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Giving Up and Replacing Activities in Response to Illness

^a Institute for Health, Health Care Policy, and Research, Rutgers, The State University of New Jersey
^b Center for State Health Policy, Rutgers, The State University of New Jersey
^c Department of Medicine, Robert Wood Johnson School of Medicine, University of Medicine and Dentistry of New Jersey, New Brunswick

Jennifer Duke, Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, 30 College Avenue, New Brunswick, NJ 08901 E-mail: jduke{at}rci.rutgers.edu.

Decision Editor: Margie E. Lachman, PhD

	Abstract

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Data from a longitudinal study of 250 older adults were used to examine activity loss and replacement as a consequence of an important illness episode. Multiple regression analyses revealed that reductions in activity were predicted by physical factors, specifically illness chronicity and severity. In contrast, replacing lost activities was facilitated by social support and optimism and inhibited by a belief in the need to conserve physical resources. An examination of the long-term benefits of replacing activities revealed that older adults who replaced a lost activity had higher positive affect levels 1 year after illness onset than those who did not replace activities. Continuing activity during illness episodes can help maintain positive well-being over time.

ADJUSTMENT to illness is a major problem for many older adults. Whether it is an illness episode with a finite timeline, such as an acute illness, injury, or surgery, or a more chronic problem, such as arthritis or long-term physical disability, older adults are often faced with the challenge of maintaining activity and well-being under difficult circumstances. Studies show that depressive symptoms and general emotional disturbance are related to disabling health problems (Parkes 1964; Sinnott 1984–1985), and older adults with physical health problems have been estimated to have twice the likelihood of developing clinical depression compared with those without such problems (Gurland et al. 1983; Prince, Harwood, Thomas, and Mann 1998).

These negative outcomes appear to be mediated by functional impairment and the consequences of this impairment in disrupting participation in everyday physical and social activities. For example, Berkman and colleagues 1986, Mirowsky and Ross 1992, and Zeiss, Lewinsohn, Rohde, and Seeley 1996 found that functional impairment accounted for the effect of physical disease on depression. Additionally, a study of both recently bereaved and recently disabled individuals found that disabled individuals showed greater psychological distress, lower self-esteem, and lower positive well-being over a 10-month period relative to the bereaved group and an age-matched control group (Reich, Zautra, and Guarnaccia 1989).

It has been shown that participation in valued activities is a critical component of well-being (Brickman and Coates 1987; Egan 1984; Williamson 2000) and that illness resulting in changes to or reductions in valued activities can contribute to declines in well-being. The present study uses longitudinal data from a sample of older adults to test hypotheses about the effects of illness and social and personal resources on three outcomes: (a) the giving up of valued activities, (b) the replacement of valued activities, and (c) the effect of failure to replace activities on well-being. If the failure to replace valued physical or social activities that have been reduced or lost is responsible for the deleterious effects of illness on emotional well-being, individuals who find replacements for such losses should show less disturbances in adjustment (e.g., less reduction in positive affect) than do those older adults who fail to generate adequate replacements.

	Theoretical Background

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The developmental changes associated with aging and coping with age-related losses have been described by activity theory (Havighurst 1963) and continuity theory (Atchley 1987), though empirical support for these early gerontological theories is limited (Fox 1981–1982; Zimmer, Hickey, and Searle 1995). Among more recent efforts to address how older adults cope with personal losses across various life domains (e.g., Baltes and Baltes 1990; Heckhausen and Schultz 1993), Brandtstadter and colleagues (Brandtstadter and Greve 1994; Brandtstadter and Renner 1990) have proposed that older adults use a combination of active, assimilative strategies and passive, accommodative strategies. Their dual process model, which is similar to early models by Neugarten 1973 and Lazarus and DeLongis 1983, posits that advancing age results in a shift away from the active adjustment of life situations to meet personal preferences (i.e., assimilation) and a parallel shift to the accommodation or adjustment of personal preferences to fit situational constraints, which makes fewer physical and psychological demands on the individual's resources (Brandtstadter, Wentura, and Rothermund 1999). Older adults who replace lost activities may be viewed as successfully using an accommodative strategy for coping with losses, a strategy marked by the ability to shift from one blocked goal or activity to another (Brandtstadter et al. 1999). If activity levels become unfeasible as a result of illness, accommodative strategies should allow individuals to reallocate attentional resources to alternative options. In this article, we explore the determinants of an accommodative strategy of replacement and its effects on subsequent well-being.

	Hypotheses

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The current study replicates and extends prior investigations on the role of illness factors and social–psychological factors on the reduction and loss and the replacement of physical and social activities. A prior study by Zimmer, Hickey, and Searle 1997 found that the severity of arthritis was related to losses and reduction in activities but was unrelated to replacement with new activities in a sample of older adults. Participants who failed to find replacements were older, less educated, unmarried, and had smaller and less intimate social networks than did those who ceased an activity but started a new one within the prior year. Although the Zimmer and colleagues 1997 data are important and provocative, they call for replication and extension, as they were cross-sectional. Prior studies also suggest that reductions in activity level are related to depressed affect (Williamson 2000; Zeiss et al. 1996) and, conversely, that increases are related to positive affect (Holahan 1988). In the present, longitudinal study, our hypotheses focused on (a) illness factors involved in the reduction or loss of valued activities, (b) illness factors involved in replacing valued activities, (c) social and personal resources involved in replacing valued activities, and (d) the emotional benefits (i.e., impact on positive affect) of replacing activities over time.

Illness factors affecting activity reduction and loss
Participants were asked to report on their single most important illness during the prior 6 years of our longitudinal study, to allow for the replication of the Zimmer and colleagues 1997 finding that the reduction and loss of activity was determined by illness severity. Therefore, Hypothesis 1 was

chronic rather than acute illnesses, higher ratings of illness severity and functional impairment, and lower self-rated assessments of general health are related to a reduction in valued activities.

Illness factors affecting activity replacement
The second focus of our study was the identification of factors affecting activity replacement. Additionally, study participants with less severe illnesses and better general health should have the energy to search for and find replacements. Thus our second hypothesis was

chronic rather than acute illnesses, lower ratings of illness severity, and higher self-rated assessments of general health are related to finding replacements for valued activities.

Social and personal resources affecting activity replacement
We also expected an association between replacing lost activities and the social and personal resources that allow older adults to re-engage with their environments. Higher levels of social support provide access to possible replacement activities, opportunities for engaging in activities with other people and social pressure to do so; data show that support has positive effects on health and well-being (Broadhead et al. 1983; Diener 1984; Minkler 1985; Okun, Stock, Haring, and Witter 1984).

The value of social support for generating replacements should be moderated by the chronicity of an illness. Family and friends may be most willing and able to offer support for acute illness and/or for the acute, onset phase of chronic illness. For example, social support has been found to be particularly helpful in generating positive health outcomes immediately following hospitalizations for coronary heart disease; its benefits diminish, however, over time (Fontana, Kerns, Rosenberg, and Colonese 1989). As members of the support network are less likely to provide the same level of aid over the longer term, successful adaptation to chronic illnesses depends to an increasing degree on the individual's internal resources. Thus, high levels of social support should facilitate replacement during acute illness episodes, thereby buffering the effects of the severity and the length of illness episodes that caused the loss of valued activities.

As social support is expected to be of value over the short term, we examined the value of two personal resources expected to affect replacement over the longer term: optimism and conservation of energy. Optimism has been shown to influence persistence toward goal attainment (e.g., Carver, Blaney, and Scheier 1979), and it has been proposed that optimistic individuals cope more effectively with distress and disease (Carver et al. 1993; Friedman et al. 1992). The psychological and health benefits of dispositional optimism have been shown across a wide array of situations (Carver and Gaines 1987; Carver, Scheier, and Weintraub 1989; Litt, Tennen, Affleck, and Klock 1992; Scheier et al. 1989; Strack, Carver, and Blaney 1987). Replacing activities may be one mechanism by which optimists successfully maintain well-being during and after an illness. Replacing activities may also be affected by the belief that conserving energy is critical for sustaining physical well-being. Conservation beliefs appear to be associated with the need to optimize adaptation by minimizing effort during the later years of life (Baltes and Baltes 1990; Carstensen 1992) and affect readiness to seek medical care during illness episodes (E. Leventhal and Crouch 1997; Prohaska, Leventhal, Leventhal, and Keller 1985). Therefore, we hypothesized that a self-regulation strategy of conserving energy serves as a barrier to accommodation to lost activities, such that those high in conservation are less likely to find replacements.

With regard to replacement, we tested Hypothesis 3:

high levels of social support and optimism enhance activity replacement, and beliefs about the conservation of energy reduce the likelihood of finding replacements.

Benefits of activity replacement over time
Although older adults are often forced to reduce or give up valued activities, those who find replacements may show less emotional disturbance over time. The maintenance of physical and social activities likely serves as an important buffer against the negative effects that often accompany illness. Physical activity has been shown to improve mood, well-being, and self-efficacy, and social activities have been linked to the absence of depression (Strawbridge, Cohen, Sherma, and George 1996), increased longevity (Berkman and Syme 1979), and positive well-being (Lomranz, Bergman, Eyal, and Shmotkin 1988; Mancini 1978; Reich and Zautra 1981; Russell 1990; Steinkamp and Kelly 1987; Zimmer et al. 1995). The role of physical and social activities in maintaining positive well-being during illness episodes has not been explored in prospective studies. We attempted to fill that gap in research by testing Hypothesis 4:

positive affect levels 1 year postillness are higher among individuals who find replacements as compared with those unable to find activity replacements.

	Methods

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Participants and Procedures
This research used data from a longitudinal survey of community-dwelling older adults, the Rutgers Aging and Health Study, that examined the relationship of psychological factors to future illness and mortality. In-depth interviews approximately 2 hr in length were conducted annually from 1991 to 1999. Interviews were conducted in participants' private dwellings (95%) or in private rooms in the community's clubhouse (5%). The interviewers, advanced psychology, sociology, or premedical students, recorded participant responses on laptop computers using CASES software (Shanks 1983).

Of the 851 participants entering the study, 459 remained at the seventh wave (1997) of data collection. Participant loss averaged 9.75% per year because of death, moving from the community, and withdrawal. The 392 participants no longer in the sample both were older (M = 74.6 and M = 71.8 respectively), t(849) = 5.52, p < .001, and reported poorer self-assessments of health at baseline (M = 3.4 and M = 3.6), t(849) = 6.80, p < .001. There were 286 (62%) women and 173 (38%) men with 76% of the women and 85% of the men having had more than 12 years of education. Half of the sample was married and 34% was widowed. The sample was made up of upper-middle class, non-Hispanic White participants (99.3%). With regard to religious affiliation, 39% of the sample was Protestant, 26% Catholic, 27% Jewish, and 8% reported "other" for religion. Participants reported an average of 16 diseases or health conditions during their adult lifetime (SD = 7.66).

Design
At the seventh wave (1997) of this longitudinal study, participants were asked whether they had experienced an illness episode in the previous 6 years that resulted in the loss or reduction of valued activities. At this time they also reported whether the illness was chronic or acute. The major dependent variable, the replacement of reduced or lost activities, was also reported on at Wave 7. The severity of the illness episode was assessed the year of onset (all illnesses were reported annually and rated for severity), and the illness as reported at the year of onset was rated for severity and functional impairment by physician judges. To examine changes in well-being, we assessed positive and negative affect annually. Illness episodes reported at Wave 1 were excluded from analyses because a pre-episode measure of positive affect was unavailable for these illnesses.

The use of retrospective Wave-7 data rather than year-of-onset data to determine whether an illness did or did not disrupt life activities seemed the most reasonable way to proceed, as the severity ratings at point of onset can be deceptive indicators of long-term impact if all illnesses are included in the sampling frame. For example, high severity ratings are likely for acute, painful head or stomach viruses or painful toothaches that last for a few days but are mostly irrelevant as disruptions of life activities. By contrast, chronic conditions that are less painful and "severe" at onset and longer-lasting or repetitive acute conditions that may be less responsive to treatment (e.g., bladder infections), can require extensive adjustments in living patterns over long time frames. The Wave-7 question was worded to restrict our focus to that set of illnesses that was considered to have an important impact. The Wave-7 reports were then validated by matching each reported illness with the reports made on the medical history updates that was taken at each annual interview. Of the 250 illnesses reported at Wave 7, 212 matched by label and year to the appropriate annual interview: The 38 cases that could not be matched were not used to test our hypotheses.

The major predictors of adaptation, social and personal resources, were assessed prior to Wave 7, the point at which the illness episode, activity reductions, and replacements were reported. As social resources, supports and demands, were recorded annually, we used the reports at the year of illness onset to predict activity loss and replacement. Of the two personal resources, optimism was measured at Wave 1, prior to all other measures, and conservation of energy, the second, was assessed at Wave 3 prior in time to 65% of the reported illness episodes and prior to the report of activity loss and replacement given at Wave 7. Self-assessments of health and negative affects were assessed annually, and the measures taken at the year of illness onset were used as controls in the main analyses. Table 1 displays the means for the items and scales.

Illness severity self-assessed
Participants reported on the severity of the illness that affected their life the most the year of illness onset. The rating was made on a 5-point scale (not at all, a little bit, moderately, quite a bit, very much) in response to the question, "How severe is it?"

Illness severity and impairment: physician-rated
Each reported illness was rated by two academic, board-certified internists on "the amount of functional impairment caused by the illness or condition" and "the life-threateningness of the illness or condition." The raters examined each participant's Wave-7 description of his or her illness, classified it by organ system and International Classification of Diseases-9 category, and rated the report on the basis of its categorization. The two ratings, one of life-threateningness and the other of the amount of functional impairment expected with such conditions, were made on 1–100-point scales (1 = least functional impairment/least life-threatening and 100 = most functional impairment/most life-threatening). The ratings were averaged across the two physicians; alphas for such ratings typically exceed .95 (see ratings of illness burden).

Illness chronicity
Participants' illnesses were categorized as either chronic (n = 173) or acute (n = 77). The acute illness group reported that their illness had ended before the Wave-7 interview, and the chronic illness group reported their illness as ongoing. Twelve participants with ongoing illnesses beginning within the year of the Wave-6 interview were placed in the acute illness group because their illnesses could not be considered chronic (e.g., a broken leg, viral infection, etc.).

Activity Reduction and Replacement
The reduction of activity scale
At Wave 7, participants were asked a set of items regarding any changes in physical activities caused by their illness. A parallel set of items assessed changes in social activities. Because the reported physical and social activities overlapped, the physical or social activity rated as the most important was used in all analyses. Of the 250 participants reporting an illness, 157 gave a higher importance rating to a physical activity and 20 gave a higher rating to a social activity; 73 did not give up any activities. All of the participants reported that the reduction or change to activities was unfavorable.

The Wave-7 question asked, "How much has the condition forced you to change or give up any physical/social activities?" Participants identified a single activity in 85.5% of the cases. In cases in which more than one activity was identified (14%), participants indicated which was the most important. The amount of interference with activities reported to this question was averaged with the mean of the two questions assessing interference with activities at the year of illness onset (the two were averaged, as they were highly correlated: r = .91). The two questions were "On an average day, how much does the condition interfere with things you need to do?" and "On an average day, how much does the condition interfere with things you like to do?" All questions used a 5-point scale (not at all, a little bit, moderately, quite a bit, very much; scale = .80).

Replacement of activity
The Wave-7 question assessing the replacement of activities was, "How much have you been able to find replacements for what you lost or gave up?" (not at all, a little bit, moderately, quite a bit, very much). An open-ended question, "What are the replacements?" identified the type of replacements.

Predictors Testing Hypotheses for Activity Reduction and Replacement
Measures of general health
Self-assessed health was examined at the year of illness onset using the single item, "In general, would you say your health is ..." (poor, fair, good, very good, excellent).

In addition to self-assessed health, a measure of lifetime illness burden prior to entering the study was assessed at Wave 1. The burden measure was designed to control for the degree to which previous illnesses affect activity loss and replacement. This measure was derived from a detailed medical history that allowed for the reporting of approximately 400 diseases experienced during the adult years. Each of the diseases reported was weighted by the ratings of six academic physicians for life-threateningness and functional impairment on a scale of 1 to 100. Physician agreement, computed for six raters across all diseases, was extremely high (Chronbach's = .97), but to obtain the most stable measure for each reported disease, we decided to drop the ratings of two physicians whose ratings were often significantly higher or lower than those of the other four. The final rating of each disease's severity was an average of the remaining four scores.

Personal resources
Optimism was assessed at Wave 1, prior to the onset of illness for all participants, using the eight-item Life Orientation Test (Scheier and Carver 1985). Responses were made on a 5-point scale (disagree strongly, disagree, neither agree nor disagree, agree, agree strongly; = .82).

Three items assessed conservation of energy at Wave 3, prior to the illness reports for 65% of the participants. The items were "Do you feel you will live longer if you conserve your store of energy?" "Are you careful to conserve your energy?" and "Do you feel that as you get older you should take more care to conserve your energy?" (= .82). Responses were on a 5-point scale (never, rarely, sometimes, often, always).

Social support and demands
The measure of social support that was used was taken the year of illness onset. Items included a measure of overall satisfaction with social support ("Overall, how satisfied are you with your social support?" assessed on a 5-point scale: not at all, a little bit, moderately, quite a bit, very much), two items assessing companionate support (e.g., "Is there someone with whom you can do enjoyable things?"), and two items assessing tangible support (e.g., "Is there someone who will help you with daily tasks when you are ill?" each item assessed on a 5-point scale: never, rarely, sometimes, often, always; = .81).

A social demands scale was assessed the year of illness onset. The three items ("How often is there someone who makes you feel burdened?" "How often is there someone who makes too many demands on you?" and "How often is there someone who makes you feel obligated to help them?") also used 5-point scales (never, rarely, sometimes, often, always; = .71). All of the measures of social support and demands were adapted from items in the Social Networks in Adult Life Questionnaire (Antonucci and Akiyama 1987; Kahn and Antonucci 1980) and the Yale Health and Aging Project (Seeman and Berkman 1988). The items are representative of those used in the social support literature (e.g., House 1981; Rook 1987; Wills 1985).

Negative and Positive Affect Measures
Negative and positive affect were assessed at each of the annual interviews. To assess the possible contribution of negative affect to activity reduction and replacement, we used the participants' report of negative affect at the year of illness onset. To assess the possible effects of activity replacement on positive affect, we used the measures of positive affect taken 1 year before illness onset and 1 year after it. Depression ( = .90), anxiety ( = .89), and positive affect ( = .88) were each measured on a 5-point scale (not at all, a little bit, moderately, quite a bit, very much). The five items used for each of the three scales had the highest loadings on two prior confirmatory factor analyses (Usala and Hertzog 1989). The complete set of items was selected from the Profile of Mood States (McNair, Lorr, and Droppleman 1971).

	Results

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Predicting the Reduction of Activity
There were no differences in age, gender, marital status, religion, education, self-assessed health, or lifetime illness burden between those who reported a new illness since 1991 (n = 250) and those who did not (n = 209). The 250 participants experiencing a new illness reported the following levels of activity reduction: 24 (10%) very much, 59 (24%) quite a bit, 36 (14%) moderate, 58 (23%) a little bit, and 73 (29%) no reduction. Except for age, which was correlated with the reduction of activity scale (r = .15, p < .05), activity reduction was unrelated to participant variables of gender, marital status, religion, education, the type of the most important illness reported, or lifetime illness burden. Therefore, only age was controlled in analyses of reductions in activity. Table 2 gives the distribution of the most important activities given up or reduced and their replacements. Although 14% of the participants reported a reduction in more than one activity, only the most important for each participant is listed.

Illness factors
Hierarchical multiple linear regression tested whether illness factors accounted for variance in the reduction of activity. Because the items assessing activity reduction were assessed at both the year of illness onset and at Wave 7, as were the predictors, these analyses are essentially cross-sectional. Age, illness chronicity, and physician-ratings of both illness severity and functional impairment were entered, followed by self-reported illness severity and self-assessed health both measured at year of onset (Table 3 ). Thirty-three percent of the variance in the reduction of activity scale was accounted for by age, illness chronicity, self-rated illness severity (year of onset), and self-assessed health (year of onset). Poor self-assessed health, the presence of a chronic rather than an acute illness, and advanced age and high levels of illness severity were related to a greater reduction in activity. Reduction of activity was unrelated to physician ratings of severity and functional impairment. It should be noted that all of the predictors of the reduction of activity described in this section remain significant in analyses using the individual items in the reduction of activity scale; the analysis with the Wave-7 item is "prospective" relative to the predictors, and the analysis with the averaged year of onset items is free of any Wave-7 retrospective bias.

Social and personal resources
Although optimism, satisfaction with social support, and negative affect (i.e., anxiety and depression) were significantly correlated with the reduction of activity scale, the association between these social and personal resources was not significant after controlling for the illness factors described above.

Predicting the Replacement of Activity
The degree of success in activity replacement claimed by the 177 participants who reported a reduction in an important activity was as follows: 15 (9%) very much, 25 (14%) quite a bit, 32 (18%) moderate, and 23 (13%) a little bit. Eighty-two participants (46%) were unable to find a substitute activity. The replacement of activity was unrelated to age, gender, marital status, religion, education, type of disease, lifetime illness burden, or the self-reported importance of the activity; these variables were eliminated from further analyses.

Illness factors
The same illness factors used in predicting the reduction of activity were used in a regression analysis predicting the dependent variable, replacement of activity. Of the five illness measures entered in the model, only illness chronicity and self-rated illness severity the year of illness onset were predictive of replacing activity. The illness factors accounted for 7% of the variance in replacement in contrast to the 30% of variance that these variables accounted for in activity reduction.

Social and personal resources
Zero-order correlations between the replacement of activity and social and personal resources showed that both social support and social demands were related to finding replacements (r = .14, p = .07; r = .17, p < .05). Personal resources were also related to finding replacements: optimism, positively (r = .22, p < .01) and conservation of energy, negatively (r = -.15, p < .05).

A model for the replacement of activity
Illness factors significantly related to replacement (illness chronicity, self-rated illness severity at onset) and all social and personal resources significantly related to replacement (social support, social demands, optimism, and conservation of energy) were entered in sequence in a hierarchical, linear regression. These factors accounted for 28% of the variance in replacement (Table 4 ); except for chronicity, all were assessed prior to the reporting of replacements at Wave 7. The interaction between illness chronicity and social support was entered as the last step, explaining an additional 3% of the variance.

The relationship of positive social support with replacement was modified by an interaction with illness chronicity: Social support facilitated activity replacement for participants reporting acute illnesses (n = 49) but was not beneficial for participants reporting chronic illnesses (n = 101). Analyses revealed a significant difference in simple slopes by group (ß = .49 for acute group, ß = .09 for chronic group), t(143) = 2.96, p < .01. These findings suggest that members of a social network are most likely to aid older adults during the initial phases of illness while leaving chronically ill older adults to rely on their personal resources.

Positive Affect 1 Year Later
Differences in positive affect following the onset of a chronic illness were compared among the no–activity-reduction group (those who had a condition but did not reduce activities), the no-replacement group (those who reduced activities but did not find a replacement), and the replacement group (those who reduced activities and were able to find a replacement). There were no differences among the three groups in age, gender, marital status, total illness burden reported at 1991, or physician-rated illness severity. However, the duration of illness for the group that did not replace activities was significantly shorter (M = 1.9) than was that for the group that did not reduce activities (M = 2.6) or those who reduced and replaced activities (M = 2.6), F(3,246) = 3.98, p < .05. Those in the no–activity-reduction group rated their illness as less severe during the year of onset (M = 2.8) than did the no-replacement group (M = 3.7) or the replacement group (M = 3.6), F(3,208) = 11.69, p < .000. The no–activity-reduction group also reported less pain (M = 1.5) than the other two groups did (M = 2.6 and M = 2.4, respectively), F(3,246) = 14.38, p < .000, and had less physician-rated functional impairment (M = 33.2) than did the other groups (M = 43.5 and M = 47.0, respectively), F(3,246) = 6.83, p < .001.

We hypothesized that when controlling for positive affect prior to illness, older adults who replaced lost activities following a chronic illness would report higher levels of positive affect than would those who did not replace reduced activities. Levels of positive affect 1 year after the onset of a chronic illness (n = 173) differed significantly among the three groups, F(3,169) = 4.29, p < .05 (see Table 5 ). Further analyses controlling for positive affect 1 year prior to the onset of a chronic illness showed the same effect, F(3,169) = 4.00, p < .05. The participants who reduced activities but did not find replacements reported lower levels of positive affect 1 year after the onset of a chronic illness than did participants in the other two groups. No differences were detected among participants reporting acute illnesses (n = 77).

	Discussion

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In contrast to the important role played by physical factors in the reduction of activities, only two illness measures predicted replacements: illness severity and chronicity. Activity replacement was predicted primarily by social and personal factors. Consistent with previous research (Zimmer et al. 1997), older adults who reported more social demands were more likely to find substitute activities. Positive social support predicted replacement only for those elderly adults reporting acute illnesses. Finding replacements was predicted by personal characteristics; positively by an optimistic outlook and negatively by the belief in the need to conserve energy for a long life. Conservation of energy also is assumed to be responsible for the swift seeking of medical care by elderly adults in comparison with the rate of care seeking by middle-aged adults (E. Leventhal, Leventhal, Schaefer, and Easterling 1993). Consistent with the goal of optimizing adaptation with minimal effort (Baltes and Baltes 1990; Carstensen 1992), it has been hypothesized that in comparison with middle-aged adults, elderly adults are more motivated to conserve resources and avoid risk of depleting their more limited physical and emotional reserves (E. Leventhal and Crouch 1997). The results for optimism and conservation point to the need to identify the specific strategies used to cope with serious chronic illness. This points to the inadequacy of unitary concepts such as "problem-focused coping" for understanding adaptation to chronic illness (Lazarus and Folkman 1984). Taken together these results suggest that physical incapacity was less important for activity replacement by older adults than were the social factors that created the opportunity and encouragement to find replacements, and the personal factors such as optimism and conservation that affected motivation to seek and find alternatives. The magnitude of these effects is impressive given that the replacement was reported 1 to 6 years after the assessment of the predictor variables. It is important to note that optimism and conservation affected replacement after we controlled for negative affect, a factor frequently presumed to be responsible for the effects of optimism.

The finding that chronicity of an illness moderates the contribution of social support on activity replacement is of particular theoretical interest. Perceptions of instrumental and companionate support were related to finding replacement activities for acute illnesses. These factors did not contribute to finding replacements for individuals reporting chronic conditions, a group characterized by sustained illnesses that are typically progressive and more functionally impairing. These findings are consistent with and expand on prior studies showing that positive social support facilitates only the initial adjustment to major, stressful life events, and that personal resources are important for the longer term (Hobfoll and Leiberman 1987). In contrast, however, involvement in a social network perceived to be demanding facilitated finding replacement activities for those with both chronic and acute conditions. It appears that demands for assistance and support from others appear to outlast the willingness to give support. This issue merits further study.

Finally, the data indicated the possible benefits of replacing activities, as levels of positive affect were higher 1 year after illness onset for those who found replacements. It should be noted that these effects were present after we controlled for both optimism and negative affect. The association of age with reducing activities in response to illness is consistent with studies from leisure sciences (e.g., Jackson and Dunn 1988; Searle, Mahon, Iso-Ahola, Sdrolias, and van Dyck 1995), which indicate that older persons are less likely to benefit from the association of high levels of general activity with increased positive affect (Holahan 1988) because they are less likely to replace activities as they age (Searle, Mactavish, and Brayley 1993). Our data suggest that the ability to sustain activity influences subsequent positive affect in the face of chronic illness and does so over and above the benefits of an optimistic outlook.

The results of this study are consistent with Baltes and Baltes 1990 model of selective optimization and with using an accommodative strategy in coping with chronic illness (Brandtstadter and Greve 1994). In accord with the Baltes model, our elderly participants compensated for activity reduction and loss by adopting less effortful behaviors that met valued goals. These compensatory actions allowed them to maintain positive affect despite the added burden of a new chronic illness. Our data underscore the benefits of successfully using the accommodative strategy of shifting from one blocked goal or activity to another in coping with chronic illness (Brandtstadter and Greve 1994; Brandtstadter and Renner 1990), but additional longitudinal studies using validated, multidimensional measures of activity reduction and replacement are needed to further explore these hypotheses (e.g., Brandtstadter and Renner 1990).

The present study has several limitations. First, more detailed, objective measures of disease and disease-related functional impairment would provide a more valid picture of the actual impact of biological factors. Second, the data are based on self-reports, and these reports may not fully correspond with behavioral measures. Factors such as optimism could affect respondents' perceptions and reports of both their illness at time of occurrence and their subsequent reports of disruption and success in finding replacements. Biased reporting does not appear to provide an adequate account for these findings, however, as negative affect, which is typically considered an indicator of biased reporting of illness events, was unrelated to any of our outcome measures, and optimism predicted replacement but not losses or reductions of activities. Third, the generalization of these results is also limited by the ethnic and socioeconomic homogeneity of our participants; although varied in religious affiliation, the participants were mostly White and sufficiently affluent to purchase homes in a retirement community. Given the properties of the sample and the use of a new and very brief measure of conservation of energy, replication is necessary.

Finally, our data were limited in several ways by our assessing illness impact at Wave 7 of the longitudinal study. One limitation was the loss of participants who had died or moved to a more sheltered living environment; it is unknown how these less healthy individuals would have responded to our questions. Another was the selection of participants on the basis of their retrospective reports of illnesses that resulted in activity reduction and the need for replacements. Although we readily matched these reports to the appropriate prior episode in 85% of the cases, which speaks to their validity, there is no way of determining why a few (n = 17) participants rated an illness at the same level of severity at year of onset as did those reporting an important illness, yet failed to identify it as having a significant impact on their lives at Wave 7. We can only conclude that these problems resolved or were in remission, as these participants were not questioned about the nature of this illness at Wave 7. This methodological problem is not one that is easily remedied, as the great majority of chronic illnesses that have significant impact on function change slowly and fluctuate in severity over months and years. Prognostication is a complex business, and there is no simple way of determining the rate or direction of change of chronic conditions regardless of whether the experience at onset is mild or severe. A possible solution is to track the course of the illness on a monthly or bimonthly basis. Our use of longitudinal data is, however, an important addition to the findings of prior studies (e.g., Zimmer et al. 1997).

The current findings suggest several new directions for research. It would be instructive to learn about the types of activities sought as replacements by older adults in response to specific illness threats and the effects of different types of replacements on subsequent adjustment. For example, longer term well-being may be enhanced by engaging in activities such as walking or socializing rather than more passive activities like watching television or listening to music. Also, it would be of interest to further evaluate hypotheses about the pathways that may determine whether it is the individual's view of an illness as chronic and part of the self (H. Leventhal, Idler, and Leventhal 1999), rather than its actual chronicity, that affects replacement and to identify the factors that affect whether the perception of chronicity matches actuality. Other issues that need to be addressed include whether the chronic view elicits depressive affect that undercuts replacement or whether it affects replacement on purely cognitive and/or strategic (conservation) grounds, as suggested by the present data and other studies (Heidrich, Forsthoff, and Ward 1994; H. Leventhal, Easterling, Coons, Luchterhand, and Love 1986).

It would be of special value if efforts at replication and extension were focused on coping with a single illness such as heart disease, cancer, or arthritis. Diseases differ in symptoms and responsiveness to self-management, and this may affect how measures of disease severity and social and personal resources contribute both to the disruption of activities and to their replacement. For example, conservation of energy might have more pronounced effects on disruption and replacement for individuals with coronary disease, as conservation is likely to be encouraged by the threat associated with the chest pain that can accompany physical activity (Aikens, Zvolensky, and Eifert 2001).

In summary, the present work extends prior studies showing that illness disrupts physical and social activities and that replacement activities can help maintain positive well-being. Studies of these processes in patients confronting specific illnesses may suggest new ways of helping people to engage in enjoyable and productive activities. Although the loss of function and its associated loss of valued activities may be an irreversible consequence of many of the chronic illnesses of older age, interventions facilitating the identification and adoption of meaningful replacements may help to sustain quality of life in later years.

	Acknowledgments

 
This study was supported by National Institute on Aging Grant AG03501.

We gratefully acknowledge Bonnie Pepper and Yael Benyamini for their earlier work on this topic. Also, special thanks go to the indispensable aid of Melissa Crouch.

Received for publication March 20, 2000. Accepted for publication October 22, 2001.

	References

TOP Abstract Theoretical Background Hypotheses Methods Results Discussion References

 

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