Resilience as a Mediator Between Demoralization and Quality of Life in Older Patients With Colorectal Cancer: A Cross-Sectional Study

Abstract

This study examined the relationships among resilience, demoralization, and quality of life (QoL) in older patients with colorectal cancer and explored the mediating role of resilience. A cross-sectional study using convenience sampling was conducted at a medical center in northern Taiwan. Data were collected through structured questionnaires, including a demographic survey, the Resilience Scale, the Mandarin Version of the Demoralization Scale, and the McGill Quality of Life Questionnaire. Correlation and mediation analyses were performed using the PROCESS macro for SPSS. Among 139 participants, resilience was negatively correlated with demoralization (γ = −0.728, P < .001) and positively correlated with QoL (γ = 0.714, P < .001). Demoralization was negatively correlated with QoL (γ = −0.719, P < .001). Mediation analysis confirmed that resilience significantly mediated the relationship between demoralization and QoL (Z = −4.69, P < .001). Enhancing resilience may reduce demoralization and improve QoL in older colorectal cancer patients. Integrating resilience-building interventions into early-stage cancer care may enhance patients’ psychological well-being and overall QoL, though further studies with more representative samples are needed.

Keywords

resilience demoralization quality of life colorectal cancer older adults mediation effect

Introduction

Colorectal cancer is the third most common malignancy and the second leading cause of cancer-related death worldwide.^1,2 According to the 2023 Taiwan Ministry of Health and Welfare report, it ranks as the third leading cause of death in Taiwan.³ Colorectal cancer is also particularly prevalent among older adults.⁴ Beyond surgery, cancer treatments often lead to progressive physical decline in older patients, increasing their vulnerability to psychological distress. This may foster feelings of hopelessness and despair, negatively impacting their quality of life (QoL) and even hindering their ability to approach the end of life with peace.^5–7 Promoting resilience—the capacity to withstand adversity—is essential in geriatric cancer care. Enhancing patients’ resilience can foster positive psychological adaptation, support coping mechanisms, and ultimately improve QoL.⁸ Resilience and demoralization are key psychological constructs in cancer care.^9–11 Resilient patients can adapt to illness-related stress, maintain a sense of meaning, and sustain a positive outlook despite adversity, leading to better QoL outcomes.^11–14 In contrast, persistent negative emotions such as helplessness and hopelessness may lead to demoralization, which significantly impairs psychological well-being and QoL.^14,15 Demoralization—marked by a loss of purpose and existential despair—is common in patients with serious illnesses. Notably, Taiwanese cancer patients exhibit among the highest reported rates of demoralization globally.¹⁶ Demoralization is more strongly associated with suicidal ideation, underscoring the importance of early recognition and intervention.^16–18 Given the high prevalence of colorectal cancer among older adults and its impact on both resilience and demoralization, this study aimed to investigate the associations among resilience, demoralization, and QoL in older Taiwanese patients with colorectal cancer, with a focus on the mediating role of resilience.

Method

Study Design and Setting

This cross-sectional study enrolled older patients with colorectal cancer from the hematology–oncology ward and the outpatient oncology clinic of a medical center in northern Taiwan.

Participants

Participants were recruited through convenience sampling, which was chosen to facilitate access to the target population within the study timeframe and ensure that all participants met the inclusion criteria. Although convenience sampling may introduce selection bias and limit generalizability, this approach was practical for recruiting eligible patients in a clinical setting.

The inclusion criteria for the study participants were as follows: (1) patients diagnosed with stage IIB colorectal cancer or above (T3-4N0M0) who had received or were receiving anticancer treatment; (2) patients aged 65 years or older who were aware that they had been diagnosed with cancer; (3) patients who were conscious and free of psychiatric disorders; (4) patients who could communicate in Mandarin or Taiwanese; and (5) patients who agreed to participate in the study. The exclusion criteria were as follows: (1) patients diagnosed with stage I colorectal cancer (T1N0M0, T2N0M0) or who only received surgical treatment (as these patients generally have better prognoses and lower psychological distress, which may confound the associations studied); (2) patients who were unaware of their cancer diagnosis; (3) patients who were suffering from severe mental illness; (4) patients who were unable to communicate verbally or in writing; and (5) patients who did not agree to participate in the study.

Based on the calculation method used in the G*Power (3.1.9.2) software package,¹⁹ a minimum sample size of 139 was determined, with a type I error of 0.05, a type II error of 0.20 (80% power), and a medium effect size (f² = 0.15) according to simple linear regression analysis.

Data Collection

The Institutional Review Board approved this study prior to its conduct. Suitable participants were screened according to the inclusion criteria, and verbal and written consent forms were obtained from patients and their families before recruitment. The recruitment period was from June 1, 2019 to November 30, 2020. Considering an incomplete response rate of 10%, 147 questionnaires were sent, and all questionnaires were returned at a return rate of 100%. However, 8 questionnaires were incomplete; therefore, 139 valid questionnaires were obtained, indicating a completeness rate of 94.56%.

The researchers collected questionnaire data through one-on-one and face-to-face interviews, including the patient's characteristic questionnaire, the Resilience Scale, the Mandarin Version of a Demoralization Scale, and the McGill Quality of Life Questionnaire-Taiwan Version (MQOL-Taiwan version).

Patient's Characteristic Questionnaire

The patient's characteristic questionnaire included gender, age, educational level, religious beliefs, marital status, economic status, primary caregiver status, cancer stage, Eastern Cooperative Oncology Group (ECOG) performance score, and type of anticancer treatment received.

Resilience Scale

This study utilized the Resilience Scale developed by Wagnild and Young²⁰ as a tool, with the Chinese version of the Frustration-Resilience Scale translated by Li.²¹

There were 25 items in total. The questionnaire was divided into five subscales: having a meaningful life (7 items), calm mind (6 items), indomitable spirit (3 items), accepting loneliness (3 items), and maintaining self-confidence (6 items). A 5-point Likert scoring method was adopted, with a total score ranging from 0 to 125. Higher scores indicate higher resilience, while lower scores indicate lower resilience. Cronbach's α for the total scale was .96. Cronbach's α values for having a meaningful life, having a calm mind, an indomitable spirit, accepting loneliness in existence, and maintaining self-confidence were .93, .90, .88, .90, and .91, respectively. A resilience scale score of 100 to 125 was classified as high resilience, 75 to 99 as medium resilience, and less than 74 as low resilience.²¹

Demoralization Scale-Mandarin Version

Kissane et al proposed the diagnosis of demoralization syndrome in 2001,²² and developed a demoralization scale in 2004,²³ which was also translated into the Demoralization Scale-Mandarin Version (DS-MV).²⁴ The DS-MV contains five dimensions: loss of meaning and purpose (5 items), dysphoria (5 items), disheartenment (6 items), helplessness (4 items), and sense of failure (4 items), with a total of 24 items given a score of 0 to 4 representing strongly disagree to strongly agree, with strongly disagree scoring zero points, and strongly agree with 4 points. Items 1, 6, 12, 17, and 19 of the DS-MV were positive declarative items, and reverse scoring was adopted. Cronbach's α for the entire scale was .92, and Cronbach's α values for each dimension were .84, .69, .88, .72, and .63, respectively. The DS-MV scores higher than 30 indicated high demoralization.^23,24

McGill Quality of Life Questionnaire-Taiwan Version (MQOL-Taiwan Version)

The original scale, the MQOL Scale, was developed by Cohen et al²⁵ to assess the QoL in patients with cancer. The MQOL Scale-Taiwan Version comprises four domains: physical symptoms (3 items), psychological symptoms (4 items), existential well-being (6 items), and social support (3 items), totaling 16 items. A digital scale measured the patient's QoL in the past seven days. Each question is scored on a scale of 0 (the most undesirable situation) to 10 (the most desirable situation). The average score of all the items in the four domains was used as the MQOL total score. In addition, the scale includes a single self-scoring item on the patient's overall QoL (with scores ranging from 0 = unsatisfactory to 10 = excellent), which was used to assess the patient's physical, psychological, economic, social, and spiritual feelings in the past two days (scores on this single-item part are often regarded as the best indicators of perceived QoL). A higher score indicates a better QoL. The content validity index of the MQOL Scale-Taiwan Version was 0.83, and Cronbach's α values for the four domains ranged from .69 to .90.²⁶

Data Analysis

The recovered questionnaire data were sorted, encoded, and entered into a computer, and the SPSS 22.0 software package was used for data processing. The statistical analysis methods included descriptive statistics, independent sample t-test, analysis of variance, Pearson product-moment correlation, and multiple regression. The latest version (2.16) of the PROCESS software program was installed and integrated with SPSS 22.0 to verify the estimated mediation effect. The Sobel test was then used to confirm the mediation effect.^27,28 In all regression and mediation analyses, age, marital status, education level, and ECOG performance status were entered as covariates to control for their potential confounding effects.

Results

Participant Characteristics

The study included 139 older patients with colorectal cancer, comprising 78 men (56.1%) and 61 women (43.9%), aged 65 to 81 years (mean = 69, SD = 11.75). Most individuals had an elementary education (28.1%), held religious beliefs (91.4%), were married (75.5%), and reported a moderate economic status (65.5%). Nearly half (48.2%) were cared for by their spouses. In terms of clinical characteristics, 46.0% were in stage III and 33.1% in stage IV, with 54.0% having an ECOG performance score of 1. Over half (51.8%) received chemotherapy alone. Detailed characteristics are presented in Table 1.

Table 1.

Demographic Characteristics of the Participants (N = 139).

Variables	Number of Participants (n)	Percentage
Gender
Male	78	56.1
Female	61	43.9
Age (range: 65-81; mean: 69; SD: 11.75)
65 to 69 years	80	57.6
70 to 74 years	24	17.3
75 to 79 years	20	14.4
≥80 years	15	10.7
Educational level
Illiterate	19	13.7
Elementary school	39	28.1
Junior high school	33	23.7
Senior high school and vocational school	27	19.4
Junior college	8	5.8
University	13	9.3
Religious beliefs
Nil	12	8.6
Buddhism	58	41.7
Taoism	60	43.2
Christianity	9	6.5
Marital status
Unmarried	6	4.3
Married	105	75.5
Widowed	22	15.8
Divorced	6	4.4
Economic status
Completely inadequate	6	4.3
Slightly adequate	29	20.9
Moderately adequate	91	65.5
Completely adequate	13	9.3
Primary caregiver
Spouse	67	48.2
Child	44	31.7
Nurse	12	8.6
Other	16	11.5
Cancer stage
Stage II	29	20.9
Stage III	64	46.0
Stage IV	46	33.1
ECOG score
0	2	1.4
1	75	54.0
2	53	38.1
3	9	6.5
Type of treatment
Chemotherapy	72	51.8
Radiotherapy	5	3.6
Chemotherapy + radiotherapy	4	2.9
Targeted therapy	7	5.0
Chemotherapy + targeted therapy	51	36.7

Description of Resilience, Demoralization, and QoL

In this study, the average total score for resilience in older patients with colorectal cancer was 91.19 (SD = 14.16), indicating a medium level of resilience. The top 3 average total scores for each dimension were: having a meaningful life (M = 25.65, SD = 4.57), having a calm mind (M = 22.04, SD = 3.31), and maintaining self-confidence (M = 21.30, SD = 3.91). The average demoralization was 27.90 (SD = 15.27), indicating low demoralization. The top 3 average total scores for each dimension were as follows: sense of failure (M = 6.74, SD = 2.85), disheartenment (M = 6.43, SD = 4.03), and helplessness (M = 4.98, SD = 3.77). The average total QoL score was 113.73 (SD = 19.97), indicating a high QoL. The top 3 average total scores for each dimension were existential well-being (M = 34.74, SD = 9.49), psychological symptoms (M = 30.09, SD = 7.67), and physical symptoms (M = 25.74, SD = 4.50). The overall QoL self-scoring item (item 17) had an average score of 6.23 (SD = 1.66).

Correlations Among Participant Characteristics and Resilience, Demoralization, and QoL

Significant correlations were found among participant characteristics, resilience, demoralization, and QoL. Resilience was positively correlated with educational level and the presence of a primary caregiver, and negatively correlated with age and ECOG performance status. Demoralization was negatively correlated with marital status (being married) and positively correlated with ECOG performance status. QoL was positively correlated with age, educational level, and marital status, but negatively correlated with ECOG performance status and the type of current anticancer treatment. No significant correlations were observed between gender, religious beliefs, economic status, cancer stage, and any of the psychosocial variables; therefore, these results are not shown in the main tables. Refer to Table 2 for further details.

Table 2.

Correlations Among Participants’ Characteristics, Resilience, Demoralization, and Quality of Life (N = 139).

Participants’ Characteristics	Number of Participants	Total Score of Resilience	Total Score of Demoralization	Total Score of Quality of Life
		M ± SD	M ± SD	M ± SD
Age
65 to 69 years	80	94.04 ± 14.67	26.66 ± 14.68	113.40 ± 19.40
70 to 74 years	24	85.71 ± 14.03	33.12 ± 17.72	106.21 ± 20.68
≥75 years	35	88.46 ± 11.51	26.77 ± 14.46	119.63 ± 19.47
F value		4.26*	1.78	3.35*
P value		.016	.173	.038
Educational level
Illiterate	19	87.95 ± 10.96	23.73 ± 15.00	116.79 ± 16.54
Elementary school	39	89.05 ± 15.45	28.69 ± 15.97	111.95 ± 20.76
Junior high school	33	88.00 ± 11.57	33.06 ± 14.23	107.94 ± 19.65
Senior high school and vocational school	27	98.81 ± 15.82	23.18 ± 15.47	124.44 ± 19.48
Above junior college	21	93.33 ± 12.76	27.52 ± 13.95	109.57 ± 18.21
F value		3.15*	2.02	3.25*
P value		.016	.095	.014
Marital status
Unmarried and divorced	12	81.67 ± 19.72	41.91 ± 18.06	91.58 ± 21.19
Married	105	92.71 ± 13.49	26.17 ± 13.93	114.78 ± 17.83
Widowed	22	89.14 ± 11.97	27.90 ± 16.53	120.77 ± 21.75
F value		3.69*	6.14**	10.06***
P value		.027	.003	.000
Primary caregiver
Other	16	88.25 ± 14.49	32.43 ± 21.60	103.75 ± 21.86
Spouse	67	94.06 ± 13.09	26.52 ± 12.22	114.64 ± 17.72
Child	44	90.45 ± 13.91	26.06 ± 15.07	117.66 ± 19.87
Nurse	12	81.83 ± 16.85	35.16 ± 19.78	107.50 ± 25.88
F value		3.07*	1.79	2.41
P value		.030	.151	.070
ECOG score
0	2	101.50 ± 10.61	21.00 ± 16.97	94.00 ± 8.49
1	75	96.51 ± 12.89	24.33 ± 13.13	117.68 ± 19.39
2	53	86.34 ± 11.61	31.13 ± 15.64	111.47 ± 19.10
3	9	73.22 ± 14.82	38.66 ± 21.71	98.44 ± 21.85
F value		13.79***	4.02**	3.83*
P value		.000	.009	.011
Type of treatment
Chemotherapy	72	90.25 ± 12.65	27.68 ± 13.95	111.67 ± 18.57
Other therapy	16	85.88 ± 21.99	33.37 ± 25.13	106.38 ± 22.59
Chemotherapy + targeted therapy	51	94.19 ± 12.69	26.23 ± 14.42	118.94 ± 20.18
F value		2.49	1.34	3.31*
P value		.087	.265	.039

*P < .05; **P < .01; ***P < .001.

Correlation Among Resilience, Demoralization, and QoL

Pearson correlation analysis demonstrated the following relationships among the key variables: resilience and demoralization showed a strong negative correlation (γ = −0.728, P < .001), indicating that higher levels of resilience were associated with lower levels of demoralization; resilience and QoL exhibited a strong positive correlation (γ = 0.714, P < .001), indicating that higher resilience was associated with better QoL; and demoralization and QoL demonstrated a strong negative correlation (γ = −0.719, P < .001), indicating that higher demoralization was associated with poorer QoL.

To understand the predictors of QoL in older patients with colorectal cancer, we examined essential attributes and disease characteristics. We then analyzed resilience and demoralization by placing these 2 items as the dependent variables in a multiple regression model as the independent variables. QoL was used. The results showed that resilience and demoralization differed significantly in predicting QoL, with 59% of the variance explained by resilience (β = .045, R² = 0.594, P < .001) and demoralization (β = −.424, P < .001). The variance inﬂation factor in the covariance diagnosis was 2.217, indicating that resilience and demoralization were predictors of QoL (Table 3).

Table 3.

Multiple Regression of Resilience, Demoralization, and Quality of Life (N = 139).

Variables	β	SD	t Value	P value	VIF
Resilience	.045	0.112	5.082***	.000	2.127
Demoralization	−.424	0.104	−5.321***	.000	2.127
R ²	0.594
F value	25.823

Abbreviations: VIF, variance inﬂation factor (inflated variance factor); QoL, quality of life.

Dependent variable: QoL.

***P < .001.

Mediating Effect of Resilience on Demoralization and QoL

The mediating effect was verified using PROCESS software. The Sobel test was further applied to examine the mediation relationships among the study variables.^27,28 Based on the theoretical framework, demoralization was defined as the independent variable (X), resilience as the mediator (M1), and QoL as the dependent variable (Y). Control variables that might influence the mediating effect were also included in the analysis.

The mediation model was tested step-by-step as follows:

Step 1: Examine the effect of the independent variable (X) on the mediator (M1). The independent variable must have a significant effect on the mediator.

Step 2: Examine the effect of the independent variable (X) on the dependent variable (Y). The independent variable must have a significant effect on the dependent variable.

Step 3: Enter the mediator (M1) into the same model and examine the effects of both X and M1 on Y. The mediator must have a significant effect on the dependent variable, and the coefficient of X → Y should decrease compared to Step 2.

A mediating effect was confirmed when all the above conditions were met. As shown in Figure 1, path a (X-M1): demoralization had a significant adverse effect on resilience (β = −.67, P < .001). Path b (M1-Y): resilience had a significant positive effect on QoL (β = .57, P < .001). Path c′ (X-Y): the direct effect of demoralization on QoL was significant (β = −.55, P < .001). Path c (X-Y): the total effect of demoralization on QoL was significant (β = −.93, P < .001).

Figure 1.

Mediating path of resilience indirectly affecting quality of life through demoralization.

The indirect effect (a × b) was −0.38 (−0.67 × 0.57). Using the Amos bootstrapping method (5000 resamples), the 95% confidence interval for the indirect effect ranged from −0.567 to −0.236, which did not include zero, indicating statistical significance. A Sobel test further confirmed the mediating effect (Z = −4.69, P < .001), demonstrating that resilience significantly mediated the relationship between demoralization and QoL. In other words, demoralization influenced patients’ QoL both directly and indirectly through its impact on resilience.

Discussion

Results from this study suggest that older patients with colorectal cancer exhibited moderate resilience and low demoralization, with an overall QoL score suggesting relatively favorable outcomes. The association between a good ECOG performance status and higher resilience aligns with previous research emphasizing the role of self-care ability in fostering psychological adaptation.^29,30 Despite low average demoralization levels, demoralization remains a critical clinical concern, as up to 23.4% of Taiwanese cancer patients experience significant demoralization.^22,31 We observed that participants aged 70 to 74, those who were unmarried or divorced, and those with ECOG scores of 3 or receiving nonstandard therapies demonstrated lower resilience, higher demoralization, and poorer QoL. These findings reinforce the role of social support, especially marital support, as a buffer against psychological distress.^32,33 Although most participants reported having religious beliefs, religion was not significantly associated with resilience, demoralization, or QoL in this sample. This may reflect cultural factors or measurement limitations related to religious involvement.

Correlation analyses confirmed the strong negative association between resilience and demoralization and the positive link between resilience and QoL, consistent with prior studies showing that higher resilience is associated with lower demoralization and better QoL among cancer patients.^34,35 These findings underscore resilience as a protective factor enhancing well-being and mitigating demoralization. Moreover, the mediating effect of resilience, explaining 40.86% of the total effect between demoralization and QoL, highlights its pivotal role in patient outcomes. Clinically, these findings advocate for the implementation of resilience-strengthening interventions as a means of enhancing QoL and reducing demoralization in older cancer patients.

Limitations

This study has several limitations. First, the cross-sectional design precludes causal inference; longitudinal studies are required to clarify the directionality among resilience, demoralization, and QoL. Second, participants were recruited from a single medical center using convenience sampling, which may limit the generalizability of the findings. Third, self-reported questionnaires are subject to recall and social desirability biases. Lastly, the relatively homogeneous religious and cultural background of the sample may have constrained variability in psychosocial outcomes.

Future Research Directions

Future research should examine the longitudinal effects of resilience on psychological well-being and QoL across diverse cancer populations. Multicenter and longitudinal studies are recommended to enhance the external validity of findings. Moreover, developing and evaluating tailored psychosocial interventions, such as mindfulness-based stress reduction, narrative therapy, or resilience training, may provide effective strategies to strengthen resilience, reduce demoralization, and ultimately improve the QoL among older patients with cancer.

Conclusion

In summary, the findings suggest that resilience plays a crucial mediating role between demoralization and QoL in older patients with colorectal cancer. Enhancing resilience may help alleviate psychological distress and improve overall well-being. These results underscore the importance of developing clinical interventions, such as psychoeducational programs and mindfulness-based therapies, to foster resilience and mitigate demoralization. Future longitudinal studies are warranted to explore causal pathways and evaluate the long-term effects of resilience-enhancing interventions on patient outcomes.

Footnotes

Acknowledgments

The researchers would like to thank the older patients with colorectal cancer who participated in this study.

Author Contributions

Yu-Shih Yeh contributed to conceptualization, methodology, software, data curation, visualization, investigation, and writing—original draft preparation. Tsui-Wei Chien contributed to conceptualization, methodology, data curation, validation, supervision, and writing—reviewing and editing. Chun-Kai Fang contributed to methodology and supervision.

Consent to Participate

All participants provided written informed consent prior to their participation in this study.

Data Availability Statement

The data supporting this study are available for inspection upon request but cannot be publicly shared. This restriction is in accordance with the informed consent obtained from participants, which permits data analysis exclusively by the research team and does not authorize disclosure to any external parties.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Considerations

This study was approved by the Mackay Memorial Hospital Institutional Review Board (Project No. 19MMHIS002).

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Tsui-Wei Chien

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