Cannabis: New Way to Calm Patients with Alzheimer’s Disease

Alzheimer’s disease is one of the cruelest conditions we know of. First, it robs you of your memories. It also makes it hard to think clearly. Balancing a checkbook, for example, can become a nightmare. Driving becomes dangerous. Managing things that used to be simple, like brushing teeth, getting dressed or preparing lunch can become almost impossibly challenging. Then there is the agitation. People with Alzheimer’s disease, Lewy body and vascular dementia often suffer from anxiety, excitation, irritability and insomnia. Is there a way to calm patients with Alzheimer’s disease that is not life threatening? A new study suggests that cannabis might reduce aggression and agitation without the side effects of antipsychotic drugs.

Beware Anti-Psychotic Medications to Calm Patients with Alzheimer’s Disease!

There was a time when a lot of nursing homes routinely administered “major” tranquilizers to people with dementia. We’re talking about antipsychotic medications such as haloperidol (Haldol) chlorpromazine (Thorazine) and trifluoperazine (Stelazine). When the atypical antipsychotics showed up, patients who were agitated, anxious, difficult or confused might be given aripiprazole (Abilify), olanzapine (Zyprexa) or ziprasidone (Geodon). For overworked staff, such medications may seem like a blessing.

FDA’s Warning About Drugs to Calm Patients with Alzheimer’s Disease:

“Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of seventeen placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality.”

A Reader Shares his Concerns About Drugs Used to Calm Patients with Alzheimer’s Disease:

Q. My wife has late stage Alzheimer’s disease. She is now in a memory care facility. They often give her sedatives to calm her agitation.

I have read that such drugs are dangerous, especially for older people with dementia. Is there anything that might be safer?

A. You are right that strong antipsychotic drugs such as aripiprazole (Abilify), olanzapine (Zyprexa), quetiapine (Seroquel) and risperidone (Risperdal) come with scary warnings.

Here is one example:

“Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death.”

It doesn’t get any more stark than that. Death is the ultimate side effect.

Such powerful antipsychotic drugs have a long list of other side effects as well. Some people have referred to antipsychotic drugs as “chemical straitjackets.” They can cause drowsiness, dizziness, headache, walking difficulties, impaired judgement or thinking, uncontrollable muscle movements, restlessness, agitation, uncontrollable urges to move or pace, anxiety, tremor, blurred vision, diabetes, depression, and suicidal thoughts. That is only a partial list, but you get the idea.

The Classic Double Bind of Alzheimer’s Disease:

Given the list of side effects above, you might assume that such strong sedatives should never be given to someone with dementia and we would not disagree with you. On the other hand, caregivers, whether family members or nursing staff, are faced with a terrible dilemma. Someone with Alzheimer’s disease can become quite agitated and say or do things that are self destructive or challenging for those trying to help. It can be very tempting to try a medicine that might calm an agitated dementia patient, even if it could have terrible side effects.

Cannabis: Another Potential Option To Calm Patients with Alzheimer’s Disease:

At a meeting of the Clinical Trials on Alzheimer’s Disease conference in Madrid, Spain (Nov. 6, 2024), researchers report that cannabis could be helpful. These investigators performed a small placebo-controlled trial using nabilone (Cesamet), a synthetic cannabinoid medication. You can listen to one of the investigators at this link.

The FDA has approved this oral capsule for treating the nausea and vomiting associated with cancer chemotherapy. The new sturd demonstrated that nabilone could reduce aggression and agitation. We were impressed with Dr. Krista L. Lanctôt’s  presentation which showed an 88% positive response if AD patients had pain, irritability, appetite changes and depressive changes. If patients “just” suffered agitation, the response rate was 47% on nabilone compared to 23% on placebo.

This probably does not come as a surprise to families dealing with patients suffering from AD. An article in the Wall Street Journal (Nov. 11, 2024) is titled “A Surprising Source of Dementia Relief: Cannabis.”

Here is a quick overview:

“Doctors who prescribe cannabis to dementia patients say it can alleviate anxiety, agitation and pain, and improve sleep, appetite and mood. While there isn’t much definitive research on the use of cannabis for dementia, several small studies have backed its usefulness in soothing agitation.

What About Nuedexta to Calm Patients with Alzheimer’s Disease?

A study published almost a decade ago (JAMA, Sept. 22/29, 2015) also offers some hope for calming agitation in AD patients. Investigators gave 220 people with Alzheimer’s disease either placebo or a combination of quinidine and dextromethorphan (Nuedexta).

Both drugs have been used for decades. Dextromethorphan is the active ingredient in many OTC cough medicines (the DM in Robitussin DM, for example). Quinidine is prescribed for irregular heart rhythms. It has been used for decades, though its roots could be traced back to the 18th century and the bark of the cinchona tree. It was first used to treat atrial fibrillation over 100 years ago.

The study involving Nuedexta for Alzheimer’s disease patients demonstrated a significant drop in agitation and aggression (JAMA, Sept. 22/29, 2015). This is an off-label use of Nuedexta. That means the FDA has not approved the drug for patients with dementia.

A study published in JAMA Internal Medicine (Jan. 7, 2019) notes that Nuedexta is only approved for the treatment of pseudobulbar affect (PBA).

The official prescribing information describes this condition:

“PBA occurs secondary to a variety of otherwise unrelated neurologic conditions, and is characterized by involuntary, sudden, and frequent episodes of laughing and/or crying. PBA episodes typically occur out of proportion or incongruent to the underlying emotional state. PBA is a specific condition, distinct from other types of emotional lability that may occur in patients with neurological disease or injury.”

It would appear that most of the prescriptions for dextromethorphan-quinidine are actually for people with dementia. The authors of this analysis point out that there are adverse effects of this drug combination: falls and urinary tract infections likely due to sedation. Other complications include arrhythmias (long QT interval) and heart failure.

The authors of the article conclude:

“In the case of dextromethorphan-quinidine, our findings show that this medication was quickly used after approval primarily in elderly patients with dementia and/or PD. Further studies should be required to evaluate the safety and effectiveness of this medication as it is currently being used.”

Any decision to consider such treatment needs to be undertaken carefully under medical supervision and only after a thoughtful review of side effects and potential interactions with other medications. There is also the cost. According to GoodRx.com, the retail cost for a month’s supply of Nuedexta could be over $1,800.

Final Words:

The cannabis research is quite fascinating. Although many older people might be reluctant to try medical marijuana to help ease the agitation of Alzheimer’s disease, others might find it worth consideration. We leave this up to medical people who treat people with AD. The study using an FDA-approved drug like nabilone (Cesamet) may make this option less scary.

Please share your own thoughts in the comment section below. Do you think cannabis is a reasonable option for someone experiencing anxiety, agitation and insomnia because of Alzheimer’s disease? Have you had to deal with a friend or family member struggling with dementia. We would like to read your story. Please share this article with anyone you think might find this topic beneficial. Thank you for supporting our work.