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Original Study
Coping Behaviors and Health Status during the COVID-19 Pandemic
among Caregivers of Assisted Living Residents in Western Canada
Colleen J. Maxwell PhD
a
,
b
,
c
,
*, Lauren Dayes BSc
a
, Joseph E. Amuah PhD
d
,
David B. Hogan MD
e
, Natasha E. Lane MD PhD
c
,
f
, Kimberlyn M. McGrail PhD
g
,
Andrea Gruneir PhD
c
,
h
, Lauren E. Griffith PhD
i
, Stephanie A. Chamberlain PhD
h
,
Emily C. Rutter MSc
b
, Kyle Corbett MA
j
, Matthias Hoben RN Dr rer medic
j
,
k
a
School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
b
School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
c
ICES, Toronto, Ontario, Canada
d
School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
e
Division of Geriatric Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
f
Department of Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
g
Center for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia,
Canada
h
Department of Family Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
i
Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
j
Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
k
School of Health Policy and Management, Faculty of Health, York University, Toronto, Ontario, Canada
Keywords:
Assisted living
caregivers
COVID-19
coping behaviors
mental health
abstract
Objectives: To examine the prevalence of coping behaviors during the first 2 waves of the COVID-19
pandemic among caregivers of assisted living residents and variation in these behaviors by caregiver
gender and mental health.
Design: Cross-sectional and longitudinal survey.
Setting and Participants: Family/friend caregivers of assisted living residents in Alberta and British
Columbia.
Methods: A web-based survey, conducted twice (October 28, 2020 to March 31, 2021 and July 12, 2021 to
September 7, 2021) on the same cohort obtained data on caregiver sociodemographic characteristics,
anxiety and depressive symptoms, and coping behaviors [seeking counselling, starting a psychotropic
drug (sedative, anxiolytic, antidepressant), starting or increasing alcohol, tobacco and/or cannabis con-
sumption] during pandemic waves 1 and 2. Descriptive analyses and multivariable (modified) Poisson
regression models identified caregiver correlates of each coping behavior.
This work was funded by an Alberta Innovates National Partnered R&I Initia-
tives Grant (#202100518), and an Establishment Grant and Professorship in
Continuing Care Policy Research awarded to MH by the Faculty of Nursing, Uni-
versity of Alberta.
The COVCARES-AB/BC study was funded by an Alberta Innovates National
Partnered R&I Initiatives Grant (#202100518), and an Establishment Grant and
Professorship in Continuing Care Policy Research awarded to MH by the Faculty of
Nursing, University of Alberta.
This study was reviewed and received ethics approval by the Health Research
Ethics Board at the University of Alberta (Pro00101048), University of Calgary
Conjoint Health Research Ethics Board (REB20-1544), Human Research Ethics Board
at the University of British Columbia (H20-01732) and University of Waterloo Hu-
man Research Ethics Committee (ORE#42494). Operational approvals from
participating assisted living homes were obtained, where required. All participants
provided written informed consent.
Consent for publication: Not applicable.
All study data and analytical output are held on a secure server at the University
of Alberta as per relevant Ethics Committees’guidelines. As such, all study datasets
are not publicly available. Access is restricted to approved study investigators and
research associates. Aggregate data and relevant statistical code are available from
the primary investigators on reasonable request. For additional information
regarding the availability of data contact Dr. Colleen Maxwell, email:
colleen.maxwell@uwaterloo.ca.
Author contributions: Study concept and design (CJM, MH); acquisition, anal-
ysis, or interpretation of data (all authors); drafting of initial manuscript (CJM, LD,
ER); critical revision of manuscript for important intellectual content (all authors);
statistical analysis (JA, CJM); administrative, technical, or material support (KC);
supervision (CJM). All authors provided approval for the final manuscript submitted
and agree to be accountable for all aspects of the work.
The authors declare no conflicts of interest.
* Address correspondence to Colleen J. Maxwell PhD, School of Pharmacy, Uni-
versity of Waterloo, 200 University Ave West, Waterloo, Ontario, Canada, N2L 3G1.
E-mail address: colleen.maxwell@uwaterloo.ca (C.J. Maxwell).
https://doi.org/10.1016/j.jamda.2022.12.017
1525-8610/Ó2022 The Authors. Published by Elsevier Inc. on behalf of AMDA eThe Society for Post-Acute and Long-Term Care Medicine. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
JAMDA
journal homepage: www.jamda.com
JAMDA xxx (2023) 1e9
Results: Among the 673 caregivers surveyed at baseline, most were women (77%), White (90%) and age
55 years (81%). Alcohol (16.5%) and psychotropic drug (13.3%) use were the most prevalent coping
behaviors reported during the initial wave, followed by smoking and/or cannabis use (8.0%), and
counseling (7.4%). Among the longitudinal sample (n ¼386), only alcohol use showed a significantly
lower prevalence during the second wave (11.7% vs 15.1%, P¼.02). During both waves, coping behaviors
did not vary significantly by gender, however, psychotropic drug and substance use were significantly
more prevalent among caregivers with baseline anxiety and depressive symptoms, including in models
adjusted for confounders [eg, anxiety: adjusted risk ratio ¼3.87 (95% CI 2.50-6.00] for psychotropic use,
1.87 (1.28-2.73) for alcohol use, 2.21 (1.26-3.88) for smoking/cannabis use).
Conclusions and Implications: Assisted living caregivers experiencing anxiety or depressive symptoms
during the pandemic were more likely to engage in drug and substance use, potentially maladaptive
responses. Public health and assisted living home initiatives that identify caregiver mental health needs
and provide targeted support during crises are required to mitigate declines in their health.
Ó2022 The Authors. Published by Elsevier Inc. on behalf of AMDA eThe Society for Post-Acute and
Long-Term Care Medicine. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Family and friend caregivers of older adults residing in congregate
care settings experienced significant emotional distress during the
COVID-19 pandemic.
1-5
Research exploring the impact of COVID-19 on
caregivers has largely been restricted to those supporting older adults
in the community
6-8
or nursing homes
4,9-11
with insufficient attention
directed to caregivers of assisted living residents.
12,13
This is an
important knowledge gap given the rapid growth of assisted living
within North America,
12,14
clinical complexity of assisted living resi-
dents,
15-17
and lower staffing and service levels in assisted living
relative to nursing homes.
16,17
These and other features of assisted
living contribute to the extensive roles assumed by caregivers in this
setting,
2,5,12,16,18
roles that were significantly hampered by pandemic-
related restrictions.
The caregiving and personal stressors and consequent adverse
mental health outcomes
1,19
experienced by assisted living caregivers
during the pandemic may have led to new or altered coping behaviors,
including seeking counseling, starting a psychotropic medication, and
increased substance use.
20-22
In the general population, studies have
shown positive associations between anxiety and/or depressive
symptoms and increased alcohol and cannabis use early in the
pandemic
20,22,23
as well as persistence in these symptoms and be-
haviors over time.
24,25
Research has also revealed sociodemographic
differences in the prevalence of mental health symptoms and sub-
stance use during COVID-19, with higher levels of both noted among
younger adults and those facing financial stressors,
25-28
and an
increased likelihood for depressive and anxiety symptoms among
women. Some, but not all,
22,27
studies showed a higher prevalence of
cannabis and problematic substance use among men.
24,26,28
Comparable data on caregivers, especially of assisted living resi-
dents, are scarce. A web-based cross-sectional survey of 5011 adults
(including 1362 unpaid caregivers) in the United States showed that
caregivers were more likely than noncaregivers to report adverse
mental health symptoms (anxiety and depressive symptoms, suicidal
ideation) and starting or increasing alcohol or drug use to cope with
COVID-19-related stress.
29
Given their extensive roles in resident care,
caregivers of assisted living residents may have faced additional and/
or unique pandemic-related stressors, placing them at particular risk
for adverse mental health outcomes.
19
Empirical data on the coping
behaviors adopted by assisted living caregivers are needed so that
appropriate mitigation efforts and resources are mobilized to optimize
their health
26
and that of their care recipients.
This study sought to examine the prevalence of coping behaviors
among caregivers of assisted living residents during the first 2 waves
of the COVID-19 pandemic and variation in these behaviors by care-
giver gender and mental health (anxiety and depressive symptoms).
Based on previous literature,
20,22-24,26,28,29
we hypothesized that the
presence of mental health symptoms would independently increase
caregiver risk of new psychotropic drug use and new or increased
alcohol, smoking, and/or cannabis use and that psychotropic drug use
would be more prevalent among women while substance use would
be more prevalent among men.
Methods
This study received ethics approval by the Health Research Ethics
Board at the University of Alberta (Pro00101048), University of Calgary
Conjoint Health Research Ethics Board (REB20-1544), Human
Research Ethics Board at the University of British Columbia (H20-
01732) and University of Waterloo Human Research Ethics Committee
(ORE#42494).
It is reported per STROBE guidelines (Supplementary Table 1).
30
Study Design, Setting, and Sample
We examined cross-sectional and longitudinal survey data from
the COVCARES-AB/BC (COVID-19 and Caregivers of Assisted living
Residents: their Experiences and Support needs) cohort study, con-
ducted in Alberta and British Columbia, Canada. Both provinces
initiated “essential visitors”policies in assisted living in mid-March
2020, allowing a single caregiver to enter for end-of-life visits or to
assist with feeding or mobility.
31
Individual homes may have
imposed more stringent bans on visitors during peak pandemic
waves.
We invited all eligible assisted living homes in both provinces (163
in Alberta, 137 in British Columbia) to participate in COVCARES-AB/BC
(Supplementary Table 2). Consenting homes distributed study mate-
rials and an open web-based survey link to all caregivers via their
internal email list and/or in-person for caregivers visiting the home.
This survey link was also distributed via social media, websites, email
lists, and newsletters affiliated with our government/caregiver
stakeholder partners. Those who identified as the primary adult
caregiver (ie, age 18þyears and most informed/involved in care) of a
resident age 65þyears living in the home for 3þmonths prior to
March 1, 2020, were eligible to participate.
The caregiver survey was administered online at baseline (October
28, 2020 to March 31, 2021) and follow-up (July 12, 2021 to September
7, 2021) by the University of Waterloo Survey Research Centre. All
baseline respondents, excluding those of residents who passed away
before wave 2 (n ¼9) or who requested no further contact (n ¼4),
were eligible to complete the follow-up survey. Each respondent was
emailed a unique survey link to permit linkage of their survey re-
sponses. Participants received a $25 coffee gift card for survey
completion.
C.J. Maxwell et al. / JAMDA xxx (2023) 1e92
Measures
Survey items included standardized validated measures used in a
study of assisted living residents and caregivers in Alberta
16,17
and/or
by the Canadian Longitudinal Study on Aging.
7,32
Measures captured
caregiver sociodemographic characteristics, physical and mental
health, social support, engagement in resident activities and care, and
pandemic-related loss of employment and income (and concern
level).
Anxiety, Depressive Symptoms, and Reported Health Change
(Baseline and Follow-up Surveys)
Caregiver anxiety was assessed with the 7-item Generalized
Anxiety Disorder scale (GAD-7),
33,34
with 7 items reflecting how
often (in last 2 weeks) respondents were bothered by feelings of
distress and worry. We used a cut-point of 8todefine a clinically
significant anxiety disorder (sensitivity 92%, specificity 70%).
35
Depressive symptoms were assessed with the Center for Epidemio-
logic Studies Depression Scale, Short Form (CES-D10)
36
consisting of
10 items capturing how often (in past week) respondents experi-
enced signs or symptoms of depression. We used a cut-point of 10
to identify clinically significant depressive symptoms (sensitivity
89%, specificity 47% for major depressive disorder).
37
Both in-
struments have been extensively used in caregiver studies.
7,32,38
Consistent with scale development,
33,34,36
respondents with
missing values for only 1 item were assigned the mean of their other
item responses before totaling their scale score. The terms ‘anxiety’
and ‘depressive symptoms’when used in the text, indicate significant
symptomatology.
Caregiver reported change in health was assessed at the time of the
survey relative to 3 months before March 1, 2020 (baseline survey)
and relative to June 2020 (follow-up survey) and examined as a 3-level
variable (somewhat/much better now; same; somewhat/much worse
and a binary variable (worse yes/no)).
Coping Behaviors (Baseline and Follow-up Surveys)
At baseline, caregivers were asked to “indicate what, if any, of the
following they used during the 3 months after March 1, 2020 because
of their experiences during the COVID-19 pandemic: (1) sought
counseling services; (2) started an over-the-counter drug to help
with sleep; (3) started a prescription drug to help with anxiety or
depression; (4) started to consume or increased use of alcohol; (5)
started to smoke cigarettes or increased smoking level; and (6)
started to consume or increased use of cannabis.”At follow-up, these
same items were asked for the period October 1, 2020 to February 28,
2021 (ie, concurrent with second pandemic wave) (Supplementary
Figure 1). To address smaller cells, all drug measures were com-
bined as new antipsychotic use, and cigarette smoking or cannabis
use were combined.
Covariates
Baseline characteristics included caregiver age, gender, marital
status, relationship to resident, ethnic/cultural identity, highest ed-
ucation, prepandemic household income, change in employment
status, and income reduction (combined with level of concern)
during the 3 months post-March 1, 2020, number of chronic
conditions, self-rated health, and perceived emotional/informational
social support. The latter was assessed using the relevant subscale of
the RAND Medical Outcomes StudydSocial Support Survey
(MOS-SSS).
39
Analyses
Baseline sample
We examined the distribution of caregiver characteristics,
including mental health symptoms and coping behaviors, overall and
by gender. Bivariate associations between caregiver baseline mental
health and reported worsening health, and their coping behaviors
were examined employing
c
2
or Fisher exact tests, where appropriate.
Separate unadjusted and adjusted Poisson regression models,
modified for binary outcomes,
40
examined the associations between
caregiver mental health, reported worsening of health, and gender
with each of the 4 coping behaviors. These models allow for a direct
estimation of risk ratios as odds ratios (from logistic regression) may
lead to an overestimate of the risk ratio for some associations.
Adjusted models included a limited number of relevant confounders
(age, ethnic/cultural identity, income reduction/concern, educa-
tion)
27,29
given sample size restrictions. We assessed whether ac-
counting for clustering of caregivers within assisted living homes
affected model estimates by including a robust sandwich variance
estimator.
41
As we found no meaningful home-level clustering, we
have reported final models without this adjustment.
Longitudinal sample
Prevalence estimates for caregiver coping behaviors, mental health
symptoms, and worsening health at the 2 time points, were compared
using the McNemar test. For this longitudinal sample, we also
examined bivariate associations between their baseline mental
health/health measures and coping behaviors reported during both
pandemic waves.
Missing data
For most baseline characteristics, including coping behaviors, the
proportion of total respondents with missing values was small (eg,
<1%-2%). Missing values were more common for anxiety and
depressive symptoms (75 and 54 respondents with 2þmissing items
for the GAD-7 and CES-D10, respectively). Differences between those
missing (vs not missing) mental health items were described previ-
ously.
19
At follow-up, missing values were rare but more common for
the mental health measures (44 and 32 respondents with 2þmissing
items for the GAD-7 and CES-D10, respectively). We explored the
nature of missing data by conducting the Little MCAR test.
42
As this
test was nonsignificant for all our measures (indicating that data were
missing completely at random) and given the low level of missing data
overall, we did not pursue multiple imputation.
Secondary Analyses
For caregivers in the longitudinal sample, adjusted (modified)
40
Poisson regression models were conducted to examine associations
between their mental health/health measures (assessed at baseline
and follow-up) with each of the coping behaviors reported during the
second pandemic wave.
All analyses were 2-tailed with statistical significance defined as P
.05. SAS v 9.4 (SAS Institute Inc) was used to conduct all analyses.
Results
Baseline Sample
There were 673 caregivers (associated with 134 assisted living
homes; 81.1% supporting residents in Alberta) who completed the
baseline survey. About two-thirds were affiliated with urban or large
assisted living homes with approximately equal distribution by
ownership status. As our recruitment strategy prevents us from
identifying the total number of caregivers informed of the open survey
C.J. Maxwell et al. / JAMDA xxx (2023) 1e93
Table 1
Distribution of Assisted Living Caregiver Characteristics, Overall and by Gender (Total Baseline Sample, n ¼673)
Characteristics Overall (n ¼673) Column % (n) Gender
Women (76.8%; 515/671)
Column % (n)
Men*(23.2%; 156/671)
Column % (n)
Sociodemographic
Province (facility located)
Alberta 81.1 (546) 81.9 (422) 78.2 (122)
British Columbia 18.9 (127) 18.1 (93) 21.8 (34)
Age
y
18-44 y 6.4 (43) 7.6 (39) 2.6 (4)
45-54 y 12.2 (82) 12.2 (63) 12.2 (19)
55-64 y 42.3 (284) 45.1 (232) 33.3 (52)
65þy 39.1 (262) 35.2 (181) 51.9 (81)
Marital status
z
Married/common-law 83.1 (555) 81.1 (415) 89.7 (140)
Other 16.9 (113) 19.0 (97) 10.3 (16)
Relationship to resident
z
Spouse/parent 5.8 (39) 4.9 (25) 9.0 (14)
Daughter/son (including in-law) 78.5 (528) 81.0 (417) 69.9 (109)
Sibling 7.3 (49) 6.0 (31) 11.5 (18)
Friend/neighbor/other 8.5 (57) 8.2 (42) 9.6 (15)
Ethnic/cultural identity
z
White 89.9 (598) 91.4 (467) 85.1 (131)
Other than White 10.1 (67) 8.6 (44) 14.9 (23)
Highest education
University 31.0 (205) 30.8 (156) 31.6 (49)
College/trade 42.5 (281) 43.0 (218) 40.7 (63)
High school or less 26.6 (176) 26.2 (133) 27.7 (43)
Household income (prior to March 1, 2020)
>$100,000 27.3 (184) 25.4 (131) 34.0 (53)
$80,000-$99,000 15.0 (101) 14.6 (75) 16.7 (26)
$50,000-$79,000 23.8 (160) 25.4 (131) 18.6 (29)
<$50,000 20.2 (136) 20.2 (104) 20.5 (32)
Missing 13.7 (92) 14.4 (74) 10.3 (16)
Income reduction (3 mo post March 1, 2020)
and level of concern
No 73.4 (494) 74.0 (381) 71.2 (111)
Yes, not concerned 4.5 (30) 4.5 (23) 4.5 (7)
Yes, somewhat concerned 14.1 (95) 13.4 (69) 16.7 (26)
Yes, very/extremely concerned 8.0 (54) 8.2 (42) 7.7 (12)
Change in employment status (3 mo post
March 1, 2020)
x
No 84.0 (562) 82.7 (424) 88.5 (138)
Yes 16.0 (107) 17.4 (89) 11.5 (18)
Health and social well-being
No of chronic conditions
None 43.1 (288) 44.6 (229) 37.8 (59)
1-2 41.6 (279) 41.1 (211) 43.0 (67)
3þ11.7 (78) 10.7 (55) 14.7 (23)
Don’t know/prefer not to answer 3.7 (25) 3.5 (18) 4.5 (7)
Self-rated health
x
Excellent 16.9 (113) 18.1 (93) 12.9 (20)
Very good 40.5 (271) 38.3 (197) 47.1 (73)
Good 31.8 (213) 31.5 (162) 32.9 (51)
Fair/poor 10.9 (73) 12.1 (62) 7.1 (11)
Change in health (vs 3 mo pre-March 1, 2020)
Better now 9.8 (66) 9.5 (49) 10.9 (17)
Same 61.3 (411) 59.7 (307) 66.0 (103)
Worse 28.9 (194) 30.7 (158) 23.1 (36)
Clinically significant anxiety disorder
z
Present 28.6 (171) 31.2 (143) 20.1 (28)
Not present 71.4 (427) 68.8 (315) 79.9 (111)
Depressive symptoms
k
Present 38.8 (240) 42.1 (199) 28.3 (41)
Not present 61.2 (379) 57.9 (274) 71.7 (104)
Emotional/informational social support
High 78.0 (493) 79.1 (382) 74.3 (110)
Low 22.0 (139) 20.9 (101) 25.7 (38)
*Includes 4 caregivers who responded ‘prefer not to answer’to item on gender (1 of these noted ‘prefer to self-describe’but their response did not make sense as they were
referring to their care recipient - so coded with ‘prefer not to answer’).
y
P<.001.
z
P<.05.
x
P<.10.
k
P<.01.
C.J. Maxwell et al. / JAMDA xxx (2023) 1e94
link, it is not possible to derive contact, cooperation, or response rates
at baseline.
Respondents were primarily women, married, White, age
55 years, and a daughter of the resident [79% (417 out of 528)]
(Table 1). Relative to men, women were significantly more likely to be
<65 years, not married, and White. They were also more likely (P<
.10) to report a pandemic-related change in employment status and
fair/poor self-rated health.
At baseline, 28.9% of caregivers reported worse health (compared
with 3 months prior to March 1, 2020) and 28.6% and 38.8% exhibited
anxiety and depressive symptoms, respectively. Mental health
symptoms were significantly more prevalent among women than
men. All 3 measures were strongly associated with each other (eg, of
caregivers with anxiety, 85.6% had depressive symptoms vs 18.6%
among those without anxiety, P<.0001; of those with anxiety, 55.6%
reported worsening health vs 19.0% among those without anxiety; P<
.0001).
During the initial pandemic wave, 16.5% of caregivers reported
they started to consume or increased their use of alcohol, 13.3% started
a psychotropic drug, 8.0% started or increased cigarette smoking and/
or cannabis use, and 7.4% sought counseling services. All coping be-
haviors were significantly more prevalent among caregivers with
anxiety, depressive symptoms, and worse health, except for seeking
counseling among those with anxiety (Figure 1 and Supplementary
Table 3). None of these behaviors varied significantly by caregiver
gender.
The strong positive associations between caregiver baseline
mental health symptoms, reported poorer health and coping behav-
iors remained robust in adjusted models. For example, among
caregivers with (vs without) anxiety, the adjusted risk ratio (95%
confidence interval) was 3.87 (2.50-6.00) for starting a psychotropic
drug; 1.87 (1.28-2.73) for new or increased alcohol use; and, 2.21
(1.26-3.88) for new or increased cigarette and/or cannabis use
(Table 2). The corresponding adjusted models for depressive symp-
toms and poorer health are shown in Supplementary Tables 4 and 5,
respectively.
Relatively younger caregivers were significantly more likely to
have sought counseling services, started or increased alcohol con-
sumption and cigarette smoking and/or cannabis use during this
initial wave. Caregivers with a reported ethnic/cultural identity
other than White were less likely to have started or increased
alcohol use but more likely to have started or increased cigarette
smoking and/or cannabis use. Relative to caregivers with a uni-
versity degree, those with high school or less education were less
likely to have sought counseling and report new or increased
alcohol use while those with a college or trade level of education
were significantly more likely to report new or increased use of
cigarettes and/or cannabis.
Longitudinal Sample
At follow-up, the response rate was 60.2% (longitudinal sample ¼
386). Caregivers who responded to both surveys were more likely to
be age 65þyears, identify as other than White, have a university de-
gree, chronic conditions, and initiated a psychotropic but were less
likely to be extremely concerned about income loss (Supplementary
Table 6). They did not vary in mental health/health measures from
those responding at baseline only.
Fig. 1. Assisted living caregiver reported coping behaviors during the initial wave of the COVID-19 pandemic, among those with clinically significant anxiety disorder, depressive
symptoms, self-reported worse health, compared with total and gender-specific prevalence (total baseline sample, n ¼673).
C.J. Maxwell et al. / JAMDA xxx (2023) 1e95
Table 2
Unadjusted and Adjusted Associations Between Assisted Living Caregiver Anxiety, Other Characteristics and Select Coping Behaviors (Total Baseline Sample, n ¼673)
Caregiver Characteristics Caregiver Coping Response
Sought Counseling Services Started OTC Product for Sleep and/or
Prescription Drug for Anxiety/
Depression
Started to Consume or Increased Use
of Alcohol
Started or Increased Smoking and/or
Cannabis use
Unadjusted Risk
Ratio (95% CI)
Adjusted*Risk
Ratio (95% CI)
Unadjusted Risk
Ratio (95% CI)
Adjusted*Risk
Ratio (95% CI)
Unadjusted Risk
Ratio (95% CI)
Adjusted*Risk
Ratio (95% CI)
Unadjusted Risk
Ratio (95% CI)
Adjusted*Risk
Ratio (95% CI)
Clinically significant anxiety disorder 1.70 (0.98-2.96)
y
1.36 (0.73-2.51) 4.27 (2.82-6.45) 3.87 (2.50-6.00) 1.85 (1.29-2.64) 1.87 (1.28-2.73) 2.97 (1.73-5.08) 2.21 (1.26-3.88)
Age (65þy¼ref group)
18-44 y 3.89 (1.60-9.48) 2.82 (1.16-6.86) 1.72 (0.89-3.34) 0.96 (0.48-1.94) 2.53 (1.41-4.56) 1.98 (1.06-3.71) 6.12 (2.83-13.21) 4.43 (1.92-10.19)
45-54 y 2.28 (0.95-5.47)
y
2.00 (0.80-5.04) 1.47 (0.84-2.57) 1.21 (0.68-2.14) 2.16 (1.29-3.61) 1.88 (1.10-3.20) 2.28 (0.95-5.47)
y
2.38 (0.93-6.09)
y
55-64 y 1.93 (0.96-3.87)
y
1.66 (0.80-3.45) 0.92 (0.58-1.46) 0.74 (0.47-1.18) 1.52 (0.99-2.34)
y
1.39 (0.91-2.11) 1.93 (0.96-3.87)
y
1.90 (0.96-3.79)
y
Gender
Woman 1.83 (0.84-3.98) 1.48 (0.66-3.33) 1.27 (0.77-2.09) 1.09 (0.68-1.76) 0.97 (0.65-1.45) 0.77 (0.51-1.15) 0.85 (0.47-1.52) 0.61 (0.34-1.11)
Ethnic/cultural identity
Other than White 1.25 (0.55-2.84) 1.08 (0.45-2.58) 0.42 (0.16-1.12)
y
0.40 (0.13-1.27) 0.33 (0.13-0.88) 0.39 (0.15-1.03)
y
1.84 (0.94-3.60)
y
2.12 (1.07-4.19)
Income reduction (3 mo post March 1, 2020)
and level of concern (No ¼ref group)
Yes, not/somewhat concerned 1.37 (0.71-2.66) 1.21 (0.61-2.40) 1.11 (0.66-1.86) 1.31 (0.78-2.19) 0.77 (0.47-1.28) 0.68 (0.40-1.16) 1.06 (0.52-2.15) 0.78 (0.35-1.73)
Yes, very/extremely concerned 2.10 (0.97-4.53)
y
1.90 (0.84-4.30) 2.66 (1.65-4.28) 1.43 (0.81-2.55) 1.51 (0.91-2.52) 0.83 (0.44-1.55) 3.10 (1.67-5.76) 1.42 (0.69-2.92)
Highest education (university ¼ref group)
College/trade 0.72 (0.40-1.29) 0.75 (0.42-1.34) 1.11 (0.68-1.83) 0.92 (0.56-1.51) 0.83 (0.56-1.21) 0.77 (0.52-1.13) 1.99 (1.02-3.88) 2.10 (1.03-4.28)
High school or Less 0.39 (0.17-0.90) 0.49 (0.21-1.14)
y
1.48 (0.89-2.46) 1.30 (0.79-2.13) 0.66 (0.41-1.05)
y
0.58 (0.36-0.96) 1.28 (0.58-2.82) 1.57 (0.66-3.72)
Missing values for 1 model variables n¼88 n¼88 n¼88 n¼88
OTC, over-the-counter.
Bolded estimates are statistically significant at the threshold P<.05.
*Adjusted for all covariates listed in the Table.
y
P<.10.
C.J. Maxwell et al. / JAMDA xxx (2023) 1e96
Among coping behaviors, only the prevalence of new/increased
alcohol use varied significantly across pandemic waves with a lower
prevalence reported during the second (11.7%) compared with the
initial wave (15.1%) (Figure 2). Prevalence estimates for anxiety,
depressive symptoms, and worsening health were all significantly
lower at follow-up compared with baseline.
Caregivers with anxiety and/or depressive symptoms at baseline
were significantly more likely to report starting a psychotropic drug
and new or increased alcohol, cigarette, and/or cannabis use during
both the initial (Figure 3, A) and second (Figure 3, B) waves. Baseline
depressive symptoms were significantly associated with seeking
counseling during both waves. Worsening health at baseline showed
less pronounced and consistent associations with coping behaviors
during both waves. Gender was not significantly associated with
coping behaviors at either wave. In adjusted models, the positive as-
sociations between caregiver mental health symptoms (assessed
either at baseline or follow-up) and their coping behaviors during the
second pandemic wave largely remained statistically significant
(Secondary analyses, Supplementary Table 7).
Discussion
Among assisted living caregivers in 2 Canadian provinces, 16.5%
started or increased alcohol use and 13.3% initiated a psychotropic
drug to help cope with the initial pandemic wave. A smaller propor-
tion reported new or increased smoking and/or cannabis use (8.0%)
and seeking counseling (7.4%). During the second wave, the preva-
lence of most coping behaviors did not change except for a signifi-
cantly lower prevalence of alcohol use. Anxiety and depressive
symptoms were common among caregivers at baseline but were less
prevalent by follow-up. During both waves, the prevalence of psy-
chotropic and substance use was2 to 4 times higher amongcaregivers
with mental health symptoms. Contrary to our hypothesis none of the
coping behaviors at either wave varied by caregiver gender.
Research on coping strategies used by caregivers during COVID-19
is limited and largely restricted to community-based care. Our study is
unique in exploring coping behaviors among caregivers to older adults
in assisted living (an especially neglected and vulnerable caregiver
population) and investigating variations in these behaviors over time
Fig. 2. Assisted living caregiver reported coping behaviors during the initial and second waves of the COVID-19 pandemic and health characteristics* at baseline and follow-up.
*Among longitudinal caregiver sample, anxiety was significantly higher among women than men at baseline (30.5% vs 19.4%) and follow-up (25.3% vs 9.6%); depressive symp-
toms were significantly higher among women at follow-up (36.3% vs 22.4%) and higher (but not statistically significant) at baseline (40.9% vs 31.2%). Reported worsening of health
did not vary significantly by gender at either time point.
Fig. 3. Assisted living caregiver reported coping behaviors during the (A) initial and (B) second waves of the COVID-19 pandemic, among those with baseline clinically significant
anxiety disorder, depressive symptoms, self-reported worse health, compared with total and gender-specific prevalence (longitudinal sample, n ¼386).
C.J. Maxwell et al. / JAMDA xxx (2023) 1e97
(across 2 pandemic waves) and by assisted living caregiver mental and
overall health. Similar to our findings, caregivers of community-
residing persons with dementia, who exhibited depression tended
to have more dysfunctional coping strategies.
43
Caregivers of
community-residing adults in the United States showed overall higher
levels of starting or increasing drug or alcohol use, compared with
noncaregivers.
29
Increased alcohol consumption in our baseline
sample was 16.5%, compared with 13% reported in the general pop-
ulation of middle age and older Canadian adults, for whom depression
and anxiety were also predictors of potentially worrisome alcohol
use.
44
Our findings contribute to an improved awareness of the sim-
ilarities and differences in pandemic-related mental health stressors
and coping support needs among assisted living caregivers relative to
caregivers in other settings.
Although baseline depressive symptoms were associated with
seeking counseling during both pandemic waves, this was not true for
anxiety. Few caregivers reported seeking counseling at either wave
despite having anxiety and depressive symptoms. This finding along
with the increased substance use noted in our study and by others
23,24
suggests many used self-medication to cope with pandemic and
caregiver related stressors given a reduced availability and/or acces-
sibility to needed mental health services during peak waves. In a small
Canadian study, caregivers of persons with dementia reported that
this inability to connect with resources would have a lasting impact on
their own health.
45
As older caregivers and those with lower educa-
tion were less likely to seek counseling in our study, this gap in
accessing services may be more pronounced for especially vulnerable
caregivers.
The absence of a gender difference in coping behaviors was un-
expected given previous studies among the general popula-
tion
24,26,28,44
and the higher prevalence of mental health symptoms
among women in our study. However, our findings are consistent with
a US study of adult caregivers.
29
Canadian studies show that women
were more likely to report experiencing stressors in response to the
pandemic,
46
and women with depression or anxiety had increased
binge drinking.
44
We did observe some age differences in coping be-
haviors wherein younger caregivers were more likely to report start-
ing or increasing alcohol, smoking, and/or cannabis use. These
differences may reflect a greater tendency for younger adults to report
more negative experiences during the pandemic,
46
including a higher
prevalence of anxiety
19
and multiple stresses related to care of parents
and children and job loss.
25-28
Strengths of this study include the use of comprehensive primary
data incorporating validated mental health measures, our longitudinal
design, and large sample of adult assisted living caregivers of all ages
from 2 Canadian provinces. Our focus on caregivers of older residents
in assisted living addresses an important knowledge gap in current
COVID-19 research. By examining both positive and potentially mal-
adaptive behaviors we provide a balanced overview of coping stra-
tegies in this caregiver population.
There are some limitations to consider. Self-reported survey data
has the potential for recall bias (a concern given the relatively long
period for baseline data collection) and social desirability bias
(particularly for questions on substance use). The analytic sample
included largely White, English-speaking women with dispropor-
tionately high socioeconomic status. There is the potential for selec-
tion bias given our recruitment strategy and use of open-survey link at
baseline. The exclusion of caregivers from diverse cultures and the
likelihood that some who declined participation did so because of
stressors limits the generalizability of our results and may have
resulted in an underestimation of mental health symptoms and
coping behaviors. Our 60.2% response rate at follow-up likely resulted
in lower power for some analyses. We did not employ validated scales
for our coping behaviors and some behaviors (eg, physical activity,
dietary changes, screen time) were not investigated. Finally, by
anchoring coping behaviors to salient time frames to enhance accu-
racy of reporting, we cannot be sure of the direction of reported as-
sociations or whether an initially reported behavior was maintained,
reduced, or discontinued over follow-up.
Conclusions and Implications
Assisted living caregivers experiencing anxiety or depressive
symptoms during the pandemic were more likely to engage in drug
and substance use as coping strategies. Enhanced awareness of care-
giver mental health needs during crises coupled with increased
availability and accessibility of counseling services and financial re-
sources are needed to mitigate declines in their health.
Acknowledgments
We thank our family/friend caregiver participants, family caregiver
organizations [Caregivers Alberta, Family Caregivers of British
Columbia], the participating assisted living homes, and government
partners [Alberta Health, Alberta Health Services, Government of
British Columbia, Vancouver Coastal Health] for their meaningful
contributions to this research. We also thank the Survey Research
Centre at the University of Waterloo for the expert administration of
the COVCARES-AB/BC baseline and follow-up web surveys and Hana
Dampf for her assistance with figure presentation.
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Supplementary Fig. 1. Timing of baseline and follow-up caregiver surveys relative to time frames for reported coping behaviors.
C.J. Maxwell et al. / JAMDA xxx (2023) 1e99.e1
Supplementary Table 1
STROBE Guidelines for Reporting Observational Studies
Item No Recommendation Page No
Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the
abstract
2
(b) Provide in the abstract an informative and balanced summary of what was
done and what was found
2
Introduction
Background/rationale 2 Explain the scientific background and rationale for the investigation being
reported
4-5
Objectives 3 State specific objectives, including any prespecified hypotheses 5
Methods
Study design 4 Present key elements of study design early in the paper 5
Setting 5 Describe the setting, locations, and relevant dates, including periods of
recruitment, exposure, follow-up, and data collection
5-6
Participants 6 (a) Cohort studydGive the eligibility criteria, and the sources and methods of
selection of participants. Describe methods of follow-up
Case-control studydGive the eligibility criteria, and the sources and methods of
case ascertainment and control selection. Give the rationale for the choice of
cases and controls
Cross-sectional studydGive the eligibility criteria, and the sources and methods
of selection of participants
5-6 and Supplementary Table 2
(b) Cohort studydFor matched studies, give matching criteria and number of
exposed and unexposed
Case-control studydFor matched studies, give matching criteria and the
number of controls per case
n/a
Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and
effect modifiers. Give diagnostic criteria, if applicable
6-7
Data sources/measurement 8*For each variable of interest, give sources of data and details of methods of
assessment (measurement). Describe comparability of assessment methods if
there is more than one group
6-7
Bias 9 Describe any efforts to address potential sources of bias 6,8-9
Study size 10 Explain how the study size was arrived at n/a
Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable,
describe which groupings were chosen and why
6-7
Statistical methods 12 (a) Describe all statistical methods, including those used to control for
confounding
8-9
(b) Describe any methods used to examine subgroups and interactions n/a
(c) Explain how missing data were addressed 8
(d) Cohort studydIf applicable, explain how loss to follow-up was addressed
Case-control studydIf applicable, explain how matching of cases and controls
was addressed
Cross-sectional studydIf applicable, describe analytical methods taking account
of sampling strategy
9
(e) Describe any sensitivity analyses n/a
Results
Participants 13*(a) Report numbers of individuals at each stage of studydeg numbers
potentially eligible, examined for eligibility, confirmed eligible, included in the
study, completing follow-up, and analyzed
9,11
(b) Give reasons for non-participation at each stage Not collected but differences
between responders/non-
responders in Supplementary
Table 6
(c) Consider use of a flow diagram
Descriptive data 14*(a) Give characteristics of study participants (eg demographic, clinical, social)
and information on exposures and potential confounders
9-11
(b) Indicate number of participants with missing data for each variable of
interest
8-9
(c) Cohort studydSummaries follow-up time (eg, average and total amount) Supplementary Figure 1
Outcome data 15*Cohort studydReport numbers of outcome events or summary measures over
time
11
Case-control studydReport numbers in each exposure category, or summary
measures of exposure
Cross-sectional studydReport numbers of outcome events or summary
measures
9-10
Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates
and their precision (eg, 95% confidence interval). Make clear which
confounders were adjusted for and why they were included
10
(b) Report category boundaries when continuous variables were categorized n/a
(c) If relevant, consider translating estimates of relative risk into absolute risk for
a meaningful time period
Other analyses 17 Report other analyses donedeg analyses of subgroups and interactions, and
sensitivity analyses
11
(continued on next page)
C.J. Maxwell et al. / JAMDA xxx (2023) 1e99.e2
Supplementary Table 1 (continued )
Item No Recommendation Page No
Discussion
Key results 18 Summarize key results with reference to study objectives 12
Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or
imprecision. Discuss both direction and magnitude of any potential bias
13
Interpretation 20 Give a cautious overall interpretation of results considering objectives,
limitations, multiplicity of analyses, results from similar studies, and other
relevant evidence
14
Generalizability 21 Discuss the generalizability (external validity) of the study results 13
Other information
Funding 22 Give the source of funding and the role of the funders for the present study and,
if applicable, for the original study on which the present article is based
Title pg and Cover Letter
An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE
checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at
http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org.
*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies.
Supplementary Table 2
Description of Assisted Living in Alberta and British Columbia, Canada and COVCARES-AB/BC Study Eligibility Criteria
Alberta BC
In Alberta, there are publicly subsidized and private pay assisted living
operators.
Publicly funded (subsidized) assisted living in Alberta is known as
designated SL.
Under the Supportive Living Accommodation Licensing Act, SL must be
licensed for resident safety and security and also comply with Accom-
modation Standards; designated SL must further comply with the
Continuing Care Health Service Standards.
Designated SL is composed of 3 progressive levels of support moving from
the lowest level of support available (SL3) to higher levels of support (SL4
and SL4-Dementia)
o SL3 is for individuals who are medically and physically stable and
can move independently or move with limited assistance. Health
care aides are available on site 24 h/d and other health care ser-
vices are scheduled and provided by home care.
o SL4 is for individuals with more complex health needs and who
might require assistance with eating and transfers. It has health
care aides and a licensed practical nurse available 24 h/d, and
other care needs (eg, rehabilitation therapy) are contracted
through home care.
o SL 4D is like SL4 but is specifically for individuals with moderate to
severe dementia.
Further details about designated SL in Alberta can be found here:
https://www.albertahealthservices.ca/cc/Page15490.aspx
https://www.albertahealthservices.ca/cc/page15328.aspx
In BC, there are publicly subsidized and private pay assisted living operators.
Under the Community Care and Assisted Living Act (which sets minimum health and
safety requirements), all publicly subsidized and private pay assisted living operators
that meet the definition of an assisted living residence under the Act are required to
be registered with the provincial assisted living registrar.
Publicly subsidized assisted living services provide housing, hospitality, and 1 or 2
personal assistance services (prescribed services) for adults who can live indepen-
dently and make decisions on their own behalf but require a supportive environment
due to physical and functional health challenges.
o Eligibility require resident to be able to make decisions on their own behalf or
who has a spouse willing to live with the resident and is willing/able to make
decisions on their behalf.
o If the resident requires 3 or more personal assistance services they are not
eligible for publicly subsidized assisted living.
BC does not differentiate various levels of assisted living depending on individual care
needs.
Further details about assisted living in BC can be found here:
https://www2.gov.bc.ca/gov/content/health/accessing-health-care/home-
community-care/care-options-and-cost/assisted-living
https://www2.gov.bc.ca/gov/content/health/accessing-health-care/finding-assisted-
living-or-residential-care/residential-care-facilities/finding-a-residential-care-
facility
COVCARES-AB/BC Study Eligibility Criteria
(1) Assisted living Homes (Alberta and BC): Eligibility criteria included homes that were licensed and publicly subsidized (termed designated supportive living in
Alberta), in operation for at least 6 months, not primarily serving psychiatric clients and with a minimum number of residents age 65þy (4 for small, 10 for large
homes, based on median bed-size).
(2) Caregivers of assisted living residents (Alberta and BC): Eligibility criteria included those who identified as the primary adult caregiver (ie, age 18þy and most
informed/involved in care) of a resident age 65þy living in the home for 3þmo prior to March 1, 2020.
BC, British Columbia; SL, supportive living.
C.J. Maxwell et al. / JAMDA xxx (2023) 1e99.e3
Supplementary Table 3
Distribution of Assisted Living Caregiver Coping Behaviors, Overall and by Reported Change in Health, Presence of Clinically Significant Anxiety Disorder and Depressive
Symptoms [Distribution Shown as Column % (n); Total Baseline Sample, n ¼673]
Coping Response Overall (n ¼673) Change in Health Clinically Significant Anxiety
Disorder
Depressive Symptoms
Worse
(28.9%; 194/671)
Same
(61.3%; 411/671)
Better
(9.8%; 66/671)
Present
(28.6%; 171/598)
Absent
(71.4%; 427/598)
Present
(38.8%; 240/619)
Absent
(61.2%; 379/619)
Sought counseling
services
Yes 7.4 (49) 12.0 (23)*4.9 (20) 9.4 (6) 11.2 (19)
y
6.6 (28) 12.2 (29)
z
4.8 (18)
No 92.6 (612) 88.0 (169) 95.1 (384) 90.6 (58) 88.8 (150) 93.4 (396) 87.8 (208) 95.2 (359)
Started OTC drug
product for sleep
Yes 9.4 (62) 19.7 (37)
x
4.9 (20) 7.8 (5) 22.5 (38)
x
4.5 (19) 20.3 (48)
x
3.2 (12)
No 90.6 (599) 80.7 (155) 95.1 (384) 92.2 (59) 77.5 (131) 95.5 (405) 79.8 (189) 96.8 (365)
Started prescription
drug to help with
anxiety/
depression
Yes 6.2 (41) 13.5 (26)
x
3.0 (12) 4.7 (3) 14.2 (24)
x
3.3 (14) 14.4 (34)
x
1.6 (6)
No 93.8 (620) 86.5 (166) 97.0 (392) 95.3 (61) 85.8 (145) 96.7 (410) 85.7 (203) 98.4 (371)
Started OTC product
for sleep and/or
prescription drug
for anxiety/
depression
Yes 13.3 (88) 28.1 (54)
x
6.7 (27) 10.9 (7) 30.2 (51)
x
7.1 (30) 29.1 (69)
x
4.2 (16)
No 86.7 (573) 71.9 (138) 93.3 (377) 89.1 (57) 69.8 (118) 92.9 (394) 70.9 (168) 95.8 (361)
Started to consume or
increased use of
alcohol
Yes 16.5 (109) 22.4 (43)
k
13.6 (55) 17.2 (11) 24.9 (42)
z
13.4 (57) 24.9 (59)
x
12.2 (46)
No 83.5 (552) 77.6 (149) 86.4 (349) 82.8 (53) 75.2 (127) 86.6 (367) 75.1 (178) 87.8 (331)
Started or increased
smoking
Yes 4.7 (31) 6.8 (13) 4.2 (17) 1.6 (1) 7.7 (13)
y
4.0 (17) 6.8 (16)
y
3.7 (14)
No 95.3 (630) 93.2 (179) 95.8 (387) 98.4 (63) 92.3 (156) 96.0 (407) 93.3 (221) 96.3 (363)
Started or increased
cannabis use
Yes 4.2 (28) 8.3 (16)*2.5 (10) 3.1 (2) 9.5 (16)
x
1.9 (8) 8.4 (20)
z
2.1 (8)
No 95.8 (633) 91.7 (176) 97.5 (394) 96.9 (62) 90.5 (153) 98.1 (416) 91.6 (217) 97.9 (369)
Started or increased
smoking and/or
cannabis use
Yes 8.0 (53) 12.5 (24)
k
6.4 (26) 4.7 (3) 15.4 (26)
x
5.2 (22) 13.5 (32)
z
5.3 (20)
No 92.0 (608) 87.5 (168) 93.6 (378) 95.3 (61) 84.6 (143) 94.8 (402) 86.5 (205) 94.7 (357)
OTC, over-the-counter.
*P<.01.
y
P<.10.
z
P<.001.
x
P<.0001.
k
P<.05.
C.J. Maxwell et al. / JAMDA xxx (2023) 1e99.e4
Supplementary Table 4
Unadjusted and Adjusted Associations Between Assisted Living Caregiver Depressive Symptoms, Other Characteristics, and Select Coping Behaviors (Total Baseline Sample, n ¼673)
Caregiver Characteristics Caregiver Coping Response
Sought Counseling Services Started OTC Product for Sleep and/or
Prescription Drug for Anxiety/
Depression
Started to Consume or Increased Use
of Alcohol
Started or Increased Smoking and/or
Cannabis Use
Unadjusted Risk
Ratio (95% CI)
Adjusted*Risk
Ratio (95% CI)
Unadjusted Risk
Ratio (95% CI)
Adjusted*Risk
Ratio (95% CI)
Unadjusted Risk
Ratio (95% CI)
Adjusted*Risk
Ratio (95% CI)
Unadjusted Risk
Ratio (95% CI)
Adjusted*Risk
Ratio (95% CI)
Depressive symptoms 2.56 (1.46-4.51) 2.18 (1.21-3.94) 6.86 (4.08-11.53) 6.13 (3.63-10.35) 2.04 (1.44-2.89) 2.03 (1.42-2.88) 2.55 (1.49-4.34) 2.04 (1.17-3.55)
Age (65þy¼ref group)
18-44 y 3.89 (1.60-9.48) 2.53 (1.01-6.31) 1.72 (0.89-3.34) 1.27 (0.68-2.39) 2.53 (1.41-4.56) 2.33 (1.30-4.16) 6.12 (2.83-13.21) 5.16 (2.30-11.55)
45-54 y 2.28 (0.95-5.47)
y
2.11 (0.84-5.29) 1.47 (0.84-2.57) 1.33 (0.75-2.35) 2.16 (1.29-3.61) 2.17 (1.31-3.59) 2.28 (0.95-5.47)
y
2.17 (0.87-5.41)
y
55-64 y 1.93 (0.96-3.87)
y
1.68 (0.80-3.55) 0.92 (0.58-1.46) 0.82 (0.52-1.28) 1.52 (0.99-2.34)
y
1.54 (1.01-2.34) 1.93 (0.96-3.87)
y
1.89 (0.97-3.68)
y
Gender
Woman 1.83 (0.84-3.98) 1.64 (0.69-3.89) 1.27 (0.77-2.09) 1.04 (0.65-1.68) 0.97 (0.65-1.45) 0.82 (0.54-1.24) 0.85 (0.47-1.52) 0.60 (0.34-1.07)
y
Ethnic/cultural identity
Other than White 1.25 (0.55-2.84) 1.33 (0.60-2.91) 0.42 (0.16-1.12)
y
0.35 (0.11-1.15)
y
0.33 (0.13-0.88) 0.36 (0.14-0.93) 1.84 (0.94-3.60)
y
1.99 (1.07-3.71)
Income reduction (3 mo post March 1, 2020)
and level of concern (No ¼ref group)
Yes, not/somewhat concerned 1.37 (0.71-2.66) 1.08 (0.54-2.18) 1.11 (0.66-1.86) 1.17 (0.71-1.93) 0.77 (0.47-1.28) 0.62 (0.38-1.04)
y
1.06 (0.52-2.15) 0.82 (0.41-1.66)
Yes, very/extremely concerned 2.10 (0.97-4.53)
y
1.31 (0.59-2.91) 2.66 (1.65-4.28) 1.49 (0.92-2.41) 1.51 (0.91-2.52) 0.96 (0.58-1.57) 3.10 (1.67-5.76) 1.48 (0.75-2.93)
Highest education (University ¼ref group)
College/trade 0.72 (0.40-1.29) 0.70 (0.39-1.26) 1.11 (0.68-1.83) 0.99 (0.62-1.56) 0.83 (0.56-1.21) 0.78 (0.53-1.13) 1.99 (1.02-3.88) 2.07 (1.05-4.08)
High school or Less 0.39 (0.17-0.90) 0.41 (0.17-1.00) 1.48 (0.89-2.46) 1.39 (0.86-2.27) 0.66 (0.41-1.05)
y
0.64 (0.40-1.04)
y
1.28 (0.58-2.82) 1.75 (0.76-4.04)
Missing values for 1 model variables n¼68 n¼68 n¼68 n¼68
OTC, over-the-counter.
Bolded estimates are statistically significant at the threshold P<.05.
*Adjusted for all covariates listed in Table.
y
P<.10.
C.J. Maxwell et al. / JAMDA xxx (2023) 1e99.e5
Supplementary Table 5
Unadjusted and Adjusted Associations Between Assisted Living Caregiver Health Change, Other Characteristics, and Select Coping Behaviors (Total Baseline Sample, n ¼673)
Caregiver Characteristics Caregiver Coping Response
Sought Counseling Services Started OTC Product for Sleep and/or
Prescription Drug for Anxiety/
Depression
Started to Consume or Increased Use of
Alcohol
Started or Increased Smoking and/or
Cannabis Use
Unadjusted Risk
Ratio (95% CI)
Adjusted*Risk
Ratio (95% CI)
Unadjusted Risk
Ratio (95% CI)
Adjusted*Risk
Ratio (95% CI)
Unadjusted Risk
Ratio (95% CI)
Adjusted*Risk
Ratio (95% CI)
Unadjusted Risk
Ratio (95% CI)
Adjusted*Risk
Ratio (95% CI)
Health (now vs 3 mo before
March 1, 2020), same ¼ref
Better 1.89 (0.79-4.54) 1.73 (0.73-4.07) 1.64 (0.74-3.60) 1.79 (0.82-3.89) 1.26 (0.70-2.28) 1.33 (0.72-2.44) 0.73 (0.23-2.34) 0.55 (0.19-1.55)
Worse 2.42 (1.36-4.30) 2.07 (1.17-3.66) 4.21 (2.74-6.46) 4.10 (2.65-6.35) 1.65 (1.15-2.36) 1.69 (1.20-2.38) 1.94 (1.15-3.29) 1.52 (0.90-2.56)
Age (65þy¼ref group)
18-44 y 3.89 (1.60-9.48) 2.56 (1.08-6.07) 1.72 (0.89-3.34) 1.42 (0.70-2.85) 2.53 (1.41-4.56) 2.44 (1.37-4.35) 6.12 (2.83-13.21) 5.95 (2.70-13.11)
45-54 y 2.28 (0.95-5.47)
y
1.80 (0.71-4.53) 1.47 (0.84-2.57) 1.29 (0.75-2.21) 2.16 (1.29-3.61) 2.18 (1.31-3.60) 2.28 (0.95-5.47)
y
2.05 (0.83-5.04)
55-64 y 1.93 (0.96-3.87)
y
1.63 (0.81-3.30) 0.92 (0.58-1.46) 0.80 (0.51-1.24) 1.52 (0.99-2.34)
y
1.57 (1.04-2.38) 1.93 (0.96-3.87)
y
1.89 (0.97-3.69)
y
Gender
Woman 1.83 (0.84-3.98) 1.54 (0.69-3.41) 1.27 (0.77-2.09) 1.02 (0.64-1.63) 0.97 (0.65-1.45) 0.78 (0.53-1.16) 0.85 (0.47-1.52) 0.63 (0.36-1.10)
Ethnic/cultural identity
Other than White 1.25 (0.55-2.84) 1.02 (0.46-2.28) 0.42 (0.16-1.12)
y
0.38 (0.14-1.05)
y
0.33 (0.13-0.88) 0.29 (0.11-0.77) 1.84 (0.94-3.60)
y
1.79 (0.96-3.36)
y
Income reduction (3 mo post March
1, 2020) and level of concern
(No ¼ref group)
Yes, not/somewhat concerned 1.37 (0.71-2.66) 1.12 (0.59-2.14) 1.11 (0.66-1.86) 1.01 (0.62-1.63) 0.77 (0.47-1.28) 0.63 (0.39-1.02)
y
1.06 (0.52-2.15) 0.82 (0.42-1.60)
Yes, very/extremely concerned 2.10 (0.97-4.53)
y
1.64 (0.75-3.55) 2.66 (1.65-4.28) 2.03 (1.22-3.40) 1.51 (0.91-2.52) 1.20 (0.73-1.96) 3.10 (1.67-5.76) 1.84 (0.94-3.61)
y
Highest Education (University ¼
ref group)
College/trade 0.72 (0.40-1.29) 0.66 (0.37-1.17) 1.11 (0.68-1.83) 0.95 (0.58-1.54) 0.83 (0.56-1.21) 0.77 (0.53-1.12) 1.99 (1.02-3.88) 2.00 (1.02-3.95)
High school or less 0.39 (0.17-0.90) 0.42 (0.18-0.96) 1.48 (0.89-2.46) 1.43 (0.88-2.32) 0.66 (0.41-1.05)
y
0.65 (0.41-1.03)
y
1.28 (0.58-2.82) 1.57 (0.70-3.56)
Missing values for 1 model
variables
n¼24 n ¼24 n ¼24 n ¼24
OTC, over-the-counter.
Bolded estimates are statistically significant at the threshold P<.05.
*Adjusted for all covariates listed in Table.
y
P<.10.
C.J. Maxwell et al. / JAMDA xxx (2023) 1e99.e6
Supplementary Table 6
Distribution of Assisted Living Caregiver Characteristics, Overall and by Participation in Baseline Only vs Baseline and Follow-Up Surveys [Distribution Shown as Column % (n)]
Characteristics Overall (n ¼673) Survey Participation
Baseline Only (n ¼287) Baseline and
Follow-Up (n ¼386)
Sociodemographic
Province (facility located)
Alberta 81.1 (546) 81.5 (234) 80.8 (312)
British Columbia 18.9 (127) 18.5 (53) 19.2 (74)
Age*
18-44 y 6.4 (43) 8.1 (23) 5.2 (20)
45-54 y 12.2 (82) 14.4 (41) 10.6 (41)
55-64 y 42.3 (284) 43.2 (123) 41.7 (161)
65þy 39.1 (262) 34.4 (98) 42.5 (164)
Gender
Women 76.8 (515) 73.7 (210) 79.0 (305)
Men
y
23.2 (156) 26.3 (75) 21.0 (81)
Marital status
Married/common-law 83.1 (555) 82.4 (234) 83.6 (321)
Other 16.9 (113) 17.6 (50) 16.4 (63)
Relationship to resident
Spouse/parent 5.8 (39) 5.2 (15) 6.2 (24)
Daughter/son (including in-law) 78.5 (528) 80.1 (230) 77.2 (298)
Sibling 7.3 (49) 6.3 (18) 8.0 (31)
Friend/neighbor /other 8.5 (57) 8.4 (24) 8.6 (33)
Ethnic/cultural identity
z
White 89.9 (598) 93.6 (263) 87.2 (335)
Other than White 10.1 (67) 6.4 (18) 12.8 (49)
Highest education
x
University 31.0 (205) 25.8 (72) 34.7 (133)
College/trade 42.5 (281) 44.8 (125) 40.7 (156)
High school or less 26.6 (176) 29.4 (82) 24.5 (94)
Household income (prior to March 1, 2020)
>$100,000 27.3 (184) 30.3 (87) 25.1 (97)
$80,000-$99,000 15.0 (101) 15.7 (45) 14.5 (56)
$50,000-$79,000 23.8 (160) 20.6 (59) 26.2 (101)
<$50,000 20.2 (136) 17.4 (50) 22.3 (86)
Missing 13.7 (92) 16.0 (46) 11.9 (46)
Income reduction (3 mo post March 1, 2020) and level of concern
x
No 73.4 (494) 74.2 (213) 72.8 (281)
Yes, not concerned 4.5 (30) 2.4 (7) 6.0 (23)
Yes, somewhat concerned 14.1 (95) 12.9 (37) 15.0 (58)
Yes, very/extremely concerned 8.0 (54) 10.5 (30) 6.2 (24)
Change in employment status (3 mo post March 1, 2020)
No 84.0 (562) 83.8 (238) 84.2 (324)
Yes 16.0 (107) 16.2 (46) 15.8 (61)
Health and social well-being
No of chronic conditions
z
None 43.0 (288) 45.4 (129) 41.2 (159)
1-2 41.6 (279) 37.3 (106) 44.8 (173)
3þ11.6 (78) 10.9 (31) 12.2 (47)
Don’t know/prefer not to answer 3.7 (25) 6.3 (18) 1.8 (7)
Self-rated health
Excellent 16.9 (113) 18.9 (54) 15.3 (59)
Very good 40.5 (271) 42.5 (121) 39.0 (150)
Good 31.8 (213) 28.4 (81) 34.3 (132)
Fair/poor 10.9 (73) 10.2 (29) 11.4 (44)
Change in health (vs 3 mo pre March 1, 2020)
Better now 9.8 (66) 11.9 (34) 8.3 (32)
Same 61.3 (411) 61.2 (175) 61.3 (236)
Worse 28.9 (194) 26.9 (77) 30.4 (117)
Clinically significant anxiety disorder
Present 28.6 (171) 29.2 (72) 28.2 (99)
Not present 71.4 (427) 70.9 (175) 71.8 (252)
Depressive symptoms
Present 38.8 (240) 38.8 (102) 38.8 (138)
Not present 61.2 (379) 61.2 (161) 61.2 (218)
Emotional/informational social support
High 78.0 (493) 78.4 (211) 77.7 (282)
Low 22.0 (139) 21.6 (58) 22.3 (81)
Coping behaviors
Sought counseling services
Yes 7.4 (49) 7.9 (22) 7.1 (27)
No 92.6 (612) 92.1 (256) 93.0 (356)
(continued on next page)
C.J. Maxwell et al. / JAMDA xxx (2023) 1e99.e7
Supplementary Table 6 (continued )
Characteristics Overall (n ¼673) Survey Participation
Baseline Only (n ¼287) Baseline and
Follow-Up (n ¼386)
Started OTC product for sleep and/or prescription drug for
anxiety/depression
x
Yes 13.3 (88) 10.1 (28) 15.7 (60)
No 86.7 (573) 89.9 (250) 84.3 (323)
Started to consume or increased use of alcohol
Yes 16.5 (109) 18.4 (51) 15.1 (58)
No 83.5 (552) 81.7 (227) 84.9 (325)
Started or increased smoking and/or cannabis use
Yes 8.0 (53) 10.1 (28) 6.5 (25)
No 92.0 (608) 89.9 (250) 93.5 (358)
OTC, over-the-counter.
*P<.10.
y
Includes 4 caregivers who responded ‘prefer not to answer’to item on sex (1 of these noted ‘prefer to self-describe’but their response did not make sense as they were
referring to their care recipient - so coded with ‘prefer not to answer’).
z
P<.01.
x
P<.05.
C.J. Maxwell et al. / JAMDA xxx (2023) 1e99.e8
Supplementary Table 7
Adjusted Associations Between Assisted Living Caregiver Anxiety, Depressive Symptoms, Health Change (Assessed at Baseline vs Follow-Up) and Reported Coping Behaviors During Second Wave of COVID-19 Pandemic
(Longitudinal Sample, n ¼386)
Caregiver Health Characteristics Caregiver Coping Response (Wave 2 eAssessed at Follow-Up)
Sought Counseling Services Started OTC Product for Sleep and/or
Prescription Drug for Anxiety/
Depression
Started to Consume or Increased Use of
Alcohol
Started or Increased Smoking and/or
Cannabis Use
Baseline Health
Adjusted*Risk
Ratio (95% CI)
Follow-Up Health
Adjusted*Risk
Ratio (95% CI)
Baseline Health
Adjusted*Risk
Ratio (95% CI)
Follow-Up Health
Adjusted*Risk
Ratio (95% CI)
Baseline Health
Adjusted*Risk
Ratio (95% CI)
Follow-Up Health
Adjusted*Risk
Ratio (95% CI)
Baseline Health
Adjusted*Risk
Ratio (95% CI)
Follow-Up Health
Adjusted*Risk
Ratio (95% CI)
Clinically Significant Anxiety Disorder 4.03 (1.81-8.99) 4.46 (1.98-10.02) 3.23 (1.84-5.64) 3.02 (1.77-5.13) 2.50 (1.35-4.61) 2.27 (1.25-4.13) 2.67 (1.11-6.43) 2.99 (1.19-7.52)
Missing values for 1 model variables n ¼38 n ¼47 n ¼38 n ¼47 n ¼38 n ¼47 n ¼38 n ¼47
Depressive symptoms 9.52 (3.29-27.57) 4.87 (2.13-11.15) 2.56 (1.45-4.49) 4.58 (2.48-8.45) 1.72 (0.94-3.17)
y
3.04 (1.67-5.52) 2.15 (0.72-6.40) 5.50 (2.00-15.14)
Missing values for 1 model variables n ¼33 n ¼35 n ¼33 n ¼35 n ¼33 n ¼35 n ¼33 n ¼35
Health Change, same/better ¼ref
Worse
3.38 (1.62-7.03) 1.94 (0.83-4.55) 2.06 (1.26-3.36) 1.46 (0.87-2.43) 1.51 (0.86-2.65) 1.56 (0.85-2.86) 0.87 (0.34-2.23) 1.63 (0.64-4.13)
Missing values for 1 model variables n ¼5n¼5n¼5n¼5n¼5n¼5n¼5n¼5
OTC, over-the-counter.
Bolded estimates are statistically significant at the threshold P<.05.
*Adjusted for age, gender, ethnic/cultural identity, income reduction/concern, and education.
y
P<.10
C.J. Maxwell et al. / JAMDA xxx (2023) 1e99.e9
