Demoralization and related factors in patients with chronic kidney disease: A Cross-Sectional Study

doi:10.21203/rs.3.rs-4813341/v1

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Demoralization and related factors in patients with chronic kidney disease: A Cross-Sectional Study

https://doi.org/10.21203/rs.3.rs-4813341/v1

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Objective

This study aimed to investigate demoralization in patients with chronic kidney disease and identify associated factors.

Methods

Participants (N = 345) with chronic kidney disease in a tertiary hospital completed anonymous questionnaire surveys. Measures included the Demoralization Scale - Mandarin Version, the Spiritual Coping Scale, the Pittsburgh Sleep Quality Index, and the Resilience Scale-14. Data were analyzed with SPSS 22.0 software, pearson correlation and linear regression analysis were used to explore factors associated with demoralization.

Results

Respondents returned 324 (93.9%) of the 345 questionnaires. The total DS -MV score was 24.55 ± 8.67. Associated factors of demoralization (R² = 0.602, F = 68.394, p < 0.001) were the duration since CKD diagnosis, spiritual coping, sleep quality, and resilience.

Conclusions

The demoralization of patients with CKD should be considered by health care providers. In this cohort, high demoralization is associated with short time since CKD diagnosis, poor sleep quality, low spiritual coping, and low resilience. Interventions to enhance spiritual coping, increase resilience ,and improve sleep quality may promote mental health of patients.

Chronic kidney disease

demoralization

spiritual coping

resilience

sleep quality

Chronic kidney disease (CKD) is a leading cause of death. Globally, an estimated 9.1% of the world’s population and 10.1% of the Chinese population affected [1–2]. Due to the pathological and physiological characteristics of CKD, although there are available treatment methods, the disease will persist for a long time. CKD is associated with a range of bodily symptoms that can make patients suffering from various symptoms of existential distress, such as the demoralization syndrome. Demoralization syndrome is a non-specific painful state that arises from an individual's sense of helplessness when facing stressful event [3]. There are currently four main instruments used to assess demoralization, the most commonly used of which are the demoralization scale and the semi-structured interview for Diagnostic Criteria for Psychosomatic Research(DCPR) [4].

Although demoralization is considered a treatable clinical disease [5], it is often overlooked by healthcare professionals as a normal response of patients to their medical condition. If a demoralized patient experiences sustained helplessness, social isolation, or shame when dealing with stressful events, they may develop thoughts of accelerating death [6]. In severe cases, they may even engage in suicidal behavior [7]. Therefore, healthcare providers need to adequately identify at-risk individuals and provide appropriate intervention.

Demoralization is most commonly reported among cancer patients [8]. In recent years, demoralization has gradually attracted attention among patients with other chronic diseases, such as human immunodeficiency virus [9], parkinson disease [10], and pain [11]. Although never previously studied in CKD, with persistent symptom burden and limited medical effectiveness, patients with CKD may be at higher risk for demoralization. Therefore, demoralization in patients with CKD deserves special attention in the clinic. Furthermore, the factors associated with demoralization among patients with CKD are uncertain.

Spirituality is a dynamic and intrinsic aspect of human nature and is related to ultimate meaning, purpose and transcendental mindfulness [12].Spiritual coping is a protective factor for individual mental health [13]. Spiritual coping can reduce susceptibility to psychological distress by enabling patients to reframe negative events in a positive light. However, the impact of spiritual coping on demoralization among patients with CKD remains unclear.

Resilience is also an important resource to maintain health and wellbeing for patients with CKD [14]. Resilience, the ability to protect individuals ' from stressful circumstances by using active coping skills [15]. A study of prostate cancer showed that resilience is negative associated with demoralization [16]. However, it is unclear whether resilience may be a potential protective factor against demoralization in patients with CKD.

More than half of patients with CKD have poor sleep quality [17]. Impaired sleep quality increases psychological distress. Previous research has demonstrated that poor sleep quality is positively correlated with demoralization among patients with cancer [18]. however, few studies have explored the relationship between sleep quality and demoralization in patients with CKD.

Therefore, our study aims to assess the demoralization levels of patients with CKD and to identify its association with variables such as spiritual coping, resilience, and sleep quality.

Study design and setting

This is a cross-sectional study of a convenience sample of

patients with CKD in a general hospitals in Yibin, China conducted from December 2023 to February 2024. The data were collected via survey by the researchers.

Sample size calculation

A priori power test was performed using Gpower 3.1 [19]. A linear multiple regression test was used, with α = 0.05, two tails; an effect size of d = 0.15; and a power (1-β) of 0.99 to compute the required sample size, which was n = 125.

21 of the 345 questionnaires were excluded because they had over 30% missing data. The remaining 324 responses were analyzed (effective response rate 93.9%).

Study participants

The inclusion criteria were as follows: (1) age ≥ 18 years, (2) patients with stage 1–5 CKD as determined by the Kidney Disease Improving Global Outcomes Classification Guidelines [20] who have not yet started maintenance dialysis, (3) able to communicate in Mandarin. Exclusion criteria were patients with clinically unstable CKD and acute disease.

This study was approved by the Medical Ethics Committee of Yibin Second People's Hospital (approval number: 2023 − 132). The purpose of the study was clearly explained to all participants, and written informed assent was obtained. The questionnaires were checked immediately after the participants completed them, and if omissions were observed, the participants were asked to return and complete them.

Measurement

Demographic characteristics questionnaire

Demographic characteristics of study participants were collected using self-administered structured questionnaires including age, sex, marital status, education level, monthly income, religion duration since CKD diagnosis, CKD staging, and Comorbidity.

Demoralization

Demoralization is measured using the 24-item Demoralization Scale- -Mandarin Version (DS-MV).The demoralization scale was developed by Kissane [21] to assess existential suffering in patients with serious medical illness. The DS-MV comprises dimensions: loss of meaning, disheartenment, dysphoria, helplessness, and sense of failure. The DS-MV uses a 5-point Likert scale ranging from 0 (extremely disagree) to 4 (extremely agree), with a total score ranging from 0 to 96 points. A cut-off of ≥ 30 indicated high demoralization. The Cronbach’s α of DS-MV was 0.92 [22]; the Cronbach’s α in this study was 0.89.

Spiritual coping

The Spiritual Coping Scale (SCS) [23] is used to assess the spiritual coping. The SCS consists of 17 items, each item was scored on a 5- point scale of 1– 5, with a total score that ranges from 17 to 85. Higher scores indicate higher spiritual coping. The scale's Cronbach’s α was 0.93[24]. In the present study, Cronbach’s α was 0.91.

Resilience

The Resilience Scale-14 (RS-14) is used to assess the resilience [25]. The RS-14 consists of 14 items, each item was scored on a 7- point scale of 1– 7, with a total score that ranges from 14 to 98. Higher scores indicate higher levels of resilience. The Chinese version of RS-14 was shown to have good reliability and validity [26]. In the present study, the Cronbach’s α was 0.87.

Sleep quality

The Pittsburgh Sleep Quality Index (PSQI) is used to assess the sleep quality [27]. The PSQI is an 18-item self-reported questionnaire. The PSQI score ranges from 0 to 21 points, with higher scores reflecting worse sleep quality. The Chinese version of PSQI has been proven to have good reliability and validity [28]. The Cronbach’s α in this study was 0.88.

Statistical analysis

SPSS 22.0 software was used for data analysis. Categorical variables are expressed as frequencies and percentages, and continuous variables are expressed as means and standard deviations (SDs). The Shapiro-Wilk test was used to verify normal distribution. Student’s t-test or one-way analysis of variance (ANOVA) were used to compare differences between groups. Pearson’s correlation was performed to determine correlations between demoralization, spiritual coping, resilience, and sleep quality. Multiple linear regression analysis was calculated to explore significant factors associated with demoralization. Statistical significance level was set at p < 0.05.

Sociodemographic characteristics of patients with CKD

A total of 324 participants completed the study. The mean age of the participants was 69.93 years (SD = 6.65). About half of the participants were between 45–59 years old (67.28%), 20.99% were aged more than 60 years old, and only 11.73% were between 18–44 years old. Most of the participants were male (64.20%), married (63.30%), and had disease duration more than 6 months (68.83%) (Table 1).

Table 1

Demographic characteristics and demoralization scores of all patients (N = 324)
Category	N(%)	DS Mean	DS SD	t/F	p-value
Age(years)
18–44	38(11.73)	22.13	3.53	4.865^a	0.008
45–59	218(67.28)	24.16	8.54
≥ 60	68(20.99)	27.15	10.42
Sex
Male	208 (64.20)	24.55	8.60	0.011^b	0.916
Female	116 (35.80)	24.55	8.83	0.011^b	0.916
Marital status
Unmarried	5 (1.50)	21.60	4.56	0.822^a	0.482
Married	205 (63.30)	24.62	8.68
Widowed	87 (26.90)	25.17	8.65
Divorced	27 (8.30)	22.56	9.20
Education level
Primary school or lower	119 (36.73)	24.63	8.31	0.605^a	0.547
Junior high school	103 (31.79)	25.17	9.41
Senior high school or higher	102 (31.48)	23.87	8.33
Monthly income ($)
0– 350	123 (37.96)	27.76	9.03	19.384^a	<0.001
351– 1070	97 (29.94)	24.32	5.40
≥ 1071	104 (32.10)	20.96	9.30
Religion
No	244 (75.31)	25.35	8.38	0.023^b	0.879
Yes	80 (24.69)	22.11	9.11	0.023^b	0.879
Duration since CKD diagnosis (months)
≤ 6	101(31.17)	19.40	2.58	44.526^a	<0.001
7– 36	116 (35.80)	24.50	9.06
≥ 37	107 (33.03)	29.47	9.16
CKD staging
Stage 1	28 (8.64)	15.93	2.51	41.575^a	<0.001
Stage 2	30 (9.26)	18.61	1.40
Stage 3a	35 (10.80)	18.74	1.15
Stage 3b	116 (35.80)	23.42	4.07
Stage 4	75 (23.15)	30.19	10.42
Stage 5	40 (12.35)	32.82	10.69
Comorbidity
1	34 (10.50)	22.18	7.28	1.855^a	0.158
2	146 (45.10)	24.36	8.90
≥ 3	144 (44.40)	25.30	8.67
DS, Demoralization Scale; SD, standard deviation
^aANOV A
^bt- test

Demoralization of patients with CKD

The average total demoralization score was 24.55 (SD = 8.67) points, while that of the individual item was 1.02 (SD = 0.36) points (Table 2). Loss of meaning had highest score on dimension (8.82 [SD = 2.82). According to the cut-off value of ≥ 30 for the demoralization score, a total of 105 (32.41%) participants were classified as having high levels of demoralization.

Table 2

Demoralization score and score of five dimensions of all patients (N = 324)
Variable	Number of items	Mean (SD) of total scores	Mean (SD) of item scores
Loss of meaning	5	8.82 (2.82)	1.76 (0.56)
Disheartenment	6	3.61 (1.27)	0.60 (0.21)
Dysphoria	5	2.92 (1.52)	0.58 (0.30)
Helplessness	4	6.11 (2.69)	1.53 (0.67)
Sense of failure	4	3.08 (1.21)	0.77 (0.30)
The total score of DS	24	24.55 (8.67)	1.02(0.36)
SD, standard deviation; DS, Demoralization Scale

Demoralization scores by demographic characteristics

The results of univariate analyses showed significant differences in levels of demoralization by age, monthly income, duration since CKD diagnosis, and CKD staging (P < 0.05) (Table 1).

Correlation between demoralization level and spiritual coping, sleep quality, and resilience among patients with CKD

As seen in Table 3, Pearson’s correlation coefficient showed that the demoralization correlated negatively with spiritual coping (r = -0.580, P < 0.01) and resilience (r = -0.754, P < 0.01). Besides, the demoralization was positively associated with sleep quality (r = 0.592, P < 0.01).

Table 3

Pearson’s correlation coefficients between demoralization and possible influencing factors
Variables	Mean of variables	SD of variables	Correlation coefficient of DS
SCS	48.874	15.639	-0.580^a
PSQI	13.219	3.274	0.592^a
RS-14	60.348	16.761	-0.754^a
^ap<0.01; DS, Demoralization Scale; SCS, Spiritual Coping Scale; PSQI, Pittsburgh Sleep Quality Index; RS-14, Resilience Scale-14

Multiple linear regression analysis

Multiple linear regression analysis (Table 4) showed that duration since CKD diagnosis, spiritual coping, sleep quality, and resilience were factors associated with demoralization; they explained 60.2% of the variance in demoralization scores (F = 68.394, P < 0.001). Duration since CKD diagnosis and PSQI positively associated with demoralization (P < 0.05), while SCS and RS-14 negatively associated with demoralization P < 0.05).

Table 4

Regression Analysis of the demoralization and possible influencing factors
Variable	B	SE	β	t	p-value	VIF
Constant	38.500	4.311		8.941	<0.001
Age	0.821	0.560	0.054	1.465	0.144	1.061
Monthly income	0.672	0.431	0.065	1.558	0.120	1.375
Duration since CKD diagnosis	1.288	0.456	0.119	2.823	0.005	1.417
CKD staging	-0.484	0.397	-0.079	-1.219	0.224	3.312
SCS	-0.060	0.030	-0.108	-2.002	0.043	2.318
PSQI	0.431	0.133	0.163	3.248	0.001	1.994
RS-14	-0.307	0.035	-0.594	-8.694	<0.001	3.705
R² = 0.602 (adjusted R² = 0.594), F = 68.394, p < 0.001

DS, Demoralization Scale; B, unstandardized regression coefficient; SE, standard error B;β, standardized regression coefficient; VIF, variance inflation factor; CKD, Chronic Kidney Disease; SCS, Spiritual Coping Scale; PSQI, Pittsburgh Sleep Quality Index; RS-14, Resilience Scale-14

Few previous studies have investigated demoralization in renal populations, and this study is one of the first to investigate demoralization and related factors in patients with CKD. We found that one-third of patients had high levels of demoralization, the DS-MV score was 24.55 and the average itemized score was 1.02. This was higher than those in a previous study among patients with chronic illnesses [29]. A possible reason for this is that most patients in our sample have been ill for more than 6 months and experience long-term symptom burden and psychological distress. The mean total DS-MV score was similar to a study of cancer patients in Taiwan [30]. This may be due to the vulnerability of patients with CKD to the loss of social roles, vulnerability, and dependence on caregivers, which are also common themes associated with demoralization in oncology patients.

In the four DS-MV dimensions, loss of meaning scored the highest, followed by helplessness. When patients' physical symptoms become challenging to treat and they face persistent emotional distress during treatment, they may start to feel a loss of meaning and a sense of helplessness. Besides, in the case of chronic conditions, patients may feel that their health is at risk and integrity is compromised, which can challenge their sense of control and purpose in life. As a result, it is important to develop psychological interventions to address feelings of meaninglessness and helplessness in patients with CKD.

Duration since CKD diagnosis was found positively associated with demoralization among patients with CKD. This is consistent with the findings of a previous study in cancer patients [31]. Over time, patients may be exposed to lack of resources and reduced ability to cope abilities while facing an increased risk of demoralization [29]. Patients with a longer time since diagnosis might encounter a heavier symptom burden, reduced self-efficacy, and a sense of helplessness in managing their disease. Healthcare professionals should prioritize addressing the demoralization experienced by patients who have been diagnosed with CKD for a longer period of time. Conducting psychological assessments of these patients can help in offering tailored treatment and care.

Our results showed that spiritual coping was negatively associated with demoralization; this indicates that spiritual coping could protect patients with CKD against high levels of demoralization. Demoralization may result from the loss of resources experienced by the patient and the inability to self-manage the disease. For patients with serious illness, spiritual coping as a recovery-related resource that can facilitate meaning-making and self-growth [32]. Positive spiritual coping can help patients with CKD accept difficulties in life, re-establish trust and hope in life, and enhance self-awareness and self-development. Moreover, when individuals face stressful events, actively using spiritual resources can help them find the meaning of life and regain their ability to control life [33]. Therefore, encouraging patients with CKD to adopt spiritual coping strategies can help effectively cope with stressors and reduce discouragement.

Consistent with previous research in cancer patients [18], we found a strong association between demoralization and sleep quality in patients with CKD. Poor sleep quality is common in patients with CKD due to factors such as medication side effects, high daytime melatonin levels, tyrosine deficiency, stress, and anxiety symptoms [34]. Sleep difficulty is related to repetitive negative thinking and worrying about the future [35]. Individuals experiencing long-term sleep difficulties may easily lead to the accumulation of negative emotions, threatening physical health, and damaging overall well-being. Moreover, studies have shown significant correlations between poor sleep quality and related phenomena including hopelessness and suicidal behavior [36–37], which may promote the occurrence of demoralization in patients with CKD. Hence, Routine assessment and appropriate management of sleep quality in patients with CKD may reduce the risk of demoralization.

Higher levels of resilience was associated with lower levels of demoralization in our sample. This finding confirms that resilience is an important contributor to maintaining mental health in patients with CKD [38]. Individuals with high resilience have psychological resources such as optimism, calmness, and openness that help them find positive meaning in challenging situations [39]. These characteristics may help patients with CKD reduce the risk of demoralization by gain a sense of control over their lives. Considering incorporating resilience-building interventions into care plans to help patients with CKD controll or mitigate demoralization, this ultimately benefits their mental health.

Limitations

First, the cross-sectional nature of the study design cannot demonstrate a causal relationship between demoralization and other factors in patients with CKD. Second, all variables were assessed using self-report methods, which may be at risk of social desirability bias or recall bias. Third, the study did not evaluate changes in levels of demoralization over time. Longitudinal studies are needed to determine changes in demoralization over time and to determine causal relationships between demoralization and stage of disease, spiritual coping, resilience, and sleep quality. Finally, most patients with CKD recruited in our study were in stage 3b (35.8%) and stage 4 (23.15%), which may limits the generalizability of our findings.

Clinical implications

Previous research has demonstrated that interventions that enhance cancer patients’ sense of meaning can improve their demoralization [5, 40], but there are no intervention studies targeting demoralization in patients with CKD. This study identified some factors (spiritual coping, sleep quality, and resilience) associated with demoralization; our findings indicate that interventions for improving sleep quality, enhancing spiritual coping and resilience may may help reduce the risk of demoralization in patients with CKD.

Considering mindfulness-based interventions (such as the compassionate mindful resilience programme) [41] or life review-based interventions (such as the dignity therapy) [40] as the main strategy to help patients find the purpose and meaning of life and activate individual resources to reduce demoralization. In addition, regular assessment of demoralization and the provision of appropriate psychological intervention may prevent suicidal ideation in patients with CKD.

This study provides a profile of the demoralization of patients with CKD. The demoralization of patients with CKD is mainly characterized by loss of meaning and helplessness. Duration since CKD diagnosis, spiritual coping, sleep quality, and resilience are factors associated with patients with CKD. These findings highlight the need for health care providers to pay greater attention to demoralization in patients with CKD. Interventions to improve sleep quality, enhance resilience and increase spiritual coping may help improve demoralization.

CKD Chronic kidney disease

DS-MV Demoralization Scale - Mandarin Version

SCS Spiritual Coping Scale

PSQI Pittsburgh Sleep Quality Index

RS Resilience Scale

Acknowledgements

The authors are very thankful for all patients participating in this study.

Authors’ contributions

DL: Study design, data analysis and manuscript drafting. LL and WYL: Responsible for the entire research, manuscript revision, comments for improvement in writing and interpretation of the results. CY, LLX, OYMQ and CCX: Data collection, data analysis and interpretation of the results.

Funding

Not applicable.

Data Availability

The data supporting the findings of this study shall be made available from the corresponding author upon reasonable request.

Ethics approval and consent to participate

The study was approved by the Medical Ethics Committee of Yibin Second People's Hospital (approval number: 2023-132). All methods were carried out in accordance with relevant guidelines and regulations. All patients had been provided written informed consent before participating this study.

Consent for publication

Not applicable.

Competing interests

None of the authors have any competing interest.

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No competing interests reported.

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Demoralization and related factors in patients with chronic kidney disease: A Cross-Sectional Study

Status:

Version 1

Abstract

Objective

Methods

Results

Conclusions

Introduction

Methods

Study design and setting

Sample size calculation

Study participants

Measurement

Statistical analysis

Results

Sociodemographic characteristics of patients with CKD

Demoralization of patients with CKD

Demoralization scores by demographic characteristics

Correlation between demoralization level and spiritual coping, sleep quality, and resilience among patients with CKD

Multiple linear regression analysis

Discussion

Limitations

Clinical implications

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1