Geriatric Patients

Cannabinoids show mixed results: megestrol acetate was more effective than dronabinol; nabilone 0,5 mg showed no superiority over placebo, but at double the dose (1,0 mg after 6 weeks) a significant increase in caloric intake; THC showed weight gain ≥10% in 17,6% of patients and improved appetite at 2,5 mg doses.

Systematic review on cannabinoids in tumor-associated anorexia in older adults; k=6 studies (5 RCTs, 1 prospective study), n=869 participants (2002-2019). Megestrol 800 mg/d more effective than dronabinol 2,5 mg 2×/d for appetite. Nabilone 1,0 mg/d over 8 weeks: significant increase in caloric intake and carbohydrate consumption vs. placebo. THC 5-10 mg/d: weight gain ≥10% in 17,6% of patients, improved chemosensory function and appetite with THC 2,5 mg vs. placebo. No serious adverse events reported.

Cannabinoids were predominantly safe in those over 50 years of age, but the THC:CBD combination showed more serious adverse events and higher discontinuation rates.

SR and meta-analysis (k=38 studies, N=2.341, mean age 63,2 years); THC: incidence rate (IR) of all ADRs 122,18 (95%-CI 38,23–253,56), serious ADRs IR=0; CBD: IR of all ADRs 111,91 (95%-CI 1,24–495,93), no serious ADRs; THC:CBD combination: serious ADRs IR 21,32 (95%-CI 0,18–93,26) — cannabinoids overall well tolerated in adults >50 years.

Dronabinol reduced agitation in Alzheimer's dementia significantly more than placebo on the Pittsburgh Agitation Scale (primary endpoint, p = 0.015), but was not significant on the NPI-C A/A (p = 0.094).

n=75 Alzheimer's patients with agitation (NPI-C A/A ≥4), randomized double-blind placebo-controlled; dronabinol (THC) up to 10 mg/day vs. placebo over 3 weeks (5 academic centers, USA). Pittsburgh Agitation Scale (PAS): significantly greater decrease under dronabinol (difference –0,74/week, SE 0,3, p=0,015, effect size 0,53). NPI-C A/A difference –1,26 (SE 0,67, p=0,094). No increased intoxication; somnolence was the only significant adverse effect. Adjunctive dronabinol safe and clinically effective for agitation in Alzheimer's dementia.

Mini-Mental State Exam total score was significantly higher in the cannabis group than in the placebo group.

Phase 2 RCT over 26 weeks in Alzheimer's dementia patients (60–80 years), THC-CBD extract (0.350 mg THC + 0.245 mg CBD daily) vs. placebo. MMSE score significantly higher in the cannabis group (p-value not reported, mixed model analysis). No significant differences in secondary outcomes or adverse events. Longest available cannabinoid study in AD patients.

No significant differences between placebo and cannabinoid medicine for behaviour, quality of life or pain, except for a decrease in agitation at the end of treatment in favour of the cannabinoid medicine.

n=21 dementia patients in nursing homes (77% female, mean age 85 years), 18-week RCT THC:CBD 3:2 vs. placebo; no significant differences in BPSD, QoL or pain except for a reduction in agitation at end of treatment in favour of CBM. Qualitative data: improved relaxation/sleep in some individuals. Post-hoc estimate: n=50 required for NPI sensitivity. Minimal side effects, medication appeared safe.

CBM showed no statistically significant difference in caloric intake compared to placebo (10 kcal difference, CI: -55-75 kcal).

Triple-blind RCT (n=17, ≥65 years with loss of appetite), 2×8,1 mg THC + 7,5 mg CBD vs. placebo (cross-over design); no significant difference in caloric intake (MD=10 kcal, 95% CI: -55 to +75 kcal, p>0,05). All possibly-associated adverse events (n=16) mild and transient; no serious adverse events.

Medical cannabis reduced pain and improved general condition in the majority of older patients with an acceptable side effect profile.

Prospective cohort ≥65 years (n=2.736, age 74,5±7,5 years), medical cannabis over 6 months; pain reduction from median 8/10 to 4/10, 93,7% reported improvement. Most common side effects: dizziness (9,7%), dry mouth (7,1%). 18,1% reduced or stopped opioids.

52,5% of patients achieved pain relief of more than 30%, 10% of more than 50%; approximately four symptoms or side effects from previous treatment were positively affected.

Retrospective analysis on dronabinol in geriatric pain and palliative care patients; practical experience on tolerability and symptom control in a vulnerable population, n not specified.

Medical cannabis did not lead to a deterioration in ADL functionality, but showed adverse events in 36% of patients.

Prospective study ≥65 years (n=119, age 79,3±8,5, 62,2% female), cannabis treatment over 6 months; ADL score remained stable (4,4±1,8 vs. 4,5±1,8, p=0,27), IADL improved (4,1±2,6 vs. 4,7±3,0, p=0,02). 36,1% adverse events, 1,7% required medical intervention.

THC:CBD cannabis extract showed significant reduction in agitation, apathy, irritability, sleep disorders and eating disorders (p<0.0001) as well as a decrease in aggressive behaviour and cognitive impairment in 45% of patients.

n=30 Alzheimer's patients (65–90 years), Bedrocan® (THC22%:CBD0.5%) twice daily for 12 weeks; NPI-Q reduction in agitation/apathy/irritability/sleep-/eating disorders (p<0.0001), CMAI reduction in aggressive behaviours (p<0.0001), MMSE improvement in cognitive impairment in 45% (p<0.0001). Limitations: small cohort, no control group, self-administered questionnaires.

In an 85-year-old patient with dementia with Lewy bodies, THC tincture led to rapid improvement of agitation after multiple antipsychotics had failed.

Single case report of an 85-year-old man with Lewy body dementia and treatment-refractory agitation. After failure of multiple antipsychotic regimens in outpatient and inpatient settings, THC tincture led to rapid behavioral improvement and discharge home. Discusses challenges of THC prescribing in geriatric dementia patients.

The evidence for the benefit of cannabinoids in older patients is overall low, while the risk of adverse effects (cognitive, cardiovascular, gait safety) is classified as significant.

Narrative review on medical cannabis in older patients; evidence for symptom relief (chronic pain, sleep disorders, cancer symptoms) sparse overall, almost all study participants <60 years. Significant concerns regarding cognitive, cardiovascular and fall risks in older adults. Recommendation: individualized benefit-risk assessment and shared decision-making.

Narrative review on medical cannabis in older adults; potential therapeutic effects for chronic pain, insomnia, anxiety/depression, dementia, nausea/vomiting, but evidence inconsistent and mostly based on self-reports/uncontrolled studies. Cannabis generally well tolerated, but neurocognitive, psychiatric and cardiovascular risks reported in limited studies. Call for more rigorous research on safety and efficacy.