I would like to congratulate all the professionals involved in developing the GesEPOC guidelines [Spanish COPD guidelines] for their excellent review and recommendations.1 However, I sadly have difficulties in extrapolating their conclusions to the type of patient I usually see in Geriatric Departments, even though one of the most common diagnoses encountered there is chronic obstructive pulmonary disease (COPD) or its respective exacerbations. In fact, it is surprising that patients over the age of 80 were excluded from one of the largest studies on the prevalence of COPD in Spain,2 when all studies indicate that it is one of the most significant and common diseases in the elderly, and equally surprising is that elderly patients are hardly mentioned in the guidelines.

Since interpretation in multimorbid patients is a highly complex task, elderly populations are routinely excluded from trials in numerous disciplines, and the evidence obtained from young populations in a generally better state of health is taken as valid for older populations. However, in the case of COPD, extrapolating the evidence from the younger population has a series of important limitations.

From a diagnostic point of view, for example, some patients may present deafness, impaired vision or sarcopenia (among other limitations), causing difficulties in the correct performance and, as a result, the correct interpretation of spirometry tests. Functional or cognitive deficits can make complex tests, or even something as simple as the 6-min-walk test, difficult to perform and interpret. Most clinical guidelines have numerous limitations, since they do not evaluate the elderly patient's wide range of needs, and the evidence obtained from these guidelines habitually underestimates the prevalence of side effects, multimorbidity and polypharmacy, as well as the functional, cognitive and social aspects, and does not reflect the clinical reality.3–5 From a treatment point of view, special consideration must be given to the iatrogenic effects that can occur in already polymedicated patients, since many of the drugs regularly used in COPD can have significant side effects in the elderly. In addition, the incorrect administration of inhaled therapies can lead not only to possible poor treatment compliance but also to poorer results from conventional treatments. Given the wide heterogeneity of this population, specific guidelines adapted and stratified according to grades of frailty, such as those already beginning to appear for some diseases like diabetes, are required.6

Although the new clinical practice guidelines in the treatment of patients with COPD (GesEPOC) are very useful, for these reasons I feel that they are limited in their use in elderly patients and could be substantially improved in this sector of the population. Despite the obvious difficulties in dealing with all aspects of COPD universally, assigning a section exclusively to the elderly patient would provide significant benefits for their clinical management. For future editions, I would urge the authors to call on professional geriatric societies to contribute with their complementary point of view.