
ive N
urs
ing
,
W
i
dya Ma
nd
al
a Cat
ho
li
c
Un
i
ver
sit
y S
ur
a
ba
ya
,
Jl. Ray
a K
al
isa
ri Selat
an 1,
Pa
kuw
on Ci
ty
, Sur
a
baya
60112, I
ndonesi
a.
Em
a
il
:
wu
la
npurnam
a@u
kw
m
s.ac.id
1.
INTROD
U
CTION
The
gl
ob
al
iss
ue
of
agein
g
popula
ti
on
in
var
i
ou
s
par
ts
of
the
world
has
raise
d
a
great
con
ce
r
n
towa
rd
s
the
hi
gh
-
prevale
nce
m
ental
diso
r
der
s
or
ps
yc
holo
gical
prob
l
e
m
in
el
der
ly
[1
]
.
Psych
ol
og
ic
al
pro
blem
s
that
are
oft
en
f
ound
in
t
he
el
de
rly
are
an
xiety
,
stress,
a
nd
de
pressi
on
[2]
.
T
he
se
three
pro
bl
e
m
s
are
consi
der
e
d
as
the
ne
gative
em
ot
ion
al
con
t
r
uct
s
[3]
.
E
vid
e
nces
sho
wed
t
hat
there
was
a
sign
ific
ant
di
f
fer
e
nce
reg
a
rd
i
ng
t
he
pr
e
valence
of
ps
yc
hiatri
c
dis
orders
betwee
n
long
te
rm
c
are
set
ti
ng
an
d
com
m
un
it
y
set
ti
ng
,
in which
th
os
e
disorde
rs
a
re
m
or
e comm
on
in
the l
ong
te
r
m
care sett
ing
[4]
Depressi
on
,
th
e
m
o
st
pr
eval
ent
m
ental
healt
h
pro
blem
fou
nd
i
n
el
de
r
ly
,
cause
a
n
e
le
vation
i
n
m
or
bid
it
y
and
m
or
ta
lity
rate,
a
decr
ease
i
n
qu
al
it
y
of
li
fe
(QOL)
,
an
d
a
n
increase
in
he
al
th
care
costs
[5
]
.
The
wi
des
pr
ea
d
hi
gh
pr
e
vale
nce
of
de
pressi
on
i
n
the
nursi
ng
hom
es
is
no
t
al
ways
fo
ll
owed
by
an
a
pp
ropr
ia
te
con
ce
r
n
f
r
om
t
he
healt
h
ca
re
prof
e
ssio
nals
i
n
the
fiel
d,
s
o
that
the
util
iz
at
ion
of
de
pr
es
s
ion
sc
ree
ning
t
est
i
s
highly
reco
m
m
end
ed
in
this
set
ti
ng
[
6]
.
D
epr
es
sio
n
is
a
serio
us
m
ental
healt
h
prob
le
m
inv
ol
ving
s
ym
pto
m
s
relat
ed
to
m
oo
d,
co
gnit
ive
,
and
physi
cal
sy
m
pto
m
s
,
influ
e
nced
by
va
rio
us
fact
or
s
(b
i
ologi
cal
,
ph
ysi
cal
,
ps
yc
holo
gical
,
and
so
ci
al
);
oft
en
occurs
in
the
el
der
ly
du
e
to
la
ck
of
s
upport
syst
em
s,
age
-
relat
ed
factors,
factors
of
e
duc
at
ion
lev
el
, hea
lt
h
sta
tus a
nd l
ack
of act
ivit
y
[7]
.
Evaluation Warning : The document was created with Spire.PDF for Python.
IS
S
N:
2252
-
8806
In
t.
J.
Publi
c He
al
th Sci. V
ol.
8
,
No.
4
,
Dec
2019
:
4
1
9
–
4
2
6
420
Anxiet
y
is
an
e
m
otion
al
co
nd
it
io
n
that
causes
disc
om
fo
rt,
c
har
act
eri
zed
by
feeli
ngs
of
w
orry,
anx
i
ous,
a
nd
f
ear,
of
te
n
occ
ur
s
in
t
he
el
de
rly
as
a
res
ul
t
of
va
rio
us
changes
ex
pe
r
ie
nced
by
t
he
agin
g
process
[
8]
.
Anxiet
y
is
mo
re
pre
valent
in
el
der
ly
with
disabili
ty
,
and
bein
g
a
si
gn
i
ficant
pr
e
di
ct
or
of
pro
gr
essi
ng
dis
abili
ty
,
cogniti
ve
im
pair
m
ent
,
an
d
nursing
hom
e
place
m
ent
[
9].
A
nxio
us
de
pr
es
sio
n,
a
sta
te
in
wh
ic
h
a
nx
ie
t
y
co
-
m
or
bi
d
with
de
pr
e
s
sion,
is
c
orr
el
at
ed
with
sever
e
sym
pt
om
s
&
i
m
pairm
ents
,
poorer
pro
gnosi
s,
increase
s
su
ic
ide
ris
k
in
el
der
ly
[
9].
Re
su
lt
s
of
a
sys
tem
at
ic
rev
ie
w
towa
rd
s
74
st
ud
ie
s
sh
owe
d
that
de
pr
essi
on
an
d
a
nx
ie
ty
are
the
m
os
t
co
m
m
on
ps
yc
hiatri
c
dis
orders
am
on
g
old
e
r
ad
ults
li
vin
g
in
long
-
te
rm
ca
re
facil
it
y
[4
]
.
Ham
i
lt
on
[
10
]
,
a
se
nio
r
res
earch
fell
ow,
the
de
velo
pe
r
of
w
or
l
dw
i
de
-
us
e
d
Ham
i
lt
on
Anx
ie
ty
Ra
ti
ng
Scal
e
(H
ARS
),
sta
te
d
that
lo
w
or
hi
gh
le
vel
of
anx
ie
ty
is
fo
un
d
in
agita
te
d
depressi
on
,
ob
sessiona
l
sta
te
,
orga
nic
dem
entia
,
hyste
ria,
and
sc
hiz
ophrenia
[
10]
.
A
nxie
ty
,
tog
et
her
with
depressi
on, wo
rr
y, a
nd s
ocial
fear
c
ould
res
ul
t i
n
ge
ner
al
iz
e
d
a
nx
ie
ty
d
is
order, es
pecial
ly
in
ol
der ad
ults
[11]
.
The
fat
her
of
stress
resea
rc
h,
Ha
ns
Sely
e,
who
f
oc
us
e
d
on
unive
rsal
pa
ti
ent
reacti
ons
to
il
lness,
sta
te
d
that
stre
ss
is
a
no
ns
pe
ci
fic
respo
ns
e
of
t
he
bo
d
y
to
any
dem
and
[
12
]
.
He
al
s
o
st
at
ed
that
eve
ry
stress
le
aves
an
in
del
ible
scar,
an
d
t
he
orga
nism
pays
fo
r
it
s
surv
ival
after
a
stre
ssfu
l
sit
uatio
n
by
bec
om
ing
a
li
ttl
e
old
e
r.
Stress
c
ause
s
press
ur
e
,
change,
an
d
e
m
ot
ion
al
te
ns
ion
;
cha
racteri
z
ed
by
the
feeli
ng
of
a
ng
ry,
anx
i
ous,
sad,
pessim
isti
c,
cryi
ng,
ir
rita
ble,
ha
vi
ng
ni
gh
tm
ares,
i
m
paired
c
on
ce
ntr
at
ion
a
nd
m
em
or
y
;
of
te
n
oc
cur
s
i
n
the
el
de
rly
due
to
the
com
m
on
prob
le
m
s
relat
ed
to
decli
ni
ng
physi
cal
he
al
th
,
lo
w
a
nd
de
cl
ining
f
un
ct
i
on
s
in
daily
li
vin
g
a
nd
c
og
niti
on
[
13
-
14]
.
I
ns
ti
tuti
on
al
iz
ed
el
de
rly
exp
e
rience
d
higher
distress
an
d
ha
d
l
ow
e
r
li
fe
sat
isfact
io
n
c
om
par
ed
to
th
ose
li
ving
in
the
com
m
un
it
y
[9
]
.
T
he
util
iz
at
ion
of
a
sta
nd
a
r
di
zed
gen
e
ral
distress
screeni
ng
te
st
cou
l
d
im
pr
ov
e
the
accu
racy
of
detect
ion
an
d
dia
gnos
is
of
an
an
xiety
or
a
depressi
ve
dis
orde
r
a
m
on
g
el
de
rly
who
receive
hom
e
care
[9]
;
wh
ic
h
in
dicat
es
that
the
pr
e
se
nce
of
distress
le
ads
to
t
he
inc
idence
of an
xiety
and
depressi
on, es
pe
ci
al
ly
in
com
m
un
it
y
-
dw
el
li
ng elde
rly
.
Anxiet
y,
stress
,
and
de
pr
essi
on,
ha
ve
sig
nificant
i
m
pact
on
el
de
rly
’s
Q
OL,
the
refo
re
these
thre
e
var
ia
bles
bec
om
e
v
ery
im
po
r
ta
nt
to
be
asses
sed
regularly
.
Ther
e
is
a
si
gnific
ant
relat
io
nship
betwe
en
a
nx
ie
ty
and
depressi
on
le
vels
with
QO
L
in
the
el
de
rly
wh
o
li
ve
in
nu
r
sin
g
hom
e
s
[8
,
15
]
;
and
t
her
e
is
a
sign
if
ic
ant
relat
ion
s
hip
be
tween
stress
le
vels
a
nd
Q
OL
in
the
el
der
l
y
,
especial
ly
in
tho
s
e
with
c
hro
nic
diseas
e,
s
uc
h
a
s
hype
rtensio
n
a
nd
dia
betes
m
el
li
tus
[16
-
17
]
.
This
st
ud
y
ai
m
ed
to
dete
rm
ine
the
best
predict
or
of
a
nxie
ty
,
stress,
a
nd
de
pressi
on
i
n
el
de
rly
li
vin
g
in
th
e
nursi
ng
hom
e,
use
f
ul
f
or
f
ut
ur
e
m
od
ific
at
ion
an
d
i
nter
ve
ntion
dev
el
op
m
ent.
By
know
i
ng
t
he
best
pre
dicto
r
of
a
nx
ie
ty
,
st
ress,
a
nd
de
pre
ssion
i
n
el
de
rl
y
li
vin
g
in
t
he
nursing
ho
m
e,
it
will
be
us
ef
ul
for
f
ut
ur
e
m
od
ific
at
ion
a
nd
inte
rv
e
ntion
dev
el
op
m
ent,
especial
ly
in
nu
rsi
ng
c
on
te
xt,
with the
u
lt
im
a
te
g
oal
o
f QOL
optim
iz
at
ion
in
the
lat
e li
fe.
2.
RESEA
R
CH MET
HO
D
This
c
ro
s
s
-
sect
ion
al
st
ud
y
i
nvol
ved
14
5
el
der
ly
in
a
pr
i
va
te
nursi
ng
ho
m
e
in
S
ur
a
baya,
I
ndonesi
a.
In
cl
us
io
n
crit
eria
w
ereat
le
ast
60
ye
ars
old
,
and
ha
ving
a
fam
i
ly
m
e
m
be
r
as
the
on
e
re
sp
onsi
ble
for
el
der
ly
care
in
the
nur
sing
hom
e
to
be
the
c
onta
ct
pe
rson
.
E
xclusi
on
crit
eria
were
re
j
ect
ion
on
f
il
li
ng
out
the
c
on
s
ent
form
,
ho
s
pital
i
zat
ion
,
a
nd
im
paire
d
co
ns
ci
ousne
ss
or
disor
ie
ntati
on
.
T
ota
l
sa
m
pling
wa
s
app
li
e
d
an
d
s
a
m
ple
siz
e
of
1
4
5
was
ob
ta
i
ned.
Ins
trum
ent
of
Ham
il
ton
Anxiet
y
Ra
ti
ng
Scal
e
(H
ARS
)
[10
]
,
Su
a
n
Prung
St
ress
Test
–
20
(
SPST
-
20
)
[
18
]
,
and
Ger
ia
tric
D
epressi
on
Sc
al
e
(G
DS)
[
19
]
wer
e
us
e
d
to
colle
ct
the
data
of
a
nxie
ty
,
stress,
a
nd
de
pr
es
sio
n
resp
ect
i
vely
.
Data
we
re
col
le
ct
ed
since
F
ebruary
-
Ma
y
2019
.
Linear
re
gr
essi
on
an
d
on
e
w
ay
ANOVA
te
sts
wer
e
us
e
d
in
data
a
naly
sis
(α<0
.05).
Et
hical
cl
earance
wa
s
issued
by
Faculty
of
Me
dicine
,
W
i
dya
Ma
nd
al
a
Ca
th
olic
Un
ive
rsity
Surabaya
,
I
ndone
sia
,
with
certi
f
ic
at
e
nu
m
ber
of
01
0/
W
M
12/KEP
K
/T/
2019.
HA
RS
is
us
e
d
to
assess
the
se
ver
it
y
of
an
xiet
y
in
bo
th
cl
inic
al
and
resea
rch
set
ti
ng
s
in
m
a
ny
par
ts
of
the
w
or
l
d
sinc
e
the
ol
d
ti
m
es
un
ti
l
rece
ntly
,
so
that
t
his
in
strum
ent
is
reall
y
po
pula
r
for
deca
des
w
orl
dwide
.
HA
RS
c
on
sist
s
of
14
it
em
s
w
hich
de
fine
d
by
a
series
of
sym
pto
m
s
m
easur
ing
both
ps
yc
hic
a
nx
ie
ty
(m
ental
agita
t
i
on
a
nd
ps
yc
ho
log
ic
al
distress
)
an
d
so
m
at
ic
anx
ie
ty
(physi
cal
com
plaints
relat
ed
to
an
xi
et
y).
Each
it
e
m
is
s
cor
e
d
on
Like
r
t
scal
e
of
“0”
(not
present
)
to
“4”
(
seve
re),
with
a
t
otal
scor
e
range
of
0
–
56,
in
wh
ic
h
le
ss
t
han
17
in
dicat
es
m
il
d
sever
it
y,
18
-
24
in
dicat
es
m
i
ld
to
m
od
erate
seve
rity
,
a
nd
25
-
30
in
di
cat
es
m
od
erate t
o
se
ver
e
le
vel
of a
nx
ie
ty
[
10]
.
SPST
wa
s
de
ve
lop
e
d
by
Tha
i
research
e
r
an
d
m
ade
sp
eci
fical
ly
fo
r
asses
sing
stress
le
ve
l
in
Thai
popula
ti
on
.
S
P
ST
consi
sts
of
20
it
em
s
in
whic
h
each
it
e
m
i
s
scor
e
d
on
Likert
scal
e
of
"
0
"
(no
stress
)
to
"
4
"
(ex
trem
el
y
hig
h
stres
s)
,
with
a
total
sco
re
ra
ng
e
of
0
-
80
,
in
w
hich
0
-
23
in
dicat
es
m
i
ld
stress
,
24
-
41
in
di
cat
es
m
od
erate
stress
, 42
-
61
in
dica
te
s
hig
h
stre
ss
, a
nd
m
or
e than
61
in
dicat
es
sever
e stre
ss
[
18]
.
SPST
-
20
ha
s b
een
te
ste
d
f
or
va
li
dity
and
reli
abili
ty
in
el
der
ly
co
m
m
un
it
ie
s
in
Surabaya
with
good
resu
lt
s
(
I
OC=0.7
8;
Cr
onbac
h'
s
Alp
ha
=0.94)
[
20
]
.
GDS
co
ns
ist
s
of
1
5
it
em
s
rat
ed
on
a
dich
ot
om
y
respon
se:
“Y
es”
or
“No
”
.
The
sc
or
e
was
one
po
i
nt
for
each
on
e
sel
ect
ed
by
respo
nd
e
nt
s.
A
sco
re
of
0
to
5
is
nor
m
al
or
unde
pr
es
sed
st
at
e,
wh
il
e
a
scor
e
great
er
than
5
sugg
est
s
depressio
n.
Re
views
valid
at
ion
s
tud
ie
s
of
G
DS
Evaluation Warning : The document was created with Spire.PDF for Python.
In
t.
J.
Publi
c He
al
th Sci.
IS
S
N: 22
52
-
8806
Th
e
best
pr
e
dictor
of a
nxiet
y,
stress,
and de
pr
essio
n a
mon
g
in
sti
tuti
onalized.
.
(
Ni
Pu
tu
Wula
n
P
urn
ama Sa
ri
)
421
ind
ic
at
ed
t
hat
it
is
a
pr
om
isin
g
t
oo
l
for
detect
ing
depressi
on
i
n
the
el
derl
y.
Evid
e
nce
s
howe
d
that
G
DS
is
a
valid
an
d
reli
able
inst
ru
m
ent
for
te
sti
ng
de
pr
essi
on
in
el
de
rly
,
an
d
al
so
s
ensiti
ve
for
a
s
pecial
co
ndit
ion
li
ke
dem
entia
an
d o
ther
physi
cal
il
ness
[21]
.
3.
RESU
LT
S
A
ND
DI
SCUS
S
ION
S
Ther
e
we
re
145
el
der
ly
par
ti
ci
pated
in
this
stu
dy.
Most
of
th
e
m
wer
e
old
ind
i
vidual
s
(75
-
90
ye
ars
ol
d)
,
fem
al
e,
m
arr
ie
d,
Chi
nese
,
seco
ndary
sc
hool
gr
a
du
at
e
d,
an
d
li
vi
ng
i
n
the
nur
sin
g
hom
e
for
1
-
3
ye
ar
s.
Ta
b
l
e 1
e
xpla
ins t
he
d
em
og
ra
phy
char
act
e
risti
c of stu
dy
respo
ndents
in deta
il
s.
Table
1.
Dem
og
ra
phy
c
ha
ract
erist
ic
No
.
Ch
arac
teristic
Frequ
en
cy
Percentag
e
(%)
1
Ag
e (
y
ears old
)
a.
Pr
e
-
eld
erl
y
(45
-
59)
b
.
Elderl
y
(
6
0
-
74)
c.
Old
(75
-
90)
d
.
Ver
y
old
(
>9
0
)
9
65
68
3
6
.20
4
4
.82
4
6
.89
2
.06
2
Gen
d
er
a.
M
ale
b
.
Fe
m
a
le
71
74
4
8
.96
5
1
.03
3
Mar
ital
statu
s
a.
Sin
g
le
b
.
Mar
ried
c.
Sep
ar
ated
/
d
iv
o
rced
d
.
W
id
o
wed
33
58
9
45
2
2
.75
4
0
.00
6
.20
3
1
.03
4
Ethn
icity
a.
Jav
an
ese
b
.
Madu
ranese
c..
Ch
in
ese
d
.
Oth
ers
55
10
76
4
3
7
.93
6
.89
5
2
.41
2
.75
5
Edu
catio
n
al back
g
rou
n
d
a.
Pri
m
a
ry sch
o
o
l
b
.
Seco
n
d
ary
sch
o
o
l
c.
Hig
h
sch
o
o
l
d
.
Un
iv
ersity
grad
u
ated
e.
Un
ed
u
cated
29
50
44
19
3
2
0
.00
3
4
.48
3
0
.34
1
1
.03
2
.06
6
Period
of
livin
g
in
n
u
rsin
g
ho
m
e (
y
ea
rs)
a.
<1
b
.
1
-
3
c.
>3
–
6
d
.
>6
33
59
41
12
2
2
.75
4
0
.68
2
8
.27
8
.27
Re
su
lt
s
of
descr
i
ptive
sta
ti
sti
c
sh
ow
e
d
that
aver
a
gely
respond
ents
ha
d
m
i
ld
anx
ie
ty
(Mean
±S
D:
16.
78±
13.69),
m
il
d
stress
(
Me
an±
S
D:
23.
14±
15.18),
and
not
depresse
d
(Mea
n±SD
:
16.78
±13.6
9)
.
Table
2
e
xp
la
i
ns
t
he
re
porte
d data
of an
xiety
, s
tress,
and
de
pr
es
sio
n
in
d
e
ta
il
s.
T
able
2.
M
eas
ur
e
d
v
aria
bles
No
.
Variables
&
levels
Frequ
en
cy
Percentag
e
(%)
1
An
x
iety
a.
Mild s
ev
erit
y
b
.
Mild to
m
o
d
e
rat
e sev
erit
y
c.
Mod
era
te to sev
ere
93
30
22
6
4
.1
2
0
.7
1
5
.2
2
Stress
a.
Mild st
ress
b
.
Mod
erate
stress
c.
Hig
h
stress
d
.
Sev
ere
st
ress
81
47
16
1
5
5
.9
3
2
.4
1
1
.0
0
.7
3
Dep
ressio
n
a.
No
r
m
al
(un
d
ep
ressed
state)
b
.
Dep
ressed
50
95
3
4
.5
6
5
.5
Re
gr
essi
on
te
st
resu
lt
s
sho
we
d
that
al
l
it
e
m
s
in
HA
RS
a
nd
SPST
-
20
co
ul
d
pr
e
dict
anx
ie
t
y
and
stress
sign
ific
a
ntly
(
al
l
p<α),
but
sens
or
y
pro
blem
and
co
ncent
rati
on
dif
ficul
ti
es
wer
e
pro
ved
to
be
t
he
best
pr
e
dictor
of
an
xiety
and
st
res
s
res
pecti
vely
.
Sensory
pro
blem
was
acco
un
t
ed
f
or
61.
2%
va
riance
of
a
nxie
ty
in
el
der
ly
li
vin
g
in
the
nursi
ng
ho
m
e
(p
=0.0
00),
wh
il
e
co
nc
entrati
on
dif
f
ic
ulti
es
wer
e
accounte
d
for
65.6%
Evaluation Warning : The document was created with Spire.PDF for Python.
IS
S
N:
2252
-
8806
In
t.
J.
Publi
c He
al
th Sci. V
ol.
8
,
No.
4
,
Dec
2019
:
4
1
9
–
4
2
6
422
var
ia
nce
of
str
ess
in
this
popula
ti
on
(
p=0.000).
Feel
in
g
i
nferio
r
t
o
oth
e
rs
was
pr
ov
e
d
t
o
be
the
best
pr
edict
or
of
depressio
n,
and
it
was
acc
ounted
for
25.
9%
va
riance
of
de
pr
essi
on,
wh
il
e
sp
irit
s,
l
ife
energy,
ha
pp
i
ness,
and
feeli
ng
w
onde
rful
to
be
al
ive
co
uld
not
sig
nificantl
y
pr
e
dict
depr
ession
i
n
this
popula
ti
on
(all
p>α).
Table
3
s
hows
the r
es
ults
of
r
egr
es
sio
n
te
st i
n detai
ls.
Table
3.
Re
s
ults o
f
sta
ti
sti
cal
an
al
ysi
s
(a)
P
redicto
rs of
A
n
x
iety
No
.
Deter
m
in
an
t
R sq
u
are
% o
f
inf
lu
e
n
ce
SIG.
1
An
x
io
u
s
m
o
o
d
0
.49
5
4
9
.5
.00
0
2
Tens
io
n
0
.30
5
3
0
.5
.00
0
3
Fears
0
.46
1
4
6
.1
.00
0
4
Ins
o
m
n
ia
0
.46
7
4
6
.7
.00
0
5
Intellectu
al
0
.52
6
5
2
.6
.00
0
6
Dep
ressed
m
o
o
d
0
.47
3
4
7
.3
.00
0
7
So
m
atic
(
m
u
scu
lar
)
0
.48
5
4
8
.5
.00
0
8
So
m
a
tic
(senso
ry
)
0
.61
2
6
1
.2
.00
0
9
Card
io
v
ascu
lar
sy
m
p
to
m
s
0
.40
3
4
0
.3
.00
0
10
Res
p
iratory
s
y
m
p
t
o
m
s
0
.48
7
4
8
.7
.00
0
11
Gastro
in
testin
al sy
m
p
to
m
s
0
.51
7
5
1
.7
.00
0
12
Gen
ito
u
rinary
s
y
m
p
to
m
s
0
.48
5
4
8
.5
.00
0
13
Au
to
n
o
m
ic s
y
m
p
t
o
m
s
0
.49
8
4
9
.8
.00
0
14
Beh
av
io
r
at interv
i
ew
0
.57
6
5
7
.6
.00
0
(b)
Pr
ed
icto
rs of
s
tress
No
.
Deter
m
in
an
t
R sq
u
are
% o
f
inf
lu
e
n
ce
SIG.
1
An
x
io
u
s o
f
m
ak
in
g
m
istak
es
0
.13
2
1
3
.2
.00
0
2
An
x
io
u
s o
f
f
ailin
g
in
r
eachin
g
the g
o
als
0
.26
9
2
6
.9
.00
0
3
Fin
an
cial pro
b
le
m
s
0
.32
7
3
2
.7
.00
0
4
An
x
io
u
s ab
o
u
t po
ll
u
tio
n
0
.48
0
4
8
.0
.00
0
5
Co
m
p
etitiv
en
ess
a
n
d
co
m
p
ariso
n
s in
lif
e
0
.48
3
4
8
.3
.00
0
6
Mon
ey
sh
o
rtages
0
.41
4
4
1
.4
.00
0
7
Mus
cle pain
s
0
.42
5
4
2
.5
.00
0
8
Tens
io
n
head
ache
0
.45
5
4
5
.5
.00
0
9
Back
pain
s
0
.44
4
4
4
.4
.00
0
10
Ap
p
etite los
s
0
.49
1
4
9
.1
.00
0
11
Migrain
e
0
.56
3
5
6
.3
.00
0
12
Feelin
g
worried
0
.42
0
4
2
.0
.00
0
13
Feelin
g
f
rus
trated
0
.50
3
5
0
.3
.00
0
14
Feelin
g
ang
ry
0
.55
1
5
5
.1
.00
0
15
Feelin
g
sad
0
.53
8
5
3
.8
.00
0
16
Me
m
o
r
y
p
rob
le
m
s
0
.58
6
5
8
.6
.00
0
17
Co
n
fus
io
n
0
.60
6
6
0
.6
.00
0
18
Co
ncentration
dif
ficult
ies
0
.65
6
6
5
.6
.00
0
19
Easily
tir
ed
0
.47
2
4
7
.2
.00
0
20
Frequ
en
t cold
0
.38
5
3
8
.5
.00
0
(c)
P
redicto
rs of
d
ep
ressio
n
No
.
Deter
m
in
an
t
R sq
u
are
% o
f
inf
lu
e
n
ce
SIG.
1
Lif
e satisf
actio
n
0
.05
2
5
.2
.00
6
2
Drop
p
in
g
activities
and
interests
0
.19
9
1
9
.9
.00
0
3
Lif
e e
m
p
tin
ess
0
.15
4
1
5
.4
.00
0
4
Bo
ring
n
ess
0
.09
6
9
.6
.00
0
5
Sp
irits
0
.01
3
-
.16
4
6
Fear
o
f
bad
thin
g
s
0
.17
0
1
7
.0
.00
0
7
Hap
p
in
ess
0
.00
2
-
.61
6
8
Feelin
g
help
less
0
.19
2
1
9
.2
.00
0
9
Pref
er
sta
y
in
g
at
h
o
m
e
0
.07
5
7
.5
.00
0
10
Me
m
o
r
y
p
rob
le
m
s
0
.24
6
2
4
.6
.00
0
11
Feelin
g
won
d
erfu
l to b
e alive
0
.00
1
-
.75
6
12
Feelin
g
worth
less
0
.16
5
1
6
.5
.00
0
13
Fu
ll of
energy
0
.01
0
-
.22
6
14
Ho
p
eless
situ
atio
n
0
.25
5
2
5
.5
.00
0
15
Feeling in
ferior
t
o
others
0
.25
9
2
5
.9
.00
0
Ther
e
are
var
i
ou
s
le
vels
of
anx
ie
ty
,
stress,
and
depressio
n
fo
un
d
in
study
resp
on
den
ts.
Ther
ef
ore
,
the
be
st
pre
dictor
of
le
vel
di
ff
e
ren
ces
of
e
ach
var
ia
ble
w
as
al
so
i
de
ntifie
d.
O
ne
way
ANO
VA
te
st
r
esults
sh
owe
d
that
al
l
it
e
m
s
in
HA
R
S
an
d
S
PST
-
20
co
uld
si
gn
ific
antly
pr
e
dict
anx
ie
ty
an
d
stre
ss
le
vels
res
pe
ct
ively
(all
p<α);
whil
e
in
de
pr
es
s
ion
,
the
re
we
re
f
our
it
e
m
s
in
GDS
wh
i
ch
c
ou
l
d
no
t
sig
nificantl
y
predict
Evaluation Warning : The document was created with Spire.PDF for Python.
In
t.
J.
Publi
c He
al
th Sci.
IS
S
N: 22
52
-
8806
Th
e
best
pr
e
dictor
of a
nxiet
y,
stress,
and de
pr
essio
n a
mon
g
in
sti
tuti
onalized.
.
(
Ni
Pu
tu
Wula
n
P
urn
ama Sa
ri
)
423
the
de
pr
e
ssio
n
le
vels
in
el
de
rly
li
vin
g
i
n
the
nur
sin
g
ho
m
e,
su
c
h
a
s:
it
e
m
5
about
sp
irit
s
(p
=
0.667
),
it
e
m
7
about
ha
pp
i
ness
(
p=0.
851),
it
e
m
11
about
fee
li
ng
won
derfu
l
to
be
al
ive
(p
=0.8
61)
,
and
it
em
13
ab
ou
t
li
fe en
er
gy
(p
=
0.379
).
Depressi
on
,
str
ess,
an
d
an
xiet
y
cou
ld
a
ff
ect
QO
L
,
s
uicide,
ph
ysi
cal
pro
bl
e
m
s,
and
s
oci
oecon
omic
sta
tus
in
el
der
ly
,
in
wh
ic
h
these
th
ree
ne
gative
em
otion
al
co
ns
tr
ucts
wer
e
ass
ociat
ed
with
dem
og
ra
phic
var
ia
bles
li
ke
sex,
e
ducat
ion,
m
ari
ta
l
sta
tus,
m
edical
con
di
ti
on
,
a
nd
ho
us
i
ng
co
nd
it
ion
s
[22]
.
Fem
al
e
gen
de
r
and
lo
we
r
ed
uc
at
ion
al
bac
kgrou
nd
had
higher
values
of
a
nx
ie
ty
an
d
de
pressi
on
[
23
]
.
I
n
this
stu
dy,
w
e
found
m
or
e
m
arr
ie
d
fe
m
al
e
than
m
a
le
el
der
ly
with
low
ed
ucati
ona
l
ba
ckgr
ound,
bu
t
ove
rall
m
i
l
d
an
xiety
and
s
tress
with
unde
pr
es
s
ed
sta
te
wer
e
f
ound
in
m
ajo
ri
ty
.
The
a
nxie
ty
disorde
rs
a
re
a
pre
valent
m
ental
healt
h
pr
ob
le
m
in
old
er
a
ge;
it
has
a
par
ti
cular
co
-
m
or
bi
dity
and
risk
fact
or
pr
o
file
[24]
.
Asid
e
from
dem
og
raphic
var
i
ables,
anx
ie
ty
disorde
rs
in
the
el
derl
y
wer
e
al
so
associat
ed
with
ne
urotic
per
s
on
al
it
y
trai
t,
cog
niti
ve
decli
ne
,
fr
ai
lt
y,
i
m
paired
ph
ysi
cal
f
unct
io
n
,
di
sabili
ty
,
and in
cre
ased
m
edicat
ion
s
i
ntake
[25
-
26]
.
Re
su
lt
s
sh
owe
d
that
m
enta
l
agita
ti
on
,
ps
yc
ho
l
og
ic
al
distr
ess,
an
d
physi
cal
com
plaints
relat
ed
t
o
anx
ie
ty
cou
l
d
pr
e
dict
anx
ie
t
y
(p
syc
hic
an
d
so
m
at
ic
)
sig
nificantl
y
in
el
der
ly
li
vin
g
in
the
nursi
ng
ho
m
e,
as
sho
wn
in
T
able
3A
t
hat
a
ll
pr
e
dictors
w
ere
acc
ounted
for
a
ce
rtai
n
num
ber
of
a
nx
i
et
y
var
ia
nce
in
stud
y
respo
nd
e
nts.
S
ens
or
y
pro
blem
s
(p
hysic
al
com
plaints
relat
ed
to
s
om
atic
anx
ie
ty
)
we
re
pro
ved
to
be
t
he
best
pr
e
dictor
of
a
nx
ie
ty
in
this
stud
y
co
ntext.
Sens
ory
pro
bl
e
m
s
cou
ld
ha
pp
e
n
in
va
rio
us
pa
rt
of
the
body,
and
se
nsory
i
m
pair
m
ent
in
old
e
r
ad
ults
can
inc
rease
thei
r
pro
ba
bili
ty
of
ex
per
ie
ncin
g
depressi
ve
an
d
anx
ie
ty
syndrom
e.
A
s
tud
y
to
wa
rd
s
7,3
89
Ital
ia
n
el
der
ly
s
howe
d
t
hat
visi
on
an
d
hear
i
ng
im
pairm
ents
are
ass
oc
ia
te
d
with
de
pr
es
siv
e
-
an
xiety
syndrom
e,
in
wh
ic
h
highe
r
an
xiety
sy
nd
ro
m
e
pr
e
valence
f
ound
in
the
he
arin
g
i
m
paired
gro
up
com
par
ed
t
o
higher
depressi
ve
syn
drom
e
pr
evale
nce
f
ound
in
the v
isi
on
-
i
m
pair
ed
gro
up
[
27
]
.
Visio
n
an
d
he
arin
g
im
pair
m
ents
in
the
el
de
rly
wh
ic
h
oft
en
cal
le
d
du
al
sens
or
y
loss
(
DS
L:
c
om
bin
ed
visi
on
and
he
ari
ng
l
oss)
was
as
so
ci
at
ed
with
de
cr
eased
m
ental
healt
h
sig
nific
antly
,
with
th
os
e
with
DS
L
ei
ther
disp
la
yi
ng
depressive
sym
pto
m
s o
r
bein
g
at
risk f
or
de
velo
ping
de
pressi
on
[28]
.
He
ari
ng
loss
,
the
m
os
t
co
m
m
on
senso
ry
def
ic
it
in
the
el
der
ly
,
co
uld
i
m
pair
th
e
e
xch
a
nge
of
inf
or
m
at
ion
wh
ic
h
sig
nifica
ntly
influ
ence
s
act
ivit
y
of
daily
l
iving
resu
lt
ed
in
lon
el
in
ess
,
iso
la
ti
on
,
dep
e
ndence
,
frustrati
on,
an
d
com
m
un
ic
at
ion
disor
de
rs
[
29]
.
A
stu
dy
towards
42
el
de
rly
hear
in
g
i
m
paire
d
patie
nts
s
howe
d
that
m
il
d
anx
ie
ty
was
c
orr
el
at
ed
with
sel
f
-
repor
te
d
hear
ing
pro
blem
s,
bu
t
de
pr
essi
on
wa
s
strongly
relat
e
d
to
s
el
f
-
per
ce
ived
hear
i
ng
h
and
ic
a
p
[
30]
.
Anothe
r
st
ud
y
towa
rds
15
i
ndivid
uals
a
ged
m
or
e
than
70
ye
ars
old
with
hea
rin
g
lo
ss
a
nd
de
pressi
ve
m
oo
d
s
howe
d
that
re
duct
ion
in
de
pr
e
ssive
sym
pto
m
s
an
d
i
m
pr
oved
Q
O
L
we
re
obser
ve
d
ea
rly
on
with
the
us
e
of
di
gital
hear
in
g
a
ids,
a
nd
m
ental
healt
h
al
s
o
c
hange
d
for
the
bette
r
[
31
]
.
Esca
pe/av
oid
a
nce
co
ping
strat
egies
is
associat
ed
wit
h
an
xiety
sens
it
ivit
y
in
the
el
der
ly
,
bu
t
the
fact
f
ound
in
an
oth
e
r
stud
y
to
wards
94
el
de
rly
sh
owed
that
el
de
rly
with
hear
in
g
pro
blem
s
did
not
us
e
escape/a
voida
nc
e
cop
i
ng
strat
egies,
the
refo
r
e
they
wer
e
not
sensiti
ve
t
o
an
xiety
[
32
]
.
The
re
su
lt
s
of
these
stud
ie
s
c
on
t
ra
dict
the
ab
ove
stu
dy
res
ults
from
Ber
na
bei,
et
al
.
(2011
)
[
27]
wh
ic
h
f
ound
that
the
hea
rin
g
-
im
paire
d
el
der
ly
are
m
or
e
su
sce
ptible
to
an
xiety
synd
r
om
e
than
de
pressi
on.
But,
al
l
stud
ie
s
agr
ee
that hea
rin
g prob
le
m
s ar
e res
ulted in
psy
ch
ol
og
ic
al
pr
ob
le
m
s in
the elder
ly
.
Anxiet
y
co
uld
influ
e
nce
st
re
s
s
le
vel
in
el
de
r
ly
becau
se
of
i
ts
eff
ect
on
ph
ysi
cal
fu
nctio
n
in
eve
ryd
ay
li
fe
[20]
.
Me
di
cal
issues
we
re
the
m
os
t
co
m
m
on
stressors
for
el
de
rly
li
vin
g
i
n
the
nursi
ng
hom
e,
and
el
der
l
y
cop
e
s
f
reque
ntly
by
pr
ay
in
g,
read
i
ng,
watchin
g
te
le
visio
n,
li
ste
nin
g
t
o
m
us
ic
,
and
ta
lkin
g
to
fr
ie
nd
s
a
n
d
fam
i
ly
[3
3]
.
Ther
e
was
ne
gat
ive
correla
ti
on
found
be
twee
n
ps
yc
ho
l
og
ic
a
l
pr
oble
m
s
and
cop
i
ng
strat
e
gi
es
in
el
der
ly
li
ving
in
the
nu
rsing
hom
e,
m
e
anin
g
if
their
co
ping
inc
re
ases
the
n
ps
y
cho
l
og
ic
al
pro
blem
s
de
crease
s
[
34]
.
Re
locat
ion
to
a
nursi
ng
hom
e
from
com
m
u
nity
set
ti
ng
c
ould
be
a
stress
or
al
s
o
for
t
he
el
der
ly
,
of
te
n
cal
le
d
as
relocati
on
st
r
ess
syndrom
e
(RSS),
in
w
hic
h
transiti
onal
care
is
need
e
d
[35]
.
RSS
has
so
m
e
cl
inica
l
m
anifestat
ion
s,
s
uc
h
as
an
xiety
,
co
nfusi
on,
h
opel
es
sn
ess,
an
d
l
on
e
li
ness,
wh
ic
h
usual
ly
diag
nos
ed
in
the
el
der
ly
rig
ht
after
a
s
hor
t
per
io
d
of
sta
yi
ng
in
the
nursing
hom
e
after
long
tim
e
li
vin
g
in
a
pr
i
vate
reside
nce
[
36]
.
Tra
ns
it
ion
al
c
are
in
nursi
ng
ho
m
es
fr
e
qu
e
nt
ly
faces
pro
ble
m
s
associat
ed
with
a
dju
stm
e
nt
by
el
der
ly
r
esi
dent
s
[35]
.
Re
su
lt
s
sho
we
d
that
physi
cal
an
d
ps
yc
holo
gical
res
pons
e
s
towa
r
ds
var
i
ou
s
stress
ors
c
ou
l
d
pr
e
dict
stress
sig
nifica
ntly
in
el
der
ly
li
vin
g
in
th
e
nursing
ho
m
e,
as
sh
ow
n
in
Table
3B
that
al
l
pr
edict
ors
wer
e
accounte
d
f
or
a
certai
n
nu
m
ber
of
stre
ss
var
ia
nce
in
s
tud
y
re
spo
nd
e
nts.
C
on
ce
ntra
ti
on
diff
ic
ulti
es
were
pro
ved
to
be
the
best
predi
ct
or
of
stress
in
this
stud
y
con
te
xt.
Co
nc
entrati
on
is
the
abil
it
y
to
mainta
in
at
te
ntion
in
a
longe
r
per
i
od.
On
e
of
acute
s
tress
reacti
on
i
s
con
ce
ntrati
on
disor
der
[
37
]
.
A
stud
y
towa
rd
s
74
el
der
ly
showe
d
that
the
pr
ese
nce
or
abs
ence
of
c
ogniti
ve
im
pair
m
ent
m
a
y
resu
lt
in
ch
r
on
ic
stres
s
an
d
cop
i
ng
strat
egies
,
in
w
hich
m
e
m
or
y
def
ic
it
m
ay
be
a
risk
fact
or
of
high
stress
le
ve
l
[38]
.
C
on
ce
ntrati
on
dis
ord
er
m
a
y
aff
ect
stre
ss le
vel in el
der
ly
be
cause
of it
s effect
on c
ogniti
ve fu
nctio
n
im
p
ai
rm
ent [
20]
.
The
st
ud
y
a
bo
ut
ass
ociat
ion
betwee
n
c
on
centrati
on
diffi
culti
es
and
stress,
e
sp
eci
al
ly
in
el
de
rly
,
is
ver
y
lim
it
ed
on
li
ne
.
Most
arti
cl
es
avail
ab
le
on
li
ne
c
orre
la
te
con
cent
rati
on
diff
ic
ulti
es
with
post
-
tra
um
at
ic
stress
dis
order
(P
TS
D),
but
no
t
with
a
ge
-
r
el
at
ed
changes
ind
uc
ed
stres
s
found
in
the
el
der
ly
.
For
in
sta
nce,
Evaluation Warning : The document was created with Spire.PDF for Python.
IS
S
N:
2252
-
8806
In
t.
J.
Publi
c He
al
th Sci. V
ol.
8
,
No.
4
,
Dec
2019
:
4
1
9
–
4
2
6
424
a
stud
y
to
w
ar
ds
el
de
rly
(v
et
eran)
with
P
T
SD
an
d
sle
e
p
disturba
nce
f
ound
that
m
ark
ed
dif
fer
e
nces
wer
e
ob
s
er
ved f
or s
ym
pto
m
s su
ch
as an
xiety
, s
el
f
-
de
pr
eci
at
io
n,
gu
il
t, a
nd c
on
c
entrati
on
diff
ic
ulti
es [
39]
.
In
the
ot
her
co
ntext,
a
stud
y
t
ow
a
r
ds
45
a
dult
s
with
m
ob
il
e
ph
o
ne
–
relat
e
d
sym
pto
m
s
(h
ea
dac
hes,
ea
rach
e
,
wa
rm
th
sensati
ons,
f
at
igu
e,
a
nd
pe
rceive
d
co
nc
entrati
on
di
ff
i
culti
es)
sho
we
d
that
con
ce
ntrati
on
diff
ic
ulti
es,
to
gethe
r
with
se
ns
at
io
ns
of
wa
rm
th
and
bur
nin
g
sk
i
n,
co
uld
increase
t
he
le
vels
of
exh
a
us
ti
ons
a
nd
depres
si
on,
bu
t
not
of
a
nxie
ty
,
stress,
a
nd
s
om
at
iz
at
io
n
[40]
.
Sti
ll
in
the
ot
her
co
ntext
,
a
stud
y
towa
r
ds
colle
ge
stu
den
ts
s
howe
d
that
academ
i
c
stress
was
correla
te
d
wit
h
co
gn
it
ive
de
fici
ts,
su
c
h
as
at
te
ntion
an
d
co
nce
nt
rati
on
dif
ficul
ti
es,
il
lness,
a
nx
ie
ty
,
de
pr
ess
ion
,
a
nd
lo
w
l
ife
sat
isfact
io
n
[
41
]
.
Both
st
ud
ie
s
s
howe
d
s
om
e
connecti
on
of
stress
a
nd
co
ncen
t
rati
on
dif
ficult
ie
s.
F
ur
t
he
r
stu
dy
in
el
der
ly
,
especial
ly
nu
rs
ing
hom
e
residen
ts,
nee
d
to
be
condu
ct
e
d
in
order
to
deter
m
ine
the
theoret
ic
al
m
echan
ism
of
b
ot
h varia
bles’
conn
ect
io
n.
Psycho
l
ogic
al
distress
co
uld
res
ult
in
de
pr
es
sio
n
in
agin
g
popula
t
ion
.
In
ph
ysi
cal
con
te
xt,
a
stud
y
to
wards
73,
131
i
nd
i
viduals
age
d
20
-
100
ye
ars
old
s
howe
d
th
at
the
m
echani
s
m
of
ps
yc
ho
log
ic
al
distress
beco
m
ing
depressio
n
is
m
edia
te
d
by
the
el
evated
le
vel
of
C
-
R
e
act
ive
P
r
otein
(CRP)
in
t
he
blood.
In
c
rease
d
CR
P
le
vels
are
associat
ed
wit
h
high
ris
k
of
ps
yc
holo
gic
al
distress
an
d
de
pr
es
sio
n
in
m
os
t
ind
ivi
du
al
s
[
42]
.
It
is
in
dicat
ed
that
t
he
ps
yc
ho
l
og
ic
al
distr
ess
co
uld
i
nduc
e
the
el
evati
on
of
CR
P
le
ve
ls
s
o
that
it
cou
ld
r
esult
in
depre
ssion.
I
n
so
ci
a
l
con
te
xt,
a
st
ud
y
in
Ja
pan
e
se
rural
com
mu
niti
es
showe
d
that
ps
yc
holo
gical
distress
was
hig
he
r
in
gro
ups
with
low
so
ci
al
capit
al
m
ea
su
re
d
by
tru
st
(lo
wer),
tha
n
gro
ups
with
high
s
oc
ia
l
capit
al
;
ind
ic
at
ing
path
ways
existe
d
from
so
ci
al
capit
al
to
ps
yc
ho
l
og
ic
al
distr
ess
via
su
pp
or
ti
ve
rel
at
ion
s
hip
s
[
43]
.
So
ci
al
capit
al
i
s
the
su
m
m
ary
of
sh
a
re
d
nor
m
s,
values,
belie
fs,
trust,
networks
,
so
ci
al
relat
io
ns,
a
nd
insti
tuti
on
s
wh
ic
h
m
o
du
la
te
d
c
oope
r
at
ion
an
d
col
le
c
ti
ve
act
ion
for
m
utu
al
be
nef
it
;
structu
re
&
c
ogniti
ve
,
bondin
g,
br
id
ging
,
an
d
li
nk
i
ng
,
stron
g
&
weak
;
a
nd
horiz
on
ta
l
&
ver
ti
cal
for
instance
[44]
.
It
is
ind
ic
at
ed
that
the
ps
y
cho
l
og
ic
al
dist
ress
in
du
ce
d
by
lower
tr
us
t
from
oth
ers
res
ul
te
d
in
low
s
ocial
ca
pital
leading
to
de
pr
es
sio
n
in
th
e elderly
.
Re
su
lt
s
sh
owe
d
that
sp
irit
s
,
li
fe
energy,
ha
pp
i
ness,
a
nd
f
eel
ing
w
onde
r
fu
l
to
be
al
ive
cou
ld
not
pr
e
dict
de
pres
sion
sig
nifican
tl
y
in
this
stu
dy
co
ntext,
w
hich
is
co
ntra
dict
the
st
ud
y
res
ults
of
Sh
ei
kh
&
Yesa
vag
e
[
21]
.
Feel
in
g
i
nf
e
r
ior
t
o
oth
e
rs
wer
e
pr
ov
e
d
t
o
be
t
he
best
pr
e
dictor
of
de
pr
es
sio
n,
w
hich
wa
s
accounte
d
f
or
25.
9%
var
ia
nc
e
of
de
pressi
on
in
t
his
stu
dy
co
ntext.
T
he
in
fer
i
or
fe
el
ing
to
wa
rd
s
oth
e
rs
ind
ic
at
ed
lo
w
sel
f
-
est
eem
in
stud
y
res
ponde
nts.
Self
-
est
ee
m
is
def
ined
a
s
“how
w
e
val
ue
our
sel
f”;
it
aff
ect
s
our
tr
us
t
an
d
r
el
at
ion
sh
i
ps
in
ever
y
pa
rt
of
li
fe
[
45
]
.
L
ow
s
el
f
-
est
eem
ref
ers
to
a
re
flect
ion
of
central
ne
gative
views
ab
out
sel
f
and
it
is
i
m
po
rtant
not
on
ly
for
e
lderly
,
but
al
so
f
or
ad
ults
and
child
ren
[4
6]
.
Depressi
on
c
ould
cau
se
by
low
sel
f
-
est
eem
wh
ic
h
is
f
requen
tl
y
fou
nd
i
n
the
el
der
ly
in
va
rio
us
co
un
try
[47]
.
Pers
on
with
l
ow
sel
f
-
est
eem
m
ay
feel
powe
rless
an
d
i
ncom
petent
abo
ut
him
sel
f/her
sel
f.
A
qual
it
at
ive
stud
y
towa
rd
s
nursi
ng
h
om
e
reside
nts
sho
wed
th
at
depressio
n
i
s
com
m
on
am
ong
el
der
ly
w
hich
at
trib
ute
d
to
l
ow
sel
f
-
est
eem
[
48]
. Th
e
refor
e
, l
ow self
-
est
eem
l
eads t
o depress
ion
i
n nursin
g
ho
m
e reside
nts
.
Ther
e
are
s
o
m
any
aspects
in
com
par
iso
n
if
so
m
eon
e
w
ants
to
c
om
par
e
him
sel
f
wit
h
the
oth
e
rs.
Ph
ysi
cal
ap
pe
aran
ce
,
ph
ysi
c
al
capa
bili
ti
es,
vocat
io
nal
a
nd
recreati
onal
interest
s,
a
nd
relat
ion
s
hip
s
a
re
al
l
def
i
ning
as
pec
ts
of
one'
s
ide
ntify.
F
or
inst
ance,
s
ocial
c
om
par
ison
a
ddr
esses
the
dam
age
to
sel
f
-
w
ort
h
a
nd
the
resto
rati
on
of
sel
f
-
e
ste
em
fo
ll
owin
g
ch
ronic
il
lness
in
eld
erly
.
I
nd
i
vidu
al
li
vin
g
with
chro
nic
il
lness
cou
l
d
resto
re
his
sel
f
-
est
eem
by
m
od
i
fyi
ng
t
hr
ee
pr
im
ary
m
echan
ism
of
so
ci
a
l
com
par
ison,
den
ia
l,
a
nd
de
riving
m
eaning
f
ro
m
the
exp
e
rience
.
Although
so
ci
al
co
m
par
iso
n
pro
vid
e
s
an
opportu
nity
to
increase
sel
f
-
est
ee
m
,
the
extent
to
w
hich
s
om
eon
e
en
ga
ge
s
in
so
ci
al
com
par
ison
act
ually
may
rep
rese
nt
gr
eat
e
r
ps
yc
holo
gical
distress
[
49
]
.
Anxiet
y,
stres
s,
an
d
de
pr
ess
ion
represe
nt
the
existe
nce
of
m
ental
distress
in
el
der
l
y
li
vin
g
i
n
the
nursi
ng
hom
e.
Nu
r
ses
w
ork
in
t
his
set
ti
ng
nee
d
to
per
i
odic
al
ly
assess
the
le
vel
of
the
se
three
va
riab
le
s
in
order
to
im
prov
e
the
resid
ents’
Q
OL,
a
nd
f
ur
t
he
r
gi
vi
ng
i
nter
ven
ti
on
s
.
As
sta
te
d
in
the
bac
kgr
ound,
by
kn
ow
i
ng
this
stu
dy
resul
ts
it
will
be
us
ef
ul
for
fu
t
ur
e
m
od
ific
at
ion
an
d
i
nter
ve
ntion
de
vel
opm
ent.
Nursin
g
inter
ven
ti
ons
co
ul
d
b
e
ra
ng
i
ng
fr
om
ph
ysi
cal
ly
-
ta
rg
e
te
d
in
te
r
ven
ti
on
to
sp
irit
ually
-
ta
rg
e
te
d
interve
ntio
n.
O
rientat
ion
pro
gram
-
based
i
nterv
e
ntio
n
w
hic
h
pro
ved
to
be
eff
ect
ive
f
or
m
anag
i
ng
these
three
pro
blem
s
[50]
.
S
piritual
-
reli
gi
on
ps
yc
hothe
rap
y
wh
ic
h
prov
e
d
t
o
be
ef
fecti
ve
f
or
im
pro
ving
de
pre
ssion
especial
ly
[51]
.
Nesli
ha
n
sug
gested
to
im
pr
ov
e
ph
ysi
cal
act
ivit
y
in
the
eld
erly
in
orde
r
to
m
anag
e
depr
ession
in the el
der
ly
. Fur
t
her im
ple
m
entat
ion
of a
f
or
em
entione
d
i
nter
ven
ti
ons i
n t
he
local
c
onte
xt of elde
rly
li
ving in
the nu
rsing
hom
e in S
ura
baya sh
ould
be
ca
ution
e
d
[
52
]
.
4.
CONCL
US
I
O
N
All
determ
inants
in
H
ARS
and
SP
ST
-
20
wer
e
pro
ve
d
t
o
be
si
gn
ific
a
nt
pre
dictors
of
a
nx
ie
ty
a
nd
stress
in
el
der
l
y
li
vin
g
in
the
nursing
hom
e
.
Sensory
pr
oblem
s
and
con
c
entrati
on
dif
ficult
ie
s
are
the
bes
t
pr
e
dictor
of
a
nxie
ty
and
stres
s
res
pecti
vely
,
wh
ic
h
we
re
ac
counted
f
or
61.
2%
a
nd
65.
6%
var
ia
nces
of
a
nx
ie
ty
Evaluation Warning : The document was created with Spire.PDF for Python.
In
t.
J.
Publi
c He
al
th Sci.
IS
S
N: 22
52
-
8806
Th
e
best
pr
e
dictor
of a
nxiet
y,
stress,
and de
pr
essio
n a
mon
g
in
sti
tuti
onalized.
.
(
Ni
Pu
tu
Wula
n
P
urn
ama Sa
ri
)
425
and
stress
in
this
popula
ti
on
.
The
re
a
re
fou
r
determ
inants
in
GDS
wh
ic
h
wer
e
not
pro
ved
to
be
sig
ni
ficant
pr
e
dictor
s
of
depressi
on,
na
m
el
y:
sp
irit
s
,
li
fe
ene
r
gy,
happine
ss,
an
d
feeli
ng
w
onde
rful
t
o
be
al
ive.
Feel
i
ng
i
nf
e
rio
r
to
oth
e
rs
is
the
be
st
predict
or
of
de
pr
e
ssion,
w
hich
was
acco
un
te
d
f
or
25.9%
va
rian
ce
of
depressi
on in
t
his stu
dy c
on
te
xt.
L
ow self
-
es
te
e
m
leads to d
epr
es
sio
n
in
nu
rsing
ho
m
e res
idents.
ACKN
OWLE
DGE
MENTS
This
stud
y
w
as
su
pp
or
te
d
for
publica
ti
on
by
Faculty
of
N
ur
si
ng,
W
i
dya
Ma
nd
al
a
Ca
tho
li
c
Un
i
ver
sit
y S
urabaya
.
REFERE
NCE
S
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G.
J.
B
y
rn
e,
N
.
A.
Pacha
n
a,
“
Anxiety
and
Depre
ss
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in
the
E
lderl
y
:
Do
W
e
Know
Any
More
?
,
”
Curr
ent
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2010
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essio
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in
E
lde
r
l
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ti
ent
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wi
th
Persi
stent
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a
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iffe
ren
ce
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,
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z,
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Pur
anda
re
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“
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le
nc
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Ps
y
ch
ia
tr
ic
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lde
r
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rm
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e
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es:
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y
ste
m
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evi
ew
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nte
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ar,
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R.
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“
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pac
t
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Based
Stress
Reduc
t
io
n
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R)
on
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ss
ion
amon
g
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der
l
y
Resid
ing
in
R
eside
nt
ial
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om
es,
”
The
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dia
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vo
l.
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J.
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don,
“
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ss
ion
in
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ing
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es,
”
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ernati
onal
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h
ogeriat
rics
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vol
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no
.
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-
1
148,
2010
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[7]
K.
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“
Diffe
r
e
nce
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Depre
ss
i
on
Le
ve
l
be
tween
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der
l
y
Li
v
es
i
n
The
Nurs
ing
Hom
e
a
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Ho
m
e
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Fam
il
ies
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Bah
asa
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a
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awa
n
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l
an,
“
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el
ati
on
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en
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Quality
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in
Nur
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”
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ik
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ac.i
d
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po/d
isk1/29/
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A.
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r
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i
am,
“
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ent
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e
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ipients,
”
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