Anxiety at The Continued Age of High Risk Towards Plague Transmission in The 2019 Coronavirus Disease Pandemic

The elderly are very vulnerable to anxiety, especially during the Covid-19 pandemic. Many elderly people are infected with this virus, especially those who have comorbids. The feeling of worrying about mortality rate raises the risk of physical condition decreasing, this further increases susceptibility to infection. This study aims to determine the description and the factors that cause anxiety. The study was conducted using a qualitative approach. Data collection methods used observation, interviews, and Geriatric Anxiety Scale (GAS). The research subjects for the initial survey were five people, then deepening to an elderly woman (BW), 63 years old who obtained the highest anxiety score. The results showed that the elderly felt anxious about their surroundings being exposed to the Covid-19 virus, it’s seen from the symptoms such as restlessness, difficulty sleeping, and disturbed concentration of thought. Anxiety is caused by physical factors such as suffering from accompanying illness, trauma from emotional experiences, and loss contact with the social environment. The conclusion that the elderly excessive worry because of their physical vulnerability so they often worried if they contracted Covid-19. Simple intervention suggestions such as remembrance therapy in order to calm the feelings and thoughts of the subject during the Covid-19 pandemic.


INTRODUCTION
The medical world received a tough test at the end of 2019. Found a phenomenon caused by a virus that infects human respiration. On December 31, 2019 in the city of Wuhan, Hubei Province, China, a pneumatic case was found that infected a group of people at a seafood market. 1 This case grew and caused many deaths in Wuhan. The World Health Organization together with the Chinese authorities began to cooperate and the etiological agent stated that a new virus was born and was named Novel Corona Virus or 2019 nCoV or Covid-19. 2,3 In the end, the emergence of this virus was declared a pandemic. 2 On June 30, 2020, sourced from the World Health Organization, 2 positive confirmed cases were 56,385 people, 24,806 patients recovered and 2,876 people died. 4 Based on data obtained from the website of the Ministry of Health 4 , it shows that 40% of the victims who died were more than 60 years old. Meanwhile 56% are those aged 50-59 years. Based on this data, it can also be seen that not only the elderly are vulnerable to severe Covid-19 infection, because on this page it also states that the 40-49 year age group recorded a mortality rate of 12,5% and those under 40 years of age were 6,25%. 47,3% of Covid-19 patients in Indonesia who died were elderly over 60 years. From this data, around 15,023 elderly people died because of Covid-19 from a total of 31.763 patients died.
History of disease is one of the factors that cause death. The risk of complications of Covid-19 is higher for some vulnerable populations, especially the elderly and individuals who have chronic conditions such as diabetes, heart disease and blood clotting problems with an average mortality rate of 1%, the death rate increases to 6% in people with cancer, hypertension or chronic respiratory disease, 7% for diabetics and 10% for heart sufferers. The death rate for people aged 80 years or more has a 15% higher risk. 5 Elderly is one of the groups or population at risk which is increasing in number. At-risk populations are groups of people whose health problems are likely to develop worse because of predisposing risk factors. 6 The Covid-19 virus or corona virus is currently the most discussed topic around the world by various groups. The occurrence of the Covid-19 virus pandemic is able to change the lifestyle of all people, both those who are directly affected or indirectly. Changes that occur suddenly will cause a little more anxiety. Excessive feelings of anxiety will certainly greatly affect the mental and physical state of the individual, maintaining mental conditions so as not to be too anxious and stressed is of course important, especially because the effect will decrease immunity, and this is what needs to be avoided. 7 The various reactions that arise when facing the Covid-19 virus pandemic are things that have never been imagined before, so they cause anxiety. In normal limits, feeling anxious is actually something that is needed by individuals against the presence of danger so that they can be better prepared. 8 The number of issues circulating about the dangers of a pandemic to the health of the elderly has added to public unrest. With this, it is very necessary to be able to select and sort out various media reports that are circulating and can be unsettling to cause excessive anxiety in the community and especially the elderly. As we know that one way to fight the Covid-19 pandemic is to always maintain and increase body immunity, thus anything that can cause excessive anxiety should be avoided. 8 According to Hanum and Rasmaliah, the quality of life of the elderly can be influenced by factors such as physical health, psychological health, social and environmental relationships. 9 Elderly is the final stage of development in the human life cycle, which is a natural process that cannot be avoided by every individual, which is divided into two, namely early age aged 60-70 years and late old age starting at age 70 until the end of one's life. 10 So far, the Covid-19 virus causes more severe infections and deaths in the elderly than adults and children. Half of Indonesia's elderly experience health complaints and the percentage is increasing with increasing age. The number of sufferers and cases of death due to Covid-19 virus infection in the elderly continues to increase every day. 11 A situation that cannot be controlled will cause panic which is an emotional aspect of anxiety, anxiety is an emotional condition that arises a feeling of discomfort in a person and is accompanied by feelings of helplessness and uncertainty caused by something that is not yet clear. 12 Anxiety is a condition that is often faced by humans as a part of life which is a source of encouragement to act towards progress and happiness in life if the condition is within normal limits, but high anxiety that exceeds normal limits will disturb the stability and balance of one's life. 13 Anxiety is an affective disorder characterized by deep fear or worry, without obstacles in responding to reality, the personality is intact or has no personality fractures (splitting of personality), disturbed but normal behavior. 14 In previous research on the Effect  which aims to find the impact of social distancing during the pandemic on vulnerable groups in Indonesia, which was obtained from several databases including the Cumulative Index to Nursing and Allied Health Literature (CINAHL), ScienceDirect, ProQuest and PubMed between 2015-2020. The results of this study indicate that one of the vulnerable groups, namely the elderly group is the group most at risk of transmitting and contracting the virus, the elderly group also has a high level of anxiety when compared to the younger age group. In addition, due to advanced age factors, low immune factors are also at higher risk of transmission of the Covid-19 virus. So that in connection with this fact, they tend to have a high level of anxiety about transmission of the virus during a pandemic. 15 Based on this explanation, this study aims to describe the anxiety and factors that cause anxiety in the elderly during the Covid-19 pandemic. The benefits of this research can then be used as a basis for choosing the right intervention design for elderly anxiety during the pandemic. Given that anxiety is very vulnerable to the elderly and during the Covid-19 pandemic, many elderly people were infected with this virus, giving rise to the formulation of the problem in this study, namely how are the descriptions and factors that cause anxiety in the elderly who are at high risk of outbreak transmission during the Covid-19 pandemic.

METHOD
This study used a qualitative approach with purposive sampling technique. Qualitative research is scientific research that is objective and oriented to reflexive methods. The objectives of qualitative research are data exploration, data description, and data explanation. 17 A qualitative approach was taken to describe descriptively the description of anxiety in the elderly who are at high risk of transmission of the outbreak during the Covid-19 pandemic and the factors that cause it. The purposive criteria for the subjects were the elderly who were over 60 years old and had a history of comorbid diseases such as diabetes, high blood pressure, stroke and others. The research subjects were 5 elderly people who met the criteria, but the main subject was an elderly woman with the initials BW and 63 years old who obtained the highest anxiety score (severe anxiety category) from the results of the anxiety assessment survey using the geriatric anxiety scale (GAS). The place of research was conducted in Banjarmasin City with a span of 2 months (June-July 2020). The data collection method in this study used triangulation techniques from various data sources.
Triangulation according to Hadi means a technique of checking the validity of data which is carried out by utilizing other things (data) for checking or comparison or data integration. 17 Sources of data used were obtained from the results of the assessment in the form of observations, interviews, and informal tests in the form of scales. The observation in this study is a non-participant observation, which means that the observer does not participate directly with the subject and is not involved in the activities carried out by the subject. This observation is to obtain data that is more complete, sharp and to know the level of meaning of each visible behavior. Observations were made by a significant other that helped obtain data about the subject's behavior, observation was also carried out as online observations via video calls during interviews.
The interviews in this study are semistructured so that their implementation can be freer and can also be more extensive (wider in scope). Semi-structured interviews are often used in preliminary research or for more indepth research on respondents. The aim is to find problems more openly, where the interviewee is asked for their opinions and ideas. 18 Interviews were conducted online because of the pandemic situation which made it impossible to meet face to face directly, conducted through chat or video calls to the subject and the significant other. The informal test, the geriatric anxiety scale (GAS), is designed for use in the elderly in the Diagnostic and Statistical Manual of Mental Disorders and differs from other anxiety measurement tools that do not fully address the full range of DSM symptoms. In particular, the GAS assesses the symptoms of affective, somatic and cognitive anxiety, all of which are symptoms of anxiety in the elderly. The elderly anxiety scale using the GAS (Geriatric Anxiety Scale) was developed by Segal, June, Payne, Coolidge & Yochim with a reliability consistency value (α = .93) consisting of 25 items to measure cognitive, emotional and physiological aspects, 5 additional items related to attention about finances, concerns about health, worries about children, fear of death and fear of being a burden to others, where each question consists of four points, namely 0, never (never at all), 1, ever (1x a week), 2, rarely (3x a week), 3, often (often almost every day) .17 The method of data analysis and presentation used is to follow the steps recommended by Miles & Huberman, namely: 19 "(1) data reduction, (2) data display, and (3) drawing conclusions and verification." The data collected in this study is more decomposed in words than a series of numbers and the results are in the form of descriptions

RESULTS AND DISCUSSION
Based on the results of the initial assessment of the 5 subjects studied using the geriatric anxiety scale (GAS), it was found that the average subject experienced anxiety in the moderate and severe categories. One subject is known to have anxiety in the severe anxiety category. The subject with the initials BW, is female, aged 63 years. The subject has normal physical development but the subject has diseases such as diabetes, high blood pressure and cholesterol. At this time the subject had difficulty speaking and lay in bed more and was dependent on drugs given by the doctor, besides that the subject also routinely performed medication in the hospital.
Based on the results of observations, the subject looked worried when answering sensitive questions, but the subject tried to focus on the interview. Subjects sometimes over-answer questions. Subjects occasionally answer sensitive questions with an anxious attitude, it could be because they are dealing with strangers, the subject also appears to be alert to their surroundings, makes a lot of movement during the interview.
From the results of interviews, both directly to the subject and from the information of his child as a significant other, information was obtained about the condition of the subject who is currently experiencing post-stroke and other diseases such as diabetes, high blood pressure, diabetes and cholesterol which affect the subject's mood. When the subject's mood is unstable, the subject looks restless and during the interview the subject looks tense, sometimes not focusing on concentrating on the conversation. The existence of the Covid-19 pandemic made the subject unable to leave the house even though the routine before the pandemic occurred the subject was still able to walk to their child's house, or meet other colleagues. The current state of the subject who is susceptible to being affected by Covid-19 makes his child prohibit the subject from leaving the house so that the subject feels disappointed and sad because of the limited social environment. The subject's anxiety about Covid-19 transmission makes the subject feel anxious and always alert when meeting other people and circumstances around him, as a result the subject feels lonely, he feels sensitive and often asks to be accompanied by his child so as not to feel lonely.
Since the beginning of the first positive case of Covid-19 in the Banjarmasin area, the subject was worried. This is because the first positive case is close to the subject's residence.
In addition, the condition of the subject who is categorized as vulnerable because of his old age and has a history of comorbidities that make him vulnerable to being affected by the Covid-19 virus makes the subject feel anxious. Not only the subject, the subject's children also felt worried and anxious because the condition of their mother, who a few months ago had decreased drastically, so inevitably had to make a referral to the hospital. After the subject's condition began to improve, the subject was allowed to return home. During his stay at home the subject felt anxiety and loneliness which was indicated by always calling his child to ask for company and even the subject experienced restlessness at night so it was difficult to sleep and never could sleep one night. His mind also has difficulty concentrating and often imagines the bad things that would happen if he contracted Covid-19.
The emergence of anxiety, fear, and bad thoughts is one of them because the subject had experienced a traumatic situation that emotionally caused a mental conflict to emerge from the emotional experience. Some time at the beginning of the pandemic the subject's health declined, the subject's children had no other choice but to bring the subject to the hospital, but all hospitals did not want to accept the subject as a patient. Of all the existing hospitals, there is only 1 Covid-19 referral hospital that is willing to accept the subject as a patient, because the slow handling given makes the subject's disease more spread to the heart and kidneys. The subject did 2 rapid tests and the results were not reactive but the hospital forced the subject's guardian to sign that the BW subject was considered a patient under Covid-19 surveillance (PDP), then the subject was forced to enter the isolation room but the subject's children choose to keep the subject in self-isolation. When in an independent isolation room, the subject is only allowed alone without anyone accompanying him for a few days to do a SWAB test. After several days of isolation, new subjects were allowed to return home after the results of the SWAB test were negative and the subject's condition began to improve.
The subject was worried about his drastically declining health, in addition to complications due to environmental conditions related to the Covid-19 pandemic making the subject anxious if he contracted it. Even though the subject had done a rapid test and the results were negative, the subject still felt anxious if one day the comorbidities suffered from complications returned.
The trauma that is felt related to the Covid-19 pandemic situation arises because of the fear that one day they have to return to the 26 Jurnal Berkala Kesehatan, Vol. 7, No. 1, May 2021: 22-28 DOI: 10.20527/jbk.v7i1.9621 hospital if the illness recurs, the subject feels afraid of being ignored or even ignored by medical personnel because of the chronic illness experienced which can cause death. From the results of the geriatric anxiety scale (GAS) given to the subject, it is found that the subject gets a total score of 67 which is included in the severe anxiety category, so it can be concluded that the BW subject who is 63 years old is in the category of having severe anxiety.
Anxiety problems that arise in the average elderly subject in the form of anxiety in the moderate and severe categories are a reaction as a result of the aging process that occurs in old age. One of the effects of aging is that it can cause cognitive disorders that have an impact on memory and intelligence (cognitive). 20 Other problems with feelings include anxiety or anxiety. Anxiety is an emotional condition characterized by feeling tense, anxious thoughts and physical changes such as an increase in blood pressure, trembling, headaches etc. 21 In the subject of anxiety that appears visible from symptoms such as feelings of helplessness due to weakened physical conditions with comorbidities, a sense of loneliness so that they always ask to be accompanied by their children, and when the subject feels restless, sometimes the subject's emotions are unstable, the subject will be angry and cry excessively. It is clear that the subject is included in the aspect of anxiety in the response of affective behavior, Muarifah states that anxiety can arise as a result of the accumulation of frustration, conflict and stress. 22 People with anxiety will find it difficult to concentrate and socialize so that it will become an obstacle in carrying out social functions, jobs and roles.
The emotion experienced by the subject depends on the condition of his body, different when the subject feels restless, the subject asks his child to accompany him to be beside him and when the subject's emotions are unstable, sometimes the subject will be angry and cry excessively. self-blame, such as feeling helpless. The subject often daydreams and sometimes even seems like a blank mind because the subject is now difficult to speak after the subject is discharged from the hospital The subject often called his child because in the past, when the subject was still healthy, he liked to go out of the house to go to his child's house and go out for company. During his stay at home the subject felt anxiety and loneliness which was indicated by always calling his child to ask for company and even the subject experienced restlessness at night so it was difficult to sleep and never could sleep one night. This is in accordance with Hayat's opinion of anxiety, namely neurotic helplessness, insecurity, immaturity, and inability to face realistic demands (environment), difficulties and pressures of daily life. 13 Subjects who have severe levels of anxiety greatly reduce the individual's perceptual field. Individuals tend to focus on something detailed and specific and don't think about anything else. All behaviors are aimed at reducing tension. The individual needs a lot of direction to focus on other areas. 23 It is like the subject focuses on the subject's child so as not to feel lonely to reduce the tension experienced by the subject. The efforts made by the subject to reduce their anxiety when there is rejection experienced by the subject, namely to silence their child, because the subject's child does not allow the subject to leave the house because of the danger of Covid-19 for the subject's health. This includes the subjects' ways of reducing anxiety. Projection is one where blaming others for one's own negligence and mistakes or shortcomings. 24 This also arises when the subject's perception is negative that he is afraid of being ignored or even ignored by medical personnel if the disease recurs during the pandemic so that it can cause death if he is infected with Covid-19. Symptoms of anxiety in general in the elderly are changes in behavior, restlessness, reduced concentration ability, reduced ability to store information, and complaints in the body such as chills, moist palms and so on. 25 As for some of the factors that cause anxiety in the elderly, among others, can be due to (1) environmental factors, it can be the environment around the place of residence which affects the way of thinking or the social environment of the subject around him, (2) suppressed emotions, (3) the causes physical. 26 This is in accordance with the condition of the subject where he is very worried about his condition because of his physical illness, the fear of relapse of illnesses during the Covid-19 pandemic makes him anxious and disturbs his feelings so that he often suppresses his emotions making him sensitive, as well as the environmental mindset at that time. who still consider Covid-19 to be very dangerous and deadly make their way of thinking even more negative and they are too afraid of being infected. While other environmental conditions that also affect the surrounding social environment which currently lacks contact, the subject feels lonely because since the pandemic they cannot walk outside and also establish social contact as usual with other people.

Mayangsari MD. et al. Anxiety at The Continued… 27
Several other factors as the emergence of anxiety in the elderly can also come from (1) internal; age, gender, level of education and motivation (2) external; family support and social support. 27 In the subject of physical factors, one of the factors that made him worried about contracting the virus was his susceptibility to the risk of comorbidities. Emotional trauma is also a triggering factor for anxiety that causes mental conflict where the subject feels that he has experienced an unpleasant situation when he was forced to enter an independent isolation room because it was suspected that Covid-19 turned out to be negative.
From the results of the assessment obtained in this study, it can be illustrated that the elderly during the Covid-19 pandemic can experience anxiety which is generally seen through somatic, cognitive, and affective symptoms with various causes, one of the most being complaints is due to decreased physical condition and vulnerability. physical because they have a disease.

CONCLUSION
Based on the research results, it can be concluded that anxiety is a negative emotional state characterized by somatic, cognitive, and affective symptoms. Elderly subjects feel anxious about their surroundings, which are now exposed to the Covid 19 virus, on average, they can be seen from the symptoms that appear, such as restlessness, difficulty sleeping, and disturbed concentration of thought. Anxiety factors arise due to physical causes such as suffering from diseases and diabetes, cholesterol, high blood pressure, and post-stroke, as well as trauma factors from emotional experiences, and loss of contact with the social environment during the pandemic. Elderly who experienced severe levels of anxiety during the Covid-19 pandemic experienced excessive worries due to their physical vulnerability so they often worried about bad things if they contracted Covid-19.
To overcome anxiety in the subject, simple intervention suggestions are given that can minimize anxiety such as remembrance therapy to calm the feelings and thoughts of the subject during the Covid-19 pandemic. Zikr therapy interventions in several studies have shown that dhikr khafi is effective in reducing anxiety levels in the elderly. 28 Dhikr therapy is also able to reduce anxiety in the elderly in Werda Nursing Homes. 29 For this reason, suggestions for further researchers of this research can be the basis for further development in making intervention designs that are suitable for the conditions of the elderly in overcoming anxiety during the Covid-19 pandemic.