A longitudinal cohort study on dispensed analgesic and psychotropic medications in older adults before, during, and after the COVID-19 pandemic: the HUNT study

Abstract

Background
There is a growing concern and debate over the inappropriate use of analgesics and psychotropic medications by older adults, especially those with dementia. The long-term effects of the COVID-19 pandemic and lockdown measures on these prescriptions remain uncertain.

Aim
The primary aim was to examine changes in the prescription of analgesics (opioids and other analgesics) and psychotropics (anxiolytics/sedatives, antidepressants, and antipsychotics) in Norwegian home-dwelling older adults before, during, and up to 2 years after the COVID-19 lockdown, with a particular focus on dementia status. Secondarily, we explored individual characteristics associated with changes in medication prescriptions.

Methods
A prospective cohort study using baseline data from 10,464 participants (54% females, mean age 76 years [SD 5.8]) from the Norwegian Trøndelag Health Study (HUNT4 70+) linked with the Norwegian Prescription Database. Age- and education-adjusted Poisson regression was applied to examine changes in prescription fills, and multilevel mixed-effects linear regression was used to estimate the mean sum of defined daily dose (DDD) per person per period during the lockdown (March–September 2020) compared to that during the corresponding months (March–September) in 2019, 2021, and 2022.

Results
Overall, prescriptions of opioids, other analgesics, and anxiolytics/sedatives were higher in 2022 than during the lockdown. People without dementia had increased prescriptions of opioids, other analgesics, and antidepressants after lockdown, whereas no changes were observed among those with dementia. Increases in prescriptions of opioids, other analgesics, anxiolytics/sedatives, and antidepressants between the lockdown and 2022 occurred mainly among those aged < 80 years, without comorbidities or mental distress, with good physical function, low fear of COVID-19, and no social isolation during COVID-19.

Conclusion
An increase in analgesics and psychotropics after the lockdown was predominantly observed among younger-old and healthier participants. This indicates that in high-income countries, such as Norway, home-dwelling vulnerable individuals seem to have received adequate care. However, the pandemic may have increased the number of vulnerable individuals. These findings should be considered when identifying future nationwide stressors that may impair social interactions and threaten mental health. They also highlight the need to evaluate medication prescriptions for older adults after the pandemic.

Trial registration
The study is registered in ClinicalTrials.gov 02.02.2021, with the identification number NCT 04792086.

Full text

Ibsenetal. BMC Geriatrics (2025) 25:85
https://doi.org/10.1186/s12877-025-05745-8
RESEARCH Open Access
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BMC Geriatrics
A longitudinal cohort study ondispensed
analgesic andpsychotropic medications inolder
adults before, during, andafterthe COVID-19
pandemic: theHUNT study
Tanja Louise Ibsen1*, Ekaterina Zotcheva1, Sverre Bergh1,2, Debby Gerritsen3, Gill Livingston4,5, Hilde Lurås6,7,
Svenn-Erik Mamelund8, Anne Marie Mork Rokstad1,9, Bjørn Heine Strand1,10,11, Richard C. Oude Voshaar12,13 and
Geir Selbæk1,14,15
Abstract
Background There is a growing concern and debate over the inappropriate use of analgesics and psychotropic
medications by older adults, especially those with dementia. The long-term effects of the COVID-19 pandemic
and lockdown measures on these prescriptions remain uncertain.
Aim The primary aim was to examine changes in the prescription of analgesics (opioids and other analgesics)
and psychotropics (anxiolytics/sedatives, antidepressants, and antipsychotics) in Norwegian home-dwelling older
adults before, during, and up to 2 years after the COVID-19 lockdown, with a particular focus on dementia status.
Secondarily, we explored individual characteristics associated with changes in medication prescriptions.
Methods A prospective cohort study using baseline data from 10,464 participants (54% females, mean age 76 years
[SD 5.8]) from the Norwegian Trøndelag Health Study (HUNT4 70+) linked with the Norwegian Prescription Database.
Age- and education-adjusted Poisson regression was applied to examine changes in prescription fills, and multi-
level mixed-effects linear regression was used to estimate the mean sum of defined daily dose (DDD) per person
per period during the lockdown (March–September 2020) compared to that during the corresponding months
(March–September) in 2019, 2021, and 2022.
Results Overall, prescriptions of opioids, other analgesics, and anxiolytics/sedatives were higher in 2022 than dur-
ing the lockdown. People without dementia had increased prescriptions of opioids, other analgesics, and antidepres-
sants after lockdown, whereas no changes were observed among those with dementia. Increases in prescriptions
of opioids, other analgesics, anxiolytics/sedatives, and antidepressants between the lockdown and 2022 occurred
mainly among those aged < 80 years, without comorbidities or mental distress, with good physical function, low fear
of COVID-19, and no social isolation during COVID-19.
Conclusion An increase in analgesics and psychotropics after the lockdown was predominantly observed
among younger-old and healthier participants. This indicates that in high-income countries, such as Norway, home-
dwelling vulnerable individuals seem to have received adequate care. However, the pandemic may have increased
*Correspondence:
Tanja Louise Ibsen
tanja.ibsen@aldringoghelse.no
Full list of author information is available at the end of the article
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Page 2 of 17
Ibsenetal. BMC Geriatrics (2025) 25:85
the number of vulnerable individuals. These findings should be considered when identifying future nationwide stress-
ors that may impair social interactions and threaten mental health. They also highlight the need to evaluate medica-
tion prescriptions for older adults after the pandemic.
Trial registration The study is registered in ClinicalTrials.gov 02.02.2021, with the identification number NCT
04792086.
Keywords Analgesics, Psychotropic medication, COVID-19, Dementia, Older adults, Longitudinal cohort-study, HUNT
Introduction
e COVID-19 pandemic and lockdown measures offer
unique opportunities to study the impact of nationwide
stressors on potentially inappropriate medication pre-
scriptions in older adults. Social restrictions following the
control measures introduced during the pandemic led to
social isolation and reduced mental and physical health
in older populations [22, 29, 40–42], and an increase in
neuropsychiatric symptoms among people with dementia
[13, 32, 39, 45]. Analgesics and psychotropic medications
are often prescribed to older adults based on symptoms
rather than a diagnosis, and frequently for durations that
exceed guideline recommendations [4, 35, 51]. erefore,
long-term studies examining how a nationwide stressor,
such as the COVID-19 pandemic and lockdown meas-
ures, affects the prescription of these medications in
older adults are highly relevant.
Previous studies have shown that the pandemic has
had an impact on medication prescriptions among older
adults. Regarding analgesics, individuals aged 65 years
and older with chronic pain used fewer opioids after
the onset of the pandemic in 2020, despite the fact that
the prevalence of high-impact chronic pain remained
unchanged [27]. Older adults commonly take other
analgesics such as paracetamol or non-steroidal anti-
inflammatory medications [28] which are also frequently
used to manage symptoms and treat COVID-19 [12]. A
comprehensive review has shown that the prescription
of such medications increased significantly from 2020
to 2022 [11]. Older adults (≥ 65 years) had an increase in
prescriptions of psychotropic medication; such as benzo-
diazepines [7, 36], other anxiolytics and hypnotics [48],
antidepressants [10], and antipsychotics [24] during the
first year of the pandemic. It has been suggested that fear
of COVID-19 infection and social isolation may have
been the main reasons for the increased use of benzodi-
azepines [36].
For people with dementia, a significant increase in
psychotropic medication prescriptions during the pan-
demic was observed in Europe [26, 32, 45], South Korea,
the USA, the UK [26], and Latin America [45]. A Nor-
wegian study of home-dwelling people with dementia
reported an increase in neuropsychiatric symptoms after
the COVID-19 lockdown. However, there has been no
corresponding increase in the use of psychotropic medi-
cations [13]. is contrasts with earlier findings that an
increase in behavioural and psychological symptoms in
people with dementia led to an increase in antipsychotic
and benzodiazepine prescriptions [45].
Prior studies on changes in medication prescriptions in
older adults during the COVID-19 pandemic were pre-
dominantly based on aggregated data at the population
level for the first year after the pandemic, highlighting
the need to provide individual-level data over a longer
period. Our aim was to deepen our insight into the ini-
tial and continuing 2-year impact of major events, such
as a pandemic, on the prescription of analgesics and psy-
chotropic medications in older adults, with a particular
focus on people with dementia. Our secondary aim was
to explore the sociodemographic and clinical characteris-
tics associated with changes in prescriptions.
Method
Study design
We used a longitudinal population-based cohort of par-
ticipants aged ≥ 70 years from the Norwegian Trøndelag
Health Study (HUNT4 70+) linked to the Norwegian
Prescription Database (NorPD). e HUNT study began
in 1984 in North Trøndelag County, Norway, and in the
fourth wave (2017–2019) the study expanded to include a
city district in Trondheim, as North Trøndelag lacks large
urban areas. Participant data from HUNT4 70 + included
sex, year of birth, dementia status, education, living
alone, and mental and physical health statuses [3]. Data
was collected either at a field station (84%), in the par-
ticipants own home (8%) or at the nursing home (8%).
Data on social isolation and fear of COVID-19 were col-
lected from the same population in January 2021, using
a postal questionnaire. Individual data were linked with
registry data on medication prescriptions from 12 March
2019 to 11 September 2022 using Norwegian personal
identification numbers. is period covers 1 year before
and 2 years after the COVID-19 lockdown in Norway.
e lockdown period (12 March to 11 September 2020)
was compared with the same months in 2019 (pre-lock-
down), 2021, and 2022 (both post-lockdown) (Fig.1). We
extended the lockdown period beyond the typically ref-
erenced timeframe from March to June 2020 because of
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Ibsenetal. BMC Geriatrics (2025) 25:85
the slow commencement of reopening and because many
older adults maintained strict social distancing measures.
During the post-lockdown period, all infection control
measures gradually eased until the Norwegian govern-
ment removed all statutory measures on 12 February
2022 [47].
Participants
e study population was selected from the HUNT4
70 + database. Detailed sociodemographic and clinical
information, along with assessments by healthcare pro-
fessionals, were collected for each participant [14]. e
fourth wave included 11,675 participants (9,930 from
North Trøndelag and 1,745 from Trondheim), of whom
7,784 completed the questionnaire on social isolation and
fear of COVID-19. We excluded nursing home residents
(n = 866); those who were admitted to a nursing home,
died, or emigrated before March 2019 (n = 143); and
those with insufficient information for the categorisa-
tion of dementia status (n = 202). e excluded group was
older (85 vs. 76 years), had a higher proportion of women
(64% vs. 54%), and had lower education (58% vs. 28%)
than the included group. A total of 10,464 participants, of
whom 1,062 had dementia, contributed with data in the
study period (March 2019 to September 2022, Fig.2).
Analgesics andpsychotropic medication
Information on the type of medication, prescription year
and month, and defined daily doses (DDD) were obtained
from the Norwegian Prescription Database (NorPD),
which provides information on all prescribed medica-
tions dispensed from pharmacies to community-dwelling
individuals in Norway. is ensures information on the
medications and doses collected by participants from
Fig. 1 Study period
Fig. 2 Flow chart, participant inclusion and categorisation
of dementia status
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Ibsenetal. BMC Geriatrics (2025) 25:85
pharmacies, although it does not confirm actual con-
sumption or adherence to the prescribed instructions.
e DDD is the assumed average maintenance dose per
day for a drug used as the main indication in adults.
DDDs are only assigned to medicines with an Anatomi-
cal erapeutic Chemical Classification (ATC) code [53].
Medications were grouped as opioids (N02A), other anal-
gesics (N02B), antipsychotics (N05A), anxiolytics/seda-
tives (N05B and N05C), and antidepressants (N06A).
Dementia
e categorization of dementia was done by two experts
from a diagnostic working group of nine doctors with
extensive scientific and clinical expertise (geriatrics, geri-
atric psychiatry, or neurology), who independently diag-
nosed dementia, mild cognitive impairment (MCI), and
types of dementia using the DSM-5 diagnostic criteria
[2]. During the diagnostic process the experts had access
to all relevant information from the HUNT4 70 + data-
set, such as education, function in activities of daily liv-
ing, neuropsychiatric symptoms, cognitive symptom
debut and course, cognitive tests (the Montreal Cognitive
Assessment (MoCA) scale [34], and the Word List Mem-
ory Task (WLMT) [33], and structured interviews with
the closest family proxy. If no consensus was reached
between the two experts, a third expert was consulted
(for details see: [14]). After the diagnostic process, the
expert group decided to use established terms, specifi-
cally dementia (instead of major neurocognitive disorder),
as defined by the ICD codes [52]. Among the 1,062 par-
ticipants, 60% had Alzheimer’s disease, 6% had vascular
dementia, and 34% had other dementias. For the analysis,
all dementia groups were combined to enhance statistical
power.
Other covariates
Covariates were obtained from the HUNT4 70 + Study
(2017–2019) and data on social isolation and fear of
COVID-19 were collected from the same population
using a postal questionnaire in January 2021. e covari-
ates are briefly described below, and detailed covariate
information is provided in the Supplementary Material.
We included sex (females vs. males), age in 2017 (< 80
years vs. ≥80 years), education (primary/secondary vs.
tertiary, to differentiate between individuals with fewer
or more than 10 years of schooling [25], living situa-
tion (living alone vs. living with someone), comorbidity
(0–1 self-reported diseases vs. 2 + self-reported diseases,
[21], mental health (no mental distress vs. mental dis-
tress, assessed using the CONOR Mental Health Index
(CON-MHI) with 2.15 as the cut-off [43], physical func-
tion (reduced vs. good, using the Short Physical Perfor-
mance battery (SPPB) [37], social isolation (not isolated
vs. isolated [18], and fear related to COVID-19 (low fear
vs. fear, assessed using the Fear of Covid-19 Scale [1, 20]
with 21 points as cut-off [31].
Statistical analysis
Sample characteristics are presented as the means with
standard deviations (SD) or frequencies with percent-
ages. In the statistical analyses, a measure of person-time
was used, where one unit of person-time corresponded
to a 6-month period. Participants who emigrated
(n = 43), were admitted to a nursing home (n = 374) or
died (n = 1,107) during the 42 months study period were
censored and contributed 0.5 units of person-time to the
period when they were censored (Table1).
In the present study, we aimed to investigate whether
there was an increase in the number of participants
obtaining the medications of interest from Norwe-
gian pharmacies (as indicated by prescription fills) and
whether the average dispensed daily dose per person
summarised for each period ( as indicated by the mean
sum DDD per person per period) increased during the
pandemic. us, our investigation of medication pre-
scriptions over time included two sets of analyses. First,
we used Poisson regression to calculate the incidence rate
ratios (IRRs) for prescription fills and the corresponding
incidence proportions (%) over time. Second, to assess
changes in DDDs, we summed the DDDs separately for
each person in each period. e mean sum of DDDs
per person per period was estimated using a multilevel
mixed-effects linear regression model with random inter-
cepts across individuals. Analyses were performed sepa-
rately for each medication group and 95% confidence
intervals (95% CI) were provided for all estimates. We
performed a sensitivity analysis to examine the influ-
ence of missingness on the COVID-19 questionnaire on
our results. Here, we repeated the main analysis only in
participants who had answered the COVID-19 question-
naire. e lockdown period (March–September 2020)
was used as a reference in all regression models, and the
corresponding months before the lockdown (March–Sep-
tember 2019) and after the lockdown (March–September
2021 and March–September 2022) were compared with
the reference period. All regression analyses were per-
formed in two steps: unadjusted and adjusted for age and
educational level. is adjustment was necessary because
the individuals who were censored were older and had
lower education levels than those included throughout
the study period, ensuring comparability across periods.
No sex differences were observed between the censored
participants and those included throughout the study
period.
To assess whether changes in prescription fills
and the mean sum of DDD during the pandemic
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Ibsenetal. BMC Geriatrics (2025) 25:85
Table 1 Number of participants reported from baseline to end of study, including participants censored due to nursing home admission, emigration, or death
¹Persons censored add 0.5 period person time, while those not censored adds 1 person time per period.
All No Dementia Dementia
Periods Persons at start
of each period,
n
Persons
censored
per period, n
Period Person
Time¹ Persons
at start of each
period, n
Persons
censored
per period, n
Period
Person
Time*
Persons
at start of each
period, n
Persons
censored
per period, n
Period
Person
Time*
12.03.19–11.09.19 10,464 178 10,375.0 9,402 99 9,352.5 1,062 79 1,023
12.03.20–11.09.20, Lockdown 10,096 188 10,002.0 9,195 124 9,133.0 901 64 869
12.03.21–11.09.21 9,735 195 9,637.5 8,960 137 8,891.5 775 58 746
12.03.22–11.09.22 9,353 230 9,238.0 8,684 174 8,597.0 669 56 641
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Ibsenetal. BMC Geriatrics (2025) 25:85
differed between people with and without demen-
tia, we repeated the regression analyses, stratified by
dementia status. Second, to explore how other indi-
vidual characteristics potentially affected changes in
prescription fills and the mean sum of DDD, we per-
formed the same analyses stratified by age, sex, edu-
cation, living situation, comorbidity, mental health,
physical function, social isolation, and fear of COVID-
19. The stratified models were adjusted for age and
education (age-stratified analyses were adjusted for
education and education-stratified analyses were
adjusted for age). All analyses were performed using
Stata (version 18.0; [44]. Statistical significance was set
at p < 0.05.
Results
e study sample comprised 10,464 participants. e
mean age as of 1 January 2017, was 76 years (SD: 5.8,
range: 68–100 years); 54% were female and 10% had
dementia. Participant characteristics across dementia
statuses are described in Table2.
A total of 7,248 participants (69%) were prescribed
medications of interest during the study period, with
the following distribution: opioids, 36.2%; other anal-
gesics, 50.3%; anxiolytics/sedatives, 33.9%; antidepres-
sants, 6.9%; and antipsychotics, 3.7% (Table3). People
with dementia were prescribed a higher mean sum of
DDD per person per period than those without demen-
tia, for all medications (Table4). For complete data on
all unadjusted and adjusted changes in prescription fills
and the mean sum DDD between the lockdown and the
pre- and post-periods, we refer to the supplementary
materials (Tables S1–S6). Results from the sensitivity
analyses excluding individuals who did not answer the
COVID-19 questionnaire did not differ from the find-
ings including the entire study sample. In the following
section, we report the models adjusted for age and edu-
cation for the entire sample and the changes stratified
by dementia status.
Opioids
Prescription lls
Opioid prescriptions were higher in 2022 than dur-
ing the lockdown (IRR 1.12, 95% CI 1.03, 1.22) (Fig.3,
TableS1). Analyses stratified by dementia status dem-
onstrated that those without dementia had a higher
rate of opioid prescriptions in 2022 (IRR 1.10, 95%
CI 1.01, 1.20) compared to that during the lockdown
(Fig.4, TableS3). No differences were found between
the lockdown and pre- or post-lockdown periods in
participants with dementia (Fig.5, TableS3).
DDD
No significant differences in the mean sum DDD per per-
son per period for opioids were observed between the
lockdown and pre- or post-lockdown periods (TableS2,
Fig. 6). Analyses stratified by dementia status demon-
strated that those without dementia had higher mean
sum DDD for opioids in 2022 (0.43, 95% CI 0.001, 0.85)
compared to the lockdown (Fig. 7, Table S4), whereas
no differences were found in participants with dementia
(Fig.8, TableS4).
Table 2 Description of the study samplea, across dementia
status
a Variables collected in HUNT4 70+, except social isolation and fear of COVID-19
which were collected through a separate questionnaire in the same population.
1 Comorbidity is dened by ≥2 self-reported diseases.
2 Mental health (CONOR-MHI), range 1-4. The cut-o for mental distress is ≥2.15
3 Physical function (SPPB), range 0-12 points. The cut-o for reduced physical
function is ≤ 8 points
4 Fear of COVID-19, range 7-35. The cut-o for fear of COVID-19 is ≥21 points
Total
N = 10,464
n (%)
No dementia
n = 9,402
n (%)
Dementia
n = 1,062
n (%)
Sex
Female 5,643 (53.9) 5,054 (53.8) 589 (55.5)
Male 4,821 (46.1) 4,348 (46.3) 473 (44.5)
Age, mean (SD) 76.4 (5.8) 75.9 (5.5) 80.4
(6.9)
<80 7,716 (73.7) 7,243 (77.0) 473 (44.5)
≥80 2,748 (26.3) 2,159 (23.0) 589 (55.5)
Education (n= 10,306)
Primary 2,861 (27.8) 2,362 (25.4) 499 (49.0)
Secondary/ Tertiary 7,445 (72.2) 6,925 (74.6) 520 (51.0)
Living situation (n = 10,027)
Living alone 3,362 (33.5) 2,947 (32.3) 415 (46.7)
Living with someone 6,665 (66.5) 6,192 (67.8) 473 (53.3)
Comorbidity¹ (n = 9,260)
0-1 self-reported diseases 5,594 (60.5) 5,184 (61.2) 410 (52.5)
>2 self-reported diseases 3,658 (39.5) 3,287 (38.8) 371 (57.5)
Mental health² (n = 8,826)
Mental distress 501 (5.7) 401 (5.0) 100 (13.8)
No mental distress 8,325 (94.3) 7,701 (95.1) 624 (86.2)
Physical function³ (n = 10,308)
Reduced physical func-
tion 2,595 (25.2) 1,950 (21.0) 645 (63.1)
Good physical function 7,713 (74.8) 7,335 (79.0) 378 (37.0)
Social isolation (n = 7,643)
Isolated 2,920 (38.2) 2,742 (37.9) 178 (44.3)
Not isolated 4,723 (61.8) 4,499 (62.1) 224 (55.7)
Fear of COVID-19⁴ (n = 7,339)
Fear 1,676 (22.8) 1,554 (22.3) 122 (33.4)
Low fear 5,663 (77.2) 5,420 (77.7) 243 (66.6)
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Ibsenetal. BMC Geriatrics (2025) 25:85
Table 3 Number (%) of persons with prescription fills for analgesics¹ and psychotropics² during the pre-lockdown, lockdown and post-lockdown periods, across dementia status³
1 Analgesics: Opioids and other analgesics.
2 Psychotropics: anxiolytics/sedatives, antidepressants, and antipsychotics.
3 Dementia status is divided in No Dementia diagnosis (No Dem) and a diagnosis of Dementia (Dem).
Psychotropic medication Persons at start
of each period Opioids Other analgesics Anxiolytics/ sedatives Antidepressants Antipsychotics
Total number of persons
with prescription fills, n (%) 10,464 3,793 (36.2) 5,358 (50.3) 3,545 (33.9) 1,764 (6.9) 388 (3.7)
Dementia status
N (%) No Dem Dem No Dem Dem No Dem Dem No Dem Dem No Dem Dem No Dem Dem
12.03.19–11.09.19 9,402 1,062 1,024 (10.9) 178 (16.8) 2,043 (21.7) 364 (34.3) 1,809 (19.2) 287 (27.0) 845 (9.0) 218 (20.5) 116 (1.2) 36 (3.4)
12.03.20–11.09.20, Lockdown 9,195 901 965 (10.5) 127 (14.1) 2,160 (23.5) 344 (38.2) 1,831 (19.9) 232 (25.7) 857 (9.3) 195 (21.6) 117 (1.3) 29 (3.2)
12.03.21–11.09.21 8,960 775 981 (10.9) 121 (15.6) 2,257 (25.2) 288 (37.2) 1,806 (20.2) 201 (25.9) 923 (10.3) 149 (19.2) 134 (1.5) 26 (3.4)
12.03.22–11.09.22 8,684 669 1,009 (11.6) 103 (15.4) 2,313 (26.6) 237 (35.4) 1,809 (20.8) 159 (23.8) 927 (10.7) 121 (18.4) 123 (1.4) 28 (4.2)
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Ibsenetal. BMC Geriatrics (2025) 25:85
Other analgesics
Prescription lls
e rate of prescriptions for other analgesics was lower
in 2019 (IRR 0.92, 95% CI 0.87, 0.98) and higher in 2021
(IRR 1.06, 95% CI 1.00,1.12), and 2022 (IRR 1.12, 95%
CI 1.06, 1.18) compared to that during the lockdown
(Fig.3, TableS1). Analyses stratified by dementia status
demonstrated that those without dementia had a lower
rate of prescriptions for other analgesics in 2019 (IRR
0.93, 95% CI 0.88, 0.98) and higher rates in 2021 (IRR
Table 4 Mean sum of defined daily dose (DDD) per person per period for analgesics¹ and psychotropics² during the pre-lockdown,
lockdown, and post-lockdown periods, across dementia status
a The whole study sample for the whole study period
¹Analgesics: Opioids and other analgesics
² Psychotropics: anxiolytics/sedatives, antidepressants, and antipsychotics
³Dementia status is divided in No Dementia diagnosis (No Dem) and a diagnosis of Dementia (Dem)
Psychotropic medication Opioids Other analgesics Anxiolytics/ sedatives Antidepressants Antipsychotics
Mean sum DDD (SD) per per-
son per perioda3.8 (21.0) 19.5 (44.7) 22.7 (60.4) 17.3 (65.7) 0.7 (10.2)
Dementia status² No Dem Dem No Dem Dem No Dem Dem No Dem Dem No Dem Dem
12.03.19–11.09.19 3.7 (20.4) 6.8 (26.3) 15.3 (39.2) 34.9 (63.8) 20.7 (57.6) 32.3 (73.7) 14.3 (61.0) 37.1 (96.9) 0.5 (9.6) 1.8 (14.8)
12.03.20- 11.09.20, Lockdown 3.5 (20.3) 6.7 (30.9) 16.6 (39.7) 36.8 (63.2) 21.4 (59.2) 28.2 (64.1) 14.6 (60.8) 35.7 (87.7) 0.5 (9.4) 2.1 (16.9)
12.03.21–11.09.21 3.6 (20.7) 6.8 (28.1) 18.9 (43.8) 38.4 (66.7) 22.2 (59.7) 28.4 (69.1) 16.5 (65.2) 31.2 (81.1) 0.5 (8.8) 2.0 (17.7)
12.03.22–11.09.22 3.8 (20.4) 5.8 (25.7) 20.7 (45.6) 35.8 (64.3) 23.0 (60.4) 27.4 (73.5) 16.7 (64.0) 30.8 (85.7) 0.6 (10.6) 1.9 (14.5)
Fig. 3 Age and education adjusted incidence proportion of prescription fills (%) with 95% confidence intervals (95% CI), calculated using Poisson
regression analysis
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Page 9 of 17
Ibsenetal. BMC Geriatrics (2025) 25:85
1.07, 95% CI 1.01, 1.14) and 2022 (IRR 1.14, 95% CI
1.07, 1.21) compared to the lockdown (Fig.4, TableS3),
whereas no differences were observed in participants
with dementia (Fig.5, TableS3).
DDD
e mean sum of DDD per person per period for other
analgesics was lower in 2019 (− 1.37, 95% CI 2.26,
0.48) and higher in 2021 (1.92, 95% CI 1.02, 2.82) and
2022 (3.50, 95% CI 2.59, 4.41) compared to that dur-
ing the lockdown (Fig.6, TableS2). Analyses stratified
by dementia status demonstrated that for participants
without dementia, the mean sum DDD per person
per period was lower in 2019 (− 1.32, 95% CI − 2.20,
− 0.44) and higher in 2021 (1.88, 95% CI 0.99, 2.76)
and 2022 (3.65, 95% CI 2.76, 4.54) compared to that
during the lockdown (Fig.7, TableS4). No differences
were observed between the lockdown and pre- or post-
lockdown periods in participants with dementia (Fig.8,
TableS4).
Anxiolytics/sedatives
Prescription lls
No significant differences in the prescription rates were
observed for anxiolytics/sedatives between the lockdown
and pre- or post-lockdown periods (Fig. 3, Table S1).
No differences were found in the analyses stratified by
dementia status (Figs.4and 5, TableS3).
DDD
e mean sum DDD for anxiolytics/sedatives was higher
in 2022 (1.16, 95% CI 0.03, 2.29) compared to that dur-
ing the lockdown (Fig. 6, Table S2). Analyses stratified
by dementia status did not demonstrate any differences
between the lockdown and pre- or post-lockdown peri-
ods in participants with or without dementia (Figs.7and
8, TableS4).
Antidepressants
Prescription lls
e rate of antidepressant prescriptions was higher
in 2022 (IRR 1.11, 95% CI 1.01, 1.22) compared to that
Fig. 4 Age and education adjusted incidence proportion of prescription fills (%) with 95% confidence intervals (95% CI), for participants
without dementia, calculated using Poisson regression analysis
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Page 10 of 17
Ibsenetal. BMC Geriatrics (2025) 25:85
during the lockdown period for participants without
dementia (Fig.4, TableS3). No differences were observed
between the lockdown and pre- or post-lockdown peri-
ods in participants with dementia (Fig.5, TableS3).
DDD
No differences in the mean sum of DDD per person per
period for antidepressants were observed between the
lockdown and pre- or post-lockdown periods (Fig. 6,
TableS2). Analyses stratified by dementia status demon-
strated that the mean sum DDD for antidepressants was
higher in 2021 (1.32, 95% CI 0.10, 2.53) and 2022 (1.31,
95% CI 0.09, 2.54) compared to that during the lockdown
for participants without dementia (Fig. 7, Table S4).
No differences were observed between the lockdown
and pre- or post-lockdown periods in participants with
dementia (Fig.8, TableS4).
Antipsychotics
Prescription lls
No differences in the prescription rates of antipsychot-
ics were observed before, during, or after the lockdown
(Fig.3, TableS1). Analyses stratified by dementia status
and other covariates did not demonstrate any differences
in the rate of antipsychotic prescriptions between partici-
pants with and without dementia (Fig.4/5, TableS3).
DDD
No differences in the mean sum of the DDD per person
per period for antipsychotics were observed before, dur-
ing, or after the lockdown (Fig. 6, Table S2). Analyses
stratified by dementia status did not demonstrate any dif-
ferences in the mean sum of the DDD for antipsychotics
for those with or without dementia (Fig.7/8, TableS4).
Other covariates
Our secondary aim was to explore how changes in pre-
scriptions were associated with individual, social, and
clinical characteristics, such as age, sex, education,
comorbidity, living situation, mental health and physical
function, social isolation, and fear of COVID-19 during
the pandemic. Findings from the stratified analysis are
described in the Supplementary Materials and Tables S5
and S6. In short, an increase in prescription fills and/or
Fig. 5 Age and education adjusted incidence proportion of prescription fills (%) with 95% confidence intervals (95% CI), for participants
with dementia, calculated using Poisson regression analysis
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Page 11 of 17
Ibsenetal. BMC Geriatrics (2025) 25:85
mean sum DDD of opioids, other analgesics, anxiolyt-
ics/sedatives, and antidepressants between the lockdown
and 2022 was found among the younger and healthier
parts of the study sample, for example < 80 years of age,
no comorbidity, no mental distress, good physical func-
tion, low fear of COVID-19, and no social isolation
during COVID. For other analgesics, the change in pre-
scriptions (lower in 2019 and higher in 2021 and 2022
compared with the lockdown) included fewer healthy
members of all dichotomous groups, except those with
mental distress. For anxiolytics/sedatives, we found sex
differences, where males experienced an increase in 2022
compared to the lockdown period, whereas no changes
were observed in females. An increase in the prescription
fills of anxiolytics/sedatives was also observed in patients
with comorbidities in 2022 (Tables S5 and S6).
Discussion
Two years after the Norwegian lockdown in March 2020,
there was an overall increase in the number of older
adults prescribed opioids and other analgesics, alongside
an increase in the mean sum DDD of other analgesics
and anxiolytics/sedatives compared with the lockdown
period. For other analgesics, the increase began during
the pre-pandemic period in 2019. Differences based on
dementia status showed that increases in prescription
fills and the mean sum of DDD occurred only in par-
ticipants without dementia, whereas no differences were
observed in participants with dementia. Our analyses
revealed that increases in prescription fills and the mean
sum DDD were primarily observed among the youngest
old and healthier participants in the study sample.
Over the past decade, opioid use has increased world-
wide [15]. However, a study examining opioid utilisa-
tion among older adults in Nordic countries from 2009
to 2018 revealed a decrease in all countries, except Ice-
land, where opioid use remained stable [15]. Our obser-
vation of an increase in opioid prescriptions 2 years after
the pandemic indicates an increase in opioid utilisation
in the older population, although we cannot be certain
that this can be causally attributed to the pandemic.
e increase in opioid prescriptions could be linked to
the reduction or closure of non-pharmacological inter-
ventions such as physiotherapy and exercise facilities,
Fig. 6 Age and education adjusted mean sum of defined daily dose (DDD) per person per period with 95% confidence intervals (95% CI),
calculated using multilevel mixed-effects linear regression
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Page 12 of 17
Ibsenetal. BMC Geriatrics (2025) 25:85
which are commonly used for pain management follow-
ing the introduction of control measures [46, 50]. Our
recent finding that older adults increased their contact
with their general practitioners during the pandemic
when other healthcare services were reduced or closed
[18], might suggest an increased reliance on medica-
tion-based pain management, potentially contributing
to a greater prescription of opioids. However, our find-
ings contrast with those of a study from the USA, which
found a decrease in opioid use during the first year of the
pandemic in older adults despite a 30% reduction in non-
pharmacological interventions [27]. A plausible explana-
tion for these differences is that, unlike the USA, Norway
had full national coverage for telephone and video con-
sultations with healthcare services during the pandemic
[49], which enabled the prescription of opioids to older
adults, if necessary.
For other analgesics, the observed increase may be
related to the recommendation to use such medica-
tions to manage COVID-19 symptoms during and
after an infection [12]. Whether the increase observed
between 2019 and the lockdown period was a result
of the pandemic or whether the prescriptions for other
analgesics had already risen before the COVID-19 out-
break remains unknown. However, other analgesics may
be substitutes for non-pharmacological interventions
for pain treatment. Contrary to expectations, we did not
find any association between comorbidities or reduced
physical function and prescriptions of opioids or other
analgesics.
Our findings demonstrating an increase in the mean
sum DDD for anxiolytics/sedatives during the COVID-
19 pandemic, indicating an increase in treatment inten-
sity, corresponds with earlier research conducted among
older adults [7, 36, 48]. However, in contrast to previous
studies, our results did not reveal any changes during
the first year after the lockdown but showed an increase
in the mean sum of DDD of anxiolytics/sedatives over
a 2-year period. is suggests long-term deterioration
linked to psychological stress resulting from the control
measures imposed during the COVID-19 pandemic,
where anxiolytics/sedatives may be seen as a proxy for
the intensity of anxiety and sleep disorders among those
who have already experienced such psychological stress.
Fig. 7 Age and education adjusted mean sum of defined daily dose (DDD) per person per period with 95% confidence intervals (95% CI)
for participants without dementia, calculated using multilevel mixed-effects linear regression
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Page 13 of 17
Ibsenetal. BMC Geriatrics (2025) 25:85
Furthermore, we found that participants with comor-
bidities had a higher mean sum of DDD for anxiolytics/
sedatives in 2022 than during the lockdown period. is
increase may be related to heightened anxiety about con-
tracting COVID-19, as individuals with comorbidities are
considered particularly vulnerable to severe health con-
sequences [16]. ere is also a concern that the observed
increase in the mean sum DDD may be linked to the use
of larger pack sizes, introduced to reduce pharmacy visits
during the pandemic. While this might explain changes
for other analgesics, though we have found no evidence
to support this, it is less likely to account for the increase
in DDD for anxiolytics/ sedatives, which emerged two
years after the COVID-19 outbreak. At this point, con-
tainment measures had been lifted, reducing the likeli-
hood that larger pack sizes were being used as a strategy
to limit pharmacy visits.
It has previously been suggested that an increase in
social isolation and fear of COVID-19 infection may have
contributed to an increase in use of benzodiazepines
(sedatives) during the pandemic [36]. However, we did
not find any such an association. We found that males
had a higher rate of prescription fills and mean sum DDD
of anxiolytics/sedatives in 2022 than during the lock-
down period, whereas no differences between the lock-
down and pre- or post-lockdown periods were observed
for females. is finding can be explained by the fact that
women are more frequent users of such medications than
males [6], leading to a less pronounced increase among
females. Furthermore, research during the pandemic
has shown that older males had less contact with others
through screen-based media than do females [9], and
additional studies have indicated that those who did not
use technology to stay connected experienced higher lev-
els of psychological stress [5, 29].
In our study, the increase in prescriptions of opioids,
other analgesics, and anxiolytics/sedatives was primarily
observed in the “healthiest groups”, that is, those younger
than 80 years, with high education, living with someone,
no comorbidities, no mental distress, high physical func-
tion, no social isolation during COVID, and low fear of
COVID-19. ere were only a few exceptions, such as
an increase in opioid prescriptions among participants
aged ≥ 80 years and those living alone, and an increase
Fig. 8 Age and education adjusted mean sum of defined daily dose (DDD) per person per period with 95% confidence intervals (95% CI)
for participants with dementia, calculated using multilevel mixed-effects linear regression
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Page 14 of 17
Ibsenetal. BMC Geriatrics (2025) 25:85
in prescriptions of other analgesics among those living
alone and those experiencing fear of COVID-19. One
reason for this may be that the “healthiest” represent
the largest groups in the analysis. However, it is possi-
ble that this group finds it more challenging than more
vulnerable groups when their quality of life is compro-
mised. Our findings also suggest that individuals with
more resources are more likely to obtain the medica-
tions they need, which aligns with trends observed in
earlier research [17]. Previous research has indicated that
vulnerable groups such as those with dementia, comor-
bidities, reduced mental health, and reduced physical
function tend to use more medication than healthy indi-
viduals [8, 38], possibly resulting in a less pronounced
increase in medication use among these groups. Fur-
thermore, vulnerable groups may already receive more
(specialised) care and are more easily offered alternative
treatment options within that care, making it unneces-
sary to start or increase medication.
We noticed some exceptions in the study, with higher
opioid prescription rates among individuals aged ≥ 80
years and those living alone. is may partly be explained
by the oldest old experiencing higher levels of pain than
their younger counterparts and requiring additional
assistance to implement non-pharmacological pain man-
agement strategies. For this age group, activities such as
walking or exercising independently may be challenging,
potentially resulting in increased reliance on medication
for pain relief. In a prior study on healthcare services, we
found that older adults aged ≥ 80 years without dementia
experienced increased hospitalizations after the COVID-
19 lockdown compared to before the lockdown, sug-
gesting significant health declines during the pandemic
[19], likely resulting in a greater need for pain medica-
tion. Similarly, those living alone may require more opi-
oids and other analgesics for pain management, as they
likely face challenges initiating physical activity indepen-
dently, contributing to reduced physical function and
greater pain. Moreover, while fear of COVID-19 might
be expected to increase psychotropic medication use, an
increase in analgesic use could suggest that fear manifests
as somatic symptoms. is aligns with evidence link-
ing fear and health anxiety to heightened somatic com-
plaints, such as pain or other physical discomforts [23].
For all medications analysed, participants with demen-
tia had a higher number of prescriptions than those with-
out dementia during the study period. Studies from other
countries have indicated an increase in the prescription
of psychotropic medications for people with dementia
during the initial months of the pandemic [26, 32], which
persisted until 2021 [26, 30, 45]. However, while those
without dementia experienced an increase in prescrip-
tions of opioids, other analgesics, and antidepressants,
we did not observe any change in prescriptions for those
with dementia. Our findings may have been different if
people with dementia admitted to nursing homes were
included in the study sample, as they represent individu-
als with more severe dementia and may be more vulner-
able to the pandemic’s impact on medication use [26,
30]. However, our findings are consistent with previous
Norwegian findings [13], suggesting that the pandemic
had no overall effect on the use of analgesics or psycho-
tropic medications among home-dwelling people with
dementia. Furthermore, our recent study on healthcare
services found that, although people with dementia expe-
rienced a temporary reduction in healthcare services
during the lockdown, these services were restored within
6–12 months. Additionally, home-dwelling individuals
with dementia experienced a similar increase in general
practitioner visits during the lockdown and subsequent
months as other older adults, ensuring equal opportuni-
ties for new prescriptions [19]. However, we cannot know
whether people with dementia were prescribed drugs
which they did not collect from a pharmacy, as we only
have information on dispensed prescriptions. Neverthe-
less, the availability of multi-dose dispensing systems and
home care services should help mitigate these challenges
and ensure that people with dementia received appropri-
ate medical care during the pandemic.
Strengths andlimitations
e strength of this study lies in its use of individual
longitudinal data from a large population-based survey
sample linked to the unique national registry data on
medication prescriptions. Because data from the HUNT
Study were collected just before the pandemic exposure,
they were not affected by recall bias. However, data on
social isolation and fear of COVID-19 were gathered 1
year after the COVID-19 outbreak, potentially intro-
ducing memory-related biases. All participants were
residents of the central region of Norway, which may not
be representative of the population in other regions of
Norway or internationally. Furthermore, the study sam-
ple predominantly comprised individuals of Norwegian
ethnicity, which limited the generalisability of the results
to other ethnic groups. In HUNT4, diagnostic codes and
health care use were similar between participants and
invitees, but participants aged > 80 years had more gen-
eral practice visits, while non-participants more often
used home nursing [3]. Although the study included
a significant number of participants diagnosed with
dementia, they accounted for only 10% of the sample,
which possibly reduced the ability to detect significant
differences over time in the dementia group. e lack of
consideration for incident cases of dementia during the
study period may limit the study’s ability to fully capture
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Page 15 of 17
Ibsenetal. BMC Geriatrics (2025) 25:85
differences in medication between those with and with-
out dementia over time. Additionally, individuals with
dementia who were admitted to nursing homes were
censored from the study due to the unavailability of pre-
scription data in such settings. is exclusion may have
introduced a bias by systematically removing individuals
requiring higher medication use, for example, to man-
age neuropsychiatric symptoms. Misclassification aris-
ing from the inclusion of incident dementia cases in the
“no dementia” group would most likely bias the observed
differences towards null, hence it is possible that the
observed differences are smaller than what would be
expected had incident dementia cases been captured.
Conclusion
Two years after the COVID-19 lockdown, we found an
increase in the prescription of analgesics and psycho-
tropic medications in older adults in Norway, which may
indicate a long-term decline in the health of older adults
after the COVID-19 outbreak. Hence, our results imply
that a national stressor such as a pandemic may place
older adults at risk of increased medication use during
and after the event. We found no impact of the pandemic
on medication prescriptions among home-dwelling peo-
ple with dementia, suggesting that vulnerable individu-
als in high-income countries, such as Norway, appear
to have been adequately cared for. However, our find-
ings suggest that the pandemic may have rendered oth-
erwise healthy older adults more vulnerable, leading to
increased medication use with the potential risk of inap-
propriate use. ese findings are important for improv-
ing health policies to address future major stressors that
impair social interactions and threaten mental health.
Additionally, these findings emphasise the importance of
reassessing medication prescriptions in older adults after
the pandemic.
Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s12877- 025- 05745-8.
Additional file 1.
Acknowledgements
HUNT is a collaborative project between the HUNT Research Centre at the
Faculty of Medicine and Health Sciences, Norwegian University of Science
and Technology, the Trøndelag County Council, the Central Norway Regional
Health Authority and the Norwegian Institute of Public Health. We would like
to thank everyone who participated in HUNT 70+ for their valuable contribu-
tions to this research.
Authors’ contributions
GS led the study project and is responsible for the concept and design of
the study, together with BHS, SB and TLI. EZ, BHS and TLI conducted the
analysis. TLI, EZ, BHS, SB, DG, GL, HL, SEM, ROV, AMMR, and GS contributed
to interpreting the data. TLI drafted the paper, with substantially contribu-
tions from all the authors in revising the drafted work. All authors read and
approved the final manuscript
Funding
This study was supported by the Norwegian Health Association (grant no.
22687).
Data availability
The data supporting the findings of this study are available from the HUNT
database and the Norwegian Prescription Database via Helsedata. However,
due to licensing restrictions, these data are not publicly accessible. Data may
be obtained from the authors upon reasonable request, pending approval
from the HUNT database and Helsedata.no
Declarations
Ethics approval and consent to participate
This study received approval from the Regional Committee for Medical and
Health Research Ethics, Norway (REK Southeast B, reference number 182575).
All procedures followed REK’s guidelines, in alignment with the principles of
the Declaration of Helsinki. This study is part of a larger project registered at
ClinicalTrials.gov (ID: NCT 04792086). Informed written consent was obtained
from all participants in the HUNT4 70+ study. For participants with reduced
capacity to consent, their next of kin provided consent on their behalf. The
consent form clearly stated that collected data may be linked to other regis-
tries for the purpose of conducting approved research projects, as was done
in this study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1 The Norwegian National Centre for Ageing and Health (Ageing and Health),
Vestfold Hospital Trust, 2136, N- 3103, Tønsberg, Norway. 2 Research centre
for Age-related Functional Decline and Disease (AFS), Innlandet Hospital
Trust, Ottestad, Norway. 3 Department of Primary and Community Care,
Radboudum Alzheimer Center, Research Institute for Medical Innovation,
Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.
4 Division of Psychiatry, University College London, London, UK. 5 Camden
and Islington NHS Foundation Trust, London, UK. 6 Health Services Research
Unit, Akershus University Hospital, Oslo, Norway. 7 Institute of Clinical Medicine,
University of Oslo, Oslo, Norway. 8 Centre for Research on Pandemics & Society
(PANSOC), at OsloMet - Oslo Metropolitan University, Oslo, Norway. 9 Faculty
of Health Sciences and Social Care, Molde University College, Molde, Norway.
10 Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.
11 Department of Physical Health and Ageing, Norwegian Institute of Public
Health, Oslo, Norway. 12 University of Groningen, Groningen, The Netherlands.
13 Department of Psychiatry, University Medical Center Groningen, Groningen,
The Netherlands. 14 Department of Geriatric Medicine, Oslo University Hospital,
Oslo, Norway. 15 Institute of Clinical Medicine, Faculty of Medicine, University
of Oslo, Oslo, Norway.
Received: 28 October 2024 Accepted: 28 January 2025
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