Iran Journal of Nursing

Introduction
The elderly population in the world is increasing rapidly. The emergence of diseases such as the severe acute respiratory syndrome coronavirus 2 (SARS CO-V 2) and the outbreak of coronavirus disease 2019 (COVID-19) has caused a serious threat for the elderly. The fear of this disease is high, which can lead to adverse health effects, such as weakened immune system. Evaluation of the psychological effects of this infectious disease on the vulnerable group including the elderly is necessary to prepare for its control. Therefore, this study aims to determine the perceived stress and fear of COVID-19 in the elderly referred to the health centers in Tehran, Iran.
Materials and Methods
This is a descriptive cross-sectional study on 260 elderly people aged >60 years who was selected using cluster sampling method from two health centers in Tehran, Iran affiliated to Iran University of Medical Sciences including Valfajr Comprehensive Health Center (n=130) and Yaftabad Comprehensive Health Center (n=130). Inclusion criteria were: age over 60 years, having a health record in selected health centers, ability to communicate, no specific mental illness, and no cognitive impairment (a score of 7 in the Abbreviated Mental Test). An informed consent to voluntarily participate in the study was obtained from all participants. 
In this study, data was collected in four months (from February 2020 to May 2020). The data collection instruments were the Abbreviated Mental test, a demographic Form, Perceived Stress Scale, and Fear of COVID-19 Scale. SPSS Software, version 20 was used for data analysis. Descriptive statistics (frequency, percentage, mean, and standard deviation) were used to describe the data and inferential statistics (independent t-test, analysis of variance, and linear regression) were employed to analyze the data.
Results
The Mean±SD age of the elderly participating in this study was 69.69±5.16 years ranged 60-84 years. Of 260 participants, 73.1% were women and 26.9% were men; Most of them (77.7%) were married and were living alone. Half of them had moderate economic status. The majority had an undergraduate degree (57.3%). The majority of them (96.9 %) were not smoking cigarette, and 69.2% had a debilitating underlying disease. About one third of them stated that one of their friends or family members had COVID-19, 66.5% perceived their health status as satisfactory, and 48.8% reported high level of perceived stress caused by COVID-19. 
The mean score of perceived stress was 41.5+10.19. Perceived stress variables showed a statistically significant relationship with age, underlying disease, and self-perceived health (P<0.001). The results of the Scheffe post hoc test showed that the mean perceived stress score in married participants was significantly lower than, and the mean perceived stress score of those living with family members was significantly lower than that of those living alone. Moreover, the mean perceived stress score of the elderly with no underlying disease and self-perceived health score of 5 or higher (optimal) was significantly lower. Regarding the fear of COVID-19, the Mean±SD score was 23.45±9.35. The highest score was related to the item 1 of the fear of COVID-19 scale stating “I have a high fear of COVID-19” (3.65), and the lowest score was related to the item 3 stating “When I think of COVID-19, my hands get cold from fear” (3.17).
Discussion 
The findings of the present study showed the high level of perceived stress in about half of the elderly in Tehran, and their fear of COVID-19 was higher than the cutoff point which requires the attention and planning by the healthcare system. Considering the adverse effects of stress and its effects on individuals’ immune system, it is recommended to develop educational interventions for older adults to increase their knowledge of COVID-19, reduce their stress, and improve their mental health.

Ethical Considerations
Compliance with ethical guidelines
Ethical approval was obtained from the Ethics Committee of the Iran University of Medical Sciences (Code: IR.IUMS.REC 1396.4540001779).

Funding
This article is the result of an independent and non-dissertation research project with code 99-1-3-18035, which was approved by the Research Vice-Chancellor of Iran University of Medical Sciences.

Authors' contributions
Conceptualization, research and review, editing and finalization: Farideh Bastani; Statistical editor: Hamid Haqqani.

Conflict of interest
The authors declare no conflict of interest. 

Acknowledgments
The authors would like to thank the officials of two health centers in Tehran, and the elderly participated in this study for their cooperation in this study.

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