Cannabinoids for the treatment of behavioral and psychological symptoms of dementia

Managing Behavioral and Psychological Symptoms of Dementia (BPSD) in the Era of Boxed Warnings

PURPOSE OF REVIEW

To provide a comprehensive overview on the evaluation and management of behavioral and psychological symptoms of dementia (BPSD) using evidence from literature.

RECENT FINDINGS

Evidence indicates efficacy for some non-pharmacological techniques including education of caregivers and cognitive stimulation therapy and pharmacological agents like antidepressant and antipsychotics for the management of BPSD. The use of antipsychotics has generated controversy due to the recognition of their serious adverse effect profile including the risk of cerebrovascular adverse events and death. BPSD is associated with worsening of cognition and function among individuals with dementia, greater caregiver burden, more frequent institutionalization, overall poorer quality of life, and greater cost of caring for these individuals. Future management strategies for BPSD should include the use of technology for the provision of non-pharmacological interventions and the judicious use of cannabinoids and interventional procedures like ECT for the management of refractory symptoms.

Cannabinoids for Agitation in Alzheimer's Disease

Agitation is a common neuropsychiatric symptom of Alzheimer's disease (AD) that greatly impacts quality of life and amplifies caregiver burden. Agitation in AD may be associated with volume loss in the anterior cingulate cortex, posterior cingulate cortex, insula, amygdala, and frontal cortex, as well as with degeneration of monoaminergic neurotransmission, disrupted circadian rhythms, and frailty. Current pharmacologic options have troubling safety concerns and only modest efficacy. There is increasing interest in cannabinoids as promising agents due to preclinical and early clinical research that suggest cannabinoids can elicit anxiolytic, antidepressant, and/or anti-inflammatory effects. Cannabinoids may relieve agitation by regulating neurotransmitters, improving comorbidities and circadian rhythms, and increasing cerebral circulation. Here we discuss the possible contributory mechanisms for agitation in AD and the therapeutic relevance of cannabinoids, including CBD and THC.

Cannabinoids for the Neuropsychiatric Symptoms of Dementia: A Systematic Review and Meta-Analysis

BACKGROUND

In 2016, the global number of individuals living with dementia was 43.8 million, representing a 117% increase from 1990-mainly due to increases in aging and population growth. Up to 90% of individuals with dementia experience neuropsychiatric symptoms (NPS). However, the limitations of current treatments for NPS have drivent he search for safer pharmacotherapies-including cannabinoids.

AIM

To assess the efficacy and acceptability of cannabinoids for the treatment of NPS in individuals with dementia.

DESIGN

Systematic review and meta-analysis of clinical trials.

SETTING AND PARTICIPANTS

Of 6,902 papers, 9 were eligible (n = 205, 44% female, 78 ± 7 years, 85% Alzheimer disease). Trials were in North America and Europe and explored tetrahydrocannabinol (n = 3), dronabinol (n = 5), or nabilone (n = 1).

MEASUREMENT

Titles/abstracts were independently screened by one reviewer and reviewed by a second. Full-text screening was by two reviewers with discrepancies resolved via a third reviewer. We extracted data on the standardized mean difference (SMD) for several NPS instruments, trial completion, and adverse events. Data were pooled using random-effects models.

FINDINGS

Cannabinoids led to significant improvements across NPS instruments, including the Cohen Mansfield Agitation Inventory (SMD = -0.80; 95% confidence interval [CI], -1.45 to -0.16), the Neuropsychiatric Inventory (SMD = -0.61; CI, -1.07 to -0.15), and nocturnal actigraphy (SMD = -1.05; CI, -1.56 to -0.54h). Cannabinoids were well-tolerated, with an overall trial completion rate of 93% (193/205) and no serious treatment-related adverse events. Treatment efficacy was associated with baseline dementia severity and dose, but not dementia subtype, age, or sex. The overall study quality was rated as low.

CONCLUSIONS

There is preliminary evidence for the efficacy and tolerability of cannabinoids as treatments for NPS. Population-based studies are needed to characterize their real-world effectiveness and acceptability.

Medical cannabis use in older patients: Update on medical knowledge

BACKGROUND

There is increasing scientific data suggesting that cannabis is beneficial for a large range of medical conditions. Physicians need up-to-date medical knowledge (i.e., indications, dose and safety properties) before prescribing cannabis for older patients, who are, a priori, more prone to its adverse effects than younger patients. A mini-review was conducted to examine the evidence on medical cannabis use in older patients.

METHODS

An English and French systematic Medline (PubMed) search, from January 1, 2001 to October 15, 2018, was conducted using the MeSH terms "Cannabis"[Mesh] OR "Marijuana Abuse"[Mesh] OR "Medical Marijuana"[Mesh] OR "Marijuana Smoking"[Mesh] combined with the MeSH terms ("Aged"[Mesh]) OR "Aged, 80 and over"[Mesh]. A total of 451 abstracts were identified and full relevant articles were retrieved and analysed.

RESULTS

Even with a growing body of data showing positive effects of medical cannabis use, mixed results have been reported. Most clinical studies have had small samples and there are few randomized controlled trials. This lack of evidence on the positive clinical effects of medical cannabis use is especially marked for older patients, few of whom have been examined.

CONCLUSIONS

There is a lack of consistent data on the clinical effects of medical cannabis use in older patients to guide cannabis prescription for this group of patients.