Existential Issues in Old Age as Narrated by Older People—An Interview Study from Norway

: Background: Research about the importance of existential issues and individuals’ responses to them in old age is growing. This study aimed to explore older Norwegians’ thoughts and experiences related to existential issues and whether or not they wanted to talk about existential concerns with others. The theoretical framework includes Yalom’s ultimate concerns and Tornstam’s theory of gerotranscendence. Methods: Individual semi-structured interviews were conducted with eleven home-dwelling older persons, ﬁve men and six women aged 73–91 years, all residing in a larger Norwegian town. The data were analysed using thematic analysis. Results: Four main themes and two subthemes regarding the participants’ existential reﬂections emerged concerning loneliness, death, and meaning. Some participants increased their interest in existential issues in old age, and only a few participants desired deeper conversations about existential issues. Conclusions: The participants were mostly satisﬁed with life, mainly did not feel lonely and were not afraid of death. Existential meaning was experienced on a horizontal level rather than a transcendent level. Although few openly wanted existential conversations, most participants conveyed a positive interview experience, suggesting that if existential conversations were offered, they would be valuable to older people.


Introduction
One thing in life is inevitable; we are all going to die eventually, and in old age, most people sooner or later start relating to existential issues.As life passes, older persons have experiences like losing loved ones that remind them that the end of life is approaching.Therefore, thinking about life and death and having existential thoughts is part of the normal ageing process.Sørensen et al. (2021) found that late adulthood scored significantly higher than youth on meaningfulness, including vertical transcendence.Existential issues and individuals' responses to them have gained empirical interest in recent decades (Helm et al. 2019), and Irvin Yalom (1980) depicts four ultimate concerns common to all people, which are death, freedom, meaninglessness and existential isolation.These are seen as core issues rather than as an exhaustive list (Helm et al. 2019).
A growing number of research studies suggest that existential issues can be important for older people receiving healthcare services (van Der Vaart and Oudenaarden 2018).However, topics such as meaning in the lives of older people are rarely covered in nursing literature (Hupkens et al. 2018).The topic is important, though, and Malone and Dadswell (2018) found that older adults desired a holistic approach to their health and well-being and that religion and/or spirituality were addressed in healthcare.Thauvoye et al. (2018) based their study on the growing body of research on spirituality and late-life functioning and found positive relations between well-being and experiencing spirituality through connectedness with the transcendent and connectedness with others.They highlight the importance of enabling and stimulating these connections and spiritual experiences for older people.A core aspect from a diaconal perspective is to facilitate dignity, autonomy, and empowerment in holistic care by not seeing the older person as an object of help but rather as a subject in their own lives (Dietrich 2014).
Internationally, recent research explores older people's religious and spiritual concerns.However, according to Rykkje et al. (2013), little Norwegian research is based on older people's experiences and reflections regarding spirituality.Knowledge based on older people's voices is needed to improve spiritual caregiving provided by caregivers.This study thus aims to explore older people's reflections and experiences around existential issues and whether they meet these concerns by talking to others or not.

Existential Issues and Secularised Norway
The term 'existential' and what it is in relation to the similar term 'spiritual' calls for clarification.As elaborated on by Kleiven et al. (2021), there are many definitions of the terms 'existential' and 'spiritual', and the terms may be used for the same phenomenon in different countries due to the translation of the word 'spiritual'.In secularised Norway, 'existential' can be perceived by younger people as a more inclusive concept than 'spiritual', the latter signalling more religious or 'New age' connotations.Therefore, this study relies on DeMarinis' definition, which fits a postmodern society as it includes both religious and non-religious worldviews: The existential dimension is focused on the individual's understanding of existentiality and the way meaning is created.This dimension includes the worldview conception, life approach, decision-making structure, way of relating, and way of understanding.It also includes the activities of expressions of symbolic significance, such as rituals and other ways of making meaning (DeMarinis 2008, p. 60) DeMarinis' definition includes cognitive functions, relations to others, activities, and ritualisation, thus emphasising the holistic view of man where the mental, social, spiritual, and physical dimensions are essential in understanding the existential.
The research literature uses both the term 'spiritual' and 'existential', and in Scandinavia, these terms can be used together and sometimes have almost similar content.Both terms are used by Hvidt et al. (2018), who indicate a need for more research regarding such issues in secularised Denmark.
On the one hand, Norwegian society is rapidly changing due to secularisation.The Church of Norway has lost much of its political and social influence in society, with a decrease in the number of church members.Still, around 70 % are members of the Church of Norway.However, the decrease in influence is most visible in terms of only 2 % participation in regular church services (Kleiven et al. 2021, pp. 21-38), and surveys concerning religious beliefs report a significant change in personal beliefs in the direction of secularisation (Taule 2014).On the other hand, there has been an increase in members of other religions and beliefs mainly due to immigration; thus Norwegian society has become more multireligious with increasing pluralism, which is particularly found in the largest cities such as Oslo (Danbolt et al. 2021).Schnell (2015, p. 152) highlights that statistics do not reveal how religious phenomena have changed profoundly in, for instance, Scandinavia.It is important to recognise that very few reject religion totally or denote themselves as atheists.Instead, orthodoxy is replaced by a need for authenticity, where faith must be validated by personal experience (Schnell 2015, p. 153).Consequently, Schnell recommends a bottom-up approach by asking what makes people experience life as meaningful.Baker and Dinham (2017, p. 5).found through interviews with 18 leading critical thinkers in the study of religions and beliefs that today, people have a different experience and conception of religiosity: "Increasing numbers of people seem to be gravitating towards a religiously fuzzy, but politically and civically intentional 'middle'".As Melder (2011) elaborates, secularisation may also increase existential vulnerability.Norwegian society is changing, yet it is difficult to say how far the process of secularisation has come (Taule 2014).Still, Norway is regarded as one of the most secular countries internationally (Kleiven et al. 2021, p. 35), and religious questions are often assumed to be private matters (Hvidt et al. 2020;Rykkje et al. 2013).

Theoretical Perspectives and Relevant Research
The study is primarily inspired by two theorists: existential psychiatrist Irvin D. Yalom and sociologist Lars Tornstam.This section will give a short introduction, along with relevant research.

Yalom's Ultimate Concerns
In the present article, Yalom's ultimate concerns are used as a conceptual theory for understanding existential issues.With reference to Freud, Yalom claims that we all have conflicting forces within ourselves as human beings.These conflicts may have varying levels of awareness and can even be unconscious to us.Furthermore, Yalom states that the primary concerns of a person "are deeply buried, encrusted with layer upon layer of repression, denial, displacement, and symbolization" (Yalom 1998, p. 171).There are different ways of identifying the conflicts.However, these human concerns arise from our very existence.Yalom explains: The existential position emphasizes a conflict that flows from the individual's confrontation with the givens of existence.And I mean by "givens" of existence certain ultimate concerns, certain intrinsic properties that are a part, and an inescapable part, of the human being's existence in the world (Yalom 1998, p. 172) Yalom's four ultimate concerns are death, freedom, existential isolation, and meaninglessness, each with its own existential conflict.They refer to the boundaries and possibilities of human existence and are the "deep structures" and "the ground that underlies all other ground" for our existence and may be seen as the basic conditions of man.Furthermore, these concerns "include such experiences as a confrontation with one's death, some major irreversible decision, or the collapse of some fundamental meaning-providing schema" (Yalom 1998, p. 172).
The existential conflict concerning death is that we want to live, but death is inescapable (Yalom 1998, p. 172).The anxiety of death torments us more than anything else, and we build up defence mechanisms to handle this anxiety (Yalom 2011, p. 47).There are few studies on death anxiety and older people, as presented in the study by Missler et al. (2011).Fortner and Neimeyer (1999) reported that their study, together with earlier studies, implies that even though there is variance within different age groups, the general results denote less death anxiety among older people than the middle-aged.An empirical study of Missler et al. (2011) among older people living in assisted living facilities in The Netherlands found that the most significant death anxiety was related to the dying process, just a little less fear for significant others and less fear of the unknown.Their study also suggests that death anxiety is high among older people in care institutions.Danbolt et al. (2021) found that among the 408 priests and deacons in their study, more than one-fourth reported that they "quite or very often talked about (. . . ) fear of death" (Danbolt et al. 2021, p. 28).
Freedom implies that the human being is thrown into the world with no safety net or given structure to build on, and the conflict lies in the responsibility to create one's structure in life.Freedom to make decisions is vital in old age, also when being a nursing home resident (Rykkje and Råholm 2014).Furthermore, freedom is closely linked to dignity (Clancy et al. 2021;Grimaldi 2015); when freedom to make one's own decisions is restricted, personal dignity may be at risk, as posited by Tolo Tolo Heggestad et al. (2015).
Existential isolation refers to the final gap between persons, where everyone is fundamentally isolated from others.Yalom elaborates on this: "The existential conflict is thus the tension between our awareness of our absolute isolation and our wish for contact, for protection, our wish to be part of a larger whole" (Yalom 1998, p. 173).Sjöberg et al. (2018) found through interviews with frail older people that existential loneliness was triggered by a sense of worthlessness when not being able to share thoughts and experiences of life, resulting in feeling disconnected from life.Conversely, meaningful togetherness with oneself and others was found to ease existential loneliness (Sjöberg et al. 2019).However, healthcare workers frequently encounter social isolation and loneliness in home-care services for older people (Munkejord et al. 2017).
Finally, according to Yalom's theory, the universe that we are born into has no inherent meaning, and the conflict consists in making meaning in a world without meaning.When crises occur in life, most people either struggle with meaningfulness or seek meaning (Schnell 2020, p. 1).Still, Schnell has described certain people as 'existentially indifferent', and these are "people who do not care if their life has meaning.They are not particularly happy with this attitude, but they do not suffer from it either" (Schnell 2020, p. 117).Most older people have experienced adversity in life.Hence it may not be surprising that the number of existentially indifferent people decrease from the age of 30-39-year-olds to the lowest figure found among people over 70, according to a German study (Schnell and Becker 2006, p. 119).
Meaning in life does not decrease with age, and Jonsén et al. (2015) found that the older people in their study attached meaning to 'Creating space for living', 'Living in connection with others and nature', 'Seeing oneself as a link between generations' and 'Having trust in God'.Regarding meaninglessness, Danbolt et al. (2021) found that more than one-fourth "quite or very often talked about (. . . ) lack of meaning".A recent Norwegian quantitative study reveals that "people in late adulthood (≥65 years) scored significantly higher on meaningfulness compared to younger adults (age 18-64)" (Sørensen et al. 2021, p. 8).

Tornstam's Theory of Gerotranscendence
The theory of gerotranscendence is an empirically based theory developed about 35 years ago, based on Tornstam's (2011) perceived mismatch between existing theories within social gerontology and empirical data.The theory focuses on positive aspects of ageing, the possibility of change and development towards maturation and wisdom, and not on the different kinds of decay that often follow the ageing process (Tornstam 1997).
The theory is not to be compared to the disengagement theory, and instead of focusing on the negative sides of growing old, gerotranscendence sheds light on maturing into transcendence.A person who matures into gerotranscendence may experience "a redefinition of the self and of relationships to others, as well as a new understanding of fundamental existential questions" (Tornstam 2011).Tornstam (2011) explained the theory of gerotranscendence with three major dimensions: The Cosmic dimension, the dimension of The self, and the dimension of Social and Personal Relationships.A person who has developed into the direction of gerotranscendence may show signs in one, two or all three dimensions.As the names of the dimensions signal, there is both a vertical and a horizontal movement.Tornstam researched older people, and the theory of gerotranscendence suggests that human ageing includes a potential to mature into a new outlook on and understanding of life and that gerotranscendence implies a shift in meta-perspective, from a materialistic and rational view of the world to a more cosmic and transcendent one, normally accompanied by an increase in life satisfaction (Tornstam 1996, p. 145) Tornstam found that solitude is an increased desire in old age, but George and Dixon (2018) discovered findings to the contrary, that the oldest old showed "less of a tendency toward development into solitude" (George and Dixon 2018, p. 37).

Materials and Methods
The research question was: "What are older people's reflections on their thoughts and feelings about existential issues, and do they possibly want to talk about this with others?".

Recruitment
Organizations working in older people care in a town in Western Norway were invited to help recruit older adults through their networks.Inclusion criteria were older homedwelling persons aged 67 years or more.Exclusion criteria were severe illnesses or health conditions that made conversations challenging, such as dementia or cognitive impairment.One senior centre responded, and from August to September 2020, participants were recruited among those visiting the centre.The leader distributed information sheets with consent forms; eleven people accepted.

The Participants
The participants were five men and six women; their ages ranged from 73 to 91 years.Table 1 presents the participants' statements on their outlook on life, which serves as background information."When I was younger, I had a so-called Christian view of life, and you trusted angels and everything."John had bad experiences from a Christian community in younger days and stated: ". . .You do not become an agnostic, you do not become an atheist, you simply become empty. . . of it.You do not have the strength to take a stand on it."

Frank (Married)
Frank did not reflect much on the more significant questions in life: "No, I do not think so much like that.I let life live!"Grete (Married) "I've been thinking about it.Have thought that those who think that we are here on earth and God takes care of us, or whatever they think, it must be easier than for me who think that this superior force-that's how I think-eh. . .there must be a power, or whatever you call it. . .energy.Yes, because or else, nothing will be created.

Data Collection through Interviews
Two participants were married to each other and were interviewed together.The ten interviews took place at locations preferred by the participants: either their home or the senior centre.The COVID-19 restrictions at the time were followed.The interviews were conducted in Norwegian, using a semi-structured interview guide with open questions (Creswell 2018;Kvale 2015) and lasted 45 min-1 h 45 min.The English translation of the sample quotes was as close to the original language as possible.The participants were asked about their reflections, thoughts, and experiences of existential issues in old age.The term 'existential' needed, in most cases, further explanation.The interviewer presented examples during the conversations and explained that 'the existential' is concerned with the basic conditions we live under, for instance, Yalom's ultimate concerns.The participants were informed that it was not necessary to discuss all the mentioned existential issues deeply, instead the conversation should concentrate on what was relevant for them.The interviews varied in focus; some persons had more experiences and thoughts around death, others on faith or meaning in life.Two of the participants had experiences from dialogue groups, which was the primary focus in those interviews.

Ethical Considerations
Approval for this study was received from the Norwegian Centre for Research Data (NSD project 861100 and 155899).Oral and written information was provided, and consent forms were signed.The participants were informed about the safeguarding of their anonymity and that they could withdraw from the study.

Analysis
The interviews were audio-recorded and transcribed verbatim.To familiarise themselves with the data and obtain a sense of the whole, the recordings and transcripts were listened to and read through several times by the authors.Data were identified inductively by the first author after several rounds of coding in NVivo.The coding indicated that death, meaning, and loneliness were the existential themes with the highest frequencies and the most thorough descriptions.Since talking about existential issues was a part of the research question, this theme was also included.
Thematic analysis (Braun and Clarke 2008), which is a method that provides help in analysing the material by categorising it (Braun and Clarke 2021;Willig 2014, p. 147), was used to look for similarities and differences in the data material.

Results
Four themes and two sub-themes are presented in Table 2.

Sub-Theme
Loneliness as part of everyday life Death as part of everyday life Trying to grasp the idea of death and an afterlife Meaning in life-or meaning of life Finding personal meaning and meaningfulness in life Talking about existential issues-or not

Loneliness as Part of Everyday Life
Eight participants reported not being lonely and did not fear becoming lonely due to needlework, reading, and meeting people and family.This was the case for John, who reflected on the word loneliness and uttered: Loneliness. . . is probably both a physi. . .both state and a feeling.The feeling of being. . .lonely, that was an ugly word.(. . . ) Loneliness. . .is. . .something that is there when you can find nothing to spend time on, at all.You do not have to be alone to be lonely.(. . . ) You can sit in the middle of an assembly and not be able to keep up, feeling pretty lonely.
Karen had experienced that it was easy to get friends in old age through the activities at the senior centre.Nevertheless, even though she did not feel lonely, she expressed that older people are not asked for their opinion on various issues, unlike in Eastern countries, where old persons are highly valued for their wisdom.She admitted that she felt more on the periphery as an older person, though not lonely.
Three participants reported feeling lonely in different ways, which had developed in old age.To Henry, loneliness was connected to not having anyone close to him in everyday life, and the senior centre was a place to get out of loneliness.He suffered from anxiety and depression, and when asked if existential isolation-to feel lonely among other people and lonely with a God or a supreme power-sounded familiar to him, he replied in the affirmative, and stated: I have to play theatre all my life.I have to play a person that I am not.I cannot sit there and be mentally ill when I am around people.(. . . ) I call my life a theatrical performance.I have to constantly play a person who . . .you deep down. . . is not you the way you are now. . .Betty and Anny had also experienced loneliness approaching in old age as husbands and friends had died, and the COVID-19 pandemic lockdowns had worsened it, despite hobbies.They missed having more time with their nearest and dearest, but distance or busyness in their lives limited it.
The participants were conscious of not being lonely or becoming lonely.Having activities or tasks were thus important but not sufficient.Human relations were essential, and the senior centre was mentioned in that respect by most of them as a place to socialise and stay active.

Death as Part of Everyday Life
For some participants, death as a theme had become more prominent in old age, for instance, when reading the obituary in the newspaper.Three participants had experienced life events that had led to thoughts around death.Betty gave an organ to a relative in her younger days, and her thoughts around death at that time were mostly linked to her children.Two others experienced severe illness, and Peter admitted that "it is obvious that such an event evokes different thoughts and perspectives.Thoughts may seek more towards death as a theme".
Others experienced it differently.For instance, Sarah claimed that getting cancer did not make her ponder more about death.She decided to use all of her strength to get well instead, focus on the here and now, and be present for the people around her. Two male participants shared the experience of not thinking more about death when being seriously ill but reflected on it and thought that some people push thoughts of death away because of fear of the unknown.Anny concentrated on living, even though she had lost her husband and several friends: "I mean. . .I want to try to live and do the best I can while I live.When I am no more, then... then I am no more".
Compared with the other participants, John conveyed an original approach to death by being indifferent.He hardly thought about death, and when asked if it was a conscious choice, he answered: "Should I be so rude as to say indifference?(. . . ) One cannot do anything about it.(. . . ) But you can say that I am a materialist and cynic, or something like that".
Except for Betty, none of the participants conveyed any fear of death, but two participants feared the pain that could accompany death.Karen explained that she had feared death earlier, especially after her parents died and then thinking to herself that she was the next in line to die but had now come to an acceptance after having joined a dialogue group where existential issues were often the topic: "You accept. . .that this [death] is something you cannot choose.You just have to accept it (. . . ) it makes life easier if you say: 'Ok, then'".Although it was not easy, Peter tried to reconcile himself with death and emphasised that even though death was diffuse to him, the unknown did not necessarily evoke fear.Henry had tried to commit suicide a few times and believed that death must be better than the life he has now, while Kirsten conveyed that she did not think about death because she lived one day at a time and had her faith.

Trying to Grasp the Idea of Death and an Afterlife
The participants portrayed different views on death, from the end of life to a transition to an afterlife or as something ungraspable.No one conveyed fear of hell.An example of death as ungraspable was Peter's view, seeing death as something mysterious: "I just have a sense that there is something, but when I say it like that then it's. . .I think there is a force outside me".As a Christian, he believed that his deceased relatives might be in heaven, though he did not have a clear image of heaven.
Henry believed that there was either nothing after death or something good since he had had hell on earth.As for heaven, he bore a hope within himself: There I have a hope of meeting those who have passed away.And that would be fantastic.(Small pause, he cries quietly).No, it is probably the greatest moment of my life.
Three participants said they did not believe in an afterlife, but one of them declared that "God is a good God, (. . . ) so we'll see what happens", and was thus open to being surprised.
Grete reflected on the soul: "I know that when I die, I perish and then I will become earth.(. . . ) But then there is something, which is that little soul, you know?"She spoke vividly about her experience of being when her mother died.The hospital window was open, as was a custom to believe that the soul wandered out of the dead body at the time of death.Grete had decided to watch the curtains closely and discovered that they only fluttered when her mother died, neither before nor after.She thought to herself: "There, the soul went out".

Meaning in Life-Or Meaning of Life
Nobody knows when death will knock on the door, and in the meantime, one challenge might be to fill life with meaning.The participants of this study found that there are at least two aspects of meaning; one is the larger question of human existence and whether there is a higher meaning to life, which is often linked to religious or spiritual beliefs, and the other is more contextual and individual and involves what can be meaningful in daily life.Still, a few participants found it difficult or did not see any difference between the two, as found in this statement by Peter: "I think that the meaning of life and meaning in life. . . is there such a big difference in those questions?I do not see that now".John shared this view and stated: "If you find meaning, then that becomes the meaning of life".
Five of the participants said they either did not believe in or understand the concept of 'meaning of life'.Some also admitted that they had not reflected on the meaning of life, like Sarah, who claimed that she was not that philosophical.Nor had Kristian reflected much on the more significant questions in life, and he and conveyed that he did not believe in a cosmic meaning, but rather in coincidences.Frank expressed that he did not know if there was more between heaven and earth than what he had seen, while Peter wondered if anyone had a good answer to what the meaning of life might be.Grete saw the creation as a circle of life but did not understand the meaning of everything dying and found it challenging to see continuity in it.

Finding Personal Meaning and Meaningfulness in Life
Apart from one, the present study participants did not convey beliefs in a cosmic meaning of life, but they instead reflected on what was meaningful to them in life, and some suggested that this would be the meaning of life.Grete offered the following suggestion: "Perhaps each individual must create the life for herself which gives meaning-to the extent that it is possible for a human being to do so".Betty occasionally pondered a little on the meaning of life, even though she stated that she was not a philosophical type of person.When asked if she thought there was a reason for her being born into this world, she gave the example that she had given an organ to a relative several decades ago: "It is a bit nice to be able to think that I have helped.(. . . ) So, I guess there's a meaning in me still being alive (laughter).You do not know anything about that, but I have faith.And that is good to have".
The participants highlighted different areas of what gives them meaning, and relations in terms of family and friends was emphasised by six participants.Frank described himself as very outgoing and claimed that dialogues with others are the most important thing in life: "I find great pleasure in talking to people.And the dialogue (. . .), you know, is the most important thing in life".
Several emphasised the notion of giving, to contribute or mean something to others as meaningful.Betty had not reflected on why she wanted to live but suggested: "Maybe I do something good for someone (. . . ) It feels good to be of use to someone".However, in old age, frailty may reduce their opportunities to help.Then, meaning may seem to be reduced or lost, as reflected upon by Anny: I think there is a meaning . . . in the way that we ought to help each other, and we should take care of each other and (. . . ) but when I am not that able anymore, there is no meaning.(. . . ) Yes, meaning is a bit lost when you cannot do that much, not being able to support others.
Three participants mentioned being active as meaningful.Examples were being engaged in a brass band, dancing, writing, being creative or being out in nature.To Frank, apart from a newborn baby and his wife, the best thing he could take into his arms was a newly printed book written by himself, while Anny reminisced around all the fun they had had through the brass band and said with conviction: "I've had a wonderful life!"As mentioned, Kristian-an atheist-did not believe in a cosmic meaning.However, when asked about meaning in life, he mentioned Jesus' Sermons on the Mount as valuable: I have a great, strong belief in the Sermon on the Mount itself, really.There is a lot in it that serves as a basis for how to . . .(Interviewer: Yes.Norms and rules?) . . .Yes.And I think that makes a lot of sense.
Contrarily, Kirsten was a Christian and concluded the interview by saying that her faith, family, and friends gave her meaning in life.When asked about what her faith meant to her, she replied instantly: "It means everything!(. . . ) Yes, and it encourages me to be kind to other people."She explained that her faith encouraged her to do voluntary work among drug addicts.Her philosophy of how to live was: "You should behave like a Christian and remember that Jesus was love; then you should also show love to others".Her meaning of life was to follow Jesus' example, including in old age.

Talking about Existential Issues-Or Not
Three categories regarding the participants' needs or desire for the opportunity to talk about existential issues were categorised; some wanted it, some had a good experience through the interview, and some did not want it.
Some participants found it exciting to talk about death, and Peter had experienced this in a conversation group: "It is liberating!".However, from his experience, speaking about death sometimes made it harmless.Karen emphasised that for her, it was valuable to speak to other older people about existential issues, and the dialogue group met a particular need: Yes, it does, because . . .we are similar in the way that, you know, the children have grown . . .grown from us in a way, you know?(Little pause) And if you wish to talk about death, then they understand it.Understand what you think and mean.Younger people do not think in the same ways, maybe.So, eh . . .no, I think that there is a great support in . . .just that . . .(little pause) we understand each other in that way.
For Peter, existential issues had become salient in old age due to seeing friends and acquaintances pass away, and his illness might have set his mind in motion in that respect, too, he said.However, he had not thought about such issues when he was busy in his career: I think in a way that the awareness of death is much stronger the older you get (. . . ) And then you turn to more existential questions that you ask more about.Maybe you have a better time to reflect too.
He desired deep conversations and conveyed that it would be important to talk to friends and with a chaplain or deacon if becoming a patient.
Grete was not religious but was positive towards religion and philosophy because she saw them as a fixed point for people, providing guidelines, security, and stability regardless of which faith it was.She had a lot of philosophical thoughts on different issues and missed having someone to discuss them with.The want for deeper conversations was shared by Henry, who earlier had been OK with more superfluous talks.However, Henry's challenge was that he was not comfortable speaking in a group because of anxiety and depression.He had weekly conversations with a psychiatrist, which he thought was better for him.
Small talks were sufficient for Betty, she stated.Nevertheless, she made a joyous discovery on speaking about her life and existential issues in the interview: I had dreaded this conversation a bit.(. . . ) Yes, because . . .I am not that philosophical in the sense that I go around analysing, you know if things are like this or like that.I thought: What shall I talk about?Is there any point in . . .?But it turned out much smoother and easier than I . . .imagined.(. . . ) It actually felt really good.
Anny was also not used to existential conversations and the interview experience was "totally OK".When asked if she missed having someone to speak to about existential issues, she answered: "No, I don't know, well yes, I guess there is a need, but . . ." She had tried to speak with her general practitioner but experienced that he did not listen to what she needed to talk about.Obviously, she wanted more social contact.
Kristian and Frank did not philosophise much and explicitly articulated that they did not long for conversations concerning existential issues.Sarah described herself as "more superficial".Still, she said that she would probably speak with her friends if the need for existential talks would come.

Discussion
The research question was "What are older people's reflections on their thoughts and feelings about existential issues, and do they possibly want to talk about this with others?"The following discussion is organised concerning the four themes of loneliness, death, meaning, and existential conversations.

Loneliness
Most participants did not feel lonely, probably because they sought community and activities, not because they enjoyed or needed solitude as maturing into gerotranscendence can lead to (Tornstam 2011).Similar findings were also identified in another study, where participants emphasised staying active when growing older (Fortuin et al. 2018).Furthermore, our finding resonates with Yalom's ultimate concerns in the way that the older people's wish for contact made them seek fellowship-in this case with people, nature, and God-and to take responsibility in creating a life they wanted.Tornstam (2011) suggests that older people are less prone to feeling lonely.John confirmed this by reporting to be alone most of the time but without feeling lonely.He discerned between being alone and lonely, echoing Tillich's (1963) distinguishment between loneliness as the pain of being alone, and solitude, the glory of being alone.
The study reports isolation related to the COVID-19 pandemic, a factor that increased their sense of loneliness in a few participants.However, independent of the pandemic, Henry, Betty, and Anny even felt lonelier in old age than before, and Grete and Henry disliked being alone.Yalom differentiates between interpersonal, intrapersonal and existential isolation even though the boundaries between them are 'semipermeable' (Yalom 1980, p. 355).The interpersonal denotes what we usually call 'loneliness', isolation from other people, as Henry, Betty, and Anny experienced to some degree.Only Henry felt existential isolation, which was maybe primarily due to his anxiety and playing theatre among other people.According to Helm et al. (2019), individuals who feel existentially isolated feel that their world views are unique and not shared by others, resembling Henry's notion that he could not reveal who he was.According to George and Dixon (2018), anxiety and depression are negatively correlated with the process of gerotranscendence.Mental factors may inhibit the process, as in Henry's situation, where he did not show traces of maturing into gerotranscendence except for not being afraid of death.
For healthcare workers, existential loneliness may be a challenge to encounter (Sundström et al. 2018), and this study provides information that can guide and strengthen caregivers' conversations and skills related to loneliness in older people.

Death
Some participants revealed that life events had led to thoughts about death.According to Hvidt et al. (2020), the growing research on spiritual care shows that spiritual considerations and needs intensify when having a life-threatening illness, which Peter experienced.In line with gerotranscendence (George and Dixon 2018;Tornstam 2011), we support that crises might stimulate the development of cosmic transcendence and a shift in meta-perspective, as that is visible in some study participants.On the other hand, Sarah, Kristian, and Frank reported that serious life events had not led to thoughts around death.Frank even admitted that he pushed thoughts of death away, which, according to Yalom, may be a defence mechanism (Yalom 2011, p. 47).
Karen's experience of thinking of herself as the next in line after her parents' deaths and the vulnerability accompanying this is not uncommon.According to Kastenbaum (2007, p. 720), the death of another person is often an anxious reminder of one's mortality.Tornstam (2011) claimed that older people came to understand existential questions in new ways, including a redefinition of life and death.Karen experienced this and had come to accept that death is inevitable.As mentioned, both Peter and Karen had also experienced talking about death as liberating and exciting, respectively.The study findings support the idea that one may become less afraid of death in old age as death becomes closer (Tornstam 2011).
An aspect of gerotranscendence (Tornstam 2011) is accepting the mysterious nature of life, and Peter conveyed that he saw death as something mysterious.He likewise did not see a barrier between faith and science.This may serve as an example of what Tornstam sees as a transcendence of intellectual boundaries where everything in life must be explained scientifically and accepting that "the answer is seldom that easy in reality" (Tornstam 2011, p. 173).Unlike Peter, John had not grown into more transcendent thinking with age, though, and he did not oppose being called a materialist.
Based on the study findings, we would like to suggest that caregivers must keep in mind that older people constitute a diverse group and that thoughts of death and interpretations of the existential vary.

Meaning
The participants wanted to help, give, and mean something to others, suggesting that generativity permeated their experiences.Schnell describes generativity as "caring for future generations, leaving traces" (Schnell 2020, p. 182), and asserts that it is the most powerful source of meaningfulness (Schnell 2011).This reflects the theory of transcendence, suggesting a gradual shift in focus from oneself to the needs of others, so-called self-transcendence (Tornstam 2011).Experiencing life as meaningful is central in gerotranscendence (Carver andBuchanan 2016), andHelvik et al. (2011) found that it is essential to create meaning for the psychological well-being of older people in life.Generativity was found among the participants through creativity, descendants, organ donation, giving and helping.This resonates with the Norwegian research by Sørensen et al. (2021), where generativity and unselfish engagement with others proved to be an important source of meaning for people aged 65 and older.
A shift in meta-perspective (Tornstam 2011) was experienced by Peter and Karen, who reflected more on existential issues in old age.None of the other participants emphasised a change in perspective, although some had not reflected on the meaning of life, nor did they believe in a cosmic meaning.Grete, on the contrary, did not talk about a shift in old age, but she had a more philosophical personality.She had been thinking about what the meaning of the circle of life could be, and it seemed that Grete's spirituality was reflected in the sense of being a part of creation (Kleiven et al. 2021).Vertical self-transcendence was not a prominent finding in this study, contrary to the study of Sørensen et al. (2021) that found the strongest relation to meaningfulness for people in late adulthood.This said, the participants were, in our opinion, not existentially indifferent (Schnell 2020), although some were uninterested in searching for cosmic meaning.
Several of the participants in the present study believed in God, but only Kirsten explicitly verbalised a belief in a cosmic meaning.Our interpretation is that those with the Christian faith (cf.Table 1) had a more down-to-earth belief and conveyed this through activities or relationships on a physical level, rather than through meditation and religious rituals on a transcendent level.Hupkens et al. (2018), in their study on meaning in life of older persons, also found that human relationships were the major source of meaning.Therefore, we argue that caregivers may learn from our findings of the importance of establishing genuine relationships to meet older people's need for existential support.

Existential Conversations
The participants conveyed positive experiences of the interviews to the staff at the senior centre, and for many of them, it was a new experience to talk about existential issues in depth.This indicates that although some people express no need for existential conversations, they may find it beneficial when given the opportunity.Some participants, however, desired deeper conversations about existential issues, and one person was interested in receiving pastoral care.These needs are essential to be recognized by healthcare professionals since existential conversations can help accept life as it was and is.
Moreover, some older people want to talk about death.Regarding end-of-life matters, differentiation between healthy and unhealthy talk of death is vital to be aware of (Alftberg et al. 2018), as an individual may have diseases or diagnoses that can worsen when speaking of death.Alftberg et al. (2018) also showed that health workers might encounter many obstacles in talking with patients about death.Having chaplains or deacons may thus be of help too.However, some older people do not desire existential conversations and their wishes to not have these discussions should be respected.
In Norway, where talking about faith or existential issues is not common for most people, we argue that spiritual and existential care may become even more important than in religious societies because people may have fewer spiritual resources and are less trained spiritually.DeMarinis (2008) sees the lack of a functioning existential worldview as a growing problem from a public health perspective.The tools offered by religions to handle existential threats are not as readily at hand in a postmodern society, resulting in new challenges to society in terms of meeting existential needs.This, in combination with existential vulnerability (Melder 2012), requires a response from the healthcare sector.One challenge, though, is that Norwegian nursing students feel that spiritual care conversations are "personal and outside of their comfort zone" (Kuven and Giske 2019, p. 53).Furthermore, healthcare workers in nursing homes are very busy and seldom have the time to address existential talks with patients or lack spiritual care competencies (Hvidt et al. 2018;Rykkje et al. 2013).Moreover, Giske and Cone (2020) reported that patients prefer chaplains over nurses for spiritual assessment, and that nurses often refer patients to the chaplain.In addition, Kaspersen (2020) found that general practitioners lack the time and training to talk about challenges in existential conversations with patients.There seems to be a need for interprofessional collaboration with professionals who are competent in talking about existential issues, as chaplains or deacons, for those who desire that.

Methodological Considerations
Thematic analysis (Braun and Clarke 2008) was chosen because it is a method for identifying, analysing and depicting patterns, similarities and differences in the data material.One of the challenges concerning thematic analysis is that categorisation can lead to decontextualization, because the categorising is made across cases and not within a single case (Maxwell and Chmiel 2014, p. 26).Therefore, to ensure trustworthiness, there was a movement between single quotes and the contexts they were derived from as a way of working hermeneutically (Gadamer 2004) and by choosing the themes that were most deeply reflected on and most answered.Both authors also read the transcripts to ensure accuracy.Furthermore, the research question was in mind when coding to guide the decision of relevant themes.Finally, thorough coding helps enhance the research (Linneberg and Korsgaard 2019).
Regarding transferability, the participants were recruited through a senior centre and thus represented older home-dwelling people who consciously seek activities and social communities.Moreover, most participants were generally content with their lives, and except for two individuals, they neither suffered from mental nor chronic diseases that hampered their life's natural progression.This may have reflected the low need of and use for existential conversations.We acknowledge that the transferability is limited due to the recruitment process.However, we also found that there are some universal aspects in our findings that might have transfer value for others.

Conclusions
The present study provides insights into perspectives on existential issues from older people, adding new knowledge to the empirical research in a Norwegian context.The participants shared different reflections and revealed that they were mostly satisfied with life, mostly not lonely, and not afraid of death.Meaning was primarily experienced on a horizontal level-through actions, activities, or relationships-rather than by meditation and religious rituals, and thus perceived on the physical level more than on a transcendent one.Due to life events and illness, a few of them experienced an increased interest in existential issues in old age.
A few wanted to talk about existential issues.However, most participants conveyed a positive experience of the interview conversation, for instance by expressing liberation and relief, suggesting that having the time and possibility to talk about important issues and experiences in life may be valuable and helpful in old age.Finally, for those who are interested or in need, having conversation partners trained in talking about existential issues may be helpful on both personal and societal levels, and on horizontal and transcendent levels.

Table 1 .
The participants' statements on their outlook on life.You should behave like you are a Christian, and remember that Jesus was love, and then you should also show love." "Yes, I probably think that my life is characterised by a Christian. . .or I know that. . .a Christian view of life."Betty (Widow) "It's good to be able to say: 'Dear God. . .thank you for letting me live.' Morning and evening.Yes.I believe so.Simple and straightforward, I do not make any philosophical questions about it."Anny (Widow) "No, I've never had a specific faith.No.But I don't know...That might be wrong, but. . ." John (Widower)