Cannabis Use Is Soaring Among Older Adults, and Clinicians Are Largely Unprepared
A 2025 narrative review synthesizes pharmacokinetic, cognitive, and safety evidence to highlight the stark mismatch between the rapid growth of cannabis use among adults over 65 and the near-total absence of geriatric-specific data to guide clinical decision-making in this vulnerable population.
Why This Matters
Cannabis use among adults aged 65 and older has grown more than tenfold in under two decades, yet the evidence base informing clinical guidance for this population remains built almost entirely on data from younger users. This gap matters because aging fundamentally alters how the body processes cannabinoids, amplifying risks for falls, cognitive impairment, and dangerous drug interactions with the very medications older adults are most likely to take. As legalization expands and dispensary access grows, clinicians are being asked questions they cannot yet answer with geriatric-specific data.
Clinical Summary
Cannabis use among Americans 65 and older rose from 0.4% in 2006 to approximately 7% in 2023, a shift driven largely by older adults seeking relief from chronic pain, insomnia, and anxiety rather than recreational motivations. A narrative review published in Psychiatric Times in 2025, authored by clinicians targeting psychiatrists and mental health providers, examines the pharmacokinetic basis for heightened risk in this group. Age-related reductions in hepatic and renal clearance, combined with increased adipose tissue, expand the volume of distribution for lipophilic compounds like THC. This means older adults experience greater peak effects and prolonged duration of action at any given dose. Oral administration further amplifies this problem through first-pass hepatic conversion of THC to 11-hydroxy-THC, a more potent and longer-lasting metabolite.
The review highlights several alarming epidemiological signals: cannabis-related emergency department visits among adults 65 and older surged more than 1,800% between 2005 and 2019, and cannabis use is associated with a roughly twofold increase in risk of serious or fatal motor vehicle crashes. CBD, often perceived as benign, inhibits multiple CYP450 enzymes (2C19, 3A4, 2C9, 2D6), creating interaction risks with warfarin, opioids, benzodiazepines, and antidepressants commonly prescribed to older patients. Evidence for cannabinoids in geriatric-specific conditions such as dementia-related agitation remains preliminary and mixed. The authors emphasize that no strong geriatric-specific efficacy data exist to support routine clinical recommendations, and that rigorous age-stratified trials are urgently needed before evidence-based guidance is possible.
Dr. Caplan’s Take
This review articulates something I encounter in practice constantly: patients over 65 arriving with cannabis products they obtained from a dispensary or a well-meaning family member, confident that what they are using is “natural” and therefore safe. What the review gets right is framing the core problem as a mismatch between population-level evidence and patient-level physiology. The mechanistic rationale for heightened risk in older adults is sound and well established. What remains missing is the clinical trial infrastructure to translate those concerns into dose-specific, product-specific guidance that I can actually hand to a patient.
In practice, I treat older adults who are already using cannabis the same way I treat any underdosed or unmonitored medication exposure: I ask what they are taking, in what form, at what dose, and how often. I screen for drug interactions, especially with anticoagulants and CNS-active medications. I do not reflexively discourage use, but I am transparent about what we do not know. For patients considering cannabis for pain or sleep, I ensure conventional options have been adequately trialed first, and if cannabis remains on the table, I favor low-dose, non-oral routes to minimize first-pass metabolism concerns.
Clinical Perspective
This review sits at the beginning of what should become a robust research arc. It consolidates pharmacokinetic reasoning and epidemiological warning signals, but it does not draw on systematic review methods, and the literature it cites includes studies with heterogeneous designs, populations, and cannabis formulations. For clinicians, the core message is clear: age-related changes in metabolism are real and directionally unfavorable for THC and CBD safety, but the magnitude of risk at specific doses and formulations remains unquantified for geriatric populations. The evidence does not support recommending cannabis for any geriatric-specific indication, but it also does not support ignoring the prevalence of use in this age group.
The drug interaction profile of CBD deserves particular clinical attention. Inhibition of CYP2C19 and CYP3A4 can elevate plasma levels of clopidogrel metabolites, benzodiazepines, certain statins, and direct oral anticoagulants in ways that may not be clinically obvious until a bleeding event or oversedation occurs. Older adults on polypharmacy regimens are especially vulnerable. The single most actionable step for clinicians right now is to routinely screen for cannabis and CBD use during medication reconciliation in every patient over 65, treating these products with the same pharmacovigilance rigor applied to any other drug exposure.
Study at a Glance
| Study Type | Narrative review / clinical practice article (CME-eligible) |
| Population | Adults aged 65 years and older |
| Intervention | Cannabis and cannabinoid products (THC, CBD, combination) |
| Comparator | Not applicable (review article) |
| Primary Outcomes | Pharmacokinetic risk profile, cognitive effects, fall and crash risk, drug interactions, efficacy for geriatric indications |
| Sample Size | Not applicable (narrative synthesis of existing literature) |
| Journal | Psychiatric Times |
| Year | 2025 |
| DOI or PMID | Not available in extracted text |
| Funding Source | Not reported in available text |
What Kind of Evidence Is This
This is a peer-reviewed narrative review published in a psychiatric trade journal, designed to inform clinical practice rather than generate or pool original data. It occupies a position below systematic reviews and meta-analyses in the evidence hierarchy. Because the authors do not describe a systematic search strategy, predefined inclusion criteria, or risk-of-bias assessment, the most important inference constraint is that the conclusions may reflect the authors’ selection of literature rather than a comprehensive or unbiased survey of all available evidence.
How This Fits With the Broader Literature
The prevalence trends cited in this review are consistent with data from the National Survey on Drug Use and Health and with prior analyses documenting sharp increases in cannabis use among older Americans following state-level legalization. The pharmacokinetic concerns echo long-standing geriatric pharmacology principles regarding lipophilic drug handling in aging populations. The CBD interaction data align with FDA-generated evidence from Epidiolex prescribing information and with case reports of warfarin potentiation.
Where this review extends the literature is in its explicit framing of the clinical problem as a geriatric-specific evidence vacuum rather than simply a substance use trend. Prior reviews have tended to address cannabis safety broadly or to focus on specific conditions; this article attempts to consolidate the pharmacological, cognitive, injury, and therapeutic dimensions into a single clinician-facing resource. The mixed evidence on cannabinoids for dementia agitation is consistent with recent trial results, including the largely negative findings from low-dose THC studies.
Common Misreadings
The most likely overinterpretation is reading this review as evidence that cannabis is categorically unsafe for older adults and should never be considered. The review does not establish that conclusion. It establishes that the risk profile is likely different and probably worse than in younger populations, but the absence of geriatric-specific trial data means we cannot quantify that risk with precision. Similarly, the 1,800% increase in cannabis-related emergency department visits is a striking figure, but it reflects a rise from an extremely low baseline and is partly attributable to increased screening, reporting, and the simple fact that more older adults are using cannabis. It should not be interpreted as a direct measure of harm severity.
Bottom Line
This narrative review consolidates a compelling pharmacokinetic and epidemiological case that cannabis use in adults over 65 carries risks that are meaningfully distinct from those in younger populations. It does not establish the magnitude of those risks through original data or systematic methods. Its primary contribution is framing the clinical urgency: roughly one in fourteen older Americans now uses cannabis, yet clinicians have almost no age-specific evidence to guide them. Until that evidence arrives, routine screening and pharmacovigilance remain the most defensible clinical response.
Frequently Asked Questions
Why would cannabis affect an older adult differently than a younger one?
As the body ages, the liver and kidneys become less efficient at clearing drugs, and body fat increases. THC is highly fat-soluble, so it gets stored in fatty tissue and released slowly, extending its effects. Reduced liver metabolism also means higher peak blood levels from the same dose. These changes can make a dose that would be mild for a 30-year-old produce significant impairment in a 70-year-old.
Is CBD safe for older adults since it does not cause a high?
CBD does not produce the intoxicating effects of THC, but “non-intoxicating” does not mean “without risk.” CBD inhibits several liver enzymes responsible for metabolizing common medications including blood thinners, certain heart drugs, benzodiazepines, and antidepressants. For an older adult on multiple prescriptions, adding CBD without medical oversight can unpredictably alter drug levels and increase the risk of adverse events.
The evidence so far is mixed and preliminary. Several clinical trials using low-dose THC for dementia agitation have produced largely negative results. A few studies using higher doses or THC-CBD combinations have shown some promise, but these findings are not strong enough to support routine use. No major clinical guideline currently recommends cannabis or cannabinoids as a standard treatment for dementia-related behavioral symptoms.
Should older adults who are already using cannabis stop immediately?
This review does not recommend abrupt cessation as a blanket policy. The more important step is for patients to disclose their cannabis use to their healthcare providers so that drug interactions can be assessed and dosing can be discussed. Clinicians can then make individualized recommendations based on the patient’s full medication list, medical conditions, and functional status. Abrupt changes in any substance use should be medically supervised.
Are dispensary products reliable enough for medical use in older adults?
Regulation of dispensary products varies widely by state, and independent testing has repeatedly found inconsistencies between labeled and actual cannabinoid content. For older adults who may be more sensitive to small changes in THC concentration, this inconsistency is a meaningful safety concern. FDA-approved cannabinoid products such as dronabinol, nabilone, and prescription cannabidiol (Epidiolex) offer standardized dosing and known pharmacokinetic profiles, though they are approved for limited indications.
References
- Choi NG, DiNitto DM, Marti CN. Older adults who use or have used marijuana: Help-seeking for marijuana and other substance use problems. Journal of Substance Abuse Treatment. 2021;120:108179.
- Han BH, Palamar JJ. Trends in cannabis use among older adults in the United States, 2015-2018. JAMA Internal Medicine. 2020;180(4):609-611.
- Substance Abuse and Mental Health Services Administration. National Survey on Drug Use and Health, 2023.
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