Letter to the Editor
In Response to: Martínez-Velilla N. GesEPOC Guidelines and Elderly Patients
Respuesta a: Martínez-Velilla N. Guía GesEPOC y pacientes ancianos
a Servicio de Neumología, Hospital Universitari Vall d’Hebron, Ciber de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
b Fundación Caubet-Cimera, Bunyola, Illes Balears, Spain
c Unidad de Geriatría de Agudos, Servicio de Medicina Interna, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain
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GesEPOC Guidelines and Elderly Patients" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">To the Editor</span>:" "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "155" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Marc Miravitlles, Joan B. Soriano, Pere Almagro" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Marc" "apellidos" => "Miravitlles" "email" => array:1 [ 0 => "mmiravitlles@vhebron.net" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Joan B." "apellidos" => "Soriano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Pere" "apellidos" => "Almagro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Universitari Vall d’Hebron, Ciber de Enfermedades Respiratorias (CIBERES), Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Fundación Caubet-Cimera, Bunyola, Illes Balears, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Unidad de Geriatría de Agudos, Servicio de Medicina Interna, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Respuesta a: Martínez-Velilla N. Guía GesEPOC y pacientes ancianos" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We welcome the comments on GesEPOC guidelines by Martínez-Velilla, and we agree with his assessment of the difficulty in diagnosis and treatment of COPD in the elderly patients.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> As noted in his letter, the prevalence of COPD in our country is known to increase with age and smoking history. Despite this, the mean age of patients included in clinical trials is typically around 65 years, with underrepresentation of older patients. Moreover, aging causes a number of functional and anatomical changes that partly resemble those produced by COPD itself, which has led some authors to consider the disease as accelerated lung aging.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Another aspect to consider is that the diagnostic criterion of bronchial obstruction based on an FEV<span class="elsevierStyleInf">1</span>/FVC ratio <0.7 leads to overdiagnosis in the elderly patients.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> For this reason, the GesEPOC guidelines recommend referring to the lower limit of normal in patients older than 70 years.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We also agree with the author on the greater difficulty of performing some explorations in this population. Although age alone does not preclude spirometric quality, it does increase the time required for its completion. In patients with cognitive impairment, the Mini-Mental State Test can be used to predict which patients will successfully perform spirometry.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In any case, spirometry is currently essential for the diagnosis of COPD, although its performance in the elderly patients can be simplified with the use of the FEV<span class="elsevierStyleInf">1</span>/FEV<span class="elsevierStyleInf">6</span> ratio.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Regarding the walking test, GesEPOC indicates that it should be substituted by the number of previous severe exacerbations (BODEx index)<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> when it cannot be performed.</p><p id="par0015" class="elsevierStylePara elsevierViewall">It is also true that most clinical practice guidelines are focused on specific diseases, and strict application in patients with multimorbidity may often be ineffective and even counterproductive, as iatrogenesis may be an issue. This stems from the lack of solid scientific evidence (necessary in clinical practice guidelines) on the simultaneous management of multiple complex chronic diseases, and means that treatment goals must be adapted to therapeutic priorities and patients’ wishes. Guidelines will never be able to encompass all the scenarios encountered in everyday clinical practice and cannot (nor do they aim to) replace the clinical judgment of each physician with his/her patient. Thus, in the case of COPD, recent studies have identified as many as 36 different comorbidities occurring at a rate of over 5%.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> These can present in many combinations in patients, leading to a possibly infinite variety of situations that no guidelines will ever be able to address. We believe that the recommendations in the guidelines, with the logical and necessary adaptations to the particular conditioning factors of individual patients, are applicable to most of the population with the disease. GesEPOC also includes aspects that are not fully addressed in other guidelines, such as respiratory rehabilitation during exacerbation, a chapter on comorbidities and another on palliative treatment. However, we recognize the need for new adaptations and collaborative efforts in subsequent revisions of the guidelines to which fellow geriatricians can make important contributions.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Miravitlles M, Soriano JB, Almagro P. Respuesta a: Martínez-Velilla N. Guía GesEPOC y pacientes ancianos. Arch Bronconeumol. 2014;50:155.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "GesEPOC guidelines and elderly patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "N. 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| 2020 July | 31 | 16 | 47 |
| 2020 June | 13 | 7 | 20 |
| 2020 May | 31 | 10 | 41 |
| 2020 April | 38 | 15 | 53 |
| 2020 March | 21 | 14 | 35 |
| 2020 February | 30 | 14 | 44 |
| 2020 January | 25 | 14 | 39 |
| 2019 December | 24 | 15 | 39 |
| 2019 November | 28 | 15 | 43 |
| 2019 October | 11 | 5 | 16 |
| 2019 September | 9 | 6 | 15 |
| 2019 August | 17 | 15 | 32 |
| 2019 July | 17 | 15 | 32 |
| 2019 June | 14 | 5 | 19 |
| 2019 May | 29 | 16 | 45 |
| 2019 April | 13 | 12 | 25 |
| 2019 March | 34 | 16 | 50 |
| 2019 February | 38 | 13 | 51 |
| 2019 January | 22 | 16 | 38 |
| 2018 December | 31 | 18 | 49 |
| 2018 November | 75 | 14 | 89 |
| 2018 October | 93 | 15 | 108 |
| 2018 September | 32 | 7 | 39 |
| 2018 May | 20 | 0 | 20 |
| 2018 April | 26 | 11 | 37 |
| 2018 March | 49 | 1 | 50 |
| 2018 February | 52 | 6 | 58 |
| 2018 January | 126 | 10 | 136 |
| 2017 December | 69 | 4 | 73 |
| 2017 November | 21 | 4 | 25 |
| 2017 October | 17 | 8 | 25 |
| 2017 September | 27 | 7 | 34 |
| 2017 August | 37 | 13 | 50 |
| 2017 July | 23 | 7 | 30 |
| 2017 June | 44 | 11 | 55 |
| 2017 May | 36 | 4 | 40 |
| 2017 April | 24 | 5 | 29 |
| 2017 March | 28 | 2 | 30 |
| 2017 February | 10 | 5 | 15 |
| 2017 January | 10 | 1 | 11 |
| 2016 December | 22 | 5 | 27 |
| 2016 November | 36 | 10 | 46 |
| 2016 October | 32 | 14 | 46 |
| 2016 September | 26 | 7 | 33 |
| 2016 August | 37 | 9 | 46 |
| 2016 July | 22 | 8 | 30 |
| 2016 May | 1 | 0 | 1 |
| 2016 April | 1 | 0 | 1 |
| 2016 March | 1 | 0 | 1 |
| 2015 December | 3 | 0 | 3 |
| 2015 October | 31 | 1 | 32 |
| 2015 September | 39 | 6 | 45 |
| 2015 August | 38 | 11 | 49 |
| 2015 July | 32 | 8 | 40 |
| 2015 June | 34 | 4 | 38 |
| 2015 May | 40 | 3 | 43 |
| 2015 April | 29 | 10 | 39 |
| 2015 March | 27 | 3 | 30 |
| 2015 February | 29 | 5 | 34 |
| 2015 January | 37 | 5 | 42 |
| 2014 December | 15 | 6 | 21 |
| 2014 November | 21 | 5 | 26 |
| 2014 October | 40 | 12 | 52 |
| 2014 September | 19 | 9 | 28 |
| 2014 August | 34 | 14 | 48 |
| 2014 July | 35 | 10 | 45 |
| 2014 May | 2 | 2 | 4 |
| 2014 April | 2 | 0 | 2 |
Show all
