New research suggests that marijuana can bring tranquility to late-stage Alzheimer’s patients tormented by bad memories or memory loss.
During our residency training in psychiatry at the Boston VA medical center between 2017 and 2021, we witnessed an arresting trend. Cannabis had been legal in Massachusetts for nearly a decade, but seemingly overnight many of the center’s elderly, Vietnam veteran patients started to declare their deep allegiance to cannabis use.
Maybe it took a decade for them to get hooked on weed, or perhaps it took that long for pot smokers to feel comfortable coming out of the closet. Whatever the case, the more we asked, the more we realized that our older patients were using cannabis, and they were using it a lot. They were hardly alone. According to data from the National Survey on Drug Use and Health, cannabis use among Americans over 65 increased from 0.4% in 2006 to 4.2% in 2018.
The more we asked, the more we realized that our older patients were using cannabis, and they were using it a lot.
Like other older adults whose cannabis use has been documented, our patients were more likely to turn to it for medicinal purposes, such as treating pain, insomnia or psychiatric symptoms, than for recreation. They used cannabis in many forms—as salves to soothe arthritis pain, tinctures to help with difficulty falling asleep, joints to relieve the stress of chronic PTSD and edibles to heal the anxiety of day-to-day life.
Our clinical training had given us skills for treating chemical dependence. We had psychotherapeutic methods to address addictive behaviors, medications to decrease cravings. But we found ourselves in a difficult position. How were we to discuss the risks and possible benefits of cannabis with an elderly patient population that held such strong beliefs about it, largely based on anecdotes about how it could treat rare diseases or improve quality of life?
Cannabis is a Schedule I substance according to federal law, which means that, by definition, it has no currently accepted medical use and a high potential for abuse. Other examples of Schedule I substances include heroin and LSD. Because of this classification, cannabis remains difficult to study, and there is no definitive resource to inform a doctor’s clinical approach to its use.
To bridge this knowledge gap, we took a deep dive into the medical literature, surveying the available evidence regarding the safety and efficacy of cannabis use in the elderly. We ultimately published a paper in the Harvard Review of Psychiatry, highlighting many areas of concern, including cannabis’s potential to interact with commonly prescribed medications, such as the blood thinning medication warfarin; its association with an increased risk of injuries and motor vehicle crashes; and its potential to impair cognition, specifically attention, memory, executive function and psychomotor function.
Recent research suggests that cannabis may help to relieve agitation by regulating neurotransmitters, reducing brain inflammation and improving circadian rhythm disturbances seen in dementia.
Our research led us to conclude that older adults should use cannabis with caution. But it didn’t lead us to dismiss its usefulness out of hand. In fact, we learned of one very promising application for the substance.
One of our teaching institutions, McLean Hospital, was studying a pharmaceutical-grade version of cannabis called Marinol (dronabinol in its generic form) to treat agitation precipitated by advancing dementia. Marinol could possibly have a calming and soothing effect without many of the risks carried by pharmaceuticals typically used in patients with end-stage major neurocognitive disorders.
We felt a personal connection to this research. Both of our grandmothers are survivors of the Holocaust, and during the pandemic, we compared stories about their faltering health and declining memories. During this period, Aaron’s 96-year-old grandmother, Marian Miklin, a very stoic personality throughout her life, began to display the same kind of severely agitated behavior that we had studied so meticulously during our geriatric psychiatry fellowships.
Most notable were Mrs. Miklin’s flashbacks. In the final months of her life, she began reliving unimaginably painful memories from Auschwitz and the Nazi labor camp called Starachowice—memories she had suppressed for nearly 80 years. She would yell out for her parents and siblings who were killed in the early 1940s, and she would confuse her medical team and family members for Nazis. Most traumatizing was that she confused her phlebotomist with the notorious “Dr. Mengele,” who had tortured her at Auschwitz, begging him to stop taking her blood. Her condition seemed unresponsive to commonly prescribed medications for dementia, and Aaron’s family wondered: Could cannabis help her?
Approximately 6.5 million Americans, or 1 in 9 people aged 65 and older, are living with Alzheimer’s dementia. Agitation, aggression, wandering, delusions, hallucinations, mood disturbances and repetitive vocalizations are very common symptoms as the disease progresses. There are no FDA-approved pharmaceuticals to treat the condition, so when behavioral techniques fail, doctors use off-label medications such as antidepressants, mood stabilizers or antipsychotics. Antipsychotics become necessary when the patient risks harming themselves or others due to the severity of the agitation, but they are only modestly effective and carry a black box warning for increasing the risk of death in this population.
Recent research suggests that cannabis may help to relieve agitation by regulating neurotransmitters, reducing brain inflammation and improving circadian rhythm disturbances seen in dementia. It is thought that cannabis binds with receptors located in the same regions of the brain implicated in dementia agitation. A study in mice further found that THC (the major psychoactive component in cannabis) may prevent the harmful plaques associated with Alzheimer’s from accumulating between neurons. Further research may yet determine whether cannabis has the potential not only to treat Alzheimer’s symptoms but to halt the disease’s progression.
Mrs. Miklin’s family members scoured the internet for answers and happened upon an article detailing the original impetus behind the clinical trials of Marinol at McLean Hospital. The Spier family in Massachusetts had gone through a remarkably similar ordeal when their family’s patriarch, Alex Spier—also a Holocaust survivor—had dementia. They found that cannabis edibles were the only thing that calmed Mr. Spier when he relived his Holocaust trauma. The Spiers’ family foundation funded the Marinol study with the hope that others might benefit from the treatment.
After consulting with the Spier family, Mrs. Miklin’s family decided to give cannabis a shot. Marinol was out of the question because of cost and access, so the family resorted to sourcing cannabis through one of Denver’s many dispensaries. After reviewing dosing strategies used in clinical trials and speaking at length with a local Denver budtender, under Aaron’s direction, they administered a small dose of marijuana in dissolving-strip form. Within minutes, her flashbacks stopped. Regular dosing allowed for the final phase of her life to be peaceful.
There is still much to learn about how cannabis may be safely incorporated into the treatment of dementia patients. Dosing protocols haven’t been established and must be carefully calibrated to avoid delirium, seizures, falls or other dangerous outcomes. Marinol, the FDA-approved formulation of cannabis, is currently approved only for a limited set of indications and is prohibitively expensive for nonapproved uses. But our study of the medical literature, together with countless anecdotes from older patients and experiences with our own families, suggests that cannabis may be useful in areas of clinical practice that have yet to be defined, such as for those suffering from agitated dementia at the end of life.
Research on cannabis hasn’t kept pace with public interest in the substance, and doctors have been left largely in the dark. We need a nuanced, evidence-based perspective so that we can safely guide our older patients and others to the best medical uses of America’s favorite herbal remedy.
—Dr. Greenstein and Dr. Solomon are board certified geriatric psychiatrists in Denver and San Diego respectively.
Source: Aaron Greenstein and Haley Solomon – wsj.com
