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Multiple myeloma is primarily a disease of older age, with a median age of 70 years at diagnosis. Management of the disease in this diverse population is challenging, in the face of comorbidities and frailties. Areas covered: This review discusses the management challenges of elderly myeloma patients in view of the current evidence and propose for performing a formal objective assessment of the functional status to guide choice of treatment. Expert commentary: The approval of many antimyeloma medications with various mechanisms of action in the past two decades had sparked the debate about choosing the best combination, duration of therapy, role of transplant and the possibility to cure myeloma after being changed to a chronic disease. Indeed, among these debates are the choice of treatment for the elderly population and approaches that might help in clinical decision making particularly with the encouraging response and survival results of newer therapies. In this population, a balance between efficacy and toxicity is required to achieve prolongation of survival while maintaining the quality of life. Objective assessment of functional status might help in this task. Prospective randomized trials specifically addressing the needs for this population is certainly required to allow for more informed treatment decisions.