Table 1.

SUD (formerly substance abuse or dependence) criteria^a

DSM-5 Criteria for SUD	Consideration for Older Adult
A substance is often taken in larger amounts or over a longer period than was intended.	Cognitive impairment can prevent adequate self-monitoring. Substances themselves may more greatly impair cognition among older adults than younger adults.
There is a persistent desire or unsuccessful efforts to cut down or control substance use.	It is the same as the general adult population.
A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.	Consequences from substance use can occur from using relatively small amounts.
There is craving or a strong desire to use the substance.	It is the same as the general adult population. Older adults with entrenched habits may not recognize cravings in the same way as the general adult population.
There is recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or at home.	Role obligations may not exist for older adults in the same way as for younger adults because of life-stage transitions, such as retirement. The role obligations more common in late life are caregiving for an ill spouse or family member, such as a grandchild.
There is continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.	Older adults may not realize the problems they experience are from substance use.
Important social, occupational, or recreational activities are given up or reduced because of substance use.	Older adults may engage in fewer activities regardless of substance use, making it difficult to detect.
There is recurrent substance use in situations in which it is physically hazardous.	Older adults may not identify or understand that their use is hazardous, especially when using substances in smaller amounts.
Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.	Older adults may not realize the problems they experience are from substance use.
Tolerance is developed, as defined by either of the following: A need for markedly increased amounts of the substance to achieve intoxication or the desired effect A markedly diminished effect with continued use of the same amount of the substance	Because of the increased sensitivity to substances as they age, older adults will seem to have lowered rather than increase in tolerance.
Withdrawal, as manifested by either of the following: The characteristic withdrawal syndrome for the substance The substance or a close relative is taken to relieve or avoid withdrawal symptoms	Withdrawal symptoms can manifest in ways that are more “subtle and protracted.” Late-onset substance users may not develop physiologic dependence; or nonproblematic users of medications, such as benzodiazepines, may develop physiologic dependence.

^aSUD is defined as a medical disorder in which 2 or more of the aforementioned listed symptoms are occurring in the last 12 months

Adapted from Barry KL, Blow FC, Oslin DW. Substance abuse in older adults: review and recommendations for education and practice in medical settings. Subst Abus 2002;23(Suppl 3):105–31; and Data from American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th edition. Arlington (VA): American Psychiatric Publishing; 2013. p. 491.

From Kuerbis A., Sacco P., Blazer D., Moore AA. Substance abuse among older adults. Clin Geriatr Med 2014; 30: 629–54; with permission.