by Gaurav Dubey
The elderly population, a term which is generally agreed to mean any individual age 65 or older, is a uniquely diverse and often complex demographic to treat
The aging baby boomers now include many frail and elderly individuals, as Knickman and Snell put in their 2002 review discussing, among several items, “the potential burden an aging society will place on the care-giving system and public finances” (Knickman & Snell, 2002).
Devastating neurodegenerative illnesses such as Alzheimer’s Disease and Parkinson’s disease, as well illnesses such as cancer and chronic pain are more prevalent in older populations and require a multimodal treatment approach. Such treatment can involve hospice care when patients are diagnosed as “prospectively dying” and are the often given very high doses of narcotics, such as morphine, to help ease this pain (Ber-sala et al., 2013) (Scitovsky, 2005).
However these powerful comfort drugs carry serious side effects that can be incredibly detrimental to one’s quality of life (Meier, 20111). A study by Ber-sala and colleagues, however, is one among several emerging studies that also indicate significant alleviation of symptoms in the elderly upon cannabis consumption (Ber-sala et al., 2013). I have discussed previously works that clearly demonstrate the efficacy of cannabis in the treatment of various disorders such as Alzheimer’s and Chronic Pain, conditions with a high prevalence in the elderly population. To this end, this article will focus on a new 2017 study by Katz and colleagues that demonstrably shows the utility and efficacy of cannabinoids in the elderly while using other related and supporting data (Katz et al., 2017). Providing safe, effective and therapeutic care for our senior citizens and adequate end of life care for hospice patients is the hallmark of a successful healthcare system and compassionate society. As such, further investigation into cannabis and cannabinoids for the elderly population is a vital responsibility for the medical community and it’s healthcare providers.
The elderly population, which is steadily increasing in numbers, is the demographic with the highest prevalence of disease and suffering (Parker et al., 1997). The need for adequate care and allocation of resources to treat this diverse population presenting with an even more diverse palette of pathologies is a critical one. Elderly patients typically consume a large amount of prescription drugs, all with varying risk and side effect profiles (Katz et al., 2017).
“Comfort Drugs” used in hospice care, such as hydrocodone, morphine and fentanyl, while generally effective at treating pain, can cause significant drowsiness and even respiratory depression, leading to death, upon overdose (Chau et al., 2008). Chau’s study also describes how normal physiologic aging can significantly alter the pharmacokinetic mechanisms of such drugs in the elderly population, which requires even greater care by the prescribing physician (Chau et al., 2008). With the mounting clinical evidence regarding the efficacy of cannabis to treat a wide variety of pathologies, including many that significantly affect the senior population, special attention should be given to the potential of adding cannabis to the arsenal of drugs to help treat the elderly.
When used simultaneously with opioids, “cannabinoids have been shown to successfully lead to a greater cumulative relief of pain” leading to patients using fewer opiods and experiencing fewer side effects (ref). Perhaps more fascinating from a neuropharmacological standpoint is the fact that cannabinoids seemed to also “prevent the development of tolerance to and withdrawal from opiates” and is even able to essentially cause a weaker dose, that wasn’t working as efficaciously for pain relief for the patient before, to become effective once again (Lucas, 2012). The reduced side effect and high safety profile both present cannabis as a compelling alternative or adjunct to these drugs as well.
In a new 2017 review analyzing clinical evidence for the utilization of cannabinoids in the elderly by Katz and colleagues, the beneficial effects of cannabis in the elderly is implicated by just some of the major conditions cannabis is known to effectively treat in the elderly: Dementia, Parkinson’s Disease, Alzheimer’s Disease and Cancer (Katz et al., 2017).
Furthermore, in discussing the safety of cannabis, Katz and colleagues state, “Cannabinoids present a relatively safe profile of action in elderly patients. Hence, cannabinoid treatment should be considered more readily when other options fail, even in cases of scarce data” (Katz et al., 2017). In fact, I strongly believe that due to the relative safety of cannabis (no reported overdoses/deaths), it should often be considered a first line treatment if possible, over the use of an opioid analgesic, for instance, which carries significantly greater risks. In a population that is often already overmedicated, the possibility of using cannabis, a compound known to be relatively safer than some of the other drugs used to treat chronic pain and illness, should be seriously considered as a mainstay treatment as more data becomes available (Katz et al., 2017).
Indeed, my article regarding cannabis use reducing the individual consumption of prescription drugs speaks to this point well.
As mentioned above, cannabis has been identified to have beneficial and therapeutic properties for several diseases with high prevalence in the elderly. One such condition that cannabis has been indicated for is Alzheimer’s Disease (AD). Indeed, Volicer et al. demonstrated in a placebo-controlled crossover-designed study that treatment with a THC analogue (Dronabinol) attenuated behavioral disturbance in Alzheimer’s patients (Volicer et al., 1997).
While critics of this study claim the lack of quantitative data make the results difficult to adequately validate, a systematic review by Woodward and authors, reporting on “the largest studied cohort of dementia patients treated with Dronabinol to date”, was able to confirm these findings. They reported that Dronabinol could serve as an efficacious “adjunctive treatment for neuropsychiatric symptoms in dementia” (Woodward et al., 2014).
Furthermore, Katz and colleagues, in reviewing this clinical data, concluded that cannabinoids seem to be a safe and effective treatment for therapy “to manage behavioral disturbances in patients” (Katz et al., 2017). Neurodegenerative disorders such as AD are debilitating and often require a multidimensional approach to treatment. Similar challenges arise when considering Parkinson’s disease, another common neurodegenerative illness prevalent in the elderly.
Parkinson’s Disease (PD) is another illness commonly associated with elderly patients and is primarily characterized by death of dopamine neurons in the substantia nigra. It often presents with symptoms such as: tremor, rigidity, gait abnormality and non-motor related clinical symptomology (Katz et al., 2017).
While the etiology of PD is still largely unknown, emerging research has uncovered that our own endocannabinoid system seems to play a significant role in the mechanism of the illness (Katz et al., 2017). This is pharmacologically fascinating as there is a lack of CB1 receptors (one of two main cannabinoid receptors in the body/brain) in the dopaminergic nigostriatal (this is spelt correctly?) neurons that are being damaged due to this serious illness.
It’s currently presumed this occurs due to the fact that the endocannabinoid system modulates GABA and glutamate transmission (two other major neurotransmitter systems in the brain not part of the endocannabinoid system) (Katz et al., 2017). The ability of our own intrinsic endocannabinoid system to play a key role in the mechanisms of this disease holds promise for the future treatment of PD with cannabis.
A common feature of both PD and AD along with other neurodegenerative disorders prevalent in the elderly is dementia, a debilitating phenomenon that has shown significant receptivity to the therapeutic applications of cannabis (Walther & Halpern, 2010). In regards to PD, cannabis has been shown to provide “significant amelioration also in rigidity, tremor, bradykinesia, pain and sleeping problems with no significant adverse effect” (Lotan et al., 2014). Furthermore, a small cohort of 22 PD patients treated with cannabis and surveyed 30 minutes after use reported “a significant improvement of 9.9 points in the mean score Unified Parkinson’s Disease Rating Scale (P<0.0001)” (Katz et al., 2017).
Another common morbidity and co-morbidity among the elderly population is cancer. Chemotherapy is a common mainstay of cancer treatment and is well known to carry seriously averse side effects that are difficult to manage for patients. A recent 2016 review by Dr. Abrams states “Cannabis is useful in combatting anorexia, chemotherapy-induced nausea and vomiting, pain, insomnia, and depression” induced by chemotherapy (Abrams et al., 2016).
In a study with 211 patients, of which 131 had a second, follow-up interview, “all cancer or anticancer treatment-related symptoms showed significant improvement (P < 0.001). Aside from memory lessening in patients with prolonged cannabis use, “no significant adverse events” were reported (Ber-sala et al., 2013). Having worked in an oncology ward for 4 summers and in my training as an EMT in Miami-Dade, I’ve personally witnessed the immense suffering of cancer patients. It’s difficult not to want to provide anything and everything to assist them, especially if they are in their final years and moments before the inevitable. Narcotics such as morphine for pain and adderall to combat the drowsiness from the morphine are common balancing acts in regards to hospice care medications.
As stated by Nersesyan & Slavin, “Stimulants such as methylphenidate or caffeine can increase alertness in patients who are experiencing somnolence on a dose of morphine that provides sufficient pain control” (Nersesyan & Slavin, 1998). With cannabis having a significantly lower side effect profile and a lower chance of adverse drug events as mentioned above, it is time to seriously consider easy access of cannabis to elderly patients suffering from these conditions, especially those in hospice care. Perhaps the pharmacokinetic mechanisms of the drug are not completely understood, however, enough compelling data exists, combined with the fact there has never been one singlepurported overdose/fatality from cannabis that serious consideration need be given to this modality of treatment.
The safety profile of cannabis next to some of the other drugs used to treat this patient population isn’t even comparable when considering potential for fatalities (that already occur every day) from opioids alone. For this and so many other reasons, it’s time to make a change.
So why restrict access to cannabis if it is beneficial for elderly and it improves their quality of life? Ber-sala, in his study, states that cannabis induced relief of symptoms in their study may in part be due to its euphoriant properties. He points out that, “from a medical point of view, the general improvement in the level of distress is important as an end-point for palliative studies, and the cause is less important (Ber-sala et al., 2013).
There is no doubt that the use of potent narcotics such as morphine and hydromorphine create powerful and potentially addicting “highs” as well, but their use is often times warranted in this situation. Thus, holding cannabis to a different standard due to this side effect is in fact holding a double standard and disrespecting science and evidence. In fact, if you’re sick and dying of cancer on your deathbed, the idea of “feeling good” is a powerful one I think many people, especially those in the medical profession, can relate with.
Another reference in regards to cannabis in popular culture is the “munchies”, essentially, the appetite-stimulation effects of cannabis use. While the data is scarce on this topic in the elderly, preliminary findings show promise (Katz et al., 2017). A few small studies (<40 people) using Dronabinol as a treatment found small changes in weight gain or increased consumption of food over shorter time intervals (Katz et al., 2017). Furtherore, when considering the “entourage effect” (define that) and the beneficial effects of, for instance, Sativex (a 1:1 THC:CBD ratio, whole plant cannabis formulation) over other synthetic cannabinoid compounds such as Dronabinol and Marinol, it begs the question about whether whole plant cannabis formulations would be even more beneficial to patients over synthetics compounds (Russo, 2008).These results call for further investigation as proper nutrition is vital to this population of patients.
The stigmatization of the “high” of cannabis and the social satire of the “muchies” can often detract from the medical necessities of these effects for cancer patients, many of whom report as truly depending on these characteristics of cannabis to help them through such illnesses (Waissengrin et al., 2015). Overwhelming data shows this population could potentially benefit greatly from cannabis use and only more research and more science can help change public perception.
The elderly population is one that suffers from an increased prevalence of a variety of severe pathologies, not the least of which including neurodegenerative disorders, cancer and chronic pain. A recent 2016 study found that “medical expenses more than double between ages 70 and 90” and that “ the government pays for over 65 per cent of the elderly’s medical expenses” (De Nardi et al., 2016). If the effects of cannabis can be reproduced in bigger trials, FDA approved treatments and therapies that are efficacious and successful can be implemented, healthcare costs and the benefit to society overall could improve. With a healthcare crisis already underway in our country, perhaps a paradigm shift such as this one is a promising one. Maybe the question we should be asking is not “can we afford to do this?” but rather, “can we afford not to?”
[Featured image credit- Endoca]
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