Sherri Mack BSN, RN
Elisabeth Mack MBA, BSN, RN

Executive Summary

Behavioral and psychological symptoms in older adults, particularly those living with dementia, neurodegenerative disease, chronic illness, or receiving palliative care, remain among the most difficult clinical challenges in long-term care and assisted living settings. Agitation, anxiety, sleep disturbance, chronic pain, appetite changes, social withdrawal, and behavioral dysregulation frequently contribute to reduced quality of life, caregiver distress, increased hospitalization risk, and escalating pharmaceutical burden (Cerejeira et al., 2012).

Conventional pharmacologic management often includes antipsychotics, benzodiazepines, sedative hypnotics, opioids, and antidepressants. While these medications may provide symptom relief, they are also associated with significant risks in geriatric populations, including falls, sedation, delirium, worsening cognition, drug interactions, and increased mortality risk in patients with dementia (American Geriatrics Society Beers Criteria® Update Expert Panel, 2023).

Cannabinoid-based therapeutics represent an emerging area of integrative symptom management in senior care. Hemp-derived cannabinoids including cannabidiol (CBD), cannabigerol (CBG), cannabinol (CBN), cannabidiolic acid (CBDA), and carefully titrated low-dose tetrahydrocannabinol (THC) interact with the endocannabinoid system and related neuromodulatory pathways involved in regulation of mood, sleep, pain perception, inflammation, appetite, and behavioral response (Lu & Mackie, 2021).

Emerging evidence suggests cannabinoids may support symptom management in older adults experiencing agitation, anxiety, sleep disturbance, pain, and appetite dysregulation, particularly when implemented using low-dose, carefully monitored protocols (Abuhasira et al., 2018; Shelef et al., 2016). Interest in cannabinoid-based care has increased in both palliative and dementia-focused settings due to concerns surrounding polypharmacy and medication-related adverse effects in medically complex populations (Whiting et al., 2015).

Recent systematic reviews and meta-analyses have further strengthened interest in cannabinoid-based approaches for behavioral and psychological symptoms of dementia (BPSD), particularly agitation and distress. Emerging evidence suggests that carefully dosed cannabinoid formulations may reduce agitation severity and improve behavioral stability in select patients, with acceptable tolerability when implemented within structured, low-dose protocols (Caplan, 2026).

This protocol provides a structured, facility-ready cannabinoid care framework utilizing Bloom Hemp softgels and gummies for symptom support in older adults. The protocol is designed to support interdisciplinary implementation within assisted living, memory care, skilled nursing, palliative care, and home care environments.

Clinical applications may include support for the following:

• Dementia-related agitation and behavioral symptoms
• Anxiety and emotional distress
• Sleep disturbance and nighttime restlessness
• Chronic pain and inflammation
• Appetite support
• Social engagement and daytime participation
• Comfort-focused and palliative care

The protocol utilizes a layered cannabinoid care model beginning with foundational daily endocannabinoid support utilizing non-intoxicating CBD and low-THC formulations. Additional symptom-targeted interventions may be introduced based on individual clinical presentation, response, tolerance, and goals of care. For residents with more complex symptom burden, carefully titrated THC microdosing strategies may be implemented using buffered multi-cannabinoid formulations.

This protocol emphasizes conservative dosing, structured monitoring, and interdisciplinary implementation within real-world care environments. The Bloom Hemp CBD product line offers standardized cannabinoid formulations with USDA Organic Hemp, consistent dosing, third-party laboratory testing, and flexible administration options that support reproducible clinical implementation across various care settings.

This document is intended for licensed healthcare professionals, nursing staff, administrators, social workers, caregivers, and interdisciplinary care teams seeking evidence-informed guidance for integrating cannabinoid-based therapeutics into senior and palliative care environments.

Section 1: Clinical Rationale for Cannabinoid Use in Seniors

Behavioral and psychological symptoms of dementia (BPSD), including agitation, aggression, anxiety, sleep disruption, and emotional dysregulation, are among the most challenging aspects of dementia care. These symptoms are strongly associated with caregiver burden, institutionalization, and increased use of high-risk medications.

Recent meta-analytic data suggest that cannabinoid-based therapies may offer clinically meaningful reductions in agitation and behavioral disturbance in select patients, particularly when low-dose, carefully titrated formulations are utilized. While additional large-scale trials are needed, these findings support the growing role of cannabinoids as a potential adjunctive strategy in dementia care (Cerejeira et al., 2012; Caplan, 2026).

In long-term care and assisted living settings, these symptoms are commonly managed with antipsychotics, benzodiazepines, sedative hypnotics, opioids, antidepressants, and other centrally acting medications. While these therapies may provide symptom relief, they are also associated with substantial risk in geriatric populations, including falls, excessive sedation, delirium, worsening cognition, orthostatic hypotension, impaired mobility, and increased mortality in patients with dementia (American Geriatrics Society Beers Criteria® Update Expert Panel, 2023).

Polypharmacy remains a major clinical concern in older adults. Residents in assisted living and memory care environments frequently take multiple medications simultaneously, increasing the likelihood of adverse drug events, medication interactions, hospitalization, and functional decline (Maher et al., 2014). As a result, clinicians and facilities are increasingly exploring integrative and lower-burden symptom management strategies that may support comfort, behavioral regulation, sleep, and quality of life while minimizing unnecessary pharmaceutical escalation.

Cannabinoid-based therapeutics represent an emerging area of interest in geriatric and palliative care due to their potential ability to address multiple symptom domains simultaneously through modulation of the endocannabinoid system (ECS). The ECS is a widespread neuromodulatory system involved in regulation of mood, stress response, sleep, appetite, inflammation, pain signaling, memory processing, and immune activity (Lu & Mackie, 2021).

The Endocannabinoid System (ECS)

The ECS includes cannabinoid receptors CB1 and CB2, endogenous signaling molecules known as endocannabinoids, and enzymes involved in synthesis and degradation. CB1 receptors are primarily concentrated within the central nervous system and influence cognition, emotional regulation, behavior, and pain perception. CB2 receptors are more prominent within immune and peripheral tissues and are associated with inflammatory and immune modulation (Lu & Mackie, 2021).

Age-related changes in endocannabinoid signaling may contribute to dysregulation of sleep, mood, pain processing, stress tolerance, and behavioral symptoms observed in older adults and patients with dementia. Cannabinoid-based interventions may help support restoration of physiologic balance across these interconnected systems.

Cannabidiol (CBD)

Cannabidiol (CBD) is the primary non-intoxicating cannabinoid utilized within this protocol. CBD has demonstrated anxiolytic, anti-inflammatory, neuroprotective, anticonvulsant, and analgesic properties in both preclinical and human research (Blessing et al., 2015). In clinical settings, CBD may support reduction in anxiety, emotional distress, chronic discomfort, behavioral dysregulation, and sleep disruption without producing intoxication.

Cannabigerol (CBG)

Cannabigerol (CBG) CBG is increasingly utilized in cannabinoid formulations designed to support mood regulation, focus, behavioral calmness, appetite, and physical comfort. While human research remains limited, emerging evidence suggests CBG may possess anti-inflammatory, neuroprotective, and neuromodulatory properties (Nachnani et al., 2021).

Cannabinol (CBN)

CBN is commonly incorporated into nighttime formulations due to its potential sedating and calming effects, particularly when combined with CBD and low-dose THC. Although formal clinical evidence remains early, observational use in sleep-focused cannabinoid formulations has increased significantly in geriatric and palliative populations.

Low-dose tetrahydrocannabinol (THC)

When carefully titrated, may provide clinically meaningful support for appetite stimulation, pain reduction, behavioral agitation, nausea, emotional distress, and sleep quality (Abuhasira et al., 2018). Within senior populations, THC dosing requires careful attention to tolerance, frailty, fall risk, cognitive status, and medication burden. This protocol emphasizes microdosing strategies utilizing buffered multi-cannabinoid formulations designed to improve tolerability while minimizing psychoactive burden.

These mechanisms support the rationale for cannabinoid use in managing complex, multi-domain symptom burden in dementia care.

Section 2: Bloom Hemp Product Formulary and Clinical Applications

The Bloom Hemp product line provides standardized cannabinoid formulations designed to support a layered, symptom-focused approach to cannabinoid care in senior and palliative populations. Products within this protocol are organized into three categories:

• Foundational daily support
• Symptom-specific functional support
• Advanced cannabinoid support for moderate to severe symptom burden

This structure allows clinicians and care teams to individualize therapy based on resident presentation, goals of care, medication sensitivity, and response to treatment while maintaining consistency in implementation across care settings.

The protocol prioritizes non-intoxicating and low-dose cannabinoid formulations as first-line interventions, with cautious escalation to buffered THC-containing products when clinically appropriate. This approach aligns with current geriatric prescribing principles emphasizing low-dose initiation, gradual titration, and minimization of medication-related adverse effects (American Geriatrics Society Beers Criteria® Update Expert Panel, 2023). Over time with cannabinoid efficacy, prescribers of other pharmaceuticals may be able to reduce dosing on more harmful medications.

Foundational Daily Support

Foundational cannabinoid support is intended to provide consistent daily endocannabinoid system modulation to support mood, emotional regulation, sleep quality, pain perception, inflammation, and overall comfort. These formulations serve as a baseline cannabinoid routine for most residents within the protocol.

Bloom Hemp Immunity Softgels

• Formulation: CBD, CBDA, CBG, CBGA
• Total Cannabinoids: 50 mg per softgel
• THC Content: THC-free
• Clinical Applications: Daytime foundational cannabinoid support
  • Anxiety and emotional distress
  • Mild agitation or behavioral dysregulation
  • Chronic pain and inflammation
  • General wellness and quality of life support
• Suggested Administration: One softgel after breakfast or lunch
  • May be used consistently as a daily baseline cannabinoid therapy

The Immunity Softgel functions as the primary daytime foundational product within this protocol. The formulation combines multiple non-intoxicating cannabinoids designed to support broad endocannabinoid activity while minimizing risk for sedation or psychoactive effects. Multi-cannabinoid formulations may provide enhanced therapeutic activity through complementary receptor interactions and modulation of inflammatory, neurologic, and stress-response pathways (Lu & Mackie, 2021; Nachnani et al., 2021).

Bloom Hemp Full Spectrum Softgels

• Formulation: CBD with low-dose THC
• Total Cannabinoids: 25 mg CBD with approximately 1 mg THC per softgel
• THC Content: Low dose THC, ~1mg per softgel
• Clinical Applications: Evening foundational cannabinoid support
  • • Evening relaxation
    • Sleep support
    • Appetite support
    • Chronic discomfort
    • Anxiety and behavioral regulation
    • Introduction of low-dose THC support
• Suggested Administration: One softgel with dinner or at bedtime.

The Full Spectrum Softgel serves as the evening foundational cannabinoid product within this protocol. The inclusion of low-dose THC may enhance therapeutic benefit for sleep, pain, appetite, and behavioral symptoms while remaining within a conservative microdosing range appropriate for many older adults when carefully monitored (Abuhasira et al., 2018).

Buffered low-dose THC formulations may be better tolerated in geriatric populations than isolated THC products due to the moderating effects of CBD and additional cannabinoids on psychoactive burden and tolerability.

Symptom-Specific Functional Support

Functional support products are intended to address specific symptom domains and may be layered onto the foundational cannabinoid routine based on resident needs and goals of care.

Bloom Hemp Sleep Gummies

• Formulation: 25mg CBD with L-theanine, passionflower, and 3mg melatonin
• Total Cannabinoids: 25 mg CBD per gummy
• THC Content: THC-free
• Clinical Applications – Support nighttime circadian rhythms
  • Sleep initiation difficulty
  • Nighttime restlessness
  • Sleep fragmentation
  • Evening anxiety or behavioral escalation
• Suggested Administration
  • 1/2 gummy after dinner and 1/2 gummy at bedtime
  • 1 full gummy 30-60 min before bed
  • May be combined with foundational full spectrum softgel

Sleep disturbance is highly prevalent in dementia and senior care populations and often contributes to worsening behavioral symptoms, caregiver burden, and reduced quality of life (Cerejeira et al., 2012). The Sleep Gummy combines CBD with calming botanical and nutraceutical ingredients intended to support relaxation and sleep continuity without relying on sedative hypnotics.

Bloom Hemp Energy Gummies

• Formulation: 25mg CBD with B9, B12, and low-dose caffeine 20mg (1/4 cup of coffee)
• Total Cannabinoids: 25 mg CBD per gummy
• THC Content: THC-free
• Clinical Applications – Daytime Energy
  • Fatigue
  • Apathy
  • Reduced daytime engagement
  • Low motivation or social withdrawal
  • Daytime mood support
• Suggested Administration
  • 1/2 gummy with breakfast and lunch
  • 1 full gummy between breakfast and lunch
  • Avoid administration late in day

Reduced participation, withdrawal, fatigue, and apathy are common in older adults experiencing chronic illness, depression, neurodegenerative disease, or medication burden. The Energy Gummy is designed to support daytime engagement and alertness while maintaining cannabinoid support. Careful monitoring is recommended in residents with caffeine sensitivity, cardiac conditions, anxiety disorders, or sleep disruption.

Advanced Cannabinoid Support

Advanced Cannabinoid Support is reserved for residents with moderate to severe symptom burden that has not adequately responded to foundational and functional interventions alone.

Bloom Hemp T65 Gummies

• Formulation: CBD 50 mg, CBG 5 mg, CBN 5 mg, THC 5 mg with a pain terpene blend per gummy
• THC Content: 5 mg THC per 1 full gummy
  • 2.5mg THC per 1/2 gummy
  • 1.25mg THC per 1/4 gummy
• Clinical Applications – Moderate to severe agitation, anxiety, appetite, pain and sleep issues
  • Moderate to severe agitation
  • Chronic pain
  • Significant sleep disruption
  • Behavioral escalation
  • Emotional distress
  • Palliative and comfort-focused care
• T65 Microdosing Guidance
  • Starting dose – 1/4 gummy (1.25mg THC) once or twice a day if needed
  • Clinical dose – 1/4 gummy (1.25mg THC) four times a day after breakfast, lunch, dinner and bedtime
  • Escalation guidance – 1/2 gummy (2.5mg THC) four times a day prn
    • May gradually increase based on tolerance and clinical response
    • Increase gradually over several days
    • Typical geriatric dosing remains 1/4 to 1/2 gummy per administration
    • Monitor closely for sedation, dizziness, confusion, balance instability, or excessive psychoactive response

The T65 Gummy is the primary THC microdosing formulation utilized within this protocol. Each gummy contains a buffered multi-cannabinoid formulation designed to improve tolerability and therapeutic flexibility through combination cannabinoid support rather than reliance on THC alone. Within geriatric populations, THC-containing products should be introduced gradually and individualized according to cognitive status, frailty, fall risk, medication burden, and prior cannabinoid exposure. Low-dose THC may provide clinically meaningful support for pain, behavioral symptoms, appetite, emotional distress, and sleep when implemented conservatively and monitored carefully (Abuhasira et al., 2018; Shelef et al., 2016).

This approach aligns with emerging clinical evidence suggesting that low-dose, multi-cannabinoid formulations may improve behavioral symptoms such as agitation while maintaining tolerability in older adults.

Formulary Integration Model

This protocol utilizes a layered cannabinoid care approach:

• Step 1: Foundational Support
  • Morning or daytime Immunity Softgel
  • Evening Full Spectrum Softgel
• Step 2: Functional Symptom Support
  • Add Sleep Gummies for nighttime symptoms
  • Add Energy Gummies for daytime engagement or fatigue
• Step 3: Advanced Symptom Escalation
  • Introduce T65 microdosing for persistent agitation, pain, sleep disruption, or palliative symptom burden

This structure allows clinicians and facilities to implement cannabinoid care in a gradual, individualized, and safety-focused manner while supporting reproducibility across interdisciplinary care teams.

Section 3: Dosing and Titration Protocol

This protocol follows a conservative “start low and go slow” approach designed specifically for older adults, medically complex residents, and individuals with increased sensitivity to centrally acting medications. Age-related physiologic changes, polypharmacy, cognitive impairment, frailty, altered metabolism, and fall risk all influence cannabinoid tolerability in senior populations and require careful clinical monitoring throughout therapy (American Geriatrics Society Beers Criteria® Update Expert Panel, 2023).

This protocol utilizes a three-tiered dosing framework

1. Foundational Daily Support
2. Symptom-Specific Add-On Support
3. THC Microdosing Escalation for Moderate to Severe Symptoms

General Dosing Principles

• Start with the lowest effective dose
• Increase slowly over several days
• Adjust one variable at a time when possible
• Prioritize consistency before escalation
• Monitor for sedation, dizziness, confusion, or behavioral change
• Utilize THC cautiously in cognitively impaired or frail residents
• Reassess clinical response regularly

Residents with dementia, advanced age, impaired mobility, or multiple sedating medications may require slower titration schedules and lower overall THC exposure. This conservative dosing strategy reflects current clinical understanding and emerging evidence indicating that lower-dose cannabinoid protocols are more appropriate and better tolerated in geriatric populations, particularly in the context of cognitive impairment and behavioral symptoms.

Foundational Daily Cannabinoid Support

This is appropriate for most residents entering the protocol and is designed to provide steady endocannabinoid support throughout the day and evening.

Morning or Midday Support – Bloom Hemp Immunity Softgel

• 50 mg total cannabinoids – CBD, CBDA, CBG, CBGA – THC Free
• Suggested Dose – One softgel after breakfast or lunch
• Clinical Goals – The Immunity Softgel is typically well tolerated due to the absence of THC and may serve as the primary daytime cannabinoid formulation for many residents.
  • Emotional regulation
  • Reduction in anxiety or agitation
  • Daytime comfort and behavioral stability
  • Chronic pain and inflammation support
  • Foundational endocannabinoid system support

Evening Support – Bloom Hemp Full Spectrum Softgel

• 25 mg CBD with approximately 1 mg THC
• Suggested Dose – One softgel after dinner or at bedtime
• Clinical Goals – The evening Full Spectrum Softgel introduces conservative low-dose THC exposure within a buffered cannabinoid formulation designed to improve tolerability and minimize psychoactive burden. Residents with significant THC sensitivity, advanced frailty, or prior adverse cannabinoid reactions may require slower introduction or delayed initiation of THC-containing products.
  • Evening relaxation
  • Sleep support
  • Appetite support
  • Reduction in nighttime restlessness
  • Enhanced comfort and behavioral calming

Symptom-Specific Add-On Support

Additional cannabinoid products may be layered onto the foundational protocol based on symptom presentation, timing, and resident goals of care.

Sleep Disturbance – Bloom Hemp Sleep Gummies

• 25mg CBD with L-theanine, passionflower, and 3mg melatonin – THC-free
• Suggested Dosing
  • 1/2 gummy after dinner and bedtime
  • 1 full gummy 30- 60 min before bedtime
• Use Cases: Difficulty initiating sleep, nighttime waking, sundowning behavior, restlessness or nighttime anxiety.
• The Sleep gummy may be used alone or combined with evening foundational support depending on symptom severity.

Low Energy or Reduced Engagement – Bloom Hemp Energy Gummies

• 25mg CBD with B9, B12, and low-dose caffeine 20mg (1/4 cup coffee) – THC- free
• Suggested Dosing
  • 1/2 energy gummy after breakfast and lunch
  • 1 full gummy between breakfast and lunch
• Use Cases: Provide more daytime energy for engagement, to reduce fatigue, help with social withdrawal, help with low motivation or apathy.
• Avoid administration late in the day to minimize sleep disruption. Energy gummy may be used in combination with other foundational support products.

THC Microdosing Escalation Protocol – Bloom Hemp T65 Gummies

THC-containing products should only be introduced when clinically indicated and after assessment of resident tolerance, cognition, medication burden, and fall risk. Microdosing strategies allow clinicians to utilize therapeutic THC exposure while minimizing psychoactive effects and excessive sedation.

• Formulation – CBD 50 mg,CBG 5 mg, CBN 5 mg, THC 5 mg, Terpene blend
• Cut in 1/4 or 1/2 for microdosing

The T65 Gummy is designed as a buffered THC microdosing formulation intended for residents experiencing moderate to severe agitation, pain, sleep disruption, behavioral escalation, or palliative symptom burden.

Initial THC Microdosing Strategy

• Suggested Starting Dose – 1/4 T65 gummy (approximately 1.25 mg THC)
• Initial Dosing – in afternoon or evening when possible to allow observation of tolerance and sedation response
• PRN Dosing – Periods of behavioral escalation or distress
• Suggested Timing – Breakfast. Lunch, Dinner, Bedtime

Escalation Guidance

If tolerated and clinically indicated:

• Increase gradually over several days by 1/4 gummy
• Typical geriatric dosing remains within 1/4 to 1/2 half gummy per administration
• Avoid rapid escalation

PRN THC microdosing may be appropriate for:

• Acute agitation
• Anxiety
• Behavioral escalation
• Breakthrough pain
• Palliative symptom burden

Suggested PRN Dose 1/4 gummy every 4 to 6 hours as needed and tolerated

Maximum Typical Geriatric Range 1/2 gummy per administration unless otherwise directed by the supervising clinician

Monitoring and Reassessment Residents should be monitored routinely following cannabinoid initiation and dose adjustments.

Desired Clinical Outcomes

• Reduced agitation or anxiety
• Improved sleep quality
• Reduced pain or discomfort
• Improved emotional regulation
• Improved appetite and digestion
• Increased participation and engagement
• Improved comfort and quality of life

Potential Adverse Effects

• Excessive sedation
• Dizziness
• Orthostatic symptoms
• Confusion
• Balance instability
• Behavioral worsening
• Increased fatigue

Most adverse effects are dose-related and improve with dose reduction, slower titration, or adjustment of THC exposure (Abuhasira et al., 2018).

Hold or reduce cannabinoid dosing if residents experience:

• Excessive sedation
• New or worsening confusion
• Increased fall risk
• Behavioral worsening
• Significant dizziness or instability
• Intolerable fatigue
• Once symptoms improve, cannabinoids may be reintroduced at a lower dose with a slower titration.

Once symptoms improve, cannabinoids may be reintroduced at a lower dose with a slower titration.

Clinical Implementation Considerations: Cannabinoid dosing in senior populations should remain individualized and interdisciplinary. This protocol is intended to support safe, structured, reproducible implementation while allowing clinicians flexibility to individualize care according to resident presentation and therapeutic response.

Section 4: Clinical Implementation Framework for Dementia-Related Agitation

This framework reflects real-world clinical approaches used in cannabinoid-based care and aligns with emerging evidence on the management of agitation and behavioral symptoms in dementia. Effective cannabinoid use in dementia care requires a structured clinical approach that integrates assessment, goal-setting, dosing, monitoring, and interdisciplinary coordination.

Assessment

A thorough clinical assessment should evaluate the type, frequency, and severity of agitation, while also identifying potential reversible causes such as pain, infection, medication side effects, or environmental triggers.

A comprehensive medication review is essential, along with screening for potential contraindications including significant cardiovascular disease, active psychosis, or history of substance use disorder.

Goal Setting

Realistic goals should be established in collaboration with caregivers and family members. Cannabinoid therapy is intended to reduce the frequency or severity of agitation and improve comfort and quality of life, but it does not reverse underlying neurodegenerative disease or restore cognitive function.

Dosing Strategy

Based on emerging clinical evidence and meta-analytic data, cannabinoid dosing for agitation often involves gradual titration within low-dose ranges. THC exposure is typically introduced conservatively and adjusted based on tolerance and clinical response.

Within this protocol, dosing remains consistent with geriatric best practices emphasizing microdosing strategies and multi-cannabinoid formulations.

Monitoring

Regular reassessment is essential following cannabinoid initiation or dose adjustment. Monitoring should include:

• Agitation severity and frequency
• Sleep quality
• Functional engagement
• Adverse effects such as sedation, dizziness, or confusion

Clinical response should be evaluated over a period of 3–7 days initially, with more formal reassessment at 4–6 weeks to determine whether continuation, modification, or discontinuation is appropriate.

Coordination of Care

Cannabinoid therapy should be integrated within an interdisciplinary care model. Coordination with primary care providers, neurologists, nursing staff, and caregivers is essential to ensure safety, consistency, and appropriate monitoring within the broader care plan.

Section 5: Safety and Drug Interactions

Cannabinoid-based therapeutics are generally well tolerated in older adults when introduced conservatively, titrated gradually, and monitored appropriately. Within senior and palliative care populations, safety considerations should focus primarily on sedation, fall risk, cognitive changes, medication burden, and individual sensitivity to tetrahydrocannabinol (THC).

General Safety Considerations

Older adults often demonstrate increased sensitivity to centrally acting medications due to age-related physiologic changes involving:

• Hepatic metabolism
• Renal clearance
• Body composition
• Neurotransmitter sensitivity
• Cognitive reserve

In addition, many residents within senior care settings are medically complex and may already be taking multiple sedating or psychoactive medications. Polypharmacy significantly increases the risk of falls, delirium, excessive sedation, hospitalization, and medication-related adverse events (Maher et al., 2014).

Common Side Effects

Most cannabinoid-related side effects are mild, reversible, and dose dependent. Side effects are more commonly associated with rapid titration or excessive THC exposure.

Potential Side Effects Include:

• Sleepiness or sedation
• Dizziness
• Dry mouth
• Fatigue
• Mild confusion
• Orthostatic symptoms
• Balance instability

These effects are typically temporary and often improve with:

• Dose reduction
• Slower titration
• Timing adjustments
• Reduction in THC exposure

CBD-dominant formulations without THC are generally associated with lower risk for psychoactive effects and are often better tolerated during initial implementation.

THC-Specific Considerations

Low-dose THC may provide clinically meaningful support for agitation, pain, appetite, emotional distress, and sleep; however, older adults may demonstrate increased sensitivity to psychoactive cannabinoids, particularly in the setting of dementia, frailty, or polypharmacy (Abuhasira et al., 2018).

This protocol utilizes buffered multi-cannabinoid THC formulations designed to improve tolerability by combining THC with cannabidiol (CBD), cannabigerol (CBG), and cannabinol (CBN). The presence of CBD may help moderate some of the psychoactive effects associated with THC exposure while supporting the therapeutic benefit (Lu & Mackie, 2021).

Fall Risk and Mobility Concerns

Sedation, dizziness, orthostatic hypotension, and impaired balance may increase fall risk, particularly in:

• Frail residents
• Residents with gait instability
• Individuals with dementia
• Patients taking sedating medications
• Residents with prior fall history

Additional monitoring is recommended:

• Following THC initiation
• During dose escalation
• Following PRN THC administration
• When combining cannabinoids with other sedating medications

Residents should be assessed regularly for:

• Gait changes
• Balance instability
• Excessive fatigue
• Altered mental status

Cognitive Considerations

Cognitive impairment does not automatically exclude residents from cannabinoid therapy; however, careful monitoring is essential in dementia and neurodegenerative populations. Potential concerns include:

• Increased confusion
• Sedation
• Delirium-like symptoms
• Behavioral worsening with excessive THC exposure

If cognitive adverse effects occur:

• Reduce THC exposure
• Return to the previously tolerated dose
• Slow titration further
• Reassess overall cannabinoid strategy

Conservative dosing and gradual escalation remain critical in cognitively vulnerable populations.

Drug Interaction Considerations

Cannabinoids may influence the metabolism of certain medications through cytochrome P450 (CYP450) hepatic enzyme pathways. Clinically significant interactions remain relatively uncommon at lower cannabinoid doses but should still be considered in medically complex residents taking multiple medications (Brown & Winterstein, 2019).

Use Additional Caution with Sedating Medications

Potential additive sedation may occur with:

• Benzodiazepines
• Sedative hypnotics
• Opioids
• Antipsychotics
• Muscle relaxants
  • Monitor for: Excessive sleepiness, respiratory suppression risk, increased fall risk, behavioral slowing

Anticholinergic Medications

This is particularly relevant in dementia populations. Antihistamines, bladder medications, and other anticholinergic drugs may increase risk for:

• Confusion
• Delirium
• Cognitive impairment
• Urinary retention

Blood Pressure Medications

Cannabinoids may contribute to:

• Mild blood pressure reduction
• Orthostatic hypotension
• Dizziness upon standing
• Monitor residents with: Frailty, dehydration risk, cardiovascular disease and history of falls.

Antidepressants and Mood Stabilizers

Most antidepressants demonstrate relatively low interaction risk with cannabinoids; however, clinicians should monitor for:

• Sedation
• Behavioral changes
• Altered medication response

Clinical Monitoring Recommendations: Routine medication dose adjustments are not typically required with conservative cannabinoid implementation, though clinical judgment should always guide care decisions.

• Review medication profile prior to initiation
• Introduce one cannabinoid variable at a time when possible
• Reassess following dose adjustments
• Monitor for unexpected sedation or behavioral change
• Coordinate with the interdisciplinary care team
• Reassess for pharmaceutical dose reductions with CBD efficacy

Hold or reduce cannabinoid dosing if residents experience:

• Excessive sedation
• New or worsening confusion
• Significant dizziness
• Increased fall risk
• Behavioral worsening
• Intolerable fatigue
• Marked gait instability

Once symptoms improve, cannabinoids may be restarted at a lower dose with slower titration if clinically appropriate.

Clinical Summary: When implemented within a structured protocol, cannabinoid-based care may be integrated safely into senior and palliative care settings. Most adverse effects are mild, reversible, and dose related. Safe implementation depends on:

• Conservative dosing
• Slow titration
• Interdisciplinary communication
• Ongoing monitoring
• Individualized care planning

The emphasis of this protocol remains symptom support, comfort, quality of life, and reduction of unnecessary medication burden while maintaining resident safety and dignity.

Importantly, available clinical and observational data, including recent systematic reviews, suggest that when cannabinoids are introduced conservatively and monitored appropriately, they are generally well tolerated in older adults and may offer a safer alternative or adjunct to higher-risk pharmacologic strategies used in dementia care.

Section 6: Frequently Asked Questions: Cannabinoid Care in Dementia & Senior Populations

Will this make my loved one “high”?

No. This protocol prioritizes non-intoxicating cannabinoids (CBD, CBG, CBDA) and introduces very low-dose THC only when needed, typically starting at ~1.25 mg.

At these levels, the goal is calm, comfort, and symptom support, not intoxication.

Is THC safe in older adults with dementia?

When used in low doses and carefully monitored, THC may support:

• Agitation
• Appetite
• Sleep
• Pain

The key difference is dose and formulation:

• Microdosing (1.25–2.5 mg)
• Buffered with CBD and other cannabinoids
• Slow titration

This is very different from recreational use.

How quickly will we see results?

• CBD (softgels): gradual effects over several days
• Sleep or Energy gummies: same-day functional response
• T65 (THC microdose): often noticeable within 30–90 minutes

Most protocols show meaningful trends within 3–7 days, though some individuals require several weeks of consistent dosing. A 4–6 week trial period is recommended before reassessment.

Can this replace medications?

Not immediately. However, facilities and providers may observe:

• Reduced agitation
• Improved sleep
• Less need for PRN medications

Over time, providers may consider medication adjustments, but this should always be done under supervision. Patience and dose adjustments are key to finding therapeutic benefits.

What symptoms respond best?

Most common improvements seen:

• Agitation and behavioral escalation
• Sleep disruption / sundowning
• Anxiety or distress
• Appetite loss
• Chronic discomfort

What if symptoms get worse?

This usually indicates:

• Dose too high
• THC introduced too quickly
• Sensitivity to cannabinoids

Action:

• Hold dosing
• Resume at lower level
• Slow titration

Is this legal in senior care facilities?

Hemp-derived cannabinoid products (CBD) are federally legal in the U.S., though facility policies vary. Staying abreast of federal and state policies is the best practice.
Implementation typically requires:

• Provider awareness or order
• Family consent
• Facility approval

Why use multiple cannabinoids instead of just CBD?

Different cannabinoids support different systems:

• CBD = calming, anti-inflammatory
• CBG = mood, focus, behavioral regulation
• CBN = sleep support
• THC = appetite, agitation, pain

Together, they create a more balanced, effective response.

Section 7: Case-Based Clinical Observations

Case 1: Agitation & Sundowning

Resident Profile: 82-year-old female with moderate Alzheimer’s disease
Symptoms: evening agitation, pacing, verbal distress

Intervention:

• Immunity softgel (daytime)
• Full spectrum softgel (evening)
• Added 1/4 T65 gummy at dinner

Outcome (5–7 days):

• Reduced evening agitation
• Improved sleep onset
• Less PRN medication use

Case 2: Withdrawal & Low Engagement

Resident Profile: 76-year-old male with vascular dementia
Symptoms: apathy, minimal social interaction

Intervention:

• Energy gummy (morning)
• Immunity softgel (afternoon)

Outcome (1 week):

• Increased participation in activities
• Improved mood and engagement

Case 3: Advanced Dementia with Pain & Restlessness

Resident Profile: 88-year-old in memory care
Symptoms: restlessness, poor sleep, suspected pain

Intervention:

• Immunity softgel (daytime)
• Full spectrum softgel (evening)
• Added ¼ T65 gummy (breakfast, lunch and dinner)
• Added 1 Sleep gummy (bedtime)

Outcome:

• Improved comfort
• Better sleep continuity
• Reduced distress behaviors

Section 8: Clinical Evidence and References

Cannabinoid-based therapeutics are being studied increasingly for their potential role in symptom management across geriatric, dementia, chronic illness, and palliative care populations. Although research in older adults remains an evolving field, current evidence suggests that cannabinoids may provide clinically meaningful support for behavioral symptoms, chronic pain, sleep disturbance, appetite dysregulation, emotional distress, and overall quality of life when implemented conservatively and monitored appropriately.

Interest in cannabinoid-based care has grown substantially in long-term care and palliative settings due to concerns surrounding polypharmacy, medication-related adverse effects, and limited efficacy of many conventional pharmacologic interventions in medically complex older adults (Maher et al., 2014).

Cannabinoids and Agitation in Dementia (Meta-Analytic Perspective): Agitation and behavioral dysregulation represent some of the most distressing and difficult-to-manage symptoms in dementia care. Traditional pharmacologic approaches, including antipsychotics and sedative medications, are associated with significant risks in older adults, including increased mortality, sedation, and cognitive decline.

A growing body of evidence, including systematic reviews and meta-analyses, suggests that cannabinoid-based therapies may reduce agitation and behavioral symptoms in patients with dementia. These analyses indicate that cannabinoids, particularly when administered in low doses and within structured protocols, may improve behavioral stability while maintaining acceptable safety profiles.

While heterogeneity in study design and formulations remains a limitation, the consistency of findings across observational studies, pilot trials, and emerging meta-analytic data supports continued clinical exploration of cannabinoid-based approaches in dementia-related agitation (Caplan, 2026).

These findings align with the clinical framework presented in this protocol, which emphasizes:

• Low-dose initiation
• Gradual titration
• Multi-cannabinoid formulations
• Functional outcome monitoring
• Safety-focused implementation

Dementia and Behavioral Symptoms: Behavioral and psychological symptoms of dementia (BPSD) including agitation, aggression, anxiety, sleep disruption, emotional dysregulation, and behavioral escalation remain among the most difficult symptoms to manage in memory care environments (Cerejeira et al., 2012).

Emerging evidence suggests cannabinoids may offer benefits for select behavioral symptoms associated with dementia. In an open-label pilot study evaluating medical cannabis oil in patients with dementia, Shelef et al. (2016) observed reductions in agitation, aggression, irritability, and caregiver distress with acceptable tolerability profiles.

Additional studies evaluating dronabinol, a synthetic tetrahydrocannabinol (THC) formulation, have demonstrated potential benefit for agitation and behavioral symptoms in severe dementia populations (Woodward et al., 2014). While larger randomized controlled trials remain needed, current findings support continued exploration of carefully titrated cannabinoid interventions within dementia care settings.

Anxiety, Emotional Distress, and Sleep: Cannabidiol (CBD) has demonstrated anxiolytic potential across both preclinical and human research. Proposed mechanisms include modulation of serotonin signaling, inflammatory pathways, stress response systems, and autonomic regulation (Blessing et al., 2015).

Sleep disturbance is highly prevalent among older adults and may worsen behavioral symptoms, caregiver burden, cognition, and overall quality of life. Cannabinoids, particularly formulations combining CBD and low-dose THC, have shown potential benefit for sleep initiation, nighttime restlessness, and sleep continuity in observational and clinical studies (Babson et al., 2017).
Within senior care settings, low-dose nighttime cannabinoid support may help reduce reliance on sedative hypnotics and other medications associated with increased fall risk and cognitive impairment.

Chronic Pain and Palliative Care: Chronic pain remains one of the most common and undertreated symptoms among older adults. Conventional pain management strategies, particularly opioids, may contribute to sedation, constipation, delirium, falls, and reduced quality of life in geriatric populations.

A large systematic review published in JAMA concluded that cannabinoids may provide modest but clinically meaningful benefits for chronic pain, spasticity, nausea, and symptom burden across multiple patient populations (Whiting et al., 2015).

Cannabinoid-based therapies are increasingly explored within palliative and comfort-focused care due to their potential ability to simultaneously support:

• Pain management
• Sleep
• Appetite
• Emotional distress
• Anxiety
• Behavioral comfort

In observational studies involving older adults, carefully monitored cannabinoid protocols have generally demonstrated favorable tolerability profiles when low-dose initiation and gradual titration strategies are utilized (Abuhasira et al., 2018).

Endocannabinoid System and Multi-Cannabinoid Support: The endocannabinoid system plays an important role in regulation of neurologic signaling, inflammation, stress response, sleep, appetite, mood, pain perception, and immune modulation (Lu & Mackie, 2021). Dysregulation within these systems may contribute to symptom burden commonly observed in dementia, chronic illness, and advanced age.

This protocol emphasizes multi-cannabinoid formulations containing cannabidiol (CBD), cannabigerol (CBG), cannabinol (CBN), cannabidiolic acid (CBDA), and carefully titrated low-dose THC. Emerging pharmacologic evidence suggests cannabinoid synergy and receptor modulation may contribute to broader therapeutic activity than isolated cannabinoids alone (Nachnani et al., 2021).

Buffered low-dose THC formulations may also improve tolerability by moderating psychoactive burden while preserving therapeutic effects relevant to sleep, appetite, behavioral regulation, and pain support.

Clinical Perspective: Current evidence supports cautious optimism regarding the role of cannabinoid-based therapeutics within senior and palliative care settings. While additional randomized controlled trials remain necessary, existing observational studies, clinical experience, mechanistic evidence, and emerging geriatric data suggest cannabinoids may provide meaningful symptom support for select older adults when implemented within a structured clinical framework.

Cannabinoid-based therapeutics should not be viewed as stand-alone replacements for comprehensive medical care, but rather as potential adjunctive tools that may improve comfort, reduce symptom burden, support quality of life, and potentially lessen reliance on higher-risk medications in appropriate patient populations.

Disclaimer: This protocol is intended for educational and clinical implementation guidance purposes only and does not replace individualized medical assessment, diagnosis, or treatment planning. Cannabinoid therapy should be implemented under the supervision of a licensed healthcare professional and individualized according to resident needs, goals of care, medication profile, and clinical response. State and federal regulations regarding cannabinoid products vary and should be reviewed prior to implementation.

Bloom Hemp CBD Products – Green Nurse Approved Products

• Bloom Hemp Advanced Immunity Softgels (THC Free)
• Bloom Hemp Full Spectrum Softgels (Low THC)
• Bloom Hemp Energy Gummies (THC Free)
• Bloom Hemp Sleep Gummies (THC Free)
• Bloom Hemp Advanced T65 Gummies (Low THC)

Holistic Caring & The Green Nurse – Education, Coaching & Consulting

• Professional Programs
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References

Abuhasira, R., Schleider, L. B. L., Mechoulam, R., & Novack, V. (2018). Epidemiological characteristics, safety and efficacy of medical cannabis in the elderly. *European Journal of Internal Medicine, 49*, 44–50. https://doi.org/10.1016/j.ejim.2018.01.019

American Geriatrics Society Beers Criteria® Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. *Journal of the American Geriatrics Society, 71*(7), 2052–2081. https://doi.org/10.1111/jgs.18372

Babson, K. A., Sottile, J., & Morabito, D. (2017). Cannabis, cannabinoids, and sleep: A review of the literature. Current Psychiatry Reports, 19(4), 23. https://doi.org/10.1007/s11920-017-0775-9

Blessing, E. M., Steenkamp, M. M., Manzanares, J., & Marmar, C. R. (2015). Cannabidiol as a potential treatment for anxiety disorders. *Neurotherapeutics, 12*(4), 825–836. https://doi.org/10.1007/s13311-015-0387-1

Brown, J. D., & Winterstein, A. G. (2019). Potential adverse drug events and drug-drug interactions with medical and consumer cannabidiol (CBD) use. Journal of Clinical Medicine, 8(7), 989. https://doi.org/10.3390/jcm8070989

Caplan, B. (2026, May 8). Cannabinoids Dementia Agitation: Meta-Analysis Evidence. CED Clinic. https://cedclinic.com/cannabinoids-dementia-agitation-meta-analysis/

Cerejeira, J., Lagarto, L., & Mukaetova-Ladinska, E. B. (2012). Behavioral and psychological symptoms of dementia. *Frontiers in Neurology, 3*, 73. https://doi.org/10.3389/fneur.2012.00073

Lu, H. C., & Mackie, K. (2021). An introduction to the endogenous cannabinoid system. *Biological Psychiatry, 79*(7), 516–525. https://doi.org/10.1016/j.biopsych.2015.07.028

Maher, R. L., Hanlon, J., & Hajjar, E. R. (2014). Clinical consequences of polypharmacy in elderly. *Expert Opinion on Drug Safety, 13*(1), 57–65. https://doi.org/10.1517/14740338.2013.827660

Nachnani, R., Raup-Konsavage, W. M., & Vrana, K. E. (2021). The pharmacological case for cannabigerol. *Journal of Pharmacology and Experimental Therapeutics, 376*(2), 204–212. https://doi.org/10.1124/jpet.120.000340

Shelef, A., Barak, Y., Berger, U., Paleacu, D., Tadger, S., Plopsky, I., & Baruch, Y. (2016). Safety and efficacy of medical cannabis oil for behavioral and psychological symptoms of dementia: An open-label, add-on, pilot study. *Journal of Alzheimer’s Disease, 51*(1), 15–19. https://doi.org/10.3233/JAD-150915

Whiting, P. F., Wolff, R. F., Deshpande, S., Di Nisio, M., Duffy, S., Hernandez, A. V., Keurentjes, J. C., Lang, S., Misso, K., Ryder, S., Schmidlkofer, S., Westwood, M., & Kleijnen, J. (2015). Cannabinoids for medical use: A systematic review and meta-analysis. *JAMA, 313*(24), 2456–2473. https://doi.org/10.1001/jama.2015.6358

Woodward, M. R., Harper, D. G., Stolyar, A., Forester, B. P., & Ellison, J. M. (2014). Dronabinol for the treatment of agitation and aggressive behavior in acutely hospitalized severely demented patients with noncognitive behavioral symptoms. American Journal of Geriatric Psychiatry, 22(4), 415–419. https://doi.org/10.1016/j.jagp.2012.11.022