xii congreso de la sociedad castellano-manchega de ... · people older than 65 años with...

XII Congreso de la SociedadCastellano-Manchega deGeriatría y Gerontología

FRAGILIDAD Y DEMENCIA

Dr. Leocadio Rodríguez MañasJefe del Sº de Geriatría

CONTENIDO DE LA CONFERENCIA A) Descripción del escenario. ¿Qué ha pasado? B) Envejecimiento y salud vs Envejecimiento y discapacidad

C) La fragilidad: ¿de qué estamos hablando? C) Enfermedad neurodegenerativa y dependencia: el caso de la demencia

D) Conclusiones-Propuestas

Halley, first life table, 1693

10 20 30 40 50 60 70 80 90 100 110 120

Halley 1687-1691

Japan 1980-1984

10 20 30 40 50 60 70 80 90 100 110 120

Halley 1687-1691

Sweden 1754-1756

Switzerland 1876-1880

Japan 1950-1954

Japan 1980-1984

Las Pirámides de población en la España del siglo XX

Evolución de la población alemana (Christensen et al., Lancet 2009)

FOD-CC

HEALTHY LIFE YEARSAT AGE 65

How many newborn are becoming adults?

100000

1751 1776 1801 1826 1851 1876 1901 1926 1951 1976 2001

DenmarkEnglandFranceJapanNetherlandsNorwaySwedenSwitzerlandUSA

sex women

Somme de lx

country

100000

1920 1930 1940 1950 1960 1970 1980 1990 2000 2010

100000

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Christensen et al. Lancet 2009

MUJERES HOMBRES

1946 1949 1952 1955 1958 1961 1964 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000 2003 2006

Female Male Total

Change in the number of centenarians in Spain

HMD data

The centenarian rate in Europe

Robine and Saito, 2009

Change in the number of centenarians in Europe vs Japan

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010

Number of centenarians (100+)

Females Males Total

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010

Number of centenarians (100+)

Fourteen European countries

Male Female Total

More than 40,000 centenarians in Japan in 2009

1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010

Number of centenarians

Females

Centenarians in Japan

August 14, 2010

There is no evidence that the maximum human life span has

changed from what it was about a hundred thousand years

ago…

Hayflick, 1996

How long are adult life durations?

20 40 60 80 100 120

1876-80

1929-32

1988-93

Modal length of life (M)

Maximum

life span Distribution of the ages at death in SwitzerlandDistribution of the ages at death in Switzerland

1876-1880, 1929-1932, 1988-19931876-1880, 1929-1932, 1988-1993

Maximum life expectancy

C) La fragilidad: ¿de qué estamos hablando? D) Enfermedad neurodegenerativa y dependencia: el caso de la demencia

E) Conclusiones-Propuestas

¿DE QUE ESTAMOS HABLANDO?

¿DE VIVIR MAS?

¿DE VIVIR MEJOR?

….QUE ES VIVIR SIN ENFERMEDAD

….QUE ES VIVIR SIN DISCAPACIDAD

Frailty

Disability

“Failure to thrive”

Successful

Accelerated

LONGEVIDAD

FRAGILIDAD/DISCAPACIDAD

“He llegado a una conclusión totalmente errónea, lo que demuestra mi querido Watson, lo peligroso que es razonar a partir de datos insuficientes.”

Sherlock Holmes en“The speckled band”

‘Llegaremos a vivir 1000 años'

Aubrey de Grey• Aubrey de Grey: "The first person to live to 1,000 might be 60 already“

• Cambridge University geneticist Aubrey de Grey believes it will soon extend dramatically to 1,000. Here, he explains why.

• http://news.bbc.co.uk/1/hi/uk/4003063.stm

OBJETIVOS¿Moscas longevas sin

alas?Un biólogo presentó un trabajo sobre moscas longevas. Un demógrafo que estaba en la sala preguntó: ¿Qué aspecto tienen esas moscas? El biólogo contestó: “Oh, sus alas cayeron”

Las políticas sanitarias y los tratamientos centrados en la longevidad aun a costa de producir discapacidad (análogas a moscas sin alas) son inaceptables en las sociedades humanas. Verbrugge, 2005

HEALTHY AGING???

People older than 65 años with disability1999 National Long-Term Care Survey.USA

PNAS, 2001

10121416182022242628

1982 1984 1989 1994 1999

Decrease

(1.47%/y)

26.2%24.2%

Participantes 1986 (%) 1999 (%) Diferencia (%)

Hombres Total 65-69 70-74 75-79 80-84 ≥85

750.192 (39,88)25,7535,6345,3362,6676,85

524.830 (19,28)11,0715,3023,3330,8146,92

-51,64-57,02-57,07-48,54-50,83-38,94

Mujeres Total 65-69 70-74 75-79 80-84 ≥85

1.332.261 (48,98)31,0140,8451,0767,5486,41

1.068.302 (28,06)14,6624,1731,7740,1455,40

-42,70-52,71-47,42-37,80-40,56-35,88

Porcentaje de >65 años con discapacidad en España (1986-1999).Encuesta Nacional de Discapacidad.

Sagarduy-Villamor et al, J Gerontol Med Sci 2005; 60A: 1028-1034.

Dependencia en AVD Instrumentales (Lawton)

ETES 2009 (AZUL) ETE 1994 (ROJO)

Newcastle 85+ cohort studyBMJ, 2009

AutopercepciónEstado de Salud

Global(%)

Mujeres(%)

Hombres(%)

Excelente 10,3 9,5 11,7

Muy bueno 29,7 28,1 32,3

Bueno 37,6 38,2 36,7

Regular 18,9 20,2 16,8

Pobre 3,5 4,1 2,5

Percepción del estado de salud en mayores de 85 años

PACIENTE CLASICO

Enfermedad aguda única

Sin repercusión funcional

Sin secuelas funcionales

PACIENTE CONTEMPORANEO

Enfermedades crónicas y múltiples

Con frecuentes reagudizaciones

Con repercusión funcional

Con secuelas funcionales

Características del Paciente del Siglo XXICaracterísticas del Paciente del Siglo XXI

Rodríguez-Mañas; 2001

65 70 75 80 85

5%10%25%50%NORMAL

65 70 75 80 85

Edad al diagnóstico

Welch HG et al., Ann Intern Med 1996; 124: 577-584.

MUJERES HOMBRES

29 JULY 2011 VOL 333 SCIENCE

Between 2008 and 2030 chronic diseases will maintain their leadership

in determining death…and disability

Causes of mortality (2008-2030)

ENVEJECIMIENTO

ENF. CRONICA

DISCAPACIDAD

Solo una pequeña proporción de ancianos con 2 ó mas enfermedades crónicastienen fragilidad o discapacidad; algunas personas sin enfermedad (o muy leve)muestran los clásico signos de la fragilidad

ETIOLOGY OF CATASTROPHYC*vs. PROGRESSIVE DISABILITY

(Ferrucci et al; JAMA 1997; 277: 728-734)

*(dependency in ≥ 3 BAVD in 1 yr.)

Weiss, 2011

CHRONIC DISEASE AND TASKS ASRISK FACTORS FOR ADVERSE OUTCOMES

Boyd CM, The American Journal of medicine (2005) 118:1225

(JAGS 2008; 56: 2171-9)

Situación funcional a los tres meses del alta

Declinan 41 9 23 19

Igual 49 87 16 70

Mejoran 10 4 61 11

declinan igual mejoran total (n=320) (n=656) (n=96) (n=1072)

Cambio en AVD básicas durante hospitalización (%)

Sager MA, Functional Outcomes of acute medical illnes andHospitalizatión in older person. Arch Intern Med 1996; 156: 645-52)

Situación funcional a los tres meses del alta

Declinan 53 34 34 40

Igual 29 43 33 38

Mejoran 18 23 33 22

declinan igual mejoran total (n=320) (n=656) (n=96) (n=1072)

Cambio en AVD instrumentales durante hospitalización (%)

Sager MA, Functional Outcomes of acute medical illnes andHospitalizatión in older person. Arch Intern Med 1996; 156: 645-52)

Biological, Psychological,Social, societal modifiers/assets and deficits

Frailty: a Complex Syndrome of Increased Vulnerability

Prevent/Delay FrailtyHealth Promotion and Prevention

Delay Onset

Delay/Prevent adverse outcomes, care

FRAILTY

Life-courseDeterminants: Biological (including genetic)PsychologicalSocial, SocietalEnvironment

Chronic Disease

Decline in physiologic reserve

Adverse outcomes•Disability•Morbidity•Hospitalization•Institutionalization•Death

Candidate markers

•Nutrition•Mobility•Activity•Strength•Endurance•Cognition•Mood

Modified from Bergman H, 2008

Frailty: a Complex Syndrome of Increased Vulnerability

Delay Onset

Delay/Prevent adverse outcomes, care

FRAILTY

Chronic Disease

Adverse outcomes•Disability•Morbidity•Hospitalization•Institutionalization•Death

Candidate markers

•Nutrition•Mobility•Activity•Strength•Endurance•Cognition•Mood

Modified from Bergman H, 2008

We need to treat or to prevent disability in old people

…We do not know exactly its causes

nor what can prevent or improve it…but we are trying to

find it out!

Hans Baldung Grien

[Las edades y la muerte.

Museo del Prado-Madrid]

N= 2.494 participants

1965measurements

1752samples

InterviewPurpose

Determine frailty and disability models. Physiopathological basis

PhenotypeDetermine predicting factorsfor disability over time. Determine precipitant factors of events. Determine aging models.

40 ml(4 tubos)

10 ml (sin EDTA)

20 ml(EDTA)

10 ml(EDTA)

SERUM1º Coagular (15 min)

2º Centrifugar3º Congelar

CELLS1º Lavar en suero frío x 22º Centrifugar (3.000 rpm)

PLASMA

Sevilla (4 Tubos)

- 2 tubos de 2,5 ml suero- 1 ml sangre+1ml agua destilada- 1 ml plasma

Dario (6 Tubos)

-5 tubos 1 ml células- 1 ml plasma

Mónica (3 Tubos)

- 1 ml células.- 2 tubos 1 ml plasma.

Pepe Viña (1 Tubo)

- 1 ml sangre (con EDTA)

Franjo (1 Tubo)

- 1 ml células

LAB SAMPLES

Sarcopenia

RATIONALE

• There is a necessity to identify old people at high risk for developing some outcomes

• There are many definitions.• With different conceptual frameworks and domains.• The criteria are not universally applicable. Depending

upon the used definition, the prevalence comes from <5% to >80%

• The definitions have been validated in epidemiological settings, but not in clinical ones

FOD-CC

Frailty: a Complex Syndrome of Increased VulnerabilityComplex problems require complex solutions

Delay Onset Delay/Prevent adverse outcomes, care

FRAILTY

Chronic Disease

Adverse outcomes• Disability• Morbidity

• Hospitalization• Institutionalization• Death

Candidate markers• Nutrition

• Mobility• Activity

• Strength• Endurance

• Cognition• Mood

PREVENTION OF IMPAIRMENT

INJURY DISABILITY DEPENDENCY

USUAL TIME OFDIAGNOSIS

APPROPRIATE TIME FOR INTERVENTION

Why do we need an operational definition of frailty?FOD-CC

Vigoroso Frágil Dependiente

ROBUST FRAIL DISABLED

Why do we need an operational definition of frailty?FOD-CC

To identify old people at risk of Disability Adverse Health outcomes

MortalityMorbidityHospitalizationPermanent institutionalization

To manage them in a different way

FOD-CC

Sternberg SA et al., JAGS 2011

RATIONALE

There are many definitions.• With different conceptual frameworks and domains.• The criteria are not universally applicable. Depending

FOD-CC

Definition AuthorFrailty is a loss of resources in several domains of functioning, which leads to a declining reserve capacity for dealing with stressors.

Schuurmans et al. (2004)

A syndrome involving grouping of problems and losses of capacities in multiple domains, which make the individual vulnerable to environmental challenge

Strawbridge et al. (1998)

A syndrome of multisystem reduction in reserve capacity as a result of which an older person’s function may be severely compromised by minor environmental stresses, giving rise to the condition of ‘‘unstable disability.’’

Campbell et al. (1997)

A biologic syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiologic systems, causing vulnerability to adverse outcomes.

Fried et al. (2001)

A combination of biological, physiological, social, and environmental changes that occur with advancing age and increase vulnerability to changes in the surroundings and to stress.

Nourhashémi et al. (2001)

A vulnerability state resulting from a precarious balance between the assets maintaining health and the deficits threatening it.

Rockwood et al. (1994)

A state of reduced physiological reserve associated with increased susceptibility to disability. Buchner et al. (1992)

A combination of aging, disease, and other factors that make some people vulnerable. Rockwood et al. (1999)

Complex and cumulative expression of altered homeostatic responses to multiple stresses resulting in metabolic imbalance.

Hamerman et al. (1999)

Frailty is diminished ability to carry out important practical and social activities of daily living. Brown et al. (1995)

A state of being neither ’’too independent’’ nor ‘‘too impaired’’ that puts the person at risk for adverse health outcomes.

Winograd et al. (1988)

Ranking of conceptual definitions of frailty definition according to a consensus of experts

Table from Gobbens et al., J Am Med Dir Assoc 2010; 11:338-343

RATIONALE

• There are many definitions.With different conceptual frameworks and domains.• The criteria are not universally applicable. Depending

FOD-CC

Instrument/studyNutritional

statusPhysical activity

Mobility Strength Energy Cognition MoodSocial

relations/social support

Modified Functional + - + - - - - -IndependenceMeasure(FIM)/Carlson et al.(1998)

Instrument - - + - - - - -‘Gealey’/Gealey (1997)

Frail Elderly Functional - - + - - - - -AssessmentQuestionnaire/Gloth et al. (1995, 1999)

Instrument ‘Chin A + + - - - - - -Paw’/Chin A Paw et al. (1999)

Instrument + + + - - - + +‘Winograd’/Winograd et al. (1991)

Self-report Screening - - + - - - - -Instrument/Brody (1997)

Table from de Vries et al. Ageing Research Reviews 10 (2011) 104-114

Frailty instruments assessed on frailty factors, publications before 2000FOD-CC

Frailty instruments assessed on frailty factors, publications since 2000 - A

Frailty Phenotype/Fried et al. (2001) + + + + + - - -, Cigolle et al. (2009), Kiely et al. (2009), and Rockwood et al.(2007)

Frailty Index, + + + + + + + +accumulation ofdeficits/Mitnitski et al. (2001), Cigolle et al. (2009), Rockwood et al. (2007, 2006)

Instrument + + + + - - - -‘Carriere’/Carriere et al. (2005)

Groningen Frailty + - + - - + + +Indicator(GFI)/Schuurmans et al. (2004)

Instrument - - + - + + - -‘Guilley’/Guilley et al. (2008)

Instrument ‘Rothman’ + + + - - + - -/Rothman et al. (2008)

Clinical Global + + + + + - + +Impression ofChange in PhysicalFrailty (CGIC-PF)/Studenski et al. (2004)

The Vulnerable Elders - - + + - - - -Survey (VES)/Salibaet al. (2001) and McGee (2008)

Frailty instruments assessed on frailty factors, publications since 2000 - B

Study of Osteoporotic + - + + + - - -Fractures (SOF)instrument/Kiely et al. (2009)

Instrument ‘Puts’/Puts et al. (2005) + + - - + + -

Instrument ‘Ravaglia’ - + + - - - + -/Ravaglia et al. (2008)

Grip strength as a single marker - - - + - - - -/Syddall et al. (2003)

1994 Frailty Measure + - - + - + - -Strawbridge/Cigolle et al. (2009) and Matthews et al. (2004)

Geriatric Functional + - + - + + - +Evaluation(GFE)/Scarcella et al. (2005)

Frailty Index- + - + - - + + +ComprehensiveGeriatric Assessment(FI-CGA)/Jones et al. (2004, 2005)

Table from de Vries et al. Ageing Research Reviews 10 (2011) 104-114

Proportion of definitions including each frailty domainper

de Vries et al. Ageing Research Reviews, 2011

FOD-CC

Sternberg SA et al., JAGS 2011

RATIONALE

• There are many definitions.• With different conceptual frameworks and domains.The criteria are not universally applicable. Depending

The definitions have been validated in epidemiological settings, but not in clinical ones

FOD-CC

Song et al., 2010

Garcia et al., 2011

Global prevalence: 8.4%

Global prevalence: 22.7%

FOD-CC

PREVALENCE OF FRAILTY IN EUROPE (SHARE STUDY)

Santos-Eggimann y cols, J Gerontol 2009

Same criteria?

In TSHA, we used the lowest percentil 20 in our population meeting the frailty criteria 4 and 5Prevalence: 8.7%

CRITERIA DEFINITION

1. Weight loss Unintentional weight loss of 4.5 Kg during the last year

2. Exhaustion Using the responses (YES/NO) to two statements of the CES-DDepression Scale (Orme J et al., 1986)

3. Physicalactivity

Assessed by the short version of the Minnesota Leisure TimeActivity questionnaire (Taylor HL et al., 1978)

4. Slowness Assessed by walk time and stratified by gender and height

5. Weakness Assessed by grip strength and stratified by gender and BodyMass Index

• Frailty will be identified by the presence of three or more of the criteria.

• Pre-frailty will be identified by the presence of one or two of the criteria

In FRADEA, we used the Fried´s criteria “comme il faut”, as they were validated.Prevalence: 13.7%

FOD-CC

BA=64.19 + (.18 x frailty score)

FOD-CC

García-García FJ, Larrión JL & Rodríguez-Mañas L., Gac Sanit 2011

RATIONALE

• There are many definitions.• With different conceptual frameworks and domains.• The criteria are not universally applicable. Depending

The definitions have been validated in epidemiological settings, but not in clinical ones

FOD-CC

With permission from H. Bergmann

RATIONALE (2)

We do have several definitions, but we do not have an operative definition for the

daily practice

FOD-CC

FOD-CC THE AIM

At the projectProviding a definition of frailty,the selected biomarker(s) identified and aguideline to allow early diagnosis of frailtyto be used in clinical practice

Kick-off meeting reportClinical definition of frailty (useful for clinicians)with a sub-aim of definition of ‘frailty’for research (animal models).

5 Focus Groups

• Geriatricians

• Basic scientists

• Non geriatricians, clinicians

• Non clinical health workers

• Social and non governmental workers

FOD-CC

THE QUESTIONNAIRE

• The conceptual framework• Proposed definition• Setting where applying the definition

(clinical settings and research settings)• Biomarkers• Biomarkers/criteria/parameter directly

relevant to the definition

FOD-CC

Construction of the 2nd Round questionnaire

FOD-CC

Table 5: Rate of Accepted and Excluded Statements According to theAlternative Classification. Final Analysis

Table 4: Rate of Accepted and Excluded Statements According to EachBlock of Questions, Final Analysis

FOD-CC

CONCLUSIONS• Frailty is a dynamic, non linear process 24 that involves

alterations in multiple domains of functioning 29, impacts multiple body systems 28, 50 and may be considered a clinical syndrome4.

• It is different from vulnerability and disability 26, 96, 97 and is often modulated by disease 102 to the extent that the presence of co-morbidities tends to exacerbate the consequences of frailty 104.

• Definitions of frailty are frequently multidimensional involving a variety of psychological, social, emotional, and spiritual elements in addition to physical components 13. Definitions of frailty should be applicable across different clinical settings 7.

CONCLUSIONS• Frailty is characterized by a decreased reserve and

diminished resistance to stressors 6. No single biomarker is adequate for the prediction and/or diagnosis of frailty 60.

• Numerous variables have been proposed for use in the diagnosis of frailty including nutritional status n8

and physical performance n14, gait speed n16 and mobility n17. In addition, mental health assessments and cognitive status evaluations are highly recommended as part of the assessment of frailty n9,

CONCLUSIONS• The consequences of frailty include an increased

vulnerability to stress in which minimal levels of stress can cause functional impairments 27, 21. Although disability can occur without prior frailty, frailty is a risk factor for disability 99.

• A major purpose of diagnosing frailty is to identify and stratify older persons at high risk for disability and/or other adverse outcomes 12, 45.

• A diagnosis of frailty is of importance because can help to predict a variety of different health outcomes including disability, falls, hospitalization, permanent institutionalization, and death 100, 59. The predictive value of frailty depends on its severity and will vary from person to person 101.

CONCLUSIONS• The diagnosis of frailty is of importance in numerous

clinical and non-clinical settings 43 in addition to geriatric medicine 48. Frailty diagnosis is useful in both primary care and community care 46 and is of value in managing older people with chronic diseases 47. Because frailty is a condition in which prevention may still be possible it is mandatory for clinicians and health workers to identify those at risk for frailty as early as possible 23. Among the interventions that show promise for the management or attenuation of frailty include a variety of healthy lifestyles n7, including physical activity n6, 22.

FOD-CC

MID-FRAIL STUDYFP7-HEALTH

A los viejos les enseñaría que la muerte no llega con la vejez, sino

con el olvido

Gabriel García Márquez

A A los viejos les enseñaría que la muerte no llega con la vejez, sino con

el olvido

Gabriel García Márquez

A los viejos les enseñaría que la muerte no llega con la vejez, sino

con el olvidoA A los viejos les enseñaría que la

muerte no llega con la vejez, sino con la pérdida de autonomía.

Théodore Géricault (1791-1824)Óleo sobre lienzo. 1822Musée du Louvre. París

DEMENCIAS , FUNCIONY FRAGILIDAD

EVOLUCIÓN

Progresivamente el paciente va perdiendo

su capacidad funcional, primero para aquellas

actividades más avanzadas y

paulatinamente para las más básicas, como la

capacidad del autogobierno y del

autocuidado.

AVANZADAS

INSTRUMENTALES

BÁSICAS

Tiempo medio de supervivencia 3-20 años

Demencia y declinar funcional

• EA: más años con discapacidad en valor absoluto y en % sobre expectativa de vida– Est epidemiológico 15 años: EA más años y

más proporción de vida con dep 6 o 7 AIVD*– Riesgo atribuible poblacional de discapacidad

incidente en ABVD/AIVD entre 11% y 36% según actividad analizada**

* Dodge HH et al. Arch Neurol 2003; 60: 253-259.** Dodge HH et al. Gerontologist 2005; 45: 222-230.

Demencia y dependencia incidente (Wolff JL et al. J Am Geriatr Soc 2005)

Ancianos complejos: reto para el sistema y para el clínico

• Patología múltiple crónica

• Problemas funcionales y mentales

• Entorno social insuficiente o débil

Enfermedad y carga de salud pública

• Nº de personas que la padecen (incidencia y prevalencia)

• Mortalidad que provoca• Costes derivados tanto directos como

indirectos

Doody et al. Dement Geriatr Cogn Disord 2005, 20: 198-208.

Tiempo

S.depresivo

diagnóstico

tnos.conducta

enf.intercurrentes

déficits funcionales

Sobrecargafamiliar

institucionalización

Mild cognitive impairment

Alzheimer’s disease

Pathology begins

757055

Enfermedad de Alzheimer y sarcopenia

• La EA se asocia con pérdida de peso (previo a su diagnóstico)

• La pérdida de peso severidad y progresión de EA• Composición corporal a lo largo de la vida y riesgo de EA

LABORATORIO DEEVALUACIONMULTIFUNCIONAL DELANCIANO

Demencia

DCND EA Cualquier tipo

OR (IC 95%) OR (IC 95%) OR (IC 95%)

Actividad física

Ninguna 1 1 1

Baja 0.66 (0.46-0.96) 0.67 (0.39-1.14) 0.64 (0.41-1.02)

Moderada 0.67 (0.52-0.87) 0.67 (0.48-0.98) 0.69 (0.50-0.95)

Alta 0.58 (0.41-0.83) 0.50(0.28-0.90) 0.63 (0.40-0.98)

Test de tendendencia

P<0.01 P=0.02 P=0.04

Actividad física y riesgo de deterioro cognitivo y demencia en > 65 años. Seguimiento a cinco años. CSHA.

Laurin D, Arch Neurol 2001; 58:498-504

CONTENIDO DE LA CONFERENCIA A) Descripción del escenario. ¿Qué ha pasado? B) Envejecimiento y salud vs Envejecimiento y discapacidad C) Enfermedad neurodegenerativa y dependencia: el caso de la demencia

D) Conclusiones-Propuestas

Eubie Blake(vivió hasta los 96)

“Si hubiera sabido cuánto iba a vivir, me hubiera cuidado más.”

THANKS FOR YOUR ATTENTION!!!

IT´S THE TIME FOR QUESTIONS

MEDICINA GERIATRICA

¡Gracias por

su atención!

lrodriguez.hugf@salud.madrid.org

¿Preguntas?¿Preguntas?

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