We would like to congratulate the authors of the updated GesEPOC guidelines,1 a document that when it was first published marked a turning point in the management of chronic obstructive pulmonary disease (COPD) in Spain. These guidelines have now been enriched by contributions from new scientific societies and a more comprehensive and integrated perspective. However, as with many other diseases, the treatment of COPD in the elderly patient is very complex, and it can be particularly difficult to address all the factors associated with aging. We believe, then, that some of the following suggestions may be helpful in subsequent revisions of the document.

When analyzing geriatric syndromes that play a significant role in the different diagnostic and therapeutic procedures, we must look beyond the conventional clinical evaluation. A comprehensive geriatric assessment must include not only social factors, but also situations such as visual and auditory defects, functional and cognitive deficits, and musculoskeletal disorders such as sarcopenia. The latter, for instance, can impact on the inhalation technique, impeding the correct use of devices and influencing diagnostic accuracy.

Moreover, while comorbidities have been recognized as a major factor in the management of COPD patients, additional problems such as dementia, including early-stage disease, must be taken into account in the elderly. Exacerbations are associated with cognitive impairment, and can even be a key factor in destabilizing a patient, tipping the scales toward a diagnosis of acute confusional state or dementia.2 The significant comorbidity burden in this population means that polypharmacy is almost unavoidable, and this increases the risk of pharmacological iatrogeny in an already vulnerable population. Deprescription, the use of corticosteroids and their side effects, and the need for a simpler approach to high blood sugar are some of the aspects that must be addressed in future consensus documents.

A very important factor that must also be taken into account is the concept of frailty. The prevalence of frailty and pre-frailty in this population has been reported in some studies to be 6.6% and 41.3%, respectively.3 These figures in themselves reflect the importance of detecting this clinical characteristic in order to provide early intervention.4 Closely linked to the concept of frailty is the concept of functionality. Conventional models are based on the quantitative and qualitative evaluation of diseases, and focus mainly on this paradigm. However, this old-fashioned system of approaching medicine on the basis of isolated diseases has become outdated.5 The health of elderly individuals must be measured in terms of function and not disease, since functionality is the parameter that determines life expectancy and quality of life, and the support and resources that our patients will require, and is one of the best indicators of health status and a predictor of adjuvant disability.