Attitudes toward successful aging in individuals with chronic disease aged 65 or over

Aim: To determine the relationship between attitudes toward aging and old age, and successful aging in individuals with chronic disease aged 65 or over. Material and methods: The Attitude Scale toward Aging and Elderliness and the Successful Aging Scale were employed in this descriptive, cross-sectional, comparative study. Data were expressed as frequency, percentage, mean, and standard deviation and were analyzed using the Kolmogorov-Smirnov test, the t test, One-Way ANOVA, and Pearson correlation analysis. p values <0.05 were regarded as significant. Results: Individuals with chronic disease had greater difficulty in accepting old age, greater social exhaustion, greater abilities to cope with problems, and higher successful aging scores. Conclusion: This study shows that despite their negative attitudes toward old age, individuals with chronic disease had greater abilities to cope with problems and aged more successfully.


Introduction
Old age is one of the turning points in an individual's life, and one that entails physical, social, psychological, and mental adaptation problems [1].
Every stage in old age, the last of the developmental periods, is affected by the positive or negative aspects of the previous stage. Simultaneously coping with one or more chronic diseases has a particular impact on the individual's attitude to age and aging [2].
Old age is described as a time of isolation, withdrawal and decay, and is evaluated as a physiological process involving difficulties in coping with numerous adverse internal and external factors, finally resulting in death [3].
The increase in the elderly population has also led to greater awareness of old age. Both birth and death rates are falling in many parts of the world [4]. Individuals' attitudes to aging and old age have been described as one of the markers of quality of life [5]. Positive attitudes are reflected in the elderly individual's quality of life and physical and psychological well-being. However, outcomes may differ among individuals with chronic disease. Increased awareness of aging in recent years has given rise to the concept of successful aging. This involves a healthy lifestyle and the ability to cope with problems [6,7].
Studies suggest that an individual's attitude toward aging is a basic indicator in the perception of old age [8]. In addition, age, nutritional status, family support, exercise and physical independence have all been emphasized as highly important factors in successful aging [9,10]. At the same time, Hartley et al. (2017) reported the imminent emergence of an aging population, that the concept of successful aging is becoming increasingly important in consequence, that relevant risk groups need to be identified, and that precautionary measures can be taken beforehand [11].
The literature describes active aging as more of an individual but highly important concept, and one of growing importance. However, the effect of the presence of chronic disease on active and successful aging has not previously been examined. The number of individuals with chronic disease is known to increase in line with age, but their attitudes to aging and old age, and their successful aging status are unclear. The present study was therefore intended to determine the relationship between attitudes to age and aging, and successful aging among individuals with chronic disease aged 65 or over.

Material and methods Type of research
A descriptive, cross-sectional and comparative study.

Research population and sampling
All individuals (n:118) aged 65 or over hospitalized at the XXX Education and Research Hospital Internal Diseases Clinic, Turkey, between 01.01.2020 and 01.06.2020, and consenting to participate were included in the study. Data were collected using the face-to-face interview method, a process lasting approximately 20 min. The final response rate was 75.2%.
Inclusion criteria: -Literate individuals consenting to take part, -Aged 65 or over, -With mini mental test scores of 24 or more, -With no communication or mental difficulties, and -Not using anxiolytic or psychiatric medications were enrolled.
Exclusion criteria: -Patients not meeting the inclusion criteria were excluded.

Data Collection Tools
The research data were collected using a questionnaire prepared by the authors, the Successful Aging Scale, and the Attitudes to Aging Scale (ASAE).
Information Form: This form consisted of 11 questions involving age, sex, education, occupation, marital status, number of children, income, type of family, and presence and nature of chronic disease.
Attitude Scale toward Aging and Elderliness (ASAE): This five-point Likert-type scale (strongly disagree, disagree, unsure, agree, strongly agree) consists of 45 items and four subscales. Its validity and reliability were studied by Otrar [6]. The total score is calculated (min 45 max 225). Three items are reverse scored (items 30, 32 and 43). Higher scores on the scale indicate more negative attitudes.
The scale's Cronbach Alpha value in this study was 0.93 (Difficulty in Accepting Aging subscale 0.87, Social Exhaustion Perception 0.87, Difficulty in Coping with Life 0.85, and Negative Image 0.48) Successful Aging Scale: The validity and reliability of this scale were studied by Hazer and Özsungur [7]. This seven-point Likert-type scale (strongly agree, agree, partly agree, uncertain, partly disagree, disagree, and strongly disagree) contains 10 questions and consists of two subscales -Healthy Aging (three items) and Coping with Problems (seven items). The lowest possible score on the scale is 10, and the highest possible score is 70, with higher scores indicating more successful aging.
The scale's Cronbach Alpha value in this study was 0.89, while subscale values were Coping with Problems 0.85, and Healthy Aging 0.86.
Data Evaluation: SPSS 23.0 software was used for statistical analyses. In addition to descriptive methods such as frequency, percentage, mean, and standard deviation, the Kolmogorov-Smirnov test was applied to assess normality of distribution. The t test and One-Way ANOVA were applied to compare normally distributed variables between the groups, while relationships between numerical variables were assessed using Pearson correlation analysis. p values <0.05 were regarded as statistically significant.

Ethics
Ethical approval was received from the XXX University Health Sciences Institute (P180R01) ethical committee before commencement of the study, institutional permission was obtained from the institution where the research was performed, and written and verbal informed consent was obtained from the participants.

Results
The mean age of the elderly individuals in the study was 73.70±5.51 years (min:68, max:85), and 54.2% were men. In addition, 88.1% of the participants were married, 46.3% were educated to primary school level, 63.7 were of average economic status, 78.8% were retired, 67.8% lived in a nuclear family, and 64.4% had at least one chronic disease.
In terms of total ASAE and subscale scores, the mean Difficulty in Accepting Aging score was 36.85±9.17, the mean Social Exhaustion Perception score was 46.55±10.76, the mean Difficulty in Coping with Life score was 33.77±7.3, the mean Negative Image score was 25.46±6.39, and the total scale score was 142.64±29.96.
In terms of total Successful Aging Scale and subscale scores, the mean Coping with Problems score was 19.53±6.85, the mean Healthy Aging score was 8.33±3.86, and the mean total scale score was 27.86±9.81 (Table 1). Analysis of ASAE scores revealed that individuals with chronic diseases had significantly higher Difficulty Coping with Old Age (p=0.000), Social Exhaustion Perception (p=0.000), Difficulty in Coping with Life (p=0.000), Negative Image (p=0.001), Coping with Problems (p=0.000), Healthy Aging (p=0.000), and total scale scores (p=0.000). Analysis of Successful Aging Scale and subscale results among elderly participants with chronic diseases also revealed significantly higher Coping with Problems (p=0.000), Healthy Aging (p=0.000) and total scale (p=0.000) scores. No significant association was determined between sex, marital status, type of family, and employment status and the Successful Aging Scale or ASAE and their subscales ( Table 2).
Significant moderate negative correlation was observed between ASAE and Successful Aging Scale scores (p=0.000). Significant negative correlation was determined between Difficulty Accepting Aging, Social Exhaustion Perception, Difficulty in Coping with Life, and Negative Image subscales and the Successful Aging Scale and Coping with Problem subscale (p<0.05). Significant negative correlation was also observed between Healthy Aging and Difficulty Accepting Aging, Social Exhaustion Perception and Difficulty in Coping with Life subscales (Table 3).

Discussion
Aging is a continuous and universal process occurring in every living thing, and that leads to a gradual diminution in all functions. However, the process varies from individual to individual.
In the present study, individuals with chronic diseases had significantly greater difficulty in accepting aging than those with no chronic disease. Acceptance of aging has been reported to be affected by such factors as the individual's economic status, existing diseases, or the loss of a loved one [12]. Another study reported that individuals with chronic diseases found it more difficult to accept old age because they exacerbate feelings of inadequacy [13]. Aközer et al., (2011) stated that chronic disease affects the individual both physically and cognitively, for which reason aging is regarded as a negativity [14].
The findings in the present study are consistent with the previous literature and support the idea that individuals with chronic disease are negatively biased against old age.
The elderly individuals in this study generally had average income levels, but no relationship was determined between income and successful aging. Dziechciaż & Filip (2014) reported that the individual's self-perception plays a particularly important role in successful aging [10]. A multi-study center of individuals aged 65 and over from China reported no correlation between income status and quality of life [15]. Guo et al. (2019) emphasized the importance of family support rather than economic status in active aging [16]. The findings of the present study are consistent with the previous literature.
Individuals with chronic diseases in this study also had a significantly higher perception of social exhaustion that those with no chronic diseases. Elderly individuals' attitudes toward old age are known to be affected by factors such as their environment, beliefs concerning old age, family structure, and experience. Considering old age in psychological, social, and political terms has been reported to play a key role in determining attitudes toward it [14]. Social relationships increasingly diminish in old age, while social roles contract, resulting in a perception of social exhaustion. This perception plays a key role in the attitude towards old age, particularly in recent times. According to activity theory, socially active individuals have  high life satisfaction and a positive attitude toward old age. Attitudes to old age in the present study suggest that a perception of social exhaustion plays an important role in enhancing negative attitudes toward old age. We think that a perception of social exhaustion plays an important role in enhancing negative attitudes toward old age. Individuals with chronic diseases in this study found it more difficult to cope with life than those with no such disease. Chronic diseases have been reported to create an adverse impact on the individual's ability to cope with life, by compromising quality of life and increasing financial costs [17]. Studies have reported that individuals aged 65 or over with chronic diseases have greater socioeconomic burdens and lower quality of life than those with no such diseases [18], that they experience more pain and restrictions [19], and that coping with life is therefore more difficult for them [20].
It has also been suggested that since individuals with chronic diseases have greater difficulty in coping with life than those with no such diseases, these should make greater use of techniques such as mind-body therapy [21]. This finding is consistent with the literature, and we think that individuals with chronic disease find it difficult to cope with life because of complicating factors.
Individuals with chronic diseases in this study also had more negative images than those with no such disease. An elderly individual's possessing a positive image of 'self' and regarding himself as a valuable being, irrespective of weaknesses in old age, is considered to be of considerable importance to successful aging [22]. Chronic diseases compromise quality of life because they result in financial losses [23]. They also cause physical and mental loss of function, and can thus impact adversely on quality of life and active aging [24]. Due to their long-term nature, chronic diseases impair the individual's quality of life, and since stress and depression are more frequent in these individuals, their self-images are negatively impacted [25]. Studies have reported greater negative images in individuals with chronic diseases compared to those without for reasons such as pain, stress, depression, and burnout [25][26][27]. Our finding is consistent with the previous literature.
Individuals with chronic diseases in this study exhibited greater abilities to cope with problems than those with no such diseases. Chronic diseases represent one of the leading health problems of our time, and strategies need to be developed against these [28]. Studies of individuals with different types of chronic disease have reported high abilities to cope with solve problems among such people [29][30][31]. Our finding was in agreement with the existing literature, and we think that individuals with longterm chronic diseases should also receive psychological support.
Individuals with chronic diseases in this study also aged more successfully than those without. Kudo et al., (2013) reported that individuals who aged successfully had high problemsolving skills and took part in social activities [32]. Helme (2001) reported that elderly individuals with chronic disease who were capable of good pain management and with highly empathetic attitudes also aged more successfully [33]. At the same time, individuals with chronic diseases have been reported to behave in a more controlled manner than those without such diseases, while successful aging is accompanied by good pain management and the overcoming of physical limitations [34,35].
We think that our finding shows that individuals with chronic diseases in this study had good pain management.
The general outcome of this study indicated that individuals with positive attitudes toward aging and old age also aged more successfully. Successful aging is a multifactorial concept involving preventing deficiencies, the maintenance of high physical and cognitive functions, and continuous participation in social activities, and is also affected by a positive attitude. Studies have reported that individuals with a positive attitude to aging are better able to adapt to changes, and thus age more successfully [36,37]. This finding indicates an association between adaptation and successful aging.
The principal limitation of this study is that the sample included only the older population. This study shows that despite their negative attitudes toward old age, individuals with chronic disease had greater abilities to cope with problems and aged more successfully. It is recommended to organize trainings on successful aging and to approach individuals with and without chronic diseases consciously about successful aging.

Disclosures:
There is no conflict of interest for all authors.