Cannabis Use Is Booming in Older Adults: Are We Ready?

Once relegated to young adults and college campuses, cannabis is now edging its way into retirement communities and geriatric clinics. This generation is increasingly lighting up—or dropping tinctures—for pain or anxiety relief, or a better night’s sleep. Cannabis use among adults 65 years and older has increased more than 10-fold over the past 2 decades, from just 0.4% in 2006 to 7% in 2023.^1,2 Clinicians are now tasked with guiding cannabis use in older adults using evidence largely derived from younger populations, applied to products with inconsistent potency, and with minimal data specific to a vulnerable demographic.³ Research in this area has not kept pace with public enthusiasm, leaving psychiatrists with limited guidance on how to navigate cannabis use with their older patients.

Metabolic shifts, polypharmacy, cognitive changes, and fall risk make cannabis use in this population even more complex. This article provides an overview for psychiatrists and mental health clinicians who are increasingly encountering patients older than 65 years using cannabis in ways that range from cautious to curious, and often without adequate clinical guidance.

Cannabis 101

Older adults report turning to cannabis primarily for what they perceive as therapeutic reasons: pain, insomnia, anxiety, depression, and Parkinson disease symptoms.^4,5 Although these indications reflect a growing interest in self- directed symptom management, it is important to recognize that much of the evidence supporting cannabis for these conditions remains scant, particularly in geriatric cohorts.

Cannabis use patterns in this age group are as diverse as the ailments. Some individuals are lifelong users, others return after decades-long hiatuses, and many are newcomers. New users, often motivated by health needs, prefer noninhaled methods including edibles, tinctures, or topicals, whereas consistent users are more likely to smoke or vape and engage in higher-frequency use.⁶

The Regulatory Landscape

The current US regulatory environment for cannabis is a chaotic patchwork. At the federal level, cannabis remains a Schedule I substance, meaning it is classified as having no accepted medical use and a high potential for abuse.⁷ Yet over 40 states have legalized cannabis for medical use, and more than 20 have approved it for recreational use. Within this murky framework, only 3 cannabis-related medications have received US Food and Drug Administration (FDA) approval:

• Dronabinol (synthetic tetrahydrocannabinol [THC]; brand names Marinol and Syndros): Approved for anorexia in patients with AIDS, and for chemotherapy-related nausea and vomiting.
• Nabilone (synthetic cannabinoid similar to THC; brand name Cesamet): Approved for chemotherapy-induced nausea and vomiting.
• Cannabidiol (CBD; brand name Epidiolex): Approved for specific seizure disorders (Lennox-Gastaut and Dravet syndromes) and tuberous sclerosis complex.

FDA-approved cannabinoid agents are tightly regulated and have well-characterized pharmacokinetic profiles, in stark contrast to the cannabis products accessed by older adults through dispensaries, which often exhibit significant variability in potency, purity, and accuracy of product labeling.⁸ That said, older patients often turn to dispensary products due to substantial monetary costs associated with off-label use of FDA-approved medications. Many obtain these products independently, without physician involvement, navigating a landscape of loosely regulated dispensaries with variable labeling standards.

Pharmacokinetics Considerations

THC and CBD are both highly lipophilic, subject to extensive hepatic metabolism (via CYP450 enzymes), and affected by the physiological changes that define aging: decreased hepatic and renal clearance, increased body fat, and altered receptor sensitivity.⁹

In older adults, these changes increase the volume of distribution and reduce clearance, potentially amplifying THC’s duration and intensity of effects, even at lower doses. When taken orally, THC undergoes significant first-pass metabolism to 11-OH-THC, a more psychoactive metabolite with greater blood-brain barrier penetration, which accounts for the stronger and longer- lasting effects of edibles compared with smoked forms that largely bypass this conversion.¹⁰

CBD, often touted as a gentler, nonpsychoactive compound, carries risk in this population as well. CBD inhibits CYP-2C19, CYP-3A4, CYP-2C9, and CYP-2D6, among other enzymes, raising the potential for pharmacokinetic interactions, particularly with antidepressants, benzodiazepines, opioids, blood thinners such as warfarin, and antiepileptics.¹¹

Neuroprotective or Neurotoxic?

In all age groups, cannabis is well known to acutely impair attention, memory, psychomotor function, and executive function, with dose-dependent effects.¹² In terms of long-term effects, 2 large longitudinal studies found that heavy cannabis use was linked to modest declines in verbal memory by midlife.^13,14 In the Dunedin cohort, long-term users showed broader cognitive decline—including a 5.5-point drop in IQ and reduced hippocampal volume by age 45—whereas infrequent users did not, indicating that both frequency and duration of use influence cognitive outcomes.¹⁵

Short-term medical cannabis use in older adults appears relatively benign, with some studies even suggesting modest cognitive improvements—likely secondary to symptom relief (eg, improved sleep or reduced pain).^16-18

Long-term recreational use, however, has been linked to slower processing speed and reduced executive functioning, and more recent cannabis use is associated with poorer working memory.¹⁹ Findings from the Health and Retirement Study reinforce this: Older adults using cannabis more than once per week demonstrated deficits in attention and short-term memory. Encouragingly, some of these effects may improve with sustained abstinence.²⁰

The bottom line is that cognitive effects likely depend on the age of onset, frequency, duration, and abstinence intervals. However, the threshold for concern is lower in older adults, especially those already experiencing mild cognitive decline.

Risky Business: Injuries and Driving

Cannabis use in older adults—particularly formulations higher in THC—can impair balance, reaction time, and coordination, increasing the risk of falls and other injuries. These impairments extend to driving, where cannabis use is associated with a 2-fold increase in the risk of serious or fatal motor vehicle crashes.²¹ In one study of older drivers, cannabis users were 4 times more likely to report driving under the influence of alcohol, compounding risk.²²

Reflecting these dangers at the population level, cannabis-related emergency department visits among adults 65 years and older surged by more than 1800% between 2005 and 2019, with the highest rates seen in men, those aged 65 to 74 years, and individuals with multiple comorbidities. Notably, even older adults without significant health issues experienced increases, highlighting that cannabis-related harms are not limited to the medically vulnerable.²³

Agitation in Dementia

Agitation is one of the most distressing neuropsychiatric symptoms of dementia and often drives caregiver burnout, hospitalization, and long-term care placement. Current pharmacologic options, like antipsychotics, offer only modest benefit and carry serious risks, so it is no surprise that cannabis has attracted growing interest as a potential alternative.

Several small randomized controlled trials have tested cannabinoids for agitation, with mixed results. Notably, studies using low doses of THC have largely been negative,^24,25 whereas more recent trials employing higher doses—such as synthetic THC or CBD/THC oil—have shown promising reductions in agitation.^26,27 A large multicenter trial of dronabinol is under way and early results suggest meaningful reductions in agitation with good tolerability.²⁸ Sedation remains the most common adverse effect, although it is often manageable with dose adjustment. Until larger, published trials provide clearer guidance, cannabinoids remain a cautiously intriguing option—unlikely to replace first-line behavioral interventions, but potentially helpful when conventional strategies fall short.

Concluding Thoughts: Between Green Rush and Gray Area

Cannabis in older adults is here to stay. The wave of baby boomers aging into Medicare while embracing cannabis as medicine—or pleasure—will continue to grow. We clinicians must approach this topic with clinical curiosity, pharmacologic rigor, and humility. The evidence base remains underdeveloped, and the physiological nuances of aging demand caution. Until we have more robust data, the best we can offer is thoughtful, individualized guidance that weighs potential benefits against real and often underestimated risks.

Dr Solomon is the clinical lead for geriatric psychiatry services at the Huntsman Mental Health Institute and serves as a clinical assistant professor of psychiatry and an adjunct assistant professor of medicine within the Division of Geriatrics at the University of Utah in Salt Lake City. Dr Greenstein is a geriatric psychiatrist in private practice in Denver, Colorado, an attending psychiatrist through the MGH Visiting program at Mass General Hospital in Boston, Massachusetts, and a clinical associate professor at Rocky Vista University in Parker, Colorado.

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